State Supported Living Centers Long-term Plan · 2017-08-11 · 5 IV. Stakeholder Feedback – CannonDesign conducted interviews and focus groups with residents, family members, SSLC

State Supported Living Centers

Long-term Plan

Rider 39 Report

January 2015

STATE SUPPORTED LIVING CENTERS: LONG-TERM PLAN

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TABLE OF CONTENTS Tables and Figures ................................................................................................................................................................ .. 3

Executive Summary ................................................................................................................................................................ 4

Rider 39 Requirements ......................................................................................................................................................... 6

Overview of State Supported Living Centers ............................................................................................................... 7

Legal Framework ................................................................................................................................................................ 7

SSLC Demographics ........................................................................................................................................................... 8

Length of Stay ..................................................................................................................................................................... 10

Budget ................................................................................................................................................................ ................... 10

Admissions and Separations ........................................................................................................................................ 11

Community Transitions ................................................................................................................................................. 14

Obstacles to Community Referral and Transition .......................................................................................... 15

Census.................................................................................................................................................................................... 16

Projected SSLC Census in 2024 .............................................................................................................................. 19

SSLC Workforce ................................................................................................................................................................. 20

Recruitment and Retention ..................................................................................................................................... 20

Turnover ................................................................................................................................................................ .......... 20

Career Ladders .............................................................................................................................................................. 22

Oversight ................................................................................................................................................................................... 23

ICF/IID Program ............................................................................................................................................................... 23

DOJ Settlement Agreement ........................................................................................................................................... 23

Streamlining the Monitoring Process .................................................................................................................. 24

Restructuring the Settlement Agreement .......................................................................................................... 24

Quality Improvement Program ................................................................................................................................... 24

SSLC QI System ............................................................................................................................................................. 25

State Office QI System ................................................................................................................................................ 25

Electronic Health Record .......................................................................................................................................... 27

SSLC Infrastructure and Systems .................................................................................................................................... 28

Facility Support Services ............................................................................................................................................... 28

Facility Condition Index ................................................................................................................................................. 30

Facility Condition Assessments .................................................................................................................................. 31

Structural and Architectural ................................................................................................................................... 32


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General Maintenance .................................................................................................................................................. 32

Building Systems .......................................................................................................................................................... 32

Building Controls ......................................................................................................................................................... 32

Code Compliance .......................................................................................................................................................... 32

2014 Facility Condition Assessment ......................................................................................................................... 33

Economic Impact of SSLCs ............................................................................................................................................ 33

Stakeholder Feedback ......................................................................................................................................................... 36

Under-Served Areas ......................................................................................................................................................... 38

Recommendations................................................................................................................................................................ . 39

Appendix A: Census by SSLC: FY 2006 – FY 2014 ................................................................................................... 43

Appendix B: Current Trends and Best Practices ..................................................................................................... 44

Appendix C: DOJ Settlement Agreement Sections ................................................................................................... 47

Appendix D: Compliance Ratings by Center .............................................................................................................. 48

SSLC Compliance Summary .......................................................................................................................................... 52

Appendix E: Stakeholder Feedback .............................................................................................................................. 53

Focus Groups and Interviews ...................................................................................................................................... 53

Funding and Quality of Care .................................................................................................................................... 53

Human Resources ........................................................................................................................................................ 58

Community-based Services ..................................................................................................................................... 59

Priorities for an Improved Delivery System ..................................................................................................... 61

Online Survey ..................................................................................................................................................................... 64

Appendix F: Prototypical Plan Diagrams .................................................................................................................... 66

Prototypical Plan Diagram of Renovated/Downsized Home and Cost ...................................................... 66

Cost Model ...................................................................................................................................................................... 66

Prototypical Plan Diagram of Specialized ICF/IID Facility and Cost ........................................................... 67

Appendix G: Facility Condition Assessment Methodologies............................................................................... 68

Condition Assessment Methodologies ..................................................................................................................... 68


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TABLES AND FIGURES Table 1. Individuals with Behavioral, Medical, and Mental Health Needs ............................................................. 9

Figure 1. Census by Length of Stay ...................................................................................................................... 10

Table 2. FY 2015 Operating Budgets by SSLC ....................................................................................................... 11

Table 3. SSLC Admission Categories .................................................................................................................... 12

Table 4. SSLC Admissions by Type of Commitment ............................................................................................. 13

Table 5. SSLC Separations and Community Transition Returns ............................................................................ 13

Table 6. SSLC Community Transitions by Type .................................................................................................... 14

Figure 2. Persons with IDD Living in State Residential Settings by Funding Source on June 30, 2012 .................. 17

Figure 3. Census for All Individuals with IDD in Texas: FY 2005 – FY 2014 ........................................................... 18

Table 7. SSLC Census by Center as of August 31, 2014 ......................................................................................... 18

Table 8. New Admissions .................................................................................................................................... 19

Table 9. Admissions under Age 22 ...................................................................................................................... 19

Table 10. Budgeted and Filled FTEs by SSLC: FY 2014 .......................................................................................... 20

Table 11. Turnover Rates at SSLCs: FY 2012 – FY 2014 ........................................................................................ 21

Table 12. Turnover Rates in Specific Positions: FY 2012 – FY 2014 ...................................................................... 22

Table 13: Biennium Appropriations for SSLC Capital Repairs and Renovations ................................................... 28

Table 14. 2012 Total Market Value and 2014 Current Replacement Value by SSLC ............................................. 30

Table 15. Deficiency Costs and Facility Condition Index by SSLC ......................................................................... 31

Table 16. 2014 Facility Condition Assessment Results ......................................................................................... 33

Table 17. Economic Impact Summary ................................................................................................................. 34

Table 18. Distance from Correspondent’s Address to SSLC.................................................................................. 38

Table E.1. Respondents by Organization ............................................................................................................. 64

Figure F.1. Concept Floor Plan: Moderate Renovation to Lufkin SSLC Residential Unit ....................................... 66

Figure F.2. Concept Floor Plan: Specialized ICF/IID Facility .................................................................................. 67


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EXECUTIVE SUMMARY The 2014-15 state budget enacted by the 83rd Texas Legislature, Regular Session, 2013, included Rider 39, requiring the Texas Department of Aging and Disability Services (DADS) to develop a 10-year plan for the provision of services to persons residing in state supported living centers (SSLCs). The Texas Health and Human Services Commission (HHSC), the Department of State Health Services (DSHS), and DADS contracted with CannonDesign to assess infrastructure and operational needs of current and future facilities and to collect stakeholder feedback to identify opportunities to improve the SSLC system over the next 10 years.

The Sunset Commission reported that “some SSLCs are needed to continue serving the declining population of people, in particular, the medically fragile and behaviorally challenging, and the alleged offenders referred to SSLCs by the court. … Even with expanded community resources, some members of these populations will continue to need the services of an SSLC for some time to come.”1 It recommends closing the Austin SSLC and establishing an SSLC restructuring commission to “right-size” the number of SSLCs required for the level of need in Texas. The 84th Texas Legislature will be debating those recommendations when it convenes in January 2015. Information from this report may be used to help inform their decisions.

This report is divided into five sections:

I. Overview of SSLCs – describes the services and supports provided at the SSLCs today; the demographics of the individuals served; budget appropriations by center; a discussion of community transitions plus the obstacles to referral or transition; census projections; and a summary of efforts to address the long-standing issue of recruiting and retaining qualified staff.

II. Oversight – describes the various regulatory agencies providing compliance oversight of the SSLCs. This includes the federal ICF/IID program; the U.S. Department of Justice settlement agreement; and the Quality Improvement program DADS is implementing to improve the quality of care and services in the SSLCs as well as to individuals who have transitioned from an SSLC into an integrated community setting.

III. SSLC Infrastructure and Systems – describes the role of facility support services and includes facility condition assessments to evaluate buildings and site elements and to approximate the costs of repairs. The 2012 total market value and 2014 current replacement value are included for each SSLC, plus 2014 bond indebtedness. Included in this section are the results of a 2014 in-depth facility condition assessment conducted by CannonDesign, at the request of HHSC and DADS, plus analysis of the economic impact of the SSLCs on local communities.

1 Sunset Advisory Commission Staff Report: Department of Aging and Disability Services, May 2014, pg. 23.


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IV. Stakeholder Feedback – CannonDesign conducted interviews and focus groups with residents, family members, SSLC staff, and representatives of multiple advocacy groups to get insights and recommendations for the 10-year plan.

V. Recommendations – DADS makes the following six recommendations for the provision of services and supports at the SSLCs over the next 10 years:

1. Transform the service delivery model of the SSLCs from institutional only to both institutional delivery and clinical support for community-based services.

2. Develop specialized programs and redesign buildings within specific SSLCs to better equip these facilities to serve individuals who are medically fragile, require significant behavioral supports, or are alleged offenders, while maintaining sufficient capacity to provide services to the general resident population.

3. Develop satellite clinics to provide medical, therapeutic, and crisis respite services for individuals with IDD that are state-funded and/or located in areas of the state that are under-served.

4. Work with local IDD authorities and community providers to develop additional community resources for individuals with IDD, such as rate reimbursement incentives for providers who serve individuals who are medically fragile and/or require significant behavioral supports.

5. Continue to develop and implement the Quality Improvement program at the state and SSLC levels.

6. Examine wages by market and pay staff accordingly, as well as commensurate with the experience and responsibilities required by the job.

DADS hopes legislators will find the information and recommendations in this report useful as they begin their deliberations on the provision of supports and services to individuals living in state supported living centers over the next 10 years.


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RIDER 39 REQUIREMENTS The 2014-15 state budget enacted by the 83rd Texas Legislature, Regular Session, 2013, included Rider 39 requiring the Texas Department of Aging and Disability Services to develop a 10-year plan for the provision of services to persons residing in state supported living centers. This plan shall consider SSLC system operational needs, including infrastructure needs of the existing facilities, future infrastructure needs, capacity and demand needs of the state, and associated costs. The plan must consider current state funded SSLC capacity for individuals requiring services, serving individuals in the most integrated setting appropriate to their needs, consideration of individuals' and/or their legally authorized representatives' preferences, opportunities for individuals to receive services close to their geographic preference, and efficient use of state resources. The plan must consider monitoring and oversight of the quality of services, effective transition of individuals into community settings, and compliance with state and federal regulations.

DADS shall coordinate with the Department of State Health Services in the development and implementation of the plan, in order to ensure consideration of cross agency issues impacting SSLCs and state hospitals. To authorize the implementation of improvements to the SSLC system related to the plan, DADS shall submit a written request to the Legislative Budget Board and the Governor. The request shall be considered to be approved unless the Legislative Budget Board or the Governor issues a written disapproval within 30 business days of the date on which the staff of the Legislative Budget Board concludes its review of the proposal and forwards its review to the Chair of the House Appropriations Committee, Chair of the Senate Finance Committee, Speaker of the House, and the Lieutenant Governor.

To comply with the requirements of the rider, HHSC, DADS, and DSHS issued a request for proposals and awarded a contract to CannonDesign and its sub-contractors to conduct an independent study to develop recommendations for the provision of services to individuals residing in SSLCs over the next 10 years. From April through September 2014, CannonDesign and its sub-contractors met regularly with an advisory group of key DADS stakeholders, interviewed over 160 individuals directly involved in the provision of services to individuals with intellectual disabilities, conducted seven focus groups, administered an electronic survey receiving over 600 responses, and toured the 12 SSLCs and the Rio Grande State Center. Data analysis was conducted covering staffing, facility infrastructure, census and resident-level trends, and compliance data. Additionally, CannonDesign and its sub-contractors performed on-site facility condition assessments of existing buildings and site infrastructure at three SSLC campuses – Denton, Lufkin, and Mexia. These three campuses were selected to represent the diverse conditions between urban and rural locations in Texas and to be representative of other campuses where the facilities were not assessed at the same level of detail. Their analyses and recommendations are included in this report.


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OVERVIEW OF STATE SUPPORTED LIVING CENTERS DADS provides specialized assessment, treatment, support, and medical services for individuals admitted to the 12 SSLCs plus the intermediate care facility (ICF) service component of the Rio Grande State Center. SSLCs are located in Abilene, Austin, Brenham, Corpus Christi, Denton, El Paso, Lubbock, Lufkin, Mexia, Richmond, San Angelo, and San Antonio. The Rio Grande State Center, located in Harlingen, is operated by DSHS and provides ICF services through a contract with DADS.

Each center is certified as an intermediate care facility for individuals with intellectual disabilities (ICF/IID), a Medicaid-funded federal and state service. Approximately 60 percent of the operating funds for centers are received from the federal government and 40 percent are provided through State General Revenue or third-party revenue sources.

The stated vision is that individuals served at SSLCs will experience the highest quality of life, supported through a comprehensive array of services designed to maximize well-being, dignity, and respect. The mission is to lead the effective design and delivery of quality outcome-based services and supports appropriate to the talents, strengths, and needs of individuals through an integrated team approach that promotes independence and quality of life. To accomplish this, the SSLCs strive to empower and support residents in realizing personal goals and to offer them a variety of quality and cost-effective services, including a comprehensive review of the living options available to them.

LEGAL FRAMEWORK Although states had the option to serve persons in community settings, it was not until passage of the federal Americans with Disabilities Act (ADA) in 1990 and the Olmstead v. L.C. decision in 1999 that states significantly expanded community services. The ADA prohibits discrimination based on disability in employment, public services, public accommodations, and telecommunications. It requires a public entity to provide services “in the most integrated setting appropriate to the needs of the person” and “make reasonable modifications in policies, practices or procedures when the modifications are necessary to avoid discrimination on the basis of disability, unless the public entity can demonstrate that making the modifications would fundamentally alter the nature of the services, program, or activity.”2

In response to the Olmstead decision, Texas started the Promoting Independence Initiative3 in 1999, which supports allowing an individual with a disability to live in the most appropriate care setting available. Two activities under the Promoting Independence Plan included community outreach and awareness and relocation services. A decade later, Senate Bill 643, 81st Legislature, Regular Session, 2009, provided additional statutory framework for the protection and care of

2 http://www.gpo.gov/fdsys/pkg/CRPT-113hrpt448/pdf/CRPT-113hrpt448-pt1.pdf, pg. 44-45. 3 The Promoting Independence Initiative includes all long-term care services and supports and the state’s efforts to improve the provision of community-based alternatives, ensuring that Texas programs effectively foster independence and acceptance of people with disabilities and provide opportunities for people to live productive lives in their home communities.

http://www.gpo.gov/fdsys/pkg/CRPT-113hrpt448/pdf/CRPT-113hrpt448-pt1.pdf


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individuals with intellectual and developmental disabilities (IDD) served by public and private providers of IDD services in Texas. Changes made under this legislation included:

• Conducting fingerprint-based criminal history checks for SSLC employees and volunteers with direct contact with persons served;

• Random drug testing of employees at SSLCs and installation of video surveillance camera systems in common areas of all SSLCs;

• Implementation of a mortality review process for persons receiving services in SSLCs; and • Formally designating the Mexia SSLC as a forensic facility to serve persons with intellectual

or developmental disabilities who are also high-risk alleged offenders.

Individuals with IDD have a wide range of service options to consider, including home and community-based services, community-based intermediate care facilities, and state-operated centers. The goal of this report is to develop recommendations for the provision of services and supports to individuals residing in SSLCs over the next 10 years while recognizing the state’s goal to serve people in the most appropriate setting.

