Attending:
Members: Jeanne Olson, Dianne Duerscheidt, Laurie Lindberg, Howard Klink,
Nancy Hazelett, Mary Lee Fay, Joanne Furhrman, Marsha Clark, Tim Kral,
Jessica Leitner, Diann Drummond, James Toews, Jack Morgan, Mike Maley, Dave
White, Fred Renter, Judy Cunio, Kristin Ahrens, Kathryn Weit, Cindy
Helvington, Tom Giles, Joe Carroll, Charlie Hammett, Charlotte Duncan, Pam
Ring, Cynthia Owens
Guests: Sandy Stewart, Karen Stahley, Gretchen Yost
Facilitator: Kent Layden

Major Agreements
o Vision: There will be a universal access to a service delivery system
that is person-centered and based on the principles of self-determination
o Goal: Public Sector(Case Management) - Private Sector (Broker)
partnership with split responsibilities
o System expansion will impact capacity
o Allocation ratios maybe shifted within a "pot" with some defined
parameters
o SDS will merge into universal access at some point and will remain an
important structure until that time
o Supportive services models must be based on consumer needs

Next Steps
o State will take comments and refine case management and broker ratios and
roles to present at next meeting.
o State will develop a draft support services model based on our discussion
for presentation at our next meeting.


Meeting Schedule
All meetings will be 9 AM to 4 PM at OTAC in Salem:
o Monday November 27
o Wednesday December 6
o Tuesday December 12
o Thursday January 4
o Wednesday January 10
o Thursday January 11
o Wednesday January 17

Improved Service Delivery System
We began the meeting by noting words or phrases that might characterize an
improved service delivery system. These include:
o Person not a case
o Values
o Focus
o Governance (consumer participation)
o Autonomy
o Consumer friendly
o Creativity
o Connected to community
o Sustainability
o Stability
o Trained and experienced workforce
o Capacity + direct service
o Economy of scale
o Funding and time flexibility

We distinguished between "brokering" and "brokerages (the implementation
mechanism)" and
agreed on a range of service delivery models: 1. All public; 2. Public (Case
Management) and Private (Brokers) with split responsibilities:3. All public
with split responsibilities (Case Management and Brokers). Our goal is a
Public-Private partnership with split responsibilities. We recognized
further that any expansion of services will have impacts on system stability
and capacity.

Other Concerns
o Portability of services across regions
o Role of local SDS groups
o Capacity - enough service providers
o Help make clear that system must be the same around the State and if so,
how this impacts choice
o Need to educate people about universal access
o Self-determination vs. Medicaid funding, how to reconcile
o What happens to current recipients in the transition
o Quality assurance
o Another level of bureaucracy with regionalization?
o Which board do we report to locally? Who's the boss?
o "Is Medicaid a program or a funding source?"

Brokerage Group Discussion (Notes from small group discussion)
Current Situation
o SDRI
o Brokering services from a variety of places (County, Providence, OTAC,
private,
ARC of Benton, Columbia Riverside, Jefferson Opportunity Foundation
o Functions: Staff, management, overall budget, eligibility for SDS,
planning for and with person, need fiscal, intern, resource development,
accessing alternative funding, contracting for implementation, monitoring,
reporting
o Budget percentages are typically: admin. 10%, brokers 30%, 60% for direct
services
Better Situation
o Have to go through brokering, can do individual approach?
Barriers
o Can't monitor lots of small contracts
o Target on a regional basis
o Administration of brokerage at economically feasible level
o Need model budget/contract with specifics, or can't RFP
Proposals
o Use models - SDRI, other models
o Clearly define functions of brokerage
o Consumer control
o Demonstrate firewall
o Model contract
o Values Guidelines
o Standards for monitoring
o Values of SDS
o Tension between focus on individual and critical mass of brokerage

Values of Regional Brokerage
o Consumer/family control of governance and individual PCPs
o Ease of access
o Clear communication between person and broker providers - human element
to access
o Flexibility to meet individuals (variety of delivery mechanisms) -
ability to get services where they are most accessible (portability)
o Staff trained in variety of SDS stuff, especially communication
o Sustainability
o Stability of staff
o Connected to local community
o "Whatever it takes"
o Desirable to have at least one brokerage per region.
o Linked across state and connected brokerages to existing system
o Most efficient use of funds (private vs. public)

