2006 - 2007 Business Plan

SRS BUDGET ENHANCEMENTS

Child Support Enforcement (CSE) Customer Service Center. A statewide customer service center contract will be established to handle child support telephone contacts, other than contacts related to payment processing, by the Kansas Payment Center. The center will be sited at a location in rural Kansas that is able to provide the necessary infrastructure for customer service center operations. The center will combine a staff of trained customer service representatives, available during daytime hours, with an interactive voice response system to respond at all times of the day. SRS system enhancements to support the voice response system will be needed. Although initially handling only child support questions, the customer service center will be configured to allow expansion to other SRS lines of business, and to other communications media, such as e-mail. The goals of the customer service center are to improve timeliness of responses and customer satisfaction, to allow caseworkers’ time to be effectively focused on increasing support collections and fee fund revenues, and to support economic development in rural Kansas. The cost of the service center is $2,000,000, of which $340,000 is fee funds, $340,000 is Economic Development Initiative funds, and $1,320,000 is Federal CSE funds.

Grandparents as Caregivers. The Governor’s Budget Recommendation adds $2,092,740 to establish the Grandparents as Caregivers Program in January 2007. The new program would serve caregivers who are at least fifty years of age with incomes below 100 percent of the Federal poverty guideline. The funding level would provide $200 per month to each child who is in the legal custody of the caregiver. This enhancement recognizes the burden on older caregivers who face a myriad of challenges, such as: declining health, lack of support, and physical, emotional and family strains. In some cases, they may not have the financial resources to raise another family, or may use their savings or deplete their retirement funds, in order to do so.

Additional Funding for Energy Assistance. The Federal government initiated assistance to low-income families for energy costs in 1982. The program’s purpose is to provide assistance for heating, cooling, energy crises, and weatherization. With no abatement in the need for energy assistance, the Federal Energy Assistance Program has remained essentially unchanged since 1982. The most common heating fuel used in Kansas is natural gas, which has increased by an average of ten percent each year over the last ten years. In 2006, the price is estimated to increase by approximately forty percent. The Governor’s Budget Recommendation provides an additional $1.0 million in State funds to complement Federal funding for Energy Assistance.

Adult Dental for the HCBS Waivers. Kansas Medicaid coverage provides adults only Emergency Dental Care when the person’s overall health is threatened. The FY 2007 GBR includes funds that would allow the provision of preventative dental care for persons served through one of the Home and Community-Based Services (HCBS) Waivers. This will allow adults with disabilities to receive regular dental check-ups, cleanings, and routine care thereby greatly improving their overall health and well being.

LEGISLATIVE PROPOSALS

Proposed Child Support Enforcement Changes. Senate Bill No. 229 is the Child Support Enforcement (CSE) bill that carried over to the 2006 Session. During the interim, CSE has worked with a number of stakeholders to review and refine the proposed changes, most of which are expected to be reintroduced as new, separate bills. If enacted, the 2006 CSE legislation will expand existing administrative enforcement options by: matching and intercepting insurance settlements otherwise payable to support debtors; authorizing administrative suspension of debtors’ driving privileges; and denying recreational licenses issued by the Department of Wildlife and Parks to support debtors certified by CSE.

It also will amend or repeal existing laws to prevent unintended sunset of a variety of statutes, streamline administrative enforcement procedures, eliminate ambiguities, and assure access to needed information about debtors.

Interstate Compact for the Placement of Children (ICPC). Kansas adopted the original ICPC in 1976. Kansas children have benefitted from the ability of custodial agencies to receive information prior to sending a child across state lines for placement, to retain jurisdiction, and arrange for services to support the placement. Kansas has benefitted because children are placed in Kansas only after approval of the placement, and the sending state, retains jurisdiction and financial responsibility.

Despite these benefits, frustration with the ICPC has grown over time as an “overly broad” application, outdated administrative process, and lack of accountability; and have resulted in the slow placement of and delayed permanency for children. Administrators, courts, families and Congress have grown impatient as geographic boundaries are blurred by the Internet, and interstate placements become a significant part of efforts to find permanency for children. The importance of a sound legal framework for interstate placements is critical.

The American Public Human Service Association (APHSA) worked with member States including Kansas, issue experts and stakeholders to make needed changes to the current ICPC. The revised ICPC narrows the types of placements covered, provides clarity regarding issues of jurisdiction and financial responsibility, provides due process for states and parties impacted by a receiving state’s decision, and a process for the development of rules. The revisions also provide for meaningful enforcement through a wide range of tools for member states to secure compliance including technical assistance, mediation, arbitration, and legal action.

The potential of Federal legislation governing interstate placements of children, makes it critical for states to work together and develop a sound compact as an alternative. The new ICPC will allow states to preserve their sovereign authority over the interstate placement of children. The revised compact will become effective upon adoption by at least 35 states.

HEALTH CARE POLICY

Increased Federal Scrutiny
The federal government continues its heightened oversight of state claims of federal funds. As a result, states are facing significant deferrals of federal funds, increased federal audits, challenges to federal cost allocations, and new federal interpretation of existing laws, regulations and state plans. Kansas is no exception.

In response to this increased scrutiny, SRS has designated two additional positions which will help oversee and monitor SRS compliance to federal Medicaid requirements. The following summarize the status of federal deferrals, audits, and penalties SRS is currently facing.

• State Hospital Medicaid Disallowance. The federal Departmental Appeals Board (DAB) is short staffed and it could be another year before SRS receives the results of the appeal on this disallowance.
  
