DRAFT FOR DISCUSSION PURPOSES
TASK FORCE REPORT
(New and revised language underlined)
1. CREATION OF TASK FORCE
The program that has evolved into today’s Child Development Services (CDS) System was first recognized in law in 1978 when a pilot project was established to stimulate regional coordination of services for preschool handicapped children by various levels of government and other local public and private agencies. Since that time, the preschool handicapped pilot projects, as they were initially known, have undergone frequent and varied legislative changes. By one count, what is now the CDS System has been subject to 21 legislative amendments in less than 20 years since enactment of the original legislation. (An outline of the legislative history of CDS is attached at Appendix A.)
Some of the legislative changes in the system have been minor or technical in nature. However, a number of the amendments have been significant affecting the structure, governance and responsibilities of CDS. Over the years, what was originally a loosely defined “system” of local agencies, officials, providers and other individuals organized and governed largely at the regional level with some oversight at the state level by the Department of Education and an interdepartmental coordinating committee of state departments has evolved into a more centralized system with a strong central office located in the Department of Education. A primary reason for this trend toward centralization at the state level has been the need to comply with increased federal governance and programmatic requirements.
Throughout this period of frequent legislative changes, one element of the original legislation that has remained part of the CDS law is the recognization of the importance of using existing local contract providers. (See Public Law 1979, chapter 727, section 1 which was the first formal codification of the preschool projects and current law, 20-A MRSA section 7732-A subsection 7, which continues to recognize the desirability of contracting for the provision of services whenever possible.)
Increasingly, as the Department of Education and CDS System has been held accountable under federal law for identifying and providing early intervention services to infants and toddlers and their families according to a strict timetable, the historical “preference” expressed in state law for using local contract providers has clashed with issues of cost efficiency in order to maximize services from the funds available. In order to satisfy legal requirements to provide timely services and to do so in a cost efficicient way, there may be instances when direct employment of service providers is preferable to contracting for services.
Although doing so is very much the exception rather than the rule, regional site boards of directors were given the authority to hire professional therapists in 1996. That authority was limited to one of three instances. Direct hire of site therapists is authorized when: (1) it is necessary to ensure proper evaluation of children, (2) it is necessary to satisfy federally mandated timelines for the provision of services; or (3) it will result in identifiable savings to the CDS System as determined by the Commissioner of Education.
The law that established the three conditions under which professional therapists may be hired, also directed the Commissioner of Education, with the assistance of the Interdepartmental Coordinating Council, to establish a method for determining the cost of employing therapists. The commissioner was to report to the Legislature’s Education Committee at the end of 1996. A copy of the report is attached as Appendix B.
During the 1997 legislative session, the Education Committee, faced with conflicting testimony regarding the methodology recommended in the report, established the Task Force to Study the Cost-Effectiveness of the Child Development Services System. The task force consists of a balanced membership of 16. The charge of the task force is to study :
1. The cost-effectiveness of hiring profession site staff as compared to contracting for services with nonprofit or for-profit agencies; and
2. Ways in which the CDS System would achieve greater administrative efficiency and economy.
The task force is to report to the Legislature at the beginning of the Second Regular Session in 1998.
In this report, the task force makes two recommendations pertaining specifically to cost-efficiency of hiring as compared to contracting for services and other recommendations that affect the administrative effectiveness and economy of the system generally.
2. TASK FORCE RECOMMENDATIONS
There are many competing interests associated with the provision of appropriate early intervention services
to eligible children and their families. Among those interests, there are the regulatory requirements and administrative
needs of state-level agencies; there are the flexibility and staffing needs of regional sites, and there are the
contract availability and predictability expectations of private and non profit agency providers. But all of these
interests are subordinate to the needs of eligible children and their families to receive coordinated, appropriate,
high quality, timely assistance consistent with state and federal law. In order to facilitate the availability
of such services to children and their families, the Task Force makes recommendations in the following areas.
I. ORDER OF ENGAGEMENT OF THERAPISTS
This section deleted as discussed 12/17/97
II. IMPLEMENTATION OF_UNIT COST METHODOLOGY
Revised based on 12/17/97 discussion; presented for discussion 1/5/98
Background: Under existing state law, one of the situations in which a regional site may hire a therapist to provide direct services, is when the Commissioner of Education has determined that doing so will result in comparable services being provided at identifiable savings to the CDS System. In other words, cost is the key factor for use of this provision of the law. A site may employ a professional therapist to provide therapy comparable to that provided by a contract provider, if the commissioner finds that use of a site employee would result in a cost savings to the system. One of the two charges to the task force is to make recommendations on the “cost effectiveness” of hiring professional site therapists as compared to contracting for professional therapy services. The task force recognizes that there are other factors influencing effectiveness of services besides cost. However, in analyzing this part of our charge we will focus on the quantitative factor of cost. Other qualitative measures of cost effectiveness are reserved for discussion elsewhere in our report.
