Denver Options, Inc. dba RMHS Twelve Month Report on Developmental Disability Services Supported by Mill Levy Funding

Transcription

1 1 Denver Options, Inc. dba RMHS Twelve Month Report on Developmental Disability Services Supported by Mill Levy Funding January 1, 2014 through December 31, 2014 The following report summarizes the scope and costs of developmental disability services provided by Denver Options, Inc., doing business as Rocky Mountain Human Services (RMHS) to Denver residents with developmental disabilities for the period of January 1 through December 31, The report details the expenditure of $11,492,988 of mill levy funding used for the array of services and supports that were delivered to adults, children and their families (see Graph A) and provides a cost methodology with detailed expenditure information by disability levels (see section III). Also, the report (in section III) provides a clear summary of the breakdown of the cost of services by funder, type of service and on a per person basis. The reader is provided with comparative information in four categories including (1) cost of services paid by all funders combined; (2) a per person cost based on using all funders combined; (3) the cost of services supported by mill levy funding, only; and (4) a per person cost for services using mill levy funding, only. Graph A: Adult Service Expenditures versus Children Service

2 2 I. Adult Services (Mill levy expenditure of $5,359,527) The total cost to serve the adult population of individuals with developmental disabilities for the year was approximately $27.7 million. Of the total cost, $22,342,344 was contributed by Federal and State government revenues and through private sector fundraising. Mill levy funding provided $5,359,527 for Adult Services, which constitutes approximately 19% of the total funding for the period. Table 1 summarizes the average cost for the year to serve individuals in the adult population. Table 1. Mean Cost of Adult Services: Yearly average per individual Source Cost Percentage By all Sources (Federal, State, City, Fundraising) $25, % All Source without City $20,183 81% City (Mill levy) $ 4,841 19% In the category of adult services, individuals who received services and supports from RMHS, through mill levy funding, were required to be residents of the City and County of Denver. Furthermore, their disability must have manifested before age 22 years, and attributable to intellectual disability or related conditions which include cerebral palsy, epilepsy, autism or other neurological conditions when such conditions resulted in impairment of general intellectual functioning or adaptive behavior, similar to that of a person with intellectual disability. The age of 22 is only used as a benchmark for the determination of eligibility for adult services which begins at 18 years and older for Supported Living Services and generally 21 years and older for comprehensive residential services. There were 2,391 individual adults enrolled throughout the reporting period (see Table 2). In the calculation of cost, the number used in this report is based on a census of 1,107. This lower number is used to account for the differences in levels and days of services; that is, 1,107 is based on a fulltime equivalent of individuals in service. Individuals, who are sick, hospitalized or out of town on a family visit are not calculated as receiving services during the periods of their absence. RMHS does not receive revenue for individuals who are absent from program, although RMHS still incurs fixed costs. In total, 8% of individuals receiving services from RMHS are ages 20 (see Table 3A) and above and represent a diverse population (see Table 3B). Approximately 61% of adults receiving services are male and 39% female. When referring to the impairment of general intellectual functioning, the person receiving services must have been determined to have an intellectual quotient equivalent of two standards below the mean (that is, 70 or less, assuming a scale with a mean of 100 and a standard deviation of 15), as measured by an instrument which is standardized, appropriate to the nature of the person s disability, and administered by a qualified professional.

3 3 Table 2. Number of Adults by Service Enrollment (n=2,391) Service Number Group Residential 54 Independent Home 172 Host Home/Companion 408 Personal Care Alternative 22 Supported Living Services 544 Wait List 1,192 Total 2,391 Table 3A. Adult Services by Age Group (n=37%) Age Range Percent Over 60 5 Table 3B. Individuals Enrolled in Services by Ethnicity (n=100%) Ethnicity Percent American Indian/Alaskan 0.63 Asian/Pacific Island 2.61 African American Hispanic Caucasian Undeclared 3.74 When referring to adaptive behavior, the person s overall adaptive behavior is limited in two or more skill areas (such as communication, self-care, home living, social skills, health and safety, and functional academics). Adaptive behavior is also measured by a standardized instrument appropriate to the person s living environment, and administered and clinically determined by a qualified professional. Additionally, when we refer to a person s adaptive behavior limitations, those limitations are a direct result of, or significantly influenced by, the person s substantial cognitive deficits and may not be attributable to only a physical or sensory impairment or mental illness. Or this reason, the classification of services to adults must have a primary diagnosis of intellectual disability and all other related impairments or disabilities are secondary.

