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D
D
C
The
home
and
community-based
waivers
are
designed
to
give
individuals
who
have
disabilities
an
alternative
to
institutional
institutional
institutionalization.
So,
therefore,
many
of
the
individuals
that
are
in
our
waiver
programs
would
otherwise
be
in
long-term
care
facilities.
They
have
to
be
a
level
of
care
in
order
to
be
in
air
waivers
the
services
that
we
provide,
complement
the
medicaid
program,
services
that
are
provided
in
our
state
plan.
These
waivers
provide,
for
example,
personal
support
services
home
making
services
to
allow
those
individuals
to
remain
in
their
home
safely
and
in
the
community.
C
So
we
have
six
home
and
community-based
waivers
in
the
department
for
medicaid
services.
We
have
our
acquired
brain
injury,
injury
and
our
acquired
brain
injury
long-term
care.
This
is
a
waiver
for
individuals
who
are
18
and
older
with
an
acquired
brain
injury.
We
also
have
our
home
and
community
based
waiver
services
or
home
and
community
based
waiver.
It's
for
individuals
who
are
over
the
age
of
65
and
or
and
older
or
individuals
of
any
age
with
a
physical
disability.
C
Our
model
waiver
2
waiver
is
designed
for
individuals
who
are
ventilator
dependent
for
12
or
more
hours
a
day
or
on
an
active
physician-monitored
weaning
plan
for
event.
Our
michelle
p
waiver
and
our
supports
for
community
living
waiver
are
very
similar
and
they
provide
services
for
individuals
with
intellectual
or
developmental
disabilities.
C
For
state
fiscal
year,
2019
here
just
a
few
little
pie,
charts
that
show
you,
the
population
served
and
the
total
amounts
paid
for
the
populations
for
each
waiver.
So,
for
example,
you
can
see
on
the
left
side
our
michelle
p,
which
is
the
blue
waiver.
We
served
ten
thousand
two
hundred
and
twelve
individuals
that
accounted
for
thirty
nine
percent
of
the
waiver
population.
C
C
C
We
estimate
so
in
order
to
for
us
to
go
through
with
redesign
we're
going
to
have
to
either
have
additional
money
or
we're
going
to
have
to
find
a
way
to
to
find
some
efficiencies
where
we
can,
and
I
think
right
now.
I
will
turn
this
over
to
pam
smith
and
let
her
talk
about
some
of
the
activities
why
we
needed
to
redesign
and
some
of
the
activities
that
we
have
taken
thus
far.
Pam.
A
A
So,
as
you
know,
michelle
p
is
our
largest
wait
list
we're
up
to
over
7
400
individuals
with
an
average
time
being
on
that
wait
list
of
three
years
the
longest
an
individual
has
been
on
that
wait
list
is
six
years.
We
have
actually
allocated
350
individuals
already
since
january
and
we'll
be
allocating
another
175
that
those
are
actually
in
the
process
of
of
going
out
right
now
for
scl.
A
It
is
broken
down,
of
course,
into
three
different
categories.
One
is
the
emergency
category,
which
means
the
individual
needs
services
right
now
or
they
either
are
institutionalized
or
are
going
to
be
institutionalized
right
now
that
there's
no
safe
alternative
for
them.
We
have
zero
on
that
waiting
list
and
have
been
able
to
maintain
that
for
quite
some
time.
Our
urgent
category,
there's
121
people
on
that
average
right
now
is
about
3.6
years
that
individuals
have
remained
on
that
category.
A
However,
at
any
point
in
time,
if
something
changes
they're
able
to
move
up
to,
they
are
able
to
request
that
emergency
slot.
The
future
planning
is
more
for
individuals
a
lot
of
times.
You'll
have
a
child,
even
a
toddler
that
will
request
to
be
placed
on
future
planning,
or
you
know,
a
young
school-aged
child,
because
they
know
at
some
point
in
time
in
the
future.
They
are
going
to
need
services,
but
they
are
not
needing
those
services
at
this
time.
