November 18, 2019
Minutes
Minutes
Present: Ed & Suellen Doggett, Mark Kemmerle, David Cowing, Debbie Dionne, Barry Schklair, Diane Boas, Kim Humphrey, Derek Fales, Heidi Bechard, Katlyn Blackstone, Dan Bonner, Betsy Mahoney, Margaret Cardoza, Helen Hemminger, Staci Converse, Peter Stuckey, John Regan, Tracey Webb, Julie Brennan, Susan Farwell, Beth MyLroie, Jenn Brooking, Bob Carpenter, Cullen Ryan, and Vickey Rand. Via Zoom – (Bangor-OHI): Maria Cameron and a SUFU Member. (Bangor-UCP): Andrew Cassidy and Will Soule. (Brunswick): Ray Nagel. (Winthrop): Cathy Dionne. (Sanford): Emily Spencer. Misc. sites: Victoria Copp, Paula Bush, Jillian Jolicoeur, Kathy Adams, Rachel Dyer, and Craig Patterson.
Cullen Ryan introduced himself and welcomed the group. Participants introduced themselves. Minutes from the last meeting were accepted.
Featured Speakers: Derek Fales, Waiver Services Director, Developmental Disabilities and Brain Injury Services, DHHS-OADS, and Heidi Bechard, Initiatives & Implementation Manager, DHHS-OADS. www.maine.gov/dhhs/oads Topic: An update on Maine’s Home and Community-Based Services (HCBS), including discussion on the provider self-assessment, FAQs, and OADS’ continued path forward to compliance.
Cullen: Today we have Derek Fales and Heidi Bechard, providing a follow-up to the September presentation on Maine’s Home and Community-Based Services (HCBS), including discussion on the provider self-assessment. Thank you for being here to present further on this, Heidi and Derek!
Heidi Bechard: As you know the Department has been working towards compliance with the Home and Community-Based Services (HCBS) Settings Rule. A lot of work has been done and I wanted to provide you with an update on the progress we have made.
Begin Presentation (Click here for the presentation)
Heidi: The federal deadline for compliance with the HCBS Settings Rule is March 17, 2022. We’re identifying what we need to do to meet that deadline. We’re requiring provider self-assessments for residential service providers and non-residential service providers. We’re asking all shared living providers to complete the self-assessment as well, though there are some portions that shared living providers who are related family members do not need to complete. The oversight agency is the one held to ensuring that those shared living provider self-assessments are completed. We also have a dedicated email for questions related to this ([email protected]). The deadline is 11/30 for providers to complete their self-assessments. We’ve held community town halls, which were wonderful, from which we’re gathering some Frequently Asked Questions (FAQs), and will be posting the PowerPoint presentation shared at those town halls as well.
Discussion:
-It was asked if the Department knows how many shared living providers are related family members.
Derek Fales: We don’t have this information. There’s nothing in our database that alerts us to the relationship for shared living providers. We’ve discussed collecting this with the Office of MaineCare Services (OMS), but I don’t know what that would look like.
-It was asked if shared living is included in just Section 21 or both Section 21 and Section 29.
Derek: It’s an available service in both Section 21 and Section 29.
-It was stated that finding the EconSys Portal on the website is difficult.
Heidi: To access the EconSys Portal, if you look on the left-hand side it says “compliance portal” – click on to that and it will bring you to where you can link on to the EconSys Portal (click here for a link directly to the EconSys Portal). Anyone with questions regarding navigating the EconSys portal while completing the self-assessments can email [email protected], which is monitored by EconSys. Due to the very short timeframe to complete the self-assessments, we have established office hours, which can be found on the OADS Newsroom (click here for the listing of office hours). For updates, you can visit the HCBS website. We want your feedback, we want you to inform us of our strengths and weaknesses, so please contact us!
-A provider stated that they completed their self-assessments last week. He stated that it was 55 questions, and though daunting at first, after the third time or so he got the hang of it, and it was almost fun. However, his agency only had to complete 18 of them, whereas others have up to 78+, which would be a lot more work.
Heidi: I’m glad to hear that, it’s positive reinforcement that it’s an ok assessment to complete. Did you learn anything about your agency while completing it?
-The provider stated that he did. He stated that you could hover over certain key words or phrases for definitions as well which was helpful. He stated that for some of the questions he could answer with the agency name Choices Are for Everyone (CAFE).
Heidi: You mention a good point – this is all about choices and ensuring that people have choices and a say in how they live their lives.
-A parent stated that she received a letter with a telephone number to call to have someone call her back. She stated that it was great to speak to a real person and have someone actually listening to her. This was a positive change.
-A provider asked why the people receiving services aren’t completing surveys.
Derek: The responsibility is on the provider – they have to ensure they’re delivering the services in accordance with the HCBS Settings Rule. The individual will have an experience survey, where they will meet with their case manager at least on an annual basis and have the opportunity to comment on their experience receiving services.
Heidi: This work takes a village, and we’re all in it together. It’s a marathon versus a sprint and we have a lot of steps to take before we reach the end goal. We will be involving people who receive services, it’s coming, and it’s imperative. The provider self-assessments will help us see the areas needing improvement. The initial Statewide Transition Plan will be posted in December, likely mid-to-late December, and there will be a 30-day public comment period, in which we will collect questions and comments, and to which the Department will respond. I welcome you all to share your thoughts, comments, or concerns.
Derek: We have to make sure we complete the decision-making and the systemic assessment first. We have to pin down dates when we think we can change laws – we have to work with the Legislature closely around this because whatever we write in the State Plan CMS will hold us accountable. It will be posted on the OMS website, there will be a public hearing, etc.; this will go through the usual process.
-It was asked how inclusive the Stakeholder Advisory Group is.
Heidi: The meetings are public, and stakeholders have been appointed by the Commissioner.
Derek: The Stakeholder Advisory Group is comprised of individuals receiving services, advocates, self-advocates, family members, providers, with the Maine Developmental Disabilities Council, among other organizations, being represented as well.
-It was asked when the next meeting is occurring.
Heidi: The December meeting will be held at Purdue in Augusta.