Current law also authorizes CDS System sites to employ professional staff in two other instances--when necessary to perform evaluations of children and to meet timelines for provision of services required by federal law. To put the employment/contracting issue in context, as of September 1997, 12 of the 15 sites employ one or more therapists to provide direct services. Forty-four direct service therapists are employed system-wide under the conditions specified in law (to achieve cost savings, to provide evaluations or to meet federal timelines). The total number contract service providers utilized by the system is (over 2000).
The Task Force does not find that hiring new site employees directly versus contracting for services is inherently more or less cost effective. The Task Force does find that implementation of a standard methodology for determining cost effectiveness could level the playing field by providing a consistent, systematic way to support a sometimes controversial decision. In order for any formula to work, it must be well defined, universally understood and consistently applied. The methodology developed by the Department of Education’s Review Cost Committee last year for determining the cost of employing staff is a good starting point. With some modification and explanation to affected parties, it could be used to compare the cost of employing staff to that of contracting for services.
In implementing the cost methodology, the availability of 3rd party reimbursement such as insurance or Medicaid or other sources of funding such as charitable contributions, grants or trust fund income should not affect the calculation of the unit cost of providing services (since the cost is the same regardless of the sources of payment). However, in determining whether there are “identifiable savings” associated with providing services by employing a CDS site therapist, other available sources of program income to the site or the contract provider, such as third party reimbursement or other sources of funding ought to be taken into account.
Recommendation: The Department of Education should implement the cost methodology it developed last year for determining the cost of employing professional therapists, including determination of the direct and indirect cost components and the production rate, but excluding adjusted unit cost determination. The methodology should be expanded to cover determination of the annual cost of contracting for services, employ commonly accepted accounting principles and definitions and be adopted as policy to guide the department and providers. The department shall provide training to regional site directors and employees and to contract providers on the use of the methodology, the definition of terms and the reporting requirements to implement the methodology.
Recommendation: (The following recommendation was suggested by a task force member after the last meeting and is presented for discussion at the 1/5/98 meeting)
Prior to either contracting for services or hiring new site employees, existing employees of a public agency such as a regional CDS site, Head Start agency, public school, public health agency or other state agency shall be utilized to provide therapeutic services, provided the existing employee is reasonably available, able to provide appropriate services and meets the needs of the family.
III. FAMILY CHOICE
To be discussed 1/5/98
Background: While order and cost effectiveness are important factors, there are other important considerations. It is extremely important that a family be able to chose a therapist who it feels is appropriate for the needs of its child and with whom that family is comfortable. The dissemination of information on early intervention services and resources available to families is critical to the ability of families to make informed decisions. At a minimum, the central directory required by federal regulation must be made readily available and regularly updated in order to help families make informed decisions.
Recommendation: The department shall compile, regularly update and disseminate, through the regional sites and other appropriate methods, a central directory of information on early intervention services and resources available throughout the state and other forms of assistance available to children and families as required by federal regulations.
IV. WORKLOAD CAP
To be discussed 1/5/98. A brief discussion on 12/17/97 raised the following: Should cap apply only to case workers (not case managers)? Should cap also apply to all providers?
Background: The ability of children and families to access appropriate services and the ability of the CDS system to serve those children and families in an adequate and timely manner depends to a large extent on the availability of therapists qualified in assessment, evaluation and provision of direct services. That, in turn, depends, in part, on the ability of those service providers to maintain a reasonable caseload. While it is not possible to establish a single, universal workload cap that would apply for all types of services in all areas of the State, a flexible cap or range could be helpful. Such a cap, for example a range of direct hours of client contact per day or week, would help ensure adequate time for necessary related therapist activities such as travel, consulting with colleagues and report writing. The cap limit would serve as a measuring stick for determining the appropriate workload of CDS System employees and should be voluntary for contract providers.
Recommendation: The department shall establish a cap on the workload for system employed professional therapists that incorporates a range of maximum hours of direct contact that will serve as a measuring tool while providing flexibility to meet the varying needs of different children and families in different areas of the State. The workload cap is voluntary for contract providers.