4 4 Table 4 highlights the secondary and other tertiary diagnoses for the individuals receiving Adult services through the reporting period. The number of conditions will exceed the number of persons served because individuals may have more than one corresponding condition. Table 4. Secondary & Other Tertiary Diagnoses for Adult Individuals with a Primary Clinical Diagnosis of Intellectual disability Diagnosis Number Seizure Disorder 348 Cerebral Palsy 247 Fragile X 19 Down Syndrome 226 Visual Impairment/Blind 124 Brain Injury 44 Speech Impairment/Non-verbal 466 Hearing Deficit/Deaf 116 Autism 247 Non Ambulatory 68 ADD 116 Maladaptive Behavior 113 For the year, 563 individuals were enrolled in Comprehensive Residential Services. These services were delivered to ensure the health, safety and welfare of the individual, and to assist in the acquisition, retention, or improvement of skills necessary to support living and successful participation in one s local Denver community. Services include specialized medical equipment, vision, dental, behavioral, transportation, self-feeding, toileting, self-care, sensory stimulation and integration, self-sufficiency, maintenance skills, supervision and the coordination of physical, occupational or speech therapies. The adult Supported Living Services Program (SLS) had an enrollment of 544 individuals. This is not a comprehensive program. It is intended to augment already available support for those individuals who either can live independently with limited supports or who, if they need extensive support, are getting that support from other sources, such as family. Supported Living Services provide the necessary assistance and support to meet the daily living and safety needs of adults who remain responsible for their own living arrangements. During the twelve month reporting period services and supports included: 1. Assistive Technology 2. Behavioral Services 3. Day Habilitation 4. Specialized Habilitation 5. Homemaker Services

5 5 6. Non-Medical Transportation 7. Dental Services 8. Personal Care 9. Respite 10. Therapeutic Services 11. Specialized Medical Equipment & Supplies 12. Vision Care 13. Vehicle Modifications The provision of these SLS services is categorized by the federal government in the terms used in Table 5. Table 5 depicts a total of twelve months of services by the number of individuals receiving the specified service. Some individuals may have received more than one service. Table 5. Type of Service: Individuals Receiving Specified Services Type of Service Number of Individuals Percent of Total Served Personal Assistance Day Habilitation Supported Employment Professional Services 10 1 Transportation 0 0 Dental/Vision/Hearing 0 0 Environmental Engineering 17 2 Total Adult Case Management services include eligibility determination, the development of an annual plan for each individual, the coordination of resources and the acquisition of services for each individual. An average of 1,131 adult individuals received active case management services each month during the twelve month period. Case managers are responsible for reviewing applications for services and meeting with prospective clients of service. Approximately 933 referrals were received for the reporting period (See Graph B) leading to 244 face-to-face intakes for individuals seeking adult services. One challenge in the provision of case management and the development of the service plan is the issue of spoken language. RMHS holds all meetings and provides written reports to individuals and their families in their preferred primary language. Approximately 23% of individuals and/or their families are monolingual non-english speaking individuals. Although many of RMHS case management staff are bilingual, when encountered with an individual or family whose language is not spoken by a RMHS employee, a professional translator is contracted. Table 6 illustrates the diversity of language and the efforts RMHS extends to provide information in a person s language of choice.

6 6 Graph B. Number of Referrals: Ages 3 and Up (n=244) Table 6. Primary Language of Individuals in Service (n=100%) Language Percentage Arabic 0.39 Amharic.14 Burmese.06 Cantonese.02 English French.04 Italian.01 Korean.02 Mongolian.02 Nepali.19 Russian.13 Spanish Somali.13 Swedish.01 Twi.05 Other 3.14 Vietnamese.01 Sign Language.28 Behavioral, Psychological and Psychiatric Services were provided to the adult population. During this year, a total of 2,746 hours were provided in therapeutic visits by RMHS Behavioral Services

