MINUTES OF THE MEETING OF THE
LEGISLATIVE COMMISSION’S SUBCOMMITTEE TO
STUDY THE STATE PROGRAM FOR PROVIDING
SERVICES TO PERSONS WITH DISABILITIES
August 6, 2002
The minutes of the Legislative Commission’s Subcommittee to Study the State Program for Providing Services to Persons With Disabilities (created by S.C.R. 32 of the 71st Session), was called to order by Senator Dina Titus, Chairman, at 9:47 a.m. on August 6, 2002, at the Grant Sawyer Office Building, 555 East Washington Avenue, Room 4401, Las Vegas, Nevada, and via simultaneous video conference at the Legislative Building, 401 South Carson Street, Room 3137, Carson City, Nevada. Exhibit A is the Meeting Notice and Agenda Packet; Exhibit B contains the Attendance Record.
SUBCOMMITTEE MEMBERS PRESENT IN LAS VEGAS:
Senator Dina Titus, Chairman
Senator Raymond D. Rawson
Assemblywoman Vonne S. Chowning
Assemblyman Jerry D. Claborn
SUBCOMMITTEE MEMBERS EXCUSED:
Senator Randolph J. Townsend
Assemblywoman Sharron E. Angle
LEGISLATIVE COUNSEL BUREAU STAFF PRESENT:
Bob Guernsey, Principal Deputy Fiscal Analyst, Fiscal Division
Jim Rodriguez, Program Analyst, Fiscal Division
Leslie Hamner, Principal Deputy Legislative Counsel, Legal Division
Carol Thomsen, Interim Secretary, Fiscal Division
EXHIBIT A: Meeting Notice and Agenda Packet.
EXHIBIT B: Attendance Records.
EXHIBITC: Packet of material to correspond with PowerPoint presentation, submitted by Jacob Snow, Regional Transportation Commission of Southern Nevada.
EXHIBIT D: Packet of material presented to the committee by Steven Dickerson.
Senator Dina Titus, Chairman, called the meeting to order and commented that during the recent 18th Special Session of the Legislature, which focused on the medical malpractice issue, and as the health care crisis and service delivery problems were discussed, it was discovered that some of the issues addressed in that debate were also very relevant to the issues before the Subcommittee. Chairman Titus recognized persons who wished to testify before the Subcommittee from the Carson City location, and advised that testimony would be heard in relation to Agenda items.
At the completion of roll call, Chairman Titus asked Bob Guernsey, Principal Deputy Fiscal Analyst, Fiscal Division, Legislative Counsel Bureau (LCB), to bring the Subcommittee up to date regarding what had occurred since the April 17, 2002, meeting. Mr. Guernsey advised that LCB staff had worked closely with Michael Willden, Director of the Department of Human Resources (DHR), and his staff, along with Donny Loux, Chief, Office of Community Based Services, Department of Employment, Training, and Rehabilitation (DETR). He noted that Ms. Loux had been instrumental in the development of several items included in Exhibit A, Tab VII, which contained a draft regarding the strategic plan for persons with disabilities. Mr. Guernsey indicated the DHR anticipated a deadline of August 16, 2002, for submittal of its recommendations, which would fit quite closely with the Subcommittee’s September 1, 2002, deadline. Mr. Willden would present testimony regarding initial recommendations to the Subcommittee when it held discussion on Agenda Items VI and VII.
According to Mr. Guernsey, the DHR had received as many as 270 recommendations as a result of the tremendous amount of work put forth by numerous persons and groups in meeting to develop the recommendations. The recommendations encompassed a long‑range plan, rather than an attempt to initiate “overnight programs, and it was Mr. Guernsey’s understanding that the final plan would span a time frame of ten years. Mr. Willden would review recommendations during his later presentation.
Budget-wise, stated Mr. Guernsey, the Subcommittee had sufficient funds within its budget to support one additional meeting, which could be in the form of a work session.
Chairman Titus thanked Mr. Willden and the DHR staff, and noted it had been wonderful for the Subcommittee to work side-by-side with the department. She felt that, while it would not be feasible or reasonable to expect that all the department’s recommendations would be endorsed, it was reasonable to expect that there would be some that would become proposed legislation.
Chairma Titus called for a motion to approve the minutes of the Subcommittee’s April 17, 2002, meeting.
SENATOR RAWSON MOVED TO APPROVE THE MINUTES OF THE APRIL 17, 2002, MEETING OF THE LEGISLATIVE COMMISSION’S SUBCOMMITTEE TO STUDY THE STATE PROGRAM FOR PROVIDING SERVICES TO PERSONS WITH DISABILITIES.
Assemblywoman Chowning indicated there were corrections that should be made in the minutes, and she would work with the secretary to the Subcommittee to address those corrections.
ASSEMBLYWOMAN CHOWNING SECONDED THE MOTION, WITH THE STIPULATION THAT CORRECTIONS WOULD BE MADE PRIOR TO FINALIZATION OF THE MINUTES OF THE APRIL 17, 2002, MEETING.
Chairman Titus noted that Senator Rawson concurred with that stipulation.
THE MOTION CARRIED UNANIMOUSLY.
Chairman Titus opened discussion of Agenda Item IV.
Tracy Becker, Program Coordinator, Nevada Association of Counties (NACO), came forward to address the Subcommittee, and introduced Ken Retterath, Director of Adult Services, Washoe County Social Services Department, who would present testimony on behalf of Washoe County. Ms. Becker noted that representatives from Clark County had previously testified before the Subcommittee, and she would provide information regarding the rural counties.
Ms. Becker indicated that NACO had initiated research to determine what services were being provided in rural counties to persons with disabilities. It was determined that rural counties were basically providing the same level of service to the disabled community as was provided to other individuals that qualified for assistance under county guidelines. Those services included medical assistance, rental assistance, assistance with utilities, and assistance with the purchase of prescription medications.
According to Ms. Becker, she contacted representatives from most of the rural areas including Carson City, and Douglas, Lincoln, Humboldt, Lyon, and Esmeralda Counties. It was determined that, in general, county entities worked closely with the senior centers which offered services such as Meals on Wheels, homebound checks, and assistance with transportation to medical or other appointments. Ms. Becker indicated that many rural counties conducted home visits for persons with disabilities, along with phone interviews for those unable to come into the offices. The smaller counties would take whatever action necessary in order to reach and assist disabled persons. Ms. Becker reiterated that there were no “special” or alternative programs available for disabled persons in the rural areas of the state.
Chairman Titus noted that was perhaps one of the problems facing the Subcommittee, and inquired whether procedures had been initiated in rural counties to identify persons with special needs, and to determine whether that population was growing, and where it was located. Ms. Becker advised that many rural counties depended on disabled persons initiating contact and seeking assistance, however, Douglas County actually held a monthly meeting with its senior center to discuss methods of providing assistance to the county’s senior and disabled population.
Chairman Titus inquired whether rural counties had identified methods by which the Legislature could assist in facilitating the delivery of services, or in identification of disabled persons. She wondered whether it would be simply a matter of financial assistance, or whether internal county organizational problems existed. Ms. Becker remarked that in many of the rural areas, it was simply a matter of money, however, believed Mr. Retterath could better address that question.
The Subcommittee was attempting to develop recommendations that could be presented to the Legislature for consideration during the 2003 Session, stated Chairman Titus, and she wondered whether Mr. Retterath could enlighten the Subcommittee regarding possible legislative assistance in delivery of services to disabled persons at the county level. Mr. Retterath concurred that there was a definite lack of money in the rural counties when it came to the matter of providing services. He emphasized that he found it difficult to speak for the rural counties, as the issues faced by Washoe County were considerably different. Mr. Retterath noted, however, that in meetings with NACO and various human service administrators, the issue of finances, or the lack of money to provide services, was discussed quite often.
Mr. Retterath informed the Subcommittee that he would like to present testimony regarding the programs offered by Washoe County. He reiterated that programs in Washoe County served all those in need, and pointed out that counties generally did not have categorical programs such as those offered by the state. Washoe County did, however, have at least three programs which served predominately disabled individuals. The first was the General Assistance Program, which offered cash assistance and included a category for the disabled. That category included both long-term and short‑term disabled persons. The program provided a supplemental cash grant to those persons who had applied for Social Security benefits, and were waiting for final determination and disbursement of those benefits, receipt of which could take anywhere from 18 to 24 months.
Mr. Retterath noted that the Subcommittee had heard previous testimony relative to the method of reimbursement to the counties for services provided, and he would not offer further testimony in that area. One question that arose was how to define “disabled,” whether it was short- or long-term, and whether it would include a person with a broken leg, or persons involved in life-altering situations. Mr. Retterath explained that Washoe County’s Group Home Care Program provided group home placement for persons who had no place of residence, and suffered from a medical illness. It was generally a short‑term program for persons who were receiving medical or other treatment that would enable them to leave the program once treatment was complete.
