MINUTES OF THE INFORMAL MEETING OF THE JOHNSON COUNTY BOARD OF SUPERVISORS:
DECEMBER 30, 2009
TABLE OF CONTENTS
Page
Mental Health/Disability Services (46)
Schedule of Remaining Budget Meetings
Chairperson Neuzil called the Johnson County Board of Supervisors to order in the Johnson County Health and Human Services Building at 1:00 p.m. Members present were: Pat Harney, Terrence Neuzil, Janelle Rettig, Sally Stutsman; absent: Rod Sullivan.
Mental Health/Disability Services (MH/DS) Director Kris Artley said there is a nice cash fund balance of $5 million, which is partially due to the State’s budget crunch. Stutsman asked for the percentage of the cash balance. Artley said she does not know the percentage, only the cash amount, and she thinks it will be a blessing. Stutsman asked if the number is for FY10. Artley indicated that it is for FY09. The fund balance for FY10 is still unknown.
Artley said the actual cost report, which was submitted September 30, 2009, showed that MH/DS was significantly overpaid by Iowa Medicaid Enterprise (IME) and Magellan Health Services (Magellan). Artley said $389,815.00 is owed by MH/DS. Deputy Auditory Dana Aschenbrenner has assured her that he did a journal entry regarding the amount in the reports he filed with the State as of September 1, 2009. The intent is to pay the amount in full when a bill is received. They have been told that the bill may not be received until at least January 2010. The amount was affected by a tremendous growth in clientele received through the case management program last year. Artley said it was also affected by the department’s change of location to the Health and Human Services (HHS) Building and the elimination of rent payments. In addition, IME submitted a new Iowa Plan based on 15 minute reimbursement, which was supposed to have been implemented October 1, 2009. Cost reports regarding the change were prepared and submitted by June 30, 2009; however, the change has not been implemented. As a result, payments are currently made at the FY09 rate, which is far too high.
Artley said the Board approved the addition of three additional case manager positions in 2007. All caseloads have subsequently returned to maximum capacity. Harney asked if money will have to be paid back over the full FY10 period since MH/DS is currently receiving FY09 rates. Artley said they will be asked for reimbursement after the actual cost report for FY10 is submitted. The phenomenal growth in clientele reduced their unit rate. Artley said the actual rate in 2008 was $302.13, and they projected $314.51 for 2009. The amount actually dropped to $250.70 due to growth in the number of clients and lack of depreciation costs incurred. That is a large difference.
Artley said she understands that depreciation figures still cannot be obtained because the final payment has not been made on the HHS Building. As a result, she cannot build it into the cost report. Harney said he thinks the depreciation would be affected by the age of the Building rather than the final payment. Artley said she has made several unsuccessful attempts to obtain necessary information. Harney asked if she requested the information from Facilities Manager Dave Kempf. Artley said yes. She has also asked Aschenbrenner who subsequently referred her to Kempf. Rettig asked if the final cost is unknown due to change orders that have not been settled. Stutsman said she thinks Kempf is holding some payment back because the items on his punch list have not been completed.
Rettig asked if Artley has projected overhead in the amount of $250.70. Artley said that was the actual cost without incorporating the depreciation schedule. It was turned in by September 30, 2009, and the figures still had not been obtained. Rettig asked if the amount of $250.70 does not include the MH/DS Department’s share of the HHS building. Artley said that is correct. Rettig asked if that is the amount they are currently billing Medicaid. Artley said they are still billing $314.51 because the change to the 15 minute increment was not made.
Rettig reiterated that MH/DS is being paid at a rate of $314.51, and they know that is too much. That is how they ended up owing IME and Magellan $389,000. Artley said they currently have the money available to pay it back. Rettig said the problem is additional overpayments because they don’t know the actual cost yet. Artley said yes, and there are some proposals regarding that issue. Everything on the chart looks well balanced, based on her experience. She said it appears there was a staff increase in 2001-2002, but she is not sure because she was not employed by the County at that time. It was incurred again in 2007, which resulted in a difference of 19%. Stutsman asked if Artley will send in an amended cost report when she has information regarding depreciation. Artley said they would, but plans have changed as of December 28, 2009. Rettig asked for the desired percentage of difference, although they would obviously prefer they were equal. Artley said her objective is to stay in the 5% to 10% range because Medicaid will provide more reimbursement. Rettig asked if that is where they would end up if all things were equal. Artley said they would hope so.
Artley said beginning January 1, 2010, a 3% increase for the Intermediate Care Facilities for the Mentally Retarded (ICF/MR) program bills will need to be reflected, per legislation that was enacted last year. That is an unfunded mandate to all counties that will cost counties about $1.6 million to augment. The formula involved .1%, and it was known that the per diem rates would go down. As a result, a 3% increase was legislated for. Artley said she finds it interesting that counties have not yet been billed for resource center bills despite the State’s financial challenges. One explanation is that the amount of reduction by the State is unknown, and they don’t want to do the work twice. As a result, MH/DS has not been billed for those individuals for the first half of FY10. Stutsman asked if Artley is aware of the amount and if she has accounted for it in her balance. Artley said a rough estimate can be obtained. They know the numbers of clients and the per diems rates, although there may be some variance due to some clients with additional sources of income and co-pays.
Artley said Executive Order 19 mandated a 10% decrease. Effective December 1, 2009, the Targeted Case Management Programs are to receive a 2.5% reduction in reimbursement. She said a 2.5% reduction still won't bring the rate down far enough, but it is better than receiving the full rate. As of December 28, 2009, IME is proposing a new rate based on a formula; however, a related telephone conference will not be held until January 7, 2010. Artley said she will fully support it because she believes it will be very advantageous for Johnson County. A waiting list began on November 1, 2009 for the The State Payment Program (SPP). As of December 30, 2009, seven individuals are on the waiting list and, eligibility is currently being determined for two additional individuals.