• Synar Penalty. In FFY 2004, Kansas’ Synar compliance rate dropped to 62 percent. As a result, Kansas was required to expend an additional $2.3 million over two years to improve its compliance with federal tobacco prohibition laws. Kansas’ most recent Synar Report shows an 80.8 percent compliance rate. Therefore, SRS faces no additional penalty in the current year.
  
• Child Welfare Managed Care Medicaid Deferral. CMS deferred all federal Medicaid funding for the Child welfare Community-Based Services contracts from July 1, 2003 through June 30, 2005. Three quarters have been settled but the remaining quarters have not. For the quarters beginning July 1, 2005, CMS is again reportedly deferring these claims due to technicalities in the state plan and lack of specific claims edits in the Medicaid Management Information System. The size of the deferrals and the length of time it is taking to get them resolved has made continued management of this internal cash flow problem impossible. The GBR includes $6.8 million to assist SRS with this cash flow problem.
  
• Community Mental Health and Behavior Management Services. CMS is requiring Kansas to rewrite the previously approved section of the state Medicaid plan for community mental health services and behavior health services to conform to CMS’ new expectations.
  
• Medicaid Administrative Claiming. In Kansas, Medicaid administration funds are provided to local education authorities, Community Mental Health Centers (CMHCs), and Community Developmental Disability Organizations (CDDOs). The methods used to claim these expenses are being reviewed by CMS and Office of Inspector General (OIG). To date, the results have not been shared with SRS.
  
• Parent Fees for HCBS Services. The CMS regional office reviewed this program recently stating that it believed CMS was entitled to a share of the fees. To date, the results have not been shared with SRS.
  
• Disability Determination Services Penalty. A second appeal was filed with HHS in September 2003. A final decision is pending.

SRS continues to monitor the work plans of federal agencies and OIG to determine what other areas of they may review next and will keep the legislature informed regarding any additions to this list of reviews.

HCP PROGRAM ISSUES

Community Supports and Services

DD Waiting List. As of January 2006, about 1,225 individuals with DD have been determined eligible and are waiting for community DD services. The Governor recommended and the 2005 Legislature approved approximately $6.25 million additional DD waiver funding to address the DD waiting list. These funds are expected to allow the number of persons served through the DD waiver to increase by 245 in FY 2006. The FY 2007 GBR includes $5.66 million additional funds to serve 465 more persons for six months further addressing the DD waiting list.

Reimbursement Rate Study for Developmental Disabilities (DD) Services. The DD Reform act requires that a rate study of reimbursement rates paid for community DD services be conducted biennially. The last completed rate study done in March 2004,reviewed the rates paid to DD providers in FY 2002. That study recommended a reimbursement rate increase for the majority of DD services totaling $15.8 million. The Governor recommended and the 2005 Legislature approved $7.5 million for DD provider reimbursement rate increases. These rate increases went into effect for services paid since July 1, 2005. The FY 2007 GBR includes $8.0 million for DD waiver reimbursement rates. This will allow an average 3.5 percent reimbursement rate increase and fulfill the recommendation made by at last reimbursement rate study. SRS is currently working with a vendor to complete a new rate study to review the adequacy of the FY 2004 reimbursement rates. The results of this rate study will be available in July 2006.

Physical Disabilities (PD) Waiver Services. Up until January 16, 2006, the waiting list for the PD waiver had been eliminated. This was accomplished by SRS adding people to services using $4.0 million in FY 2005 carry forward. The GBR spreads the FY 2005 carry forward across both FY 2006 and FY 2007. So SRS has begun a “rolling waiting list.” A rolling waiting list is when no new persons are added to service from the waiting list until a person leaves the PD waiver. This allows new people to be served, but does not cause a net increase in the number of persons served. SRS estimates about 50 new persons per month can be served using the rolling waiting list. This will result in the waiting list growing by about 40 persons per month. SRS may have already added to service more persons than the GBR can support. Actual expenditures will be monitored closely, and if necessary, a Governor’s Budget Amendment will be requested to maintain the rolling waiting list process.

Self-Directed Compared with Non-Self Directed Care. Persons receiving services through the Physical Disabilities (PD) waiver may choose to direct their own care or have a provider agency direct their care for them. Some concerns have been expressed about the amount of services person who self-direct receive compared to those who do not self-direct their own care. The Legislative Division of Post Audit (LPA) October 2004 review found that no evidence existed that agencies authorized more services when that agency also served as the person’s payroll agent. LPA has begun another review which is asking what factors explain the differences between the number of hours of services between persons that self-directed their own care compared with those who do not self-direct their care.

In response to this concern, SRS continues to provide training to the Centers for Independent Living (CILs) and independent living counselor agencies on plan of care development, and how to differentiate between the persons’ needs and their wants.

Developmental Disabilities Providers Conflict of Interest. SRS presented its five-year strategic plan to the Kansas Legislature in February 2005. Subsequent to SRS’ presentation, the House Appropriations Subcommittee requested SRS bring together a group of stakeholders to address issues regarding potential conflict of interest in the DD system. In particular, the Subcommittee asked that SRS address situations where a Community Developmental Disability Organization (CDDO) is also a Community Service Provider (CSP). (Note: A CDDO is designated in the DD Reform Act as the local administrator and manager of DD service delivery. A CSP is a direct service provider. Under current law and rule, CDDOs may also be CSPs.) SRS used the strategic plan as a guide in working through this request.

