MINUTES OF THE MEETING OF
THE LEGISLATIVE COMMISSION’S SUBCOMMITTEE TO
STUDY THE STATE PROGRAM
FOR PROVIDING SERVICES TO PERSONS WITH DISABILITIES
April 17, 2002
The third meeting of the Legislative Commission’s Subcommittee to Study the State Program for Providing Services to Persons with Disabilities was called to order by Chairman Dina Titus on Wednesday, April 17, 2002 at 9:48 a.m., in Room 4412 of the Grant Sawyer State Office Building, Las Vegas, Nevada. This meeting was videoconferenced to Room 3137 of the Legislative Building, Carson City, Nevada.
SUBCOMMITTEE MEMBERS PRESENT IN LAS VEGAS:
Senator Dina Titus, Chairman
Senator Raymond D. Rawson
Assemblywoman Vonne S. Chowning
SUBCOMMITTEE MEMBERS PRESENT IN CARSON CITY:
Senator Randolph J. Townsend
SUBCOMMITTEE MEMBERS EXCUSED:
Assemblywoman Sharron E. Angle
Assemblyman Jerry D. Claborn
LEGISLATIVE COUNSEL BUREAU STAFF PRESENT:
Bob Guernsey, Principal Deputy Fiscal Analyst, LCB Fiscal Analysis Division
Jim Rodriguez, Program Analyst, LCB Fiscal Analysis Division
Leslie Hamner, Principal Deputy Legislative Counsel, LCB Legal Division
Jo Rasey, Secretary, LCB Fiscal Analysis Division
Exhibit A Meeting Notice and Agenda
Exhibit B Attendance Record
Exhibit C Meeting Packet prepared by Staff
Exhibit D “Nevada Housing Division, Report for Special Legislative Subcommittee on Housing for Special Needs/Disabilities, Senator Dina Titus, Chair,” dated April 17, 2002, submitted by Arthur Thurner
Exhibit E “Clark County Social Service (CCSS) Fast Facts.” This Exhibit was presented to the Subcommittee but not discussed by Bertha. Warrick.
Exhibit F “State Transit Program, Fact Sheet, Small Urban and Rural Transportation, Nevada DOT,” dated January 2002, submitted by Sydnie Schlachta.
Exhibit G “State Transit Program, Grantees, Nevada DOT,” dated May 2001. This Exhibit was presented to the Subcommittee but not discussed by Sydnie Schlachta.
Exhibit H “State Transit Program, Did You Know???, Nevada DOT,” dated July 2001. This Exhibit was presented to the Subcommittee but not discussed by Sydnie Schlachta.
Exhibit I “State Transit Program, Federal Transit Administration Programs, Nevada DOT,” dated January 2002. This Exhibit was presented to the Subcommittee but not discussed by Sydnie Schlachta.
Exhibit J “TRI Deliverables,” dated April 16, 2002, submitted by Michael Willden
Exhibit K “Disability Strategic Plan Timeline,” submitted by Michael Willden
Exhibit L “Sample Target Area and Target Plan for Seniors with Disabilities,” submitted by Michael Willden
Exhibit M “Consensus for Change – A Ten-Year Agenda – DRAFT.” This Exhibit was presented to the Subcommittee but not discussed by Michael Willden.
Exhibit N “Customer Target Areas,” dated April 16, 2002. This Exhibit was presented to the Subcommittee but not discussed by Michael Willden.
Chairman Dina Titus called the meeting to order at 9:48 a.m. The secretary called the roll; all members were present with the exception of Assemblywoman Sharron E. Angle and Assemblyman Jerry D. Claborn.
February 4, 2002 Meeting
Chairman Titus asked for approval of the minutes from the February 4, 2002 meeting, incorporating her comments.
SENATOR RAWSON MOVED FOR APPROVAL OF THE MINUTES FROM THE FEBRUARY 4, 2002 MEETING INCORPORATING CHAIRMAN TITUS’ COMMENTS. ASSEMBLYWOMAN CHOWNING SECONDED THE MOTION, WHICH CARRIED UNANIMOUSLY.
Chairman Titus stated that one of the purposes of this Subcommittee is to compile an inventory of services available as a first step toward developing a clearinghouse to move toward one-stop shopping. She said the presentations today will help determine what the state, as well as various departments and counties, is providing in terms of services.
Assemblywoman Chowning introduced Steven Sampson, a family friend of 20 years who lives with disabilities. Mr. Sampson serves as her personal lobbyist, keeping her informed of the difficulties the disabled face, and referred to him as a great asset to this Subcommittee.
Chairman Titus welcomed Mr. Sampson, saying it is good to have a lobbyist and that the Subcommittee appreciates any input he may offer.
Arthur Thurner, Federal Programs Manager, Nevada Housing Division, thanked the Subcommittee for the opportunity to present the Housing Division’s report on its activities. Referring to Exhibit D, Mr. Thurner gave a brief overview of the Housing Division. The division, he said, was created by the 1975 Legislature and its original mission was along the lines of a single-family program. In 1986, the division expanded to a multi-family program with the Low Income Housing Tax Credit Program. The current Nevada Multi-Family Revenue Bond Program also is primarily multi-family. The division’s mission is to identify and respond to affordable housing needs in Nevada.
The current division goals include the Tax Credit Program that addresses numerous special needs housing. The Bond Program and the QAP (Qualified Allocation Plan), which is synonymous with the Tax Credit Program, are flexible and can adapt to changing priorities. The Housing Division is currently engaged in a study to identify special needs populations in Clark and Washoe Counties.
In response to Chairman Titus’ question, Mr. Thurner reported that the special needs population study is scheduled to be completed in July 2002.
Continuing, Mr. Thurner told the Subcommittee the following special needs populations have been identified:
· Persons with mental illness or retardation;
· HIV/AIDS patients;
· Persons with developmental and physical disabilities;
· Persons with drug or alcohol addictions;
· Transitional housing;
· Supportive homeless housing; and
· Frail elderly/senior assisted/persons with Alzheimer’s disease.
Services provided in the current QAP include:
· Child care;
· Health care services;
· Job training or job linking;
· One prepared meal a day; and
· Computer literacy training.
Other issues addressed through the Housing Division include:
· The Fair Housing Act and Section 504 of the Rehabilitation Act of 1973 which address accessibility issues primarily for persons with disabilities. The enforcement for the Fair Housing Law is carried out by the United States Department of Housing and Urban Development (HUD).
· The Federal HOME (Home Investment Partnership) Program funding which requires that at least 5 percent of units be accessible to people with mobility impairment, and that at least 2 percent of units be accessible to people with sensory impairments.
· The Weatherization Assistance Program which addresses energy, safety and health issues for households of seniors and individuals with disabilities at poverty level. Stringent weatherization standards are being incorporated into various division programs.
In the 3 tax credit allocations for 1999, 2000, and 2001, the division addressed 11 senior properties totaling 660 units developed in Clark County, 1 transitional property consisting of 75 units in Clark County, and 1 special needs project consisting of 25 units in Washoe County. Since 1999, the Bond Program has provided funding for 9 senior projects totaling 1,306 units and 2 projects that have provided special needs housing.
The HOME Program has provided funding for New Vista Ranch in Clark County for the mentally disabled; accessible space funding for statewide projects; five projects statewide for drug rehabilitation; and other HOME and Trust Fund dollars to counties for county‑sponsored programs.
Currently, the BBC Research and Consulting Group located in Denver, Colorado, is performing the Special Needs Study. The study is to more specifically identify the target population and determine the housing gap that exists. Information will be shared with developers to determine if housing can be supported.
Chairman Titus asked Mr. Thurner to explain in detail how the Housing Division sets priorities for funding; if people are on a waiting list for housing; and how many people with special needs are being served. In response, Mr. Thurner stated the Housing Division funding comes from private developers. If there is a need, it is recognized. If a developer sees a project is viable financially, the funding mechanism begins. On the bond side, a project needs both local and state approval, and generally begins in the counties. The majority of projects are in Clark or Washoe Counties because those counties have the greatest ability to bond those types of tax-exempt bond projects. On the tax credit side, the division holds meetings throughout the state in an attempt to gather input from developers, the disabled who need the affordable housing, and the counties or representative local groups in an attempt to developed a plan.
In response to Chairman Titus’ question about how the division receives input, Mr. Thurner reported there are three official public meetings. The division also holds a pre-QAP meeting in Carson City or Las Vegas. People from the affordable housing sector and the counties are invited to these brainstorming sessions.
Chairman Titus pointed out that many people who need services are not aware of the services available nor do they know where to obtain them. She asked if the Housing Division has active outreach to inform the community that this service is available other than simply a notice of the meeting. Mr. Thurner responded that whether the issue is affordable housing or other services, most of the outreach comes from local non-profit groups and the division works with them as best as possible. The division always looks for new and better methods to promote its services.
Chairman Titus asked what the Housing Division’s recommendation would be if it had a “wish list” and could ask this Subcommittee to make a recommendation to the Legislature. Without hesitation, Mr. Thurner responded more free advertising. Jean Norton, in the Southern Nevada Housing Division, has received great widespread community involvement. The Children’s Art contest has been extremely successful and has brought notoriety to affordable housing through the publication of the annual calendar. The northern division has not had as much focus or as many resources.
