MINUTES OF THE INFORMAL MEETING OF THE JOHNSON COUNTY BOARD OF SUPERVISORS:
NOVEMBER 5, 1998
TABLE OF CONTENTS
Chairperson Bolkcom 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.
Bolkcom: Call the informal meeting of Johnson County Board of Supervisors to order for Thursday, November 5th. We're starting this morning with an informal meeting. Good morning, everyone.
Lacina: Good morning.
Stutsman: Good morning.
Bolkcom: Second item on the agenda is review of the formal minutes from October 29th. Any questions or comments about those? Those will be...
Duffy: Yes, I'd like to comment that the reason why I voted against extending the office hours, that now are 8 to 5 in this department. I thought we'd be a lot better off and more public input it would be 7:30 to 4:30 and especially with the time change. So what we're really saying here is extending the amount of time for 2 hours, it's going to be plenty dark because the time has gone back. It gets dark at 5 o'clock. Anyway that's the... It wasn't that I was against extending the hours, but it was the time. I thought it should be from 7:30 to 4:30.
Bolkcom: OK. Thanks, Charlie. By clarification the Board's office had formerly been opened from 8 to 4 and this week now it's open 8 to 5 p.m. Any other comments on the questions... I'm sorry, on the minutes?
Bolkcom: Item number 3 is business from Craig Mosher, Director of the Mental Health/Developmental Disabilities Services of Johnson County, a) is the discussion regarding 28E agreement with the Iowa State Association of Counties Case Management Service to provide technical assistance to the MH/DD Case Management Unit. Good morning.
Mental Health/Developmental Disabilities Director Craig Mosher: Good morning.
Bolkcom: Good morning, Janet.
Stutsman: Good morning.
Mosher: We have this morning for informal discussion a 28E agreement with an organization established by ISAC to provide technical assistance and training to case management programs across the state. This County Case Management Service that ISAC has established is presently serving over 50 counties across the state. I think it's time for us to join that group. They provide a number of important services that help us stay up to date and in tune with a very complicated set of Federal Medicaid regulations for case management because this is a service funded by Medicaid. On the handout that you just got this morning there, I believe, on the 2nd page of that, that say service overview. It looks like this. There's a list of the services that are provided by County Case Management Service. These are detailed in the contract. We're going to suggest that you actually sign this on your formal meeting next Tuesday because you just got that handout this morning.
Bolkcom: OK.
Mosher: But that list of services, basically outlines what County Case Management Services would provide to us. They review policies and procedures. They work with Kathy Lynch in developing the rate to be sure that we get all allowable costs into the rate calculation that we can. They assure compliance with all the regulations that the Feds have. They help review financial operations and document expenses to be sure that we're doing that properly because there is an audit of this program each year. The State sends out a person to audit our books and to audit our case files to be sure that we have proper documentation in the files to justify the billings that we have submitted for the Case Management Service that gets reimbursed by Medicaid. They also will help defend if there's an audit question. They also advocate for Case Management Service at a whole variety of State meetings and with the Mental Health Commission and Human Services Commission and so forth. As well as providing a lot of training, they will come out and do training and we also will attend training that they sponsor and so forth. I think it's a smart move on our part to join and get that additional help with what's really a very complex administrative program. The cost is, there's a $600 startup fee and then there's a $5 per client per month fee. We have 287 clients so it's not real cheap, but the cost becomes part of the rate and is reimbursed by Medicaid. It's not a cost to the County to do this.
Bolkcom: OK.
Mosher: So I think it's, probably in the long run, a cost effective thing to do because it will help us operate more efficiently. Our rate is now a low one compared to a lot of the other Counties because we operate efficiently. But it's, I think, a smart thing to join and be a part of this. Janet, you had reviewed the contract. Do you want to add anything?
Assistant County Attorney Janet Lyness: I looked over the 28E agreement that ISAC had. I was concerned because it has like, 1991 codes. I (inaudible) really talk to David Vessel from ISAC. They're probably going to be revising the 28E agreement. They didn't want me to change anything because so many Counties are already signed on with this particular 28E agreement. But he says he is going to revise it and he'll send us a new one and for all of the Counties that are members to (inaudible) in the spring when he gets that revised.
