Personal Independence Commission

September 10, 2002

State Capitol Building
Jefferson City, MO
MINUTES

Members in attendance:

Lt. Governor Joe Maxwell
Kirsten Dunham
Ron Vessell
Greg Vadner
Neva Thurston
Wendy Hayes
John Solomon
Juan Samaniego
Senator Patrick Dougherty
Representative Lana Ladd Baker
Mary O'Brien
Linda Allen for Rick Horrell
Ann Deaton for Dorn Schuffman

Lt. Governor Joe Maxwell called the meeting to order.

Co-chair Reports

Lt. Governor Joe Maxwell - Addressed concerns for the next budget year.  The state will be about $500 million short again next year and limited in its ability to add any additional money to non-mandated programs.  As a commission, the goal of the PIC is to make recommendations that budget items be consumer directed.

Reports on Spenddown

Department of Mental Health - The Department of Mental Health has identified up to 4,200 individuals who qualify for Medicaid under the spenddown provision.  The breakout of these clients is approximately 18 consumers for the Division of Alcohol and Drug Abuse, 1,500 to 2,000 for the Division of Comprehensive Psychiatric Services, and 1,928 clients for the Division of Mental Retardation and Developmental Disabilities.  DMH currently pays in approximately 593 clients for the Division of MR/DD.  DMH will participate on behalf of those clients in the pay-in option that has been developed by the Division of Family Services.  For the Divisions of Alcohol and Drug Abuse and Comprehensive Psychiatric Services DMH will ensure that consumers continue to receive needed mental health services.  Needed services will be paid for out of state general revenue until such time the client becomes Medicaid eligible.  The impact on DMH will be through the payment of these services by state general revenue.  It will impact the amount of GR that is available to serve clients that are not Medicaid eligible. 

Department of Social Services - The Department of Social Services is working through the Division of Family Services.  There are about 25,000 members currently on spenddown.  DSS is working to make the spenddown program more user friendly.  There are efforts going on to make it a one-month process rather than a quarterly process and to make the application and renewal process very streamlined and almost automatic.  DSS is also working on an option to allow those who choose to pay a premium so that coverage begins on the first day of the month and goes throughout the month.  DFS was planning to send a letter to clients informing them of the pending changes, then the next week they will get their first notice about what their spenddown amount will be for October.  

Division of Vocational Rehabilitation - VR has approximately 648 clients affected by spenddown.  VR has been trying to make sure these individuals know what options are available to help minimize the effect of spenddown.  VR has also sent a letter to all effected individuals concerning the upcoming changes.  These people are served through the Centers for Independent Living around the state rather than through the VR office.  Of the 648 clients, 162 might be eligible for the Aged and Disabled Waiver.  Also, 85 of the 648 or 13% of those individuals have some third party, either friends or family, who are going to pay the spenddown for them.  VR is focusing on finding individuals who are at risk of having to turn to a nursing home as an alternative and trying to find solutions for them.  It was pointed out that having a third party pay the person's spenddown might be in conflict with the federal rules for SSI earnings.

Health and Senior Services - Health and Senior Services put a freeze on their GR funds as of September 3, 2002.  This means any new individuals applying for funds through GR will not be accepted.  They will still cover people during the period of their Medicaid application under federal guidelines and they will authorize Medicaid services for those people who are Medicaid eligible.  There are approximately 2,800 individuals through Senior Services who are on spenddown.  We will not be changing policies or procedures, so any individuals who are dual authorized will continue to be authorized and covered.  Senior Services will continue to pay for in-home services, but they will have to continue to be able those other medical expenses that will affect their spenddown.  Another policy change that was implemented, but is not related to spenddown, is any individuals who currently are hitting their GR budget that are under 18 points in level of care will no longer be able to receive care.  There is an exception process in place so if a case manager assesses an individual and determines that they are at risk to go into an institution, they can ask for an exemption.  They are also looking at those individuals where an interruption in services will cause them to be at risk of institutional placement.  A memo was sent to the caseworkers explaining the changes in spenddown.  There will also be a letter sent to providers explaining their responsibility with the new spenddown.  There is another division of Health and Senior Services affected by spenddown.  That is the Division of Environmental and communicable Diseases.  The HIV and AIDS Program has identified 300 of their 500 consumers are on spenddown.  The Division was still working on a finalized plan for dealing with this.  The medication issue is critical for these clients.  A disruption in medication affects their entire treatment.  Other services to these clients may need to be cut in order not to disrupt medication treatment.

