Personal Independence Commission

November 10, 2003

Missouri State Capitol
Jefferson City, Missouri
TRANSCRIPT OF MINUTES

MS. DUNHAM: Good morning, everyone. We're ready to get started in our meeting here. We too have a quorum now. We appreciate Wendy Hays logging in at exactly the right moment. Just for the benefit of the audience members who haven't been to our meeting before, perhaps we could do introductions and especially since we have a few newer PIC members here today.

INTRODUCTIONS: I'm Kirsten Dunham and I co-chair this with the Lieutenant Governor, and I work at Paraquad, we're an independent living center in St. Louis. I'm Bobette Figler and with the Myasthenia Gravis Foundation in St. Louis and the National Council on Alcoholism and Drug Abuse. I'm Kay Green and I'm with Missouri Department of Mental Health and Division of MR-DD, and I'm here as replacement for Anne Deaton today, who was unable to make it. Hi, I'm Klye Clower from Lieutenant Governor Maxwell's office. The Lieutenant Governor won't be here today, so I'm here in his place. I'm Anna Jackson with Ozark Independent Living in West Plains. Neva Thurston, parent, Jefferson City; Wendy Hays in Monroe City; I'm Martha Hicks, Senior Advocate, I live here in Jeff City, Good Morning. My name is Rick Horrell, Department of Health and Senior Services, Division of Community Health, Bureau of Special Health Care Needs, Linda Allen, I'm with the Department of Health and Senior Services, I'm sitting in for Nancy McAnaugh who couldn't be here today. I'm Sandra Levels. I'm with the Department of Social Services, Division of Medical Services.

MS. DUNHAM: In regards to the minutes, we have not been very formal throughout the last two years in materials of approving minutes and also most audience members and community members ask for the realtime transcript anyway. So we thought we would experiment with Donna sending out the realtime, if that doesn't meet people's needs, if we do need to do minutes, let us know and we'll return to that. But some of our feedback from past experience was that the realtime was of more interest and we didn't really go through the formal approval of minutes. We'll try it with the realtime. If had that doesn't work, give us that feedback and we can return to doing minutes and try to do better about official approval of minutes. Cochair reports. I don't have a lot to report on. I was very pleased with the work groups that met last month. I think that went really well. Everybody was very focused and were pulling in a lot of advocates to work on housing, informed choice, community education and diversion kinds of tactics. So I was really appreciating everybody getting involved in that. We did submit the annual report, as required by the end of October. And a special thanks to the special team, all the departments who worked on that and Lois Heldebrand who was the facilitator, a lot of work that group did in terms of putting together the action items and due dates was really a big chunk of that report because it does show where we're going from this point. And the report emphasized our work on informed choice in taking that training program statewide as well as really beefing up our community education, our marketing and our public awareness in terms of what options are out there. So the report either is or will soon be available on the website for the personal independence commission and I wanted to take a chance to thank the folks who were involved in the special team project. Klye, do you have a report?

MR. CLOWER: I think the only thing on our side is just to thank everyone for all their help with going through the whole special team process over the last since the beginning of this summer. I know that the Lieutenant Governor is really excited about having it start to come together and we'll get everyone, all the agencies have some really tangible thing that we're doing through the work groups too. So we're excited about the progress we're making and direction we're heading and we want to keep going that way.

MS. DUNHAM: Thank you. One of the areas of interest, of course, continues to be our Real Choice Systems Change Grant. And we are entering our third year of the grant. So this is going to be a busy time when a lot of the projects that have already been started are being completed. When we're making sure that we achieve all of the remaining grant objectives. So we wanted to just, as we start that final year get an update so that the commission understands what projects have been funded. We're kind of hearing different things about how much money is out there, what's been obligated already, what is sort of free for doing things with and we just need to get a good understanding. Klye and I met with Sherl and Sandra at the October meeting and that really helped to have a better sense of where we are and where we're going in the next year. So Sandra, are you going, or Sherl? Sherl is going to present some information that hopefully will bring you guys to the same point that Klye and I felt we were pretty comfortable last month.

MS. TAYLOR: What I wanted to do today was kind of update you on the activities that are underway for this particular year. In terms of the budget, I had asked that we defer a budget report until the next commission meeting mainly because the work groups had pulled together some tasks that they wanted to accomplish. We need to apply dollar amounts from what we consider reserve funds or funds not expended from the previous two years to those particular tasks. And work groups weren't necessarily able to identify a dollar amount that they thought they would need to accomplish those tasks. So we're going to pull that together for them. In addition to that, we also have several tasks that are being underway or proposed to be under way by the state agencies. We also need to roll those costs into those reserve funds. So by January we should have a firm handle on exactly what is available and what is obligated already, even though it may not be spent. In terms of task, as you know, the commission had requested a survey of the six demonstration pilots last year that we funded in the amount of $106,000. Surveys of those pilot projects have been completed. And a final product will be available at the next PIC meeting. Dr. Chris Rinck with the University of Missouri out of Kansas City will be making that presentation. And the members of the commission should receive the actual survey results or report prior to that meeting. If there are questions that you might have specifically to that, we would ask that if you could forward those on to us prior to the next meeting, once you get a chance to digest the report, that would be most helpful to Dr. Rinck as she is making her report to you. Under training on choices. One of the tasks in the grant for this year was to develop a power point training module on choices and Olmstead. Specifically for attorneys, judges and guardians. We're pleased to say that that project has been completed. The power point presentation has been completed and the first training will be held on november 21st here in Jefferson City at the capitol plaza hotel at the Missouri elder care's quarterly committee meeting. Under the Missouri guide for home and community-based services, as you remember we produced the guide last year and we went into revision status for this year. The informed choice committee met, the subcommittee work group on the guide met and we made revisions and those revisions have been submitted to the printer and the guide is being worked on as we speak. We anticipate that the revised guide will be available some time in early december. When that guide is available, we will be reproducing it also in various other mediums so that the guide will be printed in regular print as we have already seen. We'll print a section or a quantity in large print, in spanish, in braille, we will also have it made available on cd and video cassette and the intent is to place a bundled package of each of those various mediums to our libraries throughout the state. To make sure that there is accessible copies available. It will also be placed on the internet as we did with the original version of the guide. Under informed choice training, as you know, we completed a pilot last year. And the informed choice work group got together at the end of that pilot, reviewed how the pilot was implemented, had questions or comments and recommendations reviewed from the individuals who were trained in that original pilot process and made revisions to the curriculum. Once that was completed, the committee also pulled together an implementation schedule for the statewide training. The first training session for statewide implementation of the informed choice activities will be held in nevada, Missouri. That will be this thursday, november 13th. We expect that full implementation or total statewide activities will be completed some time in april. At the close of business on friday, we had 27 registrants for the informed choice training to be held in nevada. The final item I have is research on best practices. I believe once again during last year we talked about one of the tasks would be to identify best practices in providing community-based services throughout the state using nonstate resources was an important part of the real choice activities. And that many communities throughout the state have programs or provide services that they are either using private funds or local funds and sometimes even federal funds. We wanted to be able to document that so that those communities who had a need for services but didn't necessarily know where to start or were struggling trying to find contacts or resource people to help them build their programs, this would be a way for us to get that information out to numerous number of people. So guides will be produced over the next six months we will be doing research on what those best practices are. They will be divided into seven or eight regions so there will be regional guides. They will identify services or service models that are available using those community resources. It is anticipated that this will take approximately six months with us finishing and having a deliverable some time late may, early june. That's It.

MS. JACKSON: Can I ask a question? When you were talking about your informed choice brochures and all of these different formats, did you also include audio cassette?

MS. TAYLOR: Yes, the cassette is the audio.

MS. DUNHAM: Just a thought too. On the spanish version, that could probably go on the website as well.

MS. TAYLOR: Yes. Yes.

MS. DUNHAM: I had a couple of questions on the informed choice and maybe this may be getting too much into the report from the work group. But I will ask it now and you can tell me. Did you mention that you thought the statewide trainings would be completed by april?

MS. TAYLOR: Yes.

MS. DUNHAM: Is that different than the schedule?

MS. TAYLOR: Yes.

MS. DUNHAM: Have you guys sped up the schedule?

MS. TAYLOR: No. I'm glad you said that because there is some confusion. There's the confusion lies in the difference between the pic's informed choice work group and the informed choice work group that has been working with the grant activities from day one. The schedule that I'm talking about is the grant schedule. That's for this first year rollout. As I understand it for the pic's informed choice work group, part of the requirements of the grant is to make sure that once the grant funds are no longer available, we have a vehicle to continue this process. So the informed -- the PIC's Informed Choice Workgroup has had the task of making recommendations for sustainability. So as a part of that their recommendations are going to go to the state team, and the state team is made up of the four state agencies who are a part of the grants informed choice work group right now. April is this magic date because it was critical that the training be implemented and complete before the legislative session starts. The rationale is once the session begins, there could quite possibly be new activities for agencies to pull together, make modifications to the process. And so we needed the state team to have enough time to pull together budgets, for instance, the guide. The guide will have to be updated if there are legislative changes to those programs. So there needs to be commitments worked out among the four state agencies about how we're going to continue this training process. So they will have those three or four months to work out their details in working collaboratively. Then once the legislative session is over with, if there are changes to the program, then they as a team will need to go through and modify the curriculum and then go through this process of getting out there and providing training to update those community-based organizations that were identified in senate bill 236 a year ago. And so the recommendations from the informed choice work group, I think one of those was that training be held quarterly or four times a year. So that recommendation would go to the state team and then they would see how they could implement that quarterly training.

