The Evolution of Disability Service

posted by Chris Sparks on Friday, August 26, 2016

“What keeps you awake at night,” Marcus, one of the CPA’s completing our annual agency audit, asked me recently. This was a part of the waste, fraud, theft, and misappropriation of funds discussion he is required to have with all leadership staff. He wondered if it was cash flow, or making payroll, or compliance – all good questions in Iowa as we are five months into a fully managed care system for all Medicaid funded services. I shared that it was not those things that worried me the most, but there are plenty of things to worry about.

I worry that we will not be able to keep the promises that we made to families about services for their loved one, in some cases thirty-five years ago. I worry that the heart and soul of the organization will be lost in this transition as we become part of the medical system. I worry that we will become increasing incapable of staffing services with the number and type of people that we need and want. Those are but a few of the things that are cause for consternation.

As a field we are in the midst of massive and continuous change, each item challenging individually but truly overwhelming when taken as a whole. Some of the things we have and are facing include:

• Changing customer expectations
• Pressure to reduce Intermediate Care Facilities (ICF)s
• Home and Community Based Services (HCBS) waiver rates failing to keep pace with inflation
• Direct Support Professional (DSP) vacancy rates and turnover that are truly abysmal and despite an investment of energy and resources we can’t seem to move the needle on this critical issue
• Compliance with the Affordable Care Act (ACA) and we don’t have revenue to meet this expense
• The HCBS settings rule
• The companionship exemption
• The Department of Labor (DOL) overtime threshold change

The list continues to grow and something may be added tomorrow. It is important to note that not all of these are bad, in fact some of them are both welcome and exciting, but they still represent significant challenges that make our professional lives stressful. If we aren’t careful and disciplined we find ourselves caught up complaining and reacting.

In many states, in ways both large and small, managed care is becoming an operational reality, thrusting us into a different world. On April 1, 2016, Iowa launched a fully managed care system for all Medicaid funded services including all Long-Term Services and Supports for people with disabilities. We are now working with three managed care organizations and we find ourselves a part of the medical system.

Over the last several months, as we have transitioned to managed care, I have experienced moments of acute conflict. I sometimes struggle with the feeling that everything I have worked to build over the last thirty-three years is being torn down. I know some of you have felt that way too. In contrast there are other times I feel like this is a time of great opportunity and organizations that are nimble and committed to high quality and great customer service will prosper.

As I wrestled with those two seemingly incompatible extremes, I finally realized that both are true. What we have built is being swept away and services and supports are being re-imagined - as they have always been. And, it is a time of great opportunity for organizations that are nimble and fantastically dedicated to high quality and great customer service.

As unprecedented and complex variables in our culture make our work more challenging we must respond from a customer focused value set and with innovate options that make community membership a reality for people with disabilities.