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It’s about the care model

A disturbing incident involving an attempted rape of a woman by an intellectually disabled resident of a community-based group home last month can teach us all a valuable lesson.

We’ve been in the midst of the wrong debate here about care for people with intellectual disabilities.  We really shouldn’t be having a debate between “community-based” care versus institutional care.  What’s really at issue here is the care model for these people in Massachusetts.

Bear with me for a moment. 

On June 3, The Lowell Sun reported that a resident of a state-run group home in Chelmsford walked out of his residence, went next door and attacked a pregnant woman as she was sitting in her living room with her husband and three-year-old daughter.  The man managed to tear off Amy Hillman’s shirt and jump on top of her before he  was pulled away by Hillman’s husband, James.

The group home resident, Tholda Chhom, and James Hillman ended up in the front yard, where Chhom continued to charge at Hillman before running back to his residence just before police arrived, according to witnesses.  Chhom was later charged with assault and attempted rape, and has been placed in a “more secure state facility,”  according to The Sun.

Meanwhile, the Hillmans and their neighbors have been left asking questions.  Will Chhom be allowed to return to the group home?  Why were the Hillmans previously told that Chhom did not have violent tendencies, even though he frequently used to yell out of his window at passersby?

The Hillmans, in fact, were so concerned about Chhom, prior to the May 8 incident, that they built a stockade fence around their yard.  According to James Hillman, Chhom appeared to be left all day long in his room.  But on the day of the attack on Amy Hillman, the staff at the group home reportedly didn’t even know he had left the group residence.

It would be tempting for us to say that Chhom should never have been in a community-based group home; he should have been in a develpmental center, where, at the very least, it would have been more difficult for him to have gotten out out and to attack a resident in the community.  But that argument may miss the real point here.

What people like Chhom are missing in the community system — even in state-run community residences — is an intensive care model that meets the federal standards set for Intermediate Care Facilities.  ICF-level care, which happens to exist only in the developmental centers in Massachusetts, stipulates that residents receive onsite clinical, medical, and nursing care and full-time supervision.  Not everyone with intellectual disabilities needs this level of care.  Only a small fraction of them do.  But Chhom would appear to be one of them.

That’s why we’re so upset that the Patrick administration is shutting down four of the six remaining developmental centers without replacing the ICF care model available in them.  We don’t want the big old buildings there either.  It’s the ICF care model we want to preserve for those who need it.

We think the current residents of the developmental centers should be able to stay in their current locations in the most cost-effective residential settings, while receiving the same level of care from their familiar staff.  That might well mean they would live in small group homes on the campuses — the “postage-stamp” idea.  Meanwhile, other people in the community, such as Tholda Chhom, who need that level of care, should be able to receive it as well.

But the administration is seeking to eliminate the ICF model and replace it with care under which the ICF standards have been waived.  It’s referred to as community-based care, but it should really be labeled “waiver based” care, because the standards are lower.  Direct-care staffing levels do not have to be as high, clinical and medical personnel can “float” among different homes in geographic regions, and medications can be administered by people with less training.

What does this mean for the safety of neighborhoods around the state where thousands of community-based group homes exist?  What does it mean for people like Tholda Chhom, if there will no longer be an ICF-level facility one day to accept him?  Will he simply be thrown into prison?

Once again, let me be clear.  I’m not trying to make an argument here to preserve the six developmental centers as they exist today, although no doubt we’ll continue to be accused of that. 

Go ahead, call it all community-based care.  Just keep the care model and let the current residents of the developmental centers stay in their current locations with their familiar staff.   And finally, provide the opportunity for ICF-level care for all who need it, such as Tholda Chhom.

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What are they afraid of?

June 1, 2011 4 comments

It’s now clear that there will be no independent study of the cost of closing versus maintaining the Templeton, Monson, and Glavin developmental centers for people with profound intellectual disabilities in Massachusetts.