According to Mr. Retterath, the third program was the Medicaid Match Program that also included a nursing home program through which Washoe County provided payment for persons residing in nursing homes. Mr. Retterath explained that Washoe County was involved in a project under the auspices of the United Way entitled, “Integrative Case Management,” which included computerized case management across the spectrum. The program was not designed to satisfy the needs of any one group, stated Mr. Retterath, but rather was designed as an “across the board” program, and would address the disabled population, the homeless population, and service providers within the community. Mr. Retterath advised that it was being considered as a possible statewide program, and existed through the United Way’s “Tapestry Program.” The technology in that program would provide case management in a computerized format. Mr. Retterath stated that his testimony was only a brief overview of the programs available through the Washoe County Social Services Department as he knew them. Mr. Retterath went on to say there could be other programs within the county of which he was unaware.
Assemblywoman Chowning stated the Subcommittee would like information regarding additional programs Washoe County would like to initiate, should funding become available, and the best method of bringing additional services to the community. Assemblywoman Chowning expressed the Subcommittee’s appreciation of the programs currently made available to the disabled at the county level. She added that the Subcommittee would be interested in hearing what the counties felt the Subcommittee could do to help improve the process and make more services available to the people that needed them.
Mr. Retterath acknowledged that better coordination of services was needed, and Washoe County was attempting to address that issue through the integrated case management program. The nursing home program was also being discussed with state officials, which included three separate programs: (1) The Medicaid Program, which paid a portion of the costs; (2) The county/state match program; and, (3) The county nursing home program. According to Mr. Retterath, one of the frustrations was that many entities shared responsibilities in those programs, however, did not “sit in the same room.” For example, the Welfare Division actually conducted the eligibility portion of the county match program, while Medicaid actually paid the bills. In addition, other divisions also had some interactions or responsibilities with the program, which often led to a breakdown in communications. Some coordination in the combination of services would be helpful.
Assemblywoman Chowning asked whether Mr. Retterath agreed with the goals of the Subcommittee, and others involved in interim studies, to develop coordination of services, and in the development of a “one-stop shop” concept for services. Mr. Retterath replied agreement with that concept would depend on the definition of the “one‑stop‑shop” concept, but did believe coordination of services was necessary. Assemblywoman Chowning stated the Subcommittee would appreciate further assistance from Washoe County in assimilating legislative recommendations for the 2003 Session. While it was always helpful to have persons attend hearings and present testimony, it would be more beneficial for persons to actually participate in building the coalitions, to ensure greater success. Mr. Retterath remarked that he had met, and would continue to meet, with Ms. Loux at DETR, in an effort to continue the process.
Chairman Titus stated that since the Subcommittee began, it had heard repeatedly about the need for additional coordination and, while the term “one-stop shop” was somewhat vague, the Subcommittee was searching for a method to move in that direction, similar to the “single point of entry” concept for senior programs. Chairman Titus noted that Mr. Retterath had addressed certain programs available in Washoe County, and inquired whether there were programs available that would specifically target the mentally ill population. Mr. Retterath replied that Washoe County currently had no programs specifically designed for the mentally ill, but the county did serve the mentally ill population through its general assistance program for the disabled. Mentally ill individuals were removed from the normal process and were case-managed by a social worker versus an eligibility worker. Mr. Retterath emphasized that Washoe County did serve that population, but did not have a specific program for the mentally ill.
Mr. Retterath indicated that one of the dangers surrounding the “single point of entry” concept, and integrated case management programs, was that if several entities, such as disability groups, aging population groups, and homeless groups, created individual systems, it would simply create a more computerized system which basically operated in the same manner as the current system. Mr. Retterath believed it was extremely important to look at the broad picture when considering the issue of services to the disabled, and determine how to design a system that would cross all boundaries, because the different groups had many issues in common. He indicated it was imperative that services to the disabled be reviewed with the broad picture in mind.
Ms. Becker explained that rural counties did not distinguish whether individuals were disabled or mentally ill, and simply provided assistance to everyone. Assistance depended upon qualification under a county’s indigent guidelines, which was generally based on income.
Chairman Titus inquired whether Bertha Warrick, Assistant Director, Clark County Social Services, would like to address the Subcommittee. Ms. Warrick indicated she had provided testimony to the Subcommittee previously, however, since that time, Clark County continued to work with the State Welfare Division, and had actually co‑located some state workers within the county offices, in order to provide assistance to the whole spectrum, rather than a “single point of entry,” even though they remained two distinct systems. Ms. Warrick explained that the county and state had approximately 400 cases in common, and were constantly moving disabled people back and forth between state and county entities. Those state employees located in county offices continued to conduct state business onsite, which provided educational benefits to both county and state employees, while simplifying the process for joint constituents, many of whom were either physically or mentally disabled. Ms. Warrick indicated the program was enjoying some success in the area of client satisfaction, and ease of manageability for both the county, which provided monetary assistance to clients, and the state, which provided program management.
Ms. Warrick reported that when the county dealt with disabled persons, the process was quite lengthy, and required that the county allocated money “up front” for such clients. The county then had to wait for as long as five years until those persons accessed disability benefits and realized ongoing income. A person could not be stabilized until the source and level of income was available. According to Ms. Warrick, until that point was reached, the county simply conducted “patchwork” social work, such as providing public or affordable housing at the county rate. She noted that once a person qualified for disability, the possibility existed for better housing. Ms. Warrick reiterated that the time factor for eligibility for disability created many problems for the county, and if programs could be coordinated to shorten that period of time, the county could devise better methods of providing services for that population. At the present time, stated Ms. Warrick, the county was simply attempting to fill the gaps, which was all that could be done at the county level. She believed that issue should be addressed by the state, and a shorter timeframe would cause a change in programming at the county level to respond to the availability of programs.
Chairman Titus voiced the Subcommittee’s appreciation to Ms. Warrick for her input, and indicated that type of information would assist the Subcommittee in addressing the problem areas.
With no further testimony forthcoming regarding Agenda Item IV, Chairman Titus opened discussion on Agenda Item V.
Presentation by Clark County and Washoe County Regional Transit Commissions (RTC) on Transportation Services Provided to Persons with Disabilities
Senator Rawson pointed out that Exhibit A contained a letter from the Washoe County RTC, which indicated that 1,199,000 senior disabled rides on Citifare constituted 24 percent of Citifare’s total rides, which appeared to be in error, and should be somewhere in the vicinity of 14 percent. Gregory Krause, Executive Director, Washoe County RTC, apologized for the error, and indicated the statistic should read 1.9 million rides, which would equal 24 percent.
Jacob Snow, General Manager, RTC of Southern Nevada, commenced with a PowerPoint presentation, accompanied by a printed packet, Exhibit C. The presentation depicted the Citizens Area Transit, Americans With Disabilities Act (CAT ADA) paratransit vehicles, and Mr. Snow explained the RTC had begun the process of replacing its entire fleet over the past year. By the end of the year, the RTC would have an additional 59 vehicles to complete the changeover of the fleet. Mr. Snow noted that Assemblywoman Chowning had asked what more the Subcommittee could do, and he indicated the RTC had been working with a group of disabled and senior advocates under the auspices of the County Commission for the past six months, and had also worked with the Senior Advisory Council. That council presented a number of recommendations, specifically in the transportation arena, and the RTC had gladly participated in that process.
Those recommendations, stated Mr. Snow, included expansion of the Silver Star Service, which had been the recipient of a significant benefit from the State of Nevada, Division of Aging Services, via funding to support two new Silver Star routes. Mr. Snow advised that the Silver Star Service was a transit-based program and specifically focused on seniors with disabilities. To facilitate that program, the RTC utilized 17-passenger vans to access senior housing complexes, and provided “front door” service from a persons home to doctor’s offices, grocery stores, government facilities, and recreational facilities. Mr. Snow remarked that there were three Silver Star routes currently in operation, and the Division of Aging Services had agreed to fund two of those routes for a period of two years. The RTC could add an additional dozen of such routes, because transit services currently available on fixed routes were simply not accessible to persons with disabilities. According to Mr. Snow, there was a huge gap between services provided by the RTC for persons with disabilities and the services provided for the severely disabled, who qualified for the Paratransit Service Program. Mr. Snow explained the RTC had attempted to improve the quality of its fixed route service through initiation of a new program, Silver Star Service, to meet those needs. Mr. Snow indicated the Senior Advisory Council also recommended that the RTC review its fixed route service and contemplate route deviation, to ensure that senior complexes were more adequately served.
