The 3rd meeting of the Interim Joint Committee on Health and Welfare was held on Wednesday, July 16, 2003, at 1:00 PM, in Room 129 of the Capitol Annex. Representative Tom Burch, Co-Chair, called the meeting to order at 1:10 PM, and the secretary called the roll.
Present were:
Members: Senator Julie Denton, Co-Chair; Representative Tom Burch, Co-Chair; Senators Charlie Borders, Tom Buford, David K. Karem, Ernesto Scorsone, Katie Stine, Damon Thayer, Elizabeth Tori, and Johnny Ray Turner; Representatives Brian Crall, Robert Damron, Bob DeWeese, Mike Harmon, Jimmy Higdon, Joni Jenkins, Mary Lou Marzian, Ruth Ann Palumbo, Jon David Reinhardt, Ancel Smith, Kathy Stein, and Susan Westrom.
Guests: Debbie Hayes, Phyllis Akin, and Regina Wray, Family Care Homes; Frank Aubrey and Collette Aubrey, Ohio County Resources; Kathy Grant, Citizen; Patty Sewell and Karen Doyle, Department for Medicaid Services, Cabinet for Health Services; Joe Arnold, Mental Health; Trudy Abshire, Parent-Consumer Advocate; Marsha VanHook, ARC; Jan Day, Citizen; George Parsons, Mary Sparrow, and Cheryl Bentley, Cabinet for Families and Children; Barbara Wright, Child Support; Carol Estes, Vocational Rehabilitation; Milton Tyree, University of Kentucky; Micki Shea, NorthKey; Cathy Allgood Murphy, AARP; David Allgood, Center for Accessible Living; Prentice Harvey, Norton Healthcare; Donna Pottinger, Communicare; Karen Hinkle, Kentucky Home Health Association; Kelley Ranvier, Department for Mental Health/Mental Retardation Services, Cabinet for Health Services; Sarah Nicholson, Kentucky Hospital Association; Marty White, Kentucky Medical Association; Scott Wegenast, CCK; Clyde Lang, Cedar Lake; John Cooper, Kentucky Medical Association; Bobbie Bradley, Parent Support Group; Carol McGraw, Parent; Sharon Jackson, ARC of the Bluegrass; Linda Kuder, AARP/KAG; Carol Wheeler, University of Kentucky; Mary Hass, Brain Injury Association of Kentucky; David Gironer, Pennyroyal Center; Alice Simpson, Brad Schneider, Joe Miller, and T.C. Embry, LifeSkills; William Shannon, ARC; Paul Stratton, Mental Health/Mental Retardation; Beth Wilkerson, Autism Committee; Bonnie Hommrich and Renee Close, and Elizabeth Caywood, Cabinet for Families and Children; Duane Dringenburg, and Leah Brown, Department for Medicaid Services; Kevin J. Mahoney, Ph.D., National Program Director, Cash and Counseling Demonstration and Evaluation, James W. Conroy, Ph.D., President, Center for Outcome Analysis, and Thomas Nerney, Director, The Center for Self Determination; Donavan Fornwalt, Council on Mental Retardation; Michelle Blevins with the Division of Mental Health, Department for Mental Health/Mental Retardation Services, Cabinet for Health Services; and Shirley Eldridge, Department for Community Based Services, Cabinet for Families and Children.
LRC Staff: Robert Jenkins, Barbara Baker, Eric Clark, DeeAnn Mansfield, Murray Wood, and Cindy Smith.
The minutes of the June 18, 2003 meeting were approved without objection.
