HEALTH AND HUMAN SERVICES COMMITTEE MAY 22, 2003 - 9:00 A.M. SCOTT HEYMAN CONFERENCE ROOM
Present: M. Robertson,
Chair; N. Schuler; M. Koplinka-Loehr; P. Penniman (arrived at 9:08 a.m.)
Excused: F. Proto
Staff: J. Thomas, County Administration; T.
Herden, Social Services; M. Dolan, Social Services Commissioner; S. Whicher,
County Administrator; N. Zahler, Youth Services Director; R.
Ewald, Health Department; A. Cole, Public Health Director; B. Crosby, Health
Department; M. Roth, Cooperative Extension
Called to Order
The meeting was called to order at 9:05 a.m.
Changes to Agenda
Ms. Robertson said she would like to extend the time scheduled
for the Health Department if needed. A transfer from the Youth Services
Department was presented to the Committee for information only.
Approval of Minutes
It was MOVED by Mr. Koplinka-Loehr, seconded by Mrs. Schuler,
and unanimously adopted by voice vote by members present, to approve the
minutes of the May 7, 2003 meeting as corrected. MINUTES APPROVED.
Mr. Penniman arrived at this time.
Rollover Discussion
A follow-up report answering questions raised at the last
Committee meeting was distributed and reviewed.
Department of Social Services
First Quarter Budget Projections
Mr. Herden provided copies of updated first quarter projections
and a provisional analysis of the approved State Budget. Based on the
Department's spending in the first quarter and the State Budget, he believes
an additional $800,000 will be needed in local funds than is in the County’s
2003 budget. This number is comprised of two parts:
(1) Based on the experience in the first quarter of 2003,
projections for the local share of Department spending for the year will
be approximately $188,000 less than budgeted; ; and
(2) The approved State budget will cost approximately
$988,000 more in local share than budgeted for the year.
Mr. Herden reviewed the program expenditures comparing
the first quarter of 2002 to the first quarter of 2003. This comparison
provided the breakdown of how he arrived at the net figure of $188,000 described
above.
The chart for Gross Medicaid Benefits Paid for 2001-2003
was reviewed, showing that the greatest increases are in home health care,
nursing home care, pharmacy costs and health maintenance (Medicaid Managed
Care). Ms. Robertson asked if the caseloads data, which show the last
five years, could be graphed to make it easier to understand the trends.
Mr. Herden said he can provide the data graphically.
At this time, Mr. Herden reviewed the Provisional Analysis
of 2003-2004 State Budget. The impact on the net local costs is as
follows:
Impact on
Impact on
Net Local
Net Local
NYS Dept/Office
Description of Budget Provision
Cost 2003
Cost 2004
Department of Health
MMIS Overburden reimbursement at less-
than-budgeted levels
816,328 816,328
Cessation of Medicaid
Managed Care
Administration grants (Mr. Herden is unclear
if this was funded in the State Budget)
16,978
22,637
Department of Family Assistance
Office of Children and Family Services
20 percent shift
of Committee on Special
Education-placement costs to school districts
(7,622) (7,622)
Office of Temporary and Disability Assistance
State retention of
prior-years' Excess Withholding
of TANF Reimbursement to meet MOE
79,918 79,918
20 percent reduction in State reimbursement
for
Administration of Temporary Assistance,
Food
Stamps, and Medicaid (2003 $15M; $60M
for
full-year)*
32,904 131,616
Continuation of cap on State funds available
for funding Admin Cap Exempt plans
50,000 50,000
Full appropriation of FFY Block Grant--and
part of
FFY 03/04's grant--puts local districts
at risk of
greater share of Temporary Assistance
costs which
exceed NYS' projections**
Dollar amount unknown
Notes: The above does not reflect the proposed forgiveness of unrecouped
state "OMHR seeding" advances, a one-shot proposal worth $1.2M for our County.
Several of the negative changes in the propsed state budget will only be
in effect for part of this calendar year (3 Qtrs in some cases, 1 Qtr in
others), and the impacts of some of the worst (proposed cap on Overburden
reimbursement; proposed reduced reimbursement for "extended" detention stays;
proposed reduction on the cap in state reimbursement for TA, MA, & FS
reimbursement) loom larger in subsequent years.