The previously discussed concept of a “one-stop shop” to provide services for the disabled had also been discussed by the council, specifically in the transportation arena, and Mr. Snow noted there were a number of private providers of transportation for disabled persons, along with public providers such as the RTC. The proposal and group consensus focused on the large, very active, and professional RTC call center, and it was recommended that resources and staff be augmented at the call center, in order to provide a “one-stop shop,” or clearinghouse, for transportation information for the disabled.
Mr. Snow commented that, by nature of the operation, the Paratransit Service Program scheduled 3,000 rides per day, and those rides and the number of people changed on a daily basis. There were over 25,000 persons currently certified for the program, but that changed on a daily basis, which necessitated a change in routes every day. Mr. Snow explained that the RTC utilized a computer program to determine daily routes and, by law, the RTC was required to provide as many rides as requested by persons eligible for paratransit service. According to Mr. Snow, that was quite an “octopus” to manage when the rides changed so dramatically on a daily basis. Quite often, the vans were not completely full, and there was space for additional persons to ride.
Mr. Snow stated the RTC would like to search the community and identify those disabled persons who did not qualify under the Paratransit Service Program, and provide rides if there was a vacant spot. Those persons could call the night before a scheduled ride to ascertain whether there was a vacant spot, and whether the route was in the vicinity where they needed to be dropped off and picked up, so that the RTC could accommodate them. The RTC could take such action if it could ensure that the 25,000 persons qualified for paratransit were not being denied a ride. Mr. Snow believed there was room for improvement in that regard.
Chairman Titus asked Mr. Snow to explain to the Subcommittee how a person became qualified for paratransit service. Mr. Snow stated that everyone, by federal law, and by right, was entitled to ride on the “big bus,” or the larger vehicles operated on fixed routes by the RTC, according to the ADA. The RTC provided busses on the CAT fixed route system that were fully accessible by the disabled population. Mr. Snow explained that the RTC provided paratransit service for those individuals who were so severely disabled physically or cognitively that they could not access the “big bus.” To determine eligibility for paratransit service, a functional assessment was conducted, both physical and cognitive, by a team of doctors and physical therapists. Requirements included the ability to walk one-quarter of a mile in less than ten minutes, and the ability to negotiate curbs.
Chairman Titus inquired whether a person could simply apply to the RTC office for the paratransit service. Mr. Snow stated that a person could contact the call center, and the RTC would send a paratransit bus, whether or not they were eligible, which would transport them to the facility where an assessment would be conducted by a team of doctors and physical therapists. Chairman Titus inquired about funding for the service. Mr. Snow explained that the RTC received capital assistance from the Federal Transit Administration for the coaches, however, funding for the operating portion of the program was realized from the one-quarter of 1-cent sales tax, approved as part of Question 10 in 1991. Was there anything in Exhibit C which would cause a Question to be placed on the upcoming ballot, inquired Chairman Titus. Mr. Snow replied in the affirmative, and stated there was another Question 10 that would be on the ballot, and all services previously described up to this point would be funded from the proceeds associated with the new Question 10. The only service the RTC would be able to provide, if Question 10 did not pass and the Legislature did not take subsequent action, would be the route deviation services from its fixed routes. Mr. Snow stated when he first joined the RTC approximately three years ago, there were 2,000 rides a day scheduled on paratransit, and at the present time, 3,000 rides a day were scheduled. He believed the demands of the community were quickly outstripping the RTC’s ability to meet those demands.
Chairman Titus inquired whether the RTC could apply for additional federal funding. Absolutely, stated Mr. Snow, the RTC would apply for funding, but noted that in the past, Nevada had not been very successful in recovering its gasoline tax dollars allocated to the federal government for transit. The state did well regarding roadway funding, however, in the area of transit, did not compete well because of the lack of programs that included rail transit. Mr. Snow was pleased to report it appeared that this year, for the first time ever, the RTC would receive more in federal funding for transit than had been received in the past. Nevada had always been a “donor” in the past, but for the current year, would receive more funds that it had put in. If the program passed, the RTC would have the local match to leverage what it calculated conservatively as $3 billion in assistance from the federal government for transportation over a 25-year period.
Continuing his testimony via the PowerPoint presentation and Exhibit C, Mr. Snow stated he would discuss a few of the ways the RTC had improved its paratransit service over the last few years. The population growth had necessitated the retention of 12 older vehicles in service simply to meet the demand, and the on-time performance had improved from 88 percent to 98 percent. Mr. Snow explained that the RTC currently provided door‑to‑door service, where in the past, customers were required to sit by the curb, exposed to the elements for as long as one-half to one hour. Mr. Snow indicated that was not a desirable situation for the sensitive nature of the RTC’s clientele, and that was the reason the door-to-door service was initiated, which had resulted in a huge increase in demand for the service, because the quality and reliability had greatly improved.
Mr. Snow addressed the scheduling software required to handle the volume of rides which had been based on a Disk Operating System (DOS) in the past, and noted the RTC currently utilized a Windows system. The PowerPoint presentation and Exhibit C depicted the difference between the DOS and Windows automated scheduling systems. The new Windows system had resulted in a 25 percent increase in productivity, explained Mr. Snow, without adding new vehicles. The RTC now had a new communication system added to its fleet, which was equipped with satellite transceivers. When a person’s ride was late, a call could be placed to the RTC’s call center, and the vehicle could be tracked on satellite to ascertain the location, which had proven to be extremely helpful in improving the reliability and quality of the system. Mr. Snow reported that new radios allowed the driver to “push a button” to send a “canned” message rather than picking up the microphone and waiting for a clear signal and for information to be transferred.
Mr. Snow advised that a new service specifically designed for the disabled, entitled Citizens Area Transit, Specialized Transportation Access Routes (CAT STAR), was depicted by a picture included in the PowerPoint presentation and Exhibit C, and featured Assemblywoman Chowning with members of the Endeavor Program. According to Mr. Snow, the service was also offered to Opportunity Village and two other disabled groups throughout the Las Vegas valley area. The RTC had “skirted” around the requirements of the ADA, because of the limitations, and that had been accomplished through creation of the special CAT STAR service, which was not technically categorized as paratransit. It was really fixed-route service, explained Mr. Snow, because on a daily basis, the same group of persons were picked up and transported to Opportunity Village to work. The RTC coordinated the service directly through Opportunity Village, which then coordinated with its clientele. Mr. Snow remarked that the same driver picked up the same group of people at the same time every day, which insured that the vehicle was full. The driver then transported those persons to Opportunity Village and picked them up at the end of the day. Mr. Snow indicated that had really improved the RTC’s efficiency. Those routes were driven during the morning and afternoon hours, and during the down time, the RTC used the vans for Silver STAR (Specialized Transportation Access Routes) service. Some of the advantages pointed out by Mr. Snow were: (1) Consolidated trips to fewer vehicles; (2) More rides available on regular CAT ADA paratransit system; (3) Each agency communicated directly with passengers to ensure service; (4) Eligible riders still used paratransit for all other rides; and, (5) Cost was significantly lower per trip.
Assemblywoman Chowning referenced the picture contained in the PowerPoint presentation and Exhibit C, and noted that she had asked to visit the Endeavor Program to meet some of the persons utilizing the training program implemented by the 1999 Legislature. The program was initiated through the dedicated work of those involved with the RTC and Opportunity Village. Assemblywoman Chowning explained that funding for the CAT STAR program was very innovative, and utilized Medicaid reimbursement, which had not been available as a source of funding in the past. The program provided training for disabled persons in order to secure employment, and Assemblywoman Chowning stated she had been informed that one person had secured a full time job in the community college system, which was but one of the success stories. Before initiation of the CAT STAR transportation program, persons often missed the “big bus,” which necessitated waiting for the next bus in less than ideal weather conditions. Assemblywoman Chowning indicated the CAT STAR program made the clientele very happy, because they knew the driver that picked them up both morning and afternoon. She emphasized that it really was a success story.
Assemblywoman Chowning asked whether the demand was greater, and whether Medicaid reimbursement provided sufficient funding for the CAT STAR program. Mr. Snow advised that the demand on the program was incredibly high, and the RTC did not have enough vans or operating systems to meet that demand. Half of the cost of one trip was eligible for Medicaid reimbursement and at the close of the last fiscal year, reported Mr. Snow, the RTC had for the first time received approximately $1 million through its cooperation with the state toward reimbursement from the federal government. Mr. Snow explained the RTC expected that the current fiscal year would approach approximately $2 million in reimbursement. According to Mr. Snow, it was not sufficient funding for the program, however, the RTC was extremely grateful to receive that reimbursement; he noted there was a tremendous demand for that type of service, and if the ballot Question passed, the RTC could do a better job in meeting that demand.
