Lehman: Our next topic is business from Elaine Sweet. Director of Mental Health/Developmental Disabilities. We’re going to discuss the 28E agreement between Johnson County and Iowa State Association of Counties to implement a rate setting process for Mental Health/Developmental Disability providers.

Mental Health/Developmental Disabilities Director Elaine Sweet: I’d like to introduce to you Sue Novack. Sue is the Financial Management Director with Linn County MH/DD services. She has also chaired an effort on the part of the Iowa State Association of Counties and the Central Point of Coordination Administrators Statewide on developing a rate setting process for provider contracting. Please Welcome Sue.

Linn County Mental Health/Developmental Disabilities Financial Manager Sue Novack: Good morning. I do have some handouts. The handout in front of you is an excerpt of a Power Point presentation that I’ve done at the Board of Supervisors Spring School and then also at a state-wide meeting of the CPC’s. Elaine indicated that maybe I should give about 5 minutes of background. Primarily though I’m here to answer any questions you might have relative to the 28E Agreement proposal. As Elaine indicated I am the Financial Management Director for Linn County. I provide fiscal and administrative support to about the 29 million dollar human service component of the Linn County budget. I’m also a Certified Public Accountant and I am the chairperson of the rate setting subcommittee. My purpose today is to share with you some background information relative to the final recommendations coming out of that subcommittee. That subcommittee, these recommendations really represent the culmination of about a years worth of work. It represents input that’s been solicited from Boards of Supervisors across the State, CPC’s, MH/DD providers, DHS and ISAC staff. We solicited this input by the membership of the Committee itself, which included stakeholders from all of those groups I named. But, we also have conducted 2 statewide surveys requesting input. As I indicated, we’ve done 2 presentations to Boards of Supervisors and we’ve had 2 presentations done to CPC Statewide meetings. We also did a presentation to the Iowa Association of Community Providers. Real briefly on the background here, what’s prompting the formation of this subcommittee was the dissolution of the State’s purchase of service system. That system was established in 1970. It was a contracting process, as well as a rate setting process. That purchase of service system will end on June 30th of this year. About 2 years ago, some representatives from DHS, ISAC and CPC’s got together and decided to form a Committee to see if they could come up with a Statewide contract that could be used in lieu of the contract that was done under the old State system. Then, about a year ago, they decided to compliment that contracting process perhaps there should be a rate negotiation process and the subcommittee that I am Chairperson of for them. There is really 6 key recommendations coming out of the rate setting subcommittee. The first is that counties should formalize a rate setting process through membership and a 28E Agreement. That the 28E Board should contract for consulting services. The 28E Board should contract for administrative and fiscal support services. The 28E Board should adopt the proposed cost report form and instructions that is to be completed by MH/DD providers. The 28E Board should adopt the proposed service information form and instructions, which is to be completed by CPC Directors. The 28E Board should adopt the proposed timelines. First, the recommendation for the 28E Agreement is based upon the need to establish and formalize a rate setting methodology. We also felt that it was very important to establish a 28E Board that would have the power to contract for services, but also would have the power to review and revise the proposed forms and procedures based upon the input coming back once the process is underway. It would also establish the responsibilities of that 28E Board and formalize that. It would establish the method for determining membership fees from the participant counties. It would also establish the participant counties responsibilities under the 28E Agreement. The 2nd recommendation was really to contract with a consulting firm. The reason we are calling for that as a subcommittee is we feel that it’s essential that an entity be recognized that could provide training to the CPC’s and to the covered MH/DD providers. We also felt that it was essential that there be ongoing support throughout the process. It’s well and good to launch something with a lot of training and 3 years down the line your CEO changes and you don’t have any way to access that training and support for that new staff person coming on. We also wanted the development of MH/DD provider databases. The consulting firm would verify the accuracy, the completeness and the timeliness with which the reports are coming in from covered MH/DD providers under the process. The consulting firm would issue a unit rate summary report to each of the host counties contracting for services with covered MH/DD providers. This unit rate summary report will include information on actual costs and it will break it down by administration, occupancy, direct staff costs, support costs and other costs. All of these categories are uniformly defined on the cost report. So that when you get an administrative percentage coming in from one of the covered MH/DD providers, administration will mean the same thing across the State and he will be able to compare what percentage administration is of the total costs, for example. The unit rate report will also include key financial ratios. For example, what percentages administration of the total cost of an operation, what percentage is productivity for the various services under the agreement. The consulting firm will also issue the Statewide actual unit rate report. What this will do