*Mr. Herden explained that since 1993 the state has capped its reimbursement
for administrative costs for these programs. All increases in expenses have
been paid 100% locally since that time. This state budget reduces that reimbursement
by 20%.
**Mr. Herden is very concerned with this as the State projected a 2 percent
increase in caseloads, while Tompkins County is experiencing a 9.7 percent
increase in caseloads over March 2002.
Briefly, Mr. Herden reported on the year-end caseloads for programs subject
to New York State cap on Administrative Reimbursement. Although temporary
assistance has decreased over the last ten years, Medicaid has increased
dramatically. As of April 2003, the net caseloads for Medicaid, food
stamps, and temporary assistance are at an all-time high.
Mr. Penniman commented that there is a subcommittee of
the Tompkins County Area Development Board of Directors discussing livable
wage and the working poor, and they have decided to focus on enrolling children
in Child Health Plus. Ms. Robertson noted that when working parents
can’t earn enough to pay for health insurance, or when their employers don’t
provide it as a job benefit, taxpayers are subsidizing those employers by
paying for Child Health Plus. It is her understanding that most Wal-Mart
employees are in this situation.
Resolutions
Following a brief explanation by Mr. Herden, it was MOVED
by Mr. Koplinka-Loehr, seconded by Mrs. Schuler, and unanimously adopted
by voice vote by members present, to submit the following resolution to the
Legislature for approval:
RESOLUTION NO. - AUTHORIZATION TO CONTRACT
WITH ALCOHOL AND DRUG COUNCIL OF TOMPKINS COUNTY AND CAYUGA ADDICTION RECOVERY
SERVICES FOR DEDICATED TREATMENT SUPPORT RELATED TO THE FAMILY TREATMENT
COURT AND BUDGET ADJUSTMENT - DEPARTMENT OF SOCIAL SERVICES
WHEREAS, the Department of Social Services, Probation
Department, Mental Health Department, Family Court, Alcohol and Drug Council,
and Cayuga Addiction Recovery Services have cooperated in the creation and
implementation of the Family Treatment Court beginning in April 2001, and
WHEREAS, beginning in July 2001, and ending May 1, 2003,
the Family Treatment Court has been partially funded with grants from the
Office of Children and Family Services totaling $336,951.00, and
WHEREAS, the partner agencies have been encouraged to
apply for "follow-on" funding from the Office of Children and Family Services
due to the success of the County's Family Treatment Court, and
WHEREAS, the current fiscal situation being experienced
by the State of New York has diminished the likelihood of this "follow-on"
funding, and
WHEREAS, the partner agencies are in agreement regarding
the importance of continuing the treatment component of Family Treatment
Court as the best current alternative for willing families whose children
face foster care placement due to parental substance abuse, and
WHEREAS, the Department of Social Services and partner
agencies are also actively pursuing additional grant opportunities, and
WHEREAS, contracting with the Alcohol and Drug Council
and Cayuga Addiction Recovery Services directly will allow the department
to financially support these agencies so that the dedicated treatment positions
will be continued, and
WHEREAS, the families being served by the Family Treatment
Court are all eligible for TANF under 200% Services Funds - allowing the
Department of Social Services to contract for the services of these treatment
professionals with no additional cost to the County, now therefore be it
RESOLVED, on recommendation of the Health and Human Services
Committee, That the Department of Social Services is authorized to contract
with the Alcohol and Drug Council of Tompkins County, Inc., for the dedicated
support to the Family Treatment Court totaling $28,170 for the period of
May 1, 2003, through December 31, 2003,
RESOLVED, further, That the Department of Social Services
is also authorized to contract with Cayuga Addiction Recover Services, Inc.,
for $15,800 for dedicated treatment support to the Family Treatment Court
for the period of May 1, 2003, through December 31, 2003,
RESOLVED, further, That the Director of Finance is hereby
authorized to make the following adjustment to the budget for the Department
of Social Services:
REVENUE: 6070.44670
Federal Revenue $43,970
APPROPRIATION: 6070.54400
Purchase of Services $43,970
SEQR ACTION: TYPE II-20
* * * * * * * * * * *
Explanation: The Family Treatment Court serves families
whose children have been placed in foster care or who are at imminent risk
of such placement because of the substance abuse of the parents and caretakers.
