California Comparison to MassachusettsFor those who are not familiar with Assembly Bill 896, which proposes to
close California's institutions for people with developmental disabilities,
more information is available from this Inclusion Daily Express web page:
June 21, 1991
Roberta A. Marlowe, Ph.D.
Assistant Director
Office of Planning and Policy Development
Department of Developmental Services
MENTAL RETARDATION PROGRAMS-HOW DOES CALIFORNIA COMPARE TO MASSACHUSETTS
INTRODUCTION
The Pioneer Institute for Public Policy Research recently released a book by Edward Moscovitch entitled Mental Retardation Programs How Does Massachusetts Compare? It analyzes and presents data on costs, federal reimbursements, and client-centered issues related to planning for future services and coping with the budget crisis in Massachusetts. The general approach identifies areas where immediate cost reductions can be achieved with part of the savings being used to fund less costly alternatives-in both the short- and the long-run- and increase the proportion of the costs reimbursed by the federal government with total State cost significantly reduced. The proposed alternatives are also believed to provide higher quality of life for the persons served. The primary targets identified for cost reductions are in residential services. The data on selected progressive comparison states, which did not include California, are also presented.
Given that California is experiencing a similar fiscal crisis and struggling to improve the quality of life for those served while reducing State expenditures, some of the recommendations for Massachusetts are discussed for their applicability here.
The tables attached present California data in comparison to those of Massachusetts, using the format from the report. All cost estimates for Massachusetts in the report appear to have been based on the assumption that all initiatives have been fully implemented; program development, related training, and start-up costs seem to have been excluded for all calculations. To the extent possible, comparable data for California have been obtained. Unless otherwise specified, data in the attached tables or located elsewhere in the report are the source data for the cost, savings, and rough estimates presented here: to accurately estimate the costs and savings of alternatives presented for implementation in California, more recent source data should be used and related program development, training, and start-up costs should be computed.
STATE DIFFERENCES
Massachusetts differs from California in several key areas affecting service delivery. Some of the areas create obstacles to change in Massachusetts, others are areas where Massachusetts may change to become more similar to California. The most significant areas of difference are:
* Massachusetts is governed by consent decrees, which limit the range of viable options to reduce State school populations (the equivalent of developmental centers). These have created high staffing ratios and the dictum that State-constructed and State-operated community facilities be 60 percent of all community facilities in Massachusetts. Input from the Health Care Financing Administration (HCFA) to the court appears to have been for stricter standards than HCFA imposes in other states. California facilities are not subject to consent decrees, so DDS has greater control of population reduction. DDS also does not operate community facilities. Massachusetts apparently is not permitted to admit any additional persons to their State schools under their consent decrees.
* Massachusetts state facilities have 3.07 staff per client, while California's have 1.42 staff per resident.
* Department of Mental Retardation (DMR) does not control placements nor programming decisions until clients reach age 22; the Department of Education handles all aspects of client services through age 21. In California, DDS is responsible for clients over their entire lifetime via the regional centers.
* Residents of Massachusetts' State schools are much less seriously impaired than residents of California developmental centers (i.e., more are higher functioning in Massachusetts).(1)
* Different staffing practices exist in the two states. California has some of their own teachers, but Massachusetts sends out all residents to day programs. It also appears that Massachusetts is not staffed to provide as full a range of on-site medical services as California (e.g., EKG, EEG, dental, laboratory, x-ray, adaptive equipment). There is also no mention of behavior problems, court commitments, or dual diagnoses among clients as considerations in the deinstitutionalization process, which suggests that these populations may not be significantly served via the state schools in Massachusetts.
* Unlike California, Massachusetts does not apparently have a HCFA-imposed constant cap on the number of clients eligible for reimbursement under their Home and Community-Based Services (HCBS) Medicaid Waiver, nor outstanding issues postponing expansion of the Waiver to additional service types; however, their number of participants is negotiated with HCFA.(2)
* Personal care attendants are a Medicaid service under the State plan in Massachusetts, but not in California.(3)
* Waiting lists exist, attributed to insufficient resources, in Massachusetts for day programs, comprised mainly of persons who have turned age 22, and for residential placements, primarily listing middle-aged adults whose parents can no longer care for them. In California, DDS does not maintain waiting lists as such.
* Unlike California, Massachusetts does not appear to require exhausting generic services before expending DMR funds. There is no indication that Massachusetts' program is considered an entitlement program as is true for California.