First on the agenda were the reports of the subcommittees. Senator Denton, Co-Chair, Health Care Subcommittee, reported the subcommittee heard testimony from Dr. Steven Englender about approaches the state is taking toward containing and preventing the West Nile Virus, and SARS. The Kentucky Hospital Association, the Kentucky Medical Association, and the Cabinet for Health Services updated the committee on HIPAA compliance. The Kentucky Association of Health Care Facilities and a nursing home advocate addressed the subcommittee about staffing issues within long-term care facilities. There was a motion by Senator Buford, seconded by Senator Denton, and approved by voice vote to adopt the Health Care Subcommittee report. Next, Representative Burch, Co-Chair, Families and Children Subcommittee, reported the subcommittee heard testimony from the Cabinet for Families and Children regarding the administrative transfer of the guardianship section to the service area regions and the Kinship Care program. The Division of Child Care provided information on the current status of the child care assistance program. There was a motion by Representative Reinhardt, seconded by Senator Buford, and approved by voice vote to adopt the Families and Children Subcommittee report.
Next on the agenda was a discussion on kinship care and grandparent adoptions by Bonnie Hommrich, Deputy Secretary, Cabinet for Families and Children, and Elizabeth Caywood, Department for Community Based Services, Cabinet for Families and Children. Ms. Hommrich gave a brief update on the kinship care program. She said in 1997, the Adoption and Safe Families Act was passed in Congress. Each state was charged with implementing that law, which emphasized the importance of kinship care and relative placements for children. Kentucky piloted the program in 1999 in three regions, and implemented it statewide in 2000. This program has kept the growth of foster care at a moderate level, and has enabled the Cabinet to strengthen the ties in families and facilitate placement with relatives to avoid the trauma of foster care. At one point the program was even growing too rapidly, but in the last year the growth has only been 14 percent.
Representative Crall asked if the support for families under the kinship care program was equal to or greater than foster care. Ms. Hommrich said it is less than foster care.
Senator Tori asked about oversight on the kinship care program. Ms. Hommrich said the Department for Community Based Services oversees the program. Senator Tori asked if any fraudulent cases have been identified in the program. Ms. Hommrich said home evaluations and police checks are performed, and the children are placed through the court system. Senator Tori asked if the program was based on income. Ms. Hommrich said it is based on the children’s eligibility for TANF, and not on the income of the provider.
Next on the agenda was a discussion on state payments for family care homes by Phyllis Akin, Debbie Hayes, and Regina Wray, Family Care Homes, Hopkinsville, Kentucky. Ms. Hayes said family care homes are similar to nursing homes, but can keep only up to three elderly people in the home. For keeping the elderly in a family care home, the home receives each person’s Social Security check, plus a state supplement, for a maximum of $724. Each client receives $40 monthly for personal expenses, leaving the home with $684 per client per month, or approximately $22 a day. She would like to receive an increase to $1000 per month, and would like to be able to keep four clients. A family care home provides 24-hour care, with three meals and two snacks provided. Services include administration of medications, bathing and grooming, laundry, grocery shopping, making hair appointments, recordkeeping, and transportation to medical appointments. A family care home could help reduce the budget deficit because a family care home can care for three or four clients for the same dollars that the state pays for one person in a nursing home.
Ms. Wray added that when a caregiver leaves a family care home, the clients are still supervised by other personnel.
Senator Karem asked about state oversight for operators of family care homes. Ms. Wray said the homes keep detailed records for each person, from the food served to the medications administered, to the number of pills left per month. Also, inspections occur every 7-15 months. Every six months, the Department for Social Services visits the homes, talks to the clients individually, and checks all the rooms. Senator Karem asked if the state is doing its job with inspections. Ms. Wray said yes.
Representative Reinhardt asked about the private pay rate. Ms. Hays said the rate is $1,400 per month for private pay. Ms. Hays said she would not trade her “state pay” clients for “private pay” clients because she has grown so attached to her clients.
Representative Marzian asked about training provided for the distribution of medications. Ms. Wray said there is no minimal training for distributing medications. Employees are only required to have training in CPR and first aid. In the past, there have been two training sessions per year on the basics of family home care.
Senator Karem asked if the same state oversight is performed when the clients are all private pay. Ms. Wray said that the oversight is the same for both state pay and private pay.