MS. DUNHAM: So if -- and I think just based on past conversations with this commission, it is safe to say that we want that sustainability and we want a system to make sure that we are identifying people and getting the training going. And I think the report does have a lot of good recommendations in terms of there being one person doing the overall coordination, that there be the leadership teams on the local level and some clarification on these questions about the ongoing role of state agencies. I just think we want to make sure that that's going forward. Either that can be done through the work group or the work group referring back to the state team.

MS. TAYLOR: I think the best possible way to do that is that now that the PIC work group has these recommendations, for that to be passed on to that state team. I believe -- sandy, please help me here -- that social services is responsible for real choices which informed choice would really fall underneath. So we've identified the lead agency as being social services. So social services would function as the coordinator for that state team.

MS. DUNHAM: So that would be the team then that could follow through on these recommendations?

MS. TAYLOR: Yes.

MS. DUNHAM: And make sure -- I guess what I'm getting at is I know it takes time to do statewide trainings. But by july we will have only done four. How do we track that each of those trainings, that those trainings result in people being identified in tracking who is informed, who gets?

MS. TAYLOR: By july of this year we will have done eight. Remember, that's the recommendation for continuation. That after this year from here on out, there will be four statewide trainings. The rationale here is that the first year you are out there trying to pull people in, making them aware that the trainings, first of all, are available. So we wanted to make sure that while we had grant funds that we use this opportunity to train initially as many people as we possibly could across the state. I mean we're offering the training hopefully over the next -- up until April. We're hoping that we will not only train but independent living centers and community based advocacy organizations but that somehow we'll be able to open the door for hospital-based discharge planners, case managers, anyone who touches the lives in terms of providing choices to individuals. Now, the one thing that we are trying to ensure is that whoever we provide the training has some oversight organization attached to them.

MS. DUNHAM: So the suggested four training events, that would be for following years after the original training is done?

MS. TAYLOR: Yes.

MS. HICKS: At the workshop we talked about training before the grant ran out. And we set up a training. So far we've had only one. Now we have one coming up in Nevada. Then we were going to have one in St. Louis in January. You have stepped it up because we were planning on these going on until September when the grant -- or July, I think we said until the grant ran out. So you've really stepped this up. You have speeded up the process, and I'm wondering, you know, whether we can meet those deadlines or not.

MS. TAYLOR: This was the schedule, the last recommendations of the work group. I don't remember.

MS. HICKS: January was St. Louis.

MS. TAYLOR: The schedule is now November 13th is Nevada. January there will be a training session held in St. Louis and then the latter part of January in Cape Girardeau. Then in February Kansas City, in March Kirksville, March also Columbia, I think March is St. Joe. I have February on here so I know that's not quite right, I don't think. And April is in Sikeston.

MS. HICKS: Those are being planned as of now?

MS. TAYLOR: Yes. The facilitators for the training have identified that they are available. Curriculums will be ready and produced in mass amounts.

MS. HICKS: I think that will take a lot of work. I mean I really think that's a tight schedule. Maybe you don't think so, but I do. The second question I have is why does the legislature get involved? Because you need money to sustain training on a yearly basis? You are talking about four training sessions from here on each year? Now, are you going to ask them for money?

MS. TAYLOR: Not necessarily so.

MS. HICKS: If you are --

MS. TAYLOR: The legislature is involved simply because throughout the year legislative activities may dictate that a change or a methodology change or service program may be changed because of that legislation. Once that occurs, then the state team as we've kind of identified how we will make sure that any changes that the legislature makes will be working to change those documents, change the curriculum so that accurate information is filtered back into the community. For instance.

MS. HICKS: I don't understand their role, Sherl. In changing the curriculum, I thought we were going with this curriculum. I just think we get bogged down when they get involved.

THE SPEAKER: what it is if they change the eligibility for any of the programs. In legislation in the next session any of the eligibility, if they change it in the rules and the regs we have to go back in and change that says this is what the eligibility is for this program. It is not overall. It is fine tuning. Like if you have a specific example that would be great. If they change a small bit of a program, then we just have to change how we explain that program in the training so we're correct for whatever was done in the 2004 session. It is not like a big overhaul, little minor adjustments if they just adjusted eligibility level.

MS. HICKS: I might as well get my other concern forward. From the very beginning I've said there should be a central place where this all comes out of. I know that you have divided it between the four agencies. But I still think that if it's going to be ongoing, that there needs to be a central spot. I mean one agency needs to be responsible for getting the training done. I just -- that's my personal opinion.

MS. DUNHAM: I think that's come through in the recommendations from the work group as well. Thanks. That makes sense now that I know the four trainings will be more of an ongoing each year. On the same issue, is this the work group, I mean is there going to be a plan in terms of looking at these eight areas where we're going to do the training and how many nursing homes are in each area, how many residents in each area and some kind of plan for targeted number of people because certainly we've heard at the last meeting folks from the community want to see is what's our plan, not just train the trainers but someway of demonstrating we're getting two people. If there's timelines for when you think we'll target, we'll hit certain targets.

MS. TAYLOR: Yes. I believe that once we get a couple of these trainings underneath our belt, hopefully at the next PIC meeting we'll be able to make a presentation that will give you a better snapshot of who has attended the training. I believe -- I don't have that information with me today. But I believe we have a good mix of participants in the Nevada training. But it is only one. When we have the next PIC meeting we will have had at least two or three trainings under our belt and we'll be able to give you some statistics about who participated in the training, what type of community-based organizations, whether we were able to pull in nursing home administrators, ombudsmen, all of these particular types of individuals have been invited. We have made an assertive effort to encourage and invite individuals of all venues who service long-term care and the disabled population.

MS. DUNHAM: Other questions.

MS. FIGLER: Dave you included, like, the health care agencies such as multiple sclerosis and those kind of providers?

MS. TAYLOR: I will be able to give you a more detailed list at the next commission meeting. I can just basically tell you that we had a laundry list of organizations and entities that we invited. Whether or not they are going to participate is another story. We did invite some entities that said that they had no interest. You know, that's to be expected depending on the level of commitment in terms of financial support that an organization can afford to provide.

MS. FIGLER: Can we aDD on that list?

MS. TAYLOR: Sure can. All of your suggestions on who we may be able to encourage participation are welcome.

MS. HAYS: In January when you do the grant report, will you be recommending or will there be recommendations in terms of the individual grants and which of those or all of those or whatever have, we might want to duplicate to make some other system changes?

MS. TAYLOR: I believe we could.

MS. DUNHAM: And I know as a participant in that, we're committed even beyond when we get the grant, we're committed to doing an evaluation piece with UMKC to discover if there's best practices. So I don't know. We could start the conversation by the next meeting in terms of that evaluation being complete and it probably wouldn't be complete until a few months down the road.

MS. TAYLOR: Right. Dr. Rinck will be here, so I will certainly pass that information on to her so she can be able to have some discussion with you about that.

MS. HAYS: Good. We were hoping that part of this will go into the best practices down here that we're looking at.

MS. TAYLOR: They wouldn't go into this particular best practices but they would have their own guide. Because they are just a little bit different from the best practices here, but they will be mass produced and made available just as the other best practices are.

MS. HAYS: Thank you.

MS. DUNHAM: Another piece that we talked about on October 20th is the Division of MR-DD is going to be using some of the grant funds to evaluate some of the transition programs and policies, at least in the St. Louis area, that the department has been engaged in. I want to give Kay an opportunity to say anything if she wants to. Also I know there is a representative of the DD Council who we could talk to talk about that evaluation piece.

MS. GREEN: I'm not sure I can talk about that. I'm not sure where we are on that and which piece of evaluation was discussed. I mean we've got two or three different programs going on. We're looking at evaluating different aspects. So I'm not certain that this grant funding was to be -- was requested to evaluate the process that's called on transitioning individuals out of ICF/MR's specifically. I don't think so.

MS. DUNHAM: Sherl, do you remember which MR-DD programs we were talking about?

MS. TAYLOR: No. We received a request from department of mental health to do a spatial analysis study. That's the one that will be coming out of this particular grant. And I don't have a lot of details about what mental health is specifically planning to do programmatically, but in terms of the spatial analysis we'll be looking if a facility is closed or slated for closing, how will -- let me rephrase that. When individuals who are in a facility are transferred to the community, to community-based services, how will we have backup supports for that individual if the need arises, knowing that there is a strong possibility that if significant numbers of individuals are transitioned to the community, that it reduces the likelihood that that facility would be sustained. But we can't afford to have individuals in the community without having some form of backup support because supports do fail from time to time. So that's what we will be looking at in terms of a spatial analysis. Also in terms of in looking at closing a facility, the staff that have provided specific supports to an individual in an institutional setting, how can those staff be utilized within that community setting to continue those supports? So those are the kind of spatial analysis things that the real choice grant will be funding for mental health.

MS. GREEN: So what Sherl just talked about is separate from the evaluation piece that the planning council was going to assist with. It is not funded by the real choices grant, the evaluation piece. What they were going to evaluate is new process that we've implemented now statewide. Initially it started in St. Louis, but basically what we're saying is all admissions are temporary. I mean we're recognizing the rights of individuals to services, however we're going to make every attempt we can at the point a person comes into the habilitation center, to have a plan in place to try to transition and get that person into a community living arrangement. That's the piece that the planning council, I believe was going to evaluate. That's outside of the grant.

MS. DUNHAM: I'm looking at members of the DD Council. Perhaps since it sounds like it isn't fitting into this grant, but we're interested in hearing that project, would you be willing at the public comment to come up and share?

THE SPEAKER: Yeah.

MS. DUNHAM: Other questions on the grant report? Thank you, Sherl. Work group updates. I don't know. Sherl, did you feel that we shared everything on the informed choice work group update? Does anybody have any other questions on that work group? We've heard their plan for doing the eight presentations by April. We can make recommendations in terms of groups that you know in those areas. Certainly if you have a sway with those organizations and can peak their interests that would be helpful as well. Rob, are you doing the presentation for community education?