SSLC DEMOGRAPHICS SSLCs provide campus-based, 24-hour residential services, comprehensive behavioral treatment and healthcare services, including physician, nursing, pharmacy, and dental services. Other services include skills training; occupational, physical, and speech therapies; nutritional management; vocational programs; short-term respite, emergency services, and services to maintain connections between residents and their families and natural support systems.

Nearly half of the individuals served at SSLCs have a behavior management level of moderate4, severe5, or profound6 (46 percent); 44 percent are medically fragile7; and 61 percent have a psychiatric diagnosis in addition to an intellectual disability diagnosis (see Table 1). Sixty-nine percent of the residents have a level of intellectual disability of severe or profound.8 The most

4 Individuals with a behavior management level of moderate exhibit problem behaviors that are disruptive, interfere with the carrying out of daily living activities, and cannot be ignored or easily redirected. These behaviors require direct intervention, usually in the form of deceleration technique and/or psychotropic medication, in addition to procedures for teaching a more acceptable functional behavior. 5 Individuals with a behavior management level of severe exhibit problem behaviors that cause major disruption and threaten the health and safety of the individual, peers, or staff if allowed to continue. These behaviors are often not amenable to non-intrusive techniques and require more intense intervention to manage the situation. 6 Individuals with a behavior management level of profound exhibit problem behaviors that are of sufficient frequency and intensity such that the individual received an increase in his or her level-of-need, or the individual’s behavioral history is such that his or her initial commitment was under Chapter 46b of the state Code of Criminal Procedure or under Chapter 55 of the Family Code. 7 A medically fragile condition is defined as a chronic physical condition, which results in prolonged dependency on medical care for which daily skilled intervention is medically necessary. 8 A person is said to have an intellectual disability if, before they are 18 years of age, they have an IQ below 70 and significant difficulty with daily living skills, including looking after themselves, communicating, and


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prevalent psychiatric diagnoses for residents with profound and/or severe intellectual disabilities and/or severe or profound behavioral management or mental health needs are autistic disorder, intermittent explosive disorder, and schizoaffective disorders. The top three medical diagnoses of residents who are medically fragile are epilepsy, hypothyroidism, and cerebral palsy.

Residents age 60 and over typically require significantly more resources both prior to and following admission to an SSLC. Additionally, older adults are more likely to develop chronic medical and behavioral conditions, further complicating care for those with IDD. As individuals with IDD age in the SSLCs, they will require increasingly complex services and supports.

Table 1. Individuals with Behavioral, Medical, and Mental Health Needs

Challenging Behavior Medically Fragile Mental Health Needs*

SSLC Census Total Percent Total Percent Total Percent Abilene 356 127 35.67% 184 51.69% 187 52.53% Austin 266 81 30.45% 114 42.86% 150 56.39% Brenham 283 97 34.28% 89 31.45% 178 62.90% Corpus Christi 224 69 30.80% 108 48.21% 117 52.23% Denton 460 230 50.00% 270 58.70% 258 56.09% El Paso 110 33 30.00% 45 40.91% 74 67.27% Lubbock 203 108 53.20% 125 61.58% 137 67.49% Lufkin 322 142 44.10% 147 45.65% 169 52.48% Mexia 288 214 74.31% 69 23.96% 214 74.31% Richmond 335 141 42.09% 160 47.76% 156 46.57% Rio Grande 67 27 40.30% 20 29.85% 47 70.15% San Angelo 208 163 78.37% 41 19.71% 193 92.79% San Antonio 240 108 45.00% 93 38.75% 181 75.42% TOTALS 3,362 1,540 45.81% 1,465 43.58% 2,061 61.30%

* Mental Health Needs: Individuals with a psychiatric diagnosis in addition to an ID diagnosis. Data Source: SSLC Challenging Behaviors/Medically Fragile/Level of Need/Mental Health Needs/Guardianship as of 8/31/2014.

SSLCs also serve juveniles and adults classified as alleged offenders who are committed under Chapter 55 of the Texas Family Code and Chapter 46b of the Code of Criminal Procedure. These individuals are admitted to the SSLC system for competency evaluation or are admitted on an extended commitment. They tend to be younger and have substantially shorter lengths of stay.

The average age of the alleged offender population is 30, and 93 percent of them are male. All alleged offenders whose admission to the SSLC system is court-ordered are initially admitted to the Mexia SSLC (males) or the San Angelo SSLC (females). Behavior management needs are categorized as severe or profound for 82 percent of the alleged offender population, compared to 46 percent of the total SSLC population. Intensive behavioral health supports, including routine psychiatric

taking part in activities with others. A severe intellectual disability is defined as an IQ between 20 and 35; a profound intellectual disability is defined as an IQ below 20.


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services, are required for 78 percent of the current alleged offender population. This compares to 61 percent of the total SSLC population.

LENGTH OF STAY The SSLC length of stay (LOS) has remained high and unchanging over the years. In the most recent fiscal year 2014, the average LOS across all SSLCs was 23.8 years. However, LOS does vary significantly by admission classification. Alleged offenders and emergency admissions have lengths of stays of 4.2 and 2.6 years, respectively; while individuals admitted under the Persons with Mental Retardation Act (PMRA)9 and voluntary admissions have lengths of stays of 25 and 31 years, respectively. Figure 1 below provides a breakout of census numbers by length of stay.

Figure 1. Census by Length of Stay

Data Source: SSLC Census Length of Stay as of 8/31/2014.

BUDGET DADS SSLC Division employs nearly 14,000 people statewide to provide administrative and clinical services and supports with an annual budget of $581 million in fiscal year 2015. The following table shows the fiscal year 2015 operating budgets by center.

9 Health and Safety Code, Title 7, Subtitle D §591.001: Persons with Mental Retardation Act - It is the public policy of this state that persons with [intellectual disabilities] have the opportunity to develop to the fullest extent possible their potential for becoming productive members of society.

224 412 343 276

2,107

0

500

1000

1500

2000

2500

0-1 Year 13 Months to5 Years

6-10 Years 11-15 Years >15 Years


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Table 2. FY 2015 Operating Budgets by SSLC

SSLC FY2015 Budget Abilene $ 56,434,593 Austin $ 55,789,967 Brenham $ 44,231,059 Corpus Christi $ 39,879,696 Denton $ 75,796,588 El Paso $ 19,393,695 Lubbock $ 34,908,751 Lufkin $ 48,746,611 Mexia $ 66,503,865 Richmond $ 54,773,829 Rio Grande $ 12,300,000 San Angelo $ 39,058,999 San Antonio $ 33,485,111 TOTALS $ 581,302,764

Data Source: DADS Budget and Data Management Services.

State office operations provide coordination and support to SSLCs in the areas of medical, nursing, behavioral, habilitation, dental, pharmacy, physical and nutritional management, community placement, living options, quality assurance, policy and rules, budget, contracts, government and media relations, staff resources, training, and special projects.

ADMISSIONS AND SEPARATIONS Each county in Texas is served by one of 39 local IDD authorities (LAs), which provide general revenue services directly through a network of local providers. They also serve as the point of entry for all intellectual disability programs, including SSLCs, community-based ICFs/IID, and all Medicaid waiver programs, whether the programs are publicly or privately operated. The LAs determine eligibility and help individuals with IDD access appropriate services and supports, including admission to an SSLC. There are seven different types of admissions, as described below.


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Table 3. SSLC Admission Categories

Admission Category Definition of Admission Category

Voluntary Respite Temporary service to address the individual’s or his or her family’s need for assistance or

relief. Respite can be provided for a time period not to exceed 30 days. One 30-day extension may be allowed if the relief sought has not been provided in the initial 30 days. Admission requires consent of the adult with the capacity to give legally adequate consent, the guardian of an individual, or the parent of a minor.

Emergency Temporary admission for an individual who has an urgent need for services for a time period not to exceed 12 months. Requires consent of the adult with the capacity to give legally adequate consent, the guardian of an individual, or the parent of a minor.

Regular Long-term placement for an individual who requires habilitative services, care, training and treatment. Regular admission requires consent of the adult with the capacity to give legally adequate consent. SSLCs do not permit the regular voluntary admission of a minor.

Involuntary Regular (PMRA) Admission of an individual, committed under the Persons with Mental Retardation Act

(PMRA), Health and Safety Code, Title 7, Subtitle D, for long-term placement. Criminal Code Admission of an adult, who has been found incompetent to stand trial and there is no

substantial probability that the individual will become competent in the foreseeable future. This is a commitment for long-term placement.

Criminal Code Evaluation

Admission of an adult for a period not to exceed 60 days for a misdemeanor and 120 days for a felony. The center will submit to the court a report that describes the treatment provided to the individual, states whether the center believes the individual is competent or not competent to stand trial and whether the individual meets commitment criteria. If the court determines the individual is not competent to stand trial as a result of an intellectual and developmental disability and the individual meets criteria, the individual may be committed to an SSLC for long-term placement.

Family Code Commitment of a minor who has been found unfit to proceed as a result of IDD and who meets civil commitment criteria.

Family Code Evaluation (Chapter 55 Juvenile)

Admission of a minor for a period not to exceed 90 days. The center will submit to the court a report that describes the treatment provided to the minor, states whether the center believes the minor is fit or unfit to proceed and whether the minor meets commitment criteria. If the court determines the child is unfit to proceed as a result of an intellectual and developmental disability and the child meets criteria, the child may be committed to an SSLC for long-term placement.

There were no voluntary regular or voluntary respite admissions between fiscal years 2005 and 2014.


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Table 4. SSLC Admissions by Type of Commitment

Fiscal Year PMRA

Adult Criminal

Code

Adult Criminal

Code Evaluation

Chapter 55

Juvenile Emergency Transition

Returns Total

Admissions

FY2005 140 8 7 45 35 1 236 FY2006 152 9 5 34 22 5 227 FY2007 184 16 3 43 5 3 254 FY2008 172 18 14 46 8 11 269 FY2009 96 12 13 40 5 11 177 FY2010 86 18 15 40 3 8 170 FY2011 72 7 12 35 2 3 131 FY2012 61 21 8 32 6 5 133 FY2013 85 25 16 34 6 16 182 FY2014 114 19 10 37 7 9 196

Data Source: SSLC Admissions by Type FY2000-FY2014 (as of 8/31/2014)

Since fiscal year 2005, separations10 from the SSLCs have exceeded admissions. Admissions to SSLCs decreased 17 percent from 236 admissions in fiscal year 2005 to 196 admissions in fiscal year 2014, while separations from SSLCs increased 52 percent, from 250 to 381 in the same time frame. As a percentage of the average daily census, separations increased from five percent to 11 percent in the same timeframe. Of the 381 separations in fiscal year 2014, 261 residents transitioned into the community, 34 were discharged, and 86 were due to death.

Table 5. SSLC Separations and Community Transition Returns

Fiscal Year

Total Separations

Total Community Transitions

Transition Returns

(< 6 Months)

Transition Returns

(≥ 6 Months)

FY2005 250 76 1 0 FY2006 291 97 5 2 FY2007 294 118 3 0 FY2008 362 206 11 3 FY2009 425 252 11 8 FY2010 504 330 8 2 FY2011 344 204 3 3 FY2012 340 207 5 0 FY2013 422 287 16 5 FY2014 381 261 9 6

Data Source: SSLC Community Transitions and Community Transition Returns FY2002-FY2014 (as of 8/31/2014)

10 Separations include community transitions, discharges, and deaths.


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COMMUNITY TRANSITIONS In direct response to the Supreme Court’s Olmstead decision, Texas initiated the Promoting Independence Plan to offer community options so individuals could choose to live in the most integrated setting appropriate to their needs. As part of this effort, DADS has identified and removed barriers that impede opportunities for community placement. The table below provides a breakdown of community transitions by type of setting since fiscal year 2006.

Table 6. SSLC Community Transitions by Type

Waiver ICF Other

Fiscal Year

4 Bed

3 Bed

Foster Care

Own Home/ Family Home

Small (≤ 8

Beds)

Medium (9-13 Beds)

Large (≥ 14 Beds)

Natural Home

Nursing Home

Other TOTALS

FY2006 41 38 12 3 1

1 1

97 FY2007 47 50 10 7

1

2 1 118

FY2008 67 107 22 10

206 FY2009 84 127 31 6 2 1 1

252

FY2010 109 194 17 7 1

1

1 330 FY2011 79 112 10 2

1 204

FY2012 80 96 24 5 2

207 FY2013 142 118 21 4 1

1

287

FY2014 85 147 21 5 1

2

261 TOTALS 734 989 168 49 8 2 3 3 3 3 1,962 Data Source: SSLC Community Transitions by Type, FY2006 through FY2014 (as of 8/31/2014).

Fiscal year 2010 had a significantly higher number of transitions due to one particular center that had a large number of transitions during that time period. Consequently, recommendations and feedback from independent teams monitoring the SSLCs under an agreement with DOJ led to revisions in the community transition process in the following fiscal years. Changes included more stringent guidelines regarding post-move monitoring activities, increased responsibilities related to community provider selection by interdisciplinary team members, and more attention given to identifying and implementing supports to ensure successful placements following transition from the SSLCs.

Efforts to streamline the transition process from the centers into the community led to the creation of a state office position dedicated to coordinating and improving transition activities. SSLC leadership also began meeting with community providers, local authorities, and other DADS staff on a bi-monthly basis to address transition-related issues. Additionally, a tracking system and process for reviewing potentially disruptive community transitions were developed and implemented in September 2013. The reviews address the following events that are considered potentially disruptive:

• Psychiatric hospitalization


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• Medical hospitalization • More than three emergency room visits (medical) in a 12-month period • Death • Arrest or incarceration • More than three contacts with law enforcement in a 12-month period • Unable to locate or left the program • Provider issues – Change of homes • Provider issues – Closure • Provider issues – Confirmed abuse, neglect, and exploitation • Provider issues – Change of providers • Return to the SSLC

OBSTACLES TO COMMUNITY REFERRAL AND TRANSITION Obstacles to referral include any supports or services not currently available in a community setting to meet the needs and preferences of the individual in an alternate setting. If an interdisciplinary team (IDT) decides not to refer an individual to a community setting, then an obstacle to referral is identified. The primary reasons for not referring an individual include:

1. Individual’s reluctance for community placement. 2. Legally authorized representative’s reluctance for community placement. 3. Medical needs requiring 24-hour nursing services/frequent physician monitoring. 4. Behavioral health/psychiatric needs requiring frequent monitoring by

psychiatric/psychology staff and/or enhanced levels of supervision maintained by direct service staff.

5. Evaluation period (Ch. 55/46b alleged offenders only) 6. Court will not allow placement. (Ch. 55/46b alleged offenders only) 7. Lack of funding (e.g., non-citizens without Medicaid funding).

Other obstacles to transition include:

1. Lack of supports for people with significant challenging behaviors. 2. Lack of specialized mental health supports. 3. Need for services and supports for individuals with forensic needs/backgrounds. 4. Need for environmental modifications to support the individual. 5. Need for transportation modifications to support the individual. 6. Lack of availability of specialized medical supports. 7. Lack of availability of specialized therapy supports. 8. Lack of specialized educational supports. 9. Need for meaningful employment and supported employment. 10. Individual/LAR indecision regarding provider choice. 11. Limited residential opportunities. 12. Lack of Medicaid/SSI funding (e.g., temporary loss of benefits due to inheritance).

