MINUTES OF THE INFORMAL MEETING OF THE JOHNSON COUNTY BOARD OF SUPERVISORS:
SEPTEMBER 23 AND 25, 1997
TABLE OF CONTENTS
Chairperson Stutsman called the Johnson County Board of Supervisors to order in the Johnson County Administration Building at 9:02 a.m. Members present were: Joseph Bolkcom, Charles Duffy, Jonathan Jordahl, Stephen Lacina, and Sally Stutsman.
Stutsman: Review of the formal minutes of September 18. Any comments or discussion? We'll put those on then for Thursday.
Mary Kathryn Wallace: Senior Center Update
Stutsman: Business from Mary Kathryn Wallace regarding Senior Center update. Good morning.
Mary Kathryn Wallace: Good morning.
Lacina: Good morning.
Wallace: It's always a pleasure to report back to you. My first item is to tell you that we celebrated quite recently our 16th Anniversary of the Senior Center with a picnic at City Park. It was well attended. It was sponsored by First National Bank and we had 230 people that had a happy time and good food together, and entertainment as well. On a more businesslike item, we are in the midst of HVAC heating ventilation air-conditioning renovation. It's very needed at the Center. Our heating is quite uneven in the building and it has been reported that our energy efficiency keeps dropping. We have an item to be discussed then and voted on, decided by hopefully tonight, with City Council for a contract that has been submitted for necessary work that needs to be done for HVAC renovation. We are also replacing the fitness room floor and that is currently being done, so replacing and insulation is happening right now. Lastly, I want to again inform you and cordially invite you to the town meeting that we will be having at the Senior Center on October the 22nd from 3:30 to 5. We would like a representative of the Board who would sit at the head table, but we would love to have every Board member there to attend the meeting. It is a town meeting. It is open, so this is a good opportunity for you to be the ears that I'm not when I'm not coming here to report to you. So that's an opportunity.
Bolkcom: Great.
Wallace: Those are the items of current business that I wanted to bring to your attention. I'm happy to entertain any questions and if I can't answer them I certainly will make sure that an answer is provided. Do you have any questions?
Duffy: Is there going to be any agenda at the town meeting? Or just anything you want to talk about?
Wallace: I think there's some loose structure in opening comments, but I think then the agenda is open. We have a moderator and we want a head table with some brief opening comments and then open it to the meeting. That's my understanding from the last meeting I attended.
Bolkcom: Sounds good. It's a good forum for people to come out and talk about ways to improve the Senior Center and services provided there.
Wallace: Yes it is.
Bolkcom: It's a good idea.
Lacina: Is Charlie going to be our representative then?
Bolkcom: Yes.
Stutsman: Charlie is going to be.
Wallace: You will be the representative Charlie?
Duffy: Yes.
Wallace: Great and again, as I said, all of you are invited. We're very happy that you're attending to represent the Board Charlie.
Duffy: Thank you.
Wallace: Thank you.
Stutsman: Thank you Mary.
Bolkcom: Great. Thanks for coming.
Stutsman: You always give such a good report.
Wallace: Oh, thanks.
Stutsman: It's good to hear from you.
Bolkcom: Good luck with the energy improvements. It's a good thing to do.
Wallace: Yes. Yes it is. Thank you.
AMBULANCE DIRECTOR MIKE SULLIVAN: 2ND REVISION OF PATIENT CARE PROTOCOL
Stutsman: Business from Mike Sullivan, Director of Johnson County Ambulance Service and this is regarding patient care protocol. Good morning Mike.
Ambulance Director Mike Sullivan: Good morning.
Bolkcom: Good morning. You might want to swing that mic around so we can pick you up.
Sullivan: Yes. I sent a copy of the protocols up last week. Again, this is another revision we've made. This is the 2nd revision from the original protocol. The 1st revision was 1993. This one was prompted because of some State law changes. We finished this, this 6 month project is finally done. Again, as to resolution I'm asking the Board of Supervisors to review and approve the protocols for patient use at the Ambulance Service. The committee that we put together to do this is the same type of committee that I put together in 1993 and it consisted of staff paramedics, a field supervisor paramedic, and the Medical Director, and myself. So obviously, we've gone through and edited the draft numerous times and sent the final copy through. They are printed and they are completed, just awaiting your signatures, and when that's completed I'll have the Medical Director sign it. I didn't know if you had any questions. Really the only significant change in the protocol is a statewide effort to remove a certain medication from the treatment modalities and we've done that and that's being done statewide. The only other significant change is just in the format and the layout of the manual in that this time I incorporated the pediatric or the infant and child care modalities or treatment therapies into the adult sections as well. So it's one manual instead of 2. This is what the State has adopted from our plan in the past.
Bolkcom: So Mike, from your revision and our approval does this get submitted onto the State or does it go on to anywhere from here.