is, using the information from that service information form, it will enable the consulting form to group like services across the State together. Then, it will be disclosing what the actual cost information is on that for like services. I will talk a little bit more about that service information form in just a minute. The final report would be the Statewide negotiated unit rate report. That again will be coming across the State to all participant counties, grouping like services together. What it will do will be disclosing the negotiated rates that have been completed by the host counties that establish the upcoming reimbursement rate. The subcommittee also recommends that the 28E Board contract for administrative and fiscal support services. We recognize the 28E Board will be a volunteer Board and we feel that in order for the Board to work efficiently and effectively, that they have got to have some paid staff who is actually working for them and reporting to them. We will be looking for contracting some professional support to the 28E Board, including staffing the meetings, analyzing satisfaction surveys coming back from the members, evaluating contract proposals and acting as the liaison to the consulting firm. We also look to get some fiscal support, legal support and clerical support. The 4th recommendation of the subcommittee was that the 28E Board should adopt the cost report form and instructions. It is this cost report form and instruction that actually begins to standardize definitions, standardize units of service measures, standardize the definition of billable units, allows a mechanism whereby counties can gather actual cost data. It defines uniform classification of cost. So, for example, as I had indicated earlier, administration will mean the same thing across the State. Direct staff will be defined and therefore those ratios that are computed relative to the percentage of direct staff will be very meaningful, because they are uniformly defined across the State. Also, we’ll insure some consistent reporting. A lot of counties have individually had to grapple with what is a bed day. Does it include the day of admission? Does it include the day of discharge? 99 counties are probably doing it different ways. It defines things like, if you are a residential provider, should you be billing at 360 days a year or 365 days a year. We’ve got both of that going on. It defines whether or not a billable unit includes, for example, or consumer vacation days and consumer sick days and vocational programs. Again, you’ve got variations occurring across the State. It defines whether or not no shows would be included in a billable day. So, those are just some of the examples of the issues that are addressed and defined within those cost report and instructions. The fifth recommendation of the subcommittee was that the 28E Board should adopt the service information form. What this form will do is it’s a check the box kind of a form that will be completed by CPC’s in conjunction with covered MH/DD providers. They’d actually go down the form checking the boxes. The purpose of checking those boxes is to arrive at a 7-digit code. It’s that 7-digit code then that would be reported in to a consulting firm and that is going to allow the consulting firm to group like services across the State. The things that we are asking folks to complete, so that we can group like services include the type of service, whether it’s residential, vocational, respite for example. The unit of service, whether or not we’ve got an hour, a monthly, a daily, the size of a residential program, if applicable. Is this just a 3-4-bed house or are we talking about a 25 bed care facility here? The credentials of the clinicians; one of the key targets of the rate setting subcommittee was to include community mental health centers under this process if the host county elects to include them. In order to analyze and compare the costs coming from community mental health centers across the State, we had to be able to segregate out the credentials of those clinicians in order to make any comparison meaningful. Then, finally, Staff to client ratios. Very key again. I do performance indicators for Linn County. As I’ve tracked for example, our own in-house programs and vocational sheltered workshop and (inaudible), what I’ve attended to do is reach out and get some key indicators from other counties, other providers across the State, only to find that the definitions are not uniform. What we call work activity, where we’re staffing at a 1-5, someone else is staffing at a 1-12. You would not expect that those costs can be comparable. So, the staff to client ratio is being another key indicator and essential, in order to be able to prepare data across the State. The sixth recommendation of the subcommittee is that the 28E Board adopt the proposed timelines. The timelines are listed in front of you. We have an aggressive batch of things that have to occur. The earliest of those is that the 28E Agreement is targeted to be signed on April 20th. Very rapidly coming. That is our earliest cutoff date. I have spoken with Deb Westfold, who is being tentatively assigned by ISAC, should this agreement come up as the professional support person to the 28E Board. Deb has indicated that what she would like to have is indication from as many counties as possible, as to their interest in joining by April 20th. Obviously she is going to keep it open longer. We know our time lines are rather aggressive. What could happen, if you do not meet with the 20th deadline, would be that included in the mailing that went out on March 16th was a nomination form. Dependent upon when the Board is able to take action and actually indicate a wish to participate in the process, you may or may not be able to have those nominations considered, dependent on where you are at. But, you certainly did not want to preclude participation from anyone, just because you didn’t meet the 20th deadline. The other thing