LOCAL SYSTEM OF CARE PLAN

Problem Statement UVS continues to decentralize to the extent possible the information flow and decision making processes that affect service delivery. In order to make this effort successful, staff within the organization need to become increasingly knowledgeable about how finances within the agency work to support individual consumers. To this end, establishing training opportunities for managers covering the topics of individual finances and financial planning is seen as an important step for the future. Topics to include under this goal are:

Problem Statement: UVS provides a substantial amount of training at both a pre-service and an in-service level. A representative group of individuals serve as an Agency Training Committee which looks into the feasibility for particular training opportunities and then seek to plan, schedule, and coordinate these opportunities. As part of the survey process for this plan a number of training topics were identified for consideration in the future. Some of these areas represent topics that are currently being provided while others are new areas. This list of areas will be given to the UVS Training Committee for their consideration and planning. In addition, the Training Committee will consider the results from the UVS annual satisfaction survey to determine ongoing areas of priority, trends, and interest. The topics identified for training through the recently completed survey included the following:

Problem Statement: Within the context of training, some survey respondents identified specific areas of training that were seen as important for the target audience of consumers and for family members. These areas included:

The UVS Training Committee will be asked to consider ways to organize and offer these training opportunities. The first step in this process will be to develop a more complete interest survey to be distributed to all consumers, and to their families, guardians, and home providers. This survey will be intended to assess the level of real interest any of these groups of people have in the targeted areas. The Training Committee will then be asked to develop specific training plans for each prioritized area of interest. These trainings should begin toward the end of year 1 and continue into years 2 and 3. Ongoing surveys developed by the Training Committee will be utilized to monitor and evaluate the appropriateness and effectiveness of these (and other) sessions throughout this plan period.

Problem Statement: UVS has maintained a significant amount of in-house clinical resources that are available to individuals being supported by the agency. These in-house resources include psychiatric services, behavioral support services, and therapy services. The availability of these resources is seen by the vast majority of persons as an essential component of the UVS service array. While access to these particular clinical resources is available to those individuals who require their support, there are other clinical resources that are extremely difficult to access within the Orange County area. The resources that do exist are accessed through Medicaid provider organizations, and there are typically long waiting lists for services. In addition these services once accessed must operate according to guidelines that in many instances fall short of the types of support that most teams feel is needed. UVS has fostered a model of close involvement at the individual team level with all of its in-house clinical resources. Often this requires a short term but intensive involvement with specialty resources in order to assure that the team concerns are addressed in a complete manner. Further, a significant amount of attention from these specialty resources needs to be spent training team members. Without this level of involvement the consultation model far too frequently falls short of expectations.

In order to address the clinical needs of many UVS service recipients, it will be necessary to increase the availability and responsiveness of selected clinical specialties. The model that UVS has been using for behavioral, psychiatric, and therapy services needs to be replicated for these other clinical areas as well. By building an in-house clinical capacity, many UVS consumers will have a significant enhancement in the quality and thoroughness of their support services. To meet this need, UVS will work to determine the need for consultation agreements with the following clinical supports:

During year one of this plan, the needs of all individuals receiving services and supports from UVS will be reviewed and summarized. This process will enable the UVS managers, Executive Director, and Board of Directors to consider the relative importance of creating an in house resource for any or all of these clinical areas, and to develop a general funding strategy. Year 2 of this plan will be to implement the prioritized changes, and year 3 will be used to assess the effectiveness of any clinical resource expansion and to plan future directions.

Problem Statement: The Vermont Crisis Intervention Network was developed in 1991, with a clear goal of reducing or stopping the institutionalization of any Vermont resident with a developmental disability. Through the 13 years of this program this goal has been tenaciously pursued. This brief outline describes the program; it’s changes and the proposed evaluation procedures to be implemented in the near future.

VCIN was conceived and continues to operate based on three levels of service. Level I includes training, intended to increase staff competencies, delivered throughout the state. Level II includes individualized psychological and psychiatric consultation, with the goal of stabilization and crisis prevention. Level III services include individualized short-term, residential facilities, with the primary goal being institutional diversion.

Level I began as monthly clinical meetings for a core group of clinicians from around the state. These meetings were held for 10 years. Participation dwindled and we decided to terminate them. Currently, Patrick Frawley, Ph.D., Brandon Pedigo, M.A. and Al Vecchione, Ph.D., are focusing on providing trainings to staff at agencies as requested. The content of these trainings include; self-regulation therapy, Vermont Safety Awareness Training, the bio-psycho-social model and positive behavior supports.

Level II continues to be the primary focus of the program, with consultation provided to approximately 70 individuals this past year. Within the past three years we have been fortunate to add Brandon Pedigo, M.A. to our consultation staff.

Level III began originally with two beds available. In 1994 we closed one of these beds at the request of the Division of Developmental Services (DDS). This bed was reopened in the late winter of 2002. Through these beds we assist over 25 people per year.

