Recommendations

Nationally, residential services and supports for individuals with IDD have shifted toward person-directed planning, [20] community integration, independence, self-determination, and housing individuals in the least restrictive environment possible. While many Texans with IDD are successfully served in the community, a subset of the IDD population continues to benefit from the more intensive and extensive services and supports at the SSLCs. The Sunset Commission Report noted that “some SSLCs are needed to continue serving the declining population of people, in particular, the medically fragile and behaviorally challenging, and the alleged offenders referred to SSLCs by the court —. Even with expanded community resources, some members of these populations will continue to need the services of a SSLC for some time to come.”[21]

The Sunset Commission recommends closing the Austin SSLC and establishing an SSLC restructuring commission to “right-size” the number of SSLCs required for the level of need in Texas. The 84th Texas Legislature will be debating those recommendations when it convenes in January 2015. Information from this report may be used to help inform their decisions.

DADS makes the following recommendations for the provision of services and supports to persons residing in SSLCs over the next 10 years:

1. Transform the service delivery model of the SSLCs from institutional only to both institutional delivery and clinical support for community-based services.

One key to living in a community setting successfully is the availability of specialized services necessary to prevent individuals from having to move into more restrictive settings. Family members and local IDD authorities alike have praised the availability of specialized care at the SSLCs, including dental care, quality adaptive equipment, and managing the physical needs of individuals with complex medical conditions. According to family members, the state is not prepared for the rapid growth of aging individuals with IDD, especially those with complex needs, and there is a need for expanded services. Advocates have pointed to the lack of crisis and respite services in the community for emergencies.

As the SSLC census declines, DADS has the opportunity to expand the delivery of specialized SSLC services and supports to individuals with intellectual and developmental disabilities living in the community. Serving as resource centers for individuals with IDD would ensure comprehensive services are available to promote living in the most integrated environment possible. *These services could include:

  • Dental Services
  • Active Treatment/Specialized Day Programs
  • Habilitation Therapies
  • Durable Medical Equipment (i.e., wheelchair) Fabrication
  • Acute Care Clinics
  • Psychiatric Clinics
  • Behavioral Health Services
  • Crisis Stabilization Services

Enhanced access to medical, behavioral, and dental health services, along with robust management of chronic conditions, has been demonstrated to reduce the overall utilization of emergency and acute health care services while lowering overall costs. [22]

2. Develop specialized programs and redesign buildings within specific SSLCs to better equip these facilities to serve individuals who are medically fragile, require significant behavioral supports, or are alleged offenders, while maintaining sufficient capacity to provide services to the general resident population.

As the SSLCs continue to decrease in size, the proportion of residents who have high medical and behavioral health needs will continue to increase. SSLCs should develop more specialized programming to meet the needs of these populations. This includes designating homes, units, or campuses that will develop specialized services and supports targeted for these particular populations. This will allow the SSLCs to focus their expertise on those who present the greatest challenges to serve.

Through the past 25 years, best practice in facility design for individuals with IDD has evolved while SSLC facilities have grown increasingly outdated. Structures at the SSLCs should be updated and/or redesigned to provide safer and more therapeutic environments to meet the needs of specific populations, including, but not limited to, persons with IDD who are diagnosed with autism or dementia. The same model could be pursued for residential settings for high risk alleged offenders who may require a higher level of security in their living and day program environments.

CannonDesign developed plan diagrams and cost models for two types of residential facilities (see Appendix F). The first plan uses an existing 20-bed residence at the Lufkin SSLC as an example of renovation and reprogramming. The second is a conceptual floor plan for a specialized ICF/IID facility.

3. Develop satellite clinics to provide medical, therapeutic, and crisis respite services for individuals with IDD that are state-funded and/or located in areas of the state that are under-served.

In many areas of Texas, there is a shortage of health care professionals. Although the SSLCs can serve as resource centers in their local areas, many areas in the state are still under-served. This includes professionals who have an expertise in service delivery for persons with intellectual and developmental disabilities. Texas is a large state, and travel distances between the SSLCs are significant. To align IDD services and supports with the widely dispersed Texas population, DADS recommends developing satellite clinics to improve access to care.

After looking at population densities and the distribution of state and private ICFs statewide, CannonDesign identified the following as potentially under-served areas: the Panhandle north of Amarillo; the Rio Grande Valley near Laredo; the Dallas Fort Worth metroplex; the Houston metro area; and East Texas along the Interstate-20 corridor near Longview. Current SSLC operations would provide oversight to minimize administrative costs.