A
But
just
because
someone's
on
a
wait
list
does
not
mean
they're,
not
getting
services
today.
So
just
some
other
statistics
about
the
wait
list.
So
for
michelle
p,
the
average
age
of
the
person
on
the
wait
list
is
16
and
73
of
the
individuals
are
under
the
age
of
21,
which
means
that
they
also
are
available.
They
can
get
state
plan
services,
they
can
get
services
using
epsdt
5800
of
the
individuals
on
the
wait
list
have
medicaid
eligibility,
so
they
are
accessing
some
type
of
services
and
an
additional
143
actually
have
medicare
eligibility.
A
90
of
these
individuals
are
already
getting
services
in
another
waiver,
so
those
might
be
in
our
that's
in
the
urgent
category
and
future
planning.
So
a
lot
of
them
are
already
receiving
services
through
michelle
p,
some
of
them
through
hcb
and
are
getting
their
needs,
met
all
individuals
on
both
categories
in
scl
either
have
medicaid
eligibility
currently
or
have
medicare
eligibility,
and
we
have
issued
13
slots
allocated
13
slots
since
january
21st
in
scl.
A
A
We
spend
43
percent
less
on
our
older
individuals
or
people
with
physical
disabilities
compared
to
the
us
average,
and
this
really
speaks
to
the
concept
of
the
haves
and
the
have-nots
when
you
look
at
it
by
disability,
population,
and
so
one
of
the
things
that
I
think
is
most
important
to
stress
to
this
group.
Is
we
look
to
redesigning
waiver
and
how
to
fix
waiver
is
that
we
can't
look
at
it
with
certain
disability
groups
in
mind.
All
into
all.
A
So
what
are
our
goals
of
the
redesign
top
one
is
to
enhance
quality
of
care
to
our
participants.
We're
going
to
do
this
through
implementing
consistent
definitions
across
waivers
right
now.
If
you
looked
at
a
service
respite
or
personal
care,
for
example,
it
has
maybe
five
different
definitions
when
really
the
basis
of
the
service
is
the
same,
the
individual
you're
serving
may
have
slightly
different
needs,
but
the
service
you're
providing
to
them
is
basically
the
same
service.
A
We
want
to
look
at
a
universal
assessment
and
individualized
budgeting
that
will
help
us
with
a
couple
things
individualized
budgeting.
Once
we
get
to
a
view.
That's
not.
Everybody
gets
a
certain
menu
of
services,
or
this
is
I'm
going
to
be
on
hcb.
So
this
is
my
service
menu.
This
is
what
my
plan
looks
like,
and
we
get
down
to.
This
is
my
personal
choice
as
an
hcb
or
an
seo
or
an
abi
waiver
member.
This
is
my
menu
of
services
I
can
choose
from.
These
are
my
needs?
Here's
what
waiver
can
meet?
A
A
A
Looking
at
provider
funding,
so
you
shouldn't
have
one
waiver
that
can
get
paid
twenty
dollars.
An
hour
for
providing
personal
assistance
when
another
waiver
is
paying
eleven
dollars
an
hour
for
the
same
service
until
you
have
consistent
provider
funding
that
matches
the
services
that
are
being
provided,
you're
not
going
to
be
able
to
have
a
robust
provider
network.
A
We
also
want
to
optimize
case
management
to
support
person-centered
planning
and
abide
by
the
federal
conflict-free
case
management
regulation
we
have
found,
although
it
is
getting
better
but
we've
still
found.
Person-Centered
is
still
something
we
need
to
work
on
in
kentucky.
It
should
really
be
about
what
that
person
needs
and
what
they
want.
What
do
they
want
to
work
on?
Not
just
you're
on
a
waiver
and
here's
the
services
that
we
think
you
need.
A
A
So
what
have
we
done?
So
far?
We've
implemented
ongoing
ongoing
stakeholder
engagement
process.
I
think
this
is
one
of
our
most
important
steps.
We
need
to
hear
from
our
providers.
We
need
to
hear
from
the
people
that
we
serve.