Assemblywoman Chowning complimented the work done on last year’s Children’s Artwork, reporting that some of the art pieces in the project “Where I Live” were very moving. One work appeared to be a prison setting and was perhaps drawn by a child who has a family member in prison. She thanked the division for the excellent project and the elegant artwork. She stated her concern was that too much demand for affordable housing existed.
Continuing, Assemblywoman Chowning asked who determined that at least 5 percent of the HOME funding units must be accessible to people with mobility impairment and that 2 percent of the units must be accessible to people with sensory impairments, and asked if those figures are adequate. Should they be increased or should they be decreased? In response, Mr. Thurner agreed there always appears to be a demand for the affordable housing product. HUD develops the 5 percent and 2 percent numbers as this portion of the housing funding is federal.
Assemblywoman Chowning asked if those percentages were adequate to meet Nevada’s demand. Are those percentages sufficient to meet demand or should they be increased? Mr. Thurner responded he would rather address that question after the BBC Study is completed as it will be one of the better legitimate studies of need assessment in Nevada, particularly Clark and Washoe Counties. Assemblywoman Chowning thanked Mr. Thurner for his input, and stated she looked forward to reading the results of the study.
Senator Townsend asked when the BBC Study would be completed. Mr. Thurner responded the report is tentatively scheduled to be completed by the end of July 2002. The report is a two-part study: general census information is obtained and survey-type information is gathered.
Senator Townsend asked if there is a lack of bonding capacity, or if there is a lack of interest from the building community, or if they are equal. Responding, Mr. Thurner reported that is the unknown and one of the reasons the BBC Study is being conducted. Affordable rents depend on how additional services are billed. The issue is going to be the service component; based on the federal guidelines for affordability of rent, when an audit is conducted the rent will be one component and the service will be another.
Senator Townsend asked how the rent component is determined. Is it done on a bid basis conducted by the developer or is it based on the bond that will be let? Responding, Mr. Thurner reported rents are set by HUD based on the number of bedrooms, income, and rent limits established by HUD. The remainder of the project must be financially feasible at both the local and state levels. A portion of the tax credit will be funded by a conventional loan so the tax credits make up the equity. In all cases, they must be financially feasible in order to make the project work. The service component is the main issue.
Senator Townsend questioned whether the state and/or the county employs an individual whose job it is to work with financial institutions and the building community to determine who is interested, what rates will be, what the bids will be, and what the cost per square foot will be. That is one component of this Subcommittee’s responsibility; the other component is service. This Subcommittee needs to be aware if one component is fixed or flexible. Mr. Thurner responded that Lon DeWeese is the gentleman who works with financing, rates, and structures. Senator Townsend suggested the division report on the mechanics of how that works. Is it moving smoothly? Are there impediments to it moving smoothly that the Subcommittee might help with? The goal of the Subcommittee, he said, is fairly obvious: it would rather have one empty unit as opposed to one person on a waiting list. The Chairman of this Subcommittee, he said, as well as its members, has many friends in multiple disciplines. Perhaps the Subcommittee could ask someone in the public relations/advertising/marketing industry to develop a non-profit campaign to be produced and used in the newspapers, radio and television stations to be run on a regular basis. That might be helpful to members of the disability community who are unaware of the many services offered and unaware of where to obtain those services. Before developing a marketing program, the Subcommittee must ensure it does not change anything that currently exists. Senator Townsend offered his services relative to the media.
Chairman Titus thanked Senator Townsend and agreed with his suggestion to produce a Public Service Announcement. She asked Mr. Thurner to report back to the Subcommittee with preliminary information on the BBC Study as it becomes available so that information could be used in the Subcommittee’s recommendations to the Legislature. Chairman Titus also agreed that additional information regarding the service component and how it coordinates with the rent component would be beneficial.
Debra Parra, Home Program Administrator, Housing Division, reported that the State of Nevada receives $3,008,000 from HUD intended for the non-entitled area. However, as the majority of the population resides in Clark County, it receives a portion of the HOME funds and Washoe County receives a portion of the $3 million, along with the $4.1 million of state funds. The local government decides what portion goes to Clark County. Ms. Parra says her job is to track the money being spent in the Home Program.
Chairman Titus asked how the $3,008,000 figure is determined. Ms. Parra responded that is the lowest amount any state can receive. Can Nevada raise the amount, Chairman Titus asked. No, Ms. Parra responded. Nevada’s population is not large so it receives the minimum amount. Clark County receives $4.1 million on its own. The $3,008,000 is only for the state and is based on population.
Chairman Titus questioned how the money is used outside of Clark and Washoe Counties, noting that disability needs in the rurals may be greater. Responding, Ms. Parra said the division funded the Frost Yasmer House (a HUD brain trauma project for the disabled) in Carson City. Ms. Parra reported she used HOME funds with the Tax Credit Project to lower rents. This year Elko will have fully rent-subsidized housing so that seniors pay only $30 or $40 a month. The division has a Home Owner Rehabilitation Program for the disabled and seniors. The rurals have a Rural Housing Program using Section VIII vouchers. The rurals are given money and seniors and the disabled are taken from the bottom of the list and funded until they are at the top of the list. They are then transferred to the HUD Program which will become a lifetime program for them.
Chairman Titus asked if local governments or agencies apply to the Housing Division for these funds and how the division decides what it will fund. Ms. Parra responded the division uses a formula developed to ensure every Nevadan receives $5 of HOME funds, regardless of where they live. Ms. Parra said she directly funds six counties, and they usually work through non-profits who handle the Home Owner Rehabilitation and Down Payment Assistance Programs. She works with Art Thurner on the multi-family programs and funds them in conjunction with the Tax Credit and Bond Programs.
Chairman Titus questioned if Ms. Parra thought the program was well advertised and if the disabled population was aware of the programs. Ms. Parra responded her programs are well advertised, but could not speak for others. More applications are received than there is money to fund them. She said she funded New Vista Ranch in Clark County in 1992 because it was not a project Clark County wanted to fund; it has been a great project.
Senator Rawson asked if a complex were to be developed for the blind, would it serve the blind better to house them in their own homes or to have a centralized smaller community. He asked whom correspondence would be directed to regarding this issue.
In response, Ms. Parra asked if Senator Rawson referred to an apartment-type complex or a subdivision-type complex. Senator Rawson stated he referred to an apartment complex. Ms. Parra said the Tax Credit Program would be a good place to begin. It would depend on how big the project was. A small four-plex could be built with HOME and Account for Low Income Housing (state trust funds). Projects with 10 to 20 units would have to use tax credits. The division has Discretionary Home Funds and Discretionary Trust Funds that can be used throughout the state. Ms. Parra said all correspondence regarding these types of projects should be directed to Mr. Turner.
Chairman Titus thanked Mr. Thurner and Ms. Parra and asked that they provide the Subcommittee with the BBC Special Needs Study as soon as it becomes available.
(National Association of Counties (NACO))
Robert Guernsey, Principal Deputy Fiscal Analyst, LCB Fiscal Analysis Division, reported that Robert Hadfield, Executive Director for the Nevada Association of Counties (NACO), lateraled this item to Clark County Social Service.
Bertha Warrick, Assistant Director, Clark County Social Service, thanked the Subcommittee for the opportunity to provide comments and said she would discuss the activities in Clark County rather than covering the NACO perspective. If the Subcommittee wants additional information, Ms. Warrick said she would transmit that request to Tracey Becker and have the information submitted to the Subcommittee in writing. Chairman Titus confirmed the Subcommittee would be interested in learning of the services provided by the various counties. Ms. Warrick read from her prepared notes as follows:
Our primary mandates are to provide medical and financial assistance to persons who do not have resources from other federal, state or community programs. Our programs are based on resource levels, i.e., assets and income guidelines under our eligibility standards. The bulk of our client population is comprised of working poor people who do not have private insurance. A portion of our client population is the disabled population who are not covered by other programs at the time of application. We assist these clients in the areas of medical and financial assistance as well as providing help in applying for other applicable programs specific to their needs.
The following are the types of services Clark County Social Service may provide the disabled applicant:
· Medical Assistance – We provide an eligible disabled person a medical card which will allow them access at the University Medical Center (UMC) outpatient clinic, UMC Quick Cares and, in the future, the Nevada Health Center sites. The card covers prescriptions, durable medical equipment such as wheelchairs, prosthetic devices, shower chairs, and other medical assistance devices such as oxygen therapy, intravenous therapy, and physical, occupation and speech therapy. Medical coverage extends to payments for long-term care, group care placements and homemaker services.
Clark County Social Service also provides medical services in coordination with other entities. We provide a donation to the Office of Veteran Affairs to provide veterans transportation assistance to Veterans Affairs (VA) hospitals out of state. Additionally, we provide operational funds, case management services and nursing evaluations for Caminar, a non-profit organization running Pedregal House, a Human Immune Deficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) group living situation; and we have a Ryan White Grant from the State of Nevada to assist qualified HIV/AIDS persons with Consolidated Omnibus Budget Reconciliation Act (COBRA) and Insurance Continuation premiums, co-pay and deductible payments.