Bolkcom: All right. Questions from the Board on this 28E agreement?
Stutsman: Craig, how come we haven't done this up to this point?
Mosher: I think there was some discussion of doing it and my impression... This was before I came, but my impression is that there was just sort of let's wait and see how this develops and if we really need to do this or not; was my impression of what the questions were. I think we've seen that it really would be a help to us to have it. So I think it makes sense to go ahead and do it at this point.
Bolkcom: Other questions?
Lacina: We received presentations by ISAC down here and we were concerned that they were trying to take on the entire state. We wanted to kind of see how it was going to work. When we didn't go with them, David was disappointed that we didn't sign on at the same time, but they have shown that they can perform. We've struggled, frankly, in the audit on our files.
Bolkcom: Uh-huh.
Lacina: There's a tremendous amount of paperwork that's required to meet all of these things. I think this is very inexpensive if we can just help reduce some of that burden.
Bolkcom: Right.
Lacina: They've had to come back several times to go back through our files to make sure we didn't lose that funding. I think for the money this is a very wise move and ISAC has shown that they can do it.
Stutsman: Do they actually come out to the Counties then and work with the Counties?
Mosher: Yes.
Stutsman: It's not like you have to go to Des Moines and meet with...
Mosher: No, no, no.
Stutsman: OK.
Mosher: They have 4 staff who serve different regions in the State and come out and provide that technical assistance and help with the rate development and review our files and so forth before the audit so that we're prepared for it.
Jordahl: I can see this like in a first year, getting things up to speed and making sure they're in order. But then is this going to need to continue to be an annual process?
Mosher: Yes. I think the Counties that are doing it are doing it on an ongoing basis because the regulations do change, you do want to stay in touch with what's happening at the State and Federal level, and you'll always have new staff coming on that you need to train and so forth. Staff need ongoing training, we need to be a part of that, I think, on an ongoing basis. You're never trained enough it seems like.
Lacina: The audits are thorough, they go down into...
Stutsman: Oh, yes.
Lacina: ...the individual clients folders to look for documents. It's...
Stutsman: There are serious consequences if things aren't in order...
Lacina: (Inaudible).
Mosher: Oh, yes.
Stutsman: ...financial consequences.
Mosher: Right.
Jordahl: Not all Counties have the same degree of professional staff that we have here because of our size. It kind of goes into maybe, some are sharing CPC's for example, this service, maybe Steve you'd want to speak to this too, may have come into being in part to meet the needs of Counties that don't have the staff. I'm wondering if we do. Do we really need this? The money we're talking about here if my calculations are correct is $17,820 for this year. That's less than the cost of hiring one person to do it, but it's not a negligible cost. Of course I understand the consequences of having a problem in our audit would probably exceed $17,000, but I'd like to have somebody speak to this question of are we taking on a service that is meant for somebody else.
Mosher: The cost is reimbursed. It's not a cost to the County, for one thing. It becomes part of our rate that's reimbursed by Medicaid so it's not a cost to the County. The other point is that some of the larger Counties are members of County Case Management Services, Polk County for example. They just think it's smart to have that technical assistance to help them stay on top of things, even though they have extensive staff as well. So I do think it's a wise investment.
Jordahl: I didn't understand that it was reimbursed.
Mosher: Yes, yes. It's not a cost to the County.
Lacina: I think you're correct in that, a lot of the small counties, if you have a population of 6,000 people in the entire county, the cost per individual is really burdensome to meet all of those requirements. So there are some efficiencies by going together and having ISAC do this.
Bolkcom: Right.
Lacina: But the other side is, since they take the time to stay up with this and all of the legislation that does free up some of our caseworkers at a time when, frankly, the case loads are high. So we have to decide if we want people out working with clients or people behind a desk trying to fill out volumes of paper. In this situation, yes it is $17,000, but given the changes, given the struggle that we've had, I think it's really a prudent move plus the reimbursement.
Stutsman: I've been working on that task force with Child Welfare Services in dealing with Medicaid. And I am just sometimes overwhelmed at the complexity of this system and that it really does take a lot of time and a lot of technical expertise to make sure that you are on top of all these things. For that reason I think it's money well spent too. It's overwhelming the accountability that's involved in keeping eligible for these services.