7 Department. These visits consisted of behavioral, psychological and psychiatric services for individuals who have dual diagnoses of Intellectual disability & Mental Illness (MR/MI). The incidence of dual diagnoses is illustrated in Table 7. 7 Table 7. Incidence of Individuals in Active Service with Intellectual disability & Mental Illness: by Disorder (n=635) Disorder Incidence Bipolar Disorder 66 Borderline Personality Disorder 17 Depression 164 Intermittent Explosive Disorder 34 Organic Personality Disorder 9 Paranoid Personality Disorder 7 Pedophilia 10 PTSD 81 Schizophrenia 43 Other Psychiatric Disorders 204 Monitoring, Investigations and Training and Technical Assistance support a provision of quality assurance services that actively monitors provider services in order to adhere to State and Medicaid standards, rules and regulations. Table 8 summarizes the number of monitoring and investigations. In addition to onsite monitoring, 3,723 incident reports were reviewed during the year. In order to ensure health and safety, RMHS investigates allegations of abuse and neglect of individuals with developmental disabilities. When there is a determination or suspicion of a crime, the Denver Police Department is notified. Furthermore, the Colorado Department of Health receives reports for health issues or violations that occur in group homes. Denver Human Services Adult Protection receives reports consistent with investigation and monitoring protocols. The Colorado Department of Health Care Policy & Financing, Division for Developmental Disabilities is notified of all serious incidents and reports of deaths. RMHS Service Improvement Team provides technical assistance to service providers to improve service practices and adherence to rules and regulations. During the year, approximately 147 premove site visits were conducted to ensure that proposed residential settings were safe and appropriate.

8 8 Table 8. Quality Assurance Monitoring and Investigations Type Number Monitoring 473 Investigations 69 Pre-move Site Monitoring 147 Day Program & Admin. File Reviews 207 Technical Assistance to Providers 171 (hours) Review of Incident Reports 3,723 (separate reports) In addition to the above referenced monitoring and investigations, RMHS has two Human Rights Committees (HRC) whose function is to protect the rights of the individuals receiving services. With 375 cases reviewed during the year, the HRC takes a comprehensive examination of individuals referred for reasons identified in Table 9. Table 9. Focus of Human Rights Committee Type Number Review for use of psychotropic medications 352 Review for suspension of rights 91 Review for Restrictive Procedures 11 Review for Safety Control Procedures 19 HRC Census 1,515 Follow-up Reviews 133 Final Reviews and Referrals to HRC 107 Investigations & Inquiries 64 Total 2,292 To ensure quality services and best practices, mill levy funds supported the development and implementation of training programs and technical assistance to improve knowledge, skill and abilities of employees of Denver-based service agencies and RMHS staff. During the year, an aggregate attendance of 1,158 participants advanced their knowledge and skills from over fifteen training topics, such as: Behavioral Intervention Restrictive Procedures Service Evaluation Individualized Service Plans Positive Behavioral Supports Autism Adult, Infant, Child CPR Traumatic Brain Injury Mental Health Diagnoses Respite Provider Legal Rights Medication Administration Supported Employment

9 9 In addition to the direct services and case management provided to adults, an average of 782 individuals per month received waitlist case management. Waitlist case management includes the development of an annual Individual Plan and the monitoring of emergency situations for individuals waiting for Comprehensive and Supported Living Services. Staff field calls and provide information about community resources. When a crisis is encountered, staff members work directly with the Colorado Department of Health Care Policy & Financing and it s Division for Developmental Disabilities to acquire emergency resources, if available. In addition to the 782 individuals, during the year there was an average of 1,107 adults receiving some level of service (such as Family Support or Supported Living Services) but waiting for additional types of services (such as Comprehensive Residential or Supported Living Services). II. Services for Children and Families (Mill levy expenditure of $6,133,461) The total cost to serve the population of children with developmental delays and disabilities and their families during the reporting period was approximately $ million. Mill levy funding provided $6,133,461 in Children and Family Services, which constitutes 48 % of the total funding for these services. Table 9A summarizes the average cost for the year to serve children and their families. Table 9B indicates that 63% of the individuals receiving services through RMHS are children from birth to age 19. Table 9A. Mean Cost of Children & Family Services: Yearly average per Child/Family (n=6,860) Source Cost Percentage By all Sources (Federal, State, City, Fundraising) $6, % All Sources without City $3, % City (Mill levy) $3, % Table 9B. Percentage of Children in Services by Age Group (n=63%) Age Range Percentage Birth to In the category of Children s Early Intervention Services, a yearly average of 1,860 infants and toddlers received services to enhance child development in the areas of

