Last Updated on September 8, 2021
This article addresses
the recent DOJ settlement with the Commonwealth
of VA regarding individuals with intellectual disabilities and the impact these
new regulations have on the case managers responsible for implementing the new
policies.
In 2011, The Department of Justice (DOJ) found that the Commonwealth of VA was not providing services to individuals with intellectual disabilities with services in the least restrictive environments. This means that Virginia failed to provide enough resources in the community to prevent long-term institutionalization. These findings were in violation of the Americans with Disabilities Act (ADA). The DOJ investigation began at Central Virginia Training Center (CVTC) and expanded to other training centers throughout the Commonwealth. Following a lengthy investigation, several recommendations were made to improve Virginia’s community-based services.
The DOJ essentially called for the following:
1. Downsizing of state operated institutions
by discharging clients into community based programs. These community based
programs primarily are primarily group homes or intermediate care facilities.
Intermediate care facilities for the mentally retarded are also referred to as
an ICFMR. These facilities are similar to group homes but are better equipped
to handle residents with significant medical needs. ICFMR facilities offer the
most medically fragile to also have an opportunity to experience life in a
normal home as opposed to a hospital or institutional setting. Case managers
will be responsible for finding these individuals the appropriate placement in
the community.2. Support Coordinators will have to make face to face visits every 30 days for clients being discharged from training centers and clients with Intellectual Disability Waiver who meet the following criteria:
* Significant medical and behavioral needs
* Reside in a facility/group home with a
conditional or provisional license.
*Reside in a group home licensed for five or
more people
The
new requirements have been referred to as “enhanced case management services”.
These new regulations have had a significant impact on case management services
in Virginia. The requirement that case managers make face to face contact every
30 day s has had the most significant impact. Case managers typically make face
to face visits every 90 days. Needless to say this has created an additional
burden to an already heavy workload. On average, case managers have caseloads
that can range from 30 to over 50 cases depending on the city and agency
policies. They are responsible for coordinating and monitoring just about every
service the client receives. They arrange everything from transportation,
appointments, assistance with rent, job placement, and assistance with
obtaining medical equipment.
Thirty Day Visits vs.
Ninety Day Visits
The 30 day visits have had perhaps the most
significant impact on case managers. Conducting face to face visits every 30
days as opposed to every 90 days also adds additional wear and tear on employee
vehicles. Believe it or not, there are some city agencies and community
services boards in Virginia that don’t have agency vehicles for their case managers.
In addition, agencies have had a significant increase in employee mileage
reimbursement. In some cases, mileage reimbursement has more than doubled since
the implementation of the settlement agreement. Of course, mileage
reimbursement really does not cover the additional costs of wear and tear such
as brakes, tires, oil changes, etc. In some cases, clients have gone from
getting 4-5 visits a year from their case manager to over 12 visits per year.
In addition, the extra visits actually take away precious time that case
managers need for other duties such as coordinating referrals, requests for
services, and other administrative duties. From my experience, making a visit
every 30 days has made no difference in the level of care. Since the
requirement is every 30 days instead of once a month, service providers have an
idea of when the case manager is about to visit. Of course the case manager
will never find any issues with care when they can be prepared for the visit,
which defeats the purpose of the visit. The additional workload for case
managers has not resulted in any increase in salaries or Medicaid reimbursement
for these enhanced case management services.
Additional Workload
Not only do these new regulations take a toll
on case manager vehicles, they take a physical and mental toll on overworked
case managers. Mental health/ disability professionals already have a high
burnout rate. Adding even more responsibilities will only make the burnout rate
even higher. Another source of frustration for case managers is the lack of
incentive. All of these “enhancements” to services have resulted in no reward
for case managers in the form of increased salaries. Many case managers feel that
they are being punished by this settlement and have been burdened with
responsibilities that are just too much to maintain quality services. The
constant piling on of additional responsibilities has made it next to
impossible for even the most experienced case manager to keep up. Imagine
having a caseload of 35 cases and being required to see 20 of them every 30
days. Add in longer case notes, quarterly reports and annual reviews. Add in
the occasional crisis that requires immediate attention and the normal
processing of service requests and reviewing provider reports. In addition to
the 30 day visits, the remainder of the caseload still needs to have a face to
face visit every 90 days. That's a lot of visits to try to manage and still
keep up with the paperwork and other general work duties. This is just an
example but I assure you that a great number of case managers have more than 35
cases (more like 40+). This is simply an unreasonable burden. This is extremely
frustrating for case managers who want to do the best job they can but just
can’t because they’re overwhelmed with the new work duties.
There is no question that the transition to
more community –based services is a positive move for individuals with
disabilities. Virginia has consistently ranked among the worst in the nation in
providing community –based services. You can review the most recent data to see current progress and areas that need improvement.
There was a definite need to improve services
for the disabled. However, more consideration should have been taken when it
comes to the impact that these additional responsibilities will have on the
local agencies and case managers who will ultimately shoulder the burden of
implementing the terms of the settlement. These issues should have been
addressed years ago and not after the government files a lawsuit. The lawsuit
has sped up the process and placed more pressure on local agencies and private
providers to accommodate the influx of more individuals back into the
community. If a community based approach would have been implemented earlier,
more strategies to address the additional workload could have been implemented
and ultimately resulted in an improved quality of service to the individuals
transitioning back into the community.
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