Stutsman: As Sally said earlier, the risk is losing our funding or a delay in funding while we go through and bring things up to speed. Any recommendations though, from legal? Are there... other than...
Bolkcom: Look's fine.
Lyness: (Inaudible) a recommendation as far as (inaudible) I looked over (inaudible) I have to say the agreement. I defer to you and to (inaudible) as far as (inaudible).
Lacina: OK.
Bolkcom: Any final questions?
County Attorney Pat White: (Inaudible) was the timing. (Inaudible) getting a pretty big bundle of paper which you haven't seen before and it's on your formal agenda today, but I was asking if there was any need that it has to be voted on today. It doesn't sound like there is.
Bolkcom: We'll put it on for next Thursday.
White: (Inaudible)...
Jordahl: Uh-huh.
Bolkcom: That's fine.
White: ...before you vote. (Inaudible) can be set in next week (inaudible).
Bolkcom: That'll be fine.
Duffy: Thank you, Pat. I was going to ask about that.
Jordahl: Uh-huh.
Bolkcom: All right. We'll put this on for next Thursday. We're meeting next Thursday at 5 p.m..... or I'm sorry 5:30. No, 5. Anything else on that item? Item b, discussion regarding...
Lacina: Just a quick question. Somebody had referred earlier to doing it Tuesday, is there a time limit that we're under? Does it need to be... Thursday will work?
Mosher: Thursday's fine.
Lacina: OK. I misunderstood then.
Bolkcom: We're meeting...
Lacina: You did a lot of work on it, thank you.
Mosher: Thank you.
Bolkcom: All right. Item b is discussion regarding filling the social work position in the Mental Health/Developmental Disabilities Department.
Mosher: OK. As you know, each year we try to anticipate what our needs are going to be and we did budget for an additional social worker position in this fiscal year. I've kind of held off on filling that position, wanting to be sure that case loads really were going to continue to rise as they have been steadily, as you know. And wanting to be sure that budget-wise we were OK to do it this year. I think on both counts the time has come to take action on this. I distributed to you, or you've gotten in your packet, I think, a couple of charts that help to illustrate what the case load situation is in the department. On the first chart that shows total cases on the dotted line at the top and then is broken down by social work cases and case management cases. As you remember, the case management cases are ones that are funded by Medicaid and reimbursed by Medicaid. The social work cases are ones where we have consumers who do not have Medicaid so the County pays the cost of their social work services. But essentially the workers do the same kind of work. It's basically being sure that consumers get the services that they need. That we spend County dollars in the most efficient and effective way possible and that the services are coordinated in a way that really does meet the needs of each individual client. On that first chart you'll notice a large jump in the number of total cases in August of '97, that was when we took on a number of people that were at the Mental Health Center that we had not been providing services to before because we hadn't been carrying them as individual cases. You'll notice a little bit of a dip in August of '98 when we went through and really tried to take a look at, are there people on the case load that maybe don't need the sort of individual attention of the caseworker all the time. We found a few that we could discharge from social work and case management. So we were able to sort of reduce the case load somewhat at that point. We are however, experiencing, over the last 12 months, a steady 7% rise in the number of cases. That's higher among the social work cases and lower among the case management numbers. So that our actual case management case loads are averaging about 35 which is about where they should be. That's the target that we've established after some research, as you know. The social work cases, however, that are not Medicaid funded have really gotten beyond what's reasonable. We need to keep those case loads in the 50's and they're up to 65 at this point. It just doesn't work. It's too much for the workers to be able to have the time that they need to spend with each individual consumer to be sure that we're on top of what's happening with them. If somebody ends up going in the hospital because our worker did not have time to get to them and find out that they were decompensating. That's a significant problem for them as a person and it's also a cost to the County. It's important that we... That our workers have the time to spend with clients to stay on top of what's happening with them. It also can be a savings to the County. If the worker has the time to do the work to get somebody on the Medicaid, Medical Needy Program, for example, then we can pay a little bit of the cost and then Medicaid kicks in and pays most of it. If we don't get that work done in time and we pay all of the cost and it's much more expensive for the County. So it really is both cost effective and compassionate, I think, to keep our case loads at a reasonable level. So we'd like to propose that we fill this position at this point. It is a budgeted position, it's already in the budget, we had planned to do this. I just needed to come to you and say, now's the time and we need to go out and do it. I would like to ask Mike Weinard, too as you know, is one of our most experienced workers. You've seen Mike on other occasions and he would like to tell you a little bit about what some of the issues are that he deals with that would help explain why this is a need at this point.