Derek: There are only so many seats at Purdue, as the room has a capacity. We have had a few people who were not appointed by the Commissioner attend, and in those instances, there was room to accommodate additional people. There’s also a Zoom option as well. However, the purpose of the meeting is to attend after having already reviewed the materials, and then provide comments and guidance during the meeting. Without having the documents in advance, the meetings may not be helpful.
-It was asked how information is disseminated to other stakeholders who are not members of the Advisory Group.
Derek: After the group’s work is complete it will be available on our website.
-It was asked if materials can go out publicly before the meeting.
Derek: They cannot, unfortunately, however the town halls provide an excellent opportunity to provide additional feedback.
-It was asked how many members were appointed to the Advisory Group.
Derek: I believe there are 25 appointed members. We’re hoping to do more town halls as well, which will offer an opportunity to provide feedback and we can continue to update our FAQs. The next round will likely be in the spring when we’re doing on-site evaluations. For community support programs, many are facility based, and every facility will have a face-to-face visit.
-It was asked if these town halls are specific to this process or if they are more open-ended.
Derek: The town halls are specific to the HCBS Settings Rule.
-A self-advocate stated the systemic philosophy ought to be what the individual wants, not what the provider wants. The individual should not meet the needs of the provider, but rather the provider meets the needs of the person. The provider ought to fit into the individual’s box, not the other way around as the system has functioned for decades.
Heidi: I think you highlighted the way the current system may exist now. We’re going to be experiencing a huge shift, because the Settings Rule is about the members we’re serving, ensuring they are more integrated and included in their communities, and that they are making choices about the way they live their lives.
Derek: There are some things in our own rules and regulations that add to this dynamic. The HCBS Settings Rule requires states not have rules or regulations which presume someone can’t do something, like med management for instance, and ensure that the person has full choice. For CMS, this is just one piece of the puzzle. At a conference last week, we heard that it’s clear the states have to follow CMS regulations, as well as the Olmstead Act and the ADA. Even if CMS approves our initial plan, the Department of Justice has to ensure it complies with Olmstead and the ADA. We’re still working towards how we are defining what individual choice is, and how people are healthy and safe in the environments that they choose.
-A provider mentioned the age appropriateness question in the provider self-assessment and used the example of an individual choosing to bring and carry a doll which may not be considered age appropriate.
Derek: To clarify the age appropriateness question in the self-assessment, it’s not about what the individual is bringing with them, it’s about what’s being offered as a choice by the provider. CMS is talking about how they had gone into these center-based programs and there were paper dolls and children’s coloring books offered. The distinction here is the person’s choice versus what the provider offers.
-It was stated that it took four people multiple hours to complete the survey because some of the questions didn’t make sense based on the service they provide. It was asked if they reach out via email address if some of this could be clarified.
Heidi: When you use the [email protected] email, you’re reaching out to Derek and me, and you can absolutely reach out for clarification. I just want everyone to know that this doesn’t replace completing the survey itself. I invite you to reach out to me with any questions, comments, or concerns ([email protected]). We have a total of 298 provider accounts, and only about 47% have registered and started the self-assessments, so please spread the word as the deadline for the self-assessment is fast approaching.
Derek: CMS is putting a lot of pressure on Maine because we’re one of only four states that don’t have approved transition plans, which CMS has set a goal of having all plans approved and finalized by the end of the year. We know we won’t be able to meet that goal because we won’t be able to submit it until after the new year to allow the time needed to answer all of the comments solicited during the public comment period.
Cullen: Heidi and Derek, thank you both for being here and for presenting! Heidi, you said something that struck me that I liked, your invitation to inform the Department of its strengths and weaknesses. This is the invitation to the kind of dialogue this group has longed for and it’s a welcomed change. Thank you both again, and I hope you continue to attend future meetings!
Heidi: Thank you for having us. This should be a true collaboration!
End Presentation (round of applause)
DHHS – Office of Aging and Disability Services (OADS) - www.maine.gov/dhhs/oads - Click here for the most recent waitlist update provided by OADS staff.
Craig Patterson: I don’t have a lot of high-level updates. We recently hired an Associate Director for Developmental Services, Betsy Hopkins, who you met remotely last month. We’re now focusing on things such as legislative reports, which we have to supply around the beginning of the year. We’re working on multiple revisions across the board, including a lot of work related to our crisis system. And, we’re also making some changes to our regional offices, some of that has to do with changes with the way we’re going to manage guardianship, with changes in the probate code pushing some of that forward. We’re in all hands-on deck mode with the HCBS work because there’s so much involved in all of that. If there are any particular questions the group has, I’m happy to answer them.
-A self-advocate stated that the Commissioner recently reported on the waiting lists, which was covered on the local news. It was asked if there’s an update on the waiting lists.
Craig: From our end, part of this involves funding over which we have no have control. We’re making some offers to people on other waitlists hoping that will take some of the pressure off.
Derek: The waitlist has been a topic for many years now. Essentially, through the HCBS process we’re looking at our service system, what we are providing for services, what that means for the individual, and if there are gaps in the system that we can look to fill. CMS has new services and funding, of which we’re hoping to take advantage. We’re working closely with CMS and receiving some technical assistance around that. Any time we want to change something you have to think of the effect on the individual; can we afford to add something and not take away from someone else. There are no easy answers and it’s not an easy discussion. We need to look at the whole picture.
-It was stated that services ought to be designed with the full person in mind.
Derek: There’s some great work going on around different service models, for instance the DD Council is looking at self-directed services and how that could be an option.
-It was asked how long people are waiting for Section 29, from when the application is complete to when an offer is made.
Derek: I don’t have that number handy, but we can take it back and get the answer. There was a position funded through the Legislature to assist with applications, so we’re looking to hire for that. We get about 40 to 50 applications that have to be processed each month, and there needs to be a level of care determined for each person.
-It was asked if the waitlist is a result of the system’s capacity, funding, or something else.
Derek: There are several drivers, but it definitely depends on funding. Routinely we’ll offer more slots than what we have approved from CMS because we have more funding; then we go back to CMS. Funding is the primary driver, except for a couple of waivers where it’s capacity (brain injury and other related conditions), where they have an offer but can’t find a provider to provide the service.
-A former Legislator asked what dollar amount would eliminate the waitlist. He stated that having been in the Legislature previously, this is a question he has asked the Department to no avail.
Derek: I don’t have that figure to provide today.