MR. HONAN: I think I will just take over the hot seat here. I will make this presentation real quick. Basically what we're doing is as in conjunction with the informed choice where we're trying to inform consumers and people with disabilities of their options, also the community education work group which is similar to that in a lot of ways but what we're trying to do there is trying to promote the brochure, community-based brochure, which everyone is familiar with, which Sherl talked about and we're doing this through a systematic way of trying to attend a variety of meetings and conferences to get this information out. Klye, who was actually the chair of this committee has passed this along to me. He's already done a spreadsheet which is very handy and there's a lot of contacts on there. I have got 74 potential meetings for this information to be presented at. And basically what we've done is I have worked with a lot of the individuals in trying to solicit presenters to go to these meetings to make sure that such information such as general Olmstead supreme court decision is provided, giving a background, giving a background on what the PIC does as well as giving out the guides themselves. Currently the guides are already out. A lot of the independent living centers, aaas area on aging, a lot of other facilities have them, hospitals, etc. Some of the groups that we've been working with. I'm going to kind of read a sampling here are Missouri Alliance for Individuals with Developmental Disabilities, MOAIDD, AAAS, like I said areas age area agencies on aging. Linda Allen did that. Also APSE, Missouri Employment Summit Conference. There was a panel, myself, Delores Hampton and I think that Dorothy Parks was also there and there's been a lot of other presentations out there. What I need to know -- right now our committee consists of eight individuals and we did meet on October 20th, and we are certainly welcoming other individuals that are interested in going out into the community to make these presentations to groups that we haven't hit yet. There's a lot of individuals, a lot of groups on here that we have not hit yet. We want to make sure the whole state, at least service providers, hospitals, social workers, Missouri bar, judges, public administrators and those kinds of individuals are aware of the community-based services out there because as we know, in the past there has definitely be an install bias meaning people that service providers automatically shift people to a nursing home or some other institution. We want to make sure that the community-based options are available for folks out there. In terms of numbers, I have got about 74 potential presentations. I have marked -- we've made at least 15. I know we've probably made a lot more than that simply because not everyone is here to tell me whether they did that presentation or not. And if you want to, you can go to the PIC website which is on the governor's council website and see some of this information. This spreadsheet will be there. If you are interested in making a presentation to a group, whether it is a monthly meeting, quarterly meeting, in service, what have you, feel free to give me a call since I am the chair of this committee, this work group, I should say. Basically that's the extent of my report. I will entertain any questions if anyone does have them.

MS. DUNHAM: I may have been blanking out. Did you mention that you are also thinking about other ways of reaching people, not just through presentations but through sort of a larger effort?

MR. HONAN: To date, I know I've talked to some people. They have put this information on a listserv. If you have an e-mail or if you know of people, service providers, etc., that need this information, that we may not have or be aware of, feel free to give e-mail and that information to us because Donna Borgmeyer of my office can help out with the listserv. The listserv is one way to do it. We've also provided this information, like I said, on our website that's out there as well and I'm sure there's other ways to do this. I will say this just to let you all know and you can make recommendations or make referrals to folks in your community. I believe these brochures are available at the area agency on aging, regional advisory council offices, independent living centers, dfs offices, most division of family services offices should have them, division of medical services has them, senior centers, public health agencies, career centers and other community-based associations. These are some of the agencies we're targeting and we believe that most of the agencies already have them. As Sherl stated there's been a lot of the brochures have already been distributed. I know that there's a lot left of the first edition. When the new edition comes out, some of the first edition information will be obsolete and this is just kind of a public service announcement. If anyone does want some brochures, they are there for the taking. I hate to put a plug in for you, Sherl, to get it out of your hands. There are several boxes available and I believe there's 300 in each box. If anyone does want them, obviously connect with myself or Sherl and we can try to arrange to have them shipped to you.

MS. DUNHAM: Were you guys talking about maybe looking at public service announcements or some kind of media work?

MR. HONAN: That is in the works. We do have some contacts with some radio stations across the state as well as doing public service announcement to get this information out to a broader audience. Right now the primary focus is trying to make sure that the service providers, professionals and others do have the information. The consumers going through the informed choice training, those kind of individuals already have that information. We want to make sure it is as broad as possible. We are in a preliminary discussion to make sure we do public service announcements and get radio spots.

MS. HICKS: This is just a suggestion. But the Missouri bar puts out a wonderful handbook for seniors. And they sent me a couple of hundred and I've been spreading them around. And I think they could do one for disabled and handicapped. Because these lawyers are always advertising on TV. And they have the money to do that. But the green book and I've brought it with me several times for seniors is wonderful. It has a lot of the same type of information that this has. And they are always looking for some kind of a project. And I think it would be worth your time to talk with them.

MR. HONAN: Would you be aware, do they do this every year, every other year? How often do they put this out?

MS. HICKS: Senior handbook, I believe I've gotten it every year. They will send it to my door, 100 at a time free of charge and I can take them to meetings for seniors. I think they can do one with the same information that you are trying to get out.

MR. HONAN: This is exactly what we need. We can certainly use more suggestions. We're trying to reach as broad of an audience. Some of these things we're not made aware of. I appreciate it.

MS. DUNHAM: Especially with the issue of sustainability after the grant goes, if partnerships like that will be very important. So thank you. Other comments or questions?

MS. BAKER-OBERST: I'm just saying in regard to media contact, there is a cable tv show in St. Louis called beyond barriers that you could present this information. They are always looking.

MR. HONAN: Beyond barriers?

MS. BAKER-OBERST: We can talk about it.

MS. DUNHAM: Other questions or suggestions? Bobette, you look like you were thinking?

MS. FIGLER: I might have another contact for a media person that might be willing to interview.

MS. DUNHAM: Thanks.

MR. HONAN: Thank you very much.

MS. DUNHAM: Housing, we've got a summary of the Iowa Housing Forum. Kay, I don't know if you want to highlight anything.

MS. GREEN: I think Klye was going to talk about this.

MR. CLOWER: Well, basically the only thing I was going to say is our goal was to give everyone a copy of the report you guys sent out. Just to see if anyone from the actual meeting that took place on the 20th just wanted to go over what went on that day. I just wanted to let you guys know we're trying to move forward. If you look over the report you can kind of see the status where Missouri stacks up on who is participating with some of the other states. It was more to see if anyone after reading over this over the weekend had any issues they would like to bring forward to take to you guys or for housing people to look over the next couple of month. That's what we wanted to do with the housing one today.

MS. DUNHAM: Is there anybody here who was at the Iowa conference? Or the housing meeting on the 20th? I thought the recommendations in terms of the advocacy strategies, I mean they make a lot of sense in terms of identifying resources and distributing that information about what's available.

MS. GREEN: On the topic of housing, we would like to know who the chairman of the housing committee is? Because one of the -- on the action plan for state agencies, one thing we're supposed to do, department of mental health is schedule presentations from several different federal level housing associations. We're prepared to do that. But we don't know who to contact for that committee.

MS. DUNHAM: What might make sense is I do remember that the housing issue was under department of mental health as lead agency. I know everybody is so busy and has a lot on their plate, but if that was something that as lead agency you can identify a chair from your team.

MS. GREEN: So there's no existing committee that already has a chair?

MS. DUNHAM: Right. This is our first housing committee.

MS. GREEN: Which housing committee is this? This is a little confusing. So is this a PIC housing subcommittee?

MS. DUNHAM: It came out of, when we were presenting the plans and housing came up as part of the transition process. Then I know Anna Jackson and I think Juan expressed interest.

MS. GREEN: I'll aware that we want to include, I think there were three individuals from the commission who indicated an interest. So we're aware we want to include and we just weren't certain which committee we needed or task force, work group, whatever. So you want us to just become the chairman?

MS. DUNHAM: Is that all right with you, Klye?

MS. GREEN: Get a meeting set up. Okay.

MS. DUNHAM: I think Anna, Robin and Juan were the three; is that right, Anna?

MS. JACKSON: I was actually waiting to hear from you but I guess you didn't know that I was on that committee.

MS. GREEN: No.

MS. JACKSON: Anne Deaton took my name and number.

MS. GREEN: We were aware that you were interested and robin and juan but we didn't know who we were supposed to contact. Our housing team has made contacts with like USDA, agriculture and some of the other housing entities and they are willing to do the presentations. We just weren't certain about the next step, who to contact to have that meeting, who was chairing it. So if we just need to take on that responsibility, we'll do that.

MS. DUNHAM: Thanks. Any final thoughts on work group reports? Anything we forgot and didn't mention? Moving right along.

MR. HONAN: A quick question. Is there going to be the next meeting date of the works groups? Is there going to be a next meeting date in december?

MS. DUNHAM: I know in December the Olmstead stakeholders group is not meeting, but I don't know.

MR. HONAN: I do know the individual committees or work groups are meeting via e-mail. Mine is meeting via e-mail and phone call. Is the PIC going to sponsor a work group meeting in December? I don't know.

MS. DUNHAM: I don't think so.

MR. HONAN: Okay.

MS. DUNHAM: Again, that date we set up in October was just to facilitate the launching of these work groups. If the work groups are moving along, we don't want to impede your progress. If as a work group you have momentum and you want to meet and you have things you need to work through, don't feel like you have to feel we need to schedule an official meeting date. Move forward. We don't want to slow down the process.

MS. GREEN: So Kirsten, the October 20th work groups, were those PIC work groups?

