Notes from MISCC Committee Meetings
July 01, 2004


Jump Directly To... QA/QI Committee Transportation Committee Community Services Committee Meeting Assessment Committee

QA/QI Committee
Present: Neal Lane, Greg Jones, Harvey Rosenthal, Kim Hill, Susan Peerless, Lisa Kagan

Neal asked all Committee members and members of the audience to introduce themselves. Neal then reviewed the goal of the Committee, which is to produce principles and guidelines for the evaluation of services. What comes out of the committee should be a yardstick that evaluation tools should be measured against.

Presentations from CQC and DOH
CQC and DOH completed an analysis of the consumer satisfaction tools that are under review by the Committee.

CQC
Karen Myers Malcolm reported on behalf of CQC. CQC reviewed 19 surveys or descriptions of surveys. Karen prepared a one-page summary of each survey tool and did an overall memorandum which was handed out to committee members. Karen noted the following key issues which needed improvement:

1. Very little attention was paid to asking people about community integration and inclusion. Community integration refers to the person being physically located in the community, while community inclusion is the process of connecting people to the community. Community inclusion deals with relationships. The two questions that must be asked are 1) Will the service positively affect an outcome for the person and 2) What is the possibility that the person can make a connection to others?

The things we need to consider and focus on are:
     1. Community presence
     2. Community participation
     3. Encouraging valued social role
     4. Promotion of choice
     5. Developing competencies of individuals

2. Karen felt that the surveys need to better address abuse situations and follow up to abuse situations. Guidance needs to be given to the interviewer about what to do and to ask what the person wants to do. Karen did notice that some county OFA surveys did provide for confidentiality. She cautions that there must be a balance between rights versus protection.

3. The surveys need to be made available in the language of the community being served and account for sensory disabilities. For example, the appropriateness of the use of telephone surveys or the use of mail-in surveys.

4. The surveys didn't address service system coordination and didn't ask the person for feedback on agency process or program administration.

5. There were no standards or benchmarks for evaluating the survey results based on what the person thinks is important.

6. Monitoring of consumer satisfaction over time was lacking. You have to ask people about why they terminated a service and if they need more information and referral.

Karen advised that some state agencies only submitted summaries of the surveys and not the actual surveys.

Harvey commented that OMH is missing in this discussion and questioned why they didn't submit tools. Susan advised that the OMH tools were part of the 40 that we're submitted, but she will go back and check.

Bruce Darling commented that the point about sensory issues is important. We also must consider people with physical or cognitive disabilities and who is filling out the survey. Many CMS surveys don't give guidance (for example the MDS).

Lisa Kagan commented that OMRDD trains consumers on how to be "savvy" consumers and be a part of the services that they receive. They train consumers on how to look for quality.

DOH
Suzanne Broderick from DOH reported on the surveys that DOH analyzed. She advised that Karen from CQC discussed some of the same issues that DOH had. Karen introduced Jessica from DOH. She advised that DOH has a grant and looked and adapting the CMS consumer satisfaction survey to the TBI program.

DOH reviewed 16 groups of tools. Suzanne handed out a summary of their findings. DOH found that the overall strength of most tools was:
     · Problem identification
     · Opportunities for suggested improvements
     · Open-ended consumer input
     · User-friendliness (4 or 5 tools were somewhat difficult)
     · Wide applicability of tools

The overall weakness of tools were:
     · Insufficient Quality of Life Assessment (2/3rds of the tools didn't address this at all)
     · No information regarding reliability and validity testing
     · No measure of outcome indicators (2/3rds of the tools didn't contain any. Those that did didn't connect them with consumer goals.
     · Cultural sensitivity (To Susan this means that the questions are used in a culturally sensitive way; it's not just about language)
     · Limited attention to Data elements; assessment less than comprehensive
     · No information regarding use of a proxy

She noted that in some of the surveys, consumer satisfaction was part of the larger assessment tool (i.e. home care assessment, adult home assessment, etc.). She questioned if this is a good idea or should consumer satisfaction be evaluated separately?

Lisa Kagan pointed out that one issue for OMRDD is that we have a system where a person is involved with multiple providers. This makes it difficult to do quality of life assessments.

Neal advised that this is true in the long-term care system overall and that we need to account for this. Accountability and the customer's overall quality of life isn't there because there are multiple providers.

Lisa advised that OMRDD has a process where Service Coordinators go into a home and if things are bad there they document it. This creates tension between service providers because you have a Service Coordinator commenting on another provider's services.