Sullivan: We always keep a copy on hand for the State when they do on-site audits and they review that. The State no longer accepts, they used to accept these, they no longer accept them, probably the mounting paperwork. But I do send documentation to the State of Iowa about the changes that we've made here and the State has adopted their own statewide protocols. We meet and exceed everything the State does, of course. So they already know that, but it will be kept on hand at the Service for the State EMS Coordinator when they do an on site.
Jordahl: You said that the State had adopted this from us in the past, did Johnson County create something that the State found useful?
Sullivan: In 1993 when we made the first major revision in the treatment protocols at the Ambulance Service, there we certain procedures that this Ambulance Service performed that were not being performed statewide. So they've adopted some of these procedures and that started in 1993. Of course, I get calls from all over the Midwest, all over the country for that fact, to have copies of our protocol manuals sent to these agencies so they can try to adopt some of the things that we have.
Jordahl: So this is actually a big deal, this being revised is a...
Sullivan: It is. There is no doubt, it's the most comprehensive patient care manual in the state and one of the most comprehensive in the country.
Jordahl: Wow, congratulations.
Sullivan: Thanks.
Stutsman: It went through the Labor Management Committee and they approved of it or...
Sullivan: This is one thing we don't put through the Labor Management Committee. We establish a Protocol Committee and that consists of labor, and a field supervisor paramedic, myself and Dr. Huss. There is a group of 6 of us on that committee. We go through this page by page, make any changes that we feel are necessary, or any changes that would be required by Iowa law, from the Bureau of Health. That's how we really come about. Then the formatting is basically a decision we made as a committee. Then, it's my job to see that that gets done.
Lacina: But this is going to involve, in the early 90s when we started doing some sophisticated tracheotomies and stuff, the procedures and types of rules and regulations for that right? These are medical protocols?
Sullivan: Correct. Correct and it's sectioned out.
Lacina: It's really not something for labor to negotiate. It's care of the...
Stutsman: No, but they're aware of it and they're involved with the protocols and stuff.
Sullivan: Right. The way I like to do this in the beginning is send out a memo to the staff and ask the staff paramedics to submit to me any suggestions that they have on changing that. Of course, the ultimate decision is the Medical Director's. So we make those initial revisions, bring it to the committee, the committee reviews it with the Medical Director, at that point then the committee will make the decision, with Dr. Huss's approval, what we will and won't do and how we will and won't do it.
Stutsman: Yes. I think it's a good procedure how the whole thing is put together.
Sullivan: Yes. It works very well.
Stutsman: It's just not the Ambulance Director saying this is how we're going to do it.
Sullivan: Oh, no.
Stutsman: It involves everyone.
Sullivan: Actually most of the actual decision-making and the thought processes that go into this come from the staff paramedics.
Stutsman: Uh-huh. Good.
Bolkcom: Good work.
Stutsman: Yes. So if there aren't any... Steve did you have...
Lacina: Thursday, we'll vote.
Stutsman: Yes, I was going to say if there aren't any other questions or whatever we'll just put this on for Thursday and get it taken care of then.
Sullivan: Fine. Once that's done I'll have that page back in the original manual and then I'll send that up to you folks.
Bolkcom: Very good.
Stutsman: Sounds good.
Sullivan: Thanks.
Stutsman: Thank you Mike.
Lacina: Good work Mike.
Stutsman: Business from Dr. Craig Mosher, Director of Mental Health/Developmental Disabilities Services for Johnson County. The first item is discussion regarding the contract with ARC of Johnson County for services.
Mental Health/Developmental Disabilities Director Craig Mosher: OK.
Stutsman: Good morning Craig.
Mosher: Good morning. I wonder if we could shuffle the order slightly since Jeff isn't here yet.
Stutsman: Oh, sure. OK.
Mosher: The Hillcrest folks are here.
Stutsman: So should we talk about the contract for Hillcrest Family Services first?
Mosher: Yes, we should do that one first.
Stutsman: OK. No problem. Craig do you want to introduce who you have with you?
Mosher: Yes.
Stutsman: Thank you.
Mosher: Stacy Gray is a Therapist with Hillcrest Family Services. I think you all know Anne Armknecht, right?
Stutsman: Uh-huh.
Bolkcom: Good morning.
Mosher: As you know, we've been working on a number of contracts and this is just 2 additional ones that we need to do today. As we've switched from block grants to fee for service we've needed to do some of these. As new services become available we also need to work out a professional arrangement for providing that service. So we have some written documentation on what it is that we're purchasing and what it's going to cost and so forth. So there are 2 services which Hillcrest is proposing to provide which we would like to purchase. One is psychotherapy service to do outpatient counseling. The other is a recreation service. Maybe if I could have Stacy briefly describe the psychotherapy service.
Hillcrest Family Services Therapist Stacy Gray: Sure. This service is intended to provide direct goal-oriented structured therapeutic services to individuals who are diagnosed with mental illness. As well as providing group services to people. We have some of those going. Also to provide some family intervention for families who may have a family member who has a mental illness.