Craig: I don’t have that figure either, but part of the issue is that Appropriations has the tendency to work in the other direction. One of the things we’re trying to do with our reporting is change the way that process plays out, so that the Legislature might be more aware of what our needs are before they’re in the position to determine our funding. Making our funding needs known further in advance will be advantageous to all involved.
-It was asked if people have been on the waiting lists for years, and how offers are made from the waitlists.
Derek: There are individuals who have been on the waitlist for Section 21 for a number of years, yes. For Section 21, we don’t go by the date of application, we go by priority. However, for Section 29 we go by date of application.
-It was stated that a few people in the group were in attendance last week when Commissioner Lambrew presented to the Appropriations and Financial Affairs Committee. It was stated that the Commissioner mentioned the Section 21 waitlist, including the number of people served versus the numbers on the waitlist. She also mentioned that people on the waitlists sometimes receive other services while waiting, including children’s services which was confusing. It was asked if either Derek or Craig could comment on this. It was also mentioned that in this meeting a Legislator mentioned the minimum wage increasing in January and what effect, if any, that would have on providers’ ability to recruit and hire staff, to which the Commissioner responded that some agencies have the resources but can’t find trained people to hire.
Derek: I can’t speak for the Commissioner, but I can certainly take your questions back.
-A provider stated that some of the people on the Section 21 and Section 29 waiting lists may receive case management services funded under Section 13, so that could potentially be what the Commissioner meant.
-A parent stated that the Commissioner mentioned looking at combining the Section 21 and 29 waivers and asked if that was something into which the Department was looking.
Derek: Again, I can’t speak for the Commissioner, but as I said CMS has new services and funding available into which we’re looking. With the changes to Section 29 a few years ago, Section 21 and Section 29 are now quite similar. CMS is constantly asking us why we have two waivers when they’re essentially offering the same services. As I mentioned, the DD Council is looking into self-directed services, some states are going to the managed care approach, there are many different options. We have ongoing discussions with CMS, but as far as how far along the Department is, I couldn’t comment.
-It was stated that transparency and inclusion on this is imperative.
Derek: I can certainly take all of this back to the Department.
-It was asked what the reference to the probate code earlier in the discussion meant.
Craig: There are changes being made to the probate code statewide. I’m not an attorney so I wouldn’t want to speak to the details around that. Some of those changes are driving changes we’re making around our guardianship program, which I think will better meet people’s needs and avoid some of the struggles we’ve experienced.
-It was stated that sometimes certain terminology is used in different ways. It was asked if the discussion regarding combining Sections 21 and 29 and the possibility of a lifespan waiver were the same or different discussions.
Derek: I can’t speak to the Commissioner’s comments. However, the lifespan waiver could be a completely different waiver. The lifespan waiver Delaware uses is a completely different waiver and a different way in which they decided to deliver services to people.
-It was asked if there’s an update to the RCSS (Residential and Community Support Services) residential homes closing. It was also asked if Derek could comment on Paul Saucier’s Op Ed on public guardianship that was published.
Derek: Regarding the closure around RCSS, the Department is actively working to support case managers in identifying new providers for everyone involved. We’re required by CMS to ensure the individual has provider choice. I don’t have the figures for how many people have been placed, but that’s a question I can take back. Public guardianship falls under APS (Adult Protective Services), so I wouldn’t be able to comment on that either, but I can definitely take it back.
-It was asked if the individuals who are very content with their life in their home have the option of staying and having a different provider come in to provide services. It was stated that at least one of the homes isn’t owned by RCSS but is rented.
Derek: The Department can only authorize the person’s choice of provider. If a new provider is going to be operating that setting than we would receive a prior authorization and review that.
Staci Converse – Disability Rights Maine (DRM): In so many situations housing and services have been bundled. DRM outreached all of the people who received services from RCSS, and let people know how to reach out to DRM. One thing that came up was that it’s their home and they want to stay there. There are leases on the home and the current provider doesn’t want to transfer that lease to another provider. So, now we have a situation where people are losing their homes due to the loss of their provider. This ties back into the HCBS Settings Rule and the tenancy portion which ensures that people have legally enforceable leases. This highlights issues with our current system, and we need to ensure that people don’t end up in these circumstances again.
-It was asked what the crisis services changes were.
Craig: We haven’t worked through all of them yet, but one of the changes has to do with the intake system. For years we have been contracting with another entity to handle those calls. That has not gone as well as we would have liked. We’ve had situations where people have been unable to get through to a crisis worker and in turn have been referred to the mental health crisis team. We’ve had a fair amount of calls that were just dropped. We’re revising that whole phone system and involving the crisis staff themselves in that phone system management. It’s a fairly complex system that will involve a phone tree mechanism which will hopefully allow us to get to a place where we have no missed calls, and all calls will eventually get to the right person. Just that change in itself impacts the nature of the crisis work because they haven’t been doing that piece. The plan is to get to a place where the crisis team is doing more preventative work and less crisis response. We’ve gotten to a point where we’re constantly responding to crises versus preventing them from occurring in the first place. We’re looking at training mechanisms, and we’re trying to make use of the START model, used in other states and developed at the University of New HampshireInstitute on Disability. We’re working with them to get our crisis team aligned with the START philosophy and service delivery model. We think this will make a huge difference. All of this will take some time, and there will be other changes as we work through all of this as well.
-It was asked if there’s an update on the self-advocacy contract.
Craig: We’re working through some internal process issues and moving forward with the self-advocacy RFP process, which should be initiated within the next few weeks. In the interim, we have extended the DD Council contracts until that RFP gets released, and eventually we’ll have an awarded provider for the self-advocacy work.
Cullen: I want to thank Derek and Craig for answering questions today, and for the questions you’ll be bringing back to the Department. Thank you for the transparency and discussion around a lot of systems change seemingly occurring all at once. Hopefully Paul and/or Betsy will be able to attend next month with answers to questions unable to be answered today, as well as continuing this interactive dialogue. Thank you again, it’s great to have OADS consistently around the table, eager for our feedback!
DHHS – Office of Child and Family Services (OCFS) - www.maine.gov/dhhs/ocfs - No one from OCFS was in attendance. Click here for the most recent OCFS System Improvements Update.
Special Education Update
Beth MyLroie: Transition remains a large focus, with work occurring on better planning for transition and what happens after high school.
