Vermont Care Partners Legislative Agenda for 2018 Working Draft 4

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1 1. Appropriations Bill for Fiscal Year 2018 Vermont Care Partners Legislative Agenda for 2018 Working Draft 4 Medicaid Reimbursement Rates Act 82 and Act 85 enabled all designated & specialized services agencies to implement a $14 minimum wage and increase wages for crisis staff with the $8.37 million/2% funding increase in FY 18. The results are already evident. FY17 staff turnover rate decreased from 26.3% to 23.8% with the promise of new funding Turnover rates in FY 18 are showing improvement, including the crisis staff 2,000 staff received pay raises and now earn a minimum of $28,000 per year Vermont Care Partners requests the second stage of the workforce investment initiative - $5.74 million in general funds to conceptually achieve a $15 minimum wage for DA/SSA staff and with flexibility for agencies to target compensation increases to the most critical positions to meet community needs, address local labor market dynamics, and cover health benefit costs. Developmental Services Budget The proposed $4.3 million cut to developmental services will require a 2% reduction in services after years of underfunding and rescissions that totaled $14 million in cuts to services since Since some people served cannot manage without 24/7 support, others will experience service reductions in excess of 2%. Designated and Specialized Service Agencies (DA/SSA s) rates of reimbursement are insufficient to cover costs. There is no direct correlation between payment rates and actual cost of services DA/SSA s are currently deep into a payment reform process with DAIL that will likely lead to a reduction in services, this cut would put Vermont s most vulnerable citizens in double jeopardy People with Intellectual/Developmental disabilities typically require long-term services and supports. DA/SSA s provide a full range of services including residential, community and employment supports, crisis beds, respite, service coordination, etc. $4.3 million overrides the workforce increase agencies received this year through Acts 82 and 85 to bring staff salaries up to $14 per hour, after these salary increases have already been given The workforce investment funds were awarded in recognition of high staff turnover and vacancy rates at DA/SSA s which have been blocking access and impacting quality of care Substance Abuse Services We will support and educate on the continuing demand for opiate and other substance use disorder outpatient treatment and the need for both better reimbursement rates and expanded services.

2 2. Health Reform We will continue to advocate for the role of VCP designated and specialized service agencies to provide integrated care and participate in the All Payer Model (APM), Accountable care organization(s), blueprint and health homes. The Green Mountain Care Board should review VCP designated and specialized service agencies budgets as part of the regulatory mandate. We need to promote our value and role in the system of care, as well as our principles. We are in ongoing dialog with the Administration on developing improved service delivery and payment models. This work should feed into the proposal to incorporate mental health, developmental disability and substance use disorder services into the All Payer Model. Designated and Specialized Service Agencies have much to offer our health care system: The expertise, knowledge and relationships with these populations sits with us and, decisions, policies and outcomes should not be created in our absence The National data shows that over 40% of health care costs are related to co-occurring MH/SA conditions about which we are the experts The social determinants of health are also crucial to the success of health care reform and these are areas that we have been successful in addressing to support our clients Local goals, integration and decisions should be made locally and integrated into the expectations the state has of the ACO s ACES research shows the importance of family based mental health services. We should use this information to promote the importance of our services and the need for funding parity 3. Mental Health Services for Offenders Vermont Care Partners supports improving reimbursement rates and expanding community resources to address mental health and substance use disorders of people who at risk or involved in law enforcement and corrections. We will encourage the legislature to take action to create a high quality continuum of services to address individuals at-risk of involvement in law enforcement, individuals who are incarcerated and preventing recidivism of individuals released from incarceration. Proven model programs, such as treatment courts and the Sparrow program, have recently lost grant funding and are struggling to maintain their potential to reduce incarceration and address mental health and substance use disorders that create both individual hardship and public safety risks to our communities. Additionally, the Courts need adequate funding to participate in specialized programming. We are supportive of the recommendation that will be made by Governor s Opioid Council to establish a Master to oversee court diversion programs. 4. DVHA Unified Mental Health Budget Discussion continues on a unified mental health services implementation plan for the integration of public funding for direct mental health care services within DVHA while maintaining oversight functions and the data necessary to perform those functions at the department of jurisdiction. This analysis and proposal should be carefully analyzed by the legislature. 5. Agency of Human Services Facility Plan From a historical perspective Vermont Care Partners views large facilities as being used as a catch all for people society is struggling with, the marginalized. Investing public resources to build a large facility creates the potential of redirecting resources away from integrated community based models which are already too limited. It has the potential to diminish the system of care stated value to build resources that are community centric. Incarcerated people and people with mental illness both have better