An alternative to satellite clinics might be federally qualified health centers (FQHCs)[23] or FQHC “look-alikes,” [24] which are community-based organizations that provide comprehensive primary care and preventive care, including health, oral, and mental health/substance abuse services to persons of all ages, regardless of their ability to pay or health insurance status. However, the FQHC will be expected to specialize in providing the services necessary to support individuals with IDD.

4. Work with local IDD authorities and community providers to develop additional community resources for individuals with IDD, such as rate reimbursement incentives for providers who serve individuals who are medically fragile and/or require significant behavioral supports.*

The Sunset Commission reported they “heard from many sources that provider reimbursement rates do not account for costly medical needs, creating a disincentive to care for the medically fragile population in the community.” As a result of this, they made the following recommendation:

“To build community capacity, a number of states including Texas have HCS waiver plans that allow a select number of individual’s cost to be greater than the average cost of state institutions under certain circumstances. However, Texas’ HCS waiver only uses the higher reimbursement category for people with serious behavioral issues. DADS has recently initiated a workgroup that is studying how a rate increase could help providers serve clients with more costly medical needs, but currently providers lack the necessary funding level that would encourage the development of additional small group homes to serve people with high medical needs.” [25]

Community providers and the local IDD authorities have reported to DADS that current reimbursement rates are not adequate to cover the costs of services, such as 24-hour nursing care or specialized training, for persons who are medically fragile and/or require significant behavioral supports. Over the next two years, DADS will evaluate the impact of rate enhancements for community providers serving individuals with complex medical needs in Central Texas.* If this model proves successful, DADS should consider implementing similar systems in other areas of the state.

5. Continue to develop and implement the Quality Improvement program at the state and SSLC levels.

As noted, DADS will implement the SSLC QI program over the next three years. It is expected to transform the SSLC service delivery system, change the way that SSLCs are monitored, and provide additional supports to individuals transitioning into the community. DADS expects that the QI program will also improve the state’s ability to self-monitor the SSLCs, which will position the state to develop an exit plan from the DOJ settlement agreement. Though full implementation of the QI program will take only three years; the systems set forth through the program are expected to be sustained throughout the next decade.

6. Examine wages by market and pay staff accordingly, as well as commensurate with the experience and responsibilities required by the job.

DADS is asking the Legislature for additional funding to help decrease turnover and improve recruitment and retention at the SSLCs. This request includes salary increases and job reclassifications for certain positions. Over the next 10 years, DADS will need to consider developing additional career ladders and continuing to identify market trends and adjust salaries accordingly.* Additionally, DADS will need to continuously evaluate the market competition and make adjustments to compensation as necessary. For example, the petroleum industry in Texas has negatively impacted the recruitment and retention of DSPs at the San Angelo and Abilene SSLCs. DADS must have flexibility to adjust wages for certain markets within Texas for positions with historically high turnover rates.* Further, DADS should consider adjusting wages at SSLCs for areas with a higher cost of living.

Footnotes

  1. Person-directed planning is a process that empowers the individual and the LAR on the individual’s behalf to direct the development of a plan of supports and services that meet the individual’s personal outcomes. The process must: identify existing supports and services necessary to achieve the individual’s outcomes; identify natural supports available to the individual and negotiate needed service system supports; occur with the support of a group of people chosen by the individual and the LAR on the individual’s behalf; and accommodate the individual’s style of interaction and preferences regarding time and setting.

  2. Sunset Advisory Commission Staff Report: Department of Aging and Disability Services, May 2014, pg. 23.

  3. Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. (Available on www.IHI.org)

  4. FQHCs include all organizations receiving grants under Section 330 of the Public Health Service Act. FQHCs qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits. They must serve an underserved area or population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality assurance program, and have a governing board of directors.

  5. FQHC Look-Alikes do not receive grants under Section 330 but are determined by the Secretary of the Department of Health and Human Services to meet the requirements for receiving a grant based on HRSA recommendations. They receive cost-based reimbursement for their Medicaid services, but do not receive malpractice coverage or a cash grant.

  6. Sunset Advisory Commission Staff Report with Commission Decisions: DADS, August 2014, pg. 33.

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Updated: August 16, 2017