-It was asked if case managers and other staff are familiar with both child and adult services.
Beth: I don’t know. I know that the transition coordinators with whom I work, within about three agencies, have this familiarity. I sense that there’s an increased interest within agencies to have a specific transition coordinator within adult case management, who oversees the transition from high school into adult services.
Kathy Adams: Also, don’t forget that Voc Rehab has transition teams.
-A former special educator stated that there is a state regulation that ensures all high schools have guidance counselors. However, if a student is looking for some sort of service outside of going on to standard higher education options after high school, it was rather useless. This is a missing link for this population.
-It was stated that Maine is lagging behind when it comes to children under age one. And, for grades one through twelve Maine has a higher rate of kids in special education. If more attention was paid to younger kids, it might turn that around. It was stated that it is important to do as much as we can as early as we can, and there are definitely issues in Maine around that.
SMACT (Southern Maine Advisory Council on Transition) Update:
Kathy Adams: The next SMACT meeting is on Friday, 12/6 at 1pm, at DHHS in South Portland, and will feature Sandra Lynham, Director of Counseling and Disability Services, Southern Maine Community College discussing transition.
The January meeting will be on Friday, 1/3, and will feature Elizabeth Newport from Social Security presenting an update on Social Security programs and benefits. Also, the Department of Education (DOE) has a new statewide Special Education Director, Erin Frazier, who was previously the Director of Special Education for York schools.
Developmental Services Stakeholders Continuum of Care
Cullen: The Developmental Services Stakeholders Continuum of Care group has been working on a more user friendly diagram for the Developmental Services Lifelong CoC (DD CoC), which is nearing completion and will hopefully be an effective tool for the Legislature. The layout is much more linear and illustrates the entire lifespan. This group started reviewing the Blueprint for Effective Transition today, and will be working more on that next month.
Disability Rights Maine (DRM) Update:
Staci Converse: The Department is holding transportation listening sessions, with the first one occurring tonight. This is an opportunity to talk about the problems with the non-emergency transportation system, or more generally about the issues with transportation in Maine. If you have things to say, try to get to one of those listening sessions.
-It was asked what, realistically, could be done differently with transportation.
Staci: It’s just not working. They’re meeting internally and trying to develop a plan. They’re looking at a single broker, but we’ve tried that in the past and it really didn’t work. Non-emergency transportation is available to MaineCare recipients. However, that system is pretty inflexible and there are barriers to access – how soon you have to request a ride, when you can cancel, etc. It’s not a system designed well for people with ID/DD to access. A systemic fix they could look at for people who live in a group home setting is clarifying the regulations about who should do what (is the provider responsible for transportation or not, etc.). That would be an easy fix that would be very helpful. It’s very difficult for people in group homes to access transportation, how often they can leave the home restricts their ability to be a member of their community, to advocate for themselves, etc.
-A self-advocate stated that a lack of training amongst transportation providers is problematic. It was stated that some of the problems relate to the rates too. It was stated that if you have three strikes against you, you can’t access the service for 90 days, even if it’s not the individual’s fault and it’s the driver’s mistake. Trying to navigate the transportation system is very stressful, difficult, and filled with barriers. It was asked where the Department is in the cycle of the transportation contracts.
Staci: I think they were up recently, but it’s my understanding they held off on doing anything with them. It’s been such a mess for so long; these listening sessions provide an important opportunity for feedback.
-A self-advocate stated that lack of transportation leads to isolation and doesn’t promote community inclusion.
Craig: This has been an issue across the state for many people. People with ID/DD are impacted at a pretty high level, and we hear horror stories. When we did our listening sessions, transportation was issue number one or two because it does hit on every area of a person’s life. We certainly know there’s an issue and we’re hopeful we can play a role with other state agencies in moving this forward. It’s definitely a complex problem.
Staci: We continue to offer ongoing rights, supported decision-making, and visual gestural trainings, which can be found in the events section of our website or you can find them and register on the OADS Training website. Though often you hear about the trainings we’re offering and so on, most of the work we do is individual advocacy.
Federal & Housing Updates:
Cullen: On 9/27 the President signed a short-term CR to fund the government through November 21. If Congress doesn’t pass budget bills for the offices and agencies not yet funded for FY 20 before the CR runs out, or pass another CR, there could be a partial government shutdown. The House and Senate T-HUD budgets look very favorable and aren’t far off, but it remains to be seen if there is appetite in Congress to pass a mini Omnibus budget bill. There is a Section 811 RFP out; however, HUD made changes to its 811 program and it no longer provides bricks and mortar and rental subsidies. The Section 811 program now operates as a Section 8 program for people who are non-elderly with a disability. There are roughly sixty 811 Section 8 vouchers in the state; though MaineHousing hasn’t been able to issue them all and is taking a look at the ways in which they can be better utilized.
State Legislature Update:
Cullen: The Legislature will be back in session on 12/18. There are growing concerns around the Section 29 waitlist, and that the cliff of no services after high school has reemerged. I’m unsure if there’s emergency legislation to address that or not, but there is always the option of the Governor submitting an emergency bill. DSP rates also remain concerning. There is a carry-over bill from the first session which would set DSP rates at 125% of minimum wage, up to $15 per hour after January, so we’ll be keeping a close eye on that when the Legislature comes into session.
-It was stated that Commissioner Lambrew’s testimony in front of the Appropriations Committee appears to have downplayed the issues within the system. It was stated that there’s a lot on the Commissioner’s plate, but it did not appear as if the Section 21 and 29 waitlists were a high priority. However, most of the questions from the Committee related to Section 21 and 29 services and the waitlists, so it appears as if this is definitely on the Committee’s radar. It was mentioned that there is a legislative Workforce Commission, which originally began looking at personal care attendants and nursing care as its primary focus. However, it has expanded to include the workforce issues for the ID/DD world as well. Discussions have included advocacy around increased pay and professional advancement for DSPs. It was stated that DSPs have come to the Commission and have spoken very eloquently and movingly about their financial struggles stemming from the low rates.
The next meeting will be on Monday, December 9, 2019, 12-2pm, Burton Fisher Community Meeting Room, located on the First Floor of One City Center (food court area, next to City Deli), Portland.