We
need
to
hear
from
the
people
that
are
on
waitlist.
These
decisions
are
important
and
should
involve
them
and
they
should
have
a
voice
in
this.
A
We've
switched
service
authorization
from
a
third
party
to
the
cabinet
into
case
managers.
This
has
allowed
for
the
plans
to
become
more
patient
centered.
We
had
reports
that
case
managers
were
afraid
it
would
get
denied,
so
they
just
requested
the
mikes
of
everything
whether
somebody
needed
that
or
not
so
we're
seeing
planes
of
care
that
are
starting
to
become
more
tailored
to
the
individual.
A
We
streamline
incident
reporting
and
moved
to
the
electronic
reporting
system
in
the
medicaid
waiver
management
application,
and
we
continue
to
enhance
that
that
became
mandatory
to
use
in
december
of
2020.
the
providers,
I
believe,
really
like
it.
It
gives
them
insight
better
insight
into
it
as
well,
as
gives
us
a
very
strong
and
quick
insight
into
when
an
incident
report
comes
in
and
we
need
to
take
action
or
we
just
need
to
monitor
a
situation,
training
for
providers,
case
managers
and
internal
staff.
That's
an
ongoing
development.
A
We've
expanded
the
medicaid
waiver
management
application
access
to
all
providers,
so
this
allows
even
service
providers
now
to
come
in
and
see
the
individual's
plan
of
care
they
can
on
demand
generate
their
own
authorization
letters.
They
can
look
at
what
the
case
manager
put
in
as
goals
and
objectives
they
can
look
at
when
the
last
time
was
a
service
was
billed
how
many
units
are
left
and
how
many
have
been
used.
A
We
updated
the
patient
liability
calculation
prior
to
this
change.
Patient
liability
was
calculated
at
one
hundred
percent
of
the
federal
benefit
rate,
which
ended
up
having
we
had
members
having
a
patient
liability
to
access
their
waiver
services
of
excuse
me,
I'm
so
sorry
from
one
dollar
up
to
some
of
them
over
a
thousand
dollars.
A
A
We
have
a
specialized
group
that
deals
with
case
managers,
so
if
they're
out
in
the
field-
and
they
have
a
question,
they
have
somebody
that
they
can
call
and
directly
get
to
speak
to
and
we
receive
anywhere
from
45
to
80
calls
on
that
line.
Every
day,
we've
developed
resource
materials
for
providers,
participants
and
internal
staff.
A
We've
developed
a
lot
of
quick
reference
guides,
which
we
have
found
very
helpful.
We've
had
participants
and
other
advocates
help
us
with
those
that
really
helps
whether
you're
a
provider
or
a
participant
to
know
what
comes
next.
What
do
I
do?
Next?
Okay,
I've
been
given
waivers.
So
what
do
I
do?
Next?
A
A
We
formalize
the
grievance
and
appeals
process
and
move
reconsiderations
to
an
independent
third
party,
which
is
the
cabinet's
office
of
the
ombudsman.
So
now,
when
a
waiver
service
gets
denied
that
reconsideration
actually
is
viewed
by
someone
that
is
not
part
of
the
initial
process,
we've
introduced
updated
service
definitions,
policies
and
procedures
that
are
in
the
home
and
community
base
and
model
2
waiver
renewals.
Those
are
currently
in
the
process
of
going
through.
They
both
recently
expired,
so
we
had
to
do
renewal
applications
with
cms,
and
so
those
model
2
actually
will
be
resubmitted.
A
So
key
takeaways,
our
programs
serve
diverse
range
of
ages.
We
have
a
lot
of
pediatric
patients.
Statewide
enrollment
does
not
reflect
the
population.
Dentist
density,
suggesting
there's
access
gaps,
particularly
in
rural
area
areas
that
points
to
a
lot
of
our
issues
with
having
providers
and
our
wait
list
remain
an
issue.