Mosher: Would you say a word about the group that you're developing for borderline personality disorders. It's kind of a specialized group.
Gray: Yes. I've been doing quite a bit of training at the University of Iowa Hospitals and Clinics regarding developing a specific group for people diagnosed with borderline personality disorder. This group uses specific cognitive behavioral interventions, which have been shown kind of in the initial stages of some research currently... It's showing that this is a really effective group intervention for these kind of folks. It actually is showing that it's reducing some hospitalizations. So we're also providing those services and developing those at Hillcrest. That's kind of neat, the alliance that we have with the hospital at this point.
Lacina: Are you working with Dr. Clancy then over there?
Gray: More so with Dr. Bruce Full and Nancy Bloom, who's a Social Worker over there.
Lacina: OK.
Mosher: This is a good example of what's really emerging as a good cooperative relationship with... Because these are some powerful new techniques that have been developed for dealing with really complex problems of personality disorder, which we've had a lot of trouble treating for years. Nancy Bloom at the University has developed these techniques that are based on some that developed elsewhere and Stacy has gone through a lot of training and is now prepared to offer that to clients that need it, without having to go to the University necessarily. It's nice to have more than one provider so that you're not totally dependent on a single provider. We're real pleased to see this develop. I think it's a powerful new tool that we can use with a population that's been very hard to treat in the past.
Lacina: Then is the treatment standardized or is it developed for each individual client?
Gray: It's a manual that's standardized, however, working with specific techniques with the clients.
Lacina: So you have flexibility to go in and actually tailor this to whatever the extreme or lesser needs are.
Gray: Absolutely, there are. There are a variety of techniques you can use. Some work for some folks and some work for others. The group work is really more effective and it also reduces costs of course. However, this has also been effective with working individually, as well as in group work.
Jordahl: We've heard the name here and I guess I have to betray my innocence of psychology and ask you what does cognitive behavioral therapy mean, without going into a 15 minute disquisition on this.
Gray: Sure. I can try to. Basically, what happens is you try to look at maybe some of the distorted or dysfunctional thoughts that people may have and kind of reframe them or reshape them so they are a little more rational and functional. As well as looking at the behavioral end. For example, if someone typically uses a cutting, a self-harm, to relieve emotional pain, teaching them other techniques to use instead of the self-harm.
Jordahl: It's cognitive behavioral, so the notion is that the behavior is based on an understanding, is not a random behavior or something. I mean, what's the nub of this?
Gray: Of the disorder?
Jordahl: Or the therapy, whichever is more informative.
Mosher: Well, I think part of the idea is to treat the symptoms, to try to help people learn ways to rethink a thought process that's going through their head. Rather than going through years of sort of in depth exploration of their psyche and stuff, you try to just say OK what's the presenting problem here? Is the person cutting themselves as a way of relieving their tension? Then let's deal with the cutting and let's teach people some techniques for thinking about that differently and for setting up a structured way of having a plan for what to do when they feel like doing that. So we're in a sense, at last, able to have a way to try to reduce those behaviors that are problematic, through this technique. It has remarkable success. It's really interesting. It's better than 5 years of in depth therapy. You know you just deal with the behaviors and solve them.
Jordahl: Uh-huh. Great.
Gray: Actually the groups usually last from 12 to maybe 15 or 16 weeks and it's remarkable the amount of progress you can see in that short amount of time. It's really impressing.
Stutsman: Is participation in the group voluntary and how do you make sure that people come for the 12 to 16 weeks?
Gray: That's a good question, especially for some of these folks. Typically, yes it is voluntary. What happens in my experience, what I have seen is it is pretty rough at first. Especially becoming accustomed to accepting some of the intense emotions and things. But the more they learn they become very excited and motivated about the changes that they're able to make in their lives and the responsibility that they can take for their behaviors and their reactions to the emotional intensity. Typically it's a lot of motivation that keeps them in the group.
Stutsman: I was, of course we're requiring it, but I'm real glad these programs have outcome measures anymore. You know so that we can say if this is good and if it is making a difference and having an impact.
Gray: I also need to tell you as well and I don't think it's in there but there is a new assessment to go specifically for working with people with borderline personality disorder. We're using that assessment tool and I believe that's soon going to be on the market for people to purchase in groups. That is, we're collecting data at this time, both at the hospital and at Hillcrest with that particular assessment.
Stutsman: Craig, how many people will be in this type of therapy?
Mosher: Well, it will depend on how many need it. How many people do you have in a group now?
Gray: At Hillcrest?
Mosher: Like 6 to 8?
Gray: Yes. 6 to 8. No more than 8 people. Sometimes there is only 4 people in a group and that's really nice because they become really cohesive and really supportive of one another.