Next on the agenda was a discussion on person-centered funding and community services by Kevin J. Mahoney, Ph.D., National Program Director, Cash and Counseling Demonstration and Evaluation, James W. Conroy, Ph.D., President, Center for Outcome Analysis, and Thomas Nerney, Director, The Center for Self Determination. Dr. Mahoney said that in most states, if a person receives Medicaid and needs assistance with bathing or personal hygiene, he or she rarely has much say in when people help or what they do. The Cash and Counseling Demonstration and Evaluation is a test of consumer direction in which consumers are given the choice between receiving personal care from agencies or managing a budget with an equivalent amount of money themselves. The Cash and Counseling Demonstration involved 6,700 people in Arkansas, New Jersey and Florida. People were randomly assigned to try either system. This system does not leave someone alone to fend for himself without supervision. Counseling helps the person develop a plan.
The Cash and Counseling Demonstration project has been funded by the Robert Wood Johnson Foundation. The Centers for Medicare and Medicaid Services has given Medicaid waivers to make the demonstration possible, and Dr. Mahoney has performed a qualitative and quantitative evaluation done. In the area of quality, he looked at satisfaction with care received and the relationship with the caregiver, unmet needs for care, adverse events/health problems, and satisfaction with life. The results have been so promising that last May the Centers for Medicare and Medicaid Services issued model waivers to make it easier for any state to take this type of approach.
Mr. Nerney said the Center for Self Determination is a national group that provides technical assistance to states, counties, and families on changing the system of long-term care. Over ten years ago, his group administered two waivers, one for people with intellectual and developmental disabilities and one for people with acquired brain injuries. He wrote a proposal to the Robert Wood Johnson Foundation to determine what the system would look like for individuals with significant disabilities if resources were controlled together with family, friends, and allies. The foundation gave him the money to start the first pilot project to change the system of long-term care based on very elementary principles.
Dr. Conroy discussed the importance of the self-determination initiatives. He has evaluated “before and after” data from six states, beginning with New Hampshire, where 45 people were studied and compared. Costs decreased by 12% to 15%. In Michigan, costs decreased by 6% to 9%. Person-centered funding ultimately provides for enhanced quality of life for recipients.
Senator Karem said there is some level of self-determination currently in Kentucky and noted that the personal care attendant programs has many of the same components. Mr. Nerney said the independent living movement has lead the way on this issue.
Representative Burch asked if people are better off now after de-institutionalization many years ago. Mr. Nerney said the problem was that those people were abandoned in the community. That did not happen with the developmental disability population, but did happen on the mental health side.
Senator Buford asked if self-determination was incorporated in President Bush’s Medicaid plan. Dr. Mahoney said the administration proposal deals with the money following the person, which looks at people leaving institutions and going into the community and giving them a higher match rate. This is a cousin to self determination.
Next, David Allgood testified about the personal care attendant program. He said other states have modeled their program after the Kentucky program. The cost in Kentucky is $13,000 per year for the personal care attendant program, versus $35,000-$48,000 per year in a nursing home.
Next, Jan Day with the Center for Accessible Living said Kentucky developed the personal care attendant program in the 1980’s, and at that time it was the number one program in the country. This program is a cash and counseling and self determination system. Regulations may need to be changed to accommodate more people.
Next on the agenda was a discussion on redistributed assistive devices by Frank Aubrey, Ohio County Resources. Mr. Aubrey said that five years ago he got an idea to help people obtain medical equipment free of charge. He runs his business out of his home with no funding. He receives donations from hospitals and individuals to help people get access to medical equipment and assistive devices. He wanted everyone to know how important his program is and he stressed that the program needs to be continued once he is no longer able to maintain it.
Next on the agenda was a discussion on supports for community living by Donavan Fornwalt, Council on Mental Retardation. He said the supports for community living waiver has had a recent history of bipartisan support. Many people delivered on their promises to increase appropriations for the program. It is not enough to appropriate money; implementation must meet the need. The emergency regulation that radically reforms the rate structure has an effect on the provider infrastructure. In recent years, there has been an abuse of the emergency regulatory process in which there has been a stretch in regulatory intent. The Cabinet has described this new initiative as budget neutral. The Cabinet may say that the regulation will save the state money, but this is based on flawed data. The Medicaid cost reporting methodologies lack integrity. The provider infrastructure matters. He would like to see an entity like LRC perform a basic economic market analysis to determine the cost to serve people in a particular region. He stressed that the provider infrastructure is vital to maintain.