If the IDT determines that a referral to the community is appropriate, a referral is made for


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community transition. It is expected the person will transition into the community within six months of referral.

Post-move monitoring visits are conducted at 7, 45, and 90 days to assess whether the supports and services remain in-place to facilitate a successful transition to an alternative community setting. If the IDT becomes aware of an event that might disrupt community transition within the first 12 months, it will meet with the post-move monitor, admission/placement coordinator, and the local IDD authority to address the event.

CENSUS In the United States, an estimated 473,802 individuals with IDD lived in settings other than the home of a family member on June 30, 2012. Of those, an estimated 38,761 lived in a state-operated residence for individuals with IDD: 28 percent lived in a residence funded by a home and community-based services (HCBS) waiver; 71 percent lived in an ICF/IID; and one percent lived in a facility funded by another source. (Refer to Figure 2.)

Nationally, annual ICF/IID expenditures for fiscal year 2012 per average daily participant were $142,118, and annual ICF/IID expenditures per 100,000 state residents averaged $39.17. Texas’ expenditures were $107,830 and $39.50 respectively.11

11 In-Home and Residential Long-term Supports and Services for Persons with Intellectual or Developmental Disabilities: Status and Trends through 2012, Residential Information Systems Project (RISP); University of Minnesota, pg. 79.


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Figure 2. Persons with IDD Living in State Residential Settings by Funding Source on June 30, 2012

State Total Clients State Total

Clients State Total Clients State Total

Clients State Total Clients

US 38,761 CT 1,236 MO 721 RI 233 WY 79 NY 9,051 OH 1,134 CO 592 UT 207 NM 60 TX 3,797 PA 1,106 IA 512 AZ 172 MT 55 NJ 2,480 WA 963 MN 421 KY 149 MD 54 MS 2,262 AR 951 WI 390 NE 144 NV 48 IL 1,928 VA 948 KS 334 SD 140 ID 47

MA 1,765 FL 899 GA 300 OR 108 NH 4 CA 1,682 LA 848 TN 280 ND 94 NC 1,506 SC 745 OK 235 DE 81

Data Source: In-Home and Residential Long-term Supports and Services for Persons with Intellectual or Developmental Disabilities: Status and Trends through 2012, Residential Information Systems Project (RISP); University of Minnesota, pg. 107.

While the state-operated ICFs in Texas provide services to individuals with ID who sometimes have limited community placement options, the number of individuals served in the community has increased while the number of individuals living in an SSLC has decreased. Since fiscal year 2005, the SSLC census has declined four percent annually; in fiscal year 2014, the census was 3,362 versus nearly 5,000 in fiscal year 2005. (Appendix A shows census by SSLC.) During this same time period as seen in Figure 3, other residential programs and community-based services experienced a four percent increase in the enrollment of individuals with IDD.12

12 Other residential programs and home and community-based services include community-based ICFs/IID, Home and Community-based Services (HCS), Texas Home Living (TxHmL), Community Living Assistance and Support Services (CLASS), Deaf-Blind with Multiple Disabilities (DBMD), and the Consolidated Waiver Program (CWP) that was discontinued in FY 2013.

0123456789

10

NY TX NJ IL CA CT PA AR FL SC CO M

N KS TN RI AZ NE

OR DE N

M MD ID NH

Num

ber o

f Res

iden

ts

(Tho

usan

ds)

ICF/IID HCBS Other


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Figure 3. Census for All Individuals with IDD in Texas: FY 2005 – FY 2014

0

9,000

18,000

27,000

36,000

45,000

FY05

FY06

FY07

FY08

FY09

FY10

FY11

FY12

FY13

FY14

4,847 4,924 4,884 4,789 4,541 4,207 3,994 3,787 3,547 3,362

27,230 28,614 30,995

34,177 36,071

38,138 40,436 39,075

37,527 39,363

0

4,000

8,000

12,000

16,000

20,000

SS

LC C

ensu

s

SSLC Census Census in Community Services

Note: Census numbers for community services includes HCS, TxHmL, CLASS, and DBMD. Data Source: DADS Census for State Supported Living Centers: FY2005-FY2014: Community Services Census from DADS Budget and Data Management Services; CannonDesign 2014.

Table 7. SSLC Census by Center as of August 31, 2014

SSLC Census Alleged

Offenders at Admission

Percent Alleged Offenders

Regular Admissions

Percent Regular

Admissions

Abilene 356 0 0.0% 356 100.00% Austin 266 2 0.8% 264 99.25% Brenham 283 0 0.0% 283 100.00% Corpus Christi 224 9 4.0% 215 95.98% Denton 460 4 0.9% 456 99.13% El Paso 110 2 1.8% 108 98.18% Lubbock 203 4 2.0% 199 98.03% Lufkin 322 1 0.3% 321 99.69% Mexia 288 166 57.6% 122 42.36% Richmond 335 0 0.0% 335 100.00% Rio Grande 67 1 1.5% 66 98.51% San Angelo 208 29 13.9% 179 86.06% San Antonio 240 2 0.8% 238 99.17% TOTALS 3,362 220 6.5% 3,142 93.46%

Data Source: SSLC Census by Admission Type/Census Reduction as of 8/31/2014.


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Additional diversity in the SSLC population exists in the range of ages served. Individuals range in age from nine to 88 at one SSLC, and roughly one in five individuals is over the age of 60. The average age of new admissions is 26 years, with nearly half of those individuals admitted under 21 years of age. Tables 8 and 9 below show the percentage of individuals 21 years and younger admitted as alleged offenders versus non-offender admissions.

Table 8. New Admissions

Fiscal Year

New Admissions

Alleged Offender

Admissions

Percent Alleged

Offender Admissions

Average Age at

Admission

AdmissionsAge 0 - 17

Admissions Age 18 - 21

Total Admissions Under Age

21

Percent Admissions Under Age

21 2010 162 73 45% 26 63 27 90 56% 2011 128 54 42% 24 46 18 64 50% 2012 128 61 48% 25 41 25 66 52% 2013 166 75 45% 26 49 27 76 46% 2014 187 66 35% 27 62 26 88 47%

Data Source: SSLC Division New Admissions only as of 8/31/2014. Note: New admissions do not include community placements that return to the SSLC or transfers between facilities.

Table 9. Admissions under Age 22

Fiscal Year

Total School Age Admissions

Total Non- Offender

Admissions

Total Alleged Offender

Admissions

Total Alleged

Offender Age 0-17

Total Alleged

Offender Age 18-21

Percent Alleged

Offender Admissions

2006 124 89 35 32 3 28% 2007 151 107 44 43 1 29% 2008 149 94 55 46 9 37% 2009 85 40 45 40 5 53% 2010 90 41 49 39 10 54% 2011 64 27 37 36 1 58% 2012 66 25 41 32 9 62% 2013 76 30 46 33 13 61% 2014 88 47 41 37 4 47%

Data Source: SSLC School Age Admissions (Under Age 22) FY 2006 through FY 2015 (as of 10/31/2014)

PROJECTED SSLC CENSUS IN 2024 As noted earlier, the SSLC census has declined four percent annually since fiscal year 2005. Assuming the SSLC census continues to decline at this rate, the SSLC census would drop to approximately 2,235 by 2024. This represents a 34 percent decrease from the current census of 3,362.

As the SSLC census declines, the remaining population is likely to consist primarily of two groups: (1) an aging, long-term resident population and (2) individuals with behavioral challenges. The long-term residents tend to be older and have increasingly complex medical issues as they age. Individuals with behavioral challenges include both the long-term residents with complex


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behavioral needs as well as more recent admissions. A subgroup of these is the alleged offenders, who tend to be younger and have milder intellectual and developmental disability diagnoses.

SSLC WORKFORCE Residential supports for individuals with IDD include a complex array of services provided by a broad range of healthcare professionals, in addition to administrative and maintenance staff. Employees work closely with the individuals in residence, their families or guardians, regulatory agencies, and the public.

RECRUITMENT AND RETENTION Recruiting and retaining qualified staff has been a critical and long-standing issue for the SSLCs. With a 92 percent fill rate across all SSLCs in fiscal year 2014, DADS has had success in its recruiting efforts. The numbers of full time employees (FTEs) per resident ranges from 3.05 to 5.16 per SSLC; however, coverage gaps exist at some SSLCs for several types of key staff, including direct care staff (Direct Support Professionals – DSPs) and clinical staff.

Table 10. Budgeted and Filled FTEs by SSLC: FY 2014

SSLC Budgeted FTEs Filled FTEs Fill Rate Abilene 1,472.00 1,326.38 90.11% Austin 1,234.91 1,085.09 87.87% Brenham 1,069.65 993.38 92.87% Corpus Christi 935.80 889.25 95.03% Denton 1,745.22 1,652.36 94.68% El Paso 446.23 412.58 92.46% Lubbock 882.19 804.35 91.18% Lufkin 1,169.01 1,130.39 96.70% Mexia 1,621.50 1,486.92 91.70% Richmond 1,328.91 1,267.15 95.35% Rio Grande 274.75 241.75 88.00% San Angelo 928.40 793.07 85.42% San Antonio* 795.83 731.04 91.86% TOTAL 13,904.40 12,813.71 92.16%


TURNOVER Despite extensive recruitment and retention efforts, staff turnover at the SSLCs continues to be a challenge that negatively impacts quality of care. As seen in Table 11, staff turnover has remained between 35 percent and 37 percent in the last three fiscal years. Turnover rates are even higher among DSPs and certain medical professional positions. In fiscal year 2014, DSPs had the highest turnover at nearly 45 percent.

Employee turnover at SSLCs comes at a great cost to the centers. Turnover costs include recruitment and training costs, loss of production, lowered productivity, low morale, and


21

unnecessary overtime and contract labor costs. In fiscal year 2013, DADS spent approximately $1.75 million per month on overtime pay and $2.75 million per month on contracted professionals. Much of this expense can be directly attributed to staff vacancies, staff absenteeism, and the centers’ inability to attract qualified professionals, thus necessitating the hiring of more expensive contracted professionals.

“Conservative estimates of direct support turnover, when factoring in lost time spent in pre-service training and new employee orientation for newly hired direct support professionals versus applying this time to resident care, can cost DADS nearly three million dollars per year.”13 CannonDesign noted that this figure does not take into account the resources required to recruit and train new hires or the lost time in-between termination and onboarding a new hire and is likely only a fraction of the true cost of turnover to the SSLC system when factoring in all staff groups.

Recognizing the shortage of staff with the appropriate training and skills, it will become increasingly important to evaluate compensation packages for SSLC staff. With only a few exceptions, starting salary levels are uniform across all centers statewide, which makes it harder to be competitive in more urban markets like Austin, Denton (Dallas-Fort Worth), Richmond (Houston), and San Antonio where the cost of living and wages are higher. Conversely, it is also difficult to recruit clinical professionals to rural areas such as Lufkin and Mexia.

Table 11. Turnover Rates at SSLCs: FY 2012 – FY 2014

SSLC FY2012 FY2013 FY2014 Abilene 39.95% 46.51% 43.94% Austin 36.94% 34.97% 37.74% Brenham 35.57% 31.88% 29.70% Corpus Christi 38.95% 43.55% 35.10% Denton 41.29% 39.02% 40.26% El Paso 33.13% 37.53% 29.24% Lubbock 45.09% 39.56% 37.31% Lufkin 38.65% 35.74% 32.18% Mexia 28.24% 23.35% 21.75% Richmond 21.05% 21.33% 21.42% San Angelo 49.22% 53.03% 58.94% San Antonio 40.89% 42.70% 38.90% AVERAGE 37.41% 37.43% 35.54%

Data Source: DADS Budget and Data Management Services, October 2014.

13 Ten-Year Plan for the Provision of Services to Individuals Served by State Supported Living Centers, CannonDesign, September 2014, pg. 68.


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Table 12. Turnover Rates in Specific Positions: FY 2012 – FY 2014

Position FY2012 FY2013 FY2014

Direct Support Professionals 47.02% 46.82% 44.77%

Dentist 42.86% 28.04% 40.38%

Licensed Vocational Nurses 42.08% 32.37% 39.34%

Registered Nurses 32.36% 42.27% 27.57%

Physicians 28.63% 30.06% 16.80%

Psychiatrist 48.21% 16.67% 42.67%

Psychologist 28.83% 21.30% 28.97%

Registered Therapist 31.08% 24.39% 21.52%

Qualified Intellectual Disabilities Professionals 25.99% 23.00% 26.91% Data Source: DADS Budget and Data Management Services, October 2014.

DADS is asking the Legislature for additional funding to support initiatives to reduce turnover and improve recruitment and retention.

CAREER LADDERS To reduce high turnover rates and improve recruitment and retention of critical personnel, DADS also plans to establish a career ladder for Qualified Intellectual Disability Professionals (QIDPs) and direct support licensed vocational nurses (LVNs) and registered nurses (RNs). These positions are directly responsible for ensuring the overall safety and quality of life for all individuals served. Their duties also specifically fulfill requirements of the DOJ settlement agreement and the ICF/IID Medicaid program.

The benefits of establishing a career ladder include increased organizational efficiency and productivity as well as improved employee retention, worker productivity, and succession planning. DSPs and direct support LVNs and RNs represent approximately 62 percent of the SSLC workforce. Offering salaries that are commensurate with their experience and skill levels will improve recruitment and retention. QIDPs also serve a critical role in ensuring the overall safety and quality of life for individuals at the SSLCs. With the current turnover rate at nearly 28 percent for QIDPs, recruitment and retention of these vital positions is critical.

Career ladders provide employees with an incentive to remain at the SSLCs by giving them opportunities to advance. In turn, the SSLCs will reduce turnover costs associated with recruitment and training expenses. Structured opportunities for advancement also motivate employees to increase productivity and perform well in order to obtain new knowledge and skills.


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OVERSIGHT

ICF/IID PROGRAM To qualify for Medicaid reimbursement, ICFs/IID must be certified and comply with federal standards, referred to as Conditions of Participation (CoP), in eight areas – governing body and management, client protections, facility staffing, active treatment services, client behavior and facility practices, healthcare services, physical environment, and dietetic services.

DADS Regulatory Services, as the designated state survey agency, determines whether the SSLCs are in compliance through annual surveys, licensure inspections, and complaint and incident investigations. Survey staff verifies whether providers are meeting the minimum standards and requirements for service, determine conditions that may jeopardize client health and/or safety, and identify deficient practice areas. When such deficiencies are identified and cited, survey staff monitor the SSLC’s plan of correction to ensure that areas of inadequate care are corrected and comply with state and federal requirements.

DOJ SETTLEMENT AGREEMENT In 2009, the State of Texas and the U.S. Department of Justice entered into a settlement agreement regarding services provided to individuals with intellectual disabilities in state‐operated facilities, as well as the transition of such individuals to the most integrated setting appropriate to meet their needs and preferences. The settlement agreement covers the 12 state supported living centers plus the ICF/IID service component of the Rio Grande State Center.

Under the terms of the agreement, independent monitoring reviews are conducted semiannually14 at each center to determine compliance within each of 20 substantive sections of improvement (see Appendix C for a list of the sections). When a center achieves substantial compliance with any substantive section for three consecutive monitoring visits, no further monitoring or reporting is required for that section.

It is important to note that the settlement agreement requires that the monitors rate each provision item as being in substantial compliance or in noncompliance. It does not allow for intermediate ratings, such as partial compliance, progress, or improvement noted. Thus, a center will receive a rating of noncompliance even though progress and improvements have occurred. Therefore, it is important to read the monitor’s entire report for detail regarding the facility’s progress or lack of progress.