Artley said a local hospital is currently trying to obtain placement in an RCF facility for an SPP client, but the wording in the court order is not correct. It is a complicated process, and MH/DS staff are trying to help hospital staff understand that the services will not be funded unless each type of service is spelled out clearly. Rettig asked if seven individuals are currently on the waiting list and if two more will likely be added soon. Artley said yes, since November 1, 2009. Stutsman asked what services these individuals are currently receiving since they reside in Johnson County. Artley said they are waiting.
Rettig asked Artley to describe the range of diagnoses and the services appropriate for these individuals. Artley said she can't today because most of her staff is gone, but they are probably mentally ill and chronically mentally ill individuals. Rettig said she thinks the type of help needed by these individuals affects the broader picture. Artley agreed. Rettig said that basically nine individuals have been added in a few months. Artley agreed.
Stutsman said she wonders how those individuals are obtaining services in the meantime. Artley said the majority of the requests have involved outpatient services through mental health centers. It is possible that mental health centers are choosing to serve these individuals under their block grants, but she doesn’t know that for a fact. Stutsman said the mental health centers are basically absorbing the costs then. Artley said yes. Problems may result when those individuals are prescribed psychiatric medications because MH/DS would normally pay for the medication until they are eligible for the Patient Assistance Program. They would also provide assistance with the paper work. Artley thinks there are less than three individuals on the roster who have diagnoses of mental retardation because the majority of those individuals have Medicaid eligibility automatically. The State Payment Program doesn’t matter with Medicaid eligibility.
Rettig said Artley previously stated that individuals on the waiting list would have to be court committed in order to obtain services. Artley agreed. Rettig asked if those individuals subsequently move to the top of the list and receive a slot automatically. Artley said yes. Stutsman said the State starts paying at that time. Artley agreed. Rettig said individuals can either be committed due to committing a crime or because two people have signed for the commitment. Artley said Chapter 229 of the Code is referenced for court ordered psychiatric evaluations. MH/DS does not pay for individuals who pass through the criminal system.
Rettig asked if individuals who have not committed crimes can be committed if the police can clearly see they need help. Artley said the Sheriff's Department will not take individuals involuntarily until there is a court order. Someone would need to sign to have them committed. Rettig asked who would sign if they have no family or service worker. Artley said it is possible for a variety of people to sign. There have been situations when individuals enter the hospital voluntarily because they know they need help, but then they don’t want to stay. At that point, hospital personnel can sign to keep them there. Rettig asked if a person will be committed and moved to the top of the waiting list if they go voluntarily. Artley said only if the person tries to leave the hospital, and the doctor says they shouldn’t.
Stutsman said the need to obtain a court order in order to receive services is the problem with the system now. It is not ethical to label an individual as an involuntary commitment just so they can receive services. Artley agreed. Rettig said that is why she asked about the diagnoses of the individuals currently on the waiting list and how close they are to being committed. Artley said she hasn’t yet heard anything from the intake workers that would lead her to believe they are near that point. Rettig said providing services through commitment costs significantly more that providing services through MH/DS. Artley agreed. Harney said a hearing has to be held within a specific number of hours, and the individuals may or may not be committed as a result of that hearing. Artley agreed that is a possibility if evidence substantiating the commitment is not received.
Artley said MH/DS will no longer receive the list of disenrollees as of January 1, 2010. The State has decided to mail out the notices. MH/DS staff are pleased about the change because they had 162 court commitment records to evaluate, and Artley thinks they actually submitted a list of only 11 or 12. Artley said she was concerned that some counties were not able to capture everyone who falls in that category to automatically obtain an SPP slot. Johnson County MH/DS was only able to obtain information on those individuals through their patient advocate, the mental health centers, or other service providers. Artley said the Clerk of Court does not have enough time to assist with the project because of their furlough issues. She highly doubts the State is getting good numbers. These are the individuals who are supposed to get the first slots. Artley thinks there is currently about 4,200 people on the list, and the initial projection is to disenroll about 1,200 of them.
Artley said MH/DS was paying 37% to 38% of the non-Federal share of waiver services, but the amount was reduced to 32% and then to 28% to 29% because of Federal stimulus funding. The reduction will be eliminated on December 31, 2010 unless the legislature is able to take further action and chooses to do so. It is her understanding that training on how to track those dollars was planned for 2010. She doesn’t know what type of work that will entail because she doesn’t yet know what they are being asked to track. Stutsman asked if the non-Federal share will return to 37% to 38%. Artley said it will unless the legislature is able to find more money. Stutsman said the State will not be able to find additional money. Artley said there may be additional Federal funding that can be accessed. In FY09, MH/DS actual billings were over $4 million, and the estimated savings was $683,841. Stutsman asked what she means by estimated savings. Artley said she is referring to the amount saved due to the reduction of the non-Federal share.
Artley said a cost savings of $615,000 was initially projected, but it was not yet known that sustainment of a high employment rate would further reduce their fiscal obligation. As a result, the reduction from 32% to 29% was a surprise to many people. She said the estimated savings for FY10 is just over $1 million. The estimate for FY11 is only $357,544 due to elimination of the reduction in the non-Federal share half way through the year. The estimates are based on the State's projections. Although the State promised to support allowed growth through implementation of Senate File 69 in 1996, all of the growth during this 30 month span is being underwritten by approximately $2,210,800 in stimulus funds. Stutsman asked if the stimulus funds will end on June 30. Artley said they will end on December 31, 2010. Rettig asked if the Federal stimulus money has backfilled the State's obligation. Artley said yes. Rettig asked if Artley is referring to the amount backfilled when she says savings. Artley said yes. Stutsman said stimulus dollars were included in all DHS budgets. MH/DS is not the only department that will have a short fall if the stimulus funding is eliminated.
Rettig said the State’s solution to not disenrolling people was to use another pot of stimulus dollars. Artley said numerous CPCs requested that State of Iowa DHS Director Charles Krogmeier look at the risk pool fund balance because it is a little over $1 million for this fiscal year. He is approaching the legislature to request that those dollars be transferred to the SPP Fund. Artley said that would amount to only about half of what is needed to get through the year, and it would not eliminate the waiting list. Rettig said it would take away half of the problem involving disenrollments. Artley said they hope so. Rettig said that is for FY10. Artley agreed. Stutsman said the solutions are only short-term and do not support long-term sustainability. Artley said very poor management is involved, and it is very frustrating at the local level.