* DMR does not have responsibilities for persons with developmental disabilities who do not have mental retardation; almost 9.5 percent of California's clients do not have mental retardation.(4)
* The report finds DMR staffing for grounds and buildings to be high compared to other states and advises cuts; California's ratio is one-third of Massachusetts'.
* Massachusetts DMR has a lower proportion of expenditures reimbursed by the federal government than many states, yet had a higher proportion reimbursed in both 1988. and 1990 than did California.(5)
STATE SIMILARITIES
Despite the important differences cited, Massachusetts and California are similar in other significant ways. Some of the most pertinent similarities are:
* Most State school /developmental center residents are over age 22;
* All State school/many developmental center residents participate in off-site day programs (fewer will in California if adult education cuts for the developmentally disabled. as recently proposed, are implemented);(6)
* Both states' institutions use separate food service personnel. California returned to it alter discovering that using the higher paid direct care staff to serve food, etc., costs more and also resulted in problems with licensing inspections:(7) the report recommended that Massachusetts transfer food service responsibilities to direct care staff;
* State licensing requirements for professionals are stricter in California and Massachusetts than in some of the chosen comparison states in the report (midwestern states;, which adds to costs and staffing requirements. For example, other states have nurses and other professionals train paraprofessionalsi/direct care staff to administer routine medications and to provide some therapies; these tasks require nurses, psychologists, and therapists in California and Massachusetts.(8) Many professionals in both states are also required to be given "call-back pay" (minimum hours if called to duty without regard to time spent on call-back);(9)
* Rates for private residential service providers do not meet all provider costs, and relatively low wages result in high staff turnover and serious recruitment problems;(10)
* Both states are among the top three with significant State supplements to Supplemental Social Security Income Massachusetts added $114 in 1988 and California currently adds about $323. Both allow recipients to retain more than the $30 mandated by federal requirements
Recommendations similar to current California programs and pilots include:
* Maintain separation between State schools and community programs in the DMR budget;
* Increase community placements from State schools;
* Create a regional structure of service delivery;
* Aggressively seek more federal reimbursements; (12)
* Transition placement responsibilities of age 4 to 22 from Education to DMR;
* Aggressively seek more community supported living options/beds; and
* Recruit and train foster families for both adults and children.
PHILOSOPHICAL FRAMEWORK AND RELATED RECOMMENDATIONS
It also is instructive to review and compare some of the report's recommendations for Massachusetts from California's perspective.
Quality of life for clients is the primary consideration. Striving for the most home-like environment becomes more important than reducing physical danger risks. Recommendations for Massachusetts in the report include allowing foster placements before ramps for wheelchairs are in place; locking doors at State schools during the night, which can be automatically unlocked when fire alarms go off, instead of maintaining higher overnight staffing; and using/remodeling existing community structures rather than building new buildings because the latter may have an institutional rather than a "homey" feel.
It seems unlikely that California would license foster care before the renovations for wheelchair access are completed. especially given the legal mandates present in the recently enacted Americans with Disabilities Act. Some unknown portion of the developmental center units do lock their doors at night and have automatic unlocking linked to fire alarms and related reduced staffing, but it is not true for all.(13) New community facilities are divided between being newly constructed and using existing and or remodeled structures, but the proportions of each is not known.(14) However, DDS policy has emphasized small home-like, integrated residences since 1985 at least.
Quality of social interactions in the living arrangement is the most important criteria for placement success. Key to quality interactions is the relationships between client and care provider(s); therefore. it is desirable to avoid the residential models requiring the greatest number of different persons to provide care to individuals.(15) The bulk of California community facilities use the owner-operator model. which minimizes the use of multiple "shift staff."
Residential models of the smallest size have priority. Give priority to the models of the smallest size-i.e., semiindependent or residences for 2 or 3 persons. The larger the facility, the greater the need for administrative control mechanisms to prevent resident abuses, (16) the greater the likelihood that residents will be limited in their range of normal activities,(17) the greater the interference with developing relationships between direct care staff and residents,(18) and the lower the likelihood of achieving a homelike environment. Among the residential models explored in greatest detail were models for supported living, with flexibility within the models emphasized as essential. California is pursuing federal funding to develop supported living as an alternative.
Avoid over-regulation. Over-regulation can interfere with the flexibility and innovation necessary to meet individuals' needs creatively. California also has faced serious difficulties because of requirements for regulations.