that she has asked me to stress is that we have asked that on the 20th, when you return agreement, that you also return the one time joining fee of $500. Again, don’t let that compromise your ability to respond back to them. We recognize the claim processing time lines involved in the counties and we certainly don’t want that to act as a barrier to anyone. So, most importantly, what she is trying to do is to get the number of counties who may be interested. The other thing I have been asked related to this is, you’ve all received the information in which we actually projected the annual cost of the first year of the 28E Board, including the consulting firm and the fiscal end administrative support. Then, what we did is, we spread that cost to the 61 counties whose CPC’s said they would be recommending to their Boards of Supervisors that they participate in the process. Now, clearly, if we don’t get that membership, there is going to be some movement on those ranges of estimates that were given to counties and some concern had been expressed, especially in our current climate of what is happening with MH/DD funding. What if you don’t get that membership on? Are we going to see potentially these estimates that you gave us tripling? It would be the intent of ISAC that should the fees that have been included in the estimates, move outside of the ranges that were included in your March 16th mailing. ISAC will develop some kind of process to get back to those counties who have indicated that they wish to participate in the agreement, so that you will have some flexibility. You will not just see a tripling of this cost and not be able to do anything about it. She’ll be formalizing that process a little bit later. They don’t have it actually formalized as to what they are going to do. Their main focus right now is to try to identify how many counties potentially do we have on board with this. I will tell you that the estimates that were used were based on actual solicitation of estimates from consulting firms. I’m pretty comfortable with the numbers that were used for the 28E Board. I’ve done many of these. If we’ve got a little bit of variance, it’s coming on those consulting firm numbers. But, we actually did approach 5 consulting firms and had estimates coming back on 3 of them. So, I think that we’ve got some pretty good numbers. Advantages to membership, it establishes a defined rate setting process that will be reviewed and updated by the 28E Board as appropriate, so that this will be a living, breathing document as you will. It hopefully will evolve over time. Standardizes service and unit definitions so that services can be compared across the State. Provides access to technical assistance from a consulting firm. It provides training for covered MH/DD providers and CPC directors. It will provide accurate and consistent information on covered MH/DD providers’ actual rates, their negotiated rates and key financial ratios. What does membership mean to your county? Each county is going to have to analyze that individually and it may mean different things to different counties. It may provide some counties with a level of sophistication and negotiations that would otherwise not be available. I don’t know how active this Board is in the negotiations that would otherwise not be available. I don’t know how active this Board is in the negotiations on reimbursement rates with MH/DD providers. But, I’m very active and I have heard on numerous occasions that, first complaint, you can’t compare me to this. That would be like comparing apples and oranges. Well, you heard me say that we are attempting to make comparability across the State a possibility. But, the other thing I have heard sometimes is, for example, well, my rate is $45 and Joe Blow over hear is $48. So, you’ve got a better deal. Well, again, by the information that will be generated from this process you would be able to respond back that yes, Joe Blow does get at $3 per day higher rate than you, but he is also staffing at a 1-5 versus your staffing of 1-15. So, it gives you a level of sophistication and access to information that may not have otherwise been available to you. It provides an opportunity for counties and MH/DD provides to work together to achieve common goals and improve communications. Linn County has already begun implementation of the cost report form and instructions in our rate negotiations for FY02. One thing I will tell you is, I was a little bit apprehensive and wondered what kind of a reaction I was going to get back from folks. That reaction, quite frankly, has been very positive. I think I’m getting the positive reaction because they recognize this process, even though it has not yet been adopted across the State. They at least recognize this process as having been sympathetic to what their needs are and also having evolved from input that has been received from them. It provides access to reliable information that can be used to make rate negotiation decisions. It provides access to information developed by a credible 3rd party that can be used when discussing issues with the State. It may produce some staff cost savings associated with the development of processes and analyzing cost reports. In conclusion, I am encouraging the counties to give serious consideration to participating in the proposed County rate information system. The system becomes stronger with each additional county that is willing to participate in the process. If there ever were a time or a climate in which the counties should be working together I would say that that time and that climate is now. Especially giving what is happening with MH/DD funding. By joining together, by adopting a standardized process to develop rates and by having access to reliable cost information prepared by a credible 3rd party, the counties’ influences with MH/DD providers and with the State should be enhanced. That’s kind of your overview. I’m certainly ready to answer any questions you might have.