Mosher: I don't anticipate large numbers using this contract, but we certainly have some cases where people may be getting services at Hillcrest with HSL for example, Supported Living Program. It makes sense to have the therapy in the same program so it's a more integrated approach. So it just makes sense to have them.
Stutsman: Steve did you have a comment?
Lacina: Just I'm aware of a situation with a child that had a problem at age 5 and this contract is for 18 and above. Just briefly, for those that kind of fall in between what is available for them? Anything yet?
Mosher: Well, they can certainly go to the Mental Health Center and receive services there and they also have a similar kind of a group at the Mental Health Center.
Lacina: They do have a support group? OK. Good work.
Stutsman: Any other questions about this particular contract?
Bolkcom: Yes, I've got questions about both of them. Are these 2 new things then Craig? Are these new services? It sounds like the group is pretty new.
Mosher: It's new for the County to fund them.
Bolkcom: OK.
Mosher: They are things that Hillcrest has been doing.
Bolkcom: OK. So we've got the ARC contract, how do these 2 contracts relate to the ARC contract in there?
Mosher: Totally separate.
Bolkcom: I realize they're separate, but they're substantially different kinds of contracts.
It would appear. Is there a reason they're different?
Mosher: The boiler plate language is the same, the 12 pages of all of the departments of the contract that you've seen before with the Mental Health Center contracts. That's the same for all of them. Then these 2 attachments simply describe the services provided, paid for at the rates of the services.
Bolkcom: OK. So Hillcrest has the other 12 pages that they follow. These are just additions to that.
Mosher: Oh, yes. I just gave you the attachments because I didn't think you needed another copy.
Bolkcom: That's fine. That clarifies it for me. Additionally, the money that we're going to pay for new services, where will... Is there a...
Mosher: It's in the present budget for psychotherapy. So I don't think that will be a problem.
Bolkcom: OK. Thanks.
Mosher: It's not your money. Should we talk about the rec program for a minute?
Stutsman: Sure.
Mosher: Anne do you want to come in?
Stutsman: Change seats huh?
Hillcrest Supported Living Coordinator Anne Armknecht: That's me.
Stutsman: OK.
Armknecht: The wrecker, we've been finding, having worked for Hillcrest since '85, I'm dating myself a little bit here but I guess that's OK. Something that's worried me throughout the years is that I see clients coming back. They may have been with Hillcrest for 3 or 4 years and then all of the sudden 3 or 2 years later, a year later, they're back on our referral list. I'm wondering why. Have they fallen through the cracks? Did they lose all of their services? A lot of times people say no I'm fine. I don't need an individual. I don't need a counselor in my home, but I'm looking at this Rec Program sort of as a safety net. Now it's a voluntary program, so there's still that thing where it's up to you if you come or not, but they don't have to get into a big program. They don't have to have all of these sorts of regulations of how often they meet with the counselor. But what it allows us to do is with the other 89 clients that we serve right now, which will probably be 100 by the end of this year, it allows us to have them participate just in our rec and social programs which are actually quite huge. I think we're the only program that has a every Saturday rain, shine, holiday or whatever activity and at least 2 to 3 activities every week for clients in a safe environment. What I'm hoping this will do for some of the people who say have discharged from the program, or some that have been identified as isolating which would lead to a rehospitalization, this would be a way for us very simply and for the County extremely cheaply at 10.69 an hour for us to keep some contact with them to allow them not to isolate in their home. To allow them to have structured contact with friends and supports that they've made through Hillcrest programs. Then if they stop showing up, or we notice that an activity they may be talking to themselves, talking to voices, we note that they're very depressed. Then we can act as a safety net, not only for them just to get out and not isolate, but we can act as a safety net to call up the County worker and say hey this person is not doing well. We know they have no other supports. Let's get them some help before it gets too late which would lead to a hospitalization of some kind. So that's the basic premise. We've got tons and tons of activities. We actually had to purchase a brand new 15 person van in order to take care of the demand that we've had.
Stutsman: Well wasn't this one of the services that was identified in the OMNI, the program recreation services?
Armknecht: Yes.
Mosher: Right. When we did the needs assessment last fall, you remember that this came out as the top ranked consumer priority for social and recreational activities. I think it's because people realize that not only do they need the contact and so forth, but it's a way for them to maintain a kind of peripheral contact with the system. So that, as Annie says, when problems do develop, somebody knows about it. Then they can get help. It's very cost effective way to do that while meeting a real significant consumer need and it was included in the plan as one of the major goals and was clearly identified as being successful.
Armknecht: The important thing about it, in my estimation, is it continues to be goal oriented. People would set goals on how many activities or what they wanted to do. We have even in Hillcrest right now goals for people for the rec program that we have that says OK, I'm going to talk to one person that I don't know. You know, so we help them expand their social network and really with very little professional intervention, meaning increasing natural supports in the community. In my opinion that's the way to go. They want natural supports of church, of friends, of the guy at Burger King that knows me. That sort of thing and so we're trying to establish those.