The program has been successfully operating for two years. It is currently
serving twenty-six families and has had up to thirty-four families/participants
at one time. The program has had five graduations.
Funding for the program has come from a variety of sources including:
ATI funds; the Department's regular budget; and from the Office of Children
and Family Services TANF Preventive Grant. The Alcohol and Drug Council
was the grantee with our first year grant totaling $200,000 and the second
year totaling $136,951. Because the program has been so successful
and is a model for rural counties as well as having outcomes and participation
that exceeds much larger counties/social services districts, we fully expected
that we would receive a third year of funding. The current state fiscal
situation appears to make that unlikely. However, it is extremely important
to the partner agencies that we continue the program and that we also maintain
the funding for the dedicated support from the two treatment agencies who
have participated since the program's inception.
Since one of the requirements of the original TANF Preventive Grant was that
the persons participating be eligible for TANF Under 200% services, we know
that program participants meet this requirement at the level of 95% - 100%.
The Department can access a slightly different "pool" of these funds as a
Preventive Service. However, we are not able to proceed with this plan
in the absence of a contract with the treatment agencies.
This resolution authorizes these contracts and appropriates these funds and
revenue into the department budget.
It was MOVED by Mr. Koplinka-Loehr, seconded by Mr. Penniman,
and unanimously adopted by voice vote by members present, to submit the following
resolution to the Legislature for approval.
Ms. Dolan answered questions about the changes in DSS
over the years that have lead to a serious understaffing in this program.
In response to a question she noted that the increases cited in the Resolution
Back-Up and Explanation, of a 230% increase in the average monthly client
numbers and growth in units of services by more than 400%, have been since
1997.
RESOLUTION NO. - CREATION OF REGISTERED
PROFESSIONAL NURSE POSITION - INCREASING HOURS OF LONG TERM CARE COORDINATOR
AND BUDGET ADJUSTMENT - DEPARTMENT OF SOCIAL SERVICES
WHEREAS, the provision of assessments and access to personal care, nursing,
private-duty nursing, home health aide, Care-At-Home waiver, and PERS services
to eligible children and adults is a mandated component of the operations
of the Department of Social Services, and
WHEREAS, there has been a 418 percent increase in units of service for the
Personal Care program since 1997 with no increase in staffing, and
WHEREAS, the nursing assessments conducted by the department and the nursing
oversight of complex and costly private duty nursing and “waiver” cases insures
that the families are receiving the greatest access to care with the least
impact on the Medicaid program, and
WHEREAS, the current staffing level is not sufficient to insure that minimum
program standards are met into the future and is totally inadequate to insure
that effective management and oversight of cases is maintained in order to
insure the greatest Medicaid cost-avoidance and support for caretaker families,
and,
WHEREAS, the Long Term Care Coordinator has experienced an increase in workload
as a result of the increase in caseload of the Long Term Care and Adult Protective
Services portions of her Division, and
WHEREAS, this Coordinator has also been directed to develop a Community Guardianship
Program for the County and to update the financial management procedures
for the County in relation to Adult Protective Services clients, and
WHEREAS, this Coordinator has also been directed to represent the needs and
interests of the Department of Social Services in the community’s efforts
to improve housing for chronically homeless and disabled adults and families,
and
WHEREAS, the current 35-hour workweek of this individual is insufficient
to insure that basic supervisory responsibilities and these additional responsibilities
are met, now therefore be it
RESOLVED, on recommendation of the Health and Human Services Committee, That
one position of Registered Professional Nurse, Labor Grade N (14) at 35 hours
per week, be created in the Department of Social Services effective July
1, 2003,
RESOLVED, further, That the hours of the Long Term Care Coordinator, Labor
Grade P (16), be increased from 35 to 40 hours per week,
RESOLVED, further, That the Director of Finance is authorized to make the
following adjustment in the budget of the Department of Social Services:
Revenue: 6010.544610
Federal reimbursement $21,994
6010.543610 State reimbursement
$3,667
Total
$25,661
Local share
$ 3,665
Appropriation: 6010.51000728 Increase
Long Term Care Coordinator to 40 hours $ 3,420
6010.51000565 Create new Registered
Nurse position
$19,671
6010.58800
Fringes on above
$ 6,235
Total
$29,326
SEQR ACTION: TYPE II-20
* * * * * * * * * * *
EXPLANATION
Why is an additional Registered Professional Nurse being requested?