As the monitors have reported, the number of substantial compliance ratings is generally not a good indicator of progress. Beginning with round three, DADS subject matter experts began reading the reports, using the previous report as a baseline, looking for progress made toward substantial compliance. DADS tracks the provisions where “progress” or “improvement” is noted by the monitors, in addition to the provisions in substantial compliance.

14 Each semiannual review is referred to as a “round.” As of August 31, 2014, the independent monitoring teams have completed eight rounds at all the SSLCs, with the exception of the Austin SSLC.


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Compliance ratings for each of the eight rounds are shown by SSLC in Appendix D. The appendix also includes a summary graph showing the percentage of provisions wherein a center has made progress in addition to the percentage of provisions attaining substantial compliance.

STREAMLINING THE MONITORING PROCESS The monitoring process, which occurs semiannually at each center, is resource intensive. To alleviate some of the strain on the centers, the state and DOJ have agreed to a streamlined monitoring process, which began in the seventh monitoring round. Results show a 25 to 33 percent reduction in the volume of records produced for the monitors. However, the monitoring teams’ requests for documents pre-visit, on-site, and post-visit continue to divert resources and staff time away from providing direct services to individuals.

RESTRUCTURING THE SETTLEMENT AGREEMENT In June 2014, DOJ and DADS filed a motion with the U.S. District Court seeking approval to restructure the monitoring process and to propose an amendment to the settlement agreement. The intent is to place greater focus on outcomes for the individuals whose rights the settlement agreement is designed to protect. DADS, DOJ, and the independent monitors anticipate that the restructuring will facilitate the goals of:

• strengthening the supports and services provided to individuals transitioning to the community;

• more clearly delineating the state’s obligations and compliance expectations under the settlement agreement;

• establishing more concrete methods for evaluating compliance; • accelerating the pace of the state’s compliance; and • providing a clearer path toward the state’s successful exit from the settlement agreement.

The parties also requested the court’s approval to postpone some of the upcoming monitoring visits to allow the monitors to devote the necessary additional time and attention to developing and implementing this complex restructuring. The court approved the joint motion for postponement in August 2014. The next round of monitoring visits will begin in January 2015 and occur over a nine-month period, through August 2015.

The purpose of restructuring the settlement agreement is to develop new tools, protocols, standards, criteria, and sampling procedures. The monitors’ stated goal is to create valid tools and protocols that DADS will be able to use reliably when monitoring ends.

QUALITY IMPROVEMENT PROGRAM DADS is committed to improving the quality of life for individuals with intellectual and developmental disabilities. This commitment includes developing an outcomes-based Quality Improvement (QI) program to assess and improve the quality of care and services provided to individuals in the SSLCs and to those who have transitioned from an SSLC into an integrated community setting. The goal is to ensure that all services and supports are of good quality, meet individuals’ needs, and help individuals achieve positive outcomes, including protection from harm,


25

SSLC QI System State Office QI System

stable community living, and increased integration, independence, and self-determination in all life domains (e.g., community living, employment, education, recreation, healthcare, and relationships). The program will consist of two primary systems:

• The SSLC QI system will identify and address resident issues and track center trends. • The state office QI system will identify and address SSLC issues and track statewide trends.

SSLC QI SYSTEM The SSLC QI program is designed to identify and address issues at the resident level. Key elements include:

• The interdisciplinary team develops and implements individual support plans that are based on resident preferences, goals, strengths, needs, and assessments that identify services, supports, and protections necessary to meet those needs. The team also tracks and monitors assessments within required timeframes and resolves discrepancies.

• Incident management is the process of identifying, reporting, analyzing, and preventing unusual incidents, including abuse, neglect, and exploitation (ANE).

• Services and supports are recommended as a result of individual support plan (ISP) assessments and implemented and evaluated to ensure they are leading to the desired outcomes. These include resident rights and satisfaction; access to appropriate equipment and services; social, educational, and work opportunities; and access to behavioral and physical healthcare services.

• SSLC QI includes monitoring the timely and effective implementation of the ISP, setting SSLC goals, tracking administrative and outcome measures, identifying areas needing improvement, and documenting decision-making.

STATE OFFICE QI SYSTEM In comparison to the SSLC QI system, the state office QI system is designed to identify and address issues at the statewide level. The purpose is to maintain a planned, systematic, organization-wide


26

approach to monitoring, analyzing, and continually improving the quality of care and services provided to individuals served at the SSLCs and the ICF/IID component of the Rio Grande State Center.

Quality of Care The SSLC division has contracted with the University of Florida’s Institute for Child Health Policy (ICHP)15 to assist in developing and implementing the QI program with the following elements:

• A proposed organizational framework to guide the development of a quality of care measurement program for the DADS SSLCs;

• Sample quality of care indicators for the major domains that DADS has identified, which are important for individuals in the SSLCs and those transitioning to community settings; and

• A proposed process for measurement review and approval, particularly for those measures where no clear national standards are available.

Following implementation of the QI program, ICHP will track and trend physical and behavioral healthcare administrative and outcome measures and develop annual quality of care reports. These reports will demonstrate how the quality of physical and behavioral healthcare in the SSLCs compares to other long-term care institutional settings and populations nationwide. The reports will also track healthcare outcomes for each center and show how those outcomes compare among centers.

Care Management The SSLC division is negotiating with a vendor to provide coordinated care management services that include:

• Supporting the IDT clinicians in developing more effective care plans for SSLC residents based on risk;

• Providing resources and technical assistance to SSLC staff in implementing care management plans, including any specialized training;

• Identifying gaps in resources and reporting areas of potential improvement based on best practices and national clinical standards; and

• Providing two toll-free 24/7 hotlines – one for physical health and one for behavioral health – to individuals who have transitioned to the community, the providers, and LARs for the first 12 months.

Setting Statewide Program Goals Through the ongoing review of outcome measures, quality of care reports, care management plans, and SSLC operations, the state office will monitor SSLC and statewide trends and develop statewide program goals. This process will occur in conjunction with discussions and corrective action plans developed by a state office QI council.

15 The Institute for Child Health Policy is part of the Department of Health Outcomes and Policy in the University of Florida’s College of Medicine.


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QI Oversight and Review State office will monitor administrative and outcome measures to ensure that all SSLCs are collecting, summarizing, and analyzing the data and information correctly. This includes tracking data to identify trends and developing and implementing corrective action plans to address problems. The QI review will evaluate each center’s progress and identify and share best practices among the SSLCs. These reviews will incorporate a mock fundamental (annual) ICF/IID survey process and will include ICF/IID deficiencies cited statewide.

ELECTRONIC HEALTH RECORD An essential element of the new QI program is a robust electronic health record (EHR) to provide a means for securely and electronically sharing clinical and administrative information to support and enhance quality and continuity of care and to increase staff efficiency. Data entered into the new EHR will become a baseline for measuring and reporting the success of the quality improvement program and will enable staff to track and analyze data to identify trends across, among, and within SSLC disciplines.

Today much of the data for quality of care metrics are captured on paper and not electronically. HHSC, in coordination with DADS Information Technology and SSLC divisions, released a request for proposals in July 2014 to procure a vendor-hosted solution. Proposals are being reviewed and evaluated; DADS IT anticipates implementation in August 2015. The objectives for the EHR are to:

• Facilitate the sharing of data within and across SSLCs; • Improve the operational efficiency and productivity of SSLC staff; • Enable more consistent statewide reporting through the reliable capture of critical data for

measuring and determining quality of care outcomes and improvements; • Improve coordination of care; and • Provide a holistic view of resident health data to facilitate timely medical decisions.


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FACILITY SUPPORT SERVICES

SSLC INFRASTRUCTURE AND SYSTEMS ICF/IID regulations mandate that SSLCs maintain buildings, equipment, infrastructure, and living environments in compliance with federal and state laws, rules, policies, and regulations. Although the SSLC campuses and facilities are well-maintained, many of the buildings were constructed 50 to 60 years ago; several SSLCs, including Abilene, Austin, and San Angelo, have many buildings that have surpassed or are nearing 100 years old. Furthermore, some of the aging facilities and infrastructure are functionally obsolete and do not meet current safety, quality, and workforce industry standards in residential programs (see Appendix B). Buildings on several campuses are no longer used, pose safety and security risks, and negatively affect the perception of a quality residential environment.

Postponing repairs and renovations has resulted in continued deterioration of building systems and infrastructure, escalating deferred maintenance costs, higher replacement costs, and adverse findings in federal and state compliance reviews. For the 2014-15 biennium, DADS received $33 million for SSLC capital repairs and renovations. The appropriations for the last six months are listed in the table below.

Table 13: Biennium Appropriations for SSLC Capital Repairs and Renovations

Biennium Appropriated

Amount Appropriated

2004-05 $ 18,735,500 2006-07 $ 26,086,000 2008-09 $ 39,691,964 2010-11 $ 26,987,000 2012-13 $ - 2014-15 $ 33,117,620


DADS and DSHS have an interagency agreement with HHSC to provide facility support services (FSS) for the SSLCs and the state psychiatric hospitals across Texas. HHSC provides both direct services, such as warehouse operations, food delivery, and centralized food purchasing, and indirect services, such as data analysis, reporting, technical assistance, and consultation. The departments and functions within FSS are real estate, environmental and laundry services, computer-aided facilities management (CAFM), competency training and development, nutrition and food services, enterprise fleet management, facility support performance indicators, interstate compact coordinator, risk management, maintenance and construction, energy management, and supply services.

Coordinated services between state hospitals and SSLCs include:

• San Antonio State Hospital – provides food service, security, emergency management services, pharmacy services, and vehicle maintenance for the San Antonio SSLC.


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• Austin SSLC – provides food service to the Austin State Hospital. • Kerrville State Hospital – provides laundry service for the Austin State Hospital, Austin

SSLC, San Antonio State Hospital, San Antonio SSLC, and the Texas Center for Infectious Disease.

• Abilene SSLC – provides laundry services for the Big Spring State Hospital, San Angelo SSLC, and the Lubbock SSLC.

• North Texas State Hospital – provides laundry services for the Denton SSLC. • Richmond SSLC – provides laundry services for the Brenham SSLC and the Corpus Christi

SSLC • Mexia SSLC – provides laundry services for the Lufkin SSLC, Terrell State Hospital, Rusk

State Hospital, and the Waco Center for Youth.

FSS generates a summary report based on continuous and ongoing assessments by each of the facilities. The SSLCs are required to inspect all of their buildings and building systems and update their deficiencies in the CAFM system at least once each year. This includes changing the priority of deficiencies, updating the correction costs, archiving deficiencies that have been completed, and adding new deficiencies as they occur.

FSS estimates the cost to replace the SSLC facilities far exceeds the market value of the facilities. Even when applying a cumulative inflation factor of 3.6 percent16 to convert the 2012 total market value (TMV) of $211.8 million into 2014 dollars, the TMV increases slightly to $219.5 million.17

16 Using the CPI inflation calculator from the U.S. Department of Labor’s Bureau of Labor Statistics, $100 in 2012 has the same buying power as $103.60 in 2014. The CPI inflation calculator uses the average Consumer Price Index for a given calendar year. The data represents changes in prices of all goods and services purchased for consumption by urban households. 17 The Denton, Mexia, San Angelo, Austin, and Abilene SSLC campuses have cemeteries on site, which must be taken into account when evaluating market and replacement values.


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FACILITY CONDITION INDEX

Table 14. 2012 Total Market Value and 2014 Current Replacement Value by SSLC

SSLC‡ Year

Established as SSLC

Campus Acreage

Number of Buildings

Total Square

Feet

2012 Total Market Value*

CAFM 2014 Current

Replacement Value†

2014 Bond Indebtedness

Abilene 1957 235.7 98 626,936 $ 18,340,000 $ 112,693,116 $ 23,698,863 Austin 1917 93.4 92 672,560 25,117,022 103,656,818 12,619,900 Brenham 1974 198.3 34 366,291 8,940,975 73,598,420 7,896,930 Corpus Christi 1970 104.0 52 299,787 8,400,000 62,819,304 8,625,695 Denton 1960 187.7 83 496,511 32,157,000 98,868,141 17,263,098 El Paso 1974 20.0 19 119,128 5,100,000 29,395,794 3,719,627 Lubbock 1969 226.1 41 320,786 12,254,000 64,063,551 10,906,612 Lufkin 1962 159.2 72 364,603 10,290,000 71,600,585 13,688,502 Mexia 1946 841.6 175 702,386 7,710,000 127,634,914 21,133,327 Richmond 1968 216.8 50 506,677 12,344,866 94,253,195 21,970,571 San Angelo 1969 1,031.0 84 493,421 10,212,000 96,891,254 13,293,935 San Antonio** 1978 349.1 38 233,734 61,000,000 45,165,410 5,339,111

TOTALS 3,662.9 838 5,202,820 $211,865,863 $ 980,640,502 $160,156,171 ‡Only includes SSLCs operated by DADS. *2012 Total Market Values (TMV) data from Texas General Land Office. †Current Replacement Value (CRV) data from HHSC Facility Support Services CAFM System Report as of 10/9/2014. **San Antonio acreage and Total Market Value includes the state hospital, SSLC, and Center for Infectious Diseases. Notes:

- Number of buildings is for actual buildings only and does not include site systems. Buildings standing, but NOT capable of being used, are NOT included.

- Site systems such as water distribution, electrical distribution, and steam distribution ARE included in costs. - Current Replacement Value is the estimated cost of labor and material that would be required to replace the building. It does not include

design, general conditions, a contractor’s overhead profit, or land acquisition.

Deficiency costs reflect the critical needs that must be addressed to correct failing systems or systems that are expected to fail within four years. The facility condition index (FCI) is an industry standard rating used to establish a relative comparison of deferred maintenance conditions. The FCI is calculated by dividing the cost of high priority deficiencies by CRV.


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The overall FCI of each SSLC is indicated below using a range of values between 0.00 and 1.00. An FCI closer to 0.00 indicates fewer deficiencies while an FCI closer to 1.00 indicates that conditions have deteriorated. This value allows for a simple comparison of conditions of all the SSLCs. FCI can be loosely understood to be the ratio of the cost to correct all deficiencies within a property relative to the cost of total replacement for that same property. For example, an FCI greater than 0.6 indicates that the cost of repair and maintenance is 60 percent of the cost of replacing the building.