In supporting other programs, we provide guarantees of payment for disabled clients who have applied for Medicaid programs and, should their Medicaid be denied, to ensure continuation of medical services while their application is being processed. Many medical providers do not wait on pending Supplemental Security Income (SSI) and Title XIX with a guarantee. SSI applications often take two or three years to process. We are the backup to ensure that if an application is denied, we will guarantee payment, sometimes in advance. On the financial side, if a person is pending SSI payments, we have a contract with the state and receive reimbursement so if a person has approved their SSI check, that check comes to us first because we have been giving financial grants the entire time that person has been pending. We receive the lump sum check from SSI, take the money we have provided and within ten days send them the balance of the check. From that point forward, they get their check directly from Social Security. We also pay for COBRA insurance continuation programs to provide uninterrupted insurance coverage for medically needy clients.
· In terms of financial assistance, we provide emergency rental dollars for clients who are at risk of homelessness. We also offer other rental assistance through federal grant programs to help pay for rent and utilities for both short-term and longer term needs for disabled clients. Specifically, for long-term needs, two years ago we received a five-year $750,000 Clark County Housing Assistance for Disabled (CHAD) Housing Grant for HIV/AIDS persons. We were able to pay for housing for six months for anyone qualified and eligible under this program. We pay rent for six months, inspection costs to get in, security fees, and give them a utility allowance. We were able to get 20 people in a year in semi-permanent housing and they have that housing for up to 5 years. Under an agreement with the state we pay monthly rental assistance to disabled clients while they are pending Temporary Assistance to Needy Families (TANF) or Social Security Disability payments under a reimbursement program. We also pay for other direct expenses for transportation needs, burials or cremations.
· In our efforts to refer to other agencies, we act as advocates on behalf of clients to apply for prior resources such as Nevada Medicaid, Veterans Administration, Medical Assistance for the Aged, Blind and Disabled (MAABD), Employers Insurance, Bureau of Rehabilitation along with other state agencies, non‑profits that work with the disabled, and available medical insurance coverage carriers. Since we have gotten into the COBRA business, we know a lot of insurance carriers and try to get some of these people back on their COBRA payments. We have gone back 12 months and picked up COBRA payments, even though typically one has 62 days to make that decision. We work as advocates to get people back on services if they need that service. We assist with the application process for clients and referrals to Mental Health, Substance Abuse Agencies and to disabled equipped apartment housing. We also intercede and advocate for disabled seniors who are abused, exploited, neglected or isolated.
· Looking at other county departments, although not an inclusive listing, there are services to the disabled in the Public Guardian’s Office in the form of guardianship over the person, estate, or both, and as a representative payee for the person unable to manage their income but who does not need the legal step of guardianship.
The Parks and Recreation Department has targeted an adaptive program for persons with disabilities. The newly formed Child Welfare Department, which has Child Haven as a component, has a cottage dedicated to children with special needs, both mental and physical.
The Community Resource Management Department which oversees multiple state/local/federal grants to subproviders has several projects that serve the disabled population countywide. Finally, the Clark County Housing Authority, an entity with a quasi-relationship to county government, has housing units set aside for disabled persons.
In conclusion, we acknowledge that the primary agencies doing extensive work with disabled populations are state agencies and specific large non‑profits such as Opportunity Village and the Nevada Association for the Handicapped; however, I believe our testimony shows that Clark County does have a role in providing services to the disabled citizens of Clark County.
Chairman Titus thanked Ms. Warrick for her presentation, adding that the services provided by Social Service are very impressive and expressed the Subcommittee’s appreciation for the information. She asked if there is one place a disabled individual can go to receive a list of all services available.
Ms. Warrick responded that an agency such as Endeavor, formerly knows as the Nevada Association of the Handicapped might have a listing, adding that her office would not shuffle an individual around. Social Service would determine the individual’s needs and match them with someone to assist them. It is very difficult for disabled individuals to get from place to place so Social Service acts as a case manager and works out a plan for each individual. If someone comes in and does not know anything about the agencies, they are connected with someone who will specifically be able to help them. In the next few months, a pilot program will begin whereby state workers will be co-located in Social Service buildings so that individuals can apply for food stamps, TANF, and Medicaid in our offices. Approximately 400 clients are shuffled between two offices every month. By law, Social Service is the payer of last resort; individuals must apply for state programs first.
Chairman Titus acknowledged the pilot program sounds great and asked about the senior pilot project, the Single Point of Entry.
Ms. Warrick reported the Senior Advocate Program is now part of the Clark County Department of Parks and Community Services. It is an information and referral service located in the Cambridge Center that gathers information in order to refer seniors to appropriate agencies. The Social Service senior service unit consists of the Protective Service Unit, the Long Term Care Unit, and the Homemaker Unit, all located in one area.
Chairman Titus reported that a one-stop shopping concept was the goal of the Subcommittee for the disabled population.
Ms. Warrick responded the Single Point of Entry is something the state has been attempting to establish. Larry Spitler initiated that idea a few years ago and Social Service brought it to fruition with the help of a Title III grant, the Older Americans Act. It was primarily funded by Clark County and that model will be used statewide for seniors. It might be a good idea for the disabled population to have a single point of entry. The needs of the disabled are so specific that an individual with more technical expertise than general social workers possess is required.
Chairman Titus asked if people are on waiting lists. Ms. Warrick responded long waiting lists exist for homemaker services. The list consists of disabled, seniors, and anyone over the age of 18 needing homemaker services.
Chairman Titus asked what homemaker services consist of. Responding, Ms. Warrick stated homemaker services consist of shopping, cleaning, laundry, personal care, and meal preparation. Social Service received an independent living grant from Title III to perform heavy labor outside the normal realm such as building wheelchair ramps, installing bars in bathrooms, landscaping, and trimming bushes so that the disabled have easier access to their homes. Technical items are purchased for the disabled that make their lives a little easier such as hearing assisted telephones. We have set up lifelines for people and paid for minimal telephone services so they have a line of communication. That has been a great service for disabled individuals and Social Service is trying to get that additional money although Governor Guinn has indicated it may be diverted to other projects. Our homemaker program provides us with $1.2 million; Productive Services is $750,000.
In response to Chairman Titus’ questions, Ms. Warrick responded the $750,000 is county money and the funds Governor Guinn may divert to other projects is $130,000 of tobacco funds.
Assemblywoman Chowning stated that the dedicated state and county employees never cease to amaze her, acknowledging they do not receive the recognition they deserve. Ms. Warrick’s testimony, she said, is so enlightening because the goal of the Subcommittee is to achieve dignity and independence for the disabled. The long waiting lists are disturbing and the constant interaction needed is frustrating. The one-stop shopping is what this Subcommittee is trying to achieve. If the Subcommittee could use Social Service’s prototype, the model that seems to be working in the senior area for the disabled, then it would have achieved the one-stop shopping it desires.
Ms. Warrick pointed out that one of the reasons agencies seek grants is because of the difficulty in obtaining personnel. Personnel come with grant opportunities, sometimes for as long as a year and that might need to be taken into consideration until the economic climate improves.
Assemblywoman Chowning reported that the 2001 Legislature had attempted to secure additional positions to address the need for grant funding, and felt that grant specialist positions were definitely an asset. With the goal to provide better service to foster care children, the bifurcated system was eliminated, and those children were placed under the jurisdiction of individual counties. Assemblywoman Chowning did not feel that solution would address the needs of the disabled population, however, felt all entities should work together to provide the best possible programming with available funds. The Subcommittee applauded the achievements of Clark County Social Services, and Assemblywoman Chowning asked that Ms. Warrick provide all available information regarding the prototype.
Chairman Titus asked Ms. Warrick if the state were to implement something like that for the disabled, if she had a suggestion as to where it should be located and who should operate it.
In response, Ms. Warrick suggested a location on Oakey. It is important to have a location where everybody is located. Agencies should be as co-located as possible. Paratransit has tightened the regulations on how people are transported and it has become very difficult for the handicapped. Social Service provides bus tokens for people in need of them but sometimes it is very hard. The Cambridge Center is a good model of where many agencies are co-located; everyone knows everybody’s eligibility and applicants can be processed quickly through the system because information is shared.
Chairman Titus remarked that the Subcommittee needs to hear what Washoe County and the rurals are doing and will schedule NACO for the upcoming meeting.
Chairman Titus thanked Ms. Warrick for her presentation.
Sydnie Schlachta, Transit Section, Planning Department, Nevada Department of Transportation (NDOT), informed the Subcommittee she represented Sandy Staneo who could not be in attendance. However, Ms. Staneo asked that any questions not answered today be forwarded to her and she would provide answers in writing. Ms. Schlachta introduced Jim Fraser, Waters & Fraser Transportation Research Group.
Ms. Schlachta said the Statewide Transit Programs help serve the disabled and elderly within the small urban and rural areas of Nevada. The Transit Program deals only with small urban and rural areas of the state. The urbanized areas of Las Vegas and Washoe County have their own metropolitan Regional Transportation Committees (RTCs).
Ms. Schlachta read from her prepared notes as follows:
The Statewide Transit Program is funded through the Federal Transit Administration (FTA) Section 5310, Section 5311 and Job Access/Reverse Commute programs and provides service to the small urban (under 50,000 in population) and rural areas of the state.