The first recommendation was to develop a consumer survey that will evaluate if consumer choice is being offered; if consumers/guardians/families are educated about their choices; and are complaints and grievances being handled by the CDDO in a fashion that is satisfactory to the consumer/guardian/family. The survey results will help address a CDDO’s performance in honoring the informed choices of persons served as well as continuous and ongoing assessment of quality performance. SRS and stakeholders are currently in the process of developing an RFP to have this consumer survey completed.

In addition, a tool is being developed to monitor CDDOs’ compliance with the DD Reform Act and carrying out the tasks as outlined in their SRS contract. The monitoring tool will help address the strategic plan goals in the areas of quality improvement, consumer choice, access to employment, and persons receiving the appropriate services and supports for which they are eligible. The monitoring process will be presented to the Legislature in January 2006.

Addiction and Prevention Services

Planned Request for Proposal (RFP) for Addiction and Prevention Services. The agencies receiving SRS substance abuse grants have remained essentially unchanged for many years. SRS believes it is a good business practice to rebid these grants on a more regular basis to insure that the most effective and efficient treatment is provided to the greatest number of persons throughout the state, especially given the limited funds available. The RFP will identify specific services that the state will purchase. It is also hoped that the rates paid through the grants will be adjusted to ensure better access to services in all areas of the state. The RFP process creates the opportunity for all licensed service providers to submit a proposal to serve the Substance Abuse and Prevention and Treatment (SAPT) Block Grant funded population. The current plan is for the RFP to be ready for release in late Winter 2006. Bids will be received by early Spring 2006, and new awards issued in the Fall of 2006.

Substance Abuse Treatment for Drug Felons. The recent legislation that provides substance abuse treatment in lieu of incarceration has provided appropriate alternatives for offenders that have been life changing and has provided added resources for providers. One goal of these programs was to expand the publicly funded substance abuse treatment system. Unfortunately, to date, this goal has not been met and the system is treating more people with essentially the same service capacity. The following reflects the growth in demand for publicly funded substance abuse treatment services.

Another factor contributing to the widening treatment gap is the higher reimbursement rates paid in programs provided in lieu of incarceration. Funding for SRS clients has not grown, but the number of persons needing treatment has. These dynamics have put SRS funded clients in competition with clients receiving treatment in lieu of incarceration. As a result, SRS funded clients are waiting longer to access services.

Mental Health Services

Community Mental Health and Behavior Management Services. CMS has questioned the categorization and definition of community mental health services and behavior health services in the rehabilitation services section of the state Medicaid plan. CMS is requiring Kansas to rewrite this previously approved section of the state Medicaid plan. These changes will require some redefining of Medicaid funded community mental health and behavior management services and may require a Medicaid waiver request.

One of the required changes will result in redefining of Medicaid funded Level V and VI inpatient psychiatric treatment facilities for youth. These facilities will be required to meet certain CMS standards. As a result Level V facilities will need to increase the level of their services. This change will also place Level V and VI facilities that are larger than 16 beds under the Institution for Mental Disease (IMD) provisions of Medicaid. IMD provisions require facilities to provide all Medicaid funded services directly within the reimbursement they receive. This will require the development of a reimbursement methodology which provides flexible reimbursement to these facilities so all additional health care costs of the patients can be covered without placing providers at unreasonable risk. As a result of these changes, SRS will no longer make federal Medicaid claims for Level V and VI inpatient psychiatric treatment facilities for days youth remain in the facilities beyond the limit established in Kansas’ state Medicaid plan. While addressing these CMS requirements, SRS will work to maintain essential residential services for youth who need them, and to strengthen community-based, least restrictive service options whenever feasible.

CMS also requires that persons with Medicaid coverage have access to any willing, qualified provider. As a result some services previously provided only by CMHCs will be allowed to be provided by private providers. While taking steps to comply with these CMS’ requirements, SRS will strive to maintain the progress made in obtaining adequate Medicaid funding for community mental health services and preserve the vital aspects of the public mental health system so the critical safety net of community mental health services remains strong.

Mental Health Transformation Activities in Kansas. The Governor’s Mental Health Services Planning Council (GMHSPC) synthesized recommendations from the New Freedom Commission (NFC) summits held throughout the State during the past year. The GMHSPC used this information to develop recommendations to the state mental health authority for updating of the five year strategic plan for mental health services. In its ongoing efforts to fulfill the directives of the Governor’s Executive Order # 04-10, the council recently formed a “Transformation Subcommittee” to continue Kansas’ implementation of transformation activities. This subcommittee will be co-chaired by Jane Adams (Keys for Networking and New Freedom Commissioner) and Mike Hammond (The Association of Community Mental Health Centers of Kansas). Membership on the transformation subcommittee includes the chairs from each of the standing subcommittees of the GMHSPC, NFC summit masters, SRS mental health planners, and consumers and family members. The subcommittee began meeting the end of December 2005.

State Hospitals

State Mental Health Hospital Admissions. The state mental health hospitals (SMHH) have experienced significant growth in admissions in recent years. The hospitals have addressed growing admissions by increasing the intensity and effectiveness of hospital treatment, thereby reducing lengths of stay and stabilizing their census. The Hospitals have changed their service delivery to include crisis stabilization services for those who would benefit from a short-term, intensive hospital stay.