Table 15. Deficiency Costs and Facility Condition Index by SSLC

Deficiency Costs (DEF$)*

SSLC

CAFM 2014 Current

Replacement Value (CRV)

Priority 1 Priority 2 Priority 3 Total

Deficiency Costs

FCI (DEF$/CRV)

Abilene $112,693,116 $10,033,88 $4,378,000 $9,622,547 $24,034,425 0.2133 Austin 103,656,818 4,685,408 1,715,364 7,949,770 14,350,542 0.1384 Brenham 73,598,420 10,172,456 2,933,882 1,805,441 14,911,779 0.2026

Corpus Christi 62,819,304 8,091,686 2,751,067 1,641,220 12,483,973 0.1987

Denton 98,868,141 14,140,556 13,072,836 17,444,199 44,657,591 0.4517 El Paso 29,395,794 - 437,969 444,914 882,883 0.0300 Lubbock 64,063,551 2,071,510 4,378,004 6,659,687 13,109,201 0.2046 Lufkin 71,600,585 4,899,395 4,738,784 4,235,636 13,873,815 0.1938 Mexia 127,634,914 5,107,497 1,295,052 2,025,325 18,427,874 0.1444 Richmond 94,253,195 9,700,412 3,251,893 5,036,937 17,989,242 0.1909 San Angelo 96,891,254 4,999,400 2,618,980 10,016,824 17,635,204 0.1820 San Antonio 45,165,410 86,940 2,539,284 1,724,972 4,351,196 0.0963

TOTALS $980,640,502 $83,989,138 $44,111,115 $68,607,472 $196,707,725 0.2006 Data Source: HHSC Facility Support Services CAFM System Report as of 10/9/2014. *Deficiency Priorities: 1 = Currently Critical; 2 = Potentially Critical; 3 = Necessary, Not Yet Critical

FACILITY CONDITION ASSESSMENTS CannonDesign conducted in-depth assessments at Denton, Lufkin, and Mexia in June 2014 to evaluate the conditions of all buildings and site elements and to approximate the costs of repairs.


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The assessments were conducted to identify partial or complete repairs or replacements needed via onsite field surveys looking at structural and architectural features, general maintenance of the buildings, building systems, building controls, code compliance, and technology and telecommunications. A summary of their findings across the three facilities follows.

STRUCTURAL AND ARCHITECTURAL The majority of buildings were constructed 25 to 70 years ago. The exterior envelopes are mostly in fair condition, although the Mexia substation facility has visible cracks in foundations and mortar joints. Most roofs are in good condition, although some buildings have original roofing systems. The majority of window units are single-paned/uninsulated, resulting in energy inefficiency. Dated, institutional-looking older finishes exist in many locations and are in fair condition, although many finishes at Denton are in poor condition.

GENERAL MAINTENANCE Systems and equipment are well-maintained using regularly scheduled preventive maintenance. However, many systems and equipment elements are past their expected life cycle, and limited funding often prevents proactive replacements. As a result, many of the systems and equipment are typically operated with a failure–reactive, “repair as needed” approach.

BUILDING SYSTEMS Stand-alone heating, ventilation, and air conditioning systems result in numerous pieces of large equipment and individual control systems spread across the campuses that require maintenance and capital funding up-keep. This configuration could be improved by constructing central plants or campus utility heating and cooling loop systems. Most below-grade piping is a mix of polyvinyl chloride, and older clay and cast iron systems that are prone to failure. In addition, exfiltration in older air handling units and ductwork results in inefficient energy use.

Healthcare buildings have stand-alone emergency power generators that reflect sound facility management practices that address health, safety, and welfare provisions for all occupants. Variable frequency drives exist on some equipment units for energy savings; however, variable frequency drives with programmable controls could be applied more widely.

BUILDING CONTROLS Most temperature control and building automation systems have been replaced with direct digital controls, limiting the number of older, energy-inefficient pneumatic controls systems. Automatic lighting control systems are not installed, resulting in energy inefficiency.

CODE COMPLIANCE The majority of restroom and shower units are obsolete and non-ADA accessible which may make it difficult to use basic comfort and hygiene-related amenities. Due to the configuration of spaces and common areas, opportunities to provide reasonable accommodations to account for the lack of accessibility are limited. Fire suppression systems exist in some facilities, and appear to be code-compliant, while several buildings without systems are likely “grandfathered” or are not required to have them. All residential buildings are equipped with fire suppression systems as required by


33

the Life Safety Code. Non-separation of emergency branch power circuits in resident care areas does not meet National Electric Code (NEC) requirements. For example, emergency-powered lighting systems cannot be connected to the same panel as normally powered lighting systems.

For healthcare or institutional occupancies that are required to follow Article 517 of the NEC, the emergency power system must be divided into separate branches. Where this condition exists, this deficiency is typically flagged by whatever licensing authority has jurisdiction - and in most cases, corrections are required.

2014 FACILITY CONDITION ASSESSMENT CannonDesign used the data collected during its onsite visits at Denton, Mexia, and Lufkin, as well as the CAFM data provided by HHSC FSS, to identify new deficiencies and compare conditions that may have changed facility condition ratings and capital funding needs. In each assessment, conclusions were drawn using these comparisons and the updated data was applied to the building inventory.18

Their overall assessment results are as follows:

• The average FCI for all assessed buildings is 0.13 – a poor rating. • On average, across all three campuses, more than half of all assessed buildings are either in

poor or critical condition. • Less than one quarter of buildings were assessed to be in good condition. • The average 10 year capital and deferred maintenance deficiencies funding needs for each

campus exceeds $15 million.

Table 16. 2014 Facility Condition Assessment Results

SSLC 10 Year Needs FCI Condition

Denton $ 15,467,394 0.15 Poor Lufkin $ 9,850,300 0.09 Fair Mexia $ 20,207,221 0.14 Poor

Average $ 15,174,972 0.13

Data Source: CannonDesign, 2014.

ECONOMIC IMPACT OF SSLCS Each SSLC impacts its local communities differently, in terms of the direct and indirect earnings associated with each SSLC and the percentage of gross metropolitan product that those earnings

18 While the assessments conducted by CannonDesign have been as closely aligned as possible with HHSC CAFM data, there exist substantial differences in the assessment methods which allow for deviation in the results of the FCI ranking system. The CAFM data, maintained by HHSC, is based on the systems renewal method, and the 2014 CannonDesign data is based on the strategic replacement method. An explanation of the two methodologies is in Appendix G.


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represent, as well as the number of jobs that each SSLC supports. CannonDesign quantified the economic impact that each SSLC has in its respective community, as well as the potential impact of a facility closure. The methodology to determine the economic impact is described below:

• Annual salaries of SSLC employees were quantified. This estimate reflects the average monthly salaries for all filled positions multiplied by 12 months.

• The indirect earnings associated with the SSLCs were estimated, using the Bureau of Economic Analysis (BEA) Regional Input-Output Modeling System II Type I multiplier for Texas nursing and residential care facilities. Indirect earnings are those that exist in other industries because of SSLC transactions, sometimes referred to as the “halo effect.” For example, $100 of SSLC earnings generates $22 of earnings in other industries.

• Gross metropolitan product (GMP) for each community was calculated, using 2012 data available from BEA that included the GMP by metropolitan statistical area, metropolitan statistical area, and county.

• Direct and indirect SSLC earnings were divided by the GMP.

o If direct + indirect earnings represents one percent or more of the community’s GMP, the economic impact of the SSLC is high.

o If direct + indirect earnings are between 0.11 percent and one percent, the economic impact is medium.

o If direct + indirect earnings are 0.10 percent or less, the risk is low.

The economic impact, and risk associated with potential closure, is summarized in Table 17.

Table 17. Economic Impact Summary

Location Annual Earnings

Earnings Multiplier

Indirect Earnings

Total Earnings Dependent on

SSLC GMP by MSA

Annual Earnings

% of GMP

Earnings Impact

Risk

Abilene $ 39,461,616 1.2189 $ 8,638,148 $ 48,099,763 $ 5,993,000,000 0.80% Medium Austin $ 35,860,185 1.2189 $ 7,849,795 $ 43,709,980 $ 98,677,000,000 0.04% Low Brenham $ 32,051,858 1.2189 $ 7,016,152 $ 39,068,009 $ 1,585,915,000 2.46% High Corpus Christi $ 28,292,048 1.2189 $ 6,193,129 $ 34,485,177 $ 21,915,000,000 0.16% Medium Denton $ 52,439,293 1.2189 $ 11,478,961 $ 63,918,254 $ 31,311,031,000 0.20% Medium El Paso $ 12,312,662 1.2189 $ 2,695,242 $ 15,007,903 $ 29,717,000,000 0.05% Low Lubbock $ 25,031,835 1.2189 $ 5,479,469 $ 30,511,304 $ 11,110,000,000 0.27% Medium Lufkin $ 34,486,275 1.2189 $ 7,549,046 $ 42,035,321 $ 3,010,988,000 1.40% High Mexia $ 44,184,052 1.2189 $ 9,671,889 $ 53,855,941 $ 790,418,000 6.81% High Richmond $ 40,140,068 1.2189 $ 8,786,661 $ 48,926,729 $ 31,920,687,000 0.15% Medium Rio Grande Operated by DSHS 0.22% Medium San Angelo $ 24,894,092 1.2189 $ 5,449,317 $ 30,343,409 $ 4,266,000,000 0.71% Medium San Antonio $ 22,629,247 1.2189 $ 4,953,542 $ 27,582,789 $ 91,995,000,000 0.03% Low TOTAL $391,783,230 1.2189 $ 85,761,349 $ 477,544,579 $332,292,039,000 0.14% Data Source: Ten-Year Plan for the Provision of Services to Individuals Served by State Supported Living Centers, CannonDesign, 2014.


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The Brenham, Lufkin, and Mexia area economies are the smallest, so earnings associated with the SSLCs in those areas are the most significant. In Mexia, the total GMP is less than $1 billion, with the SSLC responsible for nearly $54 million of the area’s earnings.

Larger metropolitan areas have more robust economies, so the SSLCs are less critical to overall economic activity. Austin’s GMP exceeds $98 billion, so the SSLC earnings of approximately $43.7 million represent only a small fraction of the total economy.

The economic impact also depends on the size of the SSLC. El Paso and Denton have similar MSA GMPs, but the Denton facility is considerably larger, and therefore represents a higher percentage of the overall value of goods and services produced.


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STAKEHOLDER FEEDBACK In June 2014, CannonDesign conducted interviews and focus groups with residents, family members, SSLC staff, and representatives of multiple advocacy groups. The organizations invited to have their constituents participate included:

• ARC of Texas • Disability Rights of Texas, Inc. • Community NOW • Texans for SSLCs • Parent Association for the Retarded of Texas (PART) • Private Providers Association of Texas (PPAT) • Providers Alliance for Community Services of Texas (PACSTX) • Texas Council of Community Centers • Parents and guardians of individuals with IDD at the Denton SSLC • Parents and guardians of individuals with IDD at the Richmond SSLC • Self-advocates: residents of the Denton SSLC • Residents of the Denton SSLC

While some issues resonated more strongly with certain stakeholders, several key themes emerged.

1. Insufficient Funding

Focus group participants identified insufficient funding of the current system as a major barrier to services and quality of care both in SSLCs and in the community. Legally authorized representatives stated that low pay to direct service staff contributes directly to high staff turnover. According to one provider, “The current rate structure does not reflect the severity and complexity of need.” Representatives of LAs concurred that underfunding impedes a continuum of services and creates a fragmented system characterized on the community side by long interest lists.

2. Quality of Care

Overwhelmingly, parents and guardians of SSLC residents were highly complimentary of the quality of care their children or siblings have been receiving. Family members stressed the value of the spectrum of services that SSLCs provide including comprehensive care and that such a spectrum is not available in the community. Representatives of local IDD authorities also lauded the SSLCs for providing specialized care, including dental care, quality adaptive equipment, and managing the physical needs of individuals with complex medical conditions.

3. Community-based Services

Members of advocacy groups such as the ARC of Texas, Community NOW, and Disability Rights of Texas see many advantages and benefits for individuals with IDD living in the


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community. Individuals with IDD, according to advocates, have greater flexibility and independence in receiving community-based services and achieve “better outcomes in the community.”

The decision to transition their child or relative into the community is difficult for some family members because they see the advantage of the permanency that SSLCs offer. However, proximity to family is considered a major benefit to having individuals with IDD in a community setting. Community advocates stated that SSLCs do not foster family involvement because of distance. Family members recounted the difficulties they experienced when the only SSLC placement they could find for their child was five and one-half hours away from their home.

Family members of SSLC residents were also concerned about what they say is a lack of oversight of community-based services. Some family members of SSLC residents had bad experiences with community-based services

4. Serving Individuals with Medically Complex Needs

Family members of SSLC residents with more complex medical conditions recounted bad experiences that their children or siblings had in the community. “Community medical providers did not know how to handle him. You can’t find doctors or hospitals that will care for our individuals.”

Representatives of local IDD authorities concurred that community providers frequently do not have the skills to keep many individuals with IDD medically stable in the community.

Providers indicated that the multiple cuts in the reimbursement rates made serving individuals with complex medical needs untenable as the current rates do not reflect the severity and complexity of need. However, providers also believed that this population could be well served in the community with appropriate reimbursement or “if we have a sufficient number of individuals (such that economies of scale can be realized).”

5. Availability of Services

According to representatives of local IDD authorities, the current system is not able to serve non-citizens who are not eligible for Medicaid and alleged offenders with sexual offenses. Currently, SSLCs are the only places where these individuals can be served. Elderly individuals with IDD are also not well-served in the community and are subject to long interest lists for waiver services.

Another service gap involves the availability of specialists. Not enough neurologists, psychologists, geriatric, and other specialists are willing to serve more individuals with IDD, which according to a representative of a local authority is probably due to low reimbursement rates. In the absence of specialized care, these individuals get care from their primary care doctor, which is not always optimal.


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See Appendix E for more stakeholder feedback from the focus groups and online survey.

UNDER-SERVED AREAS SSLC leadership, staff, family members, and other stakeholders reported that the longer the drive time from the family home to the SSLC, the greater the hardship on families, making it more difficult for them to remain actively engaged in the care and lives of family members who reside at SSLCs. As the SSLC residents age, so do their family members, making it increasingly difficult to travel long distances to visit their loved ones.

Driving distances from the correspondent’s19 address to the admitting SSLC were analyzed as of July 2014, as shown below in Table 18. More than 60 percent of the residents in SSLCs live more than 40 miles away from their correspondent’s (usually the LAR) address. Abilene, Brenham, Lubbock, Lufkin, Mexia, and San Angelo have the highest percentages of family members traveling over 40 miles to the SSLC, while El Paso, Rio Grande, and San Antonio have the lowest percentages.

Table 18. Distance from Correspondent’s Address to SSLC

SSLC Census Percent Within

City

Percent Outside City (≤ 40 Miles)

Percent > 40 Miles

Percent No Contact

Address Abilene 356 17% 4% 72% 7% Austin 266 36% 15% 49% 0% Brenham 283 6% 10% 84% 0% Corpus Christi 224 25% 6% 58% 11% Denton 460 11% 36% 47% 7% El Paso 110 58% 4% 7% 31% Lubbock 203 25% 0% 70% 5% Lufkin 322 10% 6% 83% 1% Mexia 288 2% 6% 87% 6% Richmond 335 5% 46% 48% 0% Rio Grande 67 0% 48% 24% 28% San Angelo 208 11% 4% 70% 15% San Antonio 240 57% 9% 30% 5% TOTAL 3,362 18% 15% 61% 6%

Note: Correspondents may include family members, friends, advocates, etc. Driving distance adds miles to the distance between zip codes, so is higher than actual mileage. Data Source: SSLC Correspondent Mileage (Driving Distance) as of 8/31/2014.