Mr. Snow continued his testimony with a short video presentation to the Subcommittee that depicted the Silver STAR service at a home for seniors in Henderson, Nevada. The video pointed out how drivers actually assisted disabled passengers with such things as the unloading of groceries. Mr. Snow explained it was a terrific service that had lowered costs considerably and addressed the specific needs of community facilities, i.e., group homes and senior facilities, where routes were specifically designed.
In conclusion, Mr. Snow emphasized that the RTC of Southern Nevada looked forward to being able to meet the needs of the community. If the ballot Question did not pass, the community would be faced with additional reductions in transit service, and an increase in fares. Mr. Snow explained that the ability of the RTC to continue to meet the basic needs of the community would depend on passage of the ballot Question.
Chairman Titus recognized the worry about a decrease in funds, because such programs were usually the first to suffer cuts, as they served a select clientele that was not a large voting or vocal population, even though transit programs were much needed. Mr. Snow concurred, and stated the aforementioned programs were not mandatory, and the possibility existed for elimination of both the Silver STAR and CAT STAR service, and the return to a program that simply accommodated those persons who met the requirements under the law. Chairman Titus noted that the RTC had been prudent in coordinating efforts with senior facilities and the Division of Aging Services. Mr. Snow believed the RTC had developed a very good relationship with state agencies it worked with, however, there was much more that could be done, particularly in coordinating with private sector providers of transportation services, in an effort to establish a “one-stop shop” for transportation services for the disabled.
Gregory Krause, Executive Director, Washoe County RTC, introduced Lea Rogers, Paratransit Coordinator, who was the primary author of the material contained in Exhibit A, Tab V. Mr. Krause thanked the Subcommittee for the opportunity to discuss services and challenges facing the RTC in its efforts to meet the transportation needs of the disabled community in Washoe County.
Mr. Krause explained that Citifare was the primary public transportation system in the Reno/Sparks area, and carried approximately two million people that were senior and disabled, the majority of which suffered some type of disability. The RTC also operated a small van service, CitiLift, which offered door-to-door service similar to that offered in southern Nevada. According to Mr. Krause, the cost for each person served on the primary bus system was approximately $1.35 in taxpayer subsidy, and each door-to-door trip cost almost ten times that amount, or approximately $15.00 in subsidy. In some cases, the RTC absolutely had to provide the door-to-door service because the disabilities were such that the person could not physically board the busses. The RTC worked in partnership with the Northern Nevada Center for Independent Living (NNCIL) to ensure that the transit needs of disabled persons were met, however, it was critical to the RTC that whenever possible, the primary bus service was utilized by persons able to access those vehicles. Mr. Krause emphasized that CitiLift was a very critical part of the RTC’s service to the disabled, but was used for a smaller population, and made approximately 235,000 trips per year. Mr. Krause stated the Subcommittee had been very gracious in allowing him to discuss the challenges facing the RTC, and the manner in which it might provide assistance.
The situation facing the RTC in Washoe County was very similar to that in Clark County, and Mr. Krause believed it was doing a good job in meeting the needs of the disabled population, however, was not able to keep up. The RTC in Washoe County also relied on sales tax as its major funding source to pay for both Citifare (large busses), and CitiLift (small busses or vans). Mr. Krause noted that some things the RTC had undertaken in an effort to improve and become more efficient in service delivery and in meeting the needs of the disabled, centered on the way that service was provided. He explained that during the late evening hours, there was a very limited demand for the CitiLift service, so the RTC used taxicabs to address those rides, which had greatly reduced the cost and, in some cases, made it even more cost effective than using the larger vehicles. During the day, it was impossible to use taxicabs, because the rider volume was too high, but Mr. Krause indicated it worked very effectively in the evenings, and the RTC had been utilizing taxicabs for several years.
Regarding passenger incentive, Mr. Krause explained that persons were offered a free trip after they had made 50 trips on the CitiLift system without having a cancellation or “no‑show.” Because the trips were scheduled in advance, and utilized a fairly complicated computer system that allowed the dispatching system to optimize which vehicles served which trips, a cancellation or a “no-show” created a gap and inefficiency. The RTC had found that incentive to be very positive in ensuring that people who scheduled trips were on time, and also ensured that the vehicles were being used as effectively as possible.
Mr. Krause noted that the CAT STAR service in use in Clark County was very similar to Washoe County RTC’s “shoppers routes.” Those routes had been very effective and accessed the concentrated senior housing projects in order to transport seniors to areas that encompassed essential shopping services. Mr. Krause indicated the RTC relied on that service, and encouraged seniors to report where they needed to be transported, so the RTC could meet those needs to the best of its ability. The real challenge was resources, and Mr. Krause stated the RTC had been unable to keep pace with the growth of the senior population in Washoe County, which was over twice the rate of general population growth. Per Mr. Krause, that trend would continue, and the CitiLift service was being threatened by the slowdown in the economy, as the RTC also relied on sales tax revenue. As the Subcommittee was aware, that revenue source was decreasing, therefore, the RTC would be unable to continue providing the same level of service without fare increases. Mr. Krause advised that the RTC would approach its board for a possible 25 percent increase over the next 18 months in both the Citifare and CitiLift fares, while at the same time, a 4 percent service reduction was being considered.
Mr. Krause stated the solutions to the ongoing financial challenge facing the RTC included creation of CitiCare, a 501(C)(3) nonprofit group, with a board of directors that would attempt to assist seniors and persons with disabilities with travel needs. According to Mr. Krause, that was a relatively new group which had raised approximately $44,000 through donations and grants. It was anticipated that CitiCare would continue to be of great assistance to the RTC.
The RTC had entered into an agreement with Nevada Medicaid for partial reimbursement, and Mr. Krause indicated that was an important addition to the funding level. Reimbursement consisted of approximately 50 percent of the cost of providing the trips, and the RTC would support an increase in that reimbursement, if and when possible.
Mr. Krause stated the RTC’s biggest opportunity for continuing to meet and improve the level at which it met the needs of the senior and disabled population was a transportation funding ballot Question in Washoe County which was similar to that being proposed in Clark County. The proposed advisory Question, WC2, contained additional funding for the street and highway program, as well as the public transportation program, and Mr. Krause explained the component which would fund public transportation was a one‑eighth of 1 percent increase in sales tax. Those funds would actually be shared between roadway needs and public transportation, and would raise approximately $100 million over the next 30 years. Mr. Krause emphasized that the RTC felt the Question was critical in order to provide needed services, and also to address financial constraints faced by the RTC, even after accessing federal funding. Simply meeting the 20 percent local match requirement had been a real challenge to the RTC, and Mr. Krause noted it would continue to be so in the future.
Mr. Krause concluded that many good things had been happening in terms of providing and improving transportation service to the disabled community, and a number of partnerships had been created. The NNCIL was a tremendous partner in serving both the travel and training needs of the disabled public, and in completing the functional assessment process.
Chairman Titus inquired whether the Washoe County RTC had a program such as CAT STAR in Las Vegas that specifically served one facility or group of people. Mr. Krause stated that a service such as CAT STAR was in place in Washoe County, and the challenge was expanding that program and/or keeping it in place if, in fact, the reductions in sales tax and the economic slowdown reduced RTC’s funding to the level where it was forced to initiate service cuts. According to Mr. Krause, the RTC would take whatever action necessary to maintain that service, but the real issue surrounded funding to maintain the program. Chairman Titus asked whether the program in Washoe County served a specific facility such as Opportunity Village. Mr. Krause advised that the program served all of the sheltered workshops in Washoe County. He explained that the CAT STAR service in Clark County mainly focused on the need to access shopping from senior locations. As part of the Washoe County RTC’s regular CityLift service, it served virtually all of the sheltered workshops.
Chairman Titus referenced the proposed 25 percent fare increase, and asked about the current fare. Mr. Krause stated the fare for CitiLift was $1.25 per trip. Chairman Titus asked for clarification regarding the one “free” trip awarded after taking 50 trips without cancellation. Mr. Krause indicated that was the incentive to reduce the number of no‑shows or cancellations. It had been very effective and had paid for itself many times over in terms of providing an incentive to people, so that trips would be cancelled in a timely manner, if necessary, which allowed that travel time to be assigned to another passenger’s needs. According to Mr. Krause, after 50 trips with no cancellations or no‑shows, a person received a free trip on the system. Chairman Titus felt incentives were helpful, but opined that after 50 trips, the cost of one trip at $1.25 did not seem like much of an incentive.