Increased admissions have caused the Hospitals’ census to rise to critical levels several times in the last year. The increase in state mental health hospital admissions and the increased census that results, pose a serious challenge to the mental health service system. In response, SRS, in cooperation with mental health system stakeholders, developed an agreed Protocol for Managing SMHH Census Increases. Key elements of the protocol are:

• Regular communication with community partners to quickly assist with upward fluctuations;
• Extraordinary mutual planning and discharge effort when census crises loom;
• Hospitals working together to use admission diversion and transfer options;
• Seeking other treatment resources for people with intense or unique service needs; and
• Exploring and building alternative service options other than state psychiatric hospitals.

On going study from the census management work group and other initiatives from state hospital leadership and staff have explored other options to manage high census including:

• Transitional housing or “step down” services on state hospital grounds;
• Exploring public/private partnerships for alternative service delivery;
• Improving communication between hospital and community staff;
• Treatment program enhancements that ensure patients receive the most effective and efficient treatment that is consumer focused, supportive of community care, and contributes to durable recovery;
• Prompt identification of a planned discharge date to provide a reasonable target for patients, family, hospital staff, and community service providers;
• Increased focus on sound discharge planning, especially for patients who had been at the hospital for longer than one year;
• Vigorous triage assessments on admission, with the shortest effective treatment track assigned to each patient; and
• Assessing the feasibility of providing outpatient observation treatment with a psychiatric hospital especially for patients with a combination of non-SPMI (Severe and Persistent Mental Illness) diagnoses; historical success in community functioning; intoxication; or presence of a “social” rather than purely psychiatric crisis.

Care must be taken to ensure that approved resources are sufficient to meet the existing census levels at state hospitals, and are in reality sufficient to meet the needs of each patient admitted. SRS will continue to monitor care of patients, capacity of facilities and budget, and make adjustments in partnership with stakeholders to address this continuing concern.

Challenges with State Hospital Budgets. All state hospitals continue to struggle with operating costs rising far faster than inflation. The main cost drivers are pharmaceuticals and utility costs. The GBR addresses these additional costs by recommending $500,000 additional funding for Osawatomie State Hospital (OSH) for drugs and shifting about $1.4 million in unplanned salary and wage savings to other operating expenditures (OOE). Savings in salary and wages has occurred because the Sexual Predator Treatment Program (SPTP) census is not growing as fast as budgeted, and other hospitals currently have higher than budgeted staff vacancies.

Continuing to operate state hospitals at their current staffing levels, however, will have a serious affect on the quality and quantity of services patients and residents receive. Lower staffing ratios will cause services to suffer. Also, as the Larned State Hospital (LSH) census grows, particularly in the State Security Program (SSP) and SPTP, adequate numbers of staff will have to be hired. Therefore, the salary and wage savings that may be available in FY 2006 from staff vacancies cannot be counted on in FY 2007, which is reflected by the partial reinstatement of salary and wage funding in the FY 2007 GBR.

In addition, the weather has been record breakingly mild this year. If this continues and the price of natural gas stabilizes or drops, utility costs will not be as high as projected in the hospitals’ budget submissions.

Finally, drug costs are directly tied to the average daily census (ADC) of the hospitals. The higher the ADC, the more pharmaceuticals are needed to effectively treat the patients. If ADC remains stable, this cost too may not rise as fast as originally projected.

In spite of these efforts, the hospitals may still have shortfalls in OOE in FY 2006. The extent of such shortfalls will be better known in a few months at which time a Governor’s Budget Amendment may be necessary to address any remaining shortfalls.

New State Security Hospital. The new Isaac Ray building complex at LSH has been completed, and the entire state security program has been moved to the building. In addition, three of the Sexual Predator Treatment Program (SPTP) units have been temporarily moved to Isaac Ray while other buildings are being remodeled. In April 2006, after the SPTP has moved out, ninety additional beds will be opened for Department of Corrections (DOC) inmates who need some level of inpatient mental health care. SRS and DOC will jointly plan the needed services that will be provided to these inmates.

Sexual Predator Treatment Program (SPTP) Census Growth. The SPTP provides secure inpatient treatment to court committed sexually violent predators. The number of people served in the SPTP continues to increase. The SPTP census continues to rise because the number of people being committed to the program far outpaces the rate at which people successfully move through the program to less restrictive and less expensive services.

SRS is examining various approaches that could be used to slow the census growth or reduce the state costs of this program. These include:

• Coordinating treatment approaches with the Kansas Department of Corrections (DOC) and recognizing progress persons may make in such clinically equivalent DOC treatment programs when placing persons in SPTP treatment steps;
• Giving persons in SPTP more frequent opportunities to progress through the SPTP treatment steps, especially in later phases of the program;
• Developing and initiating the use of the Containment Model or Supervised Release as part of the SPTP Transition Release program. This model uses intensive community supervision and technology to closely monitor the person and, when necessary, to intervene when the person exhibits behaviors that indicate a risk of re-offense; and
• Establishing a long-term care program for persons in SPTP who are frail and elderly or disabled. Such long-term care programs would be in a segregated, isolated settings, supported by federal funding where possible, and supervised sufficiently so that the risk of re-offending is minimal.

SRS has attempted to establish a long-term care setting for one person determined by the court to be ready for transition placement. However, a lawsuit filed local government has stopped this effort. The case has been appealed to the Supreme Court for review and final determination.

These approaches could be used to moderate the growth of the SPTP census. However, even if these approaches are used to their full effect, the SPTP census is expected to continue to grow requiring increased operation costs each year. Currently, available space in the Dillon and Jung buildings is being remodeled to accommodate the growth of this program. However, if the SPTP census grows at its current level, the facility capacity at Larned State Hospital (LSH) will be filled by July 2010.