19 Correspondents may include family members, friends, advocates, etc.


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RECOMMENDATIONS Nationally, residential services and supports for individuals with IDD have shifted toward person-directed planning,20 community integration, independence, self-determination, and housing individuals in the least restrictive environment possible. While many Texans with IDD are successfully served in the community, a subset of the IDD population continues to benefit from the more intensive and extensive services and supports at the SSLCs. The Sunset Commission Report noted that “some SSLCs are needed to continue serving the declining population of people, in particular, the medically fragile and behaviorally challenging, and the alleged offenders referred to SSLCs by the court …. Even with expanded community resources, some members of these populations will continue to need the services of a SSLC for some time to come.”21

The Sunset Commission recommends closing the Austin SSLC and establishing an SSLC restructuring commission to “right-size” the number of SSLCs required for the level of need in Texas. The 84th Texas Legislature will be debating those recommendations when it convenes in January 2015. Information from this report may be used to help inform their decisions.

DADS makes the following recommendations for the provision of services and supports to persons residing in SSLCs over the next 10 years:

1. Transform the service delivery model of the SSLCs from institutional only to both institutional delivery and clinical support for community-based services.

One key to living in a community setting successfully is the availability of specialized services necessary to prevent individuals from having to move into more restrictive settings. Family members and local IDD authorities alike have praised the availability of specialized care at the SSLCs, including dental care, quality adaptive equipment, and managing the physical needs of individuals with complex medical conditions. According to family members, the state is not prepared for the rapid growth of aging individuals with IDD, especially those with complex needs, and there is a need for expanded services. Advocates have pointed to the lack of crisis and respite services in the community for emergencies.

As the SSLC census declines, DADS has the opportunity to expand the delivery of specialized SSLC services and supports to individuals with intellectual and developmental disabilities living in the community. Serving as resource centers for individuals with IDD would ensure comprehensive services are available to promote living in the most integrated environment possible. These services could include:

20 Person-directed planning is a process that empowers the individual and the LAR on the individual’s behalf to direct the development of a plan of supports and services that meet the individual’s personal outcomes. The process must: identify existing supports and services necessary to achieve the individual’s outcomes; identify natural supports available to the individual and negotiate needed service system supports; occur with the support of a group of people chosen by the individual and the LAR on the individual’s behalf; and accommodate the individual’s style of interaction and preferences regarding time and setting. 21 Sunset Advisory Commission Staff Report: Department of Aging and Disability Services, May 2014, pg. 23.


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• Dental Services • Active Treatment/Specialized Day Programs • Habilitation Therapies • Durable Medical Equipment (i.e., wheelchair) Fabrication • Acute Care Clinics • Psychiatric Clinics • Behavioral Health Services • Crisis Stabilization Services

Enhanced access to medical, behavioral, and dental health services, along with robust management of chronic conditions, has been demonstrated to reduce the overall utilization of emergency and acute health care services while lowering overall costs.22

2. Develop specialized programs and redesign buildings within specific SSLCs to better equip these facilities to serve individuals who are medically fragile, require significant behavioral supports, or are alleged offenders, while maintaining sufficient capacity to provide services to the general resident population.

As the SSLCs continue to decrease in size, the proportion of residents who have high medical and behavioral health needs will continue to increase. SSLCs should develop more specialized programming to meet the needs of these populations. This includes designating homes, units, or campuses that will develop specialized services and supports targeted for these particular populations. This will allow the SSLCs to focus their expertise on those who present the greatest challenges to serve.

Through the past 25 years, best practice in facility design for individuals with IDD has evolved while SSLC facilities have grown increasingly outdated. Structures at the SSLCs should be updated and/or redesigned to provide safer and more therapeutic environments to meet the needs of specific populations, including, but not limited to, persons with IDD who are diagnosed with autism or dementia. The same model could be pursued for residential settings for high risk alleged offenders who may require a higher level of security in their living and day program environments.

CannonDesign developed plan diagrams and cost models for two types of residential facilities (see Appendix F). The first plan uses an existing 20-bed residence at the Lufkin SSLC as an example of renovation and reprogramming. The second is a conceptual floor plan for a specialized ICF/IID facility.

3. Develop satellite clinics to provide medical, therapeutic, and crisis respite services for individuals with IDD that are state-funded and/or located in areas of the state that are under-served.

22 Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. (Available on www.IHI.org)


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In many areas of Texas, there is a shortage of health care professionals. Although the SSLCs can serve as resource centers in their local areas, many areas in the state are still under-served. This includes professionals who have an expertise in service delivery for persons with intellectual and developmental disabilities. Texas is a large state, and travel distances between the SSLCs are significant. To align IDD services and supports with the widely dispersed Texas population, DADS recommends developing satellite clinics to improve access to care.

After looking at population densities and the distribution of state and private ICFs statewide, CannonDesign identified the following as potentially under-served areas: the Panhandle north of Amarillo; the Rio Grande Valley near Laredo; the Dallas Fort Worth metroplex; the Houston metro area; and East Texas along the Interstate-20 corridor near Longview. Current SSLC operations would provide oversight to minimize administrative costs.

An alternative to satellite clinics might be federally qualified health centers (FQHCs)23 or FQHC “look-alikes,”24 which are community-based organizations that provide comprehensive primary care and preventive care, including health, oral, and mental health/substance abuse services to persons of all ages, regardless of their ability to pay or health insurance status. However, the FQHC will be expected to specialize in providing the services necessary to support individuals with IDD.

4. Work with local IDD authorities and community providers to develop additional community resources for individuals with IDD, such as rate reimbursement incentives for providers who serve individuals who are medically fragile and/or require significant behavioral supports.

The Sunset Commission reported they “heard from many sources that provider reimbursement rates do not account for costly medical needs, creating a disincentive to care for the medically fragile population in the community.” As a result of this, they made the following recommendation:

“To build community capacity, a number of states including Texas have HCS waiver plans that allow a select number of individual’s cost to be greater than the average cost of state institutions under certain circumstances. However, Texas’ HCS waiver only uses the higher reimbursement category for people with serious behavioral issues. DADS has recently initiated a workgroup that is studying how a rate increase could help providers serve clients with more costly medical needs, but currently

23 FQHCs include all organizations receiving grants under Section 330 of the Public Health Service Act. FQHCs qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits. They must serve an underserved area or population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality assurance program, and have a governing board of directors. 24 FQHC Look-Alikes do not receive grants under Section 330 but are determined by the Secretary of the Department of Health and Human Services to meet the requirements for receiving a grant based on HRSA recommendations. They receive cost-based reimbursement for their Medicaid services, but do not receive malpractice coverage or a cash grant.


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providers lack the necessary funding level that would encourage the development of additional small group homes to serve people with high medical needs.”25

Community providers and the local IDD authorities have reported to DADS that current reimbursement rates are not adequate to cover the costs of services, such as 24-hour nursing care or specialized training, for persons who are medically fragile and/or require significant behavioral supports. Over the next two years, DADS will evaluate the impact of rate enhancements for community providers serving individuals with complex medical needs in Central Texas. If this model proves successful, DADS should consider implementing similar systems in other areas of the state.

5. Continue to develop and implement the Quality Improvement program at the state and SSLC levels.

As noted, DADS will implement the SSLC QI program over the next three years. It is expected to transform the SSLC service delivery system, change the way that SSLCs are monitored, and provide additional supports to individuals transitioning into the community. DADS expects that the QI program will also improve the state’s ability to self-monitor the SSLCs, which will position the state to develop an exit plan from the DOJ settlement agreement. Though full implementation of the QI program will take only three years; the systems set forth through the program are expected to be sustained throughout the next decade.

6. Examine wages by market and pay staff accordingly, as well as commensurate with the experience and responsibilities required by the job.

DADS is asking the Legislature for additional funding to help decrease turnover and improve recruitment and retention at the SSLCs. This request includes salary increases and job reclassifications for certain positions. Over the next 10 years, DADS will need to consider developing additional career ladders and continuing to identify market trends and adjust salaries accordingly. Additionally, DADS will need to continuously evaluate the market competition and make adjustments to compensation as necessary. For example, the petroleum industry in Texas has negatively impacted the recruitment and retention of DSPs at the San Angelo and Abilene SSLCs. DADS must have flexibility to adjust wages for certain markets within Texas for positions with historically high turnover rates. Further, DADS should consider

adjusting wages at SSLCs for areas with a higher cost of living.

25 Sunset Advisory Commission Staff Report with Commission Decisions: DADS, August 2014, pg. 33.


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APPENDIX A: CENSUS BY SSLC: FY 2006 – FY 2014

SSLC FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 % Decrease Abilene 518 515 508 486 454 442 412 386 356 -31% Austin 434 434 431 401 377 355 328 288 266 -39% Brenham 401 401 385 378 340 315 298 288 283 -29% Corpus Christi 375 361 355 325 292 274 258 242 224 -40% Denton 649 641 621 582 545 519 494 484 460 -29% El Paso 144 141 138 142 136 131 124 116 110 -24% Lubbock 304 289 266 242 230 225 214 209 203 -33% Lufkin 418 427 423 415 405 377 361 342 322 -23% Mexia 493 498 517 477 417 390 372 331 288 -42% Rio Grande 75 76 75 71 72 71 70 62 67 -11% Richmond 519 508 491 462 407 378 352 339 335 -35% San Angelo 304 300 290 274 251 239 229 210 208 -32% San Antonio 290 293 289 286 281 278 275 250 240 -17% TOTALS 4,924 4,884 4,789 4,541 4,207 3,994 3,787 3,547 3,362 -32%


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APPENDIX B: CURRENT TRENDS AND BEST PRACTICES The following is a brief summary of the current trends and best practices:26

• Residential care for individuals with intellectual and developmental disabilities has shifted toward person-directed planning, community integration, independence, self-determination, and housing individuals in the least restrictive environment possible.

• Across the United States, there has been a concerted effort, beginning in the late 1970s, to transition individuals with IDD from large state-run institutions into smaller community group homes. States have been working to downsize large institutional campuses, replacing aging infrastructure with smaller, more dispersed community homes. This shift is supported by an increase in community-based programs and supportive housing to ensure successful transitions into de-institutionalized community homes.

• A key trend in non-institutional therapeutic environments is the concept of the building and site working together to form a “therapeutic platform” in which the interior space and exterior landscape are viewed as equal contributors to a healthy living environment.

• Evidence-based design supports the importance of physical and visual connections to the landscape as a means to reduce stress, anxiety, and agitation, and to provide a positive outlet for energy. In addition to improving well-being, outdoor spaces should be active participants in therapy. Outdoor spaces can be developed as restorative gardens for sensory stimulation, horticulture therapies, and recreational therapy. Outdoor spaces that are both passive and active should be provided to accommodate the variety of resident needs. Active spaces improve fitness and provide positive outlets for energy. Studies have shown the importance of physical activity for individuals with developmental disabilities as it affects balance, muscle strength, and quality of life.

Photos: Examples of interior and exterior landscape development, Lindner Center of HOPE, Mason, OH.

• Natural daylight and views, shown to reduce stress, anxiety, and depression, should be provided in not only the residential areas, but also in staff work areas. Natural daylight and

26 Ten-Year Plan for the Provision of Services to Individuals Served by State Supported Living Centers, CannonDesign, September 2014, pg. 75.


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views to the landscape assist in intuitive wayfinding. Signage should be a last resort for wayfinding. Views to the landscape can create landmarks for individuals that help one navigate through a facility. The ability to see outside, to see what the weather is like, or what time of day it is creates a “grounding effect” for residents and staff. This is of particular importance for residents who may not be able to physically go outside, and for staff who may work long shifts indoors throughout the day.

• In addition to views to the landscape, additional interior devices beyond signage should be provided to assist in wayfinding. Landmarks and reference points should be provided throughout main circulation paths and the use of color and personalization of spaces can help residents of all different cognitive functioning levels navigate throughout a facility. Double-loaded corridors with no views to landmarks or the landscape have been shown to be disorienting for people to navigate.

• The trend toward deinstitutionalization of the residential care environment is being supported by smaller resident groupings and households. The national average for small group homes for individuals with intellectual and developmental disabilities is six residents per household. In addition to smaller households, facilities are being built with residential materials, such as wood and carpet, and with better acoustics to mitigate noise. All resident daily living activities occur within the resident households, such as dining.

Photos: Examples of color, graphics, and views to the landscape to assist in wayfinding.

• Facilities for individuals with developmental disabilities should be accessible throughout for mobility and varying cognitive functioning. Flooring transitions should be seamless throughout and technology, such as automatic door openers, should be leveraged to provide further assistance. Ample space should be provided for turning radiuses of wheelchairs and other larger assistive devices. Material selection and lighting should be cognizant of individuals with visual impairments through contrast between flooring and wall materials, non-glare surfaces and lighting, avoiding high contrast patterning that can be visually disorienting to individuals.

• Trends in resident bedrooms emphasize resident dignity and privacy through providing private bedrooms or semi-private bedrooms that offer a full height wall partition for separation. In both options, private ensuite bathrooms should be provided. Private bedrooms have been shown to improve resident sleep through fewer disruptions; increase occupancy rates through fewer


46

roommate issues; and to lower infection rates. Some senior residents and residents with intellectual and developmental disabilities benefit from having a roommate. A combination of single rooms and double rooms should be considered for this resident population. For residents with complex behavioral needs and/or who have court-commitments, private bedrooms are considered best practice.

Photos: Examples of residential care units.

• Evidence-based studies indicate that environmental factors positively affect resident participation. Environmental factors such as opportunities to make choices, environmental variety and stimulation, family involvement, assistive technologies, and positive staff attitudes have all shown to improve resident participation in activities and therapies. It is important to note that studies have also shown that smaller residential environments also improved resident participation, but larger residential environments with the appropriate amount of variety and choice showed similar positive results.


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APPENDIX C: DOJ SETTLEMENT AGREEMENT SECTIONS

Section Topic Number

Measurable Conditions

C Protection from Harm – Restraints 14 D Protection from Harm – Abuse, Neglect, and Incident Management 22 E Quality Assurance 5 F Integrated Protections, Services, Treatments and Supports 17 G Integrated Clinical Services 2 H Minimum Common Elements of Clinical Care 7 I At-Risk Individuals 3 J Psychiatric Care and Services 15 K Psychological Care and Services 13 L Medical Care 4

M Nursing Care 6 N Pharmacy Services 8 O Minimum Common Elements of Physical and Nutritional Management 8 P Physical and Occupational Therapy 4 Q Dental Services 2 R Communication 4 S Habitation, Training, Education, and Skill Acquisition Programs 4 T Serving Institutionalized Persons in the Most Integrated Setting Appropriate to Their Needs 17 U Consent 2 V Recordkeeping and General Plan Implementation 4

Total Number of Measurable Provisions 161


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APPENDIX D: COMPLIANCE RATINGS BY CENTER

18 18 18 21 23

37 43

49

0

10

20

30

40

50

60

70

Round 1 Round 2 Round 3 Round 4 Round 5 Round 6 Round 7 Round 8

Com

plia

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Ratin

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Abilene SSLC

18 18 18 26

33

0

10

20

30

40

50

60

70

Round 1 Round 2 Round 3 Round 4 Round 5 Round 6 Round 7

Com

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Austin SSLC

4

20

31 26

31

41

55 59

0

10

20

30

40

50

60

70


Com

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Brenham SSLC


49

12 18 18

22 29

33 36 42

0

10

20

30

40

50

60

70


Com

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Corpus Christi SSLC

19 22

33 25

30

49 54

66

0

10

20

30

40

50

60

70


Com

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Denton SSLC

19 16 24

32 35 43

50

64

0

10

20

30

40

50

60

70


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El Paso SSLC


50

21 22 27 29

37

52

64 65

0

10

20

30

40

50

60

70


Com

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Lubbock SSLC

16

27 26 31 32

46 50

54

0

10

20

30

40

50

60

70


Com

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Lufkin SSLC

13

24 28 28

34 42 45

58

0

10

20

30

40

50

60

70


Com

plia

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Mexia SSLC


51

17 17

27 23

27 29

42 47

0

10

20

30

40

50

60

70


Com

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Ratin

gs

Richmond SSLC

11 17

28 20

30 36

46 49

0

10

20

30

40

50

60

70


Com

plia

nce

Ratin

gs

Rio Grande SC

18 21 25

34 36 43

47 55

0

10

20

30

40

50

60

70


Com

plia

nce

Ratin

gs

San Angelo SSLC


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SSLC COMPLIANCE SUMMARY Percentage of Requirements Showing Progress or Substantial Compliance

As of November 3, 2014

Note: DADS tracks the number of provisions where “progress” or “improvement” is noted by the monitors in the report, in addition to the provisions in substantial compliance.