Lehman: Does the Board have any questions or does Elaine have any information you’d like to…clarifications we need on our behalf?

Sweet: I would like to add a couple of things. First of all, Johnson County is in rather a unique situation again, in that we have so many providers whose home office is in Johnson County. So, this process has implications for a lot of other counties in addition to Johnson County. Most counties recognize the rates that the host county negotiates, which makes our rate negotiation and our contracting process more important to the other counties as well as to Johnson County, and makes it more complicated as well. We are unique in that we have over 15 provider agencies that we are host County for that are located in Iowa City. Scott County has only 3. Most of the counties that they contract with are outside of the Scott County area. The contracting, this contract and rate setting process kind of combines a lot of the things that we have been talking about in setting goals in both CQI and Finance Committee. If you take a look at the goals that have been established in our services management plan, this process kind of puts them all together and at a very reasonable cost.

Lehman: Would these expenses be run through your budget?

Sweet: Yes.

Stutsman: So, what are we talking about Elaine? Are we talking about $6,300 plus the $500?

Sweet: There is a range depending on which consulting company is chosen and…

Novack: The range for Johnson County was 63 up to 89 and there would be an additional $500. You are correct Sally.

Harney: How many counties are actively involved with this right now?

Novack: I did a presentation at the CPC meeting, and few of the counties have actually taken action on the proposal yet. We’ve had a showing of about half the hands there from CPC’s who were in process of actually recommending adoption to their board and had discussed it, and so the process was underway. Most have not concluded. I’ve only aware that Linn County has signed an agreement and sent it back.

Stutsman: Elaine, could you do this, yourself? How much time is it going to take?

Sweet: I’ve been trying to, not to this degree, but I’ve been trying to do a lot of these things. Last year was the first year that we actually put together a formal contracting process and tried to look at rate-setting. I can’t tell you how time-consuming it is. Also, the number of questions that need to be researched, and when Sue talks about comparing apples and apples, I can tell you from experience that that’s very difficult. What I tried to do last fall was start putting together just within Johnson County a document that takes a look at the things that Sue was talking about, units of service and staffing and the rates. It’s very, very difficult. One of the things that has been on my plate as wanting to begin to do as well is to actually define the services. What one provider calls SCL services and charges $35 an hour for can be very, very much different from what another provider calls SCL services and charges $40 an hour for. So, the standardization, in and of itself, I think, has very important implications.

Novack: One thing I would mention, too, Sally, is this system is designed, really, from the bottom up, in terms of who has the ultimate authority, because the authority will reside with the host county in terms of negotiating rates. The authority to determine who will be a covered MH/DD provider under this process also resides with the host county. We wanted to design a system that was flexible enough, that could address issues from MH/DD providers. Some of the MH/DD providers are not sophisticated enough in their accounting systems to be able to come on to this system in the initial year. That doesn’t mean, then, that they would never come on. It means that working with the host county, maybe they’ll come on to the process in years 2 and 3 of the proposal. So a lot of flexibility and ultimate decision-making resides with the host county in terms of who will be covered under the agreement, and then the timing with which those providers would come in under the agreement.

Thompson: So the host county would make the contract and set a rate, based on information received from the 28E agreement, and then other counties would agree to use that same rate? Is that how it would work?

Novack: The other participant counties would agree to accept rates that are negotiated by the host counties, under the proposal, but our definition of host county is somewhat broad. For example, Goodwill, operating in your county, is also operating up in Linn County. Because of our definition of host county, which is that if you have a separate program you run separate offices out of a county, I also will qualify as a host county for Goodwill Services. What will happen in that case, then, is if I believe it’s in my interest to work jointly with Elaine, we could together negotiate with Goodwill, or, because we both qualify as host counties because we think the programs are different, we may elect to individually contract. Then, any participant county who has a consumer in Johnson County would accept the rate that Elaine has negotiated, and if another county has a consumer residing in Linn County for our programs, and we have a different rate, they would accept the rate negotiated by Linn County.

Sweet: One of the things that will be very important to use in negotiating rates is the cost report. In the past, we’ve had a financial and statistical statement through the POS system. That won’t be there following June 30th of this year, so a standardized document where everyone is recording and reporting costs universally will be important to be looking at the rates as well.

Thompson: The Purchase of Service system has had a number of problems over the years, and this does seem to address most of them. It really does look like a grass roots, bottom up effort. One thing I wondered about was, the state had a rather elaborate system at one time for monitoring the contracts and making sure that providers met the terms of the contract. Is that included in here somewhere?

Novack: At this time it is not. The rate-setting subcommittee came up with a laundry list, if you will, of issues to be referred to the 28E Board. One of those issues is whether or not the scope of services from the consulting firm should include some kind of a service monitoring mechanism. But to initially get the process off the ground and get us rolling, we decided to defer that issue to the 28E Board for consideration.

Lehman: I envision a situation where we are the host county but we’re dealing with a county who has not signed up in this program. They would not recognize the charges, but I think you’re still in a better situation to say the state, this organization has recommended as we feel we were in line. I think it would only solidify your negotiations with another county, even though that, not all counties buy into it and stuff.

Thompson: I was wondering about that too. How will you deal with a county that doesn’t participate in the agreement, and privately negotiates a lower rate? Will the other counties have to make up the difference, or will the provider agency have to eat that?

Novack: I think part of that’s controlled by your own rate-setting process. I know in Linn County, when we are a primary purchaser of services, we usually include in our contracts language that says you will charge no other county less than you are charging us. Now, clearly, you don’t have that kind of power or authority to do that when you’ve got one lone consumer sitting someplace else. This process actually gives me some clout by being able to piggyback on, now, to those host counties. To the extent that the particular service I’m purchasing is in a county that is not electing to participate in this process, then I’m in no better off or worse shape than I was previously, which means every person for themselves, as they attempt to negotiate the best deal that they can. In Linn County, what we have done is that we have been piggybacking on host county rates, so I would anticipate that even if they weren’t members of this, we would piggyback on what they’ve done. But again, each county will need to make that decision; there’s nothing binding relative to that.