Featured Speaker and Topic: Paul Saucier, DHHS Director of Aging and Disability Services. Updates, and continued discussion from today’s meeting.
Unless changed, Coalition meetings are on the 2nd Monday of the month from 12-2pm.
Burton Fisher Community Meeting Room, 1st Floor of One City Center in Portland (off of the food court).
The Maine Coalition for Housing and Quality Services provides equal opportunity for meeting participation. If you wish to attend but require an interpreter or other accommodation, please forward your request two weeks prior to the monthly meeting to [email protected].
Cullen Ryan introduced himself and welcomed the group. Participants introduced themselves. Minutes from the last meeting were accepted.
Featured Speakers: Derek Fales, Waiver Services Director, Developmental Disabilities and Brain Injury Services, DHHS-OADS, and Heidi Bechard, Initiatives & Implementation Manager, DHHS-OADS. www.maine.gov/dhhs/oads Topic: An update on Maine’s Home and Community-Based Services (HCBS), including discussion on the provider self-assessment, FAQs, and OADS’ continued path forward to compliance.
Cullen: Today we have Derek Fales and Heidi Bechard, providing a follow-up to the September presentation on Maine’s Home and Community-Based Services (HCBS), including discussion on the provider self-assessment. Thank you for being here to present further on this, Heidi and Derek!
Heidi Bechard: As you know the Department has been working towards compliance with the Home and Community-Based Services (HCBS) Settings Rule. A lot of work has been done and I wanted to provide you with an update on the progress we have made.
Begin Presentation (Click here for the presentation)
Heidi: The federal deadline for compliance with the HCBS Settings Rule is March 17, 2022. We’re identifying what we need to do to meet that deadline. We’re requiring provider self-assessments for residential service providers and non-residential service providers. We’re asking all shared living providers to complete the self-assessment as well, though there are some portions that shared living providers who are related family members do not need to complete. The oversight agency is the one held to ensuring that those shared living provider self-assessments are completed. We also have a dedicated email for questions related to this ([email protected]). The deadline is 11/30 for providers to complete their self-assessments. We’ve held community town halls, which were wonderful, from which we’re gathering some Frequently Asked Questions (FAQs), and will be posting the PowerPoint presentation shared at those town halls as well.
Discussion:
-It was asked if the Department knows how many shared living providers are related family members.
Derek Fales: We don’t have this information. There’s nothing in our database that alerts us to the relationship for shared living providers. We’ve discussed collecting this with the Office of MaineCare Services (OMS), but I don’t know what that would look like.
-It was asked if shared living is included in just Section 21 or both Section 21 and Section 29.
Derek: It’s an available service in both Section 21 and Section 29.
-It was stated that finding the EconSys Portal on the website is difficult.
Heidi: To access the EconSys Portal, if you look on the left-hand side it says “compliance portal” – click on to that and it will bring you to where you can link on to the EconSys Portal (click here for a link directly to the EconSys Portal). Anyone with questions regarding navigating the EconSys portal while completing the self-assessments can email [email protected], which is monitored by EconSys. Due to the very short timeframe to complete the self-assessments, we have established office hours, which can be found on the OADS Newsroom (click here for the listing of office hours). For updates, you can visit the HCBS website. We want your feedback, we want you to inform us of our strengths and weaknesses, so please contact us!
-A provider stated that they completed their self-assessments last week. He stated that it was 55 questions, and though daunting at first, after the third time or so he got the hang of it, and it was almost fun. However, his agency only had to complete 18 of them, whereas others have up to 78+, which would be a lot more work.
Heidi: I’m glad to hear that, it’s positive reinforcement that it’s an ok assessment to complete. Did you learn anything about your agency while completing it?
-The provider stated that he did. He stated that you could hover over certain key words or phrases for definitions as well which was helpful. He stated that for some of the questions he could answer with the agency name Choices Are for Everyone (CAFE).
Heidi: You mention a good point – this is all about choices and ensuring that people have choices and a say in how they live their lives.
-A parent stated that she received a letter with a telephone number to call to have someone call her back. She stated that it was great to speak to a real person and have someone actually listening to her. This was a positive change.
-A provider asked why the people receiving services aren’t completing surveys.
Derek: The responsibility is on the provider – they have to ensure they’re delivering the services in accordance with the HCBS Settings Rule. The individual will have an experience survey, where they will meet with their case manager at least on an annual basis and have the opportunity to comment on their experience receiving services.
Heidi: This work takes a village, and we’re all in it together. It’s a marathon versus a sprint and we have a lot of steps to take before we reach the end goal. We will be involving people who receive services, it’s coming, and it’s imperative. The provider self-assessments will help us see the areas needing improvement. The initial Statewide Transition Plan will be posted in December, likely mid-to-late December, and there will be a 30-day public comment period, in which we will collect questions and comments, and to which the Department will respond. I welcome you all to share your thoughts, comments, or concerns.
Derek: We have to make sure we complete the decision-making and the systemic assessment first. We have to pin down dates when we think we can change laws – we have to work with the Legislature closely around this because whatever we write in the State Plan CMS will hold us accountable. It will be posted on the OMS website, there will be a public hearing, etc.; this will go through the usual process.
-It was asked how inclusive the Stakeholder Advisory Group is.
Heidi: The meetings are public, and stakeholders have been appointed by the Commissioner.
Derek: The Stakeholder Advisory Group is comprised of individuals receiving services, advocates, self-advocates, family members, providers, with the Maine Developmental Disabilities Council, among other organizations, being represented as well.
-It was asked when the next meeting is occurring.
Heidi: The December meeting will be held at Purdue in Augusta.
Derek: There are only so many seats at Purdue, as the room has a capacity. We have had a few people who were not appointed by the Commissioner attend, and in those instances, there was room to accommodate additional people. There’s also a Zoom option as well. However, the purpose of the meeting is to attend after having already reviewed the materials, and then provide comments and guidance during the meeting. Without having the documents in advance, the meetings may not be helpful.
-It was asked how information is disseminated to other stakeholders who are not members of the Advisory Group.
Derek: After the group’s work is complete it will be available on our website.
-It was asked if materials can go out publicly before the meeting.
Derek: They cannot, unfortunately, however the town halls provide an excellent opportunity to provide additional feedback.