The Personal Care Aide (PCA) Program – a mandated component of DSS operations
- has grown from ~ 23,000 units of service to 135,000 units of service since
1997 with no increase in staffing. The Balanced Budget
Act of 1997 scaled back Medicare-covered Home-Care Services and has caused
a dramatic increase in the demand for Medicaid Personal Care Services. Another
nurse is needed to:
Insure that minimum standards for the provision of Medicaid Managed Care
are met now and into the future.
Insure that we are able to retain experienced, compassionate, qualified
staff in the face of a dramatic shortage of nursing professionals.
Insure that our experienced staff is able to have sufficient time to manage
high-complexity, high-cost cases that provide caretakers/families with access
to care while saving Medicaid dollars.
What do the Registered Professional Nurses do?
At this time there are two Registered Professional Nurses in the Adult Protective
Services and Long Term Care Unit. These two RN’s share management for
176 Personal Care Assistance clients, 10 Private Duty Nursing Clients, 8
Care-At-Home I & II clients and authorize PERS for 115 clients.
These numbers continue to grow. In addition they are responsible for In-Home
assessments, and PRI’s for individuals in their own homes who need nursing
home care.
Our nurses respond to information requests regarding Long Term Care Services
and assist blind or disabled clients who need assistance with Medicaid applications.
Considerable time is also spent with the staff of the Medicaid Unit resolving
complicated “spend” down questions in order to insure continuing eligibility
for services.
What are the day-to-day activities of these Registered Professional Nurses?
For both the Personal Care Aide Program and Private Duty
Nursing ( PDN) cases the RN must:
- Obtain, submit and execute MD orders.
- Take the referral and assess the client in his or her own home.
- Determine whether client’s services need can fit safely within the Personal
Care or PDN program.
- Develop a plan of care.
- Make referrals to home care agencies to determine which agency can provide
benefits/services.
- Poll different agencies to determine which is the best fit with client
need.
- Follow up with all parties.
- Authorize services in WMS.
- Coordinate services with the clients, Medicaid Unit, Home Care agency &
other service providers that might include COFA, TC Health Department, TC
Mental Health, Broome Developmental Services and hospital discharge planners.
- Monitor provision of services to determine whether care plan is being followed
and adjust plans as needed.
- Respond to complaints and problems.
- Provide phone support to clients and family members and other caregivers.
Many components of this process must be repeated at the 6-month intervals
at which cases must be reviewed, and reauthorized.
How will the presence of an additional Registered Professional Nurse produce
cost-avoidance?
The process of actually managing and monitoring these costly and complex
cases has many facets including:
- Insuring that non-Medicaid resources such as Medicare and private insurance
are utilized to the fullest extent allowed by those policies and advocating
with families whenever necessary.
- By making sure that appropriate level of need is assessed at hospital discharge
& other critical case junctures when expectations and plans are made
and by helping families and caregivers to set realistic expectations for
what the Department of Social Services will provide.
- By working with families to make sure they know there is a certain amount
of care they must provide.
- By holding monthly case meetings with key persons in CAH cases which insure
that services are being provided that fit the client’s and family’s needs,
do not exceed program caps and are not duplicative of other services.
- By insuring that PND cases are managed locally and not returned to
NYSDOH prior approval staff – our only alternative without additional nurse
resources - where oversight would become severely limited and Medicaid costs
will certainly escalate.
Without additional nursing resources we have already had to limit several
of these key coordination activities, which we know save Medicaid dollars
and lead to program improvements. As the program demands continue to
grow, we will have to eliminate these activities and focus our personnel
resources on the parts of the program (conducting assessments, making nursing
visits, obtaining orders, handling aide problems) that insure client safety
and our conformance with regulations. Paperwork will remain not up-to-date.