Thompson: To me, the real advantage of this is we have no way to set rates that are consistent with other counties, unless we do it jointly.

Stutsman: I think it’s money well-spent. It’s more money out of a strained budget, but I think in these circumstances I think it’s a good way to go.

Lehman: This will provide a real mechanism for, maybe, making better use of Elaine’s time, or anyone on her staff who has to deal with this. It’s not a given, but here’s our charts, here’s our rates, rather than sitting there trying to negotiate every individual case. It would really have the hands-on experience, I think, but like Sally’s saying, my gut feeling, and only Elaine could tell me, and this would only be after the fact of what do you gain from this. It’s one of those things, how do you measure something that doesn’t happen again? If you didn’t have to sit down and negotiate these, it’s hard to put a dollar figure on something you didn’t have to do.

Stutsman: Should we put it on for next Thursday for sign the agreement?

Lehman: Is that the consensus of the board?

Stutsman: It’s going to be after the 20th, but…

Thompson: Elaine, you are recommending that we do this, right?

Sweet: Most certainly.

Stutsman: Thanks for coming down, Sue.

Novack: Thank you.

Thompson: Yes. Nice job.

Stutsman: Nice presentation.

Novack: Thank you.

Lehman: Our next item of discussion is Mental Health and Developmental Disabilities Service waiting list. We kind of touched upon this in our earlier discussion, and we wanted to assess our Mental Health and Developmental Disabilities discussion the other night, which the Planning Council, which is an advisory board to the Board of Supervisors.

Sweet: I’ve copies for your reference selected pages from Johnson County’s Services Management Plan, as approved by the state division of MH/DD. The first section talks about financial accountability. On page 11, there’s a statement that the Director of MH/DD Services will monitor the county’s expenditures on a monthly basis. When the county’s projected annual expenditures exceed the MH/DD services annual budget allocation, the director will recommend that the Board of Supervisors approve implementation of the following budget neutrality measures, the first being waiting lists implemented for all eligibility groups and all services, with exception of emergency and entitlement programs. As of March 31st, we are projects annual expenditures for MH/DD Services to be in excess of the budgeted amount. We have a fiscal year 2001 budget at $8,228,051, and projected expenditures at $8,771,913, which is approximately half a million dollars over budget. We discussed at Planning Council on Tuesday, implementation of the waiting list and the recommendation comes to you from Planning Council that the waiting list be implemented. Also in the packet that I gave you is the waiting list policy that begins on page 37. I’d like to point out a few specific items in that policy. At the top of page 37, the second paragraph… First of all, the first paragraph just repeats what we reviewed on page 11, but the second paragraph then goes on to say, when MH/DD Services funds are fully encumbered for the fiscal year, a waiting list will be maintained for persons currently in services who are requesting additional or more costly services. That assumes that persons who are currently in services will continue at the same level, and that requests for additional or more costly services would go on a waiting list. It also states, in the middle of that page, that a service coordinator, which would be a case manager or a social worker, will maintain a minimum of monthly contact with any consumer who is on Johnson County’s MH/DD Services waiting list. The reason for that being to be sure that we are monitoring anyone who is on the waiting list to be sure that their individual circumstances are not reaching a level which would be considered emergency or crisis. At the top of page 38, we have identified the emergency and entitlement services. Requests for emergency and entitlement services will be funded when all other eligibility criteria are met, irrespective of an implemented waiting list. So, even with a waiting list in place, those emergency and entitlement services would continue to be approved for funding. Planning Council, on Tuesday evening, recommended full implementation of the waiting list, and I’d like to have a little more discussion on that. The service priorities that begin on page 38 talk about all services for all persons, including those who are currently in services, and were we to implement the waiting list as it’s stated, it would mean that we would stop funding everything as of the date of implementation of the waiting list. I would like to suggest that we take a look at implementing a partial waiting list, with the intent that we will most likely be expending funds out of the carryover MH/DD fund balance by the end of this year. If you’ll look on page 41, I’d like to concentrate first of all on looking at numbers 7-13. This section begins by saying the service priorities will be invoked in ascending order when a waiting list is implemented, which means we would start at the bottom and would work up. If you look at 9, 10, 11, 12, and 13, those are all beginning services, so that means that anyone who would be coming in and requesting to begin services would go on the waiting list first. Number 8 talks about continuing treatment services for those with non-severe illness or less significant disability, and I would suggest for those who are currently in services for the continuing treatment services, that we work with the service coordinators and with the professional review committee that’s being organized, to determine those with non-severe illness or a less significant disability. The statement at the bottom of the page supports that; it says that severe illness and significant disability will be decided by a professional team of qualified mental health and mental retardation professionals. As we’re working with that team, it is my intent to include a consumer, case manager, social worker, service coordinator, whatever terminology you wish to use, as a member of that professional team for that specific case that we’ll be addressing. Moving upwards, then, numbers 6 and 7 are also beginning services, beginning residential services and beginning personal and environmental supports and vocational services, and I would suggest, too that that be implemented. Moving up from there, though, you’ll find that, with the exception of beginning treatment services for persons with severe disabilities, that all of the remainder of the waiting list policy addresses continuing supports. Again, it would be my recommendation that persons who are currently in services maintain the current level of services, and that the waiting list be implemented for beginning services.