Artley said over 100 individuals entered the system over the past year. In order to sustain operations, MH/DS purchased voice recognition software at the end of FY09. It is working for staff with upgraded computers and those who were previously well acquainted with it. The rest of the computers are too old and can't support the software. Because case managers now have to track their day minute per minute, it is necessary to have a timesheet continually open. Unfortunately, the computers are unable to support both the timesheets and the voice recognition software. Artley said many employees have given up on using the voice recognition software because it is too time consuming, and they can type faster than they can talk when the system keeps crashing.
Rettig asked what IT employees have said about the problem. Artley said they told them their computers don’t have enough memory. Rettig said the issue was recently discussed. Stutsman asked if money was included in the IT budget for replacing all the computers in MH/DS. At the time, the Board didn’t understand why it was necessary, but now she does. Artley said she does not know what IT Director Jean Schultz presented to the Board. Rettig said she is confused because it was included in the IT budget. She asked if Artley is also including it in the MH/DS budget. Budget Coordinator Rich Claiborne said it has to be in the MH/DS budget rather than the IT budget because they cannot cross funds. Neuzil said Schultz provided an update of potential purchases. Although the money would come from MH/DS, the hardware would become the responsibility of IT. Artley said IT was asked to provide MH/DS with a cost quote for replacement. The majority of the cost would be depreciated out of the MH/DS case management rate.
Harney asked how other counties are doing time tracking. Artley said a variety of methods are being used, although there is no perfect solution. She thinks part of the problem may be eliminated due to a proposal in January 2010. She will talk more about the proposal later.
Artley said one option is to upgrade the computer system, which will cost $45,000-$46,000 according to the IT department. In that case, she would also want all employees to have double monitors so they can track their time without continually minimizing and maximizing their screen displays. She thinks double monitors would be an effective time management tool. Another option is to add a targeted case management (TCM) support position. Artley thinks the former option is best, based on the current needs of staff. Stutsman asked how much money has been invested in the Dragon software. Artley indicated that she cannot remember. Stutsman said it seems like Artley would basically be giving up on the software by choosing the latter option. Artley said staff would continue to be encouraged to use the software, but their efforts will be futile unless they have computers to support it.
Rettig asked how old the computers are. Artley said she began employment in September 2007, and she thinks only a couple of computers have been purchased since then. Rettig asked if replaced MH/DS computers are allowed to be used for another purpose rather than being sold at auction. Artley said as far as she is concerned, the Board can decide whether to make them available to other departments. Rettig said a couple of departments are willing to accept recycled computers to meet their needs.
Artley said she is also concerned about changes involving the implementation of the Community Service Network (CSN). It is supposed to link all of the counties into one central data system, and she doesn’t know if it will require additional computer memory. Rettig asked how much time MH/DS staff are having to put towards TCM paperwork daily. Artley said she thinks use of the new assessment form became required on October 1, 2009, and she asked staff to track their time spent completing it. The previous assessment, which was in use for many years, took approximately four hours to complete, and the new form takes ten to 11 hours to complete. It is approximately 26 pages and is required by the State. Rettig asked if that is the amount of time it takes to complete the assessment for each client. Artley said yes.
Rettig asked if it would take less time to complete if the Dragon software was working properly. Artley said she thinks Dragon will be most useful for completing daily narratives. In order to bill, everything case managers do involving clients has to be documented in the files. Rettig asked if the assessment will become more reasonable. Artley said that is up to the State. Rettig asked if they are hearing about the problems. Artley said County Case Management has certainly voiced their opinion. She said Stutsman is a member of the Board and probably knows more about the issue. Stutsman said in her short experience, it seems they just don’t get it. There seems to be a disconnect between the DHS office and what is happening in the field. Stutsman said they are saying it’s no big deal and can be done. She thinks, in an ideal world, everyone at the Hoover Building would have to do a six month sabbatical in the field every two years, so they understood the issues. Artley agreed and said they could also see how their decisions impact real life.
Artley said MH/DS is currently averaging 617 clients per month. The net amount has been relatively stable from July 2009 to December 30, 2009 because there have been almost equal numbers of people entering and leaving the system. Although there are 11 individuals currently awaiting eligibility determination, there has not been as steep of an increase in numbers as there was in FY09. Rettig asked why. Artley said that is a good question. Stutsman said Artley was also unable to explain the large increase. Artley said there were a small number of individuals who had previously been diagnosed with having a chronic mental illness and became eligible for a new program called Habilitation, which is Medicaid funded. However, there seemed to be no consistency among the other individuals who began services. They included children, adults, individuals with chronic mental illnesses, and individuals with mental retardation. The dramatic increase during those 12 months had a drastic impact on rates.
Artley said 40 new cases have been opened since July 1, 2009, in addition to the 11 TCM cases currently awaiting eligibility determination. However, 50 cases have been discharged since that time. Rettig said she thinks people may either be giving up or not asking for help. Artley said the reasons for discharge have included moving away and things of that nature so they are natural life occurrences. Stutsman said some individuals have probably died as well. Artley agreed that a few have people have died. Rettig indicated that she would expect the number of new cases to be higher.
Artley said IME developed a new savings implementation guide on December 28, 2009. Their goal is to achieve a 2.5% savings for case management providers, per the Governor's Executive Order. She said they basically want to take the FY08 actual cost, which was $302.13 per client per month for Johnson County, and apply the inflation factor and a 2.5% reduction. The result is a proposed increase of 6.3%, which would bring Johnson County up to $321.16 per client per month.