A
A
A
Their
assessment
involved
review
of
the
waivers
all
of
our
regulations,
all
of
our
internal
processes
and
they
also
conducted
interviews
with
cabinet
staff
and
that
included
us
and
our
sister
agencies,
the
department
for
aging
and
independent
living
and
our
department
for
behavioral
health
and
intellectual
disabilities,
as
well
as
they
went
out
with
us
and
helped
conduct
40
external
stakeholder
focus
groups.
So
we
met
with
the
individuals
directly
their
caregivers
advocates.
A
A
We
need
to
look
at
payment
and
rate
setting
case
management
and
person-centered
planning.
How
can
we
do
that
better?
How
can
we
support
our
providers
better
in
doing
that
and
then
also
looking
at?
Not
just
our
waiver
service
areas
concerns,
but
our
non-waiver
concerns
so
individuals,
knowing
we
repeatedly
hear
they
don't
understand
what
they
can
access
through
regular
medicaid,
so
making
sure
that
they
understand
the
other
services
they're
eligible
for
not
just
waiver.
A
Stakeholder
engagement
will
continue
to
be
a
foundation
of
what
we
do.
I
think
that
it's
vitally
important
that
we
hear
from
all
stakeholders,
whether
it's
internal,
it's
our
providers
but,
most
importantly
it
is
our
members
and
the
individuals
we
serve
and
the
individuals
that
we
hope
to
serve
looking
at
our
waiver
quality
measures.
So
not
just
we're
going
to
put
these
changes
in.
But
how
do
we
measure?
A
A
Talking
about
the
budget
process.
Looking
at
how
can
we
modify
that
to
make
sure
again
that
we
have
individuals
that
are
getting
the
right
types
of
services
that
they
need
the
rate
setting
methodology
looking
at
the
cost,
that
providers
incur
to
provide
services
to
individuals
what
it
costs
to
serve
them
and
really
to
have
that
methodology
so
that
we
have
a
strong,
can
have
a
strong
provider
group
and
continuing
to
work
on
our
standard
operating
procedures
internally,
so
that
anytime,
there's
a
question
about
how
something
is
done,
there's
always
a
document
that
is
reviewed
annually.
A
We
want
to
update
the
case
management
approach
for
waivers.
We
want
to
continue
to
develop
tools
for
them
and
performance
standards
and
training
that
better,
reinforces
and
supports
case
managers
case
managers
really
are
the
team
lead
when
it
comes
to
waiver?
We
want
to
make
sure
they
understand.
How
can
they
lead
those
team
meetings?
How
can
they
facilitate
connections
with
providers
and
with
services
participant
directed
services
or
pds
is
very
popular
in
kentucky
we
have
probably
about
60
to
70
percent
of
our
individuals
that
access
at
least
one
participant
directed
service.
A
A
Participant
directed
services
will
continue
to
become
even
more
popular
as
we
have
less
and
less
providers
that
really
fills
in
those
gaps
when
we
don't
have
a
traditional
provider,
we
want
to
continue.
As
I
mentioned,
the
ongoing
stakeholder
engagement
process.
We
want
to
talk
about
that.
We
have
one
quality
management
business
unit
and
that
really
it
would
be.
You
have
representatives
from
every
unit
in
the
cabinet
that
has
a
place
with,
so
it
would
be
individuals
from
dms.
A
A
So
some
additional
concerns
that
weren't
included
in
the
assessment
report
the
workforce
issue,
as
I
mentioned
it,
touched
on
this
talking
about
finding
you
know
the
streamlining
the
qualifications
and
it
looked
at
that,
but
we
just
recently
did
a
survey
of
our
providers
and
42
percent
of
the
providers
who
responded
reported.
They
have
little
to
no
response
with
job
postings.
A
I
just
heard
on
one
of
the
national
groups
that
we're
a
part
of
that
right
now:
vet
techs,
so
people
that
take
care
of
pets
are
making
more
than
what
our
individuals
that
are
taking
care
of
our
loved
ones
and
our
most
vulnerable
population
are
making
pds
background
background
check,
cost
right
now.
