Brand new bag

Howdy and a quick announcement. I am now writing generally about social services, human services and professional caregiving for Examiner.com. It's something slightly closer to a job than this blog has been. The new site will take most of the effort I've been putting into this site (roughly 1400%) and be less focussed on developmental disabilities. I'll keep this site so Andy and Stanley have somewhere to rant and I can get deep in the policy weeds from time. The link to my new page is in the title of this post.

You're all welcome to join the conversation there.

Talking cents

The dollars needed to preserve the system will not be forthcoming, I'm afraid. Not for a long time, anyway. I believe our choices will be to let it all continue to crumble or start seeing nickels and dimes worth of actual service as more desirable than advocacy denominated in billion dollar bills.

In support of a resolution I've proposed to the San Gabriel/Pomona Regional Center Vendor Advisory Committee, I've recently had the opportunity to retell this story: In 2002 or so, I started receiving a lot of phone calls from Service Coordinators asking me questions that took me by surprise. But they had a pattern: Many asked about the clients' height and weight (useful mostly if you are going on rides at Disneyland or boarding a helicopter;) some asked about the clients' ambulation (useful for special olympics planning;) others asked if the client had been out of service for any extended periods, out of state or hospitalized or in prison (useful for identifying fraud, assuming the same vendor would bill fraudulently and then answer the question diligently.)

The questions were odd and there was no particular place for me to find the answers, so after receiving the calls I would generally get up, search through the client's file and, if that didn't turn up the answer, call the supervisor responsible for the case who would, next time she wasn't with a client search through notes for the answers. Then I would call the SC back with or without the right answer. I don't know how much time SCs were spending on the questions, but Arriba staff were spending several hours per week.

At some point, I found an unimpertinent way of asking "why are you asking?" and the answer came "for the waiver documentation" nine times out of ten. After that I talked to the very smart person in charge of said documentation and we worked out a template, to be included in every progress report, that would answer all of these questions. Staff already, when updating the reports looked in all the places that data would be for the answers to other questions so once we changed our template, the administrative workload here went down sharply and at least some time was saved for the SCs who eventually would learn that the answer was sitting on their own computer. At the very least, the calls per client-question fell from two to one.

Spread that change from Arriba's 100 or so clients to a regional center's some-thousand-and-some, and it might be that half a year of one person's work could be saved. That's not a ton, but it could be enough to turn an administrative position into a service position or a savings.

So, here's a question for commenters who seem to need questions: What are some other small changes that might make the cost of service left while leaving the service intact?

The pettiest post on this site

This is a very small point, but the conversation around caseload ratios for service coordinators has become too funny to leave be. What I keep hearing is that for HCBS waiver clients, the caseload ratio remains limited to 62:1 but that the cap has been lifted entirely for non-waiver clients. It makes sense that people would say this because neither CMS nor DDS nor anyone else want California to twit the federal government in a way that requires a response.

But, the assertion keeps getting made without irony or humor or apparent self-awareness so let's just us, we few who discuss here, set the record straight. If the non-waiver caseload is uncapped, then the waiver caseload is also uncapped. The reason I think so: I don't know of a regional center that has waiver and non-waiver caseloads. As far as I know, all service coordinators have mixed caseloads.

This means that that to say "we have a 75:1 caseload ratio" means the same distribution as to say "we have a 62:1 caseload ratio for HCBS clients and a 101:1 ratio for non-waiver clients (assuming 2/3 of clients are on the waiver and I did my math right.) Really, this is a very unimportant point, but I do hope you will join me in smirking whenever you hear someone claim that the caseloads are fixed for waiver clients.

Other closures

Much has been made of the pending closure of Lanterman Developmental Center, and it would be to our detriment to ignore the impact of the planned closure of Lanterman Regional Center. According to DDS Director, Teri Delgadillo, Lanterman is being closed and merged with Harbor and Westside regional centers to save money. As Ms. Delgadillo says in her statement, "The administration considers these three regional centers, which have already harmonized their service coordination process to the degree that client expectations have been regionalized. Furthermore, by pooling staff, the combined regional center will have the capacity to say 'no' in more than 80 languages."

"We certainly defer," Director Delgadillo continued, "to the combined 80-person board of the merged center in terms of naming the new facility and appointing management. But DDS personnel are recommending 'Richard Riordan Regional Center,' because we enjoy the sense of whimsy that alliteration brings."

Walt Disney Regional Center, which will be created from the merger of South Central and Orange Country RCs will have the capacity to say "please" and "thank you" in more than 30 languages and on legal pleadings.

Because a new post is sorely needed

I apologize to the few but loyal readers that not much has come to mind to write about here. There's big news about Lanterman Developmental Center, of course, a topic on which I don't feel qualified to opine about.

But, in the post below, Godwin's Law seems to have reproven itself and the phrase "dead white male philosophers" has also appeared and I feel ready to propose my own Doug's First Law of Internet Discourse: To wit, no subject is so arcane that common platitudes won't dominate the discussion once the topic has been exhausted.

