Monday, November 24, 2014

Comments on the HCBS Transition Plan

I attended the November 17 DDS presentation on its proposed transition plan in response to the recent rule on Home and Community Based Waiver (HCBS) Settings (see and proposed waiver amendments.  I’ve encouraged DDS ( to post the draft transition plan and the Power Points prominently on its website.  The November 17 presentation will be repeated on December 1 and if any of you are able to attend it would be well worth your time.  Please also submit your comments to by mid-December (I believe the deadline is 12/21), and see the comments that I have submitted below.  I know these are pretty technical, but there’s important stuff here that affects the services people get very directly.
Comments on Draft Transition Plan

The viability of the new HCBS rule itself will have to stand the test of time, and there is a question as to whether CMS assumptions about what can qualify as HCBS housing may curtail the right of persons with developmental disabilities to a full array of housing choices.  However, my comments here pertain only to D.C.’s proposed transition plan, not to the broader national rule.

Structural/budgetary issues vs. personal independence:
-          In the November 17 meeting, many valid points were raised with respect to the difficulties confronting individuals wishing to pursue their own activities without being obliged to “go with the group.” Notwithstanding the widespread emphasis on person-centered planning, structural and budgetary limitations do indeed create severe constraints on person-centered implementation in D.C. (as probably elsewhere) in situations of shared staffing.  Finding the right balance, and being transparent about the conflicting priorities, will be essential as the transition plan is reviewed for resubmission next August.  Related to this is the significant constraint on administration of medications while out in the community, an issue badly in need of revision in the name of advancing community integration.

Assessment tools:
-          The timing allowed for development of the provider and individual assessment tools (November/December 2014, not 2015 as indicated in PPt. on pages 16 and 17) is wholly inadequate.  No draft tools have been circulated as yet, even to the advisory group, and expecting development of the tool and completion of the training through the holiday season is unrealistic.
-          Submission of provider assessments to DDS by the end of January will be rushed and this expectation guarantees poor products.
-          As I pointed out in the meeting, if surveys of individuals receiving supports are conducted by DDS service coordinators the quality of the response will be highly affected by the variability in individual service coordinators’ ability to connect personally with those they serve.  If there is no alternative seen to use of service coordinators for this purpose, then DDS must allow enough time to train service coordinators who may not have the necessary skills, and the person surveyed must be given the option to invite a person of their choosing to assist in answering the assessment questions.  Only in this way will the assessment yield useful results.
-          In terms of timing, it is unfortunate that only responses by those individuals who happen to have ISP meetings during the first half of 2015 will be available to DDS before it prepares the revised transition plan in August of next year.  A different approach to the individual surveys than the one proposed might allow these to be done with all persons served during the first half of the year.

-          The draft transition plan makes reference (page 3) to an Employment Learning Community (ELC) for providers.  Since studies show that most viable employment opportunities for persons with disabilities are identified by family members or other informal supports, it is of the utmost importance for DDS to find a vehicle – possibly the Supporting Families Community of Practice – to help families and other identified unpaid supports understand how RSA, DDA and providers can assist them in a team approach to identifying work opportunities for their family members with disabilities.

-          In the meeting we were told that there would be an extension of the deadline for public comment on the transition plan, probably until December 21.  Please ensure that the revised deadline date is widely disseminated to allow others to comment on the plan.
-          What is the new target date for resubmission of the transition plan and waiver amendments, once the 12/1 followup session has been held and the comment period has expired?
-          When will there be an opportunity for public comment on the D.C. statewide transition plan, targeted for completion by the end of March 2015?

Comments on Proposed Waiver Amendments

Revisions to the current waiver do not (are not intended to) address the longstanding issue of inadequate coverage for persons with developmental disabilities in the District.  A potential Individual and Family Services waiver is still at least a year away (January 2016 soonest according to information provided in the November 17 meeting), and broadening of services to cover people with autism or other DDs is unacceptably distant, four years after the Developmental Disabilities Reform Act died in the council. Further remarks are provided below within this broader context of inadequate waiver coverage for D.C. citizens with developmental disabilities.

Individualized Day Services:
-          Many of the proposed amendments to IDS are sound, in particular concerning 1:1  availability and enhanced orientation requirements.  As I mentioned in the meeting, there are many available information resources, some of which are mass mailings from DDC and DDS itself, that should be regularly shared with all IDS providers so that community navigators can target specific developmental opportunities (classes, activities, community integration) for those they serve. 
-          However, some of the proposed IDS amendments raise a red flag.  Reduction in the rate of remuneration, combined with elimination of the Associates degree requirement, risks eroding the quality of individuals attracted to serve as community navigators, and those already hired may leave their positions when they face a $2.65/hour pay cut. A sliding scale to reward those with higher educational or job experience could help address this problem. (It is unclear from the presentation what is meant by “incentivized rates” for IDS in transition plan.)
-          In recognition of individuals’ varied needs, it is important for persons receiving 1:2 IDS services not to be paired consistently with the same individual unless they so choose.  Varied social contacts are extremely important and should be facilitated.
-          Also, with respect to IDS hours, DDS changed its earlier stated plans to raise the level to 40 hours/week.  It would be helpful to understand the thinking behind this decision (what were the types of comments that caused the reconsideration?), and DDS should revisit the 30-hour cap after another year since IDS remains relatively new.
-          As Dr. Mills continues her assistance to DDS with respect to IDS services, feedback should be sought from those who have been receiving these services in their initial phase.

Behavior Support:
-          While the motivation to avoid a heavy-handed approach to behavior support planning is a good one, the tiered approach, particularly with respect to Tier 2 time limits on developing and reviewing the BSP, carries potentially significant risks.  Behaviors may be complex without being intensive enough to lead to a Tier 3 placement, and curtailing the amount of upfront time spent on getting these plans right could actually lead to poor plans and, conceivably, behavior escalation.  Limitations on time availability for BSP developers already creates a tendency toward “cookie cutter” BSPs, which need to be avoided at all costs.  Therefore, greater flexibility in the time limits suggested for Tier 2 is warranted before the waiver amendments are resubmitted.

Other proposed rate changes:
-          The requirement that supported employment providers also be RSA providers is very welcome and will hopefully help increase coordination between DDA and RSA in the employment arena.
-          Other proposed rate increases appear well justified, and make the significant reduction in remuneration for fitness counselors seem odd.  At a minimum, the extent of the reduction should be revisited to assess the potential effects on the availability of counselors to work with persons receiving DDS support.

Increase in number of people served under the waiver:
-          While raising the ceiling in the number of people served is most welcome, the 1742 limit only serves to illustrate how few individuals with developmental disabilities in D.C. are actually able to be reached with DDS services. 

-          It is incumbent on the incoming mayor to work with the council to ensure more widespread support to the population of D.C. citizens with developmental disabilities.  Those of us most affected need to advocate strongly with our new mayor and our other representatives to address this fundamental issue of fairness.

No comments:

Post a Comment

Agree? Disagree? Have more to say? Comment here!