Bolkcom: Sounds great.
Stutsman: Any other questions?
Lacina: At what point will they graduate from the program or is it intended to be an ongoing maintenance program?
Armknecht: Well it is in some respects maintenance, but it would be where everyone would have a treatment plan for their rec participation and as they progress through the system they would have a choice of discontinuing on their own. But that would also be established through the funding source, through the social workers and case managers would definitely have a say in thinking wow this person is doing great, they really don't need this anymore and they're ready.
Mosher: Our staff has to authorize the units of service for this program just like they do for all of the others. So if our staff and the other staff feel that the need really isn't there any longer that person is ready to operate independently on their own, then we would stop authorizing that service.
Lacina: That's what I was looking for, the need base, and you explained that very well. Thanks.
Stutsman: If there are no other questions then we'll put both of these on then for Thursday. Or for approval.
Mosher: You can bring in a signed copy?
Armknecht: Yes. We have the President of the Board and our Executive Director signing it today and Fed Exing it to me tomorrow.
Mosher: Great. OK.
Armknecht: Thank you.
Stutsman: All right. Thank you.
Mosher: So you'll have it Thursday morning then, and you can sign it.
Stutsman: OK.
Armknecht: Should I bring it to you guys or Craig, signed?
Mosher: Bring it here.
Stutsman: Yes and we'll see that it gets to Craig.
Armknecht: Thank you.
Stutsman: Jeff is not here so do you want to talk about hiring a case manager?
Mosher: Why don't we do the case manager next is that's all right.
Stutsman: Sure.
Mosher: Maybe he got delayed. We got signals crossed or something.
Stutsman: Train.
Mosher: OK, let's see I gave you some handouts on this and have one other one.
Stutsman: Great, off the bat I have to ask you, what in the world is going on with the numbers?
Mosher: We're up 159, you can see...
Stutsman: I wish that were showing my income.
Bolkcom: Yes. Well the increments are only 10 so you wouldn't be a whole...
Stutsman: Yes, I know it is a little deceiving, but still...
Bolkcom: It's a million.
Mosher: Yes. We've had a real jump and you saw from the chart on the 4th page of the handout that I gave you that the case management numbers are up real significantly. The social work numbers are actually up even more. The case managers are the ones that are funded by Title 19. The social workers are funded by Johnson County and the numbers are up very sharply. It's primarily because the switch from block grants to fee for service. We've had a large number of people at the Mental Health Center and at Chatham Oaks who needed to have workers assigned so that we could monitor their cases, who came onto the caseload July 1st. Frankly, we didn't anticipate the size of those numbers a year ago when we were working out the budget. So we didn't really sort of gear up enough. As you recall, we added a case manager last spring and we added a social worker this summer. But we've just been swamped. People are working long hours trying to get all of these authorizations written so agencies can provide the service and get paid. We just have to do something. The case management side, as you can see from that thing I just handed out, we're up to 280 now, receiving case management, out of a total of 628 consumers that are on the caseload as of September 1. The target, as you recall last year we did a survey of different case management providers around other counties in the State and they were averaging 35 consumers on a caseload, per individual worker. That's a pretty good estimate of what reasonable can be expected of a single worker given the paperwork in the case management side is a great deal more than the social workers need to do on their cases. So they have to have smaller caseloads to get the paperwork done or they're not going to have any time to spend with consumers. It's extra paperwork because it's federal Medicaid money. So that's part of the price of the federal dollars. The plus side of that, of course, is that the federal government pays for this and so it's not a net cost to the County. As you recall, the case managers are almost entirely reimbursed by Medicaid for the service, so that it doesn't cost the County significantly more. The handouts that I gave you kind of walk through all those numbers and so forth. Just to refer back to the chart one more time, the line graph. You'll notice the significant jump in July and August and we're now seeing a tapering off of that, of course, because that we sort of a one time deal, bringing on the block granted consumers. But I think we'll go back probably to where we were before, which was about 3 new consumers month, the 11-12% increase that we'd been seeing over the last year and half. So I think it's a one time blip, but it's something that we do have to accommodate. We simply can't not provide that staff to do it. As is pointed out, I think Laurie does a nice job of working up these numbers. On the 2nd page of that handout you can see where the reimbursement on this one actually exceeds our costs. But we think that when we get the new case management rate figured out that we'll actually come out in about a wash, which is where we've been in the past. It just about covers our costs. So it doesn't cost the County extra dollars to add another staff person.
Stutsman: What about space-wise?
Mosher: Space is going to be very tight. We're going to have to double up. The new person that came on will have to share the office with a new one, and the latest one that we hired will have to share an office with the new person. Cheryl does have money in her budget for the computer and so forth, so we're OK in terms of equipment. This is not in our budget this year, so we would need to do a budget amendment to accommodate the extra revenue and the extra expense. But, as I said, it will be pretty much a wash. So I don't think it's a problem in terms of dollars.