MS. DUNHAM: Yes. We next have a presentation on voice activated technology. There's a program called Ralph, the home assistant and we've been learning about it in the St. Louis area through our assistant technology project. We had an a. T. Fair, which was presented at the fair and these folks have been sharing information with Paraquad, and it's really cool technology. Since we all like techie stuff, I thought it would be kind of a fun agenda item and also sort of a policy angle here too in that this is technology that if we can include in our range of home and community-based services, can help people live more independently and stay in their homes and communities. And I wanted to invite Gene Marcum and I'm not sure which of his group will be presenting but everybody can come up.

MR. MARCUM: I'm Gene Marcum and I'm with Office Center and we're a distributor for Ralph, the home assistant. It is a piece of technology that's designed, as she said, to keep people in their homes. It was originally designed for don here. I actually think he is going to be able to speak about it a lot better than I would because he uses it everyday and it's installed in his home and it was designed for him initially so that he could stay in his home. This is Don Hovert. And I will let you take over.

MR. HOVERT: That was short. We would like to thank you for letting us come today, first of all. I had polio when I was five years old. I used crutches to walk with and over the years I have never considered myself as being handicapped. I do everything that everybody else can do until two years ago when my wife passed away. I found out I was living in a home for 20 years that was not handicapped friendly to me. I had five years to go and the house was paid off. But I had a decision I had to make at that time. To find something that I could continue living in my home with, sell my home, move to an assisted living facility or move a stranger in to live with me. Well, I'm too dang independent for either one of the last two items. So I decided that I would start looking. I have a friend of mine that is a computer consultant by trade. And him and I started in working together on different things. And my thermostat sits above my fireplace. On the scooter if I could get to it, I could just reach up and guess where I'm setting something. I had no way of seeing it. My drape controls all sit behind a couch or in a corner where I could not reach. I've got beautiful ceiling fans and ceiling lights in my home but they are all on pull chains and there's no way from the scooter that I could reach any of this. So my friend started in working in designing a computer program, and I am not a computer tech by any means, way shape or form. But today I'm able to go into my office by saying Ralph, open the door. I use a patio door entrance. Any of that could come up to that door you could say the same thing and that door isn't going to move. It is all by particular voice control. Your voice is trained to the system. I get into the house. Ralph, open the front drapes. Ralph, turn on the living room light. If it wasn't for this being done for me two years ago, I would not be in my own home today. I would be someplace else living a different lifestyle than I'm accustomed to living. And I am getting older but I like my lifestyle and I'm going to continue to live my lifestyle as long as I can. With Ralph I will be able to stay there just as long as I want to stay in my home. And he's there to help me, assist me. I can even get to the point where that now when you are there by yourself sometimes, you become bored and you become lonely, so Greg went ahead and worked with the artificial intelligence side of the computer that I can sit there and I can type in something like Ralph, can you cook? And the computer is going to come back and it's going to respond do I look like a microwave oven? So, you know, it is an assistant for me. It is a friend to me and it has continued for me to be able to live in my own home today. Without this, I wouldn't be there. That's what I can say about Ralph.

MS. DUNHAM: How much does Ralph cost?

MR. HOVERT: My friend that designed Ralph, I started in looking at prices when we first started thinking about prices started out way out of my budget range. So Greg started working in designing. We can do a typical two-bedroom home for right at $3,500 including a brand new computer today. Greg is in it to help handicapped, help anybody that needs the assistance. He is not in it to make beaucoup money. He would like to make a few pennies, but he is not in it to hurt anybody at all.

MS. HICKS: Did you bring his cards?

MR. HOVERT: He's got his cards with him. He is attending in the audience. He is the guy sitting back there in the back in the yellow shirt. He's been a friend of mine over 20 years, so I know Greg very well and I know his heart is in the right place for everybody.

MS. JACKSON: Can I ask Greg a question? Have you ever worked with the Show Me Loans?

THE SPEAKER: I haven't done anything really with the project yet. I put it in for don. I made it for him originally and only basically this march did we finally decide, it has worked long enough that other people can use it. We're trying to start working on helping get it out into the public. No, we have not.

MS. JACKSON: I would be very interested to see a brochure or some development of your process.

MS. DUNHAM: We were talking last week about funding issues and I just wondered if you would share some of the challenges, barriers to the cost for people who are low income and kind of solutions or possible ideas for covering that kind of equipment?

MR. HOVERT: Well, Ralph, with the basic Ralph package sitting at $3,500, it is comparable to a lot of the equipment that's out there for disabled people. Like wheelchairs and assistive animals and a lot of the options out there run that range or higher. You can go substantially more expensive than that with a lot of the equipment out there and a lot of people first hear about the technology and their eyes bug out and something that does that for me, I couldn't possibly afford that. And right there, there's a fear barrier set up by the person who just puts it out of his mind that they could have it in their homes at all. Beyond that, we're finding a lot of like because it is new, we don't know as a company where our funding is going to come from or where the customers are going to get assistance from or loans from, and we've found a few sources. Paraquad in St. Louis has a grant for housing modification that if they meet the income requirements and some volunteering requirements, will pay up to $7500, I believe, for the system which would cover a basic system and then some. But you don't know what our options are throughout the state and we've got a dealer in central Missouri. We've got Greg operating out of Sedalia and we're in St. Louis and we're looking to get more dealers across the state and, you know, this option compared to like a nursing home for two months. A nursing home can run four, five, $6,000 a month easily. And not including the fact that the patient -- if you remove that all together from the equation, the fact that the patient is in a setting that is unfamiliar to them and has to be in an environment that they may or may not be comfortable with and around other people, you know, whether they have their own room, it depends on the place. So there's a psychological standpoint there that just somebody staying in their own home is going to be better for them all around than any other option that would be available, I would think.

MS. HICKS: Speaking as a senior and a computer illiterate, if a senior should fall or hurt themselves, can they get help through this system?

MR. HOVERT: May I answer that? After Greg installed the system in my home, this was in May, June and July of 2001 that he put this in after my wife passed away. In December 2001 I use my crutches when I'm not on the scooter. One evening I had gone to my bedroom, gotten my crutches and I had gotten off the scooter. Well, I was going towards my bed and being a klutz on my crutches as I am any more, I fell. I did not hurt myself but I fell and I'm too old and too fat to get myself up off the floor any more. So anyway I'm sitting on the floor trying to figure out what am I going to do next. And I finally scooted over to my telephone that I have in the bedroom, reached up and I called Greg. He came over and he helped me back up. At that time we decided that Ralph has to be able to do something more for people just in that very thing. So he has a system in it now that if I would happen to fall in my house, again and I'm not hurt, I can just tell the computer to call Greg, he automatically calls Greg, tells him don has fallen, he needs help up. If, god forbid but if I would really fall and really hurt myself, knock myself out or something, and I have no motion whatsoever for five minutes, the computer will ask don, are you all right? If I do not respond, I just fell asleep or something. If I do not respond then the computer will automatically start calling my own personal call list of my closest people to me first saying there's something wrong with don, you have to get over to the house and check on him immediately.

MS. HICKS: How does the computer know that you are down?

THE SPEAKER: I have motion detectors all through my house and it tells the difference between me or a dog or a cat. It can be trained to your own motion and then small animals, it can detect if you have pets living with you and so forth.

MS. HICKS: That's amazing. What about 911?

MR. HOVERT: Well, 911 in my case, I use 911 if somebody would break into my home after I have gone to bed at night or after I have left during the day, if someone would break into my home, the computer automatically turns on the video cameras when it senses the motion because I have not given it clearance that I'm back home. It turns on the video cameras and in then ten seconds later it turns on all the lights in the house and says motion has been detected, I have contacted proper authorities. Meanwhile the computer has already called 911 to tell them the house is being burglarized.

MS. BAKER-OBERST: This is all in the $3,500 package?

MR. HOVERT: Yes, ma'am.

MS. HICKS: That's amazing.

MS. THURSTON: Did I understand that all of this is for $3,500?

MR. HOVERT: Yes. For the basic home you can get.

MS. THURSTON: For a two bedroom home?

MR. HOVERT: Yes, ma'am. As I had, Greg has designed this to where he's trying to help people.

MS. THURSTON: Well, I also had a question. Do you have visual aids with this also or is that possible to have visual aids on the computer to cue people on when to do something?

THE SPEAKER: We're looking into doing more of those. We've got some and we're looking at trying to do more.

MS. THURSTON: That is another need.

THE SPEAKER: Right now the Ralph system as it stands now, we have a very small one installed in our office where we work. Ralph can be cued to remind people for medications. It comes across speakers. The computer system speaks and it comes across. It would come across speakers in the house. Everyday at 4:25 Ralph dismisses me from work and tells me I can go home. We can set it up so that if a patient is on a medication schedule where they have to take medication, they have to take a different pill at noon and in the evening and so many before bed, you can set it up so that Ralph will remind them, gene, please take the blue pill. Go and take the blue pill now. We can set it up to require a voice confirmation from me saying that I have done it so if I forget, if I go to do it and I am in the kitchen and I realize I'm hungry and I fix myself a sandwich and I totally forget about taking my medicine, which knowing me, could happen really easily, then it can go -- it will keep pestering me until I acknowledge that I have taken it. The system, if I say yeah, I have taken it and don't take it, the system can be controverted that way. But someone would have to be avoiding taking their medication to do that. I don't know that too many people, you know, who have life-saving medication prescribed to them would want to avoid taking it. It can also, if it doesn't get a response from me at all, you can set it up to call down a list to go so-and-so is asleep and isn't taking their medication and it will send out that same call. It wouldn't send out a 911 call. This would be a different type of call and it could call somebody else and go, you know, gene hasn't taken his medication. Make sure that everything is all right there.

THE SPEAKER: With the motion sensors like I use in the house, you can also put your motion sensors where your medicine is located. When they sit on the couch and not go to where their medicine is, I've taken my medicine because they are being hard headed, stubborn or whatever as we get older, the computer is going to say I'm sorry, you didn't go get your medicine. And if they just say well, just forget it, then the computer will automatically, as gene said, start calling their own personal call list and say, aunt Jane didn't take her medicine or uncle don didn't take his medicine so it is pretty well very protective of the person that lives there.