Artley said they were told about the change to the 15 minute billable unit rate on October 1, 2009. She thinks there are two problems with the change. The first is that MH/DS does not follow the Medical Model. They don’t visit with each client individually for ten minutes and narrate for the next five minutes. They may answer ten phone calls or respond to 20 emails during the first half hour of their work day. Documenting each of those things can be challenging. Some parts of the daily workload will be determined to be billable services and other services will not. Artley said a case manager could theoretically have 60 billable functions in one hour. However, she thinks a lot of CPAs, who work for various case management programs, have told IME that there is no way to bill for more than one item every 15 minutes while using good accounting principles. Artley thinks the State may be able to avoid implementation of the change, as a result.
Artley said one of the listed cons of the program states that CMS may have issues with this change in methodology upon reviewing the State plan. Apparently, their intent is to change the State plan back to the monthly unit, which she thinks has been utilized since case management began around 1987 to 1988. Artley indicated she will support the protocol since Johnson County MH/DS does not have figures for depreciation of the HHS Building, and it may be beneficial for their unit rate. She proposes hiring a new case manager in January 2010 to begin work on the 11 pending cases because the other case managers each have 33 to 35 clients. In addition, it takes about six months to learn the basics of case management, and hiring now would allow the individual to ease into it. Artley encouraged the Board to approve replacement of the computers during FY10 because MH/DS has plenty of money in their reserves, and it would free up computers for use throughout the County, as the Board sees fit.
Rettig said the County was only partially reimbursed for the actual cost of providing services. Despite the increase of 6.3%, the County will still not be reimbursed for the total amount. Artley said MH/DS will be reimbursed based on their actual cost report if the proposed formula is approved. The actual cost report for FY10 expenses will be submitted prior to June 30, 2010. Currently, there is not enough staff or depreciation to support that figure. Rettig asked if the figure could be supported if the depreciation information was obtained. Artley said she is unsure because she doesn’t know the amount of depreciation, but it would be beneficial. Rettig said it seems to her that they need to get the number and plug it in, even if it is slightly off due to the change orders being incomplete. Stutsman said there are punch list items, not change orders. Change orders add cost to the building, and there were none.
Rettig asked if there were no change orders on the HHS Building. Harney said there were some, but they are currently talking about holding money back from the contractors until all the work is finished. Rettig said the exact cost of the HHS Building should be known if there are no additional costs coming. Harney said they have it. Rettig said Artley should have that number then. Harney said the Board needs to find out why Kempf hasn’t provided the number. He may not know how to break it down by department or something. Artley said the number was requested before the last actual cost report was completed September 30, 2009, and it was not available to them. She said that may have been too soon to obtain the number, however.
Artley said something needs to be done to get the rate back up. Stutsman said Artley is indicating that adding a position and replacing the computers would do that. Artley said it would help. Rettig said she is not interested in hiring a new person just to get the rate up. The actual cost should be known. Artley said increasing the rate is not the purpose of adding the position. Absorbing the phenomenal growth in the number of clients without hiring additional staff is what drove the rate so far down. Stutsman said federal reimbursement would be received for the new employee. County tax dollars are not used to fund the position. Rettig said taxpayers are still paying for it. She said Artley previously stated that she could avoid hiring someone if MH/DS had the software and computers. Artley said they could avoid hiring an additional support staff person. Rettig said Artley also stated that the number of cases is stable. Artley said the number is currently stable.
Stutsman asked Artley for their goal in terms of the number of cases per case manager. Artley said it depends on the type of caseload. She thinks a total of 25 cases is more appropriate for dedicated caseloads predominantly involving chronically mentally ill individuals because there is significantly more volatility in daily operations. Stutsman indicated that a price is paid to access Federal funding, but that is the path the State has chosen. As a result, a numbers game is played. Although it costs everyone money, it costs everyone money either way. If Federal funding is not accessed, County money is used. Artley said if nothing more than County social work, which involves one to two contacts per month, was done with State Payment Program (SPP) clients, it would at least keep them from gaining legal settlement until MH/DS is fiscally responsible for them in a year. However, there is currently not enough staff to even do that.
Rettig asked why the County is sitting on a cash fund balance of $5 million. Artley said there are several reasons. Over the past two years, fine tuning has been done. A med fund formulary was implement, which saved just over $500,000 in one year. Federal stimulus funds also helped reduced the County’s fiscal obligation, but that funding is only temporary. Artley said she is happy about the fund balance and asked if the County has had a similar one in the past. Stutsman said they’ve always had a fund balance, but it’s never been that high. Harney asked if the money will be scooped up. Artley said she doesn’t think the money can be taken away. Rettig said she thought that occurred 12 years ago. Artley said there are many counties struggling financially. As a result, they are going to ask the Legislature not to include Federal stimulus funding in the formulas. She said if the stimulus funds are taken away and the formulas are applied as they were in the past, a lot of smaller counties will not be able to handle FY11. Rettig said she thinks having a reserve is necessary and beneficial, but $5 million is 45% of the total $12 million expenditure. That is more than a reserve.
Stutsman said it is very difficult to manage this budget. However, it has been managed very conservatively, and she thinks that is the reason for the fund balance. Artley said she prefers this situation to the opposite situation. She recently spoke to someone from a neighboring county who is hoping there will be $4,000 left in their budget at the end of FY10. That amount of money is not adequate to start a new fiscal year because property taxes are not collected until September. Rettig said she has a problem with the County sitting on $5 million if names of individuals with chronic mental illnesses remain on a waiting list. The system is broken if that is allowed to occur.
Stutsman said the County has dealt with this dilemma in the past. Although she thinks they ethically need to provide services, she questions why they pick up the State’s responsibility. The same issue arises with shelter care and detention. The County may be able to use the $5 million to take care of everyone who requests services, but it would wipe out the fund balance. Artley indicated that issues would potentially arise in FY11 if there is no money available, and she has heard that the cuts may go deeper than 10%. Although she doesn’t know whether that information is accurate, the Legislature may decide that a 10% cut is not adequate. Stutsman said the Legislature will look at the fund balance. Rettig said she would look at it too. Stutsman said counties are almost penalized for managing their budgets and indicated that a balancing act is involved. She is very nervous about offering services to everyone now because it could result in not being able to provide services to anyone in the future. She said Artley does not have any easy job.