Paratransit Administrator Lea Rogers agreed that 50 trips did sound like a tremendously high number, however, there were riders who virtually took all 50 trips every month. Those included persons who traveled back and forth to sheltered workshops throughout the area. The confusion regarding the CAT STAR service provided in Clark County and the similar services provided in Washoe County via CitiLift was because that program had been in place for many years, and services were not broken out, but were simply part of the overall CitiLift service. Ms. Rogers pointed out that Washoe County RTC did offer same-day shopper service which included almost four routes, which could easily be doubled, as they were the highest productivity routes in the system. The RTC also offered sheltered workshops rides, which were subscription rides and were highly efficient in terms of the number of people transported in the shortest possible time. Ms. Rogers explained those were the Medicaid reimbursement routes and were not designated as a separate service, but had been in place for approximately 12 years. Chairman Titus stated she was attempting to ascertain whether the service was program‑specific such as the services offered in Clark County for Opportunity Village.
Mr. Snow complimented Mr. Krause for the outstanding organization in Washoe County, and stated he had neglected to inform the Subcommittee during his presentation that a person certified eligible for paratransit had permanent, free trips on the fixed route service, because at times those persons could access the fixed route vehicles under certain circumstances. Since paratransit was so costly and the demand was so high, the Clark County RTC encouraged persons to ride the fixed route vehicles when possible, hence the ride-for-free policy. Mr. Snow indicated there were more than 35,000 trips per month by paratransit-eligible customers, which helped the RTC keep its cost down regarding paratransit.
Mr. Krause thanked the Subcommittee for the opportunity to appear and present testimony, and offered to conduct further research should the Subcommittee require additional information.
With no further testimony forthcoming regarding Agenda Item V, Chairman Titus opened discussion on Agenda Item VI.
Update on the Development of Strategic Health Care Plans by the Department of Human Resources
Michael J. Willden, Director, DHR, stated he was the person charged with implementation of the provisions of A.B. 513, which required the DHR to develop four statewide strategic health care plans:
Mr. Willden referenced material contained in Exhibit A, Tab VI, and explained that the DHR issued a Request for Proposal (RFP) in the fall of 2001, and as part of that process, the selection team selected The Rensselearville Institute (TRI) to complete both the disabled plan and the senior plan. According to Mr. Willden, through the spring of 2002, the department worked cooperatively with TRI on both plans. Mr. Willden explained that DHR, TRI, and the Task Force for Disabled People had a bit of a struggle philosophically on a number of issues, which came to a head in May 2002 in meetings with the department and the contractor (TRI). Shortly after that meeting Mr. Willden indicated TRI sent him a letter dated June 10, 2002, indicating that TRI no longer wished to be the contractor for the disabled strategic plan, but would continue as the contractor for the senior plan.
After wrestling with its options, the department felt it would be best to accept TRI’s proposal. Mr. Willden forwarded a letter to TRI accepting its offer, authorizing payment to TRI for the deliverables it had completed, delivered, and accepted by the DHR; however, payment was not authorized for the work that had not been accepted. The letter authorized TRI to continue with the senior strategic plan, and Mr. Willden noted that the senior group was pleased with TRI’s work.
Mr. Willden indicated that the department had regrouped and hired a number of individual contractors to complete the work for the disabled strategic planning process, as delineated on page 2 of his letter to Chairman Titus dated July 29, 2002, (Exhibit A, Tab VI). Mr. Willden assured the Subcommittee that DHR would deliver a final strategic plan for people with disabilities. Mr. Willden stated that the DHR had contracted with the following to complete the remaining work on the strategic health care plan for persons with disabilities:
· Charlene Harrington, University of California, San Francisco (UCSF), an independent contractor, would assist with data collection, demographics, and characteristics.
· Chris Thompson, University of Las Vegas (UNLV) Data Center, would assist with fiscal analysis.
· Patty Williams, technical writer and organizer of material.
· Betty Leyrer, technical writer and organizer of material.
· Tony Records & Associates, a nationally known Olmstead and ADA consultant.
· Gloria O’Brien and Sue Young would assist with data collection, databases, and spreadsheet creation.
Mr. Willden reported that DHR had adequate resources to finish the project, having received an appropriation of approximately $800,000 to complete all plans, along with the Medicaid matching money available through the various plans it was developing, grants available through the Division of Mental and Developmental Services, and strategic planning funds available through the Health Division. Mr. Willden did not feel the department would expend the entire $800,000 appropriation, and would revert approximately $100,000. He assured that all plans would be completed during September 2002, and the Task Force would conduct the final two or three meetings over the next two weeks. After that date, the work would consist of making sure that the information contained in the documents was accurate and the plans were cohesive. Mr. Willden indicated the final reports would be published and distributed to all involved groups, including the Legislature and local governmental entities.
According to Mr. Willden, the result would be four extremely informative documents that would assist Legislators during the 2003 Session, and throughout the 10-year strategic planning process. It would be impossible to accomplish all of the goals and objectives of the strategic planning processes in one legislative session or budget cycle; the reports would produce a set of goals that would encompass the next five Legislative Sessions. The documents would include general concepts, descriptions of waiting lists, timeframes, estimate of the effects on the waiting list, the cost to accelerate wait times and reduce the waiting list, and a rough-order of magnitude cost estimate associated with each recommendation.
Mr. Willden stated that unless the Subcommittee had further questions, he would commence with the next part of his presentation, Agenda Item VII. Chairman Titus inquired whether there were any questions from Subcommittee members, and hearing none, instructed Mr. Willden to proceed.
Presentation from the Nevada Department of Human Resources on Potential Recommendations Concerning State Service for Persons with Disabilities
Mr. Willden indicated that Exhibit A, Tab VII included his letter to Chairman Titus dated July 26, 2002, and a draft of the Table of Contents for the Strategic Plan for Persons With Disabilities. Mr. Willden reviewed the items included in the draft Table of Contents (Exhibit A, Tab VII):
Mr. Willden stated those sections were in various draft stages with a significant amount of work yet to be done in order to complete the process.
According to Mr. Willden, the organization of the plan consisted of eight groups, and the document entitled, “Draft Goals and Strategies, 2022 – 2011,” contained in Exhibit A, Tab VII, detailed the breakdown of the eight “issue” groupings:
A. Equality of Opportunity and Inclusion: Address issues such as the “no wrong door” concept, “single point of entry,” access to services, and assessments.
B. Inclusion and Full Participation of Children and Youth With Special Needs and Their Families: Address children and youth issues and listed nine goals and several objectives regarding single point of entry, data management, family support, medical coverage, positive behavior support, transition planning, and education.
C. Full Participation: Address issues related to full participation. That included assuring that persons with disabilities and their families were fully informed or had full access to relevant information, were knowledgeable, and had the opportunity to participate in the decisions that affected their lives via the policies put into place by DHR to assist persons with disabilities.
D. Independent Living: Addressed issues associated with service providers, services provided, waivers, rates, Medicaid eligibility, informational lines, and not having people at risk while waiting for institutional placement.
E. Economic Self-Sufficiency: Addressed issues dealing with employment and health care, transportation, and education.
F. Protection of Rights and Privacy: Addressed issues related to advocacy, guardianships, and the potential need for a “vulnerable adults act.”
G. Rural and Reservation Independence: Addressed issues relative to rural areas and Indian reservations independence, along with primary care and health care services, housing issues, and DHR’s relationship with Indian Health Services in rural Nevada.
H. Dignity and Dying: Addressed issues such as fast-tracking eligibility of services, financial planning, and legal counseling.
In summary, Mr. Willden indicated that between the eight groups, 23 goals, 73 objectives, and 269 strategies were developed and targeted. Some were duplicative, and there were areas still under considerable debate; however, a tremendous degree of consensus was reached throughout the working groups, i.e., the children’s group, the adult group, and the rural group on a majority of the issues. Mr. Willden further noted there was consensus regarding respite issues, waiting lists, and single point of entry or “no wrong door” concepts. The single point of entry concept did not mean that individuals could go to one building or agency for services, but rather would consist of multiple entry points, where a person could enter the system via any entry point and access information on disability services and referrals system-wide. According to Mr. Willden, one issue surrounded the decision regarding what to title that concept, i.e., “single point of entry,” “no wrong door,” or “one-stop shop.”
Chairman Titus commended Mr. Willden, his staff, and all participants working toward completion of the plan. So often, studies were funded when Legislators at both the state and federal level did not want to deal with a particular problem. The Legislative Commission’s Subcommittee to Study State Programs for Providing Services to Persons with Disabilities was appointed to ensure that the hard work put forth in the development of the Executive Branch’s strategic health plans would not become a study that simply sat on a shelf somewhere, but rather would have the backing of the Legislature to move issues forward.