The FTA Section 5310 program provides capital funds for the purchase of Americans with Disabilities Act (ADA) accessible vehicles that provide service to the elderly and persons with disabilities throughout the state. This program requires a 20 percent local match. The FTA Section 5311 program provides operating funds for public and specialized (elderly/disabled) transportation in the small urban and rural areas of the state. This program requires a 50 percent match of the deficit operating costs (gross operating costs minus fare box revenues). The FTA Job Access/Reverse Commute program provides capital and operating funds for public transportation for welfare clients and low-income individuals to access jobs and the activities associated with finding employment. This program requires a 50 percent match.
Currently, Nevada Revised Statute (NRS) 408.271 provides 10 percent matching funds, approximately $40,000 a year, for the FTA Section 5310 program, which totals approximately $400,000 annually. In addition, match monies for FTA Section 5307 funds for Las Vegas ($250,000) and Reno ($125,000) are provided annually through this same NRS. No other NRS provides funds for the Statewide Transit Programs. The NRS governing gas tax funds precludes these monies from being spent on public transportation.
In 1999, through the efforts of Senator Lawrence Jacobsen, $300,000 in state General Fund was provided to NDOT to match FTA Section 5310 and FTA Section 5311 programs for the elderly and persons with disabilities transportation services in the small urban and rural areas of the state. Since that time, no other state General Fund has been appropriated for the Statewide Transit Programs.
Referring to page 2 of Exhibit F, the Fact Sheet for Small Urban and Rural Transportation, Ms. Schlachta highlighted the following information:
Number of Sub-Recipients
FTA Section 5310 – 58
Elderly Service Providers: 32
Disabled Service Providers: 10
Tribal Service Providers: 16
Rides Provided in 2001
Elderly: 322,479 rides
Persons with Disabilities: 152,426 rides
General Public: 80,347 rides
Grand Total: 555,252 rides
PRIDE Reno (16 months in operation): 72,692 rides
PRIDE Fallon (7 months in operation): 11,028 rides
PRIDE Minden (7 months in operation): 2,841 rides
Grand Total: 86,561 rides
Referring to the 20 percent local match required by the 5310 Program and the 50 percent match required by the 5311 Program, Chairman Titus commented that many of Nevada’s small communities are strapped for funds. She asked if those communities have trouble meeting the required match and if that would make them unable to apply for these funds even though they are needed?
Jim Fraser, Waters and Fraser Transportation Research Group, responded yes, but often they make matches of like kind such as property if, for instance, they are building a bus shelter or a transit center. The communities are very creative and take advantage of most of the matches. Much of it has to do with getting people to donate to services instead of buying bus passes. If a donation is made for bus passes it can be leveraged as a match.
Mr. Fraser said Waters and Fraser Transportation Research Group serves as project manager and has the responsibility of providing training for the state. That training has been provided for approximately seven years and includes ADA training for drivers and monitoring the Section 5310 and Section 5311 funding to ensure they operate in compliance. The Group also assists with new project start-ups. These project start-ups include systems start-ups as well as the development of transit coalitions, which are very important. The state coalitions are divided into four areas: northeast, northwest, central and south. The northeast and northwest coalitions are currently operating and the southern coalition is being developed. There is a meeting at the Pahrump Senior Center on April 26, 2002, at 1:00 p.m. to develop the southern transportation coalition. The coalitions are responsible for providing local administration of the NDOT programs and provide an excellent opportunity for community input in the local areas.
Continuing, Mr. Fraser said his Group also provides a driver training program and monitors ADA compliance. Gerald Waters, Mr. Fraser’s business partner who wrote the curriculum for Community Transit Association America, has dealt with ADA for many years and always tries to upgrade his program in terms of comment, content and materials. He is responsible for providing driver training to all service providers including ADA training dealing with sensitivity, empathy training and equipment operation. NDOT ensures the rural programs are provided with lift-equipped or accessible-transportation vehicles. Mr. Fraser reported that accessibility is very important to all programs currently under development. His office ensures that when vehicles are given out they are all accessible; however, many times they are not used frequently enough so we ensure that at least it is recycled and in operational condition. Much of this has to do with oversight and ensuring operators are trained. They also ensure the air conditioning is in proper working condition.
Mr. Fraser reported he is very excited about the Las Vegas system. A new start-up system is about to begin in Pahrump, and a new system has recently begun in Winnemucca and already their ridership is equal to some of the systems that have been in operation for years. There obviously is a need and the entire system is based on the coalition of people getting involved in the community. It is important to ensure there are more resources in the community and to ensure there is more input available for the community as to their local programs.
Assemblywoman Chowning remarked that as Chairman of the Assembly Transportation Committee she had the pleasure in 1999 of helping pass legislation for Medicaid Reimbursement and for additional flexibility in public transportation to allow individuals to be picked up at their homes and taken to their destinations. She asked how these programs were operating as she understood they had been very helpful to people with disabilities in obtaining job training in Clark County. She asked that Mr. Fraser let this Subcommittee know what specific innovative measures it could help accomplish in the upcoming legislative session.
In response, Ms. Schlachta said her department receives some help from Medicaid. They give bus passes in Elko quite regularly. Bus passes are also distributed in Fallon and Ely. Those are the three areas she knew of that were utilizing the job access program for bus passes. The department has smaller connectors throughout all small urban and rural areas operating along with the PRIDE systems. Sometimes those smaller connectors will go to an individual’s home and get them to the pickup point.
Mr. Fraser confirmed the information provided by Ms. Schlachta, adding that the Medicaid reimbursement is progressing with the development of the coalitions. The coalitions are trying to get operators statewide involved in the billing process. In some areas, the department is switching from selling tickets to utilizing passes. In terms of resources, in developing our course there is always a need to expand. There still exist pockets of people who are not getting the types of service they need.
Chairman Titus agreed a lot of the problem is lack of funding. However, the Subcommittee is looking for suggestions of what it can do in addition to providing more funding to ensure the entire process works more effectively and efficiently. Chairman Titus asked how NDOT interacts with the RTC in Washoe and Clark Counties.
Mr. Fraser responded his relationship with the RTC is very satisfactory. They have been very cooperative and supportive in developing the coalitions. They have also been very enthusiastic attenders of the statewide coalition meetings. Ms. Schlachta added she would take the Subcommittee’s request for suggestions to Sandy Staneo who would provide a more formal response to the Subcommittee.
Chairman Titus asked if Mr. Fraser or Ms. Schlachta had information regarding the RTC ballot question for additional funding and projects to be on the November ballot. Neither had information on the ballot question.
Senator Rawson said that transportation will always be an issue, adding that $5‑$6 million of tobacco funds have been allocated to build a life transition center, a one‑roof building that will house all non-profit services for the disabled, including transition beds. Construction on the center begins this year.
Senator Townsend agreed that Chairman Titus’ point about the two components of additional funding and the effectiveness of the funding are very important. He said that although Ms. Chowning made an excellent point that the Subcommittee applauds everyone who works in this arena because of their dedication, the systems in which they work may not be as coordinated as they could be, not by anyone’s fault. Establishing that coordinated effort might be the key to finding ways to increase effectiveness.
Brett Frey, Architecture Division, Nevada Department of Transportation, reported the division’s responsibility is the upkeep and construction maintenance of new buildings and facilities and takes an active role in the ADA compliance. In 1992, a $1 million contract was let to bring all state facilities up to ADA compliance. From then on all new projects, remodels and renovations have incorporated ADA accessibility. The department is current on ADA compliance in the state.
Mark Davis, Architecture Division, Nevada Department of Transportation, reported the contract let in 1995 was in response to the ADA of 1992 to bring all facilities into compliance for the disabled. All facilities were brought into compliance to the greatest degree possible within architectural constraints. That included all state rest areas, welcome centers, headquarter buildings, and any facility that might have public access. In addition, the division tried to accommodate ADA accessibility at maintenance stations for other public agencies that might be utilizing gas facilities, etc.
Chairman Titus suggested a credibility gap exists between what the Subcommittee is hearing from the agencies and what people in the disabled community are saying they need. As we move toward one-stop shopping, perhaps what is needed is an ombudsman for the disabled to serve as an intermediary when this Subcommittee no longer exists.
Assemblywoman Chowning asked if NDOT had indeed made all the shelters ADA compliant. With the intent of presenting recommendations to the 2003 Legislature, what specific recommendation can the department offer the Subcommittee regarding ADA and state compliancy?
In response, Mr. Davis reported an assessment of all structures should be made by each department to determine how compliant they are and then determine what the dollar value would be to bring them into compliance. Funding, however, has always been a problem. If funding is not directed at the ADA, the department tries to accommodate each project as it progresses to bring everything into compliance.
Chairman Titus asked Mr. Davis if he knew about the RTC ballot question to which he replied he did not.
Chairman Titus suggested the Subcommittee send letters to the various agencies that have testified requesting they submit in writing a list of recommendations to be considered in the work session. In response to Chairman Titus’ question, Leslie Hamner responded the Subcommittee recommendations must be completed by September 1, 2002.
Tina Gerber-Winn, Chief of Continuum of Care Services, Division of Health Care Financing and Policy, Department of Human Resources, read from her prepared notes as follows:
I supervise Medicaid’s home and community-based service programs for the disabled and elderly. These programs include Nevada’s four waiver programs, home health agency services, personal care aide services, hospice, and nursing facility placements. I appreciate the opportunity to discuss the current state of services offered by Medicaid in light of a recent presentation offered by Steven Gold of the Public Interest Law Center.