21 16

24 27 31

44 45 53

0

10

20

30

40

50

60

70


Com

plia

nce

Ratin

gs

San Antonio SSLC

30% 20%

37% 26%

41% 40% 40% 34% 36%

29% 30% 34% 33%

28% 35%

24%

29%

35%

22% 32%

29% 21%

20% 14% 20% 22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Substantial Compliance Progress


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APPENDIX E: STAKEHOLDER FEEDBACK In June 2014, CannonDesign conducted interviews and focus groups with residents, family members, SSLC staff, and representatives of multiple advocacy groups. The organizations invited to have their constituents participate included:

• ARC of Texas • Disability Rights of Texas, Inc. • Community NOW • Texans for SSLCs • Parent Association for the Retarded of Texas (PART) • Private Providers Association of Texas (PPAT) • Providers Alliance for Community Services of Texas (PACSTX) • Texas Council of Community Centers • Parents and guardians of individuals with IDD at the Austin SSLC • Parents and guardians of individuals with IDD at the Denton SSLC • Parents and guardians of individuals with IDD at the Richmond SSLC • Self-advocates: residents of the Denton SSLC • Residents of the Denton SSLC

In addition to the interviews and focus groups, an electronic survey was conducted online in July 2014 to gather feedback from a larger group of stakeholders. The survey addressed two major issues: barriers to services for individuals with IDD under the current system and potential improvements. A link to the survey was posted on the DADS website. Six hundred and twenty-four people responded.

FOCUS GROUPS AND INTERVIEWS

FUNDING AND QUALITY OF CARE Several key themes emerged from focus group discussions and interviews. For example, concerns about lack of/insufficient funding were a theme identified by nearly all stakeholder groups, followed by quality of care in the SSLCs and in community-based settings, and human resources issues involving staffing and training. Several themes appeared to be more pertinent to certain stakeholder groups, such as SSLC management and operations and public awareness of the SSLCs.

1. Insufficient Funding Like e-survey respondents, some focus group participants identified concerns regarding insufficient funding of the current system as a major barrier to services and quality of care both in SSLCs and in the community. Some stakeholders indicated that insufficient funding is manifested in SSLCs in low pay to direct service staff, contributing to high staff turnover and considerable staff training costs. Some stakeholders also indicated that this affects community-based services through reimbursement rates that result in low salaries and no benefits.


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2. Quality of Care

According to some providers the current funding structure is not set-up to support a continuum of services. In recent years, some providers indicated that multiple cuts in rates have put them at a disadvantage, making them uncompetitive. Furthermore, some providers noted that the multiple rate cuts, without a change in expectations of service quality, aggravated the situation. In particular, some noted their concern that the rates providers receive are not sufficient for serving individuals with complex medical needs.

Like providers, some representatives of local authorities shared concerns that underfunding impedes a continuum of services and creates a fragmented system characterized on the community side by long interest lists. Some indicated that this also reduces quality of care, as providers cannot pay their staff adequately or provide the specialized training necessary.

Some respondents also expressed concern that lack of adequate funding may cause community providers to exhaust their resources and displace individuals with IDD. Consequently, some indicated that people may be bounced from provider to provider, leading to poor quality of care and deterioration in the condition of people who moved from a SSLC where they received specialized care.

The majority of parents and guardians of SSLC residents interviewed were highly complimentary of the quality of care their children or siblings have been receiving. Many indicated they value that their child or sibling enjoys life, is protected, and is independent to the extent he or she can be. They feel that this is their community and that the people in the SSLC, residents and staff, are their extended family. Some family members equate the SSLC to a “gated community.” Some family members stated their child or family member would not be alive if they lived in any other setting.

Some family members consider the SSLC “the least restrictive environment” for their children and siblings. They believe that the consistent quality of care helps their children or relatives adapt so well to their new home and environment on the SSLC campus that they “thrive instead of die.”

Several family members of SSLC residents indicated they appreciated the care and caring their child or sibling received from staff. Even when a facility is short staffed, they indicated that the SSLC staff knows how to best care for the needs of residents. A parent indicated that when her child became very ill, a staff member stayed in the hospital with her child. Another family member indicated that when his brother was in the hospital for a long time the caretakers kept the hospital staff informed of his needs. Families also indicated that staff takes the residents on outings and many community members volunteer at the facility, thus increasing the contact residents have with the community.

A few family members who participated in focus groups were critical of SSLC facilities, living conditions, and care. They indicated the residents look neglected and bored, and staff acts like babysitters instead of engaging the residents in meaningful activities. Some family


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3. Monitoring and Safety

4. Lack of Crisis and Respite Care

members said that the direct service staff does not look professional. Some indicated the housing units, especially the behavior dorm, look unclean (“they smell”), disorderly (“like a tornado went through”), and reek of smoke. Some indicated there is a lack of color, proper sounds, and variety in music.

Several family members stressed the value of the spectrum of services that SSLCs provide including comprehensive care. According to some family members, such a spectrum of services is not available in the community.

Like some family members, some of the representatives of local authorities also lauded SSLCs for providing specialized care including dental care, quality adaptive equipment, and management of the physical needs of individuals with complex medical conditions. Per one representative, SSLCs are “skilled at writing behavioral plans which assist greatly when making adjustments later on.”

A few family members of SSLC residents who had experience with community-based services appreciated the fact that “no one here will ever get a telephone call in the middle of the night to come pick up their family member…. The greatest strength of a state supported living center is when everyone else says ‘no,’ they say ‘yes.’ When someone comes asking for help for their severely disabled person they are not allowed to say ‘no.’”

Some of the family members of SSLC residents valued the “great safety on the campus.” They indicated that this feeling of safety comes from “management intervention, unannounced visits, and a zero tolerance policy for abuse.” Some family members felt that monitoring in SSLCs was well done and indicated that this level of monitoring does not exist in the community.

Some of the advocates raised safety concerns. They recounted incidents of residents abused by staff and advocated an increased use of cameras, although they are invasive and limit privacy and their use has been criticized by some of the SSLC residents who participated in a focus group. They also reported some incidents of resident-on-resident violence. In SSLCs, they said, alleged offenders are sometimes housed with individuals with complex medical needs. In comparison, they thought that community service providers can decide whom to accept and residents can choose their roommate(s).

Some safety issues, according to some of the parents, stem from conflicts between staff and residents. They believe that these conflicts are a result of placing residents with different functionality and abilities in the same housing unit. Some parents considered such placements a manifestation of poor management.

Some advocates pointed to the lack of crisis and respite services in the community. This creates a problem as hospitals may exclude individuals with IDD.


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5. Lack of Coordination among SSLCs, Local IDD Authorities, and Community Providers

6. SSLC Management and Operations

Some representatives of local authorities reported that they provide some crisis and respite care for families and have been developing more crisis services in the last two years and consider these an alternative to the state system. They monitor families who need these services and identify resources for them in the community. They use SSLCs as a referral source for emergency admissions in extreme cases.

Stakeholders held different views on the extent and effectiveness of coordination among the SSLCs, local authorities, and community providers.

Some advocates maintained that there is no coordination with the local mental health authority. Some of the advocates believe that individuals with IDD are excluded from local authority services, even if they have dual (mental health and IDD) conditions. Some of the local authorities consider themselves as the coordinators of care in the community. They provide a safety net to ensure a continuity of service. They believe their role is especially critical in rural counties where they may be the only provider. They assess individuals’ needs for supports and refer them to appropriate resources in the community. They have contracts with medical and behavioral specialists and with private providers and also use telemedicine. They also have a network of providers. They believe that the local authorities that do not provide direct services can be effective in building relationships because they are considered a “neutral” non-competitive entity. They try to work cooperatively with other providers to prevent individuals from having to move into more restrictive settings, such as SSLCs or hospitals, than they need.

Some family members of SSLC residents complained that local authorities provide partial information on what is available in the community, as they believe that they do not include the SSLC as an option, even though legislation was passed last session to require local authorities to make families aware that SSLCs are an option. The family members also believe that the SSLC is not identified as an option in admissions, review and dismissal meetings before a child with IDD completes high school.

While most family members were highly satisfied with the services and care SSLCs provide, some considered the SSLC where their child is located as poorly and inefficiently managed.

The perceived poor quality of management, according to some parents, manifests itself in inequity of resources distribution across housing units and across residents. Some family members believe that residents who have a parent or guardian who advocates for them on the campus seem to receive better services than those who don’t have an advocate. Moreover, these families noted that, in their opinion, people in administrative and supervisory positions are not well-trained and play favorites at the resident level. Some family members believe that poor management has created an inefficient use of resources.


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7. Employment for Individuals with IDD

8. Housing

9. Aging Populations

10. Lack of Technology

11. Compliance Costs

12. Public Awareness of SSLCs

Some advocates and family members of SSLC residents took opposite positions on this issue.

Advocates indicated they believe the SSLCs do not foster employment for individuals with IDD because, in one advocate’s opinion, “employment means independence and gives people with IDD more control over their lives.” Some advocates believe that SSLCs offer workshops, but no real employment, and do not give residents choice in the type of work they like to do. In comparison, according to some advocates, many who receive services through state waivers do get real jobs – a statement that some family members contend is exaggerated. Some parents of SSLC residents complimented the SSLC workshops.

Advocates were the only stakeholder group that addressed the lack of affordable housing in the community as a barrier that “may bring people back to the SSLC.”

Some representatives of local authorities and some family members of SSLC residents agreed that there does not appear to be sufficient services in the community for elderly individuals with IDD both with regard to geriatric specialists and facilities, which has resulted in long interest lists for waiver services.

Some family members believe the state is not prepared for the rapid growth of aging individuals with IDD, especially those with complex medical needs. They feel there is a need for expanded services both in SSLCs and in the community.

Some family members of SSLC residents expressed concerns about a perceived lack of technology as having an impact on staff productivity and management efficiency. They believe that more technology is needed, especially in the area of electronic medical records and a database of medical information.

The SSLCs, according to some family members, bear a huge burden in their effort to comply with the DOJ settlement. These family members have the perception that compliance is resource-intensive and requires a large volume of data and documentation. They believe compliance activities divert professional staff from providing care and estimated that professional staff spends 60 percent of their time on paperwork in compliance with DOJ and 40 percent on care. They are concerned that this appears to have negatively affected staff morale and quality of care.

Some of the family members of SSLC residents expressed concern about the perceived lack of public awareness of SSLCs and the inaccurate way in which SSLCs have been portrayed.


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1. Staffing

2. Training

SSLCs, according to these family members, do not advertise their services; families find out about SSLCs mostly through word-of-mouth and parent-to-parent. (Some of the family members were not aware of the brochure, newsletter, or website that SSLCs have.) They also attributed the lack of public awareness to what they believe to be the bias that special education programs have against institutions and their preference for group homes.

However, some family members complimented community members who serve as SSLC volunteers for “spreading the word and talking about all the good things going on at the SSLCs.” In fact, the Volunteer Services Council at that respective SSLC displays and sells resident ceramic work at a local upscale boutique, although the work is not always identified as being created by a SSLC resident.

HUMAN RESOURCES Two human resource themes emerged in the focus group discussions concerning staffing in SSLCs and community settings and the training of these staff.

Some of the participants noted concerns that the SSLCs have high turnover rates at all staffing levels. They believe that the high turnover of both direct care and professional staff is due to low or uncompetitive pay and the demands of working with individuals with IDD. They noted that the direct care people that SSLCs employ do not appear to be highly qualified; they believe they may have been attracted by the state benefits these jobs offer. Several representatives of local authorities, family members, and advocates identified the high turnover rate as a concern.

Some of the representatives of local authorities noted that finding both professional and direct care staff is also a challenge for providers of community-based services, although they don’t believe their turnover rates are as high as the turnover rates in SSLCs.

Some of the local authorities believe that community service providers are subject to high nursing turnover because of low pay and burdensome requirements to document every minute of their time. Some providers believe the system is heavily weighted toward RNs over LVNs, making the system “unbalanced” and more costly than what it should be. Some providers of community-based services contend that they are at a disadvantage as they cannot match the pay rates and benefits that SSLCs can offer.

Family members of SSLC residents were divided in their assessment of the adequacy and quality of training that direct service staff receives. While some family members considered the training the SSLC offers sufficient, other family members believe that direct service staff need more education and more on-the-job training. They feel more extensive training is needed to adequately prepare direct service staff for the responsibilities of the job.


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COMMUNITY-BASED SERVICES Five themes emerged with regard to community-based services. The themes address transitioning into community services, the services individuals with IDD and those with complex medical needs can receive in community settings, and current community service gaps.

1. Transition from SSLC to Community-based Services Some participants believe that the transition process from the SSLC to the community seems to be very confusing to individuals with IDD who were institutionalized. It may also be frightening. They recommended using an advocate (relocation specialist) who can guide the individual through both the transition process and the location of appropriate community services. One self-advocate stated that the process is very slow; it took her 18 months because she had difficulty in finding a wheelchair accessible group home.

According to some advocates, SSLC staff do not always appear to support residents who want to move to the community. They believe that SSLC staff may be recommending families to keep their loved one in the SSLC. They feel there may be an inherent conflict of interest when the transition process is handled by SSLC staff. According to some private providers, the SSLCs seem to resist transitioning residents into the community, as it does not serve their interests. They believe, “There needs to be independence in assistance with living arrangement choices for residents.”

The state has a mechanism so that money from an institution (SSLC) follows a person in to the community; however, some advocates, maintain that does not happen in every setting, which impedes the transition.

The transition process may also be impeded, some representatives of local authorities believe by the high turnover rates at all staffing levels in SSLCs. They are concerned these high turnover rates may cause a “significant lag” in transitioning individuals with IDD into the community.

The decision to transition their child or relative into the community is difficult for some family members because it is believed they see the SSLCs as a permanent placement. Some of the local authorities believe that perceived poor living conditions in a SSLC may motivate families to move their child or relative into community-based settings.

Some representatives of local authorities believe community providers typically receive current medical information, but no medical history, on individuals transitioning from the SSLCs. They contend this leads to repeat testing and increases the cost of transition.

Some family members believe the SSLCs do not always conduct a comprehensive assessment of community supports to ensure they are adequate to meet the needs of residents and ensure a successful transition into the community. These family members believe such an assessment is crucial because they maintain it takes a person with IDD a long time to make an adjustment when transitioning from a SSLC to a community-based


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2. Community Services and Supports

3. Providers

4. Individuals with Medically Complex Needs

setting.