So, lacking anything else to mind, I'll open the thread to you all with three questions:

First, if anyone out there has interacted with the Delatorre audit, I'd be interested in hearing about the tone and rigor of the inquiry. Can anyone tell how well-informed the study has been or whether it appears vindictive or exploratory?

Second, if self-determination/directed-services is no longer an available option for streamlining and improving the system, what would you all suggest as a conceptual frame for intentional systemic reform?

Third, an anonymous guest suggested something I absolutely agree with (and have agreed with in previous posts,) that more funding won't fix a broken system. Anonymous suggests Stanley's answer to the question, but I am curious for two sentence answers: Do you all think the system is primarily underfunded or primarily broken?

Some etiquette: Let's start by answering one of the three questions (as opposed to two, all or none) per comment, begin by identifying which question you are answering and, if at all possible, consider the poor blogger who feels compelled to read all the comments and try to begin with two- or three-sentence replies.

I'll try to come up with a new post before anyone begins comparing department directors to war criminals.

Who will reward the far-seeing?

OK, so this post was either not prescient or very prescient. I doubt we're done with cutting.

So, here's a topic for discussion. Immanuel Kant distinguished between phenomena, things that are observed, and noumena, things as they are in themselves. One thing I believe strongly about our system (and most others) is that the phenomena we describe when we talk about support to people with developmental disabilities, are almost entirely process. That makes sense, considering that support is initially a verb. But process is hard to defend and, really, if all we do is do, and nobody gets anything of value in itself, then it may be right that we have trouble defending. My question, regarding what our system produces, is what do you all think the noumenon is? What is the thing in itself that people with disabilities receive from all the work that goes on.

Just to handicap the discussion, "dignity," "sovereignty," "choice" or "safety" sound too abstract to me. Is there something people get from being supported that they would know they lacked if the system went away? What are those things?

So how is everybody?

Looking forward to 2010

Well, heck. The new year will bring new cuts. We all have known that for a while and none of us have any excuse for not being ready for them. I just updated my resumé, for example. I do hope people understand that the next round of cuts proposed might eliminate entire programs and, perhaps, state departments. But for my optimistic year's end post, I'd like to suggest criteria for guessing whether DDS thought through the cuts it is about to propose:

If the cuts proposed have been (tragic but) thoughtful:

1. Rates will compress toward the low end, not fall by a fixed percentage.
2. In explaining the cuts, resistance by large lobbying organizations won't be mentioned.
3. Those will be least affected who are most urgently in need.
4. The package will contain not only clear descriptions of what regional centers are to do differently, but enforcement mechanisms for reining in inventive interpretations or, at least, an expressed and manifest willingness to publicly side with other stakeholders some of the time.
5. Andy Pereira will need to think a short while before ranting.
6. Some non-residential agencies may actually close.
7. Contrary to the "furthest from the client" meme, the scope of support will narrow more than oversight fades.
8. Many members of the cost-cutting stakeholder group will complain that they weren't listened to and mean it this time.
9. The interdisciplinary team (IDT) approach, Individual Program Plan (IPP) primacy and fair hearing rights will be strengthened.
10. The limits on the IDT and IPP will be clarified, in terms of requiring a clinical and practical rationale for support.

To expand on my thinking (apart from my comment about Andy- you just gotta know Andy,) ideology will not produce a budget solution nor a human solution. To get both, consideration must be applied to efficiently shrinking the system, maximizing cuts realized (rather than scored) and minimizing disruption acknowledged (rather than ignored.)

The first challenge is that we have spent years in denial that any change to the system is necessary and one result of that is that the map of the system isn't much more detailed than it was 9 years ago when I got here (and when the map showed "Here be dragons" across the state.) So there is no real possibility that the changes to be proposed will be wise or wholesome.

That said, some common sense can be applied. It is clearly better to retain a decreased number of low-cost support agents than to continue trying to keep all the state's executive directors employed. This is why a downward compression of rates is wiser than a fixed reduction and why it is better to restore the clinical and practical requirements to the scope of a client's service than to list categories of service to be discontinued.

Because we can't describe our current reality (without lying, exaggerating or generalizing beyond the scope of surrealism,) it is important to retain whatever intelligence the system does feature. This is why both quality assurance and the ID teams remain an important feature. There's also some hope to be had that if the system shrinks more than its smarter features, the system itself can grow a little less mystical in process and product.

Likewise, for the system to grow smarter it is absolutely mandatory that regional centers grow less glib, for clients to have clear understanding of new limitations and for some agencies to close. But the most important factor is that stewardship of this system and its resources for the benefit of the people served has to improve for the remnants to matter. Which is why such proposals as an x% rate cut across the board or the evacuation of regional centers will prove a lack of good thinking by the administration.

Of course, this budget is bad enough that we just have all non-residential care proposed for elimination. In which case, dangit.