Social Worker Michael Weinard: Craig mentioned a program called Medically Needy which is a form of Medicaid. Most of the people that our social workers deal with are enough above income that they're not on standard Medicaid so we have this Medically Needy program which is a State Federal program. Client has a spend down they're assigned and if they meet their spend down, paperwork gets done then they ultimately get Medicaid which, again, as Craig said is a savings to all of us because of the Title 19 Medicaid pays for their medications and other expenses. But it's a complex program, it's very confusing, there are forms to fill out, it has to be organized. There's a timeline that everything has to be done and if you don't have somebody steering these consumers, going through the whole thing with them, it doesn't get done, they don't get Medicaid cards and then later on they or we or someone is looking at maybe medication bills of 7,8, $900 a month. Especially with some of the mentally ill people on these newer meds. Where if they had the direction earlier and we were proactive they might have a spend down of 100 or $150 to meet. Somebody helped them get the paperwork done, got done timely, they got on the program. That's an example. That one in particular, with the consumers we're working with, is really bogging us down. It takes an enormous amount of time. But to go to a comment I heard Steve make a few minutes ago, about needing to get out and see these people, rather than being bogged down with the telephones and the paperwork. That's what's happening with people like me. It doesn't matter how much experience you have. I've got nearly 27 years in this and there's days it doesn't seem like it matters. We're operating seat of the pants. It's like we're reacting to everything instead of being proactive. These phone calls like my life is really going down the tubes, I've lost my job. I don't have the money to pay next month's rent. I don't have the money to pay my meds. I'm really concerned I'm going to end up in the hospital. We need to be getting those calls and responding to them and helping people beforehand when those situations are coming up, rather than hearing about it after the person's in the hospital, after they've needed to go the care facility, after their meds have been increased and doubled, and it adds a couple hundred dollars more a month to their expenses. And as I said, we need to be the person who's out there steering that rudder and doing it proactively, rather than running around putting out, dealing with the fires and the floods. We need to be more preventive. The further this goes on, the more we find ourselves struggling with it. As Craig said, the numbers haven't gone down. When we converted some of our staff, to the social work mode 3 years ago, I think some of you will recall, we had everybody on case management up until 3 years ago, the numbers got unwieldy and we converted some of our staff, including me, to the social work mode, which meant that we could have increased cases. At the time we were talking 50,52, 55,56 and that was the literature that Laurie Smith put together for the presentation. I think I stated that for the first month or 2, and there's been times I've run in the low 70's, and right now I, and most of my coworkers, are running, as Craig said, middle 60's and at times, much higher. The consumers out there are not getting what they need from us.
Lacina: Resources expended to keep somebody at home and stable, if you can react to a incident and keep them there, versus if they go into deep depression and suicidal, from a kind of crass stand point, the cost of bringing some back from the crisis, total crisis, is so much more expensive, if we can get in there early and keep them at a higher level.
Weinard: I would say it is a lot greater cost. It's a lot greater cost. We have, as you all know, we have a great network of providers out there in this community that we contract with for services. But not only does the buck stop with us, the responsibility to oversee all this, to organize, and to give direction to this whole network, this team that our consumers have, that buck stops with us, with our workers too. If we're not able to do that as well as we're really capable of, then we're floundering around. I think we're throwing away some money out there too.
Lacina: Their quality of life is sinking as well.
Weinard: Without a doubt.
Bolkcom: Questions from the Board?
Stutsman: Craig, where are you going to put this person? There's some space concerns for the building.