3 prognoses if family relationships can be nurtured and maintained. We have learned from experience about the disempowerment and disenfranchisement associated with separation and segregation. We are hopeful that the Woodside facility will be able to be constructed on the current campus because the unique needs of youth with trauma histories and loose attachments means we should be intentional about providing residential care that builds community participation and involvement while maintaining unconditional positive regard. It is important to note that programming within correctional facilities also needs more attention. From a community provider perspective the DOC facilities have never been fully funded to provide comprehensive recovery oriented treatment for both mental health and substance abuse needs. Programs have been implemented for the higher risk populations, however fully funded and comprehensive recovery oriented treatment approaches for all populations, regardless of risk, haven t been a priority. There are significant programmatic needs for all levels of risk and for all populations. More planning and attention should be taken on this issue. There is agreement that there is a need for specialized facilitates to address specific populations. However, thoughtful consideration needs to occur to ensure the environment in which each of these populations is placed is the most clinically and programmatically appropriate. Creating a campus plan could negate taking the needs of each population as first priority Individuals who no longer require psychiatric hospitalization but who remain in need of long-term treatment in a secure residential facility setting would benefit from additional resources. Elders with significant psychiatric needs, who either do or do not meet the criteria for nursing facilities, do need new specialized residential options based on our experience with crisis bed utilization and the increased need in the CRT population. Children in need of residential treatment do need residential care at Woodside, preferably on the current campus. It has been a crucial element of the overall Children s System of Care and its loss would be very problematic. We are interested in working on a public/private partnership model with the State on a treatment facility. Investment in community-based services could reduce the number of new inpatient beds needed Emergency Department wait times have been driven up by long inpatient stays by people who require: supported housing; present with assaultive behavior; needing nursing home LOC Putting additional resources for these populations would be an important step in addressing these long lengths of stay. We also recommend better equipped reentry and transition beds and programs at the local level for the incarcerated population. (Bob Bick: Maybe, but not enough to mediate the need for the beds and politically I don t know that this is currently a marketable position.) Increasing community investments to reduce incarceration and recidivism More strategic planning needs to take place at the local level where those coming in and out of incarceration are currently living. Transitional housing programs are minimal throughout the state, and even more so in the rural regions of the state. Structured transitional programs with staff to support this population have shown effective in reducing incarceration and recidivism

4 6. Worker Compensation Sole Contractor We will monitor this issue, with the hope that it will not resurface and impact shared living providers. Should it resurface our goal will be to maintain the status of shared living providers as independent contractors, not as employees, for the workers compensation purposes. 7. Property Tax Reform We will monitor to avoid any loss of tax exempt status for our facilities. 8. Government Accountability, RBA, Outcomes With the support of the Outcomes group, we will educate the House Human Services, House Health Care Senate Health and Welfare and Appropriations Committees on the value of our system of care; our work to develop RBA outcomes and Centers of Excellence. The Outcomes report will be used to describe our services from a outcomes and value perspective. 10. Emergency Room Back-up The back-ups and long lengths of stay for adults and children in hospital emergency rooms is an egregious situation. Some children are being sent back home while awaiting inpatient care who would benefit from more immediate intervention. Diversion programs are cost-effective approaches to reducing back-ups in emergency rooms. We will develop talking points that focus on the need to shore up funding for the community mental health system, especially crisis and subacute services, as the key to addressing some of the back-up problems. Additionally, we will continue to participate on workgroups focused on how to reduce wait times which may lead to recommendations for next session. Initial recommendations: 1. Raise reimbursement rates for the designated and specialized services agencies so that salaries are on par with state employees and other health professionals to reduce vacancies and turnover of staff at all levels of care. Outcomes: greater capacity in crisis and stepdown facilities; higher quality and better treatment available in the community to prevent hospitalizations (i.e. case management, outpatient therapy, and community supports); higher capacity for quality crisis interventions in the community to prevent ED visits. 2. Increase capacity for people with geropsychiatric needs. This could be done by developing a tiered rate system that incentivizes nursing homes to accept people with geriatric and psychiatric needs; increased coordination and shared care management between Choices for Care and DAs; and/or additional funding to establish nursing and/or primary care staffing in designated agency long term residential care homes. Outcome: More capacity for people with geropsychiatric needs will open up Level One beds for those waiting in Emergency Departments. 3. Designated hospitals should be required to accept high acuity patients, as well as patients who are in Emergency Departments outside their catchment area. A centralized admissions process would allow for inpatient units to provide input on concerns about accepting a high-acuity client, but will ensure that all available inpatient beds are available to be accessed. Outcome: better dispersal of people in need of hospital-level care to available beds. 4. Designated agencies, designated hospitals, EDs, and DMH care management should develop a set of communication protocols to track those waiting for hospital placement and those waiting to discharge. These protocols will include internal and system-wide operations. This group should give consideration to including those waiting for voluntary, as well as involuntary treatment. Outcome: by increasing awareness of clients stuck in ED or inpatient hospital settings among direct care staff, case management, and leadership, the instinct to protect against risk will be balanced by a culture of accountability and risksharing at all levels of the system, reflecting an attitude of zero tolerance for long waits in Emergency Departments.