OSH/RMHF Administration Consolidation. The administrative functions supporting two state psychiatric hospitals, Osawatomie State Hospital (OSH) and Rainbow Mental Health Facility (RMHF) are being integrated to maximize existing resources. In an effort to focus limited resources on patient care, both hospitals have eliminated a number of administrative positions. One result is that critical administrative supports must be managed with enhanced efficiency, without loss of effectiveness. To best meet the needs of patients at both hospitals, the Superintendent for both has created an organizational structure that emphasizes simplicity, ease of navigation, and creates an executive team which manages both hospitals using the same resources, policies, practices and treatment philosophy. All direct clinical services at both hospitals are being managed under one Clinical Program Director who directly supervises the Directors of Nursing, Social Work, and Wellness and Recovery, who all provide their content leadership at both hospitals.

Human Resources Consolidation on Larned Campus. The Governor has directed state agencies to collaborate to achieve increased efficiencies while maintaining effective service delivery. In response to this direction, the state agencies on the Larned campus are exploring opportunities to collaborate and make resources go farther. The first of these efforts involved combining the human resources functions of these facilities into one Human Resources (HR) Center. The combined HR Center reduced HR FTEs and associated salaries from eleven to nine, a twenty percent savings. The HR Center is also meeting additional demands for HR connected with the various facility expansions occurring with Sexual Predator Treatment Program (SPTP) and the State Security Hospital. The HR Center became fully operational April 1, 2005. Other efforts to combine and share resources include vehicle fleet management and sharing other equipment.

GENERAL ISSUES

Medicare Modernization Act - Part D. Medicare Part D pays for prescription drugs for low-income seniors and persons with disabilities who are eligible for both Medicare and Medicaid. Previously, the Kansas Medicaid program paid for the drug costs for these persons.

Persons who are dually eligible and disabled, their families, providers, and advocates will need to educate themselves regarding how this change will affect how they access their drugs. These persons will have to:

• Choose a Part D Prescription Drug Plan (PDP) provider who carries the person’s prescribed medications;
• Identify PDPs and providers who can meet their needs; and
• Budget for any applicable co-pays.

 Other issues of concern include:

• Part D does not cover medications often used for the purpose of alcohol withdrawal and relapse prevention; and
• Providers serving persons in the same site, who used to obtain drugs from a single pharmacy, may need to obtain drugs from multiple pharmacies depending on the requirement of their clients’ PDP.

Part D’s impact on state hospitals varies depending on the type of hospital. The two Developmental Disability (DD) hospitals are affected the most. About 68 percent of the persons residing at the state DD hospitals are dual eligibles. The direct impact to the state mental health hospitals, if any, has yet to be fully determined, however, it has been determined that any potential savings that might be experienced in the state hospitals is not subject to Part D’s “clawback” provisions which requires states to share their related savings with the federal government.

Establishment of the Division of Health Policy and Finance. House Substitute for SB 272 directed that the health care programs administered by the former SRS program of Medical Policy/Medicaid and SRS’ single state Medicaid agency designation be moved to the Division of Health Policy and Finance (DHPF) within the Department of Administration on July 1, 2006. SRS has successfully transferred over 134 staff to the DHPF along with the responsibilities of the single state Medicaid agency.

As part of this reorganization, several Medicaid funded programs remained with SRS including:

• All Home and Community Based Services (HCBS) Waivers and related programs including HCBS waivers for persons with developmental disabilities, physical disabilities, traumatic head injuries, children with serious emotional disturbances, and children in need of medical technology for survival. Related programs staying under SRS’ administration include attendant care for independent living and targeted case management programs.
• Specialized institutional services such as state developmental disabilities and mental health hospitals, private intermediate care facilities for persons with mental retardation and related conditions, nursing facilities for mental health, rehabilitation hospitals for person with traumatic head injuries, and Level V and VI inpatient psychiatric treatment facilities.
• Specialized treatment services including behaviorial health, mental health, substance abuse treatment, and positive behavior support.
• Many administrative functions related to Medicaid including all eligibility determination functions that occur in the field.

These programs remained with SRS because they are not typically administered as integral parts of a health care delivery system. Some, like the HCBS waivers and related services, are considered in the category of long-term care. The institutional services are all highly specialized and directly related to other programs that remain. Mental health and substance abuse services are typically administered in a very different manner from other health care programs, even in private health insurance plans. The administrative functions are integrally linked to the SRS regional offices and program administration, making it much more efficient to keep them a part of SRS.

In addition, the programs that remain are part of larger service delivery systems that are supported by SRS grants, federal grants, and local funds in addition to the Medicaid funds that remained under SRS’ administration. In this way, SRS is now very much like the Department of Aging, using Medicaid funds to accomplish a larger, more specialized goal for persons for whom it is its mission to serve.

SRS is quickly developing the specialized Medicaid expertise and staffing to successfully administer these programs without the Medical Policy/Medicaid staff who previously assisted with this effort.

INTEGRATED SERVICE DELIVERY

CURRENT FEDERAL ACTIONS

The following outlines the impact of recent Federal appropriation bills. These bills have passed the Senate but had some minor amendments on the House floor. The House will again address passage of the bills when they return from their holiday break. The major changes with significant immediate or potential impacts follow:

• Prevents states from claiming federal funds for managing foster children in unlicensed relative homes and other placements.
• Disallows federal matching funds for Child Support performance incentive payments.
• Restricts the assignment of child support to the period during which a family is receiving cash assistance. This impact will be first felt in the State FY 2010 budget. As a result, state collections will gradually erode over several years.
• Increases child care funding by an estimated $1.39 million in State FY 2006 and $1.85 million in State FY 2007.
• Reauthorized the Temporary Assistance for Needy Families (TANF) Program. The bill will result in more narrow definitions of work activities, require verification of client work involvement, and, in general, increases the difficulty of meeting the TANF work participation rates.