OMRDD
Lisa Kagan reported on what OMRDD looks at in consumer satisfaction tools:
     1. Does the person have choice?
     2. Environmental modifications and supportive staff?
     3. Are there opportunities to re-assess whether the setting is appropriate?
     4. Is the person satisfied with services?
     5. Does the person feel safe?
     6. Would the person be more satisfied in a different living situation?
     7. Is it a participatory process?
     8. Is there available transportation?
     9. Does the person have close relationships with people other than the support staff?
     10. Does the person feel part of the community?
     11. Does the person work in an integrated setting?

Lisa questioned what is meant by outcome indicators. Harvey advised that it is matching up what the consumer's goals are. Did the consumer meet their goal? We should measure against the goal of the most integrated setting. Harvey noted that we have created service ghettos. The committee should raise the bar and move past that.

Neal encouraged Committee members and advocacy organizations to provide written comments. He requested that those comments be submitted within the next 30 days. The Committee will then make recommendations to the full MISCC about the principles and guidelines that all state agencies should follow.

Susan Peerless will check to see if all MISCC agencies were asked for comments and report back to Neal.

Harvey questioned if CQC could review the OMH survey.

Commentary
CQC did an excellent job of analyzing the tools. Raising the question of community integration and inclusion was excellent. NYS ADAPT has concerns about developing best practices without assessing how widespread or common the practice is. The inventorying of best practices without this could provide a misleading portrayal of services in New York State.


Transportation Committee
July 1, 2004

Present: Mike Paris, Greg Montegue, Greg Jones, Henry Sloma, Harvey Rosenthal, Susan Peerless, Lisa Kagan

Medical Motor Service, Rochester, NY
William McDonald of Medical Motor Service gave an overview of their organization. They provide over 400,000 trips per year, including 72,000 trips to older adults per year to and from seniors centers. They also provide rides to and from developmental disability day programs. Wegman's supermarkets contract with Medical Motor Service to provide a shopping shuttle for seniors and people with disabilities. In addition, Medical Motor Service subcontracts with public transit for some trips. They also provide transportation for programs at the Jewish Community Center.

Medicaid Motor Service operates a Connect-A-Ride program that is funded through Community Development Block Grant dollars. Riders pay a nominal amount for use of the service. Medical Motors also operates a program called the Irondequoit Faithlink Senior Transportation, which provides rides to seniors in Irondequoit for medical and legal appointments. The vehicle is funded through a member item from the NYS senate and operating funding is through community development funds in a subcontract with a faith based organization.

Other services provided to children and adults include foster care transportation, pre-school transportation, Medicaid transportation, transportation for mental health services and services for people with developmental disabilities. They provide brokerage services, vehicle maintenance services and safety training.

They do mix some populations. Greg M. asked if there are requirements for this? Mr. McDonald advised that yes, there are some requirements, for example if they are transporting children who have been sexually abused. Also, buses must be used to transport pre-schoolers and some adults have a problem with riding a school bus. There are also behavioral issues to consider; for example, some DDSO clients can't ride with other people. Medical Motors does mix pre-schoolers with seniors and seniors with other adults. There is no written criteria; it is a judgment call.

Mr. McDonald explained the Connect-A-Ride program. Rural residents call Medical Motor Service. It is a categorical program and Medical Motor Service determines whether you live in a town covered by the grant. They also obtain an income statement. The person can then purchase coupons for the trip. Each one-way trip is $3.00. Medical Motors may refer the person to the Wegmans Shuttle programs or if it is a medical appointment, refer them to the United Way transportation program.

Lisa questioned what government can do to help transportation. Mr. McDonald advised that local folks can get together and make transportation a priority. They can co-mingle funds. At the state level, the 5310 program encourages coordination of transportation services. We can also push for coordination becoming a priority at the local level. There also needs to be more support from Transit Authorities and Metropolitan Planning Organizations.

Harvey questioned the no-show rate of people with mental health disabilities. Medical Motor Service is implementing a peer program (CCSI will subcontract with Medical Motor Service to hire peers). Instead of just cutting people off, they'll focus on why people aren't showing up.

Henry Sloma posed a question related to paying dialysis patients to take other forms of transportation. Mr. McDonald advised that most are eligible for Medicaid transportation. People apply to Medical Motor Service and get reimbursed $7/one-way trip if they take other transportation, such as getting a ride from a family member or a friend. Medical Motor Service then bills the county.

Henry advised that the committee needs to discuss public transportation. He questioned why it was absent from the committee's charge. Greg advised that due to time constraints, the Committee decided to focus on human service agency (state funded) transportation first and if there was time, talk about public transportation. Henry noted that we have whole sections of New York State with no transportation services. We need to discuss how we get residents in rural areas from Point A, to Point B, to Point C, etc. People choose to live the country and work or go to school in the city. Henry advised that we need to hear from the Public Transit Authorities at the public forums. We need to get the people that run the Authorities, not just the ADA person who is programmed to say something. Harvey suggested that we ask them to come to the forums to speak.