Harney said he is concerned the State will take action so the fund balance can be used elsewhere. Artley said there are probably only a few Counties with a large balance. Stutsman said the State has done that in the past. If the fund balance exceeded a specific percentage, allowable growth dollars were not received from the State. Artley said there was a wedge between 10% and 15% in the past, but that has been eliminated so she thinks 10% is the maximum. Stutsman said although the County will not receive that money, it will go to counties that don’t have as much money available. There are some checks and balances involving fund balances.
Artley said she is concerned that the amount of potential growth in the next 12 months will burn staff out and influence them to quit. Neuzil asked if she is requesting three additional positions. Artley said if an additional case manager position can be added in January 2010 and the computer system is replaced, she would like to reduce the requests for FY11. She would suggest eliminating the requests for one social worker II position and the clerk I position. She would still request two social worker II positions for FY11, subject to an increase in cases. She would not consider filling the jail alternatives coordinator position unless the funding came from the Sheriff’s Office.
Artley said she previously put in a request for a .5 FTE information technology position. Just this morning she was unable to obtain necessary information without assistance from Information Technology. There is currently no IT employee who is focused solely on the system used by MH/DS, which would allow them to learn the language and understand requests for information. Stutsman said she is hesitant about adding an IT position because the Board has been consistent in not allowing other departments to add IT positions in the past. A lot of work has been put into the current IT Department, and the issues should be resolved.
Artley asked if it is possible to allow current MH/DS staff increased access to information. Stutsman said she does not understand what information is needed, but they could try to accommodate the request. Rettig said Artley is not able to pull out necessary data for reports. Artley said her State reports have to go through IT. Rettig asked if Artley has requested a way to obtain the data from IT. Artley said no. The terminology used within MH/DS is unique, and a lot of dialogue is required to convey requests for information. Although State reports are due by December 1 of each year, she begins trying to obtain the information in September. Artley indicated that it take a significant amount of time because IT staff do not understand the terminology used within MH/DS. Rettig said if one employee within IT was assigned to work with MH/DS, they would begin to understand their needs. Stutsman said she thought a specific IT employee had significant knowledge of the system, and she wonders if the issue could be worked out with IT Director Jean Schultz. Rettig said she agrees with Stutsman that IT should be one department and not spread out through the buildings. If there is a communication or work order issue, she thinks it can be worked out during a meeting involving both department heads.
Artley said she is not sure how to handle the contract coordinator position, which was filled by a temporary employee in the distant past. There was no job description at that point in time. Artley said she can justify it being a part-time position but not a full-time position. However, she doesn’t think they will be able to hire someone with the right qualifications for a part-time position. She has considered training a current staff person to complete the tasks, but the only individuals with the potential expertise are non-exempt employees. She doesn’t know how a position could be part exempt and part non-exempt. Stutsman said she doesn’t know if it’s possible, but it would be a question for Human Resources Coordinator Lora Shramek. Artley said it was originally a full-time position, but she cannot justify it.
Stutsman asked if the work could potentially be outsourced. Artley said no. Every client site rate has to be considered to determine whether the budget construction was appropriate. It is then entered into the system and subsequently returned to the appropriate case manager. The individual will need to understand budgeting. Stutsman asked whose responsibilities would be assumed by filling the position. Artley said she has been responsible for the tasks, and she needs some relief. A temporary employee previously provided extra hours when it was time to coordinate contracts because there was no one else available. Although it worked, she is not sure if the employee is comfortable with the work because she doesn’t do it very often. The tasks involve an understanding of the development and approval of rates for providers and development of contracts. Artley said MH/DS is going to do all of their contracts in FY10 because they are changing to a universal contract.
Rettig asked if that position is one of the two Artley has requested for FY11. Artley said it is a different position entirely and has nothing to do with case management. The position will fall under the CPC realm. Stutsman asked Artley to clarify her staffing requests. Artley said she would love to have another case management position in January 2010. One or two of the case manager requests for FY11 would be eliminated. Harney said he thought she was requesting two case management positions. Artley said three were initially requested, but she is willing to reduce the request to one or two for FY11. Rettig asked if that was part of this budget proposal. Artley said it is part of the decision package request, and she was originally building it into the budget. Rettig asked Claiborne if the Board has the decision packages. Stutsman said she doesn’t think so. Artley asked Claiborne if she sent him the decision packages. Claiborne said the information he has is displayed. Artley said the personnel projections went to the Auditor’s Office, and the decision packages should have gone to Claiborne. Claiborne said they will have to check on them later.
Harney said Artley is requesting a half-time position and asked if a job share situation could be utilized within administration to make it a full-time position. Artley asked if he is referring to current administrative staff. Harney said yes. Artley said no, because the department is currently short an administrative supervisor. Harney said he is asking if there is room for two half-time employees, which would equal one full-time position. He then asked if a half-time employee could be used in two different locations. Stutsman asked if he is referring to the half time contract manager position. Harney said yes. Artley said her problem is that it is an exempt position, and the majority of MH/DS staff are non-exempt. There are no exempt staff with enough time to absorb the duties. Rettig asked if there is currently a Public Heath Department employee who is classified as both exempt and non-exempt and asked whether it’s possible. Artley she doesn’t know if it’s possible to work half the day as union and half as non-union. Stutsman said it is a question for Shramek. Artley said she will check with Shramek, but she assumed it wasn’t possible.
Stutsman said Harney asked if there is any other department that has an exempt position available. If so, the two positions could be combined to create a full-time position. The MH/DS position would be complicated, however. Artley said the individual will have to have good mathematical skills, and it will not be a normal social work position by any means. Stutsman said it sounds like it is more of an accounting position. Artley agreed. Rettig asked why the position is exempt. Artley said she was not employed when the job description was written so she would have to ask Shramek. Rettig said exempt status usually indicates that the individual is in a supervisory position, but this position does not involve supervising anyone. Neuzil said it could also mean they are dealing with potentially confidential information. Stutsman and Artley agreed.