The
potential
employee
and
other
interested
third
party
or
the
participant
themselves
is
paying
for
the
background
check
cost.
A
Management,
so
how
can
you
help
us?
Of
course
the
number
one
thing
is
going
to
be
funding.
We
we
need
money,
so
I
think
several
of
you
heard
me
say
before.
If
somebody
shows
me
where
the
money
tree
is
I'll,
go
and
shake
it,
but
funding
is
going
to
be
key,
but
also-
and
this
is
the
one
thing
that
I
really
these
last
two-
that
I
want
everyone
to
remember-
is
that
holistic
consideration
of
ace
of
hcbs.
A
Remember
that
we
serve
a
variety
of
populations
and
that
each
of
these
have
should
have
equal
opportunity
to
receive
services
to
be
in
the
community
to
age
in
place
and
to
be
community
integrated.
We
need
public
support
for
updates,
so
we
do
anticipate
some
pushback
from
stakeholders.
Change
is
hard
people
don't
like
change,
so
we
anticipate
that
we're
going
to
have
some
people
just
because
we
say
we're
going
to
change
something
that
they're
automatically
going
to
have
an
opinion
or
an
issue,
even
if
sometimes
themselves,
they're,
not
even
sure
what
that
is.
A
C
If
I
could
add,
you
know,
we
know
that
the
the
waiver
populations
serve
a
very
vulnerable
population,
it's
aged
and
individuals
that
would
meet
nursing
home
level
of
care.
We
do
know
that
it
is
cheaper
on
the
on
the
aggregate.
It
is
cheaper
to
to
serve
individuals
in
our
waiver
programs
in
the
event
that
we
could
start
moving
individuals
from
a
facility
into
a
waiver.
There
would
be
some
cost
savings.
C
C
We
want
to
serve
as
many
individuals
in
our
waiver
programs
as
we
can.
We
want
all
individuals
to
be
in
the
communities.
We
know
there
are
some
issues
with
our
waiver
programs.
We
feel
like
that.
We
have
worked
on
a
lot
of
those
issues
and
are
more
than
willing
to
sit
with
our
stakeholders
to
continue
to
improve
these
programs.
C
A
A
I
don't
have
that
the
number
directly
in
front
of
me,
that's
something
I
can
get
for
you
all,
but
I
will
say
that
it's
not
a
lot,
because
the
individuals
are.
These
are
chronic
health
conditions
and
usually
we
see
individuals
that
remain
on
the
waiver
for
several
years.
But
I
can
get
that
information.
Okay,.
G
Thanks
are
appreciated
and
nice
report.
Thank
you.
Folks
did
a
very
good
job
and
I
think
your
most
telling
slide
is
probably
number
eight
you're
talking
about
40,
more
per
capita
on
people
with
developmental
disabilities
compared
to
us
average,
and
we're
spending
43
percent
less
per
capita
on
older
people.
G
So
in
summation
of
your
report,
what
we're
really
trying
to
accomplish
with
this
is
one
better
utilization
of
resources
than
what
we're
presently
doing,
and
I
think
that's
quite
evident,
but
secondly,
be
able
to
provide
services
to
those
who
currently
are
not
able
to
access
those
services.
That's
the
backlog
and
the
mail
distribution
of
the
dollars,
as
you
noted
on
this
particular
slide,
is
that
a
fair
summation
of
this.
C
G
And
commissioner,
I
appreciate
your
comment
about
even
if
there's
a
savings
and
that's
a
very
loose
word
on
the
real
utilization
resources
that,
because
of
the
pent-up
demand
that
we
have
for
these
services,
probably
that's
going
to
be
consumed.
Whatever
savings
we
do
realize,
but
I
think
it's
important
going
forward
to
recognize
where
those
savings
are
coming
from,
because
that's
a
reallocation
of
dollars
as
well.
But
you
threw
out
the
number
you
need
an
additional
43
million.
C
C
One
of
the
recommendations
or
one
of
the
statements
was
in
order
to
align
payment
across
providers
type
across
provider
types.