Consider broader and less formal measures of program success. Improved quality of life and client happiness are among the criteria to measure success considered desirable. The report advises that long, clinically-based individual service plans as the primary device for assuring quality care be de-emphasized. A peer review process rather than detailed inspections-preferably a peer located elsewhere (e.g., consultants from other states) who are not perceived as competition-are also options recommended for consideration. California also need to examine such options.
Emphasize placement prevention. Family support initiatives, while requiring increased expenditures in the short-run. accrue long-term savings in residential casts avoided. Massachusetts' current system appears to encourage parents of children to place them in expensive private schools, which is part of why DMR is proposing to assume responsibility for persons aged 4 to 22. Currently, DMR provides an average of 70 hours of respite to the families caring for 10,000 adult clients and has many 22-year-olds transitioning to DMR from Education on day program waiting lists, which may exacerbate the need for respite. Specific new initiatives recommended include:
Cash subsidies to families who maintain their children at home. As proposed, these subsidies would be limited to families of persons with severe retardation aged 4 to 22. The payment range present in other states appears to be between S200 and $250 per month (annually $2,400 to $3,000). Cash subsidies are also recommended for foster families of both adults and children at about S18.000 per year. Both are less costly alternatives compared to community residential placements (about $40.000 average in Massachusetts and $22,500 in California(19).
If the 9,504(20) California DDS clients between age 4 and 22 with a severe developmental disability(21) were eligible for a cash subsidy, the approximate cost would fall between $15.5 and $28.5 million.(22)
Massachusetts' primary target population for the foster care models (for both adults and children) appears to be persons already in residential care with severe disabilities (self-care limitations). Foster families would be recruited and trained. Ideal candidates seem to be employees of group care homes who might be interested in caring for a client they have an established relationship with for about $18,000 per year,(23) with guaranteed day programs to free them for other employment, if desired. Using existing care providers is expected to minimize parental/family resistance. This model also emulates a home environment more than most models. An additional advantage should be an increase in available openings-for both community care facilities and among newly created foster care homes- which, in turn, should help minimize the wait for placements among persons whose family is no longer able to care for them (due to caretaker advanced age, infirmity, or death). In California it could also help shorten the State Developmental Center Referral List.
Currentlv 648 children reside in developmental centers(24) costing the State about $21.1 million annually(25) and 1,581 reside in community care facilities at a FY 1989-90 cost of about $35.6 million;(26) savings in these areas could conceivably fund the subsidies and/or foster care payments for children-especially if the cap for HCBS Waiver could be raised or eliminated. Moving adults from community care to foster care would save approximately $2,500 per year each.(27) If the 5,178 adult community care residents with severe developmental disabilities moved to foster homes, the savings would exceed S23,000 per client moved, totalling $123.8 million.(29) Each of the developmental center residents transferred would save the State about $14,000 per year.(30)
Focus on ideal placements when downsizing institutions. Focusing on ideal placements rather than on facility closure planning preempts hostile responses from parents and employees. Facilities are closed when the number of residents make them uneconomical to operate. In California this resistance has been experienced because historically our method has always been to identify a facility for closure with a target date.(31) The report advises planners to consider transition services(32) for affected employees including the following:
* 30-day notice for terminated employees:
* Requirements that private residential providers interview terminated State employees for available positions;
* Give priority and training for other State jobs to terminated employees; and
* Provide a temporary subsidy of State-private salary difference for up to 3 years if terminated employees accept private provider employment.
To the extent the above supported living programs, including the ICF-MR certified model, and adult and children's foster care models have been developed and clients moved, more options should become available for developmental center community placements-both from the new programs and from available spaces in a wider range of established programs. As developmental center buildings become vacant. they can be leased for other purposes.(33). Massachusetts' recommendations include leasing to prisons, community colleges, and community hospitals. California might also consider giving priority to programs starting-up at reduced space costs, especially day programs if full day program access becomes a key objective.(34) Some space and staff could also shift to providing out-of-home respite for medically involved community clients.
Unify responsibilities for State institutions and community programs. Massachusetts has regionalized all DMR responsibilities so that the persons responsible for decisions related to reduced institutional populations are also the ones responsible for the community programs needed for community placements. This avoids "turf wars." DMR's regionalization is similar to two comparison states, who shifted responsibilities to counties where the cost-savings of deinstitutionalization served to fuel expeditious outplacement. Massachusetts is reportedly capable of reducing their State school population to 1,000 (down 66%) in four years by following the report's recommendations. Regional organization has also allowed Massachusetts to effect cost savings by merging administration of a regional office with that of the nearby State school. The trade-off inherent to this community-control model appears to be some lack of uniformity across the different State schools, which are reported to vary in their staffing ratios. It is unknown in what other ways and to what degree other areas vary, nor whether the differences are comparable to differences across California's developmental centers.