Historically, our state has not kept pace with the rest of the country in providing community-based services to prevent institutionalization. However, this trend is being broken. Staff within the Department of Human Resources is working diligently to develop new program initiatives in home and community-based services while providing recipients with greater freedom to self-direct those services. I would like to discuss the activities and statistics specifically occurring within the Division of Health Care Financing and Policy’s programs in regard to home and community-based waivers, personal care aide, home health and nursing home placements. During the past five years, Medicaid waivers have expanded dramatically thanks to legislative recognition of the need to provide for individuals in the least restrictive setting. The information presented in this testimony is derived from federal reports which are submitted to the Center of Medicare and Medicaid Services on an annual basis for each of Medicaid’s waiver programs. These waivers include the Waiver for the Elderly, commonly known as Community Home-Based Initiatives Program (CHIP), the Group Home Waiver, the Mental Retardation and Related Conditions Waiver, and the Physically Disabled Waiver. Dr. David Luke from the Division of Mental Health and Developmental Services will be discussing activities specific to his agency and the Mental Retardation and Related Conditions Waiver.
Based on most recent federal reports, Nevada has experienced a 22 percent increase in recipients being served under the waiver programs since 2000. The number of individuals served has risen from 2,233 to 2,722. Specifically, the Physically Disabled Waiver has shown a growth rate of 240 percent with an increase from 103 unduplicated recipients in 1997 to 251 in 2001. The Waiver for the Elderly in Group Care has shown a growth rate of 255 percent with an increase from 65 unduplicated recipients in 1997 to 166 in 2001. The CHIP waiver has shown a growth rate of 30 percent from 955 unduplicated recipients in 1997 to 1,240 recipients in 2001. (Ms. Gerber-Winn referred to Tables I, III and V, pages 33, 35 and 37, in the Meeting Packet.)
The services available under each waiver have increased in the past five years in an attempt to improve the programs as well. Personal emergency response systems, expanded attendant care, chore services, respite services, environmental accessibility adaptations, extended transportation, assisted living services, independent living services, home delivered meals, specialized medical equipment and supplies, and preventive dental services were added to the Physically Disabled Waiver in 2000. Personal emergency response systems and chore services were added to the CHIP waiver. The enhancement of these waivers is viewed as vital to the prevention of institutionalization and quality of life for waiver recipients. It also reflects the department’s intention to address concerns of an institutional bias within the Medicaid State Plan.
This is best reflected in Tables II, IV and VI, pages 34, 36 and 38, in the Meeting Packet, which show the cost per recipient over the last five years.
In 2001, Nevada spent $23.67 million on its waiver programs. Adding in the cost of non-waiver, or Medicaid State Plan services, the total cost of care for waiver recipients in 2001 was $36.29 million. We do not have final numbers for 2001 for our Physically Disabled Waiver because each waiver has a different renewal year. Some waivers run from December to December while others run from October to September. This amount almost doubles the 2000 waiver expenditures reported in Dr. Gold’s presentation.
Chairman Titus reported the Subcommittee appreciates the updated numbers as Dr. Gold’s presentation made Nevada look quite bleak. Ms. Gerber-Winn assured the Subcommittee her numbers are the actual numbers submitted for expenditures under the waivers. She added she did not know if they included state plan dollars. Waiver services are usually less expensive when state plan costs are added, which is the entire Medicaid Service Package. That obviously increases the amount spent on each individual. Ms. Gerber-Winn continued:
The final costs for this particular waiver will not be available for several more months based on the established waiver year.
The department recognizes the importance of maintaining community placement. The two aging waivers have always recognized the need to deinstitutionalize nursing facility residents. These individuals receive priority on their waiting lists for the CHIP and Group Home Waivers. The Physically Disabled Waiver procedures are being revised to acknowledge the need to serve individuals who are in nursing homes and Medicaid recipients in institutions for rehabilitation who are eligible only in this setting. These individuals will be given a higher priority on the current waiting list in an attempt to avoid long-term institutionalization.
In January 2001, the division completed a major overhaul of its Personal Care Aide (PCA) Program. This change added several benefits and created a new provider type: Personal Care Aide Provider Agencies. These agencies became responsible for the recruitment, scheduling and training of personal care attendants. Some agencies are also offering self‑directed care based on a fiscal intermediary model. This change has addressed recipient concerns over a lack of trained attendants and back-up issues. The back-up concerns for a disabled person refers to the need to be assured that if their scheduled caregiver fails to show that there will be another service provided to step in.
Service hours are now authorized utilizing a functional assessment tool. This tool allows for more hours of service than previously offered with a maximum of approximately 61 hours of personal care a week. This has allowed more authorized hours of service for the most severely disabled individuals currently being served. At the end of 2001, the recipients serviced under the PCA program totaled 918. This figure includes approximately 300 individuals who have transitioned over from Home Health Agency services within the last 15 months. The number of recipients served has grown 30 percent since the program was modified, with a total cost of $8,452,000 for the year.
The change in the PCA program was expected to decrease the utilization of Home Health Agency (HHA) services. In the past, this service has been used to cover temporary skilled hours of treatment as well as the chronic need for personal care aide services. The later usage was based on the lack of available PCA providers. Since the change in the PCA program, HHA utilization has decreased but not to the degree expected. An analysis of authorizations revealed that many of the assigned nursing hours is still necessary for the maintenance of community placements for severely disabled individuals, especially children with special health care needs. These individuals require the completion of intermittent skilled services as well as complex personal care tasks. Without the support of HHAs, it is apparent these individuals would not be maintained at home successfully. The demand for private duty nursing is likely to continue given the movement to maintain disabled individuals at home. It is important to note that creating access to home and community-based services will put increased pressure on the demand for nursing resources in Nevada. It actually takes more caregiver resources to maintain an individual at home than in an aggregated institutional setting.
As a point of clarification, agency records indicate 1,488 recipients received home health services in 1999, which is markedly different than the 350 reported by Dr. Gold. The cost for these services totaled approximately $6.9 million. Utilization of Home Health services has remained relatively stable over the past five years until 2001. In 2001, 1,712 recipients received Home Health services, which illustrated an 18 percent increase in utilization. Since late 1999, Home Health Services include home-based Physical, Occupational, and Speech Therapies as part of available Medicaid services. In the past two years, expenditures for in‑home therapies have increased by 71 percent, illustrating the desire to train and serve individuals in the least restrictive setting.
Staff regularly tracks the occupancy rate of nursing facilities throughout the state. In the past five years, the industry has built approximately 1,000 additional beds, primarily in Las Vegas. However, the addition of these beds has not dramatically impacted the number of Medicaid recipients being placed in such institutions. The population of Medicaid recipients residing in nursing homes has increased gradually, averaging approximately 3 percent per year, over the last five years. (Please refer to Tables VII and VIII, pages 39 and 40, in the Meeting Packet.) This compares quite favorably to the rate of growth of the Medicaid Aged, Blind and Disabled population over the same time period, which was over 5 percent per year.
Staff developed a Long-Term Care Task Force with the nursing facility industry in December of 2000 as a means to address such issues as payment and administrative practices. Part of the discussions related to the need for development of affordable assisted living opportunities, which could be housed in existing facilities with vacancies. Efforts to progress this cause will continue.
In late 2000, division staff began modifying its nursing home oversight process in an attempt to streamline reimbursement and care review. This reorganization lead to the development of the Facility Oversight and Community Integration Services (FOCIS) program. Division staff will continue to evaluate the appropriateness of payment to facilities as part of this service. Additionally, staff will work to identify and assist interested nursing facility recipients to develop a plan to re-enter the community. This work is in its beginning stages and has been challenging, as many residents are not interested in participating. Most are concerned about making another major change and no longer feel they have the community supports available, especially housing, to make this transition successful. Given this feedback, staff will add another strategy to their activities in an attempt to decrease or divert the number of individuals being admitted to nursing homes.
Staff is partnering in a pilot project with the Division for Aging Services, the Nevada State Welfare Division and Washoe Medical Center to develop a nursing home diversion program. This activity will provide assessment, information and referral, and eligibility assistance to individuals in an attempt to shorten or divert nursing home placement. This activity is expected to expand throughout the state as funding and staffing becomes available.
The division currently operates the Rehabilitation Case Management Services (RECAMS) program. This program has been in existence for the past 11 years and is based on a legislative initiative to provide long‑term services to traumatically brain injured individuals. The RECAMS program offers assessment, extensive rehabilitation, and care management in an effort to prevent institutionalization and to promote the highest level of physical functioning possible after injury and institutional rehabilitation. Recipients are offered life skills training as a means to improve independent functioning. Toward the end of the rehabilitation period, services are offered at day treatment centers and in the recipients’ own homes in an attempt to prepare for independent living. This program assists approximately 50 to 75 recipients monthly.
Besides the previously mentioned changes, the division staff is also making other efforts to improve the availability of home and community‑based services. Activities to refine the services offered under the Physically Disabled Waiver and the Mental Retardation Waiver are under way. This includes community meetings to discuss service provision as well as the improvement of policy, procedure, and coverage. Staff is also working to define expanded levels of payment for assisted living or group homes in an attempt to properly reimburse for services provided in these facilities and expand the opportunity for long-term placements.