Instead, the Patrick administration will continue on its path of closing these critically important institutions on the basis of its largely unscrutinzed claim that doing so will save money.

We figured the administration and the Association of Developmental Disabilities Providers wouldn’t want an independent assessment of that savings claim.  Now we know the leadership in the House and Senate didn’t want it either.  As a result, it will not happen.

Last week, the Senate leadership scuttled a budget amendment, which would have specified that a study of the cost of closing Monson, Templeton, and Glavin be undertaken by a non-governmental entity selected by the Inspector General. 

This occurred after the House had scuttled a similar amendment, and after the ADDP and The Boston Herald had cited inflated numbers on the cost of operating the Fernald Developmental Center.  (Fernald, by the way, wouldn’t even have been included in the proposed cost study.)

What were the administration and the ADDP, in particular, so afraid of?

I think I can guess.  There is a possibility that the entity selected to undertake the study would have come up with a conclusion that the administration, the ADDP, and the legislative leadership didn’t want to hear, i.e., that there would be little or no savings in closing the three facilities. 

Even if you believe we will save money in closing these institutions, why not verify that with an impartial study?  Because it might delay the closures of these facilities by a few months?

In fact, the administration is on schedule, as far as we know, to close all of these facilities as of Fiscal Year 2013.  Fernald, which was first on the closure list, remains open, not because of any cost studies that have been conducted, but because of administrative appeals filed by the guardians of its remaining residents.

The administration has steadily moved residents out of all four of these developmental centers.  This has caused tremendous displacement and anxiety among hundreds of families and guardians, and is leading us toward a system that no longer meets the same high federal standards of care as do the developmental centers. 

Elderly residents of these centers are being forced to leave homes many have known for practically their whole lives.  The key justification the administration has given for doing all this is saving money.   Yet, we are told we cannot afford to have an impartial review of that savings claim because it might slow down this march of “progress” by a few months.

The fact is that studies in other states have come to conclusions that don’t support the Patrick administration’s claim that closing developmental centers saves money.  (See, for instance: Journal of Mental Retardation cost studies review and Connecticut DDS studies of the cost of closing the Southbury Training School.)  Were an independent study in this state to reach a conclusion similar to those out-of-state studies, it would present a public relations problem, at the very least, for the Patrick administration.

That, it seems to us, is the real reason the administration and the ADDP fought so hard to make sure the independent cost study amendment didn’t see the light of day here in Massachusetts.   Last month, Rep. Brian Dempsey, House Ways and Means chairman, wouldn’t allow the study amendment, which had been sponsored by Rep. Anne Gobi, even to come to a floor vote in the House. 

A staff member for Senator Michael Moore, the sponsor of the independent cost study amendment in the Senate, would only say this week that “(Senate) Ways and Means was not supportive” of the amendment.  As we understand it, Moore was first told he would not be allowed to include language in the measure requiring legislative approval of the study. 

Then Moore was told he would have to knock Templeton and Monson out of the amendment, and restrict the study just to Glavin, which is in Moore’s district.  Moore complied with all of those directives.  But it didn’t help. 

Moore’s watered-down cost study amendment was nevertheless then reportedly bundled with other budget amendments in the Senate’s consolidated “no” pile, meaning it was doomed to be rejected, along with all the other amendments unwanted by the leadership, in a single voice vote on the Senate floor.  You couldn’t have done in this cost study amendment more thoroughly if you tried.

You have to hand it to the administration and the ADDP.  If they don’t want something getting through the legislative process in Massachusetts, it apparently doesn’t get through.  The problem is that doesn’t say much for the democratic process in Massachusetts.

The Herald headline and story are wrong

May 26, 2011 4 comments

On Tuesday of this week, The Boston Herald’s readership was treated to a bombshell headline and story, purportedly about government waste due to delays in the closure of the Fernald Developmental Center.

The headline was “$16M to care for 14 people”; and the story went on to imply that the 14 remaining residents of Fernald, whose guardians have filed administrative and court appeals of their transfers from the Center, are each costing taxpayers more than $1 million per year.