Changes with smaller impacts follow:

• Reduces the ninety percent federal funds match rate for child support paternity testing to 66 percent.
• Increases child welfare funding targeting activities to prevent Foster Care and increase Adoptions.
• Eliminates the TANF High Performance Bonus.
• Provides additional energy assistance funding of $1.0 billion for Federal FY 2007. Three-fourths of the $1.0 billion is reserved for emergency funding which is released at the discretion of the executive branch.
• May eliminate, or significantly reduce, federal funding for the Literacy Grant. In addition, supported employment grants, also funded entirely by federal funds, were reduced 19.6 percent, resulting in a loss of $45,000 in federal funds for State FY 2006 and $60,000 in State FY 2007.

Federal Re-authorizations

• TANF, Child Care, and Child Support Enforcement Reauthorization. The 2005 Deficit Reconciliation Act reauthorizes these three programs. At this writing, the final passage of the Act has been delayed due to a technical difference between the House and Senate versions, however, it is expected to be approved. Although several other reauthorization bills are still alive, the outlook is that little attention will be paid to these proposals in the future.
• Workforce Investment Act. Major differences must be resolved between the House and Senate versions of the Workforce Investment Act, which contains the Rehabilitation Act. A key disagreement is the extent to which Rehabilitation Act funds should be made available to support the infrastructure costs of the One-Stop Career Center Development system. The Senate requirement that would require greater involvement by requiring a phased increase in vocational rehabilitation funds (up to 1.5 percent in FY 2009) to support the One-Stop centers. The House version would consolidate vocational rehabilitation funds with adult education and dislocated workers funding into a block grant, while the Senate would leave the funding sources separate. Another difference involves the degree to which services for special education students, with disabilities transitioning to post-secondary education, should be expanded.
• Child Welfare. Comprehensive changes in the federal financing structure of the Foster Care system have been proposed by the President, Congress, and most notably by the Pew Charitable Trusts. This attention arises from a concern, that the present federal financing structure encourages an over-reliance on placement of children in Foster Care, at the expense of other more-permanent options for children who have been abused or neglected. The proposals extends federal Foster Care funding to all foster children, as opposed to those from families with very low incomes. Most of the cost of this expansion would be offset by reducing the federal matching rate. Under this proposal, states which currently have a low percentage of children qualifying for federal Foster Care funding would benefit. While it is estimated that Kansas would benefit under the proposals, insufficient information is available to determine an accurate fiscal impact.

IMPROVING SERVICE DELIVERY

Improved Access to Services. SRS has completed several phases of its service delivery redesign initiative. Nearly 1,000 community access points have been created, improving access to services. Regional service delivery models which focus on customer service and community capacity building are being implemented. A key component of these models are integrated service teams. As the name implies, staff from various service areas join to assess and identify the customer’s needs, then coordinate appropriate services for the individual or family.

The Department’s customer service focus includes evaluation of customer satisfaction. Each region, has developed criteria for measuring customer satisfaction. A baseline of customer satisfaction was established by the Docking Institute of Fort Hays State University in early 2005. The Docking report concluded more than seventy percent of customers were satisfied with access to SRS services. SRS will continue to evaluate customer satisfaction as well as address recommendations noted in the recent Legislative Post Audit report.

Child Care Electronic Payments. Child Care Assistance benefits are now paid by Electronic Benefit Transfers (EBT). Two regional pilots tested the new payment system starting in June 2005, and the EBT system was expanded statewide in September 2005. Kansas is one of the first states to make Child Care Assistance payments using EBT. The electronic process speeds payments to parents allowing child care providers to get paid faster, eliminates use of checks, restricts the use of benefits to only authorized child care providers, and requires that parents become knowledgeable of child care costs to more closely mirror private sector payments. Parents may pay providers using their EBT card at a point-of-sale terminal at the child care location, or the parent may make the payments using a telephone. Providers choose whether they want to lease the point-of-sale terminals. This new payment system has been well received by child care providers statewide as it allows them to better predict their monthly revenue, and to use the same payment policies with families receiving Child Care Assistance as private pay families. Families are now empowered to negotiate payment rates, policies and schedules with providers, and to have more input about the quality of care their child receives because they are directly involved in the payment process.

Life Skills and Youth Independent Living Program. The transition of youth from Foster Care to independent living is critical. To facilitate this transition, SRS has identified a number of strategies.

The Ansell-Casey Life Skills Assessment (ACLSA) is being used statewide to assess youth ages eight and older who are in out-of-home placement. Following assessment, appropriate life skills training is provided to these youth. Youth who are leaving the system as the result of attaining their majority are connected to a positive adult role model in their community through community-based service providers. Current or former foster youth ages fifteen and older are encouraged to participate in the Kansas Youth Advisory Council at the state and local level. The Kansas Youth Advisory Council is the voice of youth in care. Members of the council have presented their views to Guardian Ad Litem’s, the Kansas Supreme Court Permanency Planning Committee, and other organizations across Kansas. Federal funds were granted to community-based services providers and SRS regions to house youth resource rooms across Kansas. These resource rooms aid in the web-based assessment process, as well as, provide a room with computers and resources for youth to use as they work on education and/or employment skills. Education & Training Vouchers (ETV) continue to be used by youth for post secondary education or certified training programs. A total of 299 youth have participated in the ETV program since its inception in Fall 2003.