Revisions in the policy governing Adult Day Health Care are also anticipated. These changes should expand the usefulness of the service for those caregivers striving to maintain an individual at home with limited assistance. Staff is also holding meetings with advocates and parents in an attempt to develop a Special Needs Day Care Program for children. It is hoped that this service will allow parents to maintain employment by providing medically appropriate day care for their disabled children in an integrated setting.
Nevada has also capitalized on the federal initiatives to provide community-based care by applying for and receiving two systems change grants. These grants are intended to improve the quality of services provided to individuals by creating sustainable service delivery modifications, which support community-based living. The Department of Human Resources has partnered with the Department of Training and Rehabilitation to study the need for Personal Assistance Services in an attempt to improve current delivery models and to provide reliable numbers on future need. Within the Department of Human Resources, the Health Division, Community Connections, and the Division of Health Care Financing and Policy will be working together using these federal grant funds to formalize service delivery networks. This will assist parents with disabled children to more efficiently access services on a statewide basis. While our history was less than ideal, our current performance demonstrates improved responsiveness to the needs of disabled individuals. The Governor and the Legislature have shown a commitment to improving home and community-based initiatives through the funding of Assembly Bill 513, the Nevada Strategic Health Plan. This planning initiative addresses the broad needs of Nevadans including seniors, individuals with disabilities as well as the unique needs of rural communities.
Thank you again for the opportunity to speak to this very important matter. I am available for any questions you have.
Chairman Titus thanked Ms. Gerber-Winn for her excellent presentation and for gathering the information for the Subcommittee. She asked what the state provides in terms of funding or assistance for respite care for caregivers. Responding, Ms. Gerber‑Winn reported the division provides respite only under waiver programs. Under the Physically Disabled Waiver there are a certain number of hours allotted each month for respite. The Division of Aging has respite available under the CHIP Waiver. The Personal Assistance Task Force covers how to replace caregivers and how to prevent burnout as statistics indicate family care giving is the most available resource to maintain people in the community.
Mary Liveratti, Administrator, Aging Services Division, Department of Human Resources, said the division has respite services only under the waiver program, but under the Independent Living Grants, funded through the Tobacco Settlement monies. A request for proposal has been let for respite services for family members caring for an individual 60 years of age and older. There is a respite request for proposal for seniors caring for a minor child 18 years of age or younger. The division is attempting to expand respite services, but currently provides a variety of respite services through the Independent Living Grants, which include not only respite in the home, but respite in adult day care centers and residential care. Respite services are also provided under the Alzheimer’s Demonstration Grant, federal funds matched with Independent Living Grant funds. These programs provide vouchers for family members to use in a variety of settings, whether to go into the home and provide personal care, companion-type services, care in an adult day care setting, or residential care to allow a family respite for a brief period of time.
Chairman Titus stated she wanted to ensure that no members of the disabled community “fell through the cracks” and asked if there was a way to broaden that program or to ensure it is available for everyone. Responding, Ms. Gerber-Winn said part of the issue is for Medicaid to fund services because respite is a social-based model, not a medical‑based model, which is difficult to fund. It is impossible to fund that under a state plan program. Therefore, it is under the waivers. The division is investigating changes for adult day health care because it is a social–based model. Also, it is somewhat medical, somewhat social, and staff is examining ways to expand the availability of that service which would be an out-of-home caregiver situation, and to examine if that should be under a waiver to allow expansion of that service to include respite.
Assemblywoman Chowning stated that in the past, private agencies and the state community college system have taken special needs children into their day care and child development programs. There is an excellent facility in Clark County. She asked if the division was attempting to develop a special needs day care program and if they were working with existing programs. Responding, Ms. Gerber-Winn said the division has held a meeting with community representatives, people already providing special needs day care services or who have an interest in the development or expansion of current services, people who have successfully cared for children with special health care needs. The division is attempting to determine what is available, how it is funded, and will then determine how to enhance or copy it to allow people greater access to day care.
Mary Wherry, Deputy Administrator, Nevada Medicaid Office, clarified that during the meeting it was identified that waiver programs are not well advertised and opportunities exist for children who currently are in unique situations for funding for medical services. That will become the focus through the development of that community discussion. The concern is how to fund those specific services. We do not want to isolate those children in a day care unique to them, but rather to integrate them into a day care that exists for all children, similar to any other environment of care.
Paul Gowins, Rehabilitation Program Specialist, Office of Community Based Services, Department of Employment, Training and Rehabilitation, said DETR has two programs that provide respite services. The Personal Care Attendant Program provides respite to families. There were approximately 26 different organizations providing respite to children. Services are available but they are very limited in meeting the needs.
Ms. Wherry stated the Medicaid Office is attempting to create a single point of entry system on a statewide basis. That does not mean there is only one place to go for the answers; there are multiple access points but wherever someone goes they will receive information on the entire spectrum of services.
Chairman Titus asked if that would be a good model to adapt for the disabled community as well as for seniors. Ms. Wherry responded Medicaid is using funding for seniors but is trying to build a model that would be able to expand to a human service model based on the national 211 system. Instead of having different 800 numbers for each group, similar to 911, there would be 211 numbers to call for human services. An individual would be directed to the desired service. This would make it much easier and simpler for a consumer to obtain the desired information. This model could be expanded to groups other than seniors and their families.
Mr. Gowins reported the Department of Aging has been very cooperative in attempting to ensure that people with disabilities are included in these developments so that all populations can utilize them. The pilot program is not being developed in isolation. Sue Robinson has coordinated with the State Independent Living Counsel to provide ramps and various services in Clark County. The Department of Aging is not working alone, nor is Clark County.
Ms. Wherry reported the population of individuals with dementia disorder continues to grow for institutionalization. It is not in-state growth, but rather out-of-state growth. These are individuals with historical psychiatric disorders with behavior problems who are challenges for the nursing facilities. Currently, there are 77 people out-of-state in nursing facilities. Federal rules related to opportunities involving Medicaid and Medical Waivers have opened up within the last year and the division is examining what it can do to expand those rules prior to someone leaving an institution for waiver services. That was not allowed in the past. A very small number of people with traumatic brain injuries (TBI) are being treated through our programs. Part of the difficulty with those programs is that some of the services are questionable with regard to being a state plan allowed service. The division is examining whether it can perform a cost neutral waiver without additional funding. There are opportunities with additional funding to expand some of the services available for people with TBI that would only be allowed under a waiver situation.
Update of the
Development of Strategic Health Care Plans by the
Department of Human Resources
Michael Willden, Director, Department of Human Resources, reminded the Subcommittee that The Rensselaerville Institute is the contractor chosen to work on both the Disabilities and the Seniors Strategic Plans. The last few weeks have been a struggle with the contractor. In the beginning, the process was met with a great deal of enthusiasm by everyone interested in this issue. The contractor came on board in December and the process of dovetailing those two processes has been very difficult. The individuals who have worked on this issue are very concerned that they not lose meaning or intent to some of the issues and the contractor has not understood how important some of the issues are. That was made clear to him last night and the contractor has committed to move forward. The contractor simply needed a better understanding of how much work has been performed and how important it is to preserve the work of the committees and to ensure nothing is lost in the translation.
Exhibit J, Mr. Willden reported, lists the 30 deliverables the contractor is working on. Ten of the 30 have been delivered, and others are in various stages of completion. Five of the 10 have been accepted. Negotiations are being held to get the other deliverables to an acceptable standard, which should occur within a few weeks. The Disabilities Committee is behind schedule while the Seniors Committee is on schedule. After the meeting with the contractor last night, the contract will be amended slightly to move money to various points and change some of the deliverables.
Continuing, Mr. Willden said Exhibit K lists the milestones and targets remaining for completion of the project. These will be modified in the next few weeks, but the project is on schedule for completion in September.
Chairman Titus asked if the division will have recommendations for the Subcommittee in time for its work session. Mr. Willden responded yes. A large portion of the draft document will be available by July 15, 2002.
Exhibit L is a sample of the process the contractor goes through to develop the Strategic Plan using fictitious data. Briefly, the process is as follows: identify the global target areas; identify the targets to fine-tune the target areas; rationale; strategy; verification; estimated costs; and relevant data. The difficulty has been to take the bulk of the work of the task forces (identified in Exhibit M and Exhibit N), and sorting, prioritizing and moving them into a strategic planning format. The contractor has been asked to take the work of the committees for review in approximately two weeks. With or without the contractor, the division will make it work.
Senator Rawson inquired if the contractor had been paid. In response, Mr. Willden said $60,000 had been paid for five of ten deliverables. The key deliverables are to be completed in the next two months. Senator Rawson suggested the division hold back enough money to solve the problem should the contractor bail. Mr. Willden assured Senator Rawson he is monitoring that situation very closely.
Chairman Titus thanked Mr. Willden for his presentation.
Debbie Hosselkus, Deputy Administrator, Division of Mental Health and Developmental Services, Department of Human Services, read from her prepared notes as follows:
To my left is Dr. Dave Luke, Associate Administrator for Developmental Services, and to my right is Dr. David Rosin, Medical Director for the division, as well as Southern Nevada Adult Mental Health Services. Our presentation will be on the division’s efforts to be in compliance with the Olmstead decision by emphasizing least restrictive community-based services for persons with mental illness and developmental disabilities. Dr. Luke will be presenting the efforts of the Developmental Disabilities agencies and Dr. Rosin will focus on the mental health agencies. The State of Nevada supports Olmstead with the limitations of the resources we have. The division, through its vision, and Governor Kenny Guinn and the Legislators through their leadership and support, has been meeting the expectations of Olmstead for well over ten years. Let me first share with you the tremendous support the division has received from the Governor’s Office, as well as bipartisan support from the Legislature.