MS. THURSTON: Also people who have communication difficulties, is it so sensitive that it can pick up most any communication?

MR. HOVERT: I thank you for asking these questions. I have a brother that is mentally retarded. My brother comes and spends two weeks with me during the summer every single summer. What Greg has done is the computer can use a remote control device almost like a TV remote control that my brother, when he comes, he wants two things. He wants the TV remote and what he calls Ralph. That is a remote control device that he just holds in his hand and he can turn on and off the lights, open and close the drapes, whatever. When my brother first visited after Ralph was installed, I have got to tell this. He was in one bedroom sleeping one night when I put the security mode on. And he started to come out of the bedroom the next morning and Ralph goes attention, motion has been detected in the room. So my brother, when I got up he is standing in the doorway to the other bedroom and he says, Ralph won't let me out of my room.

MS. GREEN: I understand that this is a new system and you are just starting to market it. Do you have anything like even on a website?

THE SPEAKER: Yes. We have a website up. And I didn't bring any brochures with us today. We may have one copy. I think we have with us is all. But I can get you some.

MS. GREEN: Can you give us the address?

THE SPEAKER: Web address is "ralphmyfriend.com". All one word, no spaces, no dashes.

MS. GREEN: You live in the St. Louis area?

THE SPEAKER: I live in St. Louis.

MR. HOVERT: I live in Sedalia.

MS. GREEN: Is it just available in St. Louis initially?

MR. HOVERT: We're trying to find some dealers right now around the areas that would like to help us sell it. We're doing it out of Sedalia is the actual office.

MR. HONAN: This is Rob with the Governor's Council. I just want to say that I did visit the home in Sedalia. It is really pretty fascinating. It seems rather pie in the sky, but it definitely is very user friendly and it does work. I do know that one of our newsletters, bridges newsletters has done an article on that and the St. Louis post dispatch did an article I believe it was this past summer so that's out there. If people do want more information on it and I will have to say that funding is one of the barriers and I did make a lot of suggestions like, for example, through the assistive technology, service clubs in their community. A lot of time service clubs will provide donations to specific projects, those kinds of things. I know there are a lot of other ones out there. So if you do know of any other ones, just feel free to get the word out because I think this is really good technology.

MS. DUNHAM: I am wondering about Medicaid coverage. It is going to be a challenge to aDD something new. But if there's already through waivers, if assistive technology is already covered, could it be on the list of options?

MS. GREEN: I think it possibly could be covered. There's a service definition environmental -- I can't think of the technical name of it but basically there's a home modification and also one that's called adaptive equipment. Those are generic names but it is possible that we might have to tweak a definition or whatever. But it is possible that this type of technology could be covered.

MS. LEVELS: Are you speaking directly to one of our waivers, Kay?

MS. GREEN: All of our waivers have specialized medical equipment and supplies, which is also sort of like adaptive equipment or equipment that DME won't cover through the state plan. And then we also have this environmental, I forget the technical name for it. But it is like home modification. So all three of our waivers have those services in there. And I would have to look at the definition again more specifically to see if they could immediately cover this type of technology but if not, it is possible we could ask for an amendment at some time. If I can get Sandy to approve it.

MS. LEVELS: Thank you. I was kind of thinking outside of the waiver and just thinking about the Medicaid population and as a whole and I think one of my questions would be is whether or not you have talked with Medicare. Because basically Medicaid tends to follow Medicare. It is really difficult for us to approve.

MR. HOVERT: We have contacted Medicare and started through some processes there. To be honest right now, the biggest issue it is going to cost us, the money we have to pay an independent firm to evaluate the product. The last estimate I got was around $12,000, which is really out of our ballpark.

MS. ALLEN: I might make a couple of suggestions. One would be to try Missouri foundation for health. Missouri foundation for health has a lot of money right now. They are looking for special projects like this. So I will slip you a card. You give me a call and I will tell you how to get ahold of them. The second thing is through administration on aging, national family caregiver program does fund these sort of things for family, particularly when the caregiver does not live with the individual. This would be the kind of product that they would be looking forward to funding because that way it takes the place of an actual physical caregiver. So I might suggest again I will give you a name but the ten AAA directors meet on a monthly basis and I think this would be a neat project for them to look to pool their money together, some of their caregiver money together and say that they might try it, say for the first year, take like three families, test it out, see how it works, particularly with our elderly because you are not quite there yet, my man. You may think you are. You are not quite there yet. But particularly in cases where the caregiver may live out of state or in another city, I think this would be really great. The other thing is just stay on the website, particularly this CMS website that he was talking about, Medicaid and Medicare because many grants are coming out all the time, all kinds of grants coming out of that and also out of the centers for disease control. They are doing a lot of projects together for nursing home diversion and I think we shouldn't rule out the fact, even though we know this is the worst budget we've seen in a long time, we also know that there's an interim committee meeting as we speak to look at Medicaid costs and nursing home diversion is a huge topic. And I can tell you statistically that there are a lot of people who go into nursing homes simply because they cannot manage that medication. They cannot remember to take those pills. And it's always been kind of a crime to me that somebody would have to go into an institution because they can't remember to take their pill because I'm like you. I forget to take them everyday myself and I would hate to think they would put me in a nursing home. God help that nursing home. Because of that but it is very, very true. We've had little projects with little robots that just did medications and things like that but nothing that would give this kind of independence and security. As the representative for protective service for adults, this is just wonderful. The other thing I wouldn't rule out is some discussions with department of health and they are going to kill me because that's what they get for sending me to the meeting. But in terms of whether or not we could tie in some terrorism money because we've been looking very closely how do we protect our quadriplegic, paraplegic, our people who are bed bound, special needs people in case of an event, how do they make sure they get water, food, get the message on where to go to be safe. Rick and I put forward a proposal last year to get some of that terrorism money to be able to look at these people. If you have a program like this. My concern is people who are laying in that bed with no water, no food and their personal care attendant isn't coming because they have been told not to leave their house or they are busy taking care of their own family. I mean we're human beings, that's what we're going to do is take care of our own first and I'm worried about that person who lays there for even a day or so without water. So this kind of system could then alert emergency response people to the fact that they are there.

MR. HOVERT: Right now there's a feature on Ralph that ties into the internet and can announce when storm warnings are -- when they happen. I don't think it is unfeasible at all for something like a special alert in case of an incident. I don't think -- I think that would be pretty easy to incorporate into the Ralph system.

THE SPEAKER: It already knows, it keeps track if it's on that system.

MS. ALLEN: That's wonderful. If each of my social workers has 200 people to think about in case of an event, to know that the ones that were critical could take care of themselves at least to notify people would increase their chances of making it through that incident. But there are a lot of, I think the key is to get into the groove, if you will, of checking those federal registers to look what is coming out, looking at the foundations. Missouri has some really good foundations, and, you know, just never stop, just have those grant applications constantly sitting on your desk and ready to mail out and get yourself a good writer. That's the key. You have got to have a great writer. And no offense, but tech people are not always -- you know your software but writing is not always in English is usually, it is usually in computer code. That is the key. If you could look maybe to the disability community who has some excellent writers who would have an investment in making this thing work.

MS. GREEN: You may have already had some conversations with Missouri assistive technology project or council. But if not, you might want to check with them. They may not have money but they may be -- they may have resources and they may know what's been done in some other states or just information that could help you a lot.

MS. LEVELS: Now I will finish. I would really like to say Medicaid tends to be such a large payer that I think it is critical if you are going to look at something like this to see how you can make it eligible for Medicaid payments and again, it seems like you are headed in the right direction because it really needs to be evaluated. Medicaid is not going to pay for any type of technology that's not been like evaluated and approved by, like, Medicare or something like that because we tend to kind of follow behind them. Then another thing as far as the state is concerned, it does take a special line of funding if we're going to aDD something new. It has to be -- almost like you need money appropriated for that item in the budget. But again kind of like what dr. Allen was saying here, because of the interim committees on Medicaid right now, you know, this may be a time to look at how do we do something differently because we're trying to look into within Medicaid to make some decisions about how can we save money? We know if we can divert people from institutional care, it is less expensive for them to live in the community. And so but again, it needs to be evaluated and approved before Medicaid really will entertain funding. Something of that sort.

MS. ALLEN: Sandy, do you think they would have a shot at public testimony at any of those hearings?

MS. LEVELS: I'm sure they would.

MS. ALLEN: If I could have the hearing schedule.

MS. LEVELS: I think we have one coming up this week.

MS. DUNHAM: They are not really taking public testimony because I've tried to get on their witness list on several of the committee meetings, but I think certainly meeting with the committee members, there is a good option. On the cost savings we haven't really mentioned this, we could save costs in attendant services if you if you don't need an attendant as many hours as you had before. Thank you so much. Obviously I mean this is very intriguing and amazing technology. And I think many of us here will help be advocates for this program. It does sound like it keeps people independent.

MR. HOVERT: We would like to thank you for your time, and I will say if anybody would ever like to come to Sedalia to see it, I'm more than happy to open my own home and let people see. It is completely handicapped accessible to get into. So I'm more than willing to open up my home and let people see. I know we wanted Tish to speak and just to get a sense of how much public testimony there is. If I could just see of hands of folks who wanted to do public testimony. Since we don't have too much, we'll go ahead and finish public comment and we do have lunch here. So once we get through with that, we can have our reward of lunch. I would like to invite Tish Thomas for developmental disabilities planning council and we've been talking about evaluations and I may have been confused about which evaluations were covered under which grant. But in any event, I think this is an important piece of what Anne Deaton has been working on and moving forward with really making institutional placement the last resort.