Functions
o Capacity to travel/train individual brokers and negotiate rates and
service packages
o Consumer satisfaction
o Fiscal capacity - have or get it
o Administrative infrastructure - budget oversight, sufficient overhead,
technology, accounting, information management
o Able to meet certification standards
o Capacity to train and educate consumers
o Ability to develop capacity for unmet needs
o Can provide services (if truly driven by individual need...)
o Consistency across state

Action Steps
o Define certification
o Budget
o Statewide RFP allowing regional variance
o Stability (window between small enough and big enough) Requirements
o Economy of scale (e.g. reasonable administrative costs)
o Who assesses RFP and defines firewall

In discussion we noted that the difference between Universal Access and
self-directed supports is that under universal access anyone can apply. This
increases the level of risk to the system dramatically. Further, we
considered where to put the money in the beginning: into more expensive
County structures or into less expensive, but inexperienced new brokerages?
In that we don't want to overdo administrative structures, it may suggest a
regional structure to achieve economies of scale.

Ratio/Structure of Case Management / Brokers Group (Notes from small group
discussion)
Current Situation
o Not a good balance of ratios in State draft proposal, needs clarification
of rates
Better Situation
o Broker ratio down
o Case management up
o Quality standards identified for both (emphasis on outcomes) use of funds
flexible within the allocations
o Regional allocations to achieve economy of scale
o Better definition of CM/Broker roles (encourage flexibility)
o Want allocations that will provide equal access to equivalent benefit
packages with consumer choice in the selection of broker or CM
o QA loop across the state
Barriers
o Broker/CM duplication and current lack of role clarity
o Capacity at both CM and broker levels
o Lack of equal wages and benefits between public and private: fundamental
assumption that you can get broker services for less money; County pay
scales/unions/personnel classifications
o Unfunded mandate - it's taking Counties more money to do the jobs they're
given
o Personal stuff - resistance to systems change and systems/political
resistance
Proposals
o Allocation of $ for: 1. Retraining, 2. Recruitment and training to deal
with capacity issues, 3. Technical Assistance to understand roles and
restructuring
o Capture best practices - "What's really working"
o Continue to define roles of CM/broker
o Develop and agree to outcome based on QA
o Tracking/monitoring system impacts and responding
o Develop strategies for linking with other systems: ED, VR, MH, SDSD, DSO
o Involve providers in system change: training, information, impact on
providers roles and employment pool, what are the services/roles that
providers will be asked to provide
o Build support at all levels with stakeholders - need "buy in" - can't
implement policy change without support of key stakeholders (Counties, state
officials, customers, etc.)

Parking Lot (Items to be Addressed Later)
o Benefit package - funding infrastructure or funding customer services?
What's the effect on CM $ or capacity?
o How can you reconcile choice with universal access?
o Is Medicaid a program or a funding source? We discussed how expansible
can the list of services be: within the current waiver, what can be added to
the waiver, and what do we do about services that are needed but that are
beyond the waiver ("fringes")
o Are we ready to be done with the term "case manager?" Perhaps we need
new way to describe changes in function.
o SDS boards or committees need to know that they are valued and will have
future roles. We envision a full merger of the SDS into universal access at
some point. The State will send reassuring letter to this effect which
highlights the SDS membership on the UAPC.

UAPC Representative Expansion
We discussed whether any other stakeholders needed to be at the table,
especially in our current discussion of case manager/broker roles. We
decided that Case Managers' input was very important and that CMs are welcome
to attend meetings and perhaps will be specifically invited to give input at
some point. However, for now, we will honor the process that has been
established and not expand representative membership. Existing
representatives will work to ensure that all stakeholder concerns are
represented at the table.

Support Services (Benefit Package)
We discussed responsibilities under a mandated system with universal access
wherein everyone who is eligible must have access. We began looking at the
implications of different models. We noted that language is important to all
stakeholders and settled on the term "support services" to describe what is
provided to meet consumer needs. We agreed that future decisions need to be
based on needs rather than focused on $ amounts. May need to have
presumptive eligibility and a tiered system. We will continue this
discussion at our next meeting.

Handouts
There were various handouts, mostly in draft form.
o Case Management/Broker Ratios
o Boundary Issues
o Roles for Case Management and Support Brokering
o Universal Access Planning committee Information Flow Chart
o Staley/HFCA timelines
o Notes of the ODDC Planning Group Workshop, October 18-19, 2000
o Emerging Best Practices in Self Determination