A "regionalization" concept has been used in California - the Regional Resource Development Projects - to facilitate cooperation in client placement among regional center and developmental center staff. The regionalization idea could be applied in additional ways in California. It suggests an alternative DDS headquarters organizational structure that might effectively meet the challenge of significant reductions in developmental center populations. An out-placement incentive formula for regional centers could be developed. Such a formula would identify a portion of the cost savings related to each developmental center community placement to be credited to the placing regional center as special program development funds, Purchase of Services (POS) augmentation, or without designation from DDS, but with DDS reserving approval of chosen use.
Redirection of some of the savings can be cost-effective in the long-run. Massachusetts was advised to redirect 57 percent of the expenditures saved via the above recommendations to fund the family subsidy and foster care programs and to expand their respite, day programs, and other family support spending. A portion was also reserved to remove the freeze on rates for residential providers and to provide rate increases to bring residential staff wages into market parity. This was expected to reduce turnover and recruitment problems and reduce the costs of paying wage differentials to terminated State employees accepting private employment. Cost data on whether the $60 million identified for redirection to these areas would be sufficient to do all these things were not presented. California could benefit by redirecting savings to these areas in addition to expanding residential and program services for clients with head injuries, dual diagnoses, and other behavioral intervention needs. Estimates of how much would be required to fully meet these needs cannot be computed from data currently available.
SUMMARY
The recommendations for Massachusetts are expected to reduce State costs, at least in the long-term, thereby freeing funds for placement prevention and system quality enhancements. Some recommendations redirect the costs to be reimbursable under Medicaid Waiver to maximize the federal share of the costs. The savings for Massachusetts is estimated at $105 million with $60 million targeted for redirection, leaving net savings of $45 million. Although many of the specific recommendations presented are not viable for California because they are already operational, were previously tried and found not to cut costs, or would require substantial changes in positions taken by HCFA on our Medicaid Waiver program, some are worthy of more careful scrutiny. California's gross savings could approximate $138.8 million if the foster care and supported living models were fully implemented.
The cornerstone of all the recommendations is successful reduction of the institutional population. One viable idea is to focus on ideal placements rather than on planned facility closures, which would preempt resistance, so that facilities close when the population is too small to be run economically. Further regionalization via unifying the responsibilities for the developmental centers and community programs to serve the discharged individuals might expedite developmental center population reductions, especially if fiscal incentives for regional centers were a part of the initiative.
Also essential for expeditious out-placements is sufficient availability of cost-effective quality residential alternatives. Among the most cost-effective models described are the supported living models and foster care models for children and adults; the more the available spaces in such programs, the more options there should be for out-placements. These are also among the models of the smallest size believed to best enhance the quality of life and social interactions for clients. Sufficient appropriate day program resources are also necessary to effectively recruit providers to implement these residential models and maintain quality. Finally. such programs could reduce costs by serving community residents currently residing in more expensive alternatives.
Concurrently. placement prevention needs to be emphasized to stabilize the residential population. Beyond expanding -existing family support services, cash subsidies to families appears to be a cost effective alternative, in the long-run, by preventing or delaying out-of-home placements that have significantly higher costs.
________________________________________________
(1) In Massachusetts only 50 percent have profound retardation compared to 72 percent in California. For seizures it is 41 percent versus 53 percent, and it is 14 percent versus 39 percent for cerebral palsy. Thirteen percent of California center residents are deaf, while only 6 percent are in Massachusetts. Finally, 53 percent of California's center residents have a behavior disorder, while only 39 percent do in Massachusetts. Source for these figures is White, C.C., Lakin, K.C., Bruininks, R.H., and Ki, X. (1991). Persons with Mental Retardation and Related Conditions in State-0nerated Residential Facilities: Year Ending June 30. 1989 with Longitudinal Trends from 1950 to 198_9. Minneapolis: University of Minnesota, Department of Educational Psychology.
(2) California information per Arnold Griffiths, PAD. California's current cap is 3,360.
(3) California information per Arnold Griffiths, PAD.
(4) CDER data as of June 1990 presented in Californians with Developmental Disabilities. July 1990 Edition indicates DDS served 8,662 persons without mental retardation.