In the 1995 Legislature, the division received an 18.47 percent biennial increase of $20 million. In the 1997 Legislature there was a 33.84 percent biennial increase of over $45 million. The 1999 Legislature and Governor Guinn provided a 25.22 percent biennial increase of over $45 million and the 2001 Legislature and Governor Guinn provided a 23 percent biennial increase of $52 million. Table I (page 33 in the Meeting Packet) shows a breakdown of these increases between mental health and developmental service agencies. Most, if not all, of those increases went toward funding community-based services.
The division’s service vision for well over the past decade has been a community-based, customer-driven support model. This vision has driven the division’s budget planning, preparation and implementation.
Table II (page 34 in the Meeting Packet) breaks out the number of mental health non-institutional and institutional residents as of April 1, 2002. The majority of the division’s clients are receiving services in a community‑based program.
Dr. Dave Luke, Associate Administrator, Developmental Services, Department of Human Resources, read from his prepared notes as follows:
I understand that at an earlier meeting you were provided information regarding Nevada’s efforts in the area of community living for people with mental retardation and related conditions. Whereas that information was through 1996, today, I will provide information that fills in the activities of the state from 1996 through the current biennium.
Developmental Services is a part of the Division of Mental Health and Developmental Services that provides services through three regional centers: Dessert Regional Center in Las Vegas, Sierra Regional Center in Washoe County, and Rural Regional Center in Carson City. The primary role of the Regional Centers is to serve as a central coordinating function for services, planning, purchase of services, and coordination of other services for people with mental retardation or related conditions. We have had a vision for over a decade of providing a community-based living system where people can live in the community and have a great deal of direction over their life. Continuing developments in the field such as the Olmstead decision supports and affirms this approach. Governor Guinn and the Legislature have been very supportive of these efforts. While we continue to face significant challenges as the fastest growing state, we have likewise had many accomplishments.
In order to help fund community living, we have aggressively expanded the home and community-based waiver for people with mental retardation and related conditions. Table III (page 35 in the Meeting Packet) is a depiction of the growth in the waiver slots through this biennium. We have expanded from 180 slots in 1995 to 1,182, a growth of more than 650 percent. This funding with the associated state match provides supported living arrangements (SLAs) for people, as well as jobs and day training, and family respite. Each person served by the Waiver would otherwise qualify for institutional care. This means that we support well over 1,000 individuals in community alternatives to institutionalization.
The state dollars needed to use the Waiver are phased-in over the biennium, meaning that we continue to take people off the waiting list for residential services over the course of the entire biennium. At this time, there will be funding during the biennium for 167 more people in residential supports. There are currently 176 people on the waiting lists.
We are currently looking at the Waiver in order to better use it to support community living for people with more pervasive support needs and to further empower choices for people and families as they live in the community.
One of our greatest and continuing challenges is the growth of Nevada. As can be seen in Table IV (page 36 in the Meeting Packet), in 1996 we served 1,705 people; as of today we have nearly doubled services and are now serving nearly 3,100.
Growth is happening faster than we anticipated. Much of this can be attributed to the addition of services for persons with related conditions beginning in 1998. We added this service population subsequent to the Parry lawsuit. These are individuals who have diagnoses such as epilepsy and cerebral palsy that require assistance similar to what people with mental retardation need.
People with related conditions constitute 27 percent of all new cases and now account for 11 percent of people in service. Many of these are children.
Table V (page 37 in the Meeting Packet) shows our progress in providing community living options. We are budgeted to support 1,216 persons in community living, a 137 percent increase since 1996. Nevada ranks high in providing community living for persons in personalized, small settings of three or fewer people. Seventy-one percent in Nevada are in these settings versus 39 percent nationally. We rank 7th among the states.
Senator Rawson interjected that this is one of the goals.
Continuing, Dr. Luke said that simultaneous with our community growth, the state-run institutional beds have been reduced from 172 to 134, a 22 percent reduction. This means that nearly 90 percent of all residential support is provided in community settings.
Nevada never has had many institutional beds compared to the national average and we have been decreasing. We have less than 8 per 100,000 population, which places us 35th nationally; the national average is 17 per 100,000 (200 report-Braddock).
During the mid 1990s we used our facilities and expanded community living to bring more than 25 people back from out-of-state institutions. Since then, we have continued to put all new growth into community living; and since 2000 we have reduced state run beds by 36.
The people remaining in institutional settings have the most extensive disabilities and will require higher level and more specialized supports to attain community living.
In terms of expenditures, Table VI (page 38 in the Meeting Packet) displays the tremendous support provided for developmental services by the administration and Legislature. Since 1996, annual funding has increased from $26 million to $66 million, a 146 percent growth. Even more dramatically, the community-funding portion has grown from $11.6 million to nearly $44 million, a 277 percent increase.
Chairman Titus expressed her pleasure at these numbers, saying that the Legislature and Senator Rawson can take a great deal of credit for making this a priority. The Governor as well made it one of his priorities last session. Much emphasis has been placed on this subject over the last three legislative sessions, and Chairman Titus reported she is happy to see it pay off.
Dr. Luke responded the state continues to face challenges, but certainly many gains have been made. Dr. Luke continued:
Table VII (on page 39 in the Meeting Packet) shows the growth in the number of people served and the improved access to services. With your help, each region has added dedicated intake workers so that applicants are being evaluated and qualified for services in an average of two months. This is one-third the six-month average in 1996. Currently, applicants represent 3 percent of persons in service versus more than 6 percent in 1996.
There will always be some people on waiting lists as people plan and transition their moves. Also, some of the new people coming into services add to waiting lists. Our goal is to continue to move people from the waiting lists.
As you can see, that at our current growth rate, 1,000 more people will apply for services by the end of the next biennium in June of 2005.
A few other key points about Nevada:
· As one of the first states to provide cash assistance to families, we now provide 338 low-income families with cash assistance when they care for a family member with a severe or profound disability. This averages about $260 per month;
· We provide payment to Community Training Centers and others to support jobs and day training for 1,449 people. Of these, 522 are in competitive jobs or small work enclaves in state businesses. This amounts to an $8 million budget for private providers in fiscal year 2003;
Chairman Titus asked if incentives are offered to businesses that hire people with disabilities. Dr. Luke replied some incentives exist. He said the division works cooperatively with Vocational Rehabilitation and some job counselors are able to work with businesses to explain what incentives exist and how businesses can benefit. Chairman Titus emphasized the importance of offering incentives to businesses to hire people with disabilities. Every dollar earned by an individual contributes to their support, Dr. Luke said. He continued his presentation:
· 90 percent of our services are through accredited programs;
· 654 families have been given respite grants this year; and
· 196 families receive regular paid in-home care to help them maintain a family member at home.
As you are probably aware, Assembly Bill 513 provides for the development of a strategic plan for services through the Department of Human Resources. The plan addresses aging, rural health, disabilities and provider rates. We are participating in this, along with various stakeholders, to create a vision of how services should be in the future. The evaluation of provider rates for persons with disabilities is scheduled to be completed in time for budget development for the next legislative session.
I hope this information helps reassure you about the positive direction and accomplishments here in Nevada’s programs, while giving you some idea of the challenges we face while going forward.
Chairman Titus thanked Dr. Luke, and complimented him for doing an outstanding job.
Assemblywoman Chowning expressed the Subcommittee’s gratitude to the wonderful people who had worked so tirelessly through the years. Table V (page 37 in the Meeting Packet) is of such pride to see the community programs spike up versus the state hospitals and she felt sure Senator Townsend was also very pleased. She complimented the many training programs that allow the disabled to work full time in the community.
Dr. David Rosin, Medical Director, Division of Mental Health and Developmental Services and Southern Nevada Adult Mental Health Services (SNAMHS), read from his prepared notes as follows:
As Debbie Hosselkus has indicated, the division and the State of Nevada have been meeting the expectations of Olmstead for well over the past ten years, and it is committed to continuing to expand community-based mental health services to meet the state’s growing need. The Division’s mental health agencies offer a full range of community-based services, including emergency services, outpatient counseling, medication clinic with availability of newer generation medications, psychosocial rehabilitation, personal service coordination and a variety of community‑based residential supports such as residential treatment programs, group care supported living arrangements, intensive supported living arrangements and special needs beds. All these offer individualized levels of care to foster enhanced independence. During the 2001 Legislative Session, as a result of enhanced and proposed residential alternatives, the division was successful in reducing SNAMHS hospital capacity by 7 beds to the current total of 78 beds with a licensed capacity of 86, while increasing the non-institutional placements by funding 8 intensive support living arrangements and 12 special needs beds in the community. The Northern Nevada Adult Mental Health Service (NNAMHS) hospital beds were reduced by 10 beds to the current 40 beds, with a licensed capacity of 74. As a result of this reduction, 7 new positions were added to the Psychiatric Emergency Services (PES) and 12 intensive supported living arrangements were funded. The division commitment to community-based services has resulted in the addition of Parents and Children Together (PACT) teams in the north and south, intensive personal service coordination in the south, and a statewide suicide crisis hotline.
