Tennessee Disability Coalition News Blog

The Knoxville City Council will meet Tuesday, December 19th at 7pm in the City County Building on Main Street. On the agenda will be a discussion about a resolution seeking to improve accessibility of housing in Knox County. It’s hoped that concepts of Visitability might eventually find their way into the Knoxville housing code.

Visitability represents a smart, cost-effective means of improving accessibility in homes. In fact, it costs less than $500 on average to make a new home Visitable. Knoxville resident Laura Johnson will be speaking before the Council tonight and she is in the process of building an accessible home (see photos at the right).

This is not necessarily 100% accessible housing. A Visitable house is one with a no step entrance, wide doors (32 inches) for maneuvering through the home, and an accessible half-bathroom with reinforced walls although a full bath is preferred. As the number of Visitable homes increase it will make it easier for people to visit their neighbors, attend a friend’s holiday party, go to a political meeting in someone’s house, and just be part of the community.

Please come if you can because if we have success in Knoxville then it improves the chances of accessibility spreading to other communities.

For more about Visitability visit www.concretechange.org

Council Agenda - Only available in PDF

For a list of council members

To see an Accessible Gingerbread House

Four days of budget testimony from more than a dozen departments can make anyone’s head spin. If you missed the hearings they are still available here online. Most hearings last 30 minutes to an hour. Below are highlights from two of those hearings.

Division of Mental Retardation Services (DMRS)

Questions were raised about several lawsuits.

Arlington Lawsuit (West TN) - There are presently 148 people at Arlington at a cost of $850 per person per day. This comes to more than $310,000 a year for a single resident. Officials plan to close the facility within three years, in part because it would cost more than $10 million for necessary renovations. The next settlement hearing will be held in January 2007.

Clover Bottom Lawsuit (Nashville) - Green Valley has been removed from the suit and officials are turning their focus to the Harold Jordan this spring. The facility presently houses about 143 people at a cost of $900 per day. In regard to Green Valley there are about 290 residents and half of them are medically fragile.

Waiting List Lawsuit - There was a settlement agreement two years ago and since 2005 an additional 2,000 people have received services, but at least 4,800 remain on the waiting list and half of those are children. The Division indicated its intent to focus on children who are on the list and suggested that it would take only $9 1/2 million to clear the waiting list. Conceivably this money could come from procedural reforms in processing payments to providers, such reforms could save $10 million. The division suggested it might take 1 1/2 years to implement the reforms and the Governor questioned why it couldn’t take place sooner, perhaps by using Managed Care Organizations to process payments.

Commissioner Norris suggested that another goal for the coming year would be restructuring case management to make it an administrative function that would save money. Case management is presently provided through at least 23 local agencies and providers. He also suggested there was a need to restructure existing waivers for children.

There were positive signs that the Governor wanted to see stronger action taken to resolve issues faced by DMRS and that he did not care to see any undue delays. He appeared interested in clearing the waiting lists once and for all as well as speeding up the closings of developmental centers and perhaps state ICF/MRs which are costing a fortune.

However, there were concerns to come out of the hearing as well. There were suggestions that one need only raise or eliminate the cap on private ICF/MR beds in order to speed the closing of the developmental centers; however, this only transfers individuals with MR from one institution to another institution. Furthermore, Commissioner Norris suggested that most residents did not need the level of care provided in an ICF/MR.

Lifting the cap does not promote a greater utilization of home and community based services that improve independence for residents and provide greater cost savings to the state. A lifting of the cap might be a quick fix, but it doesn’t resolve the underlying need to move away from a reliance upon institutional models.

TennCare Bureau

Reported that:

• $120 million in savings from 2006 will be moved to the TennCare Reserve Fund.
  Middle Tennessee MCO’s have been competitively bid and are at full risk while there is movement to integrate physical and mental health care.
• Previous recipients of care from the Senior Services Waiver are suing to stay with Senior Services rather than move to the new expanded statewide wavier.
  There will be a hearing in March in the John B case.
• Many administrators are spending upwards of 60% of their time with matters related to lawsuits. The Governor suggested it might be time to beef up staffing so that administrators could focus more on their primary functions.
• New investment growth will outpace inflationary growth in TennCare for the first time in eight years.
• Only 25% of TennCare teens received all recommended immunizations in 2005.
• Requests an enhanced rate for providers of care to patients on ventilators.

Anticipated Expansion of Programming

1. Expanded PACE Program ($13 million) - PACE is a capitated managed care benefit for nursing-home eligible people over 55 that transports them to comprehensive medical and social services. Presently the program only operates in Hamilton County, but Knox, Davidson and Shelby counties are targeted for expansion of the program. For more on the Hamilton County program visit Alexian Brothers.
2. Electronic Visit Verification (Nearly $1million) - Technology that would enable TennCare to track provider visits to HCBS enrollee’s homes. A provider would make a call to TennCare upon arrival at a home, perform services and then make make a second call to TennCare prior to leaving.
3. Pre-Pregnancy Coverage (Nearly $3 million) - Provide Primary care and OB/GYN care to adult females between 101% and 185% of the Federal Poverty Line.
4. Smoking Cessation Products (Nearly $2 million) - Add coverages of products such as nicotine replacement gums, patches and lozenges to the pharmacy benefit.
5. Weight Watchers Expansion ($275,000) - Expand target population from obese to overweight enrollees.