During the first year of this plan we will develop a questionnaire requesting feedback and direction regarding the future of the program. This will be delivered to key personnel at DDS, all of the directors of developmental services programs, as well as to advocacy groups throughout the state. Through this process we hope that we will be able to clearly assess the specific areas upon which we should focus for the near future. These specific needs will be implemented during years 2 and 3 of this plan cycle. Specific priority steps will be agreed upon between UVS/VCIN and the State of Vermont.

During the year, Upper Valley Services may have access to one-time funds that may be used to respond to priority need areas existing within the local service area. The expenditures of these funds must correspond to the priorities established within the state System of Care Plan. Within this context, however, the following local priorities are created for the coming year. The approval and expenditure of local one-time dollars will be reviewed and approved by the Local Funding Committee in accordance with these prioritized funding areas:

Some of the issues that were identified through the various stages of collecting information and obtaining feedback were issues that were not manageable at the local level alone. For this reason these needs have been listed as system wide goals. Certainly UVS has a part to play in any corrective process that may ensue, so listing these as system priorities is not intended to suggest that UVS believes they belong solely to some other level. With this in mind, the system issues identified, and prioritized during this year’s planning process were as follows (note: some of these priorities contain specific recommendations while others do not):

Problem Statement: The DD system is funded within a tightly controlled public financing system. The vast majority of dollars funding the system are Medicaid Waiver dollars that are allocated to community organizations who are responsible for providing services and supports to eligible and approved individuals. Since the mid 1990's there has been a consistent pressure in the system to reduce the costs of services. This pressure has resulted in the lowering of average service levels, along with a massive conversion from an employee structure to a contracted work force. Additionally, the range of people accepted into services (i.e. eligible people who meet the funding priorities) has become increasingly limited meaning that many individuals with a developmental disability are not being funded at all or are receiving services in very low amounts as compared to those received prior to the mid 1990's. Despite these reductions, the overall level of funding within the system has increased over this same period of time. This increase, however, has been in response to the need to serve an increasing number of individuals, as well as meeting the critical but changing needs of persons already being served. Further, it appears that the system as a whole is serving an increasing number of individuals who have very high support needs. These include people who are elderly, people who are aging out of SRS custody, along with (and including) individuals who have a history of offending as well as other violent behaviors. These individuals are requiring a greater per person resource allocation in order to meet their essential needs as well as the needs for assuring public safety.

Resolving the funding dilemma is beyond the scope of the Local Plan. Progress in this area will result only from a collaborative effort between the State and the provider system. As such the following goals are established in the hope of influencing future policy level dialogue.

Problem Statement: As evidenced in the surveys as well as other discussions both intra and inter-agency, there is a strong sense that the system has become increasingly complex. Persons at all levels are reflecting on this increase in complexity as a barrier to the provision of services and supports. The need to be accountable for how dollars are expended, how policies are implemented, and how specific services are provided has moved nearly every aspect of the system into a morass of paper. Providers suggest that the blame for this trend lies with the state, and the state maintains that it is really providers that are creating the bulk of the complexity within the system. At times the complexity is the result of other levels such as the federal government (e.g. HIPAA). Irrespective of these competing views, the reality is that everyone interviewed believes that the system is morphing itself into a state where paper may be more important than are the people. Consequently, much of the dissatisfaction registered during the survey process was reflective of this shift in emphasis.

As with most things, there is no one place to point a finger of blame, and in fact such efforts become distractions that prevent substantive corrective action from taking place. A reality of systems is that they want to organize themselves and part of this organization process is to build structures and formal systems where there were none (or limited and inconsistent ones) previously. At times these structures make things easier and more accountable. At other times these structures may lead to the creation of more bureaucracy that purports to aid the system but in reality detracts from it.

Balancing the legitimate need for a public system to be accountable with the need to preserve and protect the capacity of the system to respond in flexible and individualized ways needs to be adopted by the entire system as a priority goal. There is no new money available to pay for more bureaucracy, consequently all parts of the system need to be clear that more rules and more structure results in more requirements being placed on system elements that are already strained. A complete system wide re-evaluation is needed. At least as much energy needs to be expended on making the system simpler for all stakeholders as is spent on crafting new requirements. In order to approach this concern, the following goals are established.

Problem Statement: Individuals with histories of severe behaviors have always challenged the community system. Over the years, however, community providers have learned a great deal about supporting these individuals within typical community based programs and services. Through the use of positive behavioral support strategies and the development of a greater appreciation for concepts such as trauma, emotional self-regulation, the importance of respectful relationships, et. al., a large number of these persons have been able to live successfully within reasonably integrated settings. Some of these individuals (including persons suffering from extremes of "reputation disorders") are doing remarkably well in their current placements. These persons actually represent some of the greatest success stories available within the entire system. As mentioned above, the Vermont Crisis Intervention Network has been extremely successful at preventing placements of persons with extremely challenging behavior within institutional settings, and fo