Rettig asked if Artley is asking for two case manager positions for FY11. Artley said she will reduce the request to one for FY11 if a case manager position is added in January 2010. Rettig asked if the positions referred to as a case manager. Artley said they are currently labeled social worker II, but they are trying to get the verbiage changed to case manager in the next union contract. Stutsman asked if they would be Medicaid reimbursed positions. Artley said they would be reimbursed for 82%, but the non-Federal share will be 18% since it involves case management.
Harney asked if the positions would be absorbed without additional funding from the County. Stutsman said Artley cannot take any funding from the County. Artley agreed. Rettig asked who would be paying the nonfederal share. Artley said it comes out of the Supplemental Fund within the confines of the MH/DS budget rather than the County General Fund. Although MH/DS is reimbursed for all services, they do have to pay the non-Federal share.
Rettig asked if there is room in the current budget to absorb the cost of two additional positions. Artley said she needs to determine the exact amount of revenues, and that has been a challenge this year because of changes in the State numbers. She only has a draft copy right now, but she is guessing it is fairly accurate. The funding for personnel and office operations are then pulled from that amount. Office operations are fairly moderate due to cost savings related to purchasing in bulk. Any money left is used for client services.
Artley said changes in the percentage of the Federal share are making it difficult to budget for client services. The current rules regarding stimulus funds will only last through half of FY11, and the rates will bounce back up after that. She can project the total cost of a new ICF/MR Program client under normal conditions when the non-Federal share is 38%. However, she needs to apply the Federal stimulus funds to half of FY11 even though she knows it will be eliminated unless the Legislature is able to access more of it. Artley said she was not aware of the change when the budget for FY10 was prepared and did not find out until the last few days of the legislative session. The funding is a tremendous benefit; however, it will not last forever.
Artley said she determines funding for stationary items, including staff and operations first. The money left over is used to determine client services. There is little room for flexibility regarding County funded services. There are some work activities services, community support programs, and vocational services that are 100% County funded. However, the majority of MH/DS services now involve Medicaid. Rettig said 18% is County money. Artley said that percentage applies to the Targeted Case Management program. The County’s share of the services under the Home and Community Based waivers that the State is augmenting with stimulus funds is normally 37% to 38%. The current share is 27% or 28%, but it will not stay that low.
Rettig said there is no way to know for sure that State or Federal funding will be available in the future to cover new positions. Efficiencies created through new software and hardware do not involve ongoing payments as adding FTEs do. She is not sure what the County will do if FTEs are added, and State and Federal funds subsequently dry up. She does not want caseloads to increase to 30 or 40 as the result of having to lay off an employee in the future if the Federal government is unable to balance their budget. Artley said the quality of the program would be significantly reduced by caseloads that large. In addition, issues involving Systems Maintenance clients have not even been addressed. All four intake staff work with those individuals. It is required because they receive 100% County funded services. They are not involved in targeted case management, and no Medicaid reimbursement is received.
Rettig said she would rather have people work hard now and carry a heavy caseload than have to fire an employee a year from now. Artley said MH/DS employees are already working at their maximum capability. With mixed caseloads, case managers can probably handle 33 to 35 cases, but they have already reached that number. Rettig asked how long the client base has been stable. Artley said she thinks additional positions were approved in the spring of 2007 and filled by July 2007. There has been no turnover since the summer of 2008. Rettig asked what changes have occurred with the client base. Artley said it has increased by 100 clients since FY09 so the caseloads of the individuals hired in 2007 were filled. Rettig said Artley indicated in line nine that MH/DS is currently averaging 617 clients per month and the number is relatively stable. She asked how long the number has been stable. Artley said the number has been relatively stable over the past six months due to individuals entering and exiting the system. The unstable component involves the time it takes to complete an assessment, which has increased from four to ten or eleven hours. Rettig clarified that the workload has not remained stable due to the new assessment, but the client base has remained stable. Artley agreed.
Artley again stated that she does not know what to do about the client coordinator position. Stutsman said the Board has discussed completion of a skills assessment for County employees to determine whether departments could share some employees. This may be the perfect opportunity to involve Human Resources. Artley asked if there are any Certified Public Accountants (CPAs) employed by the County. Stutsman said there are some CPAs employed in the Auditor’s Office. Claiborne disagreed.
Harney asked if the work could be contracted out on a part-time basis. Stutsman said she asked Artley that, but she thought there are some private agencies that deal solely with Medicaid billing and contracting. Artley asked if she is aware of some agencies. Stutsman said no, but she thought there were individuals who specialize in that area. Harney asked how many hours are needed. Artley said she thinks 20 hours.
Stutsman said a CPA may not want to work only 20 hours, and she wonders how much money they would need to be paid. She asked Claiborne how much money a CPA earns. Claiborne said a CPA with their own firm would earn approximately $100,000/year. Rettig asked if a CPA is necessary. Artley said an individual with skills of that caliber is needed. Rettig said County Auditor Tom Slockett also thinks the Auditor’s Office needs more assistance with accounting. She asked if the client coordinator position requires the same amount of job expertise. Artley said she doesn’t think she can answer the question because she doesn’t know anything about the accounting functions within the Auditor’s Office. She thinks there are individuals with varying ability levels employed in the Auditor’s Office. Claiborne agreed.
Artley said the position should be filled by someone who understands the mechanics of budgeting and the ability to learn contracting. There are a lot of service providers, and they often call MH/DS to obtain guidance regarding information received from the State. Although some of those agencies have very capable staff, other do not. Harney suggested Artley talk to Shramek to discuss ideas. Stutsman said the issue could also be discussed at an Elected Officials/Department Heads Meeting to determine whether others have similar needs or available staff. She thinks brainstorming is needed.