The following is data provided to us by the national Association of State Mental Health Program Directors 1999 Survey. Table VIII (page 40 in the Meeting Packet) shows the increases in revenues for mental health services from fiscal year 1981 to fiscal year 1997. Table IX (page 41 in the Meeting Packet) shows the expenditures for inpatient care and community-based programs from fiscal year 1981 to fiscal year 1997. Table X (page 42 in the Meeting Packet) shows Nevada’s expenditures between inpatient care and community-based programs compared to the national averages. As you can see, the national average for expenditures of community-based programs is 56 percent, while Nevada’s expenditure is 75 percent. The national average for expenditures for inpatient care is 41 percent and Nevada’s expenditure is at 24 percent. Tables XI and XII (page 43 and 44 in the Meeting Packet) display Nevada’s expenditures for mental health for fiscal year 1981 and fiscal year 1997 comparing state hospital inpatient programs to community-based services.
Nevada currently ranks 35th in actual dollars and per capita expenditures. That same survey ranked Nevada 47th when it comes to the state per capital expenditures for state hospitals. This low ranking reveals that Nevada is placing more emphasis and resources on community-based services. Nevada ranks 20th in expenditures for community-based programs.
In conclusion, if a suit is brought under Olmstead, the division and the state are in a legally defensible position with respect to its budget choices, planning and with respect to the services it provides. It is our strong belief that based on the statistics and the facts of the matter, it is not likely that the division would lose on the Olmstead issue.
This concludes our presentation and we would be more than happy to answer any questions.
Chairman Titus thanked Dr. Rosin for the reassurance he gave the Subcommittee.
Linwood Gallagher, consumer and advocate for the blind, thanked the Subcommittee for its efforts on behalf of one-stop shopping. When he came to Nevada in 1991 he complained because it did not appear there was a willingness of agencies to coordinate with one another. Subsequently, an advocacy group was formed in Carson City that approached services for the blind asking them to compile a list of available services and distribute them to the blind population. When no progress was seen, the Legislature was approached and a bill was presented. That bill was withdrawn prior to session and as it was a matter of confidentiality as to who the author was, the matter was not pursued further. While one-stop shopping is a great idea, consumers see this quite often as a vehicle whereby it becomes an umbrella organization whose funds become limited, services prioritized, and certain minority groups within the minority find themselves without funds. The blind is a minority group within the minority and this has happened to the blind several times. He expressed hope that the Subcommittee would keep this in mind and make recommendations to prevent this from occurring.
Chairman Titus thanked Mr. Gallagher for his presence at the meeting. She reported she had worked considerably with Jean Peyton on the issue of the blind and assured Mr. Gallagher she recognized the importance of the group. She reiterated Senator Rawson’s earlier point regarding what channels to go through to establish a residency for the blind, saying that is certainly on the Subcommittee’s agenda. She reassured Mr. Gallagher that when the Subcommittee refers to one-stop shopping, in no way will it be an excuse to cut funding or to consolidate programs to serve fewer people. That is not the intention of this Subcommittee and the record of the people on this Subcommittee clearly shows that is not the direction in which it is moving.
Steven Sampson told the Subcommittee that people with disabilities need the funding now and his recommendation is to do whatever is needed to get the funding to the disabled in as rapid a manner as possible.
Paul Gowins agreed that the Subcommittee hears from individuals testifying that everything is going well; however, when they walk from the room they know that is not what they will hear. The various departments have done a good job and have taken the led of this Subcommittee, and in particular Senator Rawson and Chairman Titus, in working with the assets they have. The disability community has noticed and appreciates that fact. There has been improvement and he stated that in his capacity as the Independent Living Counsel staff person. He reiterated that the counties often provide many services. The RTCs, he said, are definitely struggling to provide transportation to people with disabilities. Clark County’s funding alone is approximately $18 million short and they struggle to find funding simply to continue the services they have. He encouraged the Subcommittee to have agencies present recommendations on what it can do to remove some of the barriers that exist. Carson City is in the process of incorporating as a transportation entity and there may be something the Legislature can help them with. The state has done a very good job ensuring ADA compliance and has made great strides. The housing agency is probably one of the most cooperative groups to work with, but they are one of the most limited in funding. Their funding sources are not that great and to meet the needs of affordable, accessible housing, many issues will have to be examined. Opportunity Village is an organization the Subcommittee might want to hear from. Enforcement of the Fair Housing Act in Nevada has been nil to none. Several groups are working to incorporate better enforcement of fair housing so that buildings meet at least the minimum standards. This Subcommittee has brought pressure to have the issues of the disability community dealt with and he believes those efforts are being met.
Chairman Titus thanked Mr. Gowins for his comments. She suggested the next Subcommittee meeting would include presentations from some of the agencies he suggested such as RTC, fair housing, and the other counties. She would also like to hear from the advocacy and private groups that support the various agencies.
Mary Evilsizer is Executive Director, Southern Nevada Center for Independent Living; Vice Chair for the Adult Services Subcommittee on the Disability Task Force; and serves on the State of Nevada Independent Living Advisory Counsel. The Center, she said, has been approached by the City of North Las Vegas Housing Authority as well as the Clark County Housing Authority to support them in applying for more funding and vouchers for individuals with severe disabilities as well as for seniors. She reported that in other parts of the nation Centers for Independent Living are trying to rally their housing authorities to apply for such funding to increase the housing options. Housing will always be a problem but she commended all housing authorities for their initiative in this effort. When the Center met with the RTC both agencies agreed to undergo three training sessions from the RTC to learn exactly what their standpoint is. It will then be taken into the community so that other consumers and professionals can learn from that prospective. It is not an ADA issue with RTC, but a customer service issue. The Single Point of Interest Grant is being facilitated by the Nevada Division on Aging and has been very gracious in inviting the disability community to participate in their project.
Ms. Evilsizer read the following letter from Dr. Thomas B. Pierce, Ph.D.:
Senator Titus and esteemed committee members.
I am sorry that I am not able to be with you today, but a previous university appointment has precluded me from attending your meeting. I have asked Mary Evilsizer to read these comments to you. Currently, I am the chair of the Adult Subcommittee for the Disability Task Force, a member of the Task Force on Disability and Aging, and a member of the Steering Committee. As I spoke to you last, I have been integrally involved in the process of developing the state plan for people with disabilities. I have been very impressed with the progress made by the numerous service providers, organizations, and consumers with disabilities.
Over the past several months the Subcommittee on Adults has worked many long hours developing issues that will be addressed in the plan. These issues have come from the hard work of the disability community. Many of these meetings have been used to develop specific goals, objectives, and strategies to improve services for Nevadans with disabilities. Many of these meetings have included heartbreaking accounts of how Nevadans with disabilities have been hurt, ignored, or neglected by the system.
Our original intent was to identify issues to be included in the state plan. What we noticed was the commitment among those participating to develop specific strategies to remedy systemic problems that interfere with independence and meaningful community participation. This group of more than 100 individuals, representing every disability group, showed great courage in trying to unravel the problems in the service delivery system. We were proactive in our attempts to find out the truth of statements by researching each and every issue. We wanted to make sure that the issues that were set forth were real issues and not urban myths perpetrated by rumor. I am very confident that the plan that will be forthcoming will be an honest description of service strengths and gaps in the current system. More importantly, the plan will be the voice of people with disabilities.
I am also confident that people with disabilities will tackle the very hard decisions of prioritizing these issues into a plan that will be thoughtful and meaningful. So far, each and every time we have met, people have come to unanimous agreement on strategies for the plan. We have been diligent in our resolve and finally see that the community of people with disabilities will be included in meaningful participation in decisions about their lives.
On a personal note, I must tell you that none of this could have been done without the support of state staff, most notably Donny Loux and Jeanelle Mulvenon. I do need to say a very special thank you to Director Mike Willden. I have never seen an individual in state government who is so supportive, knowledgeable, and compassionate. Mr. Willden has been instrumental in making sure that the plan we put forward is inclusive of all disability groups and that all voices are included. I am very grateful to his intelligent and thoughtful questions. This process simply could not have gone this far without his help. I will be eternally thankful to him for his wisdom.
I am confident that the plan you will soon receive will be one that is fully inclusive, rich in strategic planning, and respectful of individuals who have been excluded from participation in the democratic process. I thank you for this opportunity to participate in this process and assure you that I have learned more than I ever expected about the real lives of people with disabilities.
I again apologize for my not being able to attend your meeting. I hope that if there is anything that I can do to assist you, that you do not hesitate to contact me.
Thomas B. Pierce, Ph.D.
University of Nevada Las Vegas
Chairman Titus thanked Ms. Evilsizer for her presentation and asked that the Subcommittee be kept informed of the developments with the training and the RTC.
The next meeting of the Subcommittee is tentatively scheduled during the week of June 25, 2002.
There being no further business before the Subcommittee, the Chairman adjourned the meeting at 12:49 p.m.
Senator Dina Titus, Chairman
Copies of exhibits mentioned in these minutes are on file in the Research Library of the Legislative Counsel Bureau, Carson City, Nevada. You may contact the Library at (775‑684-6827).