The only problem is that the headline and story are wrong.  I just received a letter from Department of Developmental Services Commissioner Elin Howe, confirming our information that the annual cost of caring for the remaining 14 people at Fernald is projected at $8.9 million.  It seems the $16 million is the projected cost of keeping Fernald open throughout the current fiscal year, during which time there have been far more than just 14 people living there.

As of the end of last June (at the start of the current fiscal year), there were some 70 residents left at Fernald, according to our records, and by the end of July, that number was down to about 40.  The adminstration has steadily moved people out, and 14 is the number of residents who remain as of this month.  So, the $16 million cost clearly reflects a higher number of residents than 14.

Moreover, Commissioner Howe stated in her May 25 letter that:

While the costs associated with operating Fernald have dropped following the census (residential population) reduction, the per-person costs have actually increased as the census declines in the final stage of closure.  This has been a typical pattern in previous closures.

In other words, a per-person cost spike is something that occurs in virtually all developmental center closures — it’s not something unique to Fernald because of the appeals filed by the guardians.  There are certainly added costs associated with the delay in closing Fernald, but those costs are something the administration should have anticipated as part of the overall cost of closure.

Nevertheless, the inaccurate claim that $16 million is being  spent on 14 residents was immediately seized upon this week by the Association of Developmental Disabilities Providers, whose members stand to benefit from new state contracts as Fernald and three other developmental centers are closed.  ADDP President Gary Blumenthal decried the alleged $16 million cost as “tremendous” and “excessive,” and implied that the Fernald guardians are responsible for it.

On Wednesday, the Herald’s editorial page picked up on the theme, stating that the alleged $16 million being spent on 14 Fernald residents is taking away from community-based services “and it’s impossible to argue that point.”   It’s especially difficult to argue it when the editorial’s point is based on deliberately misleading and inaccurate information.

The Herald editorial, by the way,  is very carefully worded not to equate the $16 million directly with the 14 residents, although it puts the two numbers as close together in the same paragraph as possible.  And of course the editorial never even bothers to mention our longstanding contention that the costs of operating Fernald and the other developmental centers have been overstated by the administration in comparisons made with the community system.

(I talked at length, by the way, with the Herald reporter about that whole developmental center-versus-community cost issue when she called me the day before her story ran on Tuesday.  None of that made it into print, of course.)

I would also note that Howe stated in her letter that the 95 staff left at Fernald is a projected number after a current round of layoffs is completed.  Howe provided a number of reasons for that apparently high number of remaining staff, and concluded that “all appropriate staff reductions have been or are being  taken and the remaining staff are necessary to meet the remaining residents’ needs.” 

We’re not sure, however, that  it’s the case that DDS has done everything they could to reduce costs lately at Fernald, particularly if — as Stephen Sheehy, the attorney for the remaining residents has pointed out — DDS has failed to take steps to move the remaining residents into one location on the campus.  That is something, according to Sheehy, that the residents would welcome, and which would no doubt save some money.
 
 

Setting the record straight about Fernald and COFAR

May 24, 2011 2 comments

If any more evidence was needed that the human services providers and the Patrick administration are attempting to tarnish the Fernald Developmental Center’s families in order to discredit the highly successful model of state-run care for the intellectually disabled in Massachusetts, today’s Boston Herald story provides it.

“16M to care for 14 people,” is the headline; and in the story, Gary Blumenthal, president of the Association of Developmental Disabilities Providers, calls the cost “excessive” and blames it on the guardians of the remaining Fernald residents because they are delaying the Center’s closure.  Those guardians have simply exercised their statutory right to file administrative and Superior Court appeals of the transfers of their wards out of Fernald.