Artley asked if there is any hope in obtaining concrete figures for depreciation so she can refigure the cost report. She hopes to find out in January whether a monthly unit rate or a 15 minute billing rate will be used. MH/DS case managers will be a lot happier if a change is implemented because they currently have to track time minute by minute.
Stutsman said she thinks the Board needs to direct the Auditor’s Office to report that information to Artley. Rettig said they should be able to report the exact amount if there have been no change orders in recent history. Only about 5% is being held back to ensure the punch items are completed. Rettig said she thought there must be some bills they are unaware of if he was unable to report a number. If Stutsman is right that there aren’t any, she doesn’t understand why the information hasn’t already been provided. Rettig thinks the Board should send the message that Artley needs it now. Stutsman said the Board should seek the information if Artley has been unable to obtain it. Artley said the information will certainly help support the case management rate. Stutsman said she and Harney are Kempf's liaisons. Claiborne said he has an old number from Kempf for the price of the HHS Building in excess of $14 million. Although he is not sure whether that number has changed, he doesn’t know why the number would be difficult to determine. Harney it should involve the cost of the building compared to its life expectancy. Artley said it involves the cost of the building, but she thinks a chart from the nursing profession is used as well. She thinks sidewalks and parking garages are considered differently. Rettig said determining the cost of utilities may be the issue because they may not be able to do so until the building has been in use for a few years. She heard that the geothermal system did not initially function properly. Artley said MH/DS is not being compensated for those things because they haven’t had those numbers since they moved into the building in January 2009. In the past, they paid rent and utilities and worked in the numbers.
Stutsman suggested that she, Harney, Artley, Kempf, and Deputy Auditor Dana Aschenbrenner meet to discuss their needs and how to meet them. Artley indicated that she would like the cost report done as soon as possible, but she needs hard numbers or a formula to do so. Stutsman asked if the first of the week is soon enough to meet. Artley said yes.
Artley asked if there is Board support to move forward with adding a case manager position for January 2010. She wants to emphasize that another case manager would not be hired until there is a sufficient number of clients to support the position. The request would be taken to the Targeted Case Management Advisory Board before being presented to the Board of Supervisors. Stutsman said she is always hesitant to add new staff, and there is always concern regarding the availability of Federal funds. Someone may need to be laid off if the Federal funds are not available in the future. Artley said it is a mandated service, and she thinks they need to take care of the consumers. Services must be provided to applicants who qualify for targeted case management and are Medicaid eligible. There is no choice.
Harney said the Board does not like it when employees are hired out of the budget cycle. Artley said MH/DS staff have been trying to keep up for quite some time, and they are starting to feel the pressure. She thinks a lot of the pressure relates to the new assessment and tracking their billable time. Artley would prefer they spent their time providing quality services.
Artley said as part of cost savings measures over the past couple of years, MH/DS staff have discussed reviewing client needs versus wants. They determine whether there is a medical necessity, functional necessity, et cetera. If funding requests are not being utilized, staff are asked to reduce them because they encumber the system. Artley said they’ve never had a good understanding of the cost of services because large requests were made in the past despite using only about half of the amount.
Rettig said she is supportive of the off-budget technology request because the changes will reduce time spent preparing documents. However, she does have a problem with adding FTEs in the middle of a fiscal year, and she thinks it is a budgeting issue. It doesn’t matter where the funding comes from. A lot of the funding streams are fragile, and she doesn’t have enough confidence in them to add a position.
Claiborne said the Board added an FTE off budget cycle for the Medical Examiner’s Office. Stutsman said she thought the Board did so for Ambulance as well. Claiborne said that decision involved the purchase of a chassis, but an FTE was added for the Medical Examiner’s Office. Rettig said both will be paid with County money so there are no uncertainties regarding funding. Use of Federal and State funds for the MH/DS position make her hesitant. Artley said MH/DS has more than adequate reserves to fund the position. Rettig said she does not support the position. Harney said he doesn’t think the Board is currently making a decision. Artley is making her presentation now and a decision will be made later.
Artley said she does need to know what to include in the budget. She can’t increase the budgeted amount later because she has a set amount of money to work with. She has to deal with the positions before making other decisions. Harney asked when it must be completed. Artley said she needs to know ahead of time because she cannot request positions after the budget has been turned in. Harney said he understands that and asked when her budget has to be turned into the State. Artley said she has the same deadline as the Board and everyone else.
Harney said the purpose of this meeting is to hold a budget hearing and request. A decision whether to approve an out of cycle request would be made at a different Board meeting. Neuzil said he thinks Artley should submit the FY11 budget with the assumption that the additional positions will not be added until FY11 since an official decision will not be made now. If the Board decides to approve a position before that time, they will let Artley know before the final budget is complete. Neuzil thinks Sullivan should be included in the conversation, and the pros and cons of adding a position should be discussed at a meeting in the next three weeks. Stutsman said there is something to be said for spending down the fund balance. Neuzil said it may be advantageous to review the situation in the next few weeks. If the amount of money is as high as anticipated, it may be advantageous to add positions.
Neuzil said Artley should provide the Board with an executive summary of the current and projected numbers of consumers per case manager. Artley said the number is currently at the maximum. Neuzil said it would be helpful to learn about the justification for the recommended number of consumers per case manager versus the average number across the state. Artley said MH/DS case managers have mixed case loads, which means they each serve individuals with a variety of diagnoses. Although some case managers focus on children or senior citizens, there are a variety of diagnoses. Artley believes working with a variety of individuals allows case managers to handle a higher number of cases, such as 34. If all the cases involved individuals with chronic mental illnesses, she would attempt to reduce caseloads to 25.
Neuzil suggested the item be placed on an agenda for a Board meeting during the second week of January. The Board should have received the decision packages by that time. Neuzil said the Board has a fairly good understanding of the amount Artley will be requesting. It can be determined through the MH/DS fund. Artley said she will reduce the request for social worker II positions to two for FY11, based on the analysis of the last six months.