Mr. Willden advised that he would address what he felt were some of the major themes included in the “Draft Goals and Strategies, 2002 – 2011” document included in Exhibit A. It would be impossible to cover all 269 issues, and Mr. Willden apologized in advance to anyone who might be offended by the omission of a particular issue. Referencing the document, Mr. Willden pointed out that the issues printed in red ink were those that might require some Legislative or fiscal attention. He then commenced with his presentation.
A. Equality of Opportunity and Inclusion:
Goal 1, Objective 1, page 1, discussed the “no wrong door concept,” and Mr. Willden reiterated there was consensus surrounding that issue.
Goal 1, Objective 2, page 1, discussed an online resources directory, and the development of a method to catalogue resources offered by the state, county, nonprofit, and volunteer organizations. Mr. Willden stated he had made home visits to persons with disabilities who were unable to physically move about, but were sophisticated computer users, and he felt the online directory was a tremendous recommendation.
Goal 1, Objective 3, page 2, dealt with work that needed to be done in the areas of solid assessments, and assuring that the DHR was complying with the least restrictive environments. That concept was a goal that was repeated throughout the document.
Goal 1, Objective 4, page 2, discussed personal assistance services (PAS), and Mr. Willden indicated that S.B. 174 from the 2001 Legislative Session established an advisory committee to address issues regarding PSA rates paid by state agencies, waiting lists, and service criteria and eligibility. Mr. Willden remarked that future budgets submitted by DHR and DETR would include decision modules with specific recommendations relative to S.B. 174 and PAS. The strategies would also recommend that all state agencies which had provisions for personal assistant services allocate sufficient funding to ensure that those PAS applicants who were identified as being “at imminent risk” of institutionalization were processed and approved for services within 180 days of receipt of the application.
Goal 1, Objective 5, page 3, dealt with waiver slots. Specifically, Mr. Willden explained, the proposal recommended that waiver slots would be funded at a level which ensured that persons identified as being at imminent risk of institutionalization would have their application reviewed and processed within 180 days of receipt of the application.
Goal 1, Objective 6, page 3, discussed the implementation of a Positive Behavioral Supports Network, and identification of a permanent funding source for that network. Mr. Willden pointed out that initial funding for the network was provided by the Task Force for the Fund for a Healthy Nevada. The idea here would be to integrate the network into the process and provide for a permanent funding source for long-term support of that network.
Goal 1, Objective 8, page 4, dealt with mental health medications and funding. The primary objective here was to ensure that persons received necessary medications when they need them. It was suggested that perhaps there should be a program similar to the Senior Rx Program.
Goal 2, Objective 1, page 4, discussed the county match program and its potential implication on waiver service. Since counties did not fund waiver programs, it could be a disincentive for the state to remove a person from institutional care that was being paid for through the county match program, and place them on the state funded waiver services. Mr. Willden stated that disincentive should be reconciled, and discussion was underway by the Legislative Committee for Children, Youth, and Families about the possibility of the state assuming all of the county institutional services and elimination of the county match program. According to Mr. Willden, there was an ongoing healthy debate surrounding the issue.
Goal 2, Objective 4, pages 5 and 6, discussed presumptive eligibility, which had been discussed during previous Legislative Sessions. Mr. Willden explained when a person applied for SSI or Social Security Disability Insurance (SSDI), there were long waits. The question was how to service those people during waiting periods pending receipt of Medicaid, SSI, or SSDI, and how disabled services would be organized from a bureaucratic standpoint. Recommendations considered included creating a new state disability ombudsman position, establishing a state office of disability and planning, reorganizing the current structure within DHR to create a new division for disability services, or moving services from one division to another. Mr. Willden advised there were at least four divisions within DHR and one within DETR that dealt with disabled services, and the way those divisions were structured was discussed under the objective, in the form of recommendations. Mr. Willden opined that reorganization of the services was needed, because it was extremely difficult to manage disabled services from four different divisions and one different department. One suggestion would combine the divisions of Aging Services with Disabled Services.
B. Inclusion and Full Participation of Children and Youth with Special Needs and Their Families.
Goal 1, Objective 1, page 9, discussed the single point of entry concept for children with disabilities, and Mr. Willden acknowledged the DHR was reorganizing some of its children’s services, and with budgetary allowance, would continue to reorganize children’s developmental early childhood services.
Goal 1, Objective 2, page 9, addressed development of a web-based clearinghouse of information for children with disabilities and their families.
Goal 1, Objective 4, page 10, referenced data collection, and Mr. Willden pointed out the DHR was woefully inadequate in the collection of data.
Goal 2, Objective 2, page 11, highlighted respite care, which Mr. Willden noted was an extremely important issue.
Goal 3, Objective 1, page 11, discussed childcare for children with disabilities. Mr. Willden stated he would meet with representatives from the Endeavor Program on August 7, 2002, to review that program’s childcare facility in Las Vegas. The department would also review the program’s waiting lists and rates DHR paid for childcare services for children with disabilities. According to Mr. Willden, the DHR paid the same rates for childcare for a disabled child as those for a healthy child, and an improved rate structure was under consideration.
Goal 4, Objective 1, pages 12 and 13, addressed early intervention services and the need to be in compliance with Individuals With Disabilities Education Act (IDEA), Part B and Part C.
Goal 6, Objective 1, page 13, discussed the aspect of medical/service delivery in a timely manner, and Mr. Willden commented that DHR had made tremendous strides during the past 18 months enrolling children in the Medicaid and Nevada Check Up Program. He noted that Governor Guinn had been committed to that concept, even during tough financial times. Mr. Willden emphasized that DHR and the state should ensure that children were being enrolled in some type of health care program.
Goal 7, Objective 3, page 14, addressed the creation of a 24-hour call center. Mr. Willden believed persons should have the ability to call for information.
Goal 8, Objective 2, page 15, outlined the concept of higher education for youth with disabilities, and would make it possible to attain an AA degree in Independent Living. Mr. Willden felt that was an interesting recommendation, and one that would promote dignity and self-respect for children with disabilities that prevented them from entering traditional higher education coursework.
C. Full Participation.
Goal 1, Objectives 1 and 2, page 16, detailed the commitment of full participation for people with disabilities and their families in the service delivery process, and policy and decision-making that would impact their lives and those of their families. Mr. Willden noted the adage of “nothing about us, without us” was the theme of the objective.
D. Independent Living.
Goal 1, Objective 1, pages 18 and 19, contained a significant discussion regarding medically necessary services, such as availability of disability management, illness prevention programs, and dental services in both urban and rural Nevada. Mr. Willden acknowledged that DHR did not provide an active dental services program, even though it had made much progress in that area.
Also addressed was development of incentives for medical professionals to accept Medicaid and Medicare clients, which was not just related to persons with disabilities, but also relative to low-income families. One of the strategies under this objective dealt with assurance of access to financial assistance and/or subsidies to qualified people with disabilities who could not afford prescription drugs. Mr. Willden pointed out that persons who were Medicaid-eligible could receive prescriptions, however, perhaps the state should consider a “Disabled” Rx Program fashioned after the current Senior Rx Program; the source of funding for such a program had not yet been identified.
Goal 1, Objective 2, page 19, discussed establishment and funding a state level 211 or 800 service access to accompany the “no wrong door” concept.
Goal 1, Objective 3, pages 20 and 21, addressed the availability of companion assistance for disabled persons, and encouraged the development of a Medicaid Cognitive Impairment Waiver to assure delivery of companion assistance. Mr. Willden disclosed that many disabled individuals required an assistant to help with daily living issues such as shopping.
Goal 1, Objective 4, page 22, outlined strategies for seniors with disabilities. Mr. Willden stated it was important to provide mental health services to the senior population.
Goal 1, Objective 6, page 23, included discussion of Indian Health Services, and Mr. Willden emphasized that DHR needed to develop an understanding of the services available in Nevada through Indian Health Services, and ensure that as DHR planned for the needs in rural Nevada, it worked together with that service. Indian Health Services operated a number of clinics throughout rural Nevada, and Mr. Willden stated it would be a question of whether or not the DHR could access those clinics. Representatives from Indian Health Services had voiced concern regarding the lack of access from reservations to assist disabled persons. Mr. Willden pointed out that the nearest 24/7 Indian Health Services Hospital was located in Phoenix, Arizona.
Goal 1, Objective 7, page 23, dealt with Medicaid eligibility issues such as allowable assets and disposable income versus gross income. Mr. Willden felt the SSI and Medicaid services process was extremely important. A person eligible for SSI in Nevada was categorically eligible for Medicaid, in the event that person made a separate application for Medicaid services. Other states had initiated a process whereby a person determined eligible for SSI was automatically enrolled in Medicaid, and Mr. Willden opined it was time Nevada resolved that issue, and became a state that offered automatic enrollment.