Timeline Update from Departments

Lt. Governor Maxwell requested the names of the contact people for each department.  This will be the person responsible for keeping the Commission informed and up-to-date on where each department is in meeting their timelines.  The person reporting for the Department of Mental Health will likely be Kay Green or Dorn Schuffman; Health and Senior Services will be Linda Allen; Vocational Rehabilitation will be Ron Vessell and Greg Vadner will report for Department of Social Services.

Department of Mental Health - Ann Deaton reported DMH is partnering with Americore, Vista, UMKC, and the Missouri Planning Council to train Vista volunteers to work with persons with disabilities and their families to teach self-determination and self-advocacy skills.  They are also working on a curriculum to train people about self-report when there's abuse/neglect.  MR/DD is looking at a third waiver in addition to their standard waiver and the special Lopez waiver.  The new waiver would be a capped waiver to serve persons who have lesser needs. There are waiting lists for people wanting to move out of habilitation centers or waiting to get on a waiver program.  Ms. Deaton feels DMH is on track with most of the PIC action plan items. 

Department of Social Services - Greg Vadner reported for both the Division of Family Services and the Division of Medical Services.  The Department is on track and moving forward in implementing the Ticket to Work Program.  DSS is working with other divisions and/or departments trying to facilitate waivers and give technical assistance or data.

Vocational Rehabilitation - Ron Vessell reported under Item 3 where multiple agencies serve a consumer, a lead agency should be named.  VR is working with other agencies on that issue.  The next issue is training consumers on how to coordinate, negotiate, purchase, direct, hire and fire attendants.  Each of the Centers for Independent Living has their own curriculums for training individuals.  These need to be pulled together as one training program.  VR is also working with Senior Services to develop a universal application form for Home and Community Based Services across agencies.

Department of Health and Senior Services - Linda Allen reported that Senior Services is working on a single document outlining available services.  They are working on a statewide database that would tie in with the statewide information system of the Area Agencies on Aging.  This database will hold all the providers, their array of services and where they are located.  Another database containing information on available funding streams and how to access them is now available for those who call in with long-term care needs.  They are also working on a database to provide quality assurance information about providers.  DSS has met with other agencies that share providers and have added these agencies to their mailing list for providers who are sanctioned by the Division or providers who are put on probation by the Division.  Also, DSS has been meeting with other agencies to establish a lead agency.  On No. 4 and 5 all new employees receive training on informed choice during their two-week new employee training.  Also, DSS has an appeal process in place.  They are also working on universal application and assessment forms.  These should be in place shortly.  There is a task force working on a statewide uniform waiting list.

Lt. Governor Maxwell stated that the department timeline reports would be an agenda item each month for the PIC meetings.  Common tools for reporting these activities will be established.  When a department says they have met a goal the Commission will look at it and if necessary vote on it.

Public Testimony

Cheryl Boever - Parent of a son with mental retardation, autism and explosive disorder.  Her son had been receiving services through St. Louis Regional Center.  The family then moved to Hawaii for two and a half years, then moved back to Missouri.  While in Hawaii they received in-home supports for their son.  When the family moved back to Missouri there was no funding available and they are getting no services at all.  The mother had requested out-of-home placement, but that was also denied. 

Jean Haase - Parent of three sons, two of which have disabilities.  One has Asberger's Syndrome with severe depression; the other son has severe bipolar disorder, anxiety disorder and cognitive defects.  She has asked for in home supports for both of her sons but has not received any services.  She was told she should consider asking Division of Family Services to take custody of her sons so they would qualify for Medicaid and get the services they need. 