Despite the dramatic program growth – with average monthly number of
clients increasing by 230% and units of services growing by over 400%, the
average monthly cost per client of personal care services has increased by
only 77%. Much of this is due to the case/care management that has
been provided by our Registered Professional Nurses.
Why request this position and increase in hours now?
Although we have known for some time that both these requests would be needed,
our hope was to push them into the 2004 budget process. Nearly all
the management activities described above in the Personal Care, Care-At-Home
management and Private Duty Nursing programs must be eliminated if we do
not obtain additional nursing resources. I am very fearful of losing
incredibly talented and committed RN staff if we do not obtain help for our
existing staff very soon. Nurses in the current health care environment
have numerous options and it is important that the county not lose key staff
to burnout if it is avoidable.
The Long Term Care Coordinator has seen significant increases in the volume
and complexity of her job as the caseload has grown and as Long Term Care
services are increasingly meeting the needs of younger disabled individuals
in addition to the frail elderly. She has also been directed by me
to assume additional duties that relate to both the Long Term Care and Adult
Protective services program areas under her direction. These include the
development of a community guardianship program which both the Office for
the Aging, and DSS recognize is greatly needed as the number of individuals
in institutional settings for whom no one is appointed or willing to make
critical decisions increases. The Long Term Care Coordinator is representing
the Department of Social Services in several groups whose task is to develop
funding proposals that will support development of additional housing that
meets the needs of disabled adults, and department financial management procedures
– which guard the income and assets of elderly or disabled adults for whom
DSS is payee and/or guardian - need additional work.
The supervisor has begun that work, but it will not be completed and proper
oversight maintained without additional time in the supervisor’s workweek.
Youth Services
Update on Recreation Partnership and Facilities plans
for 2004
Ms. Zahler briefly reviewed the updated plans and policy
questions for the County’s role in the Recreation Partnership and in fiscally
supporting recreation facilities owned by the City. Ms. Robertson thanked
Ms. Zahler for presenting the issues and policy questions clearly to the
Committee. The two policy questions related to the Recreation Partnership
are as follows:
1. Will the Committee recommend keeping $38,110
in the 2004 target budget?
2. When and how will the County decide whether it
has a role to play in holding this inter-municipal initiative together or
whether it is officially withdrawing from the Partnership?
Discussion followed on these questions and Mr. Koplinka-Loehr
stated he feels it is the intention of the Legislature that the County will
not continue as a member of the Rec Partnership past 2004; legally we cannot
pull out sooner than that. However, Mr. Penniman feels it is important
to continue the staff support the County has been providing, as an in-kind
contribution. Ms. Zahler clarified that the agreement would need to
be modified removing the County as a member but the description of the County's
role as described in the agreement would remain the same.
Mr. Koplinka-Loehr explained why he feels the County should
be withdrawing from the agreement. The County is not a recreation provider,
it evaluates and plans. At this time, it is not the County's goal to
become recreation providers. Ms. Zahler understands the County's
position, but feels the County's funding enables recreation services be provided
and is the "glue" that holds this intermunicipal effort together. Ms. Robertson
noted that by providing staff support the County can continue to serve this
function, at least in part.
At this time, the Committee reviewed the information and
policy questions concerning Recreation Facilities. At Mr. Koplinka-Loehr's
request, Ms. Zahler provided additional information on the suggestion that
the County consider the role of supporting infrastructure at Cass Park by
assuming ownership to bond future capital improvements. Below is a
list of questions Committee members asked Ms. Zahler to have addressed
before members felt they could decide:
- Who (i.e., which municipalities) is using the facilities?
- What are the costs and possibilities of raising revenue?
- How will the Recreation Partnership adjust program fees to support maintenance
of the facilities?
- What is included in the City's definition of capital projects and/or other
projects and what are their expected lifetimes?
- What are the consequences if the County does not contribute?
The Committee understands that the fee structure for recreation facilities
will not change this year; these discussions would only affect operations
beginning in 2004 at the earliest.