We
would
have
to
take
funding
or
reduce
reimbursement
to
certain
providers
and
increase
reimbursement
to
other
providers
which
basically
resulted
in
you
know,
rob
and
peter
to
pay
paul
and
there's
going
to
be
winners
and
losers.
C
So
that
was
one
of
the
biggest
reasons
for
the
redesign
or
for
the
pause
on
the
redesign,
because
in
order,
if
we
did
not
do
that,
if
we
just
brought
all
other
providers
up
to
the
highest
level
of
payment
reimbursement
for
the
other
provider
types
waiver
provider
types,
it
would
be
an
imp.
We
would
need
an
infusion
of
43
million
dollars
to
do
that
in
order
to
to
balance
that
out
without
reducing
reimbursement
to
one
waiver
provider
type.
G
I
appreciate
that
and
I
can
be
supportive
of
that,
but
I
think
I'd
like
to
see
a
little
bit
more
refinement
of
the
numbers.
You
know.
I
think
we
need
to
make
a
projection
as
to
how
much
it's
going
to
cost,
to
provide
the
services
of
those
in
waiting.
What
the
projected
savings
could
be-
and
I
know
that's
a
very
tough
one-
to
come
up
with,
because
it's
purely
speculative,
but
in
order
to
really
understand
the
full
scope
of
this.
G
D
D
C
D
Okay,
thank
you
yeah
and
I'm
with
senator
meredith.
I
would
like
to
echo
his
comments
that
I
think
that
it's
important
that
we
talk
about
funding
in
more
specific
terms,
so
that
we
know
what
our
task
is
once
we
reconvene
in
january,
and
we
and
we
have
that
real,
solid,
comfortable
breakdown
for
everybody.
Thank
you
very
much
for
your
testimony.
H
H
H
So
I
think,
there's
a
big
selling
point
to
that.
Also,
I
would
suggest
recruiting
maybe
some
cnas
through
cna
classes,
to
because
they've
got
basic
nursing
skills.
That
would
be
very
handy
and
I'm
familiar
with
your
program,
because
I
know
people
that's
on.
That's
that's
participants
in
these
waiver
programs,
so
I
commend
you
for
the
job
that
you're
doing
feel
free
to
reach
out
to
me.
Thank
you.
Thank.
C
You
thank
you
so
much.
We
know
that
these
these
programs
provide
such
a
valuable
service
and
again
the
medicaid
program
is
typically,
it
is
the
go-to
program
to
solve
these
sorts
of
issues
that
is
very
difficult
to
solve,
because
we
are
the
only
agency
that
covers
waiver
services
for
the
particularly
personal
support
services
and
home
making
services
that
allow
individuals
to
stay
in
their
home.
I
Thank
you,
mr
chairman,
and
commissioner
and
pam.
Thank
you
both
for
being
here
today
and
I'll.
Try
to
limit
this.
We
could
probably
have
a
five
or
six
hour
conversation
on
all
this,
but
I'll
I'll
focus
on
just
a
couple
specific
issues.
One
thing
that
I've
never
seen
is
a
breakdown
on
the
various
services,
whether
it
be
cls
respite.
I
You
know,
with
all
the
services
involved
under
these
waivers,
a
breakdown
on
how
many
hours
and
have
you
all
done,
any
studies
in
relation
to
those
services
have
you
identified
particular
services
that
might
be
the
greatest
area
of
savings
and
I
think
you're
right
there.
There
are
a
lot
of
times
that
you
know.
Services
are
granted
that
really
aren't
as
specific
as
they
should
be.
C
We
we
do
look
and
analyze
services
that
are
being
delivered
across
the
waiver
programs,
and
I
think
that
that
would
be
something
that
we
could
definitely
bring
to
this
committee.
When
we
start
talking
about
the
the
budget
and
the
funding
that
senator
adams
and
senator
meredith
were
referencing,
I
think
that
it
would
be
a
really
good
exercise
to
look
at
what
payments
are
being
made
across
the
waiver
types
for
specific
services.