E. Economic Self-Sufficiency.
Goal 1, Objective 3, page 25, referenced employment and health care coverage for persons with disabilities. Mr. Willden noted programs in that area had been developed, however, attempts to assist persons in attaining economic self-sufficiency should not endanger their health care coverage.
Goal 1, Objective 4, page 26, discussed accessibility of transportation services.
F. Protection of Rights and Privacy.
Goal 1, Objectives 1 and 2, page 29, dealt with the process and availability of guardianships, and a recommendation for passage of a “Vulnerable Adults Act” regarding abuse of persons with disabilities who resided in segregated settings Mr. Willden indicated he had not fully researched the necessity of a separate act to address the issue of abuse, or whether it could be addressed through current laws. The recommendation was for a zero tolerance state plan.
G. Rural and Reservation Independence.
Goal 1, Objective 3, page 32, addressed nesting or combining primary and mental health care services in rural areas, including early childhood developmental and mental health services. Mr. Willden indicated that DHR was working on a pilot project with Rural Clinics, Carson-Tahoe Hospital, and other health care centers on a nesting project where access to a primary care physician would provide assistance with mental health services, or access to a mental health clinic would provide assistance with primary care service. The same level of services available in urban areas was not available in rural areas, and often persons were required to travel great distances to access services.
H. Dignity and Dying.
Goal 1, Objectives 1 and 2, pages 36 and 37, outlined some dignity and dying, end of life issues and recommendations. Mr. Willden explained that establishment of a “fast-track” system would assure that persons with terminal disabilities were fast-tracked into the service and eligibility system, provided with in-depth financial planning, and provided legal counseling regarding certain issues.
That concluded Mr. Willden’s presentation, and he advised the plan should be completed within the next month. Chairman Titus thanked Mr. Willden for his presentation, and stated Subcommittee members would review the goals and objectives contained in the document carefully. The Subcommittee could consider the end report via a final work session to determine what issues would require Legislative assistance, and what issues it would recommend for consideration during the 2003 Session.
Senator Rawson opined that the state was well served by Mr. Willden, and noted that he had established an environment and atmosphere where people were not afraid to come forward with issues. Senator Rawson hoped the Governor fully appreciated Mr. Willden’s usefulness. Chairman Titus agreed, and noted that it was not an easy task. It was a mammoth task as every small group felt very strongly about their specific problem, and the efforts to bring those interests together to view the “big picture” was an incredible challenge.
Mr. Guernsey stated it was his understanding that the deadline for the Subcommittee was prior to September 1, 2002, with the powers of the Subcommittee reporting to the Legislative Commission by that date. Leslie Hamner, Deputy Principal Legislative Counsel, LCB, stated that was generally correct, however, the Subcommittee could request an extension from the Legislative Commission based on the timing of the report from DHR, and the activities surrounding the 18th Special Session.
Chairman Titus stated the Subcommittee would keep that deadline in mind, and asked Mr. Willden to keep the Subcommittee apprised of further movement toward completion of recommendations. Mr. Willden noted that he had received a letter asking for DHR’s recommendations by August 16, 2002, and the DHR would provide a report that defined final recommendations by that date. The only problematic area would be the fiscal notes related to some recommendations, however, DHR would meet the recommendation deadline of August 16, 2002.
Assemblywoman Chowning echoed the comments made by Senator Rawson, and noted that it was absolutely yeoman’s work. She indicated she had attended a Presidential Summit in Washington, D.C. a few years ago, where “nothing about us, without us” had been the common theme, and disabled persons had simply asked to be involved in the decision-making process.
Assemblywoman Chowning referenced page 19 of the “Draft Goals and Strategies, 2002‑2011” report, number 1.n, which pertained to access to financial assistance and/or subsidies to qualified people with disabilities who could not afford the cost of prescription drugs. She explained that in the past, efforts had been made to increase mental health offices in the communities, and a contract existed between the state and pharmacies in North Las Vegas, however, that practice was discontinued, and pharmacy distribution was placed back in the appropriate offices. That action had apparently been taken to promote cost savings. Assemblywoman Chowning asked for further information regarding that issue, because it was not necessary to reconstruct a program that had already proven to be cost-effective. Mr. Willden stated DHR had and would continue to research that issue, and noted there were pending Bill Draft Requests (BRDs) relative to the bulk purchase of medications. According to Mr. Willden, a bulk purchasing process had already been established, and DHR continued to study the best method of running the pharmacy or “med” clinics. It was his understanding that the program had shifted to the use of community providers for pharmacy needs, and persons were not restricted to utilizing the “med” clinics.
Assemblywoman Chowning referenced Goal 1, Objective 1, number 1.k, page 18, of the report, which discussed incentives for medical professionals to accept Medicaid and Medicare clients. During the recent 18th Special Session of the Legislature, which dealt with the medical malpractice insurance crisis, one point brought to light was the need to update reimbursement policies. Assemblywoman Chowning felt that was an area which would require significant research, as it was difficult to develop incentives when medical professionals were not receiving proper and adequate reimbursement.
According to Assemblywoman Chowning, at its April 17, 2002, meeting the Subcommittee was advised by Arthur Thurner, Federal Programs Manager, Nevada Housing Division, that a “special needs population study” was scheduled for completion in July 2002, and she inquired whether a copy of the completed report could be provided to the Subcommittee. Before a decision could be made on Goal 1, Objective 2, number 2.c, page 19, regarding establishment of a disability liaison position within the State Housing Division to coordinate housing information, Assemblywoman Chowning felt that report should be reviewed.
Chairman Titus advised that Mr. Guernsey would attempt to secure that report for the Subcommittee’s perusal. Regarding the development of incentives for medical professionals, Chairman Titus stated that perhaps more prompt reimbursements might be a major incentive.
Senator Rawson mentioned that one of the spin-offs of the 18th Special Session of the Legislature was a pro-bono stipulation regarding a waiver of immunity when a physician or a dentist provided care in a state or nonprofit facility, and did not expect reimbursement, which should allow the program of donated dental services in rural Nevada to expand.
Chairman Titus thanked Mr. Willden for his presentation, and opened the Public Testimony portion of the Agenda.
Steven Dickerson advised the Subcommittee that he would testify as a resident of Reno. He stated he would like to put a “face” on some of the issues that people in Nevada with disabilities were facing. Mr. Dickerson stated he was but one of thousands of people in Nevada suffering from a disability, and under current Nevada law, there was no requirement for a publisher or manufacturer of instructional material to offer that material in an alternative format for persons with different disabilities to access independently, without assistance.
Currently, stated Mr. Dickerson, students in Nevada with disabilities that prevented them from accessing printed material were in grave need of a law that would provide the same access opportunities as people without disabilities. Publishers and manufacturers of printed materials who offered that material in educational institutions within the State of Nevada should be required to also distribute such material in an alternative format. Mr. Dickerson noted that the alternative format could be anything from Braille, large print, recordings, or another accessible media that made it easy for persons with disabilities to use existing technology to access that material. Mr. Dickerson indicated members had been provided copies of pertinent California law, which addressed the issue, and the U.S. House and Senate proposals that dealt with the issue specific to grades K-12, Exhibit D. Whether or not those proposals were drafted into law, Mr. Dickerson believed that Nevada should address the issue, because it was something that all students with disabilities faced.
Mr. Dickerson stated he was but one student with a visual impairment, however, his proposal was not designed to assist only those persons with visual impairments. It would be very instrumental in providing assistance to students with various disabilities who faced hurdles in accessing printed material. According to Mr. Dickerson, the current situation in the area of technology provided the ability to address those hurdles, and it was simply a matter of brining the necessary people to the table to develop plans and strategies to put those technologies to the best use.
Mr. Dickerson explained that his visual impairment was the result of an aviation accident he suffered while on active duty in the military. He stated he used speech technology to read for him. Without that technology, Mr. Dickerson indicated he would not be where he was at the present time, having worked very hard to return to school for his graduate degree and pursue those interests he felt passionate about. Accessing printed materials in a classroom environment had presented a tremendous hurdle. Mr. Dickerson stated when publishers were approached about providing that material in a usable format, the process became very long and difficult in the effort to convey that the only thing people with disabilities were asking for was that publishers provide the material in a usable format.
According to Mr. Dickerson, it was time that disabled people in the State of Nevada had a law supporting them in that effort. Publishers wanted to promote sales of goods to the public at large, and should understand that there were many different faces to that public, along with many different needs. For example, Mr. Dickerson indicated he had contacted the publisher of a text he was using for a graduate class, and asked the publisher whether the material could be edited and presented in a format that would be readable for him. The publisher replied that it was not possible to edit the text, and suggested Mr. Dickerson contact the disability resource center at his college or university for possible assistance. The reply was received approximately three weeks after the course had ended, and Mr. Dickerson pointed out that put him in a position where he struggled throughout the class because he was not able to access the same material in the educational setting that was available to the rest of the students.