Some members of advocacy groups such as the ARC of Texas, Community NOW, and Disability Rights of Texas see many advantages and benefits for individuals with IDD to live in the community. They believe Individuals with IDD have greater flexibility and independence in receiving community-based services and achieve “better outcomes in the community.” SSLCs, according to the opinion of some advocates, do not foster independence because of low expectations.

According to one advocate, “Community placement increases the involvement of the family and expands the social connections for individuals with IDD.”

Living in the community, according to a representative of a local authority, gives individuals “the choice of how to spend their day” and helps them respond more quickly to change.

Some advocates believe proximity to family is a major benefit to having individuals with IDD in a community setting.

Some family members of SSLC residents were concerned about the perceived lack of oversight of community-based services, stating they had previously had bad experiences with community-based services. One parent said that when her daughter was in a community home and almost died, no one from the community home came to the hospital to visit her or inquire about her situation.

Advocates raised several issues concerning providers of community-based services. According to these advocates, it is believed that providers are limited in what they can provide due to the state’s reimbursement rates. They contend providers need greater support from the state and believe the state needs to do a better job of screening and training providers.

Some of the advocates feel the current system requires providers to make large investments without any certainty or guarantee that their community home will be approved. It is their belief this limits the number of providers entering the community-based services market.

The current system, according to some providers is over-regulated. In their opinion, “Too many resources are diverted to compliance and to issues that have nothing to do with service.” They believe that especially burdensome are the billing guidelines and nursing paperwork requirements. The paperwork requirements are so extensive that they have to hire multiple staff to enter the data and monitor the paperwork.

The issue of serving individuals with complex medical needs in the community was highly controversial. According to the Sunset Report, individuals with complex medical needs


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5. Community-based Services Gaps

1. Increase Funding and Pay

comprise less than ten percent of the SSLC population: 329 out of 3,400 SSLC residents.

Some advocates maintain that more people with complex medical needs are being served in the community.

Some family members of SSLC residents with more complex medical conditions recounted bad experiences that their children or siblings had in the community. They believe, “Community medical providers did not know how to handle him. You can’t find doctors or hospitals that will care for our individuals.”

Some representatives of local authorities concurred that frequently community providers do not have the skills to keep many individuals with IDD medically stable in the community.

Some providers believe that multiple cuts in the reimbursement rates have made serving individuals with complex medical needs untenable and do not reflect the cost to provide care to these individuals. However, these providers also believed that this population could be well served in the community with appropriate reimbursement or “if we have a sufficient number of individuals [such that economies of scale can be realized].”

According to some representatives of local authorities, there are several groups of people that the current community services system is not able to serve. These include non-citizens who are not eligible for Medicaid and registered sex offenders. Currently, SSLCs are their only option. Elderly individuals with IDD are not well served in the community because they are subject to long interest lists for waiver services.

Another perceived service gap is the availability of specialists. There does not appear to be enough neurologists, psychologists, geriatric, and other specialists willing to serve more individuals with IDD, which according to a one representative of a local authority is probably due to low reimbursement rates. In their opinion, in the absence of specialized care, these people get care from their primary care doctor, which is not always optimal.

PRIORITIES FOR AN IMPROVED DELIVERY SYSTEM This section presents both recommendations for improving the current system and suggestions on the evolution of the system over the next 10 years.

To improve the funding situation, participants in several focus groups suggested that Texas obtain a Medicaid waiver with a housing component similar to the home and community-based services waiver for individuals with IDD.

Some family members of SSLC residents believe the current funding levels are detrimental to retaining direct care staff. They would like to see an adjustment in funding and pay levels, including a cost of living raise.


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2. Increasing Availability of Services in the Community

3. Better Use of State Resources/Increase System Efficiencies

4. Specialized Services for Individuals with Medically Complex Needs

According to some of the local authorities, it is unclear what funding sources should be braided together at the local level. They believe instead of being two separate entities, with a lot of overlap, IDD and behavioral health need to be under the same director. They maintain the different reporting authorities and funding streams make integration of services at the local level difficult.

Some of the advocates believe the system will see an expansion of community services and a decline in SSLC admissions over the next 10 years. It is their belief that the system will have greater incentives to place individuals with IDD in the community and greater disincentives for placing individuals with IDD in a SSLC. They also believe transition from SSLCs into community settings will be faster.

Some local authorities suggested helping providers prepare for community placements (transitioning from SSLC) by providing them with transition funding. They contend, “There would be more progress if the provider were able to get the home modified ahead of time to make the transition a lot smoother.” They think preparing community-based homes ahead of the transition increases the success of the transition and makes the adjustment process smoother.

Some of the local authorities envision a community-based residential infrastructure that will completely eliminate the need for SSLCs. They noted it has been done successfully in other states and believe it could also be implemented in Texas. They think to accomplish this, “we have to get our communities skilled, educated, and ready. Providers would have to increase their skill level, expertise, and training, and bring on more medical staff or contract it out. We need to get short-term and clinical services set up. We need more intense funding.”

Some providers would like to see the level of regulation lowered and the system streamlined, thereby eliminating burdensome reporting requirements and increasing the system’s efficiencies. They believe, in order to achieve such efficiencies, providers should have flexibility in spending the funds.

Interest lists should decrease and eventually be eliminated, according to some providers.

Some of the providers would also like the system to be outcomes-based and accountable to the residents.

According to some advocates, they believe the community needs to develop its medical resources to serve people with IDD, especially those with complex medical needs. Furthermore, they think the reimbursement structure needs to be adjusted to reflect the cost of providing such services.


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5. Development of Short-term Crisis Placements

6. Role of the SSLC

7. State Policies

According to some representatives of local authorities, in order to serve a wide range of IDD populations, the system must have the capacity as well as become more efficient with co-locating people with those needs.

Some of the advocates see the current system evolving into a more transitory system with more crisis beds in the community and intermediate or step-down facilities to help people successfully transition from an institutional setting to a smaller, community setting.

In the next 10 years, local authorities believe they will have their own crisis system, so that people will not need to go to a SSLC. Their service coordinators will have smaller caseloads so they can manage more effectively. It is believed the availability of short-term specialty care will help phase out institutionalization.

The role of SSLCs will change in the next 10 years. Stakeholders’ vision of the future role of the SSLCs ranged from non-existent to expanding. Some representatives of local authorities envisioned the closure of all SSLCs and serving all individuals with IDD, regardless of their level of need for specialized care, in the community. Some providers envisioned the SSLCs becoming niche providers. Some family members’ vision ranged from maintaining the status quo to expanding the role of the SSLCs.

Some of the providers and family members envisioned the role of the SSLC as a central resource both for SSLC residents and for the community because of the expertise SSLC staff have.

Most family members of SSLC residents did not want to see a change in the role and functioning of SSLCs. They believe some populations cannot be served well in the community either because community-based providers do not have the skills and/or expertise to serve these individuals or because their care is too costly relative to current reimbursement rates.

According to some advocates, in the next 10 years, any institutional placement will be short-term whether it is a SSLC or a crisis placement.

According to some advocates, state policies should reflect a true continuum of services. They maintain, the policies should shift toward greater community supports. In their opinion, the main goal should be to place everyone in the community and provide supports to allow them to live as independently as possible. They also think the money should follow the person from all institutional settings into the community.

To achieve this shift in state policies, they feel providers, advocates, and residents should take part in the state-level planning process.


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ONLINE SURVEY Survey respondents were associated with a wide range of organizations. Nearly one-half of the respondents were associated with DADS and more than one-quarter were either family members or guardians of individuals with IDD. Members of local authorities for IDD services constituted seven percent of the respondents and private providers accounted for five percent of respondents.

Table E.1. Respondents by Organization

Organization Number (N=624) Percentage

DADS 299 47.9% Family members/Guardians 171 27.4% Local Authority for IDD Services (Community Center) 44 7.1% ARC of Texas 3 0.5% Community NOW 2 0.3% Disability Rights, Inc. 2 0.3% IDD resident 8 1.3% Parents Association for Retired Texans 3 0.5% Private Provider Association of Texas 14 2.2% Provider Association for Community Services of Texas 13 2.1% Texans for SSLCs 5 0.8% Employee (ex-employee) of SSLC 13 2.1% Private provider of IDD services 5 0.8%

Other organization/non-profit 16 2.6% DFPS 4 0.6% Volunteer 3 0.5% Advocate, concerned community member 7 1.1% Other 12 1.9%

Data Source: CannonDesign, 2014.

Survey respondents were located in urban (37.2 percent), suburban (31.9 percent), and rural (28.7 percent) areas.

Survey Findings The current system providing services to individuals with IDD has significant limitations overall as well as with regard to its SSLC and community-based components, according to 60 percent or more of survey respondents. Overall, it is believed the current system does not have enough funding, job opportunities for people with IDD, or enough services to meet the needs of individuals with IDD. Concerns were also expressed that the SSLC population is declining, and SSLCs have difficulties retaining staff. Other concerns noted were; community-based services staff have limited training and skills to care for people with IDD, especially for those with complex medical and behavioral conditions. Also, it is believed by some of the respondents that the community-based system is not


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sufficiently monitored to assure quality care.

Survey respondents’ assessment of the current system was slightly associated with their rural, suburban, or urban location. Respondents located in rural areas had a slightly more positive view of the system’s funding than respondents in urban or suburban areas. Rural respondents were more certain that the biggest challenge for SSLCs is keeping staff and a larger percentage of rural and suburban respondents ‘agreed’ or ‘strongly agreed’ that SSLCs are located where their services are most needed.

The assessment of the current system was associated with survey respondents’ affiliations. Private providers had considerably more positive views of the community-based services system and its ability to serve individuals with IDD regardless of the complexity of their needs. Views of members of local authorities were closer to those of private providers than to those of family members/guardians and DADS or SSLC employees. Family members/guardians were most critical of community-based services followed by DADS and SSLC employees.

Based on their assessment of the current system, survey respondents, regardless of location, considered top system needs to include:

• Better training and pay for SSLC staff so SSLCs can keep staff and improve services. • More long term residential choices for individuals with IDD who are aging. • Increased training and job opportunities for individuals with IDD.

The identification of greatest system needs varied somewhat among survey respondents based on their affiliation.

• A larger percentage of family members/guardians identified more beds/facilities and updated SSLC facilities as the greatest needs.

• A larger percentage of DADS and SSLC employees identified better training, pay for SSLC staff, and more or better technology on SSLC campuses as the greatest needs.

• A larger percentage of members of local authorities considered more funding for community services for people with IDD, more community-based and in-home support services, more long-term residential choices for aging individuals with IDD, and increased training and job opportunities for individuals with IDD as the greatest system needs.

A larger percentage of private providers considered higher reimbursement rates, better coordination and interactions between community-based providers and SSLCs, and assurances that placements will be available for individuals with IDD if they lose their place as the greatest system needs.


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Source: Ten-Year Plan for the Provision of Services to Individuals Served by State Supported Living Centers, CannonDesign, September 2014, pg. 89.

APPENDIX F: PROTOTYPICAL PLAN DIAGRAMS

PROTOTYPICAL PLAN DIAGRAM OF RENOVATED/DOWNSIZED HOME AND COST The following plan diagram uses an existing 20 bed residence at Lufkin SSLC as an example renovation and reprogramming possibility. The plan reduces the number of residents from 20 to six, providing a combination of private and double resident rooms all with ensuite bathrooms. Vacated space on the unit is re-purposed for staff and social activity space. On-unit dining and an ADL kitchen are added to the home in vacated space. Additional windows are added to increase natural daylight throughout the household and interior finishes would be upgraded to improve acoustics throughout the home. Layouts for existing housing and number of residents served vary across a SSLC and between SSLCs across the state. Plans to renovate and downsize SSLC houses will need to be explored on a campus-by-campus, house-by-house basis.

Figure F.1. Concept Floor Plan: Moderate Renovation to Lufkin SSLC Residential Unit

COST MODEL Escalating to January 2017 dollars and assuming single story, cold-formed metal frame construction and a combination of residential exterior veneer materials–brick veneer, cement fiberboard, faux stone veneer and 60 percent glazing, the cost model for planning should assume $285 to $315 per SF for a residential care facility with behavioral healthcare upgrades, such as tempered and laminated glazing, and tamper and vandal resistant fixtures, hardware, etc. Homes for residents who are medically fragile that include medical gases and ceiling lifts, the cost model for planning should assume $270 to $300 per SF. For major interior renovation that would include


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Source: Ten-Year Plan for the Provision of Services to Individuals Served by State Supported Living Centers, CannonDesign, September 2014, pg. 88.

gutting existing homes and buildings, new interior walls, lighting, and new finishes, the cost model for planning should be in the range of $215 to $230 per SF. For moderate interior renovation that would include some demolition and new interior wall partitions, all new finishes and new lighting, the cost model for planning should be in the range of $175 to $185 per SF.

PROTOTYPICAL PLAN DIAGRAM OF SPECIALIZED ICF/IID FACILITY AND COST The following plan diagram provides six bed apartments connected to centralized social and therapy spaces. All housing and activities are physically connected and equally accessible to all residents. Housing units then connect to a centralized administration, medical services and centralized therapy services off-unit, but nearby. Direct sightlines throughout the campus improve safety and security. Reduced travel distances increase staff efficiency and resident access. Staff work areas are integrated on the apartments and within the central shared therapy and support spaces. The model can be expandable from 72 residents to 120 residents by adjusting from six bed apartments to ten bed apartments. Planning on eight to 12 residents per acre, the new facilities would require between ten to 15 acres.

Figure F.2. Concept Floor Plan: Specialized ICF/IID Facility


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APPENDIX G: FACILITY CONDITION ASSESSMENT METHODOLOGIES

While the assessments conducted by CannonDesign have been as closely aligned as possible with HHSC CAFM data, substantial differences exist in the assessment methods that allow for deviation in the results of the FCI ranking system. The primary reasons for the differences between the CAFM and CannonDesign FCIs are:

• The ten-year time frame – 2004 and 2014 – between assessments, and the changes that have occurred during that time (i.e., some equipment and systems growing older and others being replaced).

• The 2004 CAFM data, maintained by HHSC, is based on the systems renewal method, and the 2014 CannonDesign data is based on the strategic replacement method.

• Different useful life assessments of existing building and site systems.

CONDITION ASSESSMENT METHODOLOGIES Systems renewal is a more liberal approach to facility assessment wherein any deficient component triggers the replacement of an entire system. Systems renewal is also triggered when components or systems reach the end of their expected service life as per industry standards. Additionally, the system renewal approach typically calls for in-kind replacement of components and systems. This method produces high costs for deferred maintenance budgeting.

Strategic replacement is a value-driven approach based on repairing or replacing only the at-risk or failed components or systems. The components and systems are evaluated in detail and the observed field conditions determine their remaining useful life. With correct installation and proper maintenance, many components and systems can function beyond industry standard expectations. Additionally, weighted criteria such as the risk and impact of failure of components and systems are factored into the ranking methods within the strategic replacement approach. Also, this approach calls for modernization rather than in-kind replacement such that the most cost-efficient technologies are introduced into the facilities. This is the method that was used for the 2014 assessment, dataset and analysis performed by CannonDesign. This method results in a strategic alignment of the actual replacement cost of components and systems with detailed and specific actionable deferred maintenance plans and budgeting tools.

Documents

State Supported Living Centers Long-term Plan · 2017-08-11 · 5 IV. Stakeholder Feedback – CannonDesign conducted interviews and focus groups with residents, family members, SSLC