Thompson: The daily implementing of the waiting list, everyone, all new clients and all requests for additional services go on the waiting list. And this list that we’re talking about now is the, sort of the order in which people would be reinstated, or given services?

Sweet: Well, this particular section of the plan is one that has been identified as one that we need to work on and amend, but it begins by saying service priorities will be invoked in ascending order when a waiting list is implemented. Your question as to, if it would be implemented as we’re going off the waiting list, I believe that that was the original intent and I was not party to the discussions when this policy was adapted; it’s a carryover from the original plan. But it’s my belief that the intent was for this to work in both areas, because we talk about the continuing services as well.

Thompson: Well, I was working off of the statement in the prior page that says that once a waiting list is in place, that it’ll be reviewed on a monthly basis, and then I was thinking, well, if in a future month you discovered that there was some money available, but not enough money to get rid of the waiting list, then this would be the order in which you would consider new clients.

Sweet: Right. But in that case, I would think it would go in the reverse order. And it doesn’t…I didn’t…I don’t find where it says that.

Thompson: I remember when we discussed this in the Continuous Quality Improvement Committee, we talked about recommending that the whole thing be taken out, and that the decision of the interdisciplinary team be substituted for this. Because I think the comment was made in the meeting the other day that the cases are so individual, that to have a list like this just probably is going to be unfair to someone.

Sweet: I believe that we do have the flexibility within this policy to be sure that emergencies are identified, and that those needs are met.

Lehman: Can we do that without doing some type of amendment? Interpretation, I think, is what we’re talking about here.

Sweet: I think the flexibility is there within this plan, but I also think that we need to continue the amendment process, with regard to this waiting list policy section.

Thompson: It appears that the decision about who comes off the waiting list in what order is ultimately up to you and our plan. So maybe you could administer it with the interdisciplinary team by telling them to consider these priorities when they make recommendations to you.

Sweet: Right. And if you go back to page 11, there’s a statement…well, there are a couple of statements on page 11…well, one… The second item under the financial accountability budget neutrality measures is that individualized service plans will be reviewed by the interdisciplinary team in an effort to identify more cost-efficient services to address each consumer’s needs. We’ve already implemented that, and we’re in the process of doing that. I think that allows some flexibility for us, as well. There are general statements throughout the plan, however, that allow for administrative exceptions, and give the CPC director the authority to make administrative exceptions on an individual basis, as necessary. That, certainly, is something that I feel comfortable in doing, with the assistance of the Professional Review Team, and I think it’s very important that there not be one individual that’s making all of the decisions. I am putting together that Professional Review Team at this point in time, and it will be a team of clinical professionals, not administrators. It will be clinical persons, who are familiar with persons with mental illness, mental retardation, developmental disability, and brain injuries, that will meet and consult on the difficult cases. If there’s a question as to whether or not it is a crisis and emergency and urgent need, it will be that team that will be reviewing the case and making a recommendation.

Stutsman: So you said anybody that’s getting current services will not be cut back.

Sweet: If they’re currently in services, it would be my recommendation that we not discontinue those services, other than within the policy statement on page 11 that talks about the workers, it talks about individualized service plans reviewed by the interdisciplinary team, to identify more cost-efficient services. We implemented that several weeks ago. We’ve had the service coordinators working with the interdisciplinary teams and the consumers to identify those places where cost-efficient services might be identified.

Neuzil: And that funding would come from, that’s assuming that we would have a carryover balance, which might be taken away through the legislature.

Sweet: The MH/DD Services fund balance at the end of last fiscal year was just over $1.1 million. If we do nothing and continue to spend at the same rate that we have for the last 9 months, we’re projecting that we will overspend by just over a half a million dollars this year. So that half million dollars would come out of the $1.1 million fund balance at the end of last year. If we implement the waiting list as we’ve just discussed, that will lower the projected expenditures. We won’t continue to bring people into the system at the rate that we have. We won’t be approving new services other than the emergency and the entitlement, so it’s likely that if the waiting list is implemented, that that over-expenditure will be less than the half a million. But whatever it is, it would come out of the fund balance.