In conclusion, Mr. Dickerson stated he was testifying before the subcommittee in an effort to see Nevada join the list of other states where laws had been passed that required publishers to make materials available to students, colleges, and universities, so that disabled students could access that material and pursue their educational goals and passions.
Chairman Titus thanked Mr. Dickerson for his testimony, and believed he presented a very valid point to the Subcommittee. She indicated she had recently spoken at a community college class where persons had been assigned to provide sign language for hearing impaired students. Chairman Titus believed if a college could make accommodations for that disability, it was only right to research appropriate accommodations for visually impaired students. Senator Rawson stated he expected to run into opposition regarding the matter because of the costs involved, however, hoped to move forward and ascertain the best method to address the issue.
Assemblywoman Chowning stated one point of interest would be the cost of such a program, and since similar programs had been put into place in other states, she asked LCB staff to provide information regarding those programs relevant to funding issues, and legislation which created the programs. Assemblywoman Chowning referenced the copy of House and Senate bills contained Exhibit D, and asked Mr. Dickerson whether he was aware of the progress or outcome of that legislation.
Mr. Dickerson disclosed that as of August 5, 2002, the bills were still under consideration, and he would continue to follow the progression of that legislation. He believed there were several options available to Nevada in moving forward with such a program, however, was unsure of the cost involved in the process. Mr. Dickerson assured the committee that he would continue his attempts to contact different publishers to determine the exact process involved in the conversion of a textbook to an alternative format. In today’s world, it was hard to believe that any publisher was using outdated machines and/or processes to produce textbooks, and Mr. Dickerson believed the process was completed through technology, therefore, it should not prove to be tremendously costly to convert texts from a printed format to an electronic format. That electronic format could then be utilized in different setting to assist people with varying disabilities.
Assemblywoman Chowning agreed that various publishers vied for the state’s business and if the cost difference was not too severe, she felt that stipulation could be written into contracts as a requirement to assist students in the State of Nevada. She thanked Mr. Dickerson, as a private citizen, for bringing the issue to the attention of the Subcommittee, and noted she would not have been aware of the issue had Mr. Dickerson not brought it before the Subcommittee.
Chairman Titus interjected that at the very least, the Subcommittee could attempt to enlist assistance from the Board of Regents, in an attempt to make the issue part of university and community college system policy.
Mr. Dickerson remarked that he was currently a graduate student at the University of Nevada, Reno (UNR), and offered nothing but praise for the service he had received from the disability resource center at UNR, along with backing from UNR in assisting persons with different types of disabilities achieve their educational goals. However, stated Mr. Dickerson, if publishers were made aware of the degree of work that disability resource centers encountered in an effort to provide services to just one student, especially when magnified by 500 to 1,000 students with disabilities, perhaps they would become more aware of what was being asked of them, and realize the necessity of having resources in place.
Chairman Titus remarked that it was encouraging to hear that the university resource centers were doing a good job. She then inquired whether there was further public testimony to come before the Subcommittee.
Linwood Gallagher indicated the comment had been made that the disabled community was not a very vocal group, however, he considered himself a “rare breed,” as he had contacted the Governor’s Office several times over the past few years. During the 2003 Legislative Session, Mr. Gallagher disclosed he had circulated a complaint to members regarding the matter of agencies failing to coordinate with one another regarding services offered, and he was pleased that the Subcommittee had chosen to address that specific issue.
One of the issues Mr. Gallagher believed the Subcommittee should consider was the reluctance on the part of agencies to coordinate with one another, however, he was unsure how the Legislature could address that issue. One example he had used in the past was that in Carson City alone, there were three separate locations for computers with adaptive equipment: (1) the community college; (2) the State Library; and, (3) the Rehabilitation Division. Perhaps it was felt that once a disabled person learned to operate one computer, that person could simply access the other computers and benefit from the services offered at each of the three locations; however, explained Mr. Gallagher, there was a learning curve for each of the computers. Mr. Gallagher conveyed that as far as he was aware, he was the only blind person that had actually learned all three systems, along with the system on his home computer. That was a total of four separate systems he was required to learn because of the lack of coordination between agencies.
Continuing, Mr. Gallagher remarked that when Services to the Blind responded to his concerns, the reply was that when persons were approved for college educations, home computers were purchased based on need. Mr. Gallagher felt that was good, but noted that disabled persons were often told that the agency would like to help, but was out of funds. If thousands of dollars were “sitting around” and not being used based on approved students receiving individual computers, Mr. Gallagher stated that seemed like a waste of money.
According to Mr. Gallagher, it had been stated that because of increased population, funding was not available at the state level, but he had illustrated that funds were not being wisely used at times, and it seemed if there was an increase in population, there should be a corresponding increase in tax revenue. Information that had not been brought forward was the year-by-year breakdown of the budget for each individual department, and the percentage of the total state budget that applied to each agency. Mr. Gallagher felt that information was necessary to really appreciate how wisely the money was being used. Presumably, there had been an increase in the tax base, and the question was how that increase was being distributed.
Mr. Gallagher stated he was under the impression that a one-stop shop had been initiated a few years ago, however, at today’s subcommittee hearing, testimony indicated that such a concept did not exist. Mr. Gallagher remarked that his brother would also address the subcommittee regarding his attempt to secure assistance for his special needs. Mr. Gallagher had accompanied his brother in this endeavor, and they found that there was no one-stop shop available. With the indulgence of the Subcommittee, Mr. Gallagher indicated his brother would provide testimony.
Chairman Titus voiced the Subcommittee’s appreciation for Mr. Gallagher’s testimony, and pointed out that members were glad to hear from persons who were directly affected by the services. The Subcommittee had emphasized the need for additional information and access, along with better coordination, from the very beginning. Regardless of the jargon used, Chairman Titus stressed that members did agree that better coordination was needed. Perhaps that had not been the case in the past among executive departments, but Mr. Willden’s earlier testimony indicated there was a definite attempt underway to improve coordination, and recommendations would be forthcoming regarding the reorganization of appropriate agencies. Earlier testimony had also addressed county and state offices working together in shared facilities and staff in an effort to provide better coordination. Chairman Titus reiterated that the Subcommittee certainly did see that as important and was moving in that direction. Regarding the issue of population growth, Chairman Titus agreed that if there were more people, tax revenue would increase, however, there would also be additional needs for those people. The 2003 Legislature would grapple with the whole question of the tax structure.
Robert Stokes came forward to address the Subcommittee, and indicated he used a voice “enhancer” because he had lost his voice to cancer. Mr. Stokes informed the Subcommittee that he, with the assistance of his brother, had tried to ascertain how to locate the services he needed. However, he and his brother had contacted at least seven different organizations and had received the “run around” from each. Mr. Stokes stated he would like to know how he, and persons like him, could find the necessary information.
Chairman Titus advised Mr. Stokes that a staff person would speak with him to take his name and address, in an effort to provide answers to his questions, and put him in contact with the appropriate agencies.
Mr. Gallagher applauded the Subcommittee for its attempt to bring about the much‑needed coordination, and he hoped its efforts would be successful. Chairman Titus thanked Mr. Gallagher and Mr. Stokes for their testimony.
With no further public testimony to come before the Subcommittee, Chairman Titus asked members to consider future meeting dates.
Scheduling of Future Meeting Dates
If the subcommittee received information from the DHR by August 16, 2002, Chairman Titus asked whether members felt a meeting should be scheduled during the last week in August, or should the Subcommittee seek an extension beyond the September 1, 2002, deadline?
Mr. Guernsey pointed out that Subcommittee members would need time to assimilate the information presented by the DHR, and he suggested that an extension be requested. Chairman Titus asked whether a letter should be forwarded to the Chair of the Legislative Commission requesting an extension into September and outlining the reasons for such a request. Senator Rawson concurred, and felt the extension request should also be based on the fact that it was an extraordinarily complicated issue.
SENATOR RAWSON MOVED TO FORWARD A LETTER TO THE CHAIR OF THE LEGISLATIVE COMMITTEE REQUESTING AN EXTENSION OF THE SEPTEMBER 1, 2002, DEADLINE.
ASSEMBLYWOMAN FREEMAN SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
With no further business to come before the Subcommittee, Chairman Titus declared the hearing adjourned at 12:03 p.m.
Carol Thomsen, Interim Secretary
Senator Dina Titus, Chairman