Next, there was a motion by Senator Karem, seconded by Senator Tori, and approved by voice vote to approve 900 KAR 6:050 & E – establishes requirements for the orderly administration of the Certificate of Need (CON) Program (CHS/CON); 907 KAR 1:479 & E – establishes durable medical equipment covered benefits and reimbursement for the Medicaid Program and replaces the emergency administrative regulation needed to curtail uncontrolled growth in the Durable Equipment program spending (CHS/DMS); 907 KAR 1:680 – establishes the provisions for vaccines provided through the Vaccines for Children Program (CHS/DMS); 908 KAR 3:050 – establishes the patient cost per day for board, maintenance, and treatment for a state-operated mental health/mental retardation facility (CHS/DMHMRS); 908 KAR 4:030 – specifies the operating procedures of the Traumatic Brain Injury Trust Fund Board including the board, benefits management, application to the Trust Fund and appeals; 921 KAR 1:400 – establishes the requirements for child support and medical support orders (CFC/DCBS); 921 KAR 2:015 & E – amends the standard of need (eligibility) for residents of a personal care home for the State Supplemental Program due to the pass along of the 2003 Supplemental Security Income cost of living increase by the Social Security Administration effective January 1, 2003 and replaces the emergency regulation filed on December 27, 2002 (CFC/DCBS); 922 KAR 1:130 – changes requirements for the Kinship Care program that provides funds and assistance to a family member who provides care for a child as an alternative to foster care (CFC/DCBS); 922 KAR 3:031 – repeals 922 KAR 3:030 (CFC/DCBS); 922 KAR 6:010 – establishes the requirements for the use of Community Service Block Grant Funding (CSBG) by community action agencies to serve people with poverty level incomes (CFC/DCBS); and 922 KAR 6:061 – repeals 922 KAR 6:060 and 922 KAR 6:070 (CFC/DCBS).
The next item on the agenda was a hearing on the FFY 2004 Community Mental Health Services Block Grant. Michelle Blevins with the Division of Mental Health testified about the block grant. She said the application is required for the funds that become available in federal fiscal year ’04. The bulk of the application is the Division’s plan for services for adults with severe mental illness and children with severe emotional disturbances. One requirement of the block grant application is to describe the systems of care.
Representative Burch asked about the money involved in the block grant. Ms. Blevins said the total is $5.8 million, split between adult and children’s services. There was a motion by Senator Buford, seconded by Senator Thayer, and adopted by voice vote to approve the block grant.
The next item on the agenda was a hearing on the FFY 2004 and 2005 Community Services Block Grant and Community Food and Nutrition Plan Legislative Hearing. Elizabeth Caywood and Karen Doyle with the Department for Medicaid Services testified in regard to the block grant. Ms. Caywood said the grant is a two year block grant with no state matching funds. It was developed in conjunction with community action agencies who receive over 95 percent of the federal allocation for direct services and the administration of the services. The purpose of the block grant is to assist states and communities working through a neighborhood of community action agencies and other neighborhood based organizations with the reduction of poverty through revitalization of low income communities. Activities are designed to assist low income, elderly, migrant, or seasonal farm workers, homeless individuals and families to secure and maintain meaningful employment, obtain adequate education, make better use of available income, obtain and maintain adequate housing, obtain emergency services, assist with better nutrition, establish linkages with the community, remove obstacles and solve problems that block the achievement of self sufficiency, improve health, and eliminate other causes of poverty.
Representative Burch asked how much money is involved in the block grant. Ms. Caywood said they received almost $11 million last year.
There was a motion by Senator Karem, seconded by Senator Tori and adopted by voice vote to approve the block grant.
There being no further business, the meeting was adjourned at 3:05 p.m.