MS THOMAS: Thank you very much. My name is Tish Thomas, and I'm representing the Missouri Planning Council on Developmental Disabilities but I would also like to say that I'm a family member of a person that lives at the Marshall Hab Center and that I'm the director of an adult day health care program too. So I have many avenues of interest into Olmstead and this commission. Missouri Planning Council for Developmental Disabilities would like to propose that the PIC and Department of Social Services use funds from the Real Choice Systems Change Grant to finance a study of the challenges and resources that individuals encounter as they leave or enter institutional settings. The Planning Council and IHD at UMKC have discussed about Hab centers. However, in light of the commission's charge studies issues faced by individuals in institutional settings including nursing homes we feel that the evaluation we envision could be easily expanded to include all people with special needs, whether they live in nursing homes or any other institutional settings. While some progress has been made in increasing awareness and encouraging transition through the informed choice training, Missouri guide to home and community-based services there is many questions still left unanswered and many system issues that have not been addressed. Once individuals indicate that they are interested in moving from a particular setting or informed that they have other options, we feel that it is imperative that we expand our understanding of their experiences. We hope that through the study we will gain an increased understanding of such questions as what barriers and supports individuals face in moving from an institution or individuals offered multiple options for community living and does someone listen and accept their choices and act on their input, are people offered assistance, training or support in preparing to leave the institution, what are the average time frames for moving once someone indicates their choice to transition? Now how quickly do decision makers meet to make a decision. The state feels there is not an appropriate community option for an individual or if the family doesn't think there is an appropriate option too for that matter. How effective are current efforts to reduce the number of individuals who are admitted to institutional settings and what processes and procedures report and hinder these efforts, what are the influence of parent or guardian preference commitment in the transition process? Are individuals satisfied with the quality of life and their support services once they do transition to the community? What can this teach us about assisting others? In situations where money is able to follow the person, what did we learn from this? Can we use this knowledge to assist others in transitioning? The council has a proposal from UMKC-IHD to study some of these. We do not have sufficient funds to carry out the study independently and feel that since it is closely in line with the mission of the PIC this may be a viable alternative. We're willing to assist in the implementation of any study and would certainly like to provide oversight. We feel that a study of this caliber will assist in Missouri's moving Olmstead decision forward so that people of all ages and disabilities have increased options to live independently in their homes and communities. Kay, you mentioned planning council helping fund a study or evaluation of the process that the division is using, I don't think that the planning council has not voted to fund that. So I wanted to make sure that was clear.

MS. GREEN: The status of that wasn't clear to me exactly where, but I didn't think -- I didn't know the status of where all of that was. Special ed.

THE SPEAKER: This is what the planning council would like to do, would like to work with PIC and social services in this grant and with UMKC to study this process here, this informed choice process. We don't want to limit it with people with developmental disabilities. We want to expand it to people with mental illness, people, senior citizens, whatever. We want to work with other groups and try to have access to the systems change grant to help fund these things because this is not just a developmental disabilities issue.

MS. DUNHAM: It sounds like maybe there's some overlap with things. Maybe it is just, I don't know if the team can sit down with the DD Council and kind of figure out because certainly what Sherl mentioned with the spatial analysis talking about individuals being transitioned, she mentioned the question how will we have backup supports which fits with the issue of community capacity.

MS THOMAS: The council definitely supports that. There is no doubt about it but we want to make sure it is expanded to all people.

MS. HICKS: I don't know whether you have access to this report from Marshall Rehab Center. You went so fast and see.

MS THOMAS: I'm sorry.

MS. HICKS: When you are a senior, you don't digest these things as rapidly as you did when you were younger. So I'm not sure what all of your concerns are. But I think some of them maybe are answered in this Marshall Rehab. That was the first pilot that was done. It is a wonderful report and I think perhaps some of the things that you hit on are in this report. I'm not real sure.

MS. DUNHAM: I think that evaluation was more evaluating people who were actually transitioned, transition process itself. One kind of remark I might make is I agree that needs to be studied, of course that implies that we're actually transitioning people first. Maybe this could spur some of that activity.

MS THOMAS: Are those people that have been transitioned are they really transitioned into the community? Are they transitioned into a nursing home? I mean there's a lot of things to look at.

MS. THURSTON: I had a question. Thank you, Tish, for bringing that up. I understand or I think I did on the spatial analysis that MR-DD was thinking about is the issues of backup support and would the people who worked in the Hab centers follow the people to the community? But I think what I see here is that how do people really do once they are moved into the community? Dot the i's and cross the t's and I'm not sure that's covered in all things. So I hope that it is a part of the grant. They can look at some of these things. And I think you are talking about people moving out, not just moving out of the Hab centers into the community but what about people who are in restricted environments such as group homes and so on and people with mental retardation in the nursing home. So I think what happens when you really move to the community?

MS. LEVELS: I think my question, Tish, is do you already have the study written out, something that you want to submit to the PIC for social services to take a look at?

THE SPEAKER: I think UMKC has it.

MS. THURSTON: It needs to be sort of brushed up a little bit or redefined. Toto there's a foundational proposal that UMKC has. I'm not equipped right now to talk about it in any detail. But there is something that's been proposed.

MS. LEVELS: I think that we would definitely like to take a look at it, but some of the others were saying it appears that there's some overlap. It seems like some of the questions that you want answered are already out there somewhere trying to be answered. And then I think I have a concern about how long do you intend for the study to be? Because some of the questions, it appears, that there is kind of like a longitudinal study because you can't just put them out there and go tomorrow and ask them how do they like living in the community? They would probably say fine. You ask them six months or a year down the road how do they like living out in the community. It would be interesting to take a look at it and see what you have there and where overlap exists and are there some things in there to take a look at.

MS THOMAS: That's the only way you can look at are successes or failures are on a longitudinal basis. Sure, it worked for a month but what about a year from now. As far as the Marshall Study has been concerned, I'm co-guard want with my father with my sister and she cannot self-advocate. She's nonverbal. She's very low functioning and needs assistance with all activities of daily living. And I answered the survey yes, I was interested. I wanted to be talked to but no, don't talk to my sister. It wouldn't do any good. I have yet to be contacted. I know they are dealing with the first wave of people who self-advocate. I think that's wonderful. I'm sitting on ready. I want to be a part of the process and I know things take time but we also just need to -- my father and I and family members do not want to look at moving my sister until there's capacity there. So all of these questions look at capacity. The planning council, their position on this is that we believe in community inclusion. We believe that everyone should have that option to live in the community but it needs to be done carefully and sensibly and it needs to be a part of their choice and there needs to be capacity for true choice. So that's what we would like to look at with what's going on now is it being done correctly? Are all parties doing what they are supposed to be doing? True choice is really an issue here.

MS. HAYS: Do you have a --

MS. THURSTON: The only thing I wanted to bring up too. The Marshall Study was really good but it is really on a limited amount of people, so we hope that we see larger groups that you can get a bigger cross-section of larger group than we've seen.

MS. HAYS: And then cost, do you have an estimated?

MS THOMAS: No, I don't. I don't have that information with me.

MS. ALLEN: I was going to say too part of what will evolve now that we've got the quality assurance grants as the agencies sit down and talk about what are the outcomes that we're investing in that those things might fall out, we're having our first meeting next week to talk about that quality assurance system. So those are very important things to make sure that those agencies stay cognizant of because as we develop that system, it has to be something we can sustain and Sandy's point is well taken. We can invest money now to do a study but if we don't, each agency doesn't invest in the outcome data, it is going to be another one of those blurps on the screen.

MS. DUNHAM: It sounds like getting more detailed proposal to Sandra and Dr. Allen and Kay Green, that would be helpful and certainly we all want to find a way to get those questions answered, maybe through a combination of covering it through a couple of different ways we can address it.

MS. LEVELS: Tish, if you send it to me I will share it with the other agencies.

MS. ALLEN: She's good about sharing.

MS THOMAS: I know Sandra is. Thank you very much.

MS. DUNHAM: Thank you. Rich Blakley from DCAI in Viburnum, we welcome you forward.