Harney: Is there prioritization as to someone that may need services more than someone that’s already on the list, or do you just…you mentioned you’re going to use the ones that’s on the list…or are getting services now have priority. Is there a way of going through that and trying to see who may need help more than someone else?

Sweet: Other than emergency and entitlement programs, it’s not clearly stated that we would do that. However, that professional team of, or the professional review team could certainly be looking at that as well. I would anticipate if a waiting list is implemented, that it will probably be there for the remainder of this fiscal year. July 1st, we’ll have new funding. If you take this in context with the earlier discussion, though, on the proposed budget cuts for fiscal year 2002, we have a problem of significant magnitude. We’re projecting overextending this year’s budget by half a million dollars if we don’t implement the waiting list. That will probably project into next year as well, so over a 15-month period, we’re projecting over-expenditures of one million dollars. At the same time, the legislature is proposing cutting our revenues by anywhere from $72,000 to $1.1 million. The worst-case scenario, the way it appears right now, if it were the $1.1 million, that would mean an impact of $2.1 million on MH/DD Services budget over the next 15 months. There’s no way that there is $2.1 million to find in our MH/DD Services budget without hurting people, without declining funding for persons who have significant needs. This is not a position that any CPC wants to find themselves in. Unfortunately, this is happening across the state.

Harney: Will this prioritization offset that half million that you’re talking about?

Sweet: I don’t think it will. Right now, we only have 2 months left in the fiscal year. Had we implemented this earlier, last fall, even January, we certainly could have come closer. No, I don’t expect to have a half a million dollars impact in the remaining 2 months of the year.

Harney: I didn’t think so.

Sweet: I think we need to realize that we will be expending out of our fund balance.

Neuzil: Yes.

Sweet: Unless we actually start cutting people who are currently in services. If we want to have that discussion, then we can certainly do that.

Thompson: I still feel like we need an answer to the cash versus accrual question that I asked at the meeting on Tuesday. Do the numbers that you’re using to calculate the overage include people that we paid for in this fiscal year who would have been accrued to last year?

Sweet: The numbers that we’re reporting are on a cash basis.

Thompson: (Inaudible).

Sweet: So anything that was paid from July 1st forward, that would be the case. If you want to look at an accrual basis, whatever we paid after July 1st that was attributable to services before July 1st should be subtracted from that amount. But, on the other side of it, then, anything in the coming July, August, September that we pay for, for services provided in April, May, and June, would have to be added. Our accruals have been fairly consistent over the last few years. They run $600,000 to $700,000 in accruals. So on one end you subtract, but then on the other end you add.

Thompson: I just wanted to make sure that the numbers that we’re looking at apply the same calculation to both ends of the year.

Stutsman: Do we need to take formal action, then, to implement the waiting list?

Sweet: This is on the informal agenda today, and I don’t know if you can. If you can, it would be my recommendation, but…

Stutsman: No, no, I mean do we need to put this on for next Thursday?

Sweet: I would recommend that you do that. But I would recommend that we put a moratorium on, effective today, on processing new applications, pending your decision next week. I think by doing that, we can be reasonably assured that the routine processes are in place, and if the announcement is made today that a waiting list might be implemented next Thursday, I want to avoid any perception that there was any manipulation in presenting requests for funding, and in any way influencing the way the routine system has been working. One of my other concerns is the summer program, the children’s summer program. The familiar name for it has been Teenplace. That program, we’ve spent extensive time working on developing that program. We have, I think, in the neighborhood of 25 or 30 children that will be participating, that plan to participate in that for the summer. 2 agencies have invested a lot of time and energy and made commitments for building space and for staff to present that program for June, July, and August. Last year, that program, the total for the summer was approximately $65,000. I would like to suggest also that we proceed with funding that program this summer. There’s 3 weeks in June, not quite 3 weeks in June, that would fall under the current year, and then the remainder of it would go into the next fiscal year, when there will be funding available again, on July 1st.

Thompson: I would certainly support that.

Sweet: These are families that have been planning their summers and depending on that. We have children with significant needs that will probably be in very serious positions if that summer program doesn’t continue this summer.

Lehman: I guess I don’t want into setting priorities right now, but what dollar amount does that usually…

Sweet: It was $65,000 for the entire summer last year, but that’s spread over 2 fiscal years.

Neuzil: Maybe that needs to be a part of this as well, in the sense of trying to…particularly ones that are split within fiscal years. As we do all these things, it seems to me that we should continue to…the process, at least, of looking at what’s working and what’s not within this plan. Let’s face it, this plan was written at a time when times were very good, and I don’t think a lot of people anticipated that this time would ever happen, and we’re here. So, I hope that that process continues in regards to making changes to the waiting list, if that needs to be taken.