Bruce Darling, audience member, advised that when the committee is looking at models, Rochester has tried to get individual agencies to pool their resources, but it didn't work. Contracting back to a single provider is a way to achieve cooperation.

Lisa Kagan pointed out that another issue is that parents want transportation available for their children at all times. Contracting transportation out works. What doesn't work is pushing the ARC to let other people on their vehicles.

5310 Program
Mike from DOT discussed the 5310 program. It is a federal program with 80% federal dollars and the grantee has to come up with 20% to purchase a vehicle. It is meant to be used when public service doesn't meet their needs. Ever application is scored by DOT and other entities. One scoring criteria is "coordination". The maximum number of points you can receive for coordination is 3. Most other criteria is only 1 or 2 points, so it gives more weight to coordination.

Medical Motor Services is a best practice as a coordinating agency.

Public Comment
Bruce Darling commented that you have to look at the gaps, not just best practices. RGRTA is cutting back on paratransit through recertifications. The Committee must address issues like this. The Committee also needs to focus on worker transportation because people need assistance with things like getting out of bed. Congregate transportation is an issue. It affects people living in the community when transportation is being used to transport people to and from day programs first thing in the morning and at 3:00 in the afternoon.

Greg advised that Committee members should send him recommendations by July 9th so that he can report to the full MISCC on July 12th.

Commentary
NYS ADAPT is pleased that Henry Sloma brought up the importance of Public Transit Authorities. The Committee must deal with the public transportation issue as it is a very important part of the discussion. As stated during the public comment period, the Committee must also address transportation for workers.


Community Services Committee Meeting
July 1, 2004

Present: Tim Williams (OASAS), Kim Hill, Harvey Rosenthal, Constance Laymon, Kathy Kuhmerker, Susan Peerless, Lisa Kagan, Kathy Bunnell

Review of last meeting
     -Identify available services
     -Identify gaps
     -Improve public awareness
     -Improve access to services
     -Discussed public forums

Report/Presentation to Full MISCC
Observations: principles and guidelines
     · Negotiating various sources of information can be difficult
     · NY needs better services, but not necessarily more services
     · People seek information in times of crisis
     · Must be accommodation for language
     · Information should not only be about Medicaid services
     · We lack information on privately funded programs

Constance questioned if anything has trickled down to service authorizers about Olmstead and choice? Old school nurses tell people that they have to go into nursing homes. If something hasn't gotten out, we should recommend that it does. Kathy advised that letters were sent to hospitals and nursing homes about discharge planning. Lisa advised that for OMRDD, it isn't just a letter that goes out; we need to raise consciousness and constantly bombard the system that it is not appropriate that people don't go to the most integrated setting. Tim Williams suggested that the principle should be that there is a continuous evaluation of policies, regulations, etc. Tim suggests that the Committee makes this an overarching principle.

Harvey questioned how this exercise extends beyond principles and guidelines. How do we make goals for agencies and then, years from now, evaluate it? The Committee needs to make recommendations on how agencies can improve and then come back on a regular basis so we can monitor them. Kathy advised that that our recommendation should be that we put out a set of principles and guidelines and have the agencies go back and evaluate how their programs and services meet the principles and guidelines. Harvey advised that we should also ask what agencies have in mind to better their programs. We need to do more than just take a year to develop principles and guidelines. Lisa advised that coming up with the principles and asking agencies to look at how they meet the principles is a lot of work. What brings about change are pockets of excellence that the MISCC should encourage and support. We need to look at best practices.

Harvey commented that the Committee must also look at unmet needs. At some point people are going to ask what we did to get people out of institutions and the MISCC will be measured by this.

Kathy commented that the Olmstead decision talks about within the financial constraints of the state. Kim commented that there are budget constraints, but we should be putting forth the best recommendations and let the Legislature deal with the budgetary issues. Lisa advised that it is not always about new money; it's about best practices. Harvey commented that it is about more than best practices; it's about identifying gaps and making recommendations. We need to look at waiting lists. Kathy said that it might be the Council's charge, but not the Committee's charge.

Kathy advised that in addition to what has already been discussed, the Committee should create more principles and guidelines. Kim questioned if the Committee could ask each agency to self-evaluate and determine if all of the money has been spent wisely. Kathy told her that she knows from the Health Department, that they wouldn't be able to do this. Harvey pointed out that it might not be practical to do this. Lisa advised that change happens from the vision, not from taking money or adding new money. Kathy questioned if one of the principles should be that the State have a vision for long term care.