Julie Rosco - Judevine Service Center.  Asked the parents to be there to share their stories with the Commission.  Also expressed gratitude for the services that have been protected.  Coordination of services and education of caseworkers are two very important issues.

Workgroups and Organization

Lt. Governor Maxwell stated he felt the Commission would be more effective if it broke into workgroups.  Workgroups could continue the work of the Commission between meetings and could also take some of the pressure off the departments.  Kirsten Dunham had outlined a proposal for workgroups based on the work John Solomon and the Organizational Committee did.  She kept the same committee names but added the Real Choice Systems Change Grant activities that she felt fit under each committee. 

Discussion followed.  It was decided that the establishment of workgroups would be added as an agenda item for the October 8, 2002 PIC meeting.  Some general guidelines would need to be established.  The workgroups would report to the PIC on their activities and would not be able to take any action without approval of the PIC.

Informed Choice Training

There are two issues.  The Informed Choice Workgroup would like some direction from the PIC.  They would like a motion from the PIC approving what they are doing.  Neva Thurston made a motion to continue with the Informed Choice Curriculum as far as the grant.  Juan Samaniego seconded the motion.  Discussion followed.  Ron Vessell asked what the motion entailed.   Kirsten Dunham replied the motion entails continuing the curriculum, conduction the trainings, and having a staff person from each department that is committed to being a part of the trainings and the pilot trainings.  Linda Allen raised concerns about her comfort level with the trainings.  Ms. O'Brien responded that the pilot training was meant to work out the bugs.  Ms. Allen stated she and Senior Services fully support the Informed Choice Training.  Her concern is the nursing home industry and not wanting to antagonize the industry.  Also, Senior Services is getting ready to launch their enhanced MCO program, which will be up and running by January or February of next year.  MCO will identify why people need long-term care and what is needed for them to stay in the community.  This will go into a database.  Ms. Allen does not want anything to jeopardize this program.  The MCO and the Informed Choice Training could be tied together. 

Ann Deaton, DMH, requested that the training have the approval of department and agency directors before it is piloted for the first time. 

Neva Thurston repeated the motion that they continue with the curriculum.  The motion was voted on.  Motion carried.

The departments need to select their contact person to participate in the Informed Choice Training and submit the names of these persons by Friday, September 13, 2002.  The Informed Choice training package will be delivered to the PIC by November 12, 2002.

Report on Department of Mental Health, Division of MR/DD

Last year there were 14 consumers in the Higginsville Habilitation Center who moved into the community.  The monies followed them into the community and DMH was able to downsize one entire unit at the Higginsville Hab. Center.  There are 38 persons across four habilitation centers that are potential people to reside in the community.

Of the more than 26,000 persons Division of MR/DD serves 106 have been placed in nursing facilities.

Another issue is there are approximately 10,000 people living at home with elderly parents.  This number is probably not accurate because there are many parents who are not known to the Regional Centers because they have not requested services.  If they do request services from the Regional Centers there are two problems: People are not choosing to go to hab centers, but if they did there are not enough beds.  They are trying to place people in the community but they do not have the finances and the resources to meet those needs, especially if these people have assets and are not Medicaid eligible. 

There was some discussion as to the percentage of Medicaid funding that goes to community services as opposed to institutional services.  Lt. Governor Maxwell said his office would get the exact numbers on this for the Commission.

Update on Real Choice Systems Change Grant

Linda Allen reported that DSS has been in contact with Rutgers, the technical assistance organization for the Real Choice Systems Change Grant.  Rutgers has provided very valuable information and technical assistance.  They are also helping Missouri look at RFP's for help with housing, transportation, etc.  This information will be shared with the work groups.

Motion was made by Mr. Vessell to adjourn the meeting and seconded by Mr. Solomon.  Motion carried.