Artley asked if Rettig was previously talking about upgrading the computer system to support the Dragon software. Stutsman said replacing the computers. Rettig said she thinks it’s easier to spend the money one time. She needs a lot more information to justify another FTE. She needs to understand what is happening across the state and to see information regarding case loads in Linn County. Stutsman said there are recommendations regarding case numbers, but she cannot remember them off hand. Artley said she thinks the last email recommended caseloads of 30 to 32. Rettig said there are also recommendations regarding Sheriff’s deputies that the County is unable to meet. Recommendations are one thing and reality is another. It is easier for her to support spending one-time money than money that may not be available in the future.
Artley said the morale within MH/DS was deplorable when she began employment with the County, and she does not want it to return to that state. Rettig said the County is growing in many ways, but they must be able to justify and document decisions. She said Artley asked the Board for guidance, and she doesn’t think she can give that guidance without more information.
Artley said if the new IME protocol for case management billing is approved, she is going to project those numbers and use them for anticipated revenue. She knows she cannot use the number she has today because it indicates they already owe money back. She cannot support last year’s actual number because it did not incorporate any depreciation. Artley said she doesn’t know what the rate will be until another cost report is done. Rettig said the last cost report was done in September 2009 and asked if she can amend it whenever she wants. Artley said yes, but a projected cost report is done to set their rate for the next fiscal year. They were required to complete one based on the 15 minute unit reimbursement rate, and they did before June 30, 2009. Artley said the State methodology was not changed, and they continued to use last year’s rates.
Artley said that is okay for Johnson County because they are getting a lot of money from the State. She hopes it is sitting in the bank drawing interest. Rettig said some banks do not even want to hold the money, and she thinks it is earning almost no interest. Artley said the bottom line is that she would rather give money back to the State than have it owed to the County because she doesn’t know that it would ever be received. Johnson County is in a better position than many other counties who are already at their maximum. Programs in those counties will take a hit if FY08 rates are used while Johnson County’s program will not.
Artley said she will build the hardware purchase into the budget and wait until FY11 for the FTEs for the social worker position. She still thinks she can reduce the number of requested positions if the number of cases remains steady. The number appeared to be increasing when she initially prepared the decision packages. Stutsman said the discussion will be continued in January. Neuzil agreed. Claiborne said the MH/DS budget will need to be revisited on January 11, 2010. Due to schedule conflicts, the Board decided to schedule the meeting for January 12, 2010 at 9:00 a.m. instead. Claiborne said he must have the budget completed by the end of January.
Neuzil said the level of the MH/DS levy will not change because they always use the full amount. The details of the budget will change, however. Claiborne said he will need that information as soon as possible for completion of the State form. Artley asked if they intend to levy the maximum amount regardless of the amount of reserve funds. Neuzil said that is what they’ve always done. Stutsman asked Artley for her recommendation. Artley said it is the decision of the Board. Stutsman said they usually base the decision upon the recommendation of the CPC. Neuzil said they have done so during the nine years he has been a Supervisor. Artley said most counties have reached 100% over the course of time. Stutsman asked for the motivation for the levy, and said it relates to access to State funds. Artley agreed and said it has to do with the formulas and obtaining allowed growth. The Iowa Association of Counties (ISAC) distributed a chart describing how to obtain the money. However, the ledgers have changed over the years, and she thinks they are now at a 10% level. Artley said due to the current state of the economy, she prefers that the County has their own money available to them.
Artley said she agrees with Rettig regarding SPP clients. A group of key people will be pulled together to analyze services that are needed to be humanitarian. However, the changes have occurred so quickly that there has not yet been time to organize the group. Artley said she will count on 100% of the levy and plug that number in. Artley asked if it would be helpful to receive a copy of billing statistics, which illustrate growth since 2007. Rettig said yes.
Claiborne said January 25, 2010 and January 27, 2010 are available to schedule budget meetings. He would like to meet for a general discussion on January 26, 2010 and to review the tally sheet. He will have information on the General Basic Fund, based on the Board’s decisions. Neuzil said he has written down a number of different questions and issues regarding the budget and asked the other Board members to be prepared to discuss situations and potential Board decisions at the budget meeting scheduled for January 26, 2010. He provided examples of issues that need to be resolved, including whether Conservation will submit information to the Board, obtaining the Joint Emergency Communication Center’s (JECC) budget, employee salaries, and bond payoffs. Neuzil thinks they should also communicate with the County Attorney’s Office regarding the Shueyville Road project and attempt to resolve the issue. If there is interest in using general obligation bonds to pay for that road project, the County Attorney’s Office will need to start the process of preparing a contract. In addition, there are questions regarding the payback system and requiring Shueyville to reimburse the County over a period of time.
Rettig asked Neuzil to provide her with a copy of his list since she may not have been present during all of those discussions. Stutsman asked if the lists should be sent to Claiborne. Neuzil agreed and said he will send it to Claiborne. Rettig said it would be beneficial if Claiborne would compile the lists and provide them to the Board. Claiborne said a lot of the items are also included on the tally sheet. Neuzil agreed and asked Claiborne to resend the tally sheet to the Board with any recent changes.
Neuzil anticipates that the MH/DS presentation on January 12, 2010 will take a significant length of time. There will be a substantial lag between that meeting and the meeting scheduled for January 25, 2010. He asked if there is any interest in scheduling an additional budget meeting. Claiborne said additional meetings will be necessary. Neuzil indicated that the schedules of Board members will begin filling up soon. Rettig asked if Claiborne thinks additional budget meetings are needed early or later in January. Claiborne said mid to late January to make final decisions. Although he knows the levy for MH/DS, he needs to enter the information in the software. The Board decided to schedule a Budget Meeting for January 22, 2010 following the Formal and Informal Board Meetings. Rettig asked if another Budget Meeting is needed for February. Claiborne said he needs to begin completing the State form during the last week of January so the budget must be firm by that time. Neuzil said the Board will be able to provide fairly good direction following the Budget Meeting on January 27, 2010. Any additional questions or issues should be directed to Claiborne.
Adjourned at 2:52 p.m.
By Nancy Tomkovicz, Recording Secretary