-It was asked how many members were appointed to the Advisory Group.
Derek: I believe there are 25 appointed members. We’re hoping to do more town halls as well, which will offer an opportunity to provide feedback and we can continue to update our FAQs. The next round will likely be in the spring when we’re doing on-site evaluations. For community support programs, many are facility based, and every facility will have a face-to-face visit.
-It was asked if these town halls are specific to this process or if they are more open-ended.
Derek: The town halls are specific to the HCBS Settings Rule.
-A self-advocate stated the systemic philosophy ought to be what the individual wants, not what the provider wants. The individual should not meet the needs of the provider, but rather the provider meets the needs of the person. The provider ought to fit into the individual’s box, not the other way around as the system has functioned for decades.
Heidi: I think you highlighted the way the current system may exist now. We’re going to be experiencing a huge shift, because the Settings Rule is about the members we’re serving, ensuring they are more integrated and included in their communities, and that they are making choices about the way they live their lives.
Derek: There are some things in our own rules and regulations that add to this dynamic. The HCBS Settings Rule requires states not have rules or regulations which presume someone can’t do something, like med management for instance, and ensure that the person has full choice. For CMS, this is just one piece of the puzzle. At a conference last week, we heard that it’s clear the states have to follow CMS regulations, as well as the Olmstead Act and the ADA. Even if CMS approves our initial plan, the Department of Justice has to ensure it complies with Olmstead and the ADA. We’re still working towards how we are defining what individual choice is, and how people are healthy and safe in the environments that they choose.
-A provider mentioned the age appropriateness question in the provider self-assessment and used the example of an individual choosing to bring and carry a doll which may not be considered age appropriate.
Derek: To clarify the age appropriateness question in the self-assessment, it’s not about what the individual is bringing with them, it’s about what’s being offered as a choice by the provider. CMS is talking about how they had gone into these center-based programs and there were paper dolls and children’s coloring books offered. The distinction here is the person’s choice versus what the provider offers.
-It was stated that it took four people multiple hours to complete the survey because some of the questions didn’t make sense based on the service they provide. It was asked if they reach out via email address if some of this could be clarified.
Heidi: When you use the [email protected] email, you’re reaching out to Derek and me, and you can absolutely reach out for clarification. I just want everyone to know that this doesn’t replace completing the survey itself. I invite you to reach out to me with any questions, comments, or concerns ([email protected]). We have a total of 298 provider accounts, and only about 47% have registered and started the self-assessments, so please spread the word as the deadline for the self-assessment is fast approaching.
Derek: CMS is putting a lot of pressure on Maine because we’re one of only four states that don’t have approved transition plans, which CMS has set a goal of having all plans approved and finalized by the end of the year. We know we won’t be able to meet that goal because we won’t be able to submit it until after the new year to allow the time needed to answer all of the comments solicited during the public comment period.
Cullen: Heidi and Derek, thank you both for being here and for presenting! Heidi, you said something that struck me that I liked, your invitation to inform the Department of its strengths and weaknesses. This is the invitation to the kind of dialogue this group has longed for and it’s a welcomed change. Thank you both again, and I hope you continue to attend future meetings!
Heidi: Thank you for having us. This should be a true collaboration!
End Presentation (round of applause)
DHHS – Office of Aging and Disability Services (OADS) - www.maine.gov/dhhs/oads - Click here for the most recent waitlist update provided by OADS staff.
Craig Patterson: I don’t have a lot of high-level updates. We recently hired an Associate Director for Developmental Services, Betsy Hopkins, who you met remotely last month. We’re now focusing on things such as legislative reports, which we have to supply around the beginning of the year. We’re working on multiple revisions across the board, including a lot of work related to our crisis system. And, we’re also making some changes to our regional offices, some of that has to do with changes with the way we’re going to manage guardianship, with changes in the probate code pushing some of that forward. We’re in all hands-on deck mode with the HCBS work because there’s so much involved in all of that. If there are any particular questions the group has, I’m happy to answer them.
-A self-advocate stated that the Commissioner recently reported on the waiting lists, which was covered on the local news. It was asked if there’s an update on the waiting lists.
Craig: From our end, part of this involves funding over which we have no have control. We’re making some offers to people on other waitlists hoping that will take some of the pressure off.
Derek: The waitlist has been a topic for many years now. Essentially, through the HCBS process we’re looking at our service system, what we are providing for services, what that means for the individual, and if there are gaps in the system that we can look to fill. CMS has new services and funding, of which we’re hoping to take advantage. We’re working closely with CMS and receiving some technical assistance around that. Any time we want to change something you have to think of the effect on the individual; can we afford to add something and not take away from someone else. There are no easy answers and it’s not an easy discussion. We need to look at the whole picture.
-It was stated that services ought to be designed with the full person in mind.
Derek: There’s some great work going on around different service models, for instance the DD Council is looking at self-directed services and how that could be an option.
-It was asked how long people are waiting for Section 29, from when the application is complete to when an offer is made.
Derek: I don’t have that number handy, but we can take it back and get the answer. There was a position funded through the Legislature to assist with applications, so we’re looking to hire for that. We get about 40 to 50 applications that have to be processed each month, and there needs to be a level of care determined for each person.
-It was asked if the waitlist is a result of the system’s capacity, funding, or something else.
Derek: There are several drivers, but it definitely depends on funding. Routinely we’ll offer more slots than what we have approved from CMS because we have more funding; then we go back to CMS. Funding is the primary driver, except for a couple of waivers where it’s capacity (brain injury and other related conditions), where they have an offer but can’t find a provider to provide the service.
-A former Legislator asked what dollar amount would eliminate the waitlist. He stated that having been in the Legislature previously, this is a question he has asked the Department to no avail.
Derek: I don’t have that figure to provide today.
Craig: I don’t have that figure either, but part of the issue is that Appropriations has the tendency to work in the other direction. One of the things we’re trying to do with our reporting is change the way that process plays out, so that the Legislature might be more aware of what our needs are before they’re in the position to determine our funding. Making our funding needs known further in advance will be advantageous to all involved.
-It was asked if people have been on the waiting lists for years, and how offers are made from the waitlists.
Derek: There are individuals who have been on the waitlist for Section 21 for a number of years, yes. For Section 21, we don’t go by the date of application, we go by priority. However, for Section 29 we go by date of application.