MR. BLAKLEY: Thank you, Kirsten, members of the commission. I'm Executive Director of the Independent Living Center in Viburnum, Missouri. I'm speaking for the center in Viburnum but I'm also speaking for a number of other centers who feel as I do. We're the grass roots down there. We're the people who actually provide the services to the consumers and really the only home and community based service that is Olmstead compliant and consumer directed pas program. We've seen in the past three years Missouri go from a state of leadership to a state of one of the lowest provision of services to people who want to be independent and living in the community. Frankly, our disappointment is profound. I'm not sure exactly where to go with this. I have no written statement prepared except to say that our disappointment in this commission is also rather profound. We're out there on the grass roots. We see consumers day after day. We see people struggling to survive on a limited number of hours a day who meet the 18 point assessment, who cry to -- Who are eligible for nursing homes but don't want to go in there. This is an Olmstead decision, folks. This is the law. This is what everything is based on that we do in an independent living center. What we're seeing instead of Missouri keeping ahead of the pace falling back further and further, as I said, due to the fact that the nonmedical eligible program, for example. In the past few years it has almost been cut in half. For ten years I and several others have worked to increase this program for people who are not Medicaid eligible. We used to get maybe five, ten slots a year from the legislature. We were happy with that. You know what, those five, ten slots a year have suddenly evaporated into thin air. They are not there any more. We've gone from 250 people on an NME program down to 140. There is disgraceful, there is a waiting list. They are not on Medicaid, they cannot go into the MAWD program and are frankly sitting there trying to figure out a way to survivor without going to a nursing home and losing all of their assets. Medicaid state plan, Olmstead compliant plan that's there, hours have been cut why? I'm sorry Mr. Vessell has left but part of the problem they did not request enough funds last year. This commission has done nothing that I have seen to tell VR that they need to request the funding that this program needs to survive. People have gone from an average of say four or five hours a day in attendant services in their own home down to an average of around the lower three. They say it doesn't hurt. They blame it on CMS rules out of the federal government. That's false. That's misleading and something that we know is not true. These hurts are -- these cuts that have hurt people with disabilities to live in their own homes and it's also going to cause some people to go back into nursing homes. House bill 11 money that was passed that was supposed to be funded, the money follow the person that we're all aware of doesn't work. It just doesn't work. Why doesn't it work? Because the commission here investigated the why house bill 11 funding isn't working. I have heard nothing really from this commission and I don't think any of the other independent living centers around has heard anything from this commission either. That's why independent living centers don't come here to listen to you folks because as I was sitting over there I heard a lot of talk, I heard things about trainings, I heard some of the niceties, we're advocates out in the field. We're not doctorates. We're not agency heads. We're not people who work in politics. We're trying to provide basic services to individuals that need those services. I plead with you to take a more proactive advocacy role not only in the legislature but in implementing some of the laws that are already on the books. Ladies and gentlemen, if you go out there and you do a few evaluations along with some of the staff with the independent living centers near your area, I think you will actually see what I am talking about. I would challenge you to find at independent living center in your area, there is 21 in the state. I'm sure there's one close by where people live. Go out on an evaluation and see how it works, see the amount of paperwork that has been created by vr that we have to fill out, the caps that have been put on programs that aren't necessarily. They are artificial. They are not part of medical services, they are there to do one thing, cuts hours, save money because VR blew it at the very beginning of the request when we did not ask for enough money for the legislature to fund this program. That's the bottom line. It is not the fact that the rules are such and such needs to be done. Bottom line is vocational rehabilitation did not request the funds it needed in advance. It knew how many people were going to be put on this program. It had the projected numbers of how many new individuals were going to increase over the course of the year. They also knew how much money it would need to fund those individuals. It did not request it. Two plus two does not equal five. You cannot serve more people with the same amount of money. They ask for the same amount of money. Therefore, what has happened independent living centers administrative rates have already been cut 5%. It looks like vr is trying to cut us more. That's going to affect the services we provide, increase our caseloads. Home health care hasn't been cut as far as I know. Nursing homes got an increase. I mean where is this going? Where is this leading? This is the Olmstead compliant program. If you receive home health care services, which I think there is definitely a place for, I agree with, home health care people can't take out your garbage. They cannot dust your house. I mean what are you going to do if you can't ever get your garbage taken out and you can't do it yourself? You are either going to have a friend do it or you will have to go into a nursing home. These are some of the things I'm looking at that we see every single day. I wish this commission would take a harder role on this and would advocate harder with the political process and not be so politicized itself. The perception out there across the state that this commission was formed as a political commission to do a few studies, to do a little bit of talking and not do anything hard core. Frankly, if you can tell me what you have done in the past two and-a-half years besides put out a very nice-looking brochure, something substantive, I would appreciate hearing what it is. Thank you for your time. I would be happy to answer any questions you might have.

MS. DUNHAM: I can agree that I don't think people's lives are better off than they were three years ago. I mean just the budget cuts, recession, people losing jobs, health care costs going up, losing housing, agencies like CILS and other groups that typically offer assistance are maxed out. You know, we are in an era of cost containment, Medicaid cost containment committee is looking at what are options for cutting Medicaid costs? I think it is a scary trend and it is not making people's lives better and it's not moving us forward on Olmstead implementation. I think all of those things are true. I would urge, certainly if there's questions about what VR's policy, what they have been doing on some of the hours, you know, talk to Ron. I'm sure he would be.

MR. BLAKLEY: I think he walked out before public testimony. I was disappointed in that. I think he is a decent person. I think everybody here are decent people. I think you all are here because you want to help. Sometimes with a commission like this. I've been on commissions like this before, you sort of get into a mind set of not really seeing what you are doing is affecting people out in the field, out in the grass roots level. It may be that I'm not sure but I know in VR's spot it may have come from the governor's office they couldn't request more money. It's been political. I don't know what went on inside back doors, smoke-filled rooms but I know this program has been cut and it's been cut and now they are trying to make up for it by cutting consumers' hours. It has been painful for those individuals. I don't care what they say. It has been painful. Unmet needs. Some of them are just not being met. Pretty soon what's going to happen is -- I know what their stated goal is. Their stated goal is to bring consumer hours down to 2.88 per day. You are talking numbers. You are not talking people when you say that.

THE SPEAKER: Amen.

MR. BLAKLEY: Thank you. We have to bring that. They are saying we have got to get the consumer numbers down to 2.88 or 2.89 for our budget to last the rest of the year before we'll have to do something different. We're not hours, folks. We're not hours at all. We're people out there. And I come from the Ozarks, from Viburnum down between Steelville where you see a lot of poverty and a lot of Medicaid and a lot of people with disabilities who cannot get out, go anyplace on their own who may live 40 miles from the nearest town. It doesn't work this way. The caps must be removed that VR has imposed. I would recommend fully this commission support that. I think it is ridiculous having caps on home keeping and housekeeping and transportation and other things individuals may need. I think this commission has to recommend that Voc Rehab actually request the money it needs instead of playing politics, but I think the commission has the authority to at least request that. This is an independent commission, from what I understand. You have the ability and you have the right to make those requests and make those demands upon agencies. But my feeling is do you have the nerve and do you have the advocacy within you to do this? That's my request to you. Make the House Bill 11 money work the way it was supposed to work. They may ignore you. Politicians may totally ignore you like we've been ignored. I have got to tell you you at least have to try.

MS. DUNHAM: Typically we have never gotten into talking about department budget requests on this commission in terms of whether we're independent or not. We're basically an advisory to the governor. We make recommendations to the governor but we've never been a part of being -- of setting state department budgets. Certainly we have our recommendations, the issues that we think need to be addressed.

MR. BLAKLEY: If you advise the Governor, then you can advise the Governor to advise department heads to follow Olmstead law. That seems pretty simple to me. Frankly they are not doing it because what they are doing is they are taking Olmstead and making a joke out of it. It is a Supreme Court decision. This is something that's come down from the highest court in our land and Missouri is not only back pedaling as fast as they can. In some instances it seems that they are ignoring it. I used to be proud to live in this state. It was a leader in the country and now it has gone from leadership to one of the middle ground or lowest.

MS. DUNHAM: And I think --

MS. HICKS: May I say something? I think you have presented a good case and I think you have been very articulate. I was a teacher for about 30 years and then I became an advocate of seniors in the state of Missouri. I work with Silver Haired Legislature and I come to the capitol frequently. I live here in Jefferson City and I know most of the secretaries in the capitol, I have taught most of them. So I have some in here. What I'm saying to you is that I do think this commission is advisory. I think you are talking about a money problem. And I think you have to get advocates who can come up here and talk to the legislature about the budget and about -- you need to get legislators informed about the problems. And I think this is where you can do some good, write to them. I know I worked on teacher retirement about five years. People think letters and e-mails are not important. But let me give you just one example. We were trying to get a bill that would raise the probate to 50,000. It was 15 in the state of Missouri. And one of the men on the committee was a lawyer who made his living by probate. I called his hometown and had one of our men go down to the nutrition center and say, he's not going to vote this out. He got 65 telephone calls that afternoon. That worked. And that's what you have to do. People have forgotten that you can put pressure on at the local level. When we were working on the nursing home bill last year, I called these legislators in Jefferson City. I went down at 8 o'clock -- you are laughing, Klye because a bunch of us, I got a bunch of people to go down at 8 o'clock in the morning and stare down one of the house committees who was going to change it back to the way they wanted it. But in the long run, my legislator here in Jefferson City called me. He had gotten the message that we were not going to let them change that nursing home bill back and he called me and he said, Martha, what is it you want in that nursing home bill? Now, I felt like that was a real success story. So I think you are aiming -- I think your heart is in the right place but I do think perhaps that you need to get down at the grass roots level. There must be representatives all around you down there that you could call and tell them, you know, what the situation is. If you don't get any response, the ballot box is your answer.

MR. BLAKLEY: I can tell that you are or have been an advocate just by the way you handled yourself during the course of this commission meeting. I respect that highly. I can't see your name tag.

MS. HICKS: I want to tell you I worked for two years on this choices committee. You have never seen so much -- I didn't know a thing about this when I went in there. And I thought my, they are being persnickety because they wanted to get the curriculum just right. You don't just go in and transition a person out into the community without giving it a lot of thought and frequently during our sessions, I would say to this committee and it was mostly professionals. I would say, well, why do you have to do that? I think you are just being too careful. But oh, they talked me down every time. I learned a lot because you can't just transition a person to the community without a lot of thought, a lot of work and believe me, that curriculum that's out there has been thoroughly thought through and worked on so that when you transition somebody, if you go by that curriculum, you are doing it the right way. I can assure you of that.

MR. BLAKLEY: I understand you have to have pots and pans, you have to have a bed for somebody, a house, all of this. This is what we do. This is what we try our best to do. Unfortunately one of the funding problems is that Medicaid hasn't written waivers for this which are out there. There is a nursing home waiver to transition people out which will buy these things that individuals need. That's one of the things perhaps this commission could recommend also is for DSS to write this type of waiver. In addition to that, we do write letters to our legislators. We're in the process of that right now. Every independent living center in the state, they have said they are willing to call their consumers, let them know about the reason they have been cut. Frankly we have not ourselves have not advocated the way we should in the past but recently we're getting our act together. We're telling our consumers why, it is a matter of money. It is the matter that vocational rehabilitation did not request enough money. The reason their hours are getting cut is not because of the official but the official rules that have been imposed by VR and that they need to call their legislators and write their legislators. Our center along, our legislators alone in our area received 88 letters from our consumers. That's 10%.