Proposed 2008 TennCare Budget - By the Numbers

• Medical and Behavioral Health Services - 41%
• Pharmacy - 18%
• Long-Term Care - 13% (presumably nursing home care)
• Mental Retardation Services - 11%
• Medical Cost Sharing - 6%
• Miscellaneous - 5%
• Administrative - 3%
• Dental - 2%
• Long Term Care Alternatives (HCBS & PACE) - 1%

This means that about $939 million will go into traditional long-term care, presumably nursing homes and institutions, while only $55 million goes into Home and Community Based Alternatives.

TennCare 2008 Budget Presentation in PDF format - Note: it is not available in text or html format for users of screen readers.

Last spring the legislature passed a bill that will eventually add 160 private ICF/MR beds. This law does so without ensuring that individuals in developmental centers or ICF/MRs (Intermediate Care Facilities/Mental Retardation) will also have a greater opportunity to choose home and community-based services (HCBS). However, the bill did grant the state greater oversight of private ICF/MRs.

In addition, the law established a task force to “review oversight, utilization, and future need for ICF/MR services and make recommendations to the general assembly and governor by June 30, 2007.” It set the composition of this task force to include, “Three (3) of the members of the task force shall be appointed by DMRS from a list of persons provided by Tennessee Community Organizations and three (3) of the members shall be appointed by DMRS from a list of persons provided by ARC of Tennessee. The remaining three (3) members shall be employees of DMRS or other state agencies.”

You may have noticed that the law makes no provision for including persons with mental retardation on the task force and for those unaware, Tennessee Community Organizations represents private ICF/MR providers.

To date this task force has met at least three times with the last meeting taking place on November 29th. So far these meetings have focused on educating task force members on issues such as state and federal regulation, licensing and Certificates of Need, as well as protection from harm issues. The committee has not yet taken an in depth look into utilization of ICF/MRs or future need, if any, for additional ICF/MRs.

However, a couple of troubling suggestions have already been made although none led to additional discussion as they were “off the cuff” comments. These suggestions were:

1. Amend the above law so that the 160 new beds could be also be filled by people who are not being transferred from the developmental centers. This would lead, inevitably, to an increase in the number of institutionalized individuals rather than a “no net gain.”
2. Amend state law or regulation so that ICF/MRs can bypass the Certificate of Need (CON) requirements for medical facilities which these are. This suggest was prompted by the fact that assisted living facilities do not need a CON. However there is a great difference between the two modes. Assisted living facilities draw no state or federal dollars whereas ICFs rely almost exclusively upon public dollars for their operation. In fact, public money is regularly used to buy real estate for ICFs that are privately owned.

It’s far too soon to predict whether such suggestions could make it into the task force’s report to the legislature, but one would hope that such a recommendation would be rejected by the legislature until greater HCBS were available to residents of the developmental centers and ICF/MRS.

So far as the report to the legislature, drafting may still be several months away but it is expected to focus on three areas as contained in the law. They are 1) oversight, 2) utilization, and 3) future need. Fortunately, some have already suggested that a comprehensive review of future need must also include review of HCBS for people with MR because this would naturally impact the need, if any, for additional institutional beds.

In light of the Legislature’s stated desire in a 2005 resolution to move Tennessee away from its reliance on institutionalization one hopes that any report would include recommendations about how to reduce our state’s reliance on institutions such as developmental centers and ICFs for individuals with mental retardation. Such a recommendation would be in line with thinking at the Centers for Medicare and Medicaid Services which is also shifting its emphasis to home and community based services.

The new law on ICF/MR Expansion in PDF format — Note: the state routinely posts documents only in PDF formats which may not be accessible to people who use screen readers.

2005 TN Legislative Resolution on HCBS in PDF format

Centers for Medicare and Medicaid Services on ICF/MRs

CMS website reads in part, “The ICF/MR benefit is an optional Medicaid benefit. The Social Security Act created this benefit to fund “institutions” (4 or more beds) for people with mental retardation, and specifies that these institutions must provide “active treatment,” as defined by the Secretary …Since the implementation of the current regulations in 1988, there has been a major shift in thinking in the field of developmental disabilities. Emphasis is now on people living in their own homes, controlling their own lives and being an integral part of their home community.”

If you are interested in following the development of the ICF/MR Task Force then feel free to attend public meetings scheduled for the months ahead. Meetings are held at the Johnson House at the Clover Bottom Developmental Center in Nashville. The next meeting is set for Tuesday, December 12th from 10:30am to 3:30pm.

Other meetings have been tentatively scheduled for January 4th, January 23rd, February 21st, March 13th and March 27th.