Moreover, we’ve just learned that DDS stated in Superior Court earlier this month that the cost of operating Fernald may actually be $9.8 million, not $16 million (more about that below).  Secondly, if, in fact, 95 staff do remain at Fernald for the remaining residents, as the Herald story and DDS say, that is an indication of mismanagement on the part of DDS; it’s not the fault of the guardians.

Meanwhile, in a comment on our previous post on Blue Mass Group about the use of Fernald as a political football, Blumenthal (under the user name, Garyof Sudbury), chides COFAR for encouraging “endless appeals and endless studies” in an effort to keep the developmental centers open.  This is a mischaracterization of COFAR’s role in advocating for adequate care for DDS clients.

Here, to the best of our knowledge, is what is really happening regarding Fernald and the other developmental center closures:

1.  Earlier this month, the administration provided numbers on the cost of operating Fernald that are nearly 40 percent lower than what it is publicly citing to the Herald.  In a comment posted on the COFAR blogsite, Stephen Sheehy, the attorney representing the remaining Fernald residents, states that on May 6,  DDS submitted an affidavit in Middlesex Superior Court that the cost of keeping Fernald open is approximately $9.8 million per year.

DDS Commissioner Elin Howe stated in a conference call last week that the cost of operating Fernald this year was $15.6 million.  The Herald is saying $16 million (and stating, by the way, that was the cost last year when there were far more than 14 people left at Fernald).  So, who knows what the real figure is.

2.  The administration and the ADDP are ignoring COFAR’s longstanding proposals to rightsize the remaining developmental centers in Massachusetts or otherwise operate them more efficiently. 

COFAR and other affiliated organizations have long called for “postage-stamp” arrangements at the developmental campuses that would enable current residents to remain there and receive the same level of care while the rest of the campuses were developed for other uses.  No one is advocating the preservation of  large, outdated buildings on these campuses.  What we do want to preserve is the model of care that currently exists there in the most cost-effective way possible.

The administration has never even wanted to discuss the postage-stamp approach.  They have always viewed the issue in purely binary terms: either we continue to operate all the facilities as they are today, or we close them all and evict all their remaining residents.  There have been no other options even worth considering for them.

3.  The ADDP is deliberately mischaracterizing the history of litigation over Fernald in order to paint COFAR as somehow responsible for the cost of delay in closing Fernald.

Here’s a brief history of that litigation (reprised from my response to GaryofSudbury):

From 1974 to 1993, U.S. District Court Judge Joseph Tauro presided over the landmark Ricci v. Okin consent decree case, which brought about significant improvements in care and services at Fernald and other developmental centers in Massachusetts.

In 2004, the Fernald plaintiffs in the Ricci case (some of whom are COFAR members) urged  Tauro to reopen the case, not to delay Fernald’s closure, which Tauro said he would not do, but to investigate apparent violations of Tauro’s order that transfers out of Fernald must result in equal or better care.  It was the Patrick administration — not COFAR or the Fernald plaintiffs — who then went to court to appeal Tauro’s 2007 ruling in which he found that DDS had engaged in a systemic violation of his order.

In 2008, the U.S. Court of Appeals overturned Tauro’s 2007 ruling.  The Fernald plaintiffs appealed to the U.S. Supreme Court, arguing that the Appeals Court had not given Tauro due deference in their decision. The Supreme Court declined to hear the case.

Since that time, some of the Fernald guardians have exercised their statutory and regulatory rights to file administrative appeals of the transfers of their wards from Fernald, on the grounds that these transfers would not result in improved services.  COFAR has not publicly or privately encouraged or discouraged those appeals.  We fully support the personal decisions that any guardian chooses to make in these cases.

It’s perhaps ironic that if the administration had agreed years ago to consider our proposal to develop cost-effective group homes delivering the current level of care on the current campuses, we could have avoided all the delays and litigation that the providers and the administration are now decrying.