(5) See Table 2 for data. In 1990, California was 29.5 percent reimbursed by the federal government, while Massachusetts was 31.3 percent. When Title XIX Targeted Case Management (TCM; reimbursement begins, California's rate will increase and may become higher than Massachusetts.
(6) California information per Clara Cargile, DCD.
(7) California information per Clara Cargile, DCD.
(8) California information per Clara Cargile, DCD.
(9) California information per Clare Cargile, DCD.
(10) In Massachusetts current rates result in payment at about 53,000 less than cost per client per year. Two reports based on 1987 California data suggest the same is true to a significant extent in California: Price Waterhouse with Albert Lowey-Ball Associates, Department of Developmental Services 1988 Residential Rate Study. Long Term Rate Setting Recommendations. January 20, 1989, and DDS, Report on Wages, Taxes and Benefits Provided to Residential Care Staff, January 1991. The former report indicated that most Special Services and Negotiated Rate residential facilities were operated at a loss and that it was possible some other owner-operated facilities wouid show a loss if reimbursement to owner operators for their work had been included as a cost. The second report identified a sizable number of facilities who were not paying legally mandated costs; it is possible that some unknown portion of these would also have shown a net loss had these mandated expenses been paid and included as costs. (California allows $83 be kept for personal and incidental expenses in residential care, Massachusetts permitted those in Medicaid qualified facilities to retain $65).(11) Eliminating the State SSI supplement is being considered to help balance Massachusetts' budget.
(11) California data provided by John Moise, CSD.
(12) Its unknown whether Massachusetts' casework reimbursements are covered under Title XIX Targeted Case Management.
(13) California alarm and related staffing information per Clara Cargiie, DCD.
(14) California facility construction information per Lindsay Grader. CSD. This is a type of data DDS does not collect.
(15) Research studies supporting this premise were cited including Conroy, James W. and Valerie J. Bradley. The Pennhurst Longitudinal Study: A Report of Five Years of Research and Analysis. Temple University and the Human Services Research Institute for the U.S. Department of Health and Human Services, March 1. 1985.
(16) Administrative control mechanisms add to cost.
(17) For example, ICF/MR accountability demands and dietary and sanitary regulations may prevent participation in meal planning and preparation, shopping, and cleaning activities.
(18) When 8-hour shift schedules are used interference is especially likely.
(19) See Table 1 for this data.
(20) Based on CDER data June 1991.
(21) Severe developmental disability is defined as severe or profound mental retardation and/or severe impact(s) of autism, of cerebral palsy and/or of one or more types of seizures.
(22) The top figure is based on a rate of $250 for every client meeting this definition, the low figure is based on a $200 rate limited to clients meeting the definition living at home who numbered 6,463 as of June 1991 CDER data.
(23) This amount is 167 percent of the average annual salary of direct care staff working full time ($5.39 per hour at 2,000 hours) and 269 percent of what two-thirds of direct care staff working full time (minimum wage of $3.35 per hour at 2.000 hours) made in 1987 based on data presented in Chen, Bubpha, Direct Care Supervision Staff Hourly Wage Study, DDS, OPPD, May 1991. The $18,000 rate is based on the Missouri rate of $50 per day for those with severe handicaps. Given the wage differential shown here, a lower average rate might provide sufficient incentive; this would also increase the savings.
(24) According to June 1991 CIDER data.
(25) Assumes State pays half the 5178 per day cost.
(26) Based on average cost of $22,507
(27) This could be reduced if too many do not have appropriate day programs.
(28) Number based on CDER data June 1991; savings based on highest residential rate of $3,493 per month.
(29) This could be reduced if too many do not have appropriate day programs.
(30) Assumes half the cost of $178 per day is paid by the State.
(31) California history provided by Clara Cargile, DCD.
(32) The report gives the impression that recruitment of qualified professionals for staffing state schools is not an issue in Massachusetts to the degree it is in California; therefore, transition services are likely even more important for California.
(33) This is a continuation of current practice. but statewide 100 percent of space is not currently used. Space for a classroom would be available at all seven centers per Mike Koester, DCD.
(34) To a degree, day activity programs are currently leasing space per Mike Koester, DCD.
Mental Retardation Services: How Does Massachusetts Compare? Pioneer Institute for Public Policy Research in 1991.
85 Devonshire Street, 8th floor
Boston, MA 02109
Phone 617-723-2277