Hurricane Katrina/Rita Efforts. The agency was directly involved in the effort to meet the needs of persons impacted by Hurricanes Katrina and Rita in late August 2005. SRS was a critical partner in the State’s emergency management response to the disasters, and developed several One-Stop facilities in Wichita, Topeka, and Kansas City to help provide access to services and potential shelter for evacuees. Special guidance was provided to regional staff for the provision of basic services such as food, cash, and medical assistance. Streamlined application processes were implemented around federal instructions, and assistance provided on a priority basis for evacuees. Many program requirements were waived or temporarily suspended to provide immediate access to benefits. SRS is reviewing requirements that were waived or temporarily suspended to determine if they can be waived or streamlined on an ongoing basis.

As a result of SRS relief efforts, 1,200 individuals received assistance. Persons were also linked to Red Cross and FEMA for additional assistance available through these entities. A total of 3,233 Hurricane Katrina evacuees and 361 Hurricane Rita evacuees arrived in Kansas over the course of several months. In addition to providing services to evacuees, the agency sent 33 Regional and Central Office staff to Louisiana over the course of several weeks to help Louisiana staff take food stamp applications. Through these efforts, thousands of local residents were able to be served in a timely manner.

Transitional Support for Released Drug Felons. SRS supports providing Temporary Assistance for Families (TAF), child care assistance, and food assistance to persons convicted of drug felonies. Passage of any bill which provides these benefits would increase caseloads in these program, and thus, have a fiscal impact on the SRS budget.

Kansas Early Head Start Expansion. Kansas Early Head Start is a comprehensive prevention/early childhood development program for children and pregnant women, birth to age four. Through early intervention, this program enhances children's physical, social, emotional, and cognitive development, enables parents to be better caregivers and teachers to their children, and helps parents meet their own goals, including economic independence. Currently, 13 Early Head Start programs serve 32 Kansas counties and 825 children. The additional $1,852,779 in the Governor’s Budget Recommendation will allow approximately 192 additional children to be served, bringing the total children served to 1,017.

CHILD WELFARE INITIATIVES IN PROCESS

Maintaining Families and Supporting Older Youth. In the last budget session, SRS proposed that children who are neither abused nor neglected (i.e., Child in Need of Care/Non-Abuse Neglect (CINC/NAN)) not be allowed to come into custody. This proposal caused a concern with stakeholders. SRS believes the initiative supports our plan to offer services without having a child removed from their home, but agrees that the community needs to be more prepared to help provide needed services to families. A workgroup was formed to gather input on this proposal and to assess next steps. It was decided to first examine the CINC/NAN population. SRS has contracted with the University of Kansas to examine the data, complete case reads, and interview staff and stakeholders, including those in the court system. The review should be completed by Spring. For this reason, SRS will not seek passage of Senate Bill 171.

Customer Service in Child Welfare. Legislators, the SRS Secretary, Customer Services staff throughout SRS, and the child welfare community-based services providers receive complaints from individuals regarding their experience with the Kansas child welfare system. The basis of many of these complaints is how their family perceived they were treated by a child welfare staff person. A charter team comprised of SRS and community-based services providers staff was initiated in May 2005 to address this topic. The workgroup’s charge was to:

• Develop a plan to improve customer services in the child welfare system;
• Identify immediate and future steps to execute the plan; and
• Oversee execution of the plan.

As a result of the workgroup’s final recommendations, SRS will issue a monthly bulletin on customer service, assess training opportunities to ensure the emphasis on family centered customer service, and encourage community forums to gather feedback from consumers.

Collaboration with the Courts. Congress provides funds annually for state Court Improvement Programs (CIP). The FFY 2005 allotment for Kansas is $168,765. SRS provides these funds to the Office of Judicial Administration to develop a Court Improvement Plan related to court oversight of child in need of care and juvenile offender cases. The initial Court Improvement Plan focused on creating and implementing a data collection system to help meet federal requirements involving the court system. The next plan will facilitate legal and judicial participation and collaboration in all stages of the federal Child and Family Services Review (CFSR).

Child Protective Services Improvements. SRS began work with the National Resource Center (NRC) on Child Maltreatment in July 2005, to assess the child abuse and neglect intake and assessment process. The NRC recommended strengthening the use of safety criteria in the intake and investigation process as well as throughout the life of the case. This approach relies on collection and analysis of discrete information sets rather than evaluating every aspect and detail of each family member’s life. The focus is on the severity of the threat, the vulnerability of the child, and the protective capacity of the caregiver. When the intake and assessment process has been updated with the enhanced safety criteria, SRS will provide training to regional staff to ensure the change is incorporated into practice.

Kansas Foster Child Educational Assistance Act. The Foster Care Tuition Waiver program supporting secondary education of former foster children will sunset June 30, 2006. Under this program, eighty percent of the tuition/fees for eligible applicants is paid from federal child welfare funds, while the twenty percent state match is provided by the Kansas Board of Regents schools. One hundred and nineteen youth have benefitted from this program since its inception.