10 cognition, speech, communication, physical, motor, vision, hearing, social-emotional development, parent-child interaction, screening and comprehensive developmental assessments. Although research on early intervention services for children birth to three years of age reports that for every dollar spent on early intervention services will calculate to a long-term tax savings of $9 to $13, statewide public policy only provides funding to serve a small portion of children in need of early intervention. For example, the State provides yearly funding that serves approximately 710 of Denver s children with special needs. There are two to three times more children in services each month. Without intervention, these children will eventually require more expensive adult services. RMHS follows nationally recognized best practices by providing family choice of provider and location of services. Home-based services are considered the location of choice because it represents the most natural environment for the child and family. Table 10 highlights early intervention services by location and number of hours of services provided during the year. Table 10. Early Intervention Services: Hours of Service & Location Early Intervention Hours of Services Home-based Total Hours 42, To be considered for services and supports, a child (of a Denver resident) must be less than five years of age and at risk of having a developmental disability because of the presence of one or more factors, such as: a) Chromosomal conditions associated with delays in development. b) Congenital syndromes and conditions associated with delays in development. c) Sensory impairments associated with delays in development. d) Metabolic disorders associated with delays in development. e) Prenatal and perinatal infections and significant medical problems associated with delays in development. f) Low birth weight infants weighing less than 1200 grams, or g) Postnatal acquired problems resulting in delays in development. Furthermore, a child can receive services under the age of five, if he or she is significantly delayed in one or more of the following areas: communication, adaptive behavior, social-emotional, motor, sensory, or cognition. A child under the age of

11 11 three who lives with one or more parents who have a developmental disability is considered categorically eligible for early intervention services. All childhood developmental experts agree on the importance of early intervention services during the years of birth to three. During this period of time, early intervention services are critical for cognitive and social and physical development. Unaddressed issues can lead to major complications in later childhood, adolescence, and carry into the adult years. The costs of services to children are significantly less than services to adults. The exception is services for children with autism. Because of the importance of identification of children at such a young age where every month that a child is without service can lead to a significant human and financial cost, RMHS continuously outreaches to the community for child identification, screenings, evaluations and assessments. The expansion and maintenance of referral networks throughout the City to reach all diverse populations is critical. Toward this end, RMHS distributes informational materials and sponsors or participates in forums to reach Denver families and health-related professionals. Many families and health professionals need to be informed or educated about the conditions of developmental disabilities and how to apply for services. Services to children by gender are disproportionate with 36% female children and 64% male children. Similar to national surveillance data, approximately 1 of every 68 children assessed by RMHS in Denver is on the autism spectrum. There has been a rising incidence of children with autism with approximately 12% of children served by RMHS being diagnosed as a child with autism spectrum disorder. Family Support Services provides a program of support and services to 798 families in their role as primary caregivers for a family member with a developmental disability living in the family s home. The focus of the program is to prevent costly

12 12 Graph C. Number of Referrals: Ages Birth to Three (n=2,621) out-of-home and institutional placements. Services include therapies, medicine, durable medical equipment, home ramps and modifications. Family support services provided during the twelve month period also included psychological/emotional supports. Various forms of respite were provided, including both out of home and inhome care, thus enabling family members to have rest and time for the completion of personal tasks and activities. Table 11 illustrates services by type and percentages. Table 11. Type of Family Support Services Service Percent Respite 67 Professional Services 11 Home Modifications, Assistive Technology & Supplies 2 Transportation 1 Medical & Dental 2 Other (camp diapers, etc.) 17 Parents & Siblings Education & Supports 0 Total 100

13 13 III. Cost Breakdown and Cost Methodology for Developmental Disability Services In the area of developmental disabilities services, RMHS serves over three thousand children, families and adults in active and waitlist services with monthly variable costs. The variability is a result of changes to the human condition. While some individuals will need personal care for their inability to feed themselves, to monitor oxygen or g-tube feeding, etc; other conditions change from day to day, such as behavioral issues, psychological conditions, and routine medical and physical related issues common to the general population, such as becoming ill with flu or pneumonia, or needing to go to a dentist for a sudden toothache. However, in order to control cost, each service area has a financial ceiling in concert with funding the needs of each individualized plan of service. The state s Division for Developmental Disabilities establishes the rates and expenditure ceilings for Medicaid services. Medicaid rates can only be exceeded with waivers or amendments to service plans that are submitted by RMHS to the state s Division for Developmental Disabilities. Case managers include an analysis that must demonstrate that the individual requires an increase in services based on life changes. The state must review and approve the request for increases of services and rates, although there is no guarantee that the state will approve the request. In the expenditure of state general funds, mill levy funds and private contributions, RMHS follows the same rate setting levels established by the state in order to be consistent and fair, but uses an internal resource allocation protocol to review and approve changes to rates and services. Furthermore, in the area of cost control, RMHS has created a pool of preferred providers whose rates are discounted from 25% to 50% on average compared to the customary and usual rates paid in the general population. For example, the average therapeutic rate for early intervention services is $88.00 per hour compared to $ per hour for the same services delivered outside of the RMHS community of providers. In order to control and manage cost decisions, an expenditure methodology based on tiers is used to track average and projected costs. The tiers are based on levels of severity of disability including psychiatric and behavioral issues, medical fragility, level of mental and cognitive capacity, among other clinical factors listed in Tables 4 and 7, in addition to ongoing individualized risk assessments. Additional cost factors inclusive of the average rate of service include ancillary service costs that are directly related to service delivery, such as case management, transportation, and durable medical equipment, among others. The following Charts A and B report average per person costs based on specific services and tiers as described above.