5 11. Consent by Minors for Mental Health Treatment Act 35 (H.230) This act allows a minor to consent to receive outpatient treatment from a mental health professional without the consent of the minor s parent or legal guardian. Outpatient treatment in the context of this act refers to psychotherapy and other counseling services that are supportive, but not prescription drugs. We had a legal analysis done on the new statute and do not see a need to take legislative action, because it should not significantly disrupt the current practices and procedures of outpatient treatment providers. 12. Independent School Approval Rules Act 49 (H.513) The miscellaneous education act suspends the State Board of Education s rulemaking process on independent school approval and establishes a study committee to provide recommendations to the legislature, with a report due back on December 1, Vermont Care Partners provided testimony about designated agency schools and advocated for a seat on the study committee. The final language of the bill calls for two seats to be selected by the Council on Independent Schools, of which all our schools are members, rather than two seats selected by VISA, of which only one of our schools is a member. This bill has been signed into law and the study committee has begun meeting. Vermont Care Partners is monitoring the meetings and is working with study group members to influence the recommendations. VCP will monitor any further legislative action that occurs. 14. Special Education Vermont Care Partners members testified about the array of integrated mental health services we provide in schools. Our school-based services can be a solution to some of the problems raised by both rising special education costs and increasingly dysregulated student behavior in some of the following ways: For both our school-based services and our independent schools, our funding model leverages Medicaid Match so that schools pay only a portion of the cost of behavioral supports that the highestintensity students require; The innovative MTSS [Multi-tiered Services and Supports and PBIS [Positive Behavior Intervention and Supports] contracts that we provide in several schools fit well with a census-based approach because they are designed to support the emotional-behavioral needs of the whole student body preventatively; Our 14 therapeutic independent schools should be seen as a necessary part of the continuum of special education services. These are not general education independent schools but schools specifically designed to serve students with emotional, behavioral, and developmental disabilities. We will request that as the House Education Committee shapes the workgroup tasked with developing an implementation plan for a census funding model that a representative from Vermont Care Partners be included in the membership of the workgroup. As the group seeks to incentivize the use of early, preventative behavioral supports and how to establish a cost effective process for extraordinary cost reimbursement, we can contribute our expertise in building integrated contracts that leverage Medicaid dollars through the mental health system to do both. 15. Involuntary Psychiatric Treatment The proposal to speed up the time frame for initiating involuntary treatment is likely to be brought to the Legislature as a tool to reduce emergency room and inpatient flow issues. Vermont Care Partners has not taken a position on the issue in the past and members have not accepted the responsibility to directly administer involuntary medication.

6 16. Involuntary Sterilization A bill will be introduced to repeal an archaic section of statute, Title 18 Chap 204: Sterilization which allows for the involuntary sterilization of a person with developmental disabilities. The existing statute, a throwback to the eugenics movement, is not in alignment with VCPs values of self-determination and choice. Although there might be some Vermonters who would object to the repeal of this law, Vermont Care Partners supports this bill and see this legislative action as a good opportunity to educate health providers about the rights of individuals with developmental and intellectual disabilities to exercise selfdetermination. 17. Universal Primary Care Vermont Care Partners supports S An act relating to a universal, publicly financed primary care system which is under consideration by the Senate Health and Welfare Committee. This bill will call for a study of financing options. Mental health services are defined as primary care in Vermont Statutes. 18. Study of Orders of Non-Hospitalization Vermont Care Partners is supportive of S.203 a bill to study improvements in the use of Orders of Non- Hospitalization (ONH) to minimize the use of coercion. Vermont Care Partners will be represented on the study committee. 19. ACES/trauma Vermont Care Partners has testified at Senate Health and Welfare on the role of DA/SSAs in addressing toxic shock and trauma in children and families. We are particularly supportive of developing a trauma coordinator positon at the Agency of Human Services. 20. Limiting Employee Compensation Vermont Care Partners has testified to Senate Government Operations Committee in opposition to limiting compensation levels to the level of the Governor s. We emphasized the importance of pay equity for direct service workers with state government employees as the more critical issue in meeting the needs of vulnerable Vermonters.