In summary, as we pointed out in our previous post, what we’re now seeing is a campaign by the administration and the providers to use Fernald to discredit a proposed budget amendment that would require an independent cost study before the Templeton, Monson, and Glavin developmental centers could be closed.  The argument being made by the administration and the provders is that this budget amendment would cause delays in the closures of those three facilities, and that soon we will be paying the same high costs to keep those centers open that we’re allegedly paying for Fernald.

This is nonsense.  An independent cost study will simply help us determine whether we’re on the right track fiscally in closing these facilities.  As I hope we’ve shown, we can’t leave it solely up to this administration to provide credible numbers or other information about this matter.

Fernald being used as political football

May 22, 2011 10 comments

The Fernald Developmental Center may be almost closed, but it’s now apparently being used as a political football by the administration and the human service providers who are seeking to close at least three additional state facilities for persons in Massachusetts with intellectual disabilities.

In the past month, both the providers and the administration have cited an allegedly high current operating cost for Fernald as a reason to oppose a cost study prior to closing the Monson, Templeton, and Glavin centers.  Nevermind that Fernald is not even included in a proposed state budget amendment calling for the cost study.  

Moreover, while we haven’t yet seen the Fernald budget numbers the providers and the administration are citing, we understand the reportedly high cost is due to a decision by the administration to maintain an unusually high number of staff at the facility for its 19 remaining residents.   The reason for the high staffing level isn’t clear.  The guardians of those remaining residents have filed administrative appeals of Fernald’s closure.

During the ongoing budget debate in the Legislature, the Department of Developmental Services  and the Association of Developmental Disabilities Providers have been telling legislators that it is costing as much as $917,000 per resident per year to operate Fernald.   As the linked State House News story shows, ADDP President Gary Blumenthal last month cited that Fernald cost figure, which was disclosed by DDS,  in order to discredit a House budget amendment requiring an independent cost study prior to closing Monson, Templeton, and Glavin.

The logic of the administration and the provders appears to go something like this:  “Because we’re spending an unusually high amount this year to keep the Fernald Center open for the remaining residents,  we shouldn’t even waste time studying the cost of closing or maintaining  three other facilities where the costs actually happen to be considerably lower.   The Fernald cost shows we must close all four of these facilities as fast as possible.”

That this tactic has had an impact in the Legislature became clear when a small group of COFAR members met on Wednesday of last week with a staff member of Senator Stephen Brewer, chairman of the Senate Ways and Means Committee, to push for the cost study amendment.   The staffer, without any prompting, mentioned she had heard Fernald was costing $18 million this year to operate.

That afternoon, in a conference call, I asked DDS Commissioner Elin Howe about the reported $18 million cost.  Howe said the cost was closer to $15.6 million, which would translate to a still sky-high figure of $821,000 per person to keep Fernald running this year.  When I asked what the money was being spent on, Howe said the high cost was due to the fact that 95 staff remain at Fernald — a staff-to-resident ratio of 5 to 1.

I was so taken aback by what Howe had just said that I didn’t think to ask her why the administration is maintaining such a high staffing ratio at Fernald.  That ratio appears to be the reverse of the 1 to 3.2 staff-to-resident ratio required under federal regulations for Intermediate Care Facilities.   The next day, at DDS’s request, I submitted a written question to Howe about the situation.  I haven’t yet gotten a response.

Howe, by the way, said that if I wanted to get the same Fernald budget numbers that Blumenthal was citing to the State House News Service and which DDS has apparently provided to legislators, I would have to file a freedom of information request.  I did so the next day.

I then heard that day from Senator Brewer’s office that the high staffing level at Fernald is reportedly due to a court order that has prevented DDS from moving the remaining 19 residents there into one building on the campus.  But we’ve heard from other sources that there may not actually have been any such court order.

Whatever the reason for Fernald’s current operating cost, to introduce Fernald into a debate over whether to even study the cost of operating the Monson, Glavin, and Templeton centers is disingenuous and misleading.  Luckily, Senator Brewer now appears to understand that.  “We know it’s not accurate (to link the alleged Fernald cost to the other three facilities),” the staff member said.