In regard to policy question number two, the Committee agreed that the County
could support the hiring of a consultant to help with grant writing to assist
the City in researching alternative revenue sources.
Updated information was provided concerning refinancing
youth services in collaboration with DSS, and reorganizing County Youth Services
personnel services with Cooperative Extension. It was noted that only a relatively
small adjustment (one staff position) might be possible.
The Committee reviewed the policy questions relating to
City-County negotiations on merging the two youth departments. Ms.
Robertson said she is not in support of the policy question that County consider
a capital project to modify the Ithaca Youth Bureau building to house all
staff together at a larger location. Mr. Penniman said he would be
willing to meet with the City and appropriate County staff concerning the
Sales Tax Agreement if a written proposal suggesting changes is prepared
by the City.
Mr. Koplinka-Loehr said he supports the initiative in
asking OCFS and the State Association to send a team here to independently
assess the pro's and con's and potential costs and benefits of a merger.
The Committee agreed with this direction. It was the Committee's consensus
to delay serious negotiations on structural changes, with respect to Cooperative
Extension as well as the City, until the transitions take place in their
respective leadership.
Health Department
Resolution
It was MOVED by Mr. Koplinka-Loehr, seconded by Mr. Penniman,
and unanimously adopted by voice vote by members present, to submit the following
resolution to the Budget and Capital Committee for approval:
RESOLUTION NO. - APPROPRIATION
FROM CONTINGENT FUND - REPLACEMENT PAY - HEALTH DEPARTMENT
WHEREAS, the Health Department has an employee out on
medical leave for greater than two months in the Children With Special Care
Needs Program, and
WHEREAS, the Fiscal Policy of Tompkins County allows for
replacement pay from the Contingent Fund, now therefore be it
RESOLVED, on recommendation of the Health and Human Services
and Budget and Capital Committees, That the Director of Finance is hereby
authorized and directed to make the following budget appropriation:
FROM: A1990.54440
Contingent Fund
$2,106
TO:
A4047.51000519 Salary - Senior Typist
$1,658
A4047.58800
Fringes
$
448
SEQR ACTION: TYPE II-20
* * * * * * * * * *
Explanation: The employee has been out of work since December 13, 2002,
and remains out at this time. The period of replacement is January
6, 2003 - April 4, 2003.
Neighborhood Notification Law
Mr. Ewald updated the Committee on the Department's activities
that have included preparation, research, and planning. Two committee
meetings have been held with Monika Roth of Cooperative Extension, Weights
and Measures, and the Environmental Management Council. Media releases
have been prepared and Monika Roth conducted meetings for commercial applicators,
homeowners, and retailers; County staff attended these. A web site
with frequently asked questions has been developed and four phone calls for
information have been received so far. For the period of January to
March 2003, time spent by Environmental Health Division staff has totaled
$2,622.61 in salary and fringes and approximately $52 has been spent for
printing. As this program is not eligible for State Aid, Ms. Cole estimated
that approximately $400 has been lost in State Aid.
Mrs. Schuler reported that the costs for Cooperative Extension
as reported by Ms. Roth have been $2,500.38. This figure includes
printing, postage, salary, etc. Ms. Cole commented that a request was
made by Cooperative Extension for reimbursement for direct expenses and staff
time. Mr. Penniman feels a Contingent Fund request would be appropriate.
Ms. Roth noted that this summer she will have a work study student who will
follow-up with landscape companies to see what they are doing and continue
with media outreach, at lower cost. In addition, the Environmental Educator
position at Cooperative Extension will be filled in early June, and this
ongoing educational effort will be part of that person’s job.
Mr. Koplinka-Loehr was excused at 10:58 a.m.
Following discussion, Mr. Whicher suggested a resolution
be prepared for the next Committee meeting to enter into a contract with
Cooperative Extension and to request $5,000 from Contingent Fund for the
expenses incurred and expected through 2003. Ms. Cole would have the authority
to reimburse Cooperative Extension up to $5,000, if needed.
Mr. Ewald commented that there will likely be very little
enforcement this year; until people get used to the law the County’s efforts
will be to educate people and help them comply.