Harvey summarized that the Committee is discussing having a vision, principles, guidelines and how does it apply to unmet need. Tim suggested that the Committee is talking about having a MISCC level statewide vision (the full MISCC should do this), principle and guidelines, state agencies will examine policies, processes and procedures, state agencies should identify best practices as change agents (this is a continuous process) and using the principles and guidelines to implement strategies.

Kathy summarized the principles and guidelines that the committee developed:
     · Information should be user-friendly
     · Focus on quality outcomes
     · Appropriate balance between medical and non-medical services
     · System should provide services that meet consumers identified needs
     · Self-determination
     · Culturally and language appropriate
     · Services should be responsive to the diverse needs of consumers and enhance quality of life
     · Person-centered
     · Dignity of Risk

Kathy Bunnell commented that quality of life is important. She noted that we should talk about issues instead of programs.

Susan advised that she will do a crosswalk of all the committees and send to the committee chair.

Public Comment
Bruce Darling commented that the Committee must make recommendations to reform the system. If the amount of work is a problem, the MISCC should develop workgroups like other states. Bruce said that consumers cannot wait months and years for recommendations and that the MISCC should use identified best practices to form principles and make specific recommendations.

Bob Gumson commented that he thought the vision was community first and non-biased informed choice. The vision should be that New York actively seeks out and uses all available resources to maximize the ability of its citizens to live in the most integrated setting based on individual needs.

Commentary NYS ADAPT is concerned that the Chair of the Committee has taken the position of not spending new money to a horrific extreme. When the community representatives on the Committee talked about services, she automatically assumed that they were calling for new services. We also remain concerned because the Committee is only focusing on principles and guidelines, instead of actually changing the system.


Assessment Committee
July 1, 2004

Present: Nancy Martinez, Lisa Kagan, Susan Peerless, Constance Laymon, Harvey Rosenthal

Lisa advised that the Committee asked each state agency to provide assessment tools. It was overwhelming and didn't go back with what the statute says. The Committee wants to look at tools and procedures used to identify people who can benefit from services in a more integrated setting. The Committee needs to capture assessment for community services and look at things that are moving the system forward.

Lisa looked at all the assessment tools and spoke with state agency staff about the following best practices:

OMRDD
     · Assessment for HCBS Waiver. The idea of someone qualifying for HCBS if they are eligible for an ICF is a best practice.
     · Medicaid Service Coordination. Assessment that is used asks what the person wants and needs.
     · Real Choice Grant project
     · Consumer Education Initiatives. OMRDD contracts with Self Advocacy Association and Parent to Parent.
     · Self Determination Project. It's about assessing what the person wants and letting the resources go with the person.

DOH
     · Nursing Facility Transition starter grants. The grant allow ILCs to go in and assess and assist people in moving out.
     · Discharge Planning Workgroup
     · Care at Home Waiver
     · Long Term Home Health Care Program Waiver
     · TBI Waiver
     · Being assessed for home care (CHHA, PCA, private duty nursing)

Assessment procedures for the waivers are good.

OASAS
     · Level of Care determination process

OCFS
     · CCSI Program (Coordinated Children's Services Initiatives). This is a program to serve children who are multiply diagnosed. They cut across systems.

SOFA
     · Long-Term Care Ombudsman Program
     · Planning for the long-term care Point of Entry system

OMH
     · Psychiatric Rehabilitation Readiness Determination

CQC
     · Everything that CQC does is informed by the idea of the most integrated setting.

Harvey noted that Lisa suggested that assessments have a bias towards community integration. Institutional assessments have an institutional bias. Lisa explained that the assessment is based on culture and availability of other services. Harvey commented that the Committee should ask agencies to evaluate assessments and look for biases. A shortcoming of the tools is that they could be biased.

Karen from CQC said that about a year ago, CQC funded a training program to train ombudsman to go into Adult Homes. The problem is that the ombudsman were afraid to go into Adult Homes with a high concentration of people with psychiatric disabilities. Lisa requested a written summary on this.

Public Comment
Anna from the DDPC advised that the Committee may want to look at the assessment process as a 2-step process. The first step is letting the person know the options and ask if they want to move. The second step is to develop service plans.

Bruce Darling advised that they should use the MDS data in nursing homes to create an automatic referral process. He noted that Maryland is developing this and Texas is moving forward with it. Bruce also noted that he found it interesting that parents' income and resources are exempt for children on the Katie Beckett Waiver, but the State wants to eliminate spousal refusal for adults seeking community based services.

Commentary
The Committee has developed a list of best practices. However, the best practices listed do not explain how the State will identify people who could benefit from community services, in accordance with the MIS Law. Giving the example of the assessment process for 1915(c) waivers as a best practice does not get to the root of the problem. The Committee needs to recommend a way that people in nursing homes and other institutional settings can be identified for community services. Linking the MDS to an automatic referral would be one way to accomplish this.


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