MS. HICKS: Let me tell you something. If Voc Rehab got a call from your local legislator, he may be from Podunk, you know.

MR. BLAKLEY: He is.

MS. HICKS: If Ron Vessell gets a call from that legislator today, Ron Vessell will listen to him. Don't kid yourself because he's there. He is the servant of that legislator. So if you have a beef, get that legislator to call Ron Vessell. I know enough of these professionals here in Jeff City to know that they jump.

MS. ALLEN: Amen, sister.

MS. HICKS: When they get a call from a legislator. So if you have a beef with Ron, you get your local legislator, even if he's from Podunk.

MR. BLAKLEY: I don't think it is even so much Ron. I think it is more coming from above Ron. It is coming from perhaps the Governor's Office themselves. I don't know. I do know that it is a matter of money, though.

MS. HICKS: Don't hesitate to call the Governor's Office.

MR. BLAKLEY: We have and our state representative, who is a democrat, has written a letter to the Governor as well. On the broader scope, though, our own independent living center, this commission can help as well and I'm requesting this commission to help by advising the Governor's Office to fund this program because this is the Olmstead compliant program, if you think about it. We can actually transport consumers to groceries stores or any other care program you can. We can actually take people's garbage out. We can do things for individuals like housekeeping to keep people in their homes, to keep their quality of life as high as possible. VR does not like to talk about quality of life because they say that doesn't attract funding for their program. You know, it is there and it's from central medical services also that it is an issue they want to see increased. I don't want to take too much more time of the committee. But our program here is only 4%, 4% of the entire only and community-based services. Home health care -- I have some statistics here, 31% of the home and community based direct personal care.

MS. ALLEN: Can you clarify that because there's a difference between home health and in home?

MR. BLAKLEY: I'm talking about DHSS personal care.

MS. ALLEN: That's in-home.

MR. BLAKLEY: I apologize.

MS. ALLEN: that's all right.

MR. BLAKLEY: Also nursing homes have 23% of the residents right now, RN visits account for 14%. Our program, our administrative rate that we receive through not-for-profit independent living centers currently stands at 11.64 per hour. That is cheaper than anyplace else you are going to find an administrative rate. I believe DHSS personal care is somewhere in the neighborhood of 13.70. Somewhere here might know the exact now.

MS. ALLEN: 13.71. I now get to round a penny.

MR. BLAKLEY: That is a lot different than 11.64. I hope you understand that not only are we cost effective, but we provide pretty good services and people choose their own person who they want to fire. They can fire that person if they don't like it. That is the beauty of that program. It can work for not only physical disabilities but other types of disabilities as well and we encourage this commission to support this program, to please recommend to the governor's office the way it should be funded and to please also remember House Bill 11, which is passed at least two years ago isn't working the way it was intended to work. Money is not following the consumer.

MS. ALLEN: I wanted to make a comment. Thank you so much because from the Department of Health and Senior Services we do appreciate the services the independent living centers give. Sometimes we find ourselves caught in the middle in the battle between the in-home industry who wants their piece and independent living centers that have their rightful place in the marketplace. But I think not to speak for.

MR. VESSELL: Because he does his own budget but I think as a person who sat through those budgets, I just can't imagine that Ron wouldn't ask for the money that he needs. Now, whether we get that or not is a different argument but certainly we're all aware of waiting lists and we're aware of what those individuals cost. I think over the past three years, particularly what we've seen is we ask for the money that we need for individuals and you think you have got the money that you need for individuals but by the time the dust settles on the year with withholds examine core cuts and more withholds and more withholds, you end up having to put a freeze on a pot of money that you thought would serve everyone. I think the one thing that this commission has done, at least from my perspective is really encouraged the different agencies to work together. When the funding is tight, I think it is even so imperative for all of us to be sitting at the same table and saying, you know, we worked on several cases this year where the consumer came to the agency that was serving them and said you don't give me enough hours, I can't stay in my home. I can't manage my needs with these hours and the fact that the encouragement here is for me to go to MR-DD's people or me to go to Ron's people and sit down and say how can we pull together what I can give them, what you can give them and what Kay's people can give them to make sure they can stay at home so there's a value in that. I think Missouri does have a long ways to go. I spend a lot of time talking with other state directors and I know what they are up against but I will tell you what, we still look a lot better than a lot of states. You can look at some states who have over 30, 40, 50,000 people on a waiting list and you are thinking man, that just must feel really frustrating. But I think the key in times like this. Everybody is focusing on the money. I think right now we need to stop talking about money until it is there and we need to start talking about how we create a system that's going to take what money we've got and make it really work. We have Missouri can brag and we do this, I think our people are very good at keeping people out of nursing homes and I'm not going to make any excuses for how good I think we are doing that with the system we've got. We have the lowest occupancy rate. We're like number 49 out of 50 down there for occupancy rate and I think that's part of the thing that's coloring the effort when you are on the band wagon to say keep people out of nursing homes, keep people out of nursing homes and the legislators see that you are doing a pretty darn good job of keeping people out of nursing homes. The message doesn't get there that the people that are going to be forced into that situation are waiting out there at the curb to be forced into that. So part of what I think this commission has done too is really recognize that we have to collect data on our people. We have to prove to the legislature that there is a group of people out there and these are their needs. It isn't just one emotional story after another. There is a huge contingency and with Martha's guidance, that contingency will call and show up and do those kinds of things. But we as state agencies are now sitting down saying how can we present this as a unified force for people with disabilities to make sure that it becomes a priority. But and each agency can speak for themselves but there has never in the years I've run budget for the state agency ever been a message coming down saying don't ask for the money you need. It has just never happened.

MR. BLAKLEY: Two points. First of all, there is a relatively lower occupancy rate that Medicaid is still paying for beds that are not being used. I mean people may not realize this, there is going to be an empty bed in Medicaid they will be paying dollars for that bed and no one is in there. When you have people that are in community-based settings, you don't have brick and mortar to pay for, you don't have mortgages to pay for, you don't have air conditioning in the summer to pay for, heat in the winter, you don't have a charge nurse to pay for. All you have to pay for is that person coming into that individual's home to assist them. When people in nursing homes say they provide 24-hour care, that's false. They provide 24-hour bed. That's the thing I see about nursing homes. Another point is when you talk about the money, the money is -- it is never about the money, you are right. It is about priorities. There are still road projects going on. Other things are happening in the state. The state is still functioning. Those are higher priorities than they are right now. This commission needs to make itself a higher priority in the eyes of the budget. And another point I must take issue with is when you ask exactly the same amount of money you ask for in a previous year knowing, knowing that you are going to get more consumers on a program because it is an entitlement program and you cannot cap it, then you have misled the appropriations committee. That's my opinion.

MS. DUNHAM: Well, certainly.

MR. BLAKLEY: I've been known not to mince words.

MS. DUNHAM: Certainly the perspective that the grass roots bring, certainly you make the points that people's lives aren't better off right now and I think I can say in this commission supports the consumer-directed program and we will support it.

MR. BLAKLEY: I just hope you do it a bit more proactively and make strong recommendations to the governor's office. Thank you very much for your time.

MS. DUNHAM: That was all we had scheduled for public testimony. Our next meeting will be January 12th and I don't know if it's going to be -- is it going to be here? It will be scheduled here at 10:30 on January 12th.

MS. THURSTON: Yes. I want to go back to the presentation of the Missouri planning council made and also the comments that Kay made in relation to the department of mental health. I feel like that there may be overlapping but I think and the Missouri planning council was asked to present exactly what they had in mind but I would like to see what the division also has in mind and what overlap that is. It is one that tends to be person centered on what really happens to the person that they moved to the community and some of the things that the division is looking at, is that more in the support system such as backup support and provider issues such as people transferring from the Hab centers to do staffing? I think these are all important. But I think the overlapping, I'm not sure. I think there's two sides here that are looking at two different things and I think that the people that go out into the community and the direct care that they are getting and the quality of life, by the way I like those words -- that's really what we're interested in when we evaluate people who have moved to the community. So when I look at the spatial analysis if we're asking one group to see what they really want to do, we need to ask the division or department to list what their thoughts are on analysis so this commission can look at both of those.

MS. GREEN: On the spatial analysis that we've requested, I don't have a lot of detail information on that. However, I think it was that the purpose of that is to look at long-range planning and really it is to look at the impact if state institutions were closed, downsized and closed. Is there then the capacity? What would happen for people who have emergency-type needs, how could we really meet all of the need then in the community? So I think the spatial analysis had to do more from that -- it is more from that perspective and then what the planning council and UMKC are proposing to do, that was something new to me. I'm not familiar with that proposal at all.

MS. THURSTON: I think the question and I don't understand the overlap.

MS. DUNHAM: There may not be.

MS. GREEN: I think maybe there isn't but I don't know enough about each of the proposals to really say that there isn't.

MS. THURSTON: I hope there is not an overlap. There are two different things here.

MS. DUNHAM: Good point. We didn't mention before Ron left that he is actually retiring at the end of December but perhaps we can welcome him back to the January meeting for some kind of recognition for his service on the commission. He sort of slipped in and out before we could do anything to embarrass him too much, although your testimony might have served. Anyway, we will see everybody in January. No meeting in December so enjoy yourselves and I'm sure we'll be back here more than we want to in January. So thank you.

C E R T I F I C A T E

I, Deborah L. Reithmeyer, do hereby certify that I appeared at the time and place first hereinbefore set forth; that I took down in stenotype the entire proceedings had at said time and place; and that the foregoing pages constitute a rough draft transcript of my stenotype notes.

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Registered Professional Reporter