Mosher: That's a very good question. It's going to mean that they'll have to double up with somebody else. We're at the point where we don't have any additional space and a new worker has to go in with an existing worker and they have to share an office. That's the real problem because if you need to see a consumer in your office, you can't do that if somebody else is there. You have to meet someplace else. You've got 2 people talking confidential cases on the phone in the same room. You've got confidentiality problems, as well as just sort of quality of working environment for the people that are there. Those offices, as you know, aren't very large to begin with and to put 2 people in one is very tight. It's a problem but we don't have any solution at the time, at this time.
Stutsman: Is anybody sharing offices in this unit now?
Mosher: There are 3 now that are sharing. 3 offices that are sharing and this would be the 4th then. I hope that with our long range planning we're working on solving this but it's an immediate problem and there's no solution except to double up.
Duffy: Well I think there is a solution. There's a meeting room. Don't they use that?
Mosher: We do that but it's... it means dragging your stuff in there and dragging it back out.
Lacina: Then they have to move out every time.
Duffy: Well, yes, that's the way we've been doing it here too.
Mosher: Well and we do that but it's...
Stutsman: Are you talking, Charlie, about converting that meeting room into offices?
Duffy: No, I'm just saying that for something confidential there shouldn't be 2 people in one room. There are other ways around it and I'd say to probably (inaudible)...
Jordahl: Does that figure 3 apply to that DHS component too, or are there more people doubled up?
Mosher: No, there are other people in DHS, I believe, that are doubled up. That's just in our unit.
Lacina: Uh-huh.
Jordahl: Great.
Weinard: To be very candid too, there are 2, what we call outer offices in that outer perimeter, the famous offices that have windows, that everybody likes. Those offices do have, I believe, around 20% more square footage. They are deeper, a couple feet deeper as you walk in. Those are the ones that we currently have people doubled in. There are one or 2 of those left. The most senior people left on our staff, who have not been asked to double, those people are my coworkers. They are painfully aware that when we come in and talk to you about something like can we add another worker to the staff, what one of the implications is and I don't think you would talk to one of those people who would rather keep a single office as opposed to having another worker to be working with the consumers. We're very aware of what the implications, as least the short term ones are in that building. It's something we‘ve discussed in Labor Management too, as Sally (inaudible).
Lacina: I hope you share with them we appreciate that.
Weinard: Uh-huh.
Bolkcom: I've got a couple general questions in terms of... I think there is concern... I'm concerned about the increase in number employees in this department over the last, I don't know, couple of years. You've described a case load where you've got emergency situations that I think everybody would agree would need immediate attention. We'd hope to have somebody there but, Craig or Mike, can you give some sense of the case loads in general? Do we have people of the... Say if somebody has a caseload of 63 or 5 people, how much contact do those 65 people have on a regular basis with the social worker? I'm assuming not all 65 of those cases are people getting ready... that just lost their jobs and are suicidal. I'm trying to get a sense of the average case load. The other question I had was in terms of this number... I assume people get social work services and then they don't anymore, that they graduate or they move on. So once you're in the system, how do you get out of the system, I guess, is the question.
Mosher: As long as the person is receiving County funding, as long as we're paying for their services, we need to have someone who identifies what services are needed and authorizes the County dollar. So one of the jobs that Mike and the other workers do is to sign the authorizations that say we're going to purchase X number of hours of supported department living service for this particular client for the next 6 months. Somebody needs to actually authorize those County expenditures and that's the job of the worker who knows what that case is. Individuals that are receiving County funding will have a worker all the time that they are receiving County funding. It may be... it's long term arrangement. Many of these people are going to need services the rest of their lives.
Bolkcom: ...are long term, sure.
Mosher: So yes, it's a permanent deal.
Bolkcom: So what about case loads? Give me some sense of that.