Bolkcom: So Craig, looking at just the chart here since like November of last year until now we've seen about a 70 person increase in the case management load. Does that reflect... So we would need basically... How does that relate to this request and other hires that we've done, case managers, will this be the 2nd person that we're increasing since November of last year?
Mosher: Yes. See we added one last spring.
Bolkcom: Right.
Mosher: That had been planned for the summer before when that was written into the budget. Then, this is an additional one on top of the one who started last spring.
Bolkcom: OK. In terms of the caseload for like Chatham Oaks, I don't know how this divided up, but I would imagine that, and I don't know this, but I would imagine that we have a number of people at Chatham Oaks that have been there for a long time that have maybe less case management needs than somebody else let's say at Hillcrest or out in the community. Is it possible for that caseload to be larger in relationship to other caseloads because of...
Mosher: Well, what we do is we tend to spread cases around so that one individual doesn't get you know a major grouping of any particular group of individuals. So that the Chatham Oaks cases have been distributed among different workers. In effect what that does is it means maybe you have a case here that takes a little less work, it allows for the extra work that's required for someone who is very active. When we have consumers, for example, in the Impact Program who are just out of the hospital and having all kinds of symptoms and problems and stuff, and you've get a weekly staffing at Impact to go to and that sort of thing, it's much more intensive and so it takes a lot more time. So they kind of balance.
Bolkcom: Sure. OK. Makes sense.
Jordahl: Did any of these consumers go to the DHS Facility to be seen or does the social worker generally travel?
Mosher: It works both ways. I would say it's probably more travel than come into the office.
Jordahl: I was wondering about the double office, you know whether...
Mosher: Well, that creates a problem and long-term, as we've discussed, we have a space problem there that we're going to have to deal with. We do need to continue talking about that.
Jordahl: So how's that actually... Does one worker have to then leave the office, or is there an interview room that people can go to?
Mosher: We have several conference rooms, that if they're not busy they can use. There is often, somebody is gone for a day, and so you can use their office. We're pretty good at flexing that space, so it works out. It's just one more thing to shuffle.
Lacina: How do you plan on addressing the duplication that will exist in some areas of case management? We're doing more case management, but under the block grant scenario, we had case management out there and we're now taking over that workload at our level. I'm not real wild about the County continuing to pay the overhead costs for those case workers if they still exist in these other programs.
Mosher: Well, I don't think it's the same job Steve. I think that the social workers at Chatham Oaks are providing social work services to the people out there. That's not quite the same as what a case manager does in terms of a case planning, and authorizing a funding, and general tracking of the person's entire program. Chatham Oaks is more focused on the services the person gets out there, but many of those consumers are enrolled in programs at Good Will. They may be going to day treatment at the Mental Health Center, they may have a job of some sort in the community, the may be going to other kinds of activities, they may be involved in Hillcrest even. So that our workers are involved in trying to manage all of those services and be sure that people get what they need and not more than they need and that the County's money is spent well. Whereas the Chatham Oaks workers are more focused just on the services that Chatham Oaks is providing and they're plenty busy. I know that they only have 2 social workers for 90 people out there and I think they're doing well to manage it with that. So I don't think it's a duplication. I know the names get, it sounds like they overlap, but I think what the workers actually do is quite different.
Stutsman: Out at Chatham Oaks, everybody that lives out there isn't necessarily part of the County program. Is that right?
Mosher: That's right. Sure. They have people from other counties that we wouldn't have anything to do with. We don't have workers involved or anything. Then they have private pay people that we don't have anything to do with either. I mean, if a person or their family is paying for their care, then we don't have a worker involved at all. Our workers are involved when County dollars are involved, because it's our job to authorize and to monitor those dollars and be sure they're spent well.
Jordahl: Craig, we look at this graph here, and I'm kind of a fan at looking at trends. If you were to project this line you'd say we've got a trend here that's going really wild.
Mosher: Don't project it.
Jordahl: Yet this is going to flatten out, is it not? I mean we've got a notch here of people, Chatham Oaks for example, who are now needing social workers but that doesn't mean that this is going to be a continual influx into the system.
Mosher: I don't see why there should be.
Jordahl: At this kind of rate anyway.
Mosher: No, there certainly shouldn't. I expect we will go back to the 11-12% increase. I don't know any reason why it won't keep on going up the way it has the last year and a half to 2 years, about 3 new people a month. But there is no reason to think that it's going to jump like this because this is just an artifact of the switch from block grants to fee for service.
Stutsman: I guess to follow up on that I'd like to have you come in again maybe in 3 months and see where we're at on this.
Mosher: You bet. You bet.
Lacina: Yes, because at some point I guess I need an update of where we're at on the State MIS System too.