Sweet: My staff meets weekly, and we are in the process of identifying areas that we can be taking a look at. I, too, am reviewing the plan, and there will be certain policy areas that will be on the agendas for the May committee meetings, with regard to plan revisions and suggestions for some of the things that we might do.

Lehman: OK. According to the Service Plan, the Board of Supervisors do need to take formal plan to implement the waiting list. What about the other 2 steps, the individualized service plans, does that need to be acted upon, too?

Sweet: That’s in process, but that’s an internal departmental procedure that has been implemented.

Lehman: OK. It doesn’t need Board action for that?

Sweet: No.

Lehman: Do I have consensus to put on the waiting list, to Action/Discussion next week, as Elaine presented it to us?

Harney: Yes.

Neuzil: Yes.

Harney: Do we have to do anything as far as the moratorium she asked about? Should we do that now, or does that have to wait until next week?

Thompson: I don’t think we can . We can’t take action today.

Stutsman: No.

Sweet: You can’t.

Neuzil: No.

Lehman: No.

Thompson: That would have to be an administrative decision that you make.

Sweet: I believe I will do that as an administrative decision.

Lehman: OK. We’ll look to that for next week, then. Bob Welsh, do you have some comments?

Bob Welsh: My question is, is Elaine proposing that the waiting list start with priority item 6 and 1 through 5 (inaudible) waiting list, or is it (inaudible). I wasn’t clear on that.

Sweet: I’m recommending that we implement the waiting list beginning, that section is introduced by saying service priorities will be invoked in ascending order when a waiting list is implemented. I’m suggesting that we implement it at number 13 and work up through number 6.

Lehman: I think I heard Elaine’s opinion was that she had flexibility without doing amendment, those in ascending order, so…

Welsh: So there would be a waiting list, practicality for 1 through 5?

Sweet: At this time, that’s my recommendation.

Thompson: You mean people applying for those services would automatically get them, without being put on a waiting list?

Sweet: The only new application included in that is number 4. The rest are all continuation of services. Were we to implement the waiting list as it’s written right now, the day of implementation, we would stop funding for everyone in every service; there would be no additional expenditures other than the emergency and entitlement. I’m not proposing that we do that. I’m not proposing that we take persons who are in non-waiver SCL and give them 30 days notice that their funding ends on a certain date.

Lehman: OK. We have direction there, next week?

Neuzil: And, as far as communication goes, in regards to letting our service providers and clients know what’s going here, what do you plan on doing?

Sweet: I have a meeting scheduled at 2:00 this afternoon with the service providers, so that I could share with them the discussions this morning.

Neuzil: Great.

Sweet: The individual case managers are fully aware of the problem and they are addressing their individual clients on an individual basis.

Thompson: I guess since we have press here, this is a good time to reiterate that continuing services would continue, and that no one would have their service dramatically cut.

Lehman: OK. A difficult subject, but I think we’re on course there to take responsible action.

Stutsman: We’re doing what the plan has laid out.

Sweet: We’re doing what Senate File 69 intended.

Lehman: OK. Next item is Discussion/Action Needed, Mental Health/Developmental Disabilities Service Management Information System.

Sweet: Just a few minutes to talk about the management information system that we have been studying and that we continue to look at. First of all, I’d like to clarify that under no conditions would I even be continuing this in the financial situation that we’re dealing with were it not for additional one-time revenues that have come in this fiscal year that can be used for this project. I think it’s very important, not only as we address the current situation, but the long-term funding implications as well, that we design our services management plan, and Johnson County’s system so that our income, our ongoing income, is balanced with our ongoing expenditures. This current fiscal year, we had a targeted case management quality assurance initiative that generated almost $200,000 in unanticipated revenues for MH/DD Services. I think it’s also important when you’re looking at funding cuts and making decisions that impact people so dramatically, it’s so important to have timely and accurate financial and statistical data to work with. One of the reasons we were not able to identify problems quite as early in the past is that most of the things that we do are done manually, and we’re very dependent on staffing levels and our ability to generate those numbers manually. So we do continue to look at a management information system. This too was addressed at Planning Council on Tuesday evening. We will be collaborating with the county-wide financial software group to look at the system that the county is looking at, and we will continue to look at the needs of MH/DD Services as well. We’re putting together a task force that will identify the specifications for an MH/DD Clinical and Financial Information System, and we’ll be bringing more information back to the Board on that.

Lehman: OK. As that develops, we’ll wait to hear from the task force. Any questions for Elaine on that? We have heard that discussed at the Planning Council, so, and had a demonstration from one source. OK. Anything else, Elaine? I guess that’s enough, but appreciate your efforts.

Sweet: Thank you.

Harney: Thank you, Elaine.

Neuzil: Thank you.

(Continued in Part 3)