Weinard: I have a small group of individuals, 2, 3, 4 that I frankly, maybe see face to face, maybe twice a year. But yet, if they are getting some other service, there's a phone contact there. I would like to think I am reasonably aware of what's going on. I have other individuals maybe right now, as many as 12 to 15, that I am seeing a couple times a month and getting several phone calls a month from other providers working with them. We have people, obviously, working with as many as 5 or 6 different agencies and then I am supposed to be the hub of that and orchestrate everything that is going on. Now my case load is exclusively mentally ill, the vast majority of my people, and what I have found with people I have discharged in the past, the higher your case load gets, the more you press and the more you look around to find someone who's doing well enough to discharge and we don't necessarily automatically take them off of our caseloads when the County is no longer funding. We have a buffer period, a transition period where we keep the person on our caseload. We keep in touch with them by phone and we know what is going on. Then we get to a point, we sit down and talk with them about the actual discharge. We send them a letter. They know what to do to get back in touch. What I have found is, the higher my load's been and I look around for people that I think can make it on their own without my assistance and I'm discharging those people. In consultation with my supervisor, that's how this is handled. Those people, most of them, unfortunately are coming back onto our rolls and some of them are coming back on within a few months, almost to the point it's an embarrassment if you were the worker that discharged them. The fellow next door to you is saying to you someday, gee I have this person on my caseload now and here's what I found out has happened to them in the last 2, 3 or 4 months since they worked with you. As opposed to, if I had less people to work with and could do a much more comprehensive job... I'm thinking that people that I discharged several years ago, when the load was lower... I think the road was paved much better for them. They haven't gone forever without services but they've been able to handle it on their own for a much longer period of time than what we are seeing now. Recidivism is an unfortunate word, that's not a great word, but for lack of a better one right now, that does happen. No matter how good our network is, no matter how good the providers and the medications... A lot of these people obviously have these disabilities or the illnesses for life. It's not going to go away.
Bolkcom: Thanks, Mike. OK, other questions.
Stutsman: Craig, is there any kind of system in place for case weight, am I using the right term? I know that some cases require a lot more intensity than other cases. We see the number 65 cases, well I'm sure not all those cases are requiring regular contact. Like Mike said, some people he sees once or twice a year. Do you have anything like that in place, so we have a better handle of just exactly the amount of work that's required for each one of these cases?
Mosher: Yes. We don't have a sort of numerical rating scale for that the way DHS does but what we do is Sally Murray and Kelly Weston, the supervisors, allocate cases according to how severe those cases are and what they expect the demands are going to be on the worker's time. So each worker has a balance of cases that are very severe and that are going to require a lot of time and cases that are less severe and that will require less time. We try to keep that balanced. That's sort of the way that we do that. We don't have a numerical scoring system the way DHS does with that.
Weinard: If I'm showing 5 more on the tally, that does not necessarily mean that my supervisor will not bring me the next case, as opposed to my coworker who is showing 5 less than I have. You get into cultural factors with some of the clients. Some of them need to have a male worker to work with and vice versa. We have our varying backgrounds and some of us have more expertise in one area than another. Mine is primarily in working with people with mental illnesses. If we have coming through intake... the next 4 people are people with mental illness, the chances are she needs to come to me with at least one of those individuals to add to my case load, especially if we've got another specialist who deals in developmental disability or autism for example.
Bolkcom: OK. Any final questions?
Lacina: You're kind of trapped. In one hand, you're worried about recidivism but on the other hand, you've got the State looking over your shoulder, going through your records, under this managed care concept. We're all trying to be efficient. So you're kind of stuck in the middle in both situations.
Weinard: It's nothing that computers are going to do for us, unfortunately. We've talked about that and we've milked about all we can out of it.
Mosher: I don't think we need any formal action on this but I need your agreement to go ahead and fill the position.
Bolkcom: OK. Is the Board OK with that?
Stutsman: Uh-huh. Yes.
Mosher: Is that OK? Can I do that?
Lacina: It's in the budget and we planned for it.
Mosher: It's budgeted. It's all set.
Bolkcom: All right. Any other business? Craig? Mike?
Duffy: I'd like to make...
Bolkcom: Charlie...
Duffy: The Department of Human Services... I really appreciate the people that work in that department, including you 2, because we always did say that put people first and it looks to me like you care about people, both of you. That's really what it's all about. But I ask this all the time, are we gaining on the enemy? Sometimes I'm not so sure, especially how the economy, especially the farm economy... I appreciate what you're doing.
Mosher: Thank you.
Bolkcom: Thanks, thanks, Mike. Have a good day.
(Continued in Part 2)