-It was stated that a few people in the group were in attendance last week when Commissioner Lambrew presented to the Appropriations and Financial Affairs Committee. It was stated that the Commissioner mentioned the Section 21 waitlist, including the number of people served versus the numbers on the waitlist. She also mentioned that people on the waitlists sometimes receive other services while waiting, including children’s services which was confusing. It was asked if either Derek or Craig could comment on this. It was also mentioned that in this meeting a Legislator mentioned the minimum wage increasing in January and what effect, if any, that would have on providers’ ability to recruit and hire staff, to which the Commissioner responded that some agencies have the resources but can’t find trained people to hire.
Derek: I can’t speak for the Commissioner, but I can certainly take your questions back.
-A provider stated that some of the people on the Section 21 and Section 29 waiting lists may receive case management services funded under Section 13, so that could potentially be what the Commissioner meant.
-A parent stated that the Commissioner mentioned looking at combining the Section 21 and 29 waivers and asked if that was something into which the Department was looking.
Derek: Again, I can’t speak for the Commissioner, but as I said CMS has new services and funding available into which we’re looking. With the changes to Section 29 a few years ago, Section 21 and Section 29 are now quite similar. CMS is constantly asking us why we have two waivers when they’re essentially offering the same services. As I mentioned, the DD Council is looking into self-directed services, some states are going to the managed care approach, there are many different options. We have ongoing discussions with CMS, but as far as how far along the Department is, I couldn’t comment.
-It was stated that transparency and inclusion on this is imperative.
Derek: I can certainly take all of this back to the Department.
-It was asked what the reference to the probate code earlier in the discussion meant.
Craig: There are changes being made to the probate code statewide. I’m not an attorney so I wouldn’t want to speak to the details around that. Some of those changes are driving changes we’re making around our guardianship program, which I think will better meet people’s needs and avoid some of the struggles we’ve experienced.
-It was stated that sometimes certain terminology is used in different ways. It was asked if the discussion regarding combining Sections 21 and 29 and the possibility of a lifespan waiver were the same or different discussions.
Derek: I can’t speak to the Commissioner’s comments. However, the lifespan waiver could be a completely different waiver. The lifespan waiver Delaware uses is a completely different waiver and a different way in which they decided to deliver services to people.
-It was asked if there’s an update to the RCSS (Residential and Community Support Services) residential homes closing. It was also asked if Derek could comment on Paul Saucier’s Op Ed on public guardianship that was published.
Derek: Regarding the closure around RCSS, the Department is actively working to support case managers in identifying new providers for everyone involved. We’re required by CMS to ensure the individual has provider choice. I don’t have the figures for how many people have been placed, but that’s a question I can take back. Public guardianship falls under APS (Adult Protective Services), so I wouldn’t be able to comment on that either, but I can definitely take it back.
-It was asked if the individuals who are very content with their life in their home have the option of staying and having a different provider come in to provide services. It was stated that at least one of the homes isn’t owned by RCSS but is rented.
Derek: The Department can only authorize the person’s choice of provider. If a new provider is going to be operating that setting than we would receive a prior authorization and review that.
Staci Converse – Disability Rights Maine (DRM): In so many situations housing and services have been bundled. DRM outreached all of the people who received services from RCSS, and let people know how to reach out to DRM. One thing that came up was that it’s their home and they want to stay there. There are leases on the home and the current provider doesn’t want to transfer that lease to another provider. So, now we have a situation where people are losing their homes due to the loss of their provider. This ties back into the HCBS Settings Rule and the tenancy portion which ensures that people have legally enforceable leases. This highlights issues with our current system, and we need to ensure that people don’t end up in these circumstances again.
-It was asked what the crisis services changes were.
Craig: We haven’t worked through all of them yet, but one of the changes has to do with the intake system. For years we have been contracting with another entity to handle those calls. That has not gone as well as we would have liked. We’ve had situations where people have been unable to get through to a crisis worker and in turn have been referred to the mental health crisis team. We’ve had a fair amount of calls that were just dropped. We’re revising that whole phone system and involving the crisis staff themselves in that phone system management. It’s a fairly complex system that will involve a phone tree mechanism which will hopefully allow us to get to a place where we have no missed calls, and all calls will eventually get to the right person. Just that change in itself impacts the nature of the crisis work because they haven’t been doing that piece. The plan is to get to a place where the crisis team is doing more preventative work and less crisis response. We’ve gotten to a point where we’re constantly responding to crises versus preventing them from occurring in the first place. We’re looking at training mechanisms, and we’re trying to make use of the START model, used in other states and developed at the University of New HampshireInstitute on Disability. We’re working with them to get our crisis team aligned with the START philosophy and service delivery model. We think this will make a huge difference. All of this will take some time, and there will be other changes as we work through all of this as well.
-It was asked if there’s an update on the self-advocacy contract.
Craig: We’re working through some internal process issues and moving forward with the self-advocacy RFP process, which should be initiated within the next few weeks. In the interim, we have extended the DD Council contracts until that RFP gets released, and eventually we’ll have an awarded provider for the self-advocacy work.
Cullen: I want to thank Derek and Craig for answering questions today, and for the questions you’ll be bringing back to the Department. Thank you for the transparency and discussion around a lot of systems change seemingly occurring all at once. Hopefully Paul and/or Betsy will be able to attend next month with answers to questions unable to be answered today, as well as continuing this interactive dialogue. Thank you again, it’s great to have OADS consistently around the table, eager for our feedback!
DHHS – Office of Child and Family Services (OCFS) - www.maine.gov/dhhs/ocfs - No one from OCFS was in attendance. Click here for the most recent OCFS System Improvements Update.
Special Education Update
Beth MyLroie: Transition remains a large focus, with work occurring on better planning for transition and what happens after high school.
-It was asked if case managers and other staff are familiar with both child and adult services.
Beth: I don’t know. I know that the transition coordinators with whom I work, within about three agencies, have this familiarity. I sense that there’s an increased interest within agencies to have a specific transition coordinator within adult case management, who oversees the transition from high school into adult services.
Kathy Adams: Also, don’t forget that Voc Rehab has transition teams.