V. QUALITY ASSURANCE / ACCOUNTABILITY
Revised as discussed 12/17/97; to be reviewed 1/5/98
Discussion: Both the program goals and objectives, and the legal obligation, of the CDS System are to assure compliance with Federal law in the coordination and provision of early intervention services to eligible children and their families. Federal law requires periodic monitoring and reporting of all aspects of the CDS System to assess the level of compliance with federal obligations. The federal Office of Special Education Programs monitors programs and reviews state plans on a 3-year cycle.
The Task Force feels that compliance with federal law does not necessarily guarantee high quality programs. There needs to be a statewide system of quality assurance applicable to the performance of the CDS System, the regional sites and contract providers to bring up standards across the state. The focus should be on the ability of the system to provide appropriate services and on identifying areas where concerns exist.
Recommendation: The Department of Education shall develop and implement a quality assurance initiative (e.g., a continuous quality improvement program) for the CDS System. The purpose of the quality assurance program is to provide a mechanism to establish performance goals and indicators that the department can use to assess the effectiveness of the CDS System in providing comprehensive early intervention services for eligible children and their families. At minimum, the quality assurance program should monitor and report on the effectiveness of the CDS System as determined by performance indicators that assess the system’s progress towards achieving the following:
· provide consistent and timely screening and evaluation services to eligible children and their families;
· ensure consistent quality of early intervention programs, including the ongoing coordination of therapeutic services;
· account for the type, frequency and intensity of early intervention services provided throughout each of the system’s regional sites;
· assess the progress made by children in attaining their IFSP goals and objectives;
· evaluate the satisfaction of parents;
· determine the need for special education placement of children transitioning to kindergarten; and
· calculate the cost-savings of investing state resources in early intervention services as compared to special education and other therapeutic services through the implementation of a longitudinal study that tracks the progress of children who received early intervention services.
The Task Force recommends that the Commissioner of Education should establish a quality assurance initiative that involves key stakeholders in the early intervention services system to participate in the determination of the necessary goals, standards, and performance indicators for the CDS system. The quality assurance initiative’s planning committee should -- at minimum -- have the following representation: a CDS board member, a CDS site coordinator, a parent, an accountant, a contract service provider, a designee of the Commissioner of the Department of Human Services, and a designee of the Commissioner of the Department of Mental Health, Mental Retardation & Substance Abuse Services. Once the Department of Education develops an appropriate quality assurance program, the CDS System should be required to report annually to the Commissioner of Education and Joint Standing Committee on Education & Cultural Affairs on the effectiveness of the system in providing comprehensive early intervention services for eligible children and their families as determined by established system goals, standards, and performance indicators.
VI. REGIONAL CONSOLIDATION
To be discussed 1/5/98; brief discussion on 12/17/97 raised the following issue: Would cost efficiencies be gained by consolidating some administrative and technical support functions by regions (e.g., accounting, contracting, and auditing)?
Discussion: In reviewing the historical evolution of the CDS System from a provider-based, decentralized model to a regional site-based and state-coordinated model, the Task Force has acknowledged the need for flexible state policies and regulations that can allow maximum administrative efficiency and programmatic effectiveness for the diverse needs of different regions of the State. Yet, there has been little consideration given to the costs and benefits of maintaining 15 regional sites as compared to the costs and benefits of other regional models that: (1) maintain between one and 15 CDS service coordination / delivery sites; and (2) further consolidates administrative and technical support services for a number of regions.
VII. INTER-AGENCY COLLABORATION / COORDINATION OF RESOURCES
To be discussed 1/5/98; brief discussion on 12/17/97 raised the following issue: Is it necessary to reassert the need for interagency collaboration and coordination of resources among existing programs (i.e., DOE, DHS, DMHMRSAS, Head Start, Public Health Nurses, etc.)?
Discussion: In response to federal requirements, the Department of Education has been designated as the “lead agency” responsible for coordinating the State’s early intervention services. While it may be prudent for a single agency to take responsibility for meeting federal statutes and regulations, the need for interagency collaboration and coordination of resources is critical in achieving cost-efficiency and cost-effectiveness. In the discussion to eliminate the proposed recommendation regarding a prescribed “order of engagement,” the Task Force may have implicitly ignored the cost-efficiencies currently available through interagency collaboration and coordination of resources. Should one of the Task Force’s recommendations reassert the critical need for such collaboration and coordination?
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