14 14 Mill Levy Yearly Report: January 1 December 31, 2014 Chart A: Comprehensive Residential Services (Comp): Cost Breakdown # of Individuals Average Cost per Person (All) Average Cost per Person (ML) Tier Cost per Tier (All) Cost per Tier (ML) COMP $ 6,570,002 $ 15,578 $ 1,271,109 $ 3, $ 2,509,502 $ 65,608 $ 485,518 $ 12, $ 2,459,014 $ 76,248 $ 475,749 $ 14, $ 2,400,566 $ 86,507 $ 464,441 $ 16, $ 2,733,199 $ 95,068 $ 528,796 $ 18, $ 1,556,184 $ 119,706 $ 301,078 $ 23, $ 301,284 $ 200,856 $ 58,290 $ 38,860 Total 563 $ 18,529,751 $ 3,584,982 SLS Total Adults Total ,107 $ 2,894,628 $ 11,579 $ 560,028 $ 2,240 $ 3,042,992 $ 17,413 $ 588,733 $ 3,369 $ 1,732,543 $ 22,872 $ 335,198 $ 4,425 $ 500,032 $ 29,414 $ 96,742 $ 5,691 $ 434,862 $ 35,499 $ 84,133 $ 6,868 $ 321,231 $ 41,449 $ 62,149 $ 8,019 $ 245,833 $ 39,333 $ 47,562 $ 7,610 $ 9,172,120 $ 1,774,545 $ 27,701,871 $ 5,359,527

15 15 Chart B: Early Intervention & Family Support Services: (EI & FSSP) Cost Breakdown EI & FSSP $ 4,016,399 $ 4,629 $ 1,931,099 $ 2, $ 366,585 $ 5,313 $ 176,255 $ 2, $ 1,022,777 $ 6,043 $ 491,755 $ 2, $ 1,296,593 $ 7,056 $ 623,406 $ 3, $ 1,398,142 $ 8,152 $ 672,231 $ 3, $ 1,852,418 $ 9,344 $ 890,649 $ 4, $ 2,803,776 $ 13,984 $ 1,348,065 $ 6,724 Total 1,860 $ 12,756,691 $ 6,133,461 Adults and children who receive services in Denver are disbursed throughout the entire city and county. Table 12 illustrates the heaviest concentrations of services by zip code where the number of individuals exceeds 100 per code. Table 12. Concentration of Services by Zip Code: Minimum of 100 individuals by Zip Code Zip Code Numbers served III. Appeals/Grievances/Complaints The following months are being reported on: January 1, 2014 to December 31, The following months are being reported on: October, November and December. During this quarter one new appeal was filed. The appeal filed was regarding a CES denial. This hearing is set to take place in January of Three hearings were held in the month of

16 October - one SLS denial, one CES eligibility denial, and one hearing regarding developmental disability determination. RMHS received initial decisions regarding all three. RMHS lost the CES appeal, and needs to file exceptions. RMHS won the DD determination and SLS hearing. One new CES appeal was filed during this time period and was scheduled for a hearing in January. Annual Review of 2014: This annual review is of Medicaid appeals for the year of During this time period nine appeals were filed regarding the following program decisions: - two HCBS-SLS, three developmental disability determinations, three HCBS-CES, and one HCBS-DD waiver. From these nine appeals six were dismissed prior to the actual date of the hearing, two were held and RMHS' decision was upheld, and one was held and RMHS' decision was reversed. This case is still in process. The exceptions to this decision will be filed and final agency decision from the Office of Appeals has not been made. 16 Please send inquiries to: Stephen R. Block, PhD Executive Director Rocky Mountain Human Services SBlock@rmhumanservices.org