-A former special educator stated that there is a state regulation that ensures all high schools have guidance counselors. However, if a student is looking for some sort of service outside of going on to standard higher education options after high school, it was rather useless. This is a missing link for this population.
-It was stated that Maine is lagging behind when it comes to children under age one. And, for grades one through twelve Maine has a higher rate of kids in special education. If more attention was paid to younger kids, it might turn that around. It was stated that it is important to do as much as we can as early as we can, and there are definitely issues in Maine around that.
SMACT (Southern Maine Advisory Council on Transition) Update:
Kathy Adams: The next SMACT meeting is on Friday, 12/6 at 1pm, at DHHS in South Portland, and will feature Sandra Lynham, Director of Counseling and Disability Services, Southern Maine Community College discussing transition.
The January meeting will be on Friday, 1/3, and will feature Elizabeth Newport from Social Security presenting an update on Social Security programs and benefits. Also, the Department of Education (DOE) has a new statewide Special Education Director, Erin Frazier, who was previously the Director of Special Education for York schools.
Developmental Services Stakeholders Continuum of Care
Cullen: The Developmental Services Stakeholders Continuum of Care group has been working on a more user friendly diagram for the Developmental Services Lifelong CoC (DD CoC), which is nearing completion and will hopefully be an effective tool for the Legislature. The layout is much more linear and illustrates the entire lifespan. This group started reviewing the Blueprint for Effective Transition today, and will be working more on that next month.
Disability Rights Maine (DRM) Update:
Staci Converse: The Department is holding transportation listening sessions, with the first one occurring tonight. This is an opportunity to talk about the problems with the non-emergency transportation system, or more generally about the issues with transportation in Maine. If you have things to say, try to get to one of those listening sessions.
-It was asked what, realistically, could be done differently with transportation.
Staci: It’s just not working. They’re meeting internally and trying to develop a plan. They’re looking at a single broker, but we’ve tried that in the past and it really didn’t work. Non-emergency transportation is available to MaineCare recipients. However, that system is pretty inflexible and there are barriers to access – how soon you have to request a ride, when you can cancel, etc. It’s not a system designed well for people with ID/DD to access. A systemic fix they could look at for people who live in a group home setting is clarifying the regulations about who should do what (is the provider responsible for transportation or not, etc.). That would be an easy fix that would be very helpful. It’s very difficult for people in group homes to access transportation, how often they can leave the home restricts their ability to be a member of their community, to advocate for themselves, etc.
-A self-advocate stated that a lack of training amongst transportation providers is problematic. It was stated that some of the problems relate to the rates too. It was stated that if you have three strikes against you, you can’t access the service for 90 days, even if it’s not the individual’s fault and it’s the driver’s mistake. Trying to navigate the transportation system is very stressful, difficult, and filled with barriers. It was asked where the Department is in the cycle of the transportation contracts.
Staci: I think they were up recently, but it’s my understanding they held off on doing anything with them. It’s been such a mess for so long; these listening sessions provide an important opportunity for feedback.
-A self-advocate stated that lack of transportation leads to isolation and doesn’t promote community inclusion.
Craig: This has been an issue across the state for many people. People with ID/DD are impacted at a pretty high level, and we hear horror stories. When we did our listening sessions, transportation was issue number one or two because it does hit on every area of a person’s life. We certainly know there’s an issue and we’re hopeful we can play a role with other state agencies in moving this forward. It’s definitely a complex problem.
Staci: We continue to offer ongoing rights, supported decision-making, and visual gestural trainings, which can be found in the events section of our website or you can find them and register on the OADS Training website. Though often you hear about the trainings we’re offering and so on, most of the work we do is individual advocacy.
Federal & Housing Updates:
Cullen: On 9/27 the President signed a short-term CR to fund the government through November 21. If Congress doesn’t pass budget bills for the offices and agencies not yet funded for FY 20 before the CR runs out, or pass another CR, there could be a partial government shutdown. The House and Senate T-HUD budgets look very favorable and aren’t far off, but it remains to be seen if there is appetite in Congress to pass a mini Omnibus budget bill. There is a Section 811 RFP out; however, HUD made changes to its 811 program and it no longer provides bricks and mortar and rental subsidies. The Section 811 program now operates as a Section 8 program for people who are non-elderly with a disability. There are roughly sixty 811 Section 8 vouchers in the state; though MaineHousing hasn’t been able to issue them all and is taking a look at the ways in which they can be better utilized.
State Legislature Update:
Cullen: The Legislature will be back in session on 12/18. There are growing concerns around the Section 29 waitlist, and that the cliff of no services after high school has reemerged. I’m unsure if there’s emergency legislation to address that or not, but there is always the option of the Governor submitting an emergency bill. DSP rates also remain concerning. There is a carry-over bill from the first session which would set DSP rates at 125% of minimum wage, up to $15 per hour after January, so we’ll be keeping a close eye on that when the Legislature comes into session.
-It was stated that Commissioner Lambrew’s testimony in front of the Appropriations Committee appears to have downplayed the issues within the system. It was stated that there’s a lot on the Commissioner’s plate, but it did not appear as if the Section 21 and 29 waitlists were a high priority. However, most of the questions from the Committee related to Section 21 and 29 services and the waitlists, so it appears as if this is definitely on the Committee’s radar. It was mentioned that there is a legislative Workforce Commission, which originally began looking at personal care attendants and nursing care as its primary focus. However, it has expanded to include the workforce issues for the ID/DD world as well. Discussions have included advocacy around increased pay and professional advancement for DSPs. It was stated that DSPs have come to the Commission and have spoken very eloquently and movingly about their financial struggles stemming from the low rates.
The next meeting will be on Monday, December 9, 2019, 12-2pm, Burton Fisher Community Meeting Room, located on the First Floor of One City Center (food court area, next to City Deli), Portland.
Featured Speaker and Topic: Paul Saucier, DHHS Director of Aging and Disability Services. Updates, and continued discussion from today’s meeting.
Unless changed, Coalition meetings are on the 2nd Monday of the month from 12-2pm.
Burton Fisher Community Meeting Room, 1st Floor of One City Center in Portland (off of the food court).
The Maine Coalition for Housing and Quality Services provides equal opportunity for meeting participation. If you wish to attend but require an interpreter or other accommodation, please forward your request two weeks prior to the monthly meeting to [email protected].