I
think
that
will
help
us
move
forward
as
make
some
decisions,
as
we
move
forward.
I
But
financially,
you
know
we
do
have
to
be
aware
of
the
providers
and
making
sure
that
there
are
services
available
throughout
the
state
to
to
provide
whatever
services
are
approved
with
that
being
said,
one
other
thing
I
want
to
get
into,
and
I
don't
want
to
spend
a
lot
of
time
on
this.
I
know
we
need
to
move
on
for
11
years
now.
I
have
struggled
to
understand
the
process
for
bringing
people
on
to
the
waiver,
and
I'm
going
to
ask
you
one
more
time.
I
A
So
right
now
we
are
at
about
ten
thousand
two
hundred
or
two
fifty
we're
close
we're
within
200
or
250
of
that
cap
of
the
10
500
it.
It
fluctuates
a
little
bit
day
to
day,
but
we're
we're
right
in
that
range.
And
so
we
still
when
I
came
on
in
this
position,
we've
been
allocating
for
michelle
p,
every
90
days
for
at
least
the
last
two
years,
so
part
of
that
was
originally
to
get
on
the
michelle
p
waitlist.
A
A
We
always
reserve
between
30
and
50
slots
for
individuals
that
that
lose
their
services
through
no
fault
of
their
own,
so
something
happens
and
they
lose
medicaid
eligibility
and
they
need
to
work
through
that
or
a
lot
of
times.
They
were
admitted
as
a
child,
and
now
that
they've
crossed
the
age
threshold
that
they
actually
need
a
disability
determination.
Sometimes
that
can
take
a
little
while,
so
we
always
will
reserve
you
know
30
to
50
slots
for
that,
so
that
we
could
bring
somebody
back
on
and
not
be
right
at
our
cap.
A
I
A
I
So
so,
let's
assume,
let's
let's
say
there
are
10
000
and
let's
say
during
any
during
a
given
year
and
I'm
just
just
for
discussion.
I
don't
have
any
idea
what
the
numbers
are
and
that's
really
not
important.
But
let's
say
that
500
people
on
michelle
p
waver
pass
away
in
a
given
year,
I'm
assuming
that
those
slots
are
recycled.
A
A
So,
even
if
an
individual
passes
away,
if
they
utilized
one
service
within
that
date,
range
that
slot
cannot
be
reused
until
the
next
waiver
year
begins
on
9-1,
but
every
every
year,
beginning
september
1st
we
will
take
all
of
the
slots
that
have
been
vacated.
So
somebody,
you
know
moved
from
michelle
p
to
scl.
They
moved
out
of
state.
They
passed
away.
All
of
those
slots
then
get
get
reinfused
into
what's
available.
I
And
and
the
the
standard,
the
reimbursement,
it's
70,
30,
correct,
yeah,
okay
and
I
I'm
tr.
I
struggle
to
grasp
this
three-year
average
waiting
period
because
I
simply
don't
know
of
anyone
in
our
area.
That's
getting
approved
and
that's
been
a
struggle
that
we
have
had
for
years,
and
I
know
people
that
have
been
on
the
list,
many
that
have
been
on
the
list
five
six
seven
years,
so
I
struggle
with
this
three
year
average.
I'm
not
sure.
I
agree
with
that.
A
A
A
I
A
I
E
Thank
you.
Senator
carl
and
I've
got
a
real,
quick
question.
I'd
like
to
ask:
if
you
go
to
slide
seven,
it
indicates
that
kentucky
has
outpaced
the
growth
of
national
1915
c
spending,
and
then
we
also
rank
19th
in
volume
of
spending
of
all
states
and
this
ranking
outpaces
that
our
space
is
the
26th
most
populated
state.
Do
we
have
a
higher
percentage
of
our
residents
that
are
have
disabilities
than
do
other
states?
A
E
E
F
We
don't
have
it
for
record.
I
apologize
again,
I'm
steve,
shannon,
I'm
the
executive
director
of
carp,
carpenter,
association
of
cuny
mental
health,
centers
11
of