BEFORE THE Department of Public
health and human services of the
STATE OF MONTANA
In the matter of the amendment of ARM 37.87.1331 pertaining to home and community-based services (HCBS) for youth with serious emotional disturbance (SED)
NOTICE OF AMENDMENT
TO: All Concerned Persons
1. On October 28, 2010 the Department of Public Health and Human Services published MAR Notice No. 37-522 pertaining to the proposed amendment of the above-stated rule at page 2512 of the 2010 Montana Administrative Register, Issue Number 20.
2. The department has amended the rule as proposed with the following changes from the original proposal. Matter to be added is underlined. Matter to be deleted is interlined.
37.87.1331 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: PROVIDER REQUIREMENTS
(1) Services funded through the program may only be provided by or through a provider that:
(a) and (b) remain as proposed.
(c) has been determined by the department to be qualified to provide services to youth with serious emotional disturbance in accordance with the criteria set forth in these rules:
(i) a wraparound facilitator and home-based therapist cannot be employed by the same agency when serving on the treatment team and providing services to a specific youth enrolled in the HCBS waiver for youth with serious emotional disturbance (waiver).
(d) through (2) remain as proposed.
AUTH: 53-2-201, 53-6-113, 53-6-402, MCA
IMP: 53-6-402, MCA
3. The department has thoroughly considered the comments and testimony received. A summary of the comments received and the department's responses are as follows:
COMMENT #1: One commenter expressed a concern that the proposed rule change will take away the family's choice of a therapist for youth enrolled in Home and Community-Based Services waiver for youth with serious emotional disturbances (waiver).
RESPONSE #1: The department does not agree. The waiver will allow the family to choose therapists that are enrolled in the waiver. If a youth is already working with a therapist prior to the family participating in the waiver, the relationship with the therapist may continue as long as the therapist enrolls as a waiver provider of home-based therapy. There will be a list of wraparound facilitators for the family to choose from. If there are no available wraparound facilitators, the Plan Manager, who is an employee of the department, will be the wraparound facilitator. Plan Managers will recruit waiver providers, including wraparound facilitators and home-based therapists, to increase access in the urban and rural areas where the waiver is operational.
COMMENT #2: One commenter indicated there are some geographic areas of the state where there may only be one qualified provider for both the wraparound facilitation and home-based therapy. The commenter feared the family would be unable to access home-based therapy.
RESPONSE #2: The goal of the department is to aggressively increase capacity for wraparound facilitation. The department's response to comment #1 addresses the youth's continued involvement with a home-based therapist. In addition, the department has received federal approval to implement a "geographical factor" to offset travel costs for home-based therapists or wraparound facilitators who must travel outside their usual business locations to provide waiver services. The purpose of the "geographical factor" is intended to offset additional costs in rural service delivery which should encourage availability of home-based therapists and wraparound facilitators. The department is in the process of developing the policy to address geographical access challenges.
COMMENT #3: One commenter appreciates the department's creative and effective ways to meet the needs of families and children.
RESPONSE #3: The department appreciates this comment.
COMMENT #4: One commenter suggested the department develop a mechanism to support the objectivity of family choice in the provision of services to allow for the possibility that the wraparound facilitator and home-based therapist are from the same agency.
RESPONSE #4: The department does not agree. The role of the wraparound facilitator is to support families, including the family with the support needed to make good choices in the delivery of therapeutic services. Adding a mechanism to the facilitation process for the sake of gaining access to a home-based therapist from the same agency would add significant complexity to the facilitation process without significant benefit to families. When a family is in crisis, objectivity may be compromised. Some families may be accustomed to other service delivery models where choice has not been an option. When the wraparound facilitator and home-based therapist are from the same agency, the family may feel subtle pressure to choose only this agency.
COMMENT #5: One commenter expressed a concern that the proposed amendment limits family choice in the provision of services which contradicts the basic tenants of the wraparound philosophy.
RESPONSE #5: The department does not agree. Families are given the choice of whether to participate in the waiver. Once in the waiver, families have the choice of facilitators and home-based therapists. This structure is intended to encourage choice, not restrict it. As stated in the response to comment #1, "There will be a list of wraparound facilitators for the family to choose from. If there are no available wraparound facilitators, the Plan Manager, who is an employee of the department, will be the wraparound facilitator. Plan Managers will be recruiting waiver providers, including wraparound facilitators and home-based therapist, to increase capacity in the urban and rural areas where the waiver is operational". In addition to voice and choice, an important component of the values associated with wraparound services is that it is "community-based". "Community-based" includes team-based services where the individualized plan is developed by a wraparound team consisting of the family, natural supports, and formal supports that care about and know the youth and family. The process is family-focused with maximum family involvement; a design that supports the family's choice by allowing them to be fully participatory in identifying the needs of the youth and family and subsequently choosing programs and services to meet those needs.
COMMENT #6: One commenter noted his experience in the implementation of high fidelity wraparound services and stated his support for the proposed rule revisions. The commenter stated that when the wraparound facilitators and home-based therapists were from the same agency, the agencies were built "wraparound silos". A wraparound silo had the effect of excluding other outside community agency involvement.
RESPONSE #6: The department concurs with the commenter's observations.
COMMENT #7: One commenter suggested that the department add another section to the proposed rule to allow a small percentage of the cases to have the same agency employ the wraparound facilitator and home-based therapist.
RESPONSE #7: The department does not agree that an exception should be made even for a small percentage of enrolled waiver youth. For further detail, please refer to the department's response under comment #5 and comment #6.
/s/ John Koch /s/ Mary Dalton for
Rule Reviewer Anna Whiting Sorrell, Director
Public Health and Human Services
Certified to the Secretary of State December 13, 2010