The Kansas Foster Child Educational Assistance Act would allow the current program to sunset and be replaced with a true tuition waiver program. All applicants enrolled in the current program on or before June 30, 2006, would remain eligible based on previous requirements until completing their course of study. Federal regulations prohibit the use of federal funds for both tuition and other education related expenses. If tuition is truly waived, SRS will be able to provide additional funding up to $6,250 per youth for other costs of higher education, including:
room/board, books, transportation, special fees, technical equipment and other costs associated with higher education.

 Modeled after the Kansas National Guard Educational Assistance Act, Adoption of the Kansas Foster Child Educational Assistance Act would provide the flexibility needed to meet changing requirements for federal financial participation in the program and retain the benefits of the current program. While setting limits and insuring accountability, it supports the Kansas Board of Regents and SRS in a cooperative effort to develop a true tuition waiver program.

Positive Behavior Supports. Three years ago, SRS partnered with the Kansas Institute for Positive Behavior Supports (KIPBS), focusing on developmental disabilities. The focus has now shifted to child welfare to explore ways to integrate Positive Behavior Supports (PBS) in the areas of prevention and out-of-home placement. PBS is the integration of valued outcomes, behavioral and biomedical science, validated procedures, and systems change, in order to enhance quality of life and prevent problem behavior. The goal is to train experts who will build capacity across Kansas, provide access to online resources and instruction free of charge, and to create a unified network of professionals across services who support PBS and person-centered planning. The target population is children with a developmental disability who engage in socially inappropriate behaviors at such frequency or intensity that they are at risk of out-of-home placement. In Foster Care, PBS could be used with resource parents and birth parents to help facilitate timely reintegration. Professionals trained in PBS can bill Medicaid for their services. There is no out-of-pocket cost for the family. The trained facilitator works closely with the family to help the youth grow as an individual, and to assess and analyze what is important to the family and the youth so the plan can be designed to fit their needs. The facilitator visits the home and school frequently to make sure the agreed upon plan is implemented correctly. The facilitator trains all staff who work with the youth to make sure they understand the youth’s unique characteristics. Elements of PBS can be found in other approaches, but PBS integrates nine critical features into a cohesive whole: comprehensive lifestyle change, a life span perspective, ecological validity, stakeholder participation, social validity, systems change/multi-component intervention, emphasis on prevention, flexibility in scientific practices, and multiple theoretical perspectives. SRS will be exploring how this approach can be integrated into other populations. A statewide group facilitated by KIPBS has recently convened to develop a statewide plan and vision for PBS in the State of Kansas.

SERVICE RESTRICTIONS

Rehabilitation Services Restriction. Since April of 2004, Rehabilitation Services has been able to serve all eligible applicants. Because of the increase in the numbers of applications for services and the associated increase in expenditures, a waiting list for services was initiated on October 14, 2005. This waiting list will result in the approximately 500 individuals in FY 2006, and 1,000 individuals in FY 2007. In addition, the beginning of services to applicants with the most severe disabilities will be delayed by an estimated 45 to 90 days. In January, 675 applicants with the most severe disabilities were removed from the list and services began. At that time, an estimated 1,200 persons remained on the Category 1 waiting list.

While an additional $2.7 million ($550,000 SGF) was received in FY 2004 for rehabilitation services, caseloads increased by nearly 1,200 cases between FY 2004 and FY 2005 resulting in the depletion of available funding.

PERFORMANCE AND AWARDS

Adoption Incentive Award. Kansas received $440,000 for FFY 2004 and $706,000 for FFY 2005. The funds are awarded based on increases in adoptive placements of children. For the most recent FFY 2005 award, Kansas adoptions exceeded the established baseline by approximately 28 percent. These funds must be used to eliminate barriers to adoption and help find permanent families for children who would benefit by adoption; particularly children with special needs. The focus has and will continue to be:

• The development and implementation of an adoption training and technical assistance programs;
• Increased placements in adoptive families of minority children who are in Foster Care and have the goal of adoption with a special emphasis on recruitment of minority families;
• Post-legal Adoption services for families who have adopted children with special needs;
• Placement of children in kinship care arrangements: pre-adoptive/adoptive families; and
• Building partnerships between public, private nonprofit agencies, and communities to achieve the adoption goals.

Food Stamp Bonus. On June 24, 2005, the U.S. Department of Agriculture (USDA) notified SRS of an $861,132 high performance bonus for improvement in food stamp payment accuracy for FFY 2004. Kansas improved its food stamp error rate from 10.45 percent in FY 2003, to 5.11 percent in FY 2004, and was the second most improved state in the nation. In addition to the High Performance Bonus, a penalty from FY 2002 of $373,344 was waived since Kansas came in under the national average. If Kansas remains below the national average in FY 2005, USDA will forgive the remainder of the FY 2002 sanction, or $373,344 of the $1.5 million sanction from FY 2002. As of the end of June 2005, our error rate was 5.7 percent compared to a national average of 5.5 percent. The Department will use the performance money received from USDA to further enhance payment accuracy in the Food Stamp Program and to improve and enhance access to the program.

TANF Family Formation Bonus. Kansas received an award of $131,055 from the Administration for Families and Children for its efforts in increasing the number of children living in two-parent families between FYs 2003 and 2004. The agency has begun partnering with the Kansas Healthy Marriage Institute based in Wichita and holding workshops targeted at TANF and other low income consumers regarding healthy relationships. A series of events have been held throughout the State to provide similar instruction. Kansas has also been chosen as a demonstration site and received grant monies to continue to expand these workshops and reach more consumers.

Federal Foster Care Review. Kansas is the only state in Region VII to have passed the 2005 Federal Title IV-E review with no errors.

Page last updated: February 6, 2006