Stutsman: Oh, the Management Information System. Uh-huh.
Lacina: It just seems like everything is exploding as far as more and more people and we need to figure out why. Again, going back to Jonathan's point if we look at trend lines, yes this was an anomaly, but there's no decrease in you graph and if things continue as they are we're going to have a very serious problem. So at some point we're going to have to really get into the numbers and start figuring out what's going on.
Mosher: That's right. We are.
Jordahl: I mean to pick up on that, the slope seems to be increasing even prior to July 1.
Mosher: It is. Yes. Yes, and that's part of the challenge with the new managed care system is to try to manage that increase and new consumers with a capped budget. That's exactly one of the reasons this was all created was to try to manage that problem. You're quite right. It's something we need to really pay attention to.
Lacina: We need to find out, is the only way you can get out of this is by death? I mean are we having any success on the other end of it, or are we just continually bringing more and more people on, growing those numbers, and again that MIS system is going to be extremely important to see what we're doing.
Mosher: Right.
Stutsman: Maybe we'll find that we're serving more clients, but spending the same kind of dollars because we're doing a better job of managing, you know, the clients that are in the system. I hope that's what we'll find.
Mosher: I think that's really the hope of this. Is that we'll find services that are more efficient. The Impact Program, for example, out of the University is on the face of it, it costs a little extra to provide this in-home psychiatric and nursing care, but it sure saves dollars in terms of hospitalization and so forth. Those aren't all County dollars, so we need to be careful about sort of what's County and what somebody else is paying. But to the extent that people go to the Mental Health Institute, MHI, in Independence, those are County dollars and so it is cost effective to provide other services. That is part of the challenge of what we're trying to do.
Bolkcom: The other thing about that, I mean, the cost to the County to add this position is basically nil. I mean because of the federal involvement. Hopefully, be having these cases better managed through the managed care program, we're going to do exactly that. We're going to make our dollars go further. So it's like we've got to spend money to save money. In this case, the money that we're spending is not coming out of our pocket directly.
Mosher: Right.
Lacina: Well there is a cost to the County. We're now talking space needs, we're talking computer systems, we're talking further support.
Mosher: Oh, yes there is some cost.
Bolkcom: Sure.
Lacina: To say that there's no cost to the County...
Bolkcom: For the position, for the salary part of it is what I meant, but you're right.
Mosher: Salary and benefits and that stuff are paid. But you're right. We have some sort of overhead costs that are part of it.
Lacina: But you're in a tough position because there are a lot of needs out there. On the other hand, resources are tight.
Mosher: Uh-huh.
Stutsman: Craig, just for my clarification, Kelly's unit, that's the case managers right?
Mosher: Right.
Stutsman: Sally's unit is the social workers?
Mosher: Social workers. Right.
Bolkcom: What kind of excess capacity will we have to manage cases Craig, with this new position, people will be at what?
Mosher: The new position will bring the caseloads that are now at 40 down to 35.
Bolkcom: OK, so there will be some room to grow there.
Mosher: Which is the low end of our 35 to 37 target range. So we've got room.
Lacina: But the contract is 45, is it? Or did we lower that?
Mosher: The legal limit is 45, but it's not a manageable caseload at 45. Nobody around the State is running at 45, because they can't do it and get the paperwork done.
Jordahl: If you project this 11-12% growth into next year, I think we've got... How many case managers do we have? With the new one?
Mosher: There are 7 now.
Jordahl: 7 now, will be 8.
Mosher: This will be 8.
Jordahl: This will be 8, so you've got 8... I've got a calculator, I don't know if I want to spend time calculating this stuff. My questions basically is at what point... I assume it sounds like next year... I mean you've got room for 2 times 8, 16 people to come in to the system. You've got 290 here times 10% would be 29 right? So that means another case manager next year.
Mosher: If that rate continues at about 3 new clients a month you could hit 36 new clients a year. That's right.
Jordahl: Or basically a new case manager every year.
Mosher: Uh-huh.
Lacina: Well on this graph you did it in one month.
Jordahl: Yes, of course...
Mosher: But that's because of this situation.
Stutsman: Are there any other questions? Are we ready to put this on for Thursday?
Bolkcom: I'm fine with it.
Duffy: Yes, Sally, I would like to make a statement. Listening here one of the concerns that I found several years back was after the, I guess so called child reached 18, they are adults. They were in their loved ones home, not real severely with disabilities. I don't like the word handicapped, I try to stay away from it. What would happen to me, or what would happen to a father when we die, and where's this person going to receive some help? Because a lot of those folks have jobs and are hard workers, all they need was somebody to kind of look in on them, pick them up from work, and take care of them. So what I'm hearing this morning, over the age 18, that there is something more done? Is that what I heard?
Mosher: Well, when in a person turns 18 we get involved, whereas up to that time the school system has basically been managing the case. The AEAs have been doing that. At age 18 we would assign a worker, and we would authorize the services, and we would start paying for services for individuals. That is, I mean that's one of the ways the caseload goes up is when people turn 18. That's clearly a source of the new people coming into the system. We can't do anything about that. That's just a given. Those are Johnson County people.
Duffy: But what I mean, still what happens in a case then? Let's say the father has been dead for several years and the mother is taking care of this person after he or she gets home from work, something happens to her, then what happens? Because I've been asked that question quite a few times.
Mosher: Yes. Well and then we would sit down and work out with that individual and their family, if they can, what services are most appropriate. Sometimes, you know, a foster family may be the solution. Sometimes you may be looking at residential care if there is no other solution. There are a variety of... Sometimes a supported apartment with workers coming in to provide support services like Systems provides for example, might be a solution. So there are a variety of solutions, but our workers would be involved at the point in helping that family decide what was the best thing to do. I mean it's a legitimate concern because parents provide a great deal of support and care for people. That's something the County doesn't have to pay for, that's just a family affair and people are very good about that. We assist wherever we can and one of the ways, for example, that we assist with that is a respite care service. So that if a family is caring for a disabled child at home, they can take a vacation or they can go to the movies or something by themselves and get some rest from the constant care and that. So there are a variety of services that we do pay for that help with that situation.
Duffy: Thank you.
Stutsman: Any other comments or questions? Put this on for Thursday then, if the Board is OK with that? Do you want to discuss the ARC contract or do you want to wait and put it on for another time?
Mosher: Let's go ahead and talk about it and I think you can sign it, I mean Jeff doesn't need to be here to... I can present it I think. This one, I did give you the full contract with the boiler plate and all that on this one, and the 2 attachments that describe that services. Again, this is the last major agency that had a block grant before that's now switched over to the fee for service. This contract basically provides for 2 services that the ARC provides. One is a vocational service where they provided supported employment to individuals with mental retardation and developmental disabilities. That involves job development, job placement, placing the individual on the job and then ongoing job coaching. They call it... follow along job coaching, where you have a staff person stay in touch with the situation so that they're there to provide support if needed to keep that person on the job, so they don't get fired or something when problems develop. The second program that the ARC provides is a respite program, as we were just describing. It essentially provides daycare, child care, for individual families that have a disabled person. As you can imagine, if you have a child with a serious disability it may be difficult to find a daycare or a child care provider to... Particularly child care in the evenings is the hard one. Not everybody wants to take on that challenge. So the ARC trains people in how to provide that care and certifies them and monitors those situations to be sure that the care is appropriate and the family is satisfied and so forth. We help support that service as well. It's real valuable too, because it allows a family sometimes to keep a child in the home that otherwise they might sort of run out of patience with or be unable to care for because of the demands of the disability. So it's a really good way to help keep people in the family homes for a much longer period of time, provide some support for parents and that.
Stutsman: Any questions? OK, we'll put this on for Thursday then. Does this finish all the contracts for fee for service? Is everybody switched over now?
Mosher: I believe this wraps it up. Yes. It's certainly all of the major ones, the Chatham Oaks, and the Mental Health Center, and the ARC, were the 3 big ones. The Lipotech and CompuServe and stuff, we've also taken care of now. So I think we're pretty much done.
Lacina: My memory is failing me on this, so help me Craig. We had discussed boiler plate language which would be a disclaimer as far as liability on these contracts. I know we talked to the County Attorney about it, but I don't remember what was resolved.
Mosher: Well the feeling finally was that it was kind of an exchange. You know we would put that kind of language in and then the agency would request it too.
Lacina: That's right.
Mosher: John Bulkley's feeling was it doesn't really provide significant legal protection anyway that you're going to get sued.
Lacina: We're all going to be nailed. That's right.
Mosher: So he thought it was more trouble than it was worth and to have the agency come back and say we want that language too, might be more of a problem for us as a County that we didn't necessarily want to get into. So he advised against it.
Lacina: That's right, thank you.
Bolkcom: I had a question about Chatham Oaks and the lease agreement. That's kind of a side issue to the contracts but...
Mosher: Yes, it is a side issue, it's totally separate but I talked with Bill Sueppel on Friday and I've tried to get a hold of Mary again. They haven't signed it yet and Mary had said she would get it signed at their July Board meeting and I don't' think they met in July. At the August meeting it didn't get signed. Mary is now on vacation in Africa as a matter of fact. She's on this wonderful trip to Africa. I wish I could've gone. Sounds really exciting.
Mosher: So as soon as she gets back next week I will get together with her and I am determined to reach some kind of compromise with them on this. I think we need to get it signed and if we have to go 2 years we'll go 2 years but I think we need to get it signed and get done with it so... That's my intent at this point.
Stutsman: Anything else Craig?
Mosher: That will do it.
Stutsman: OK.
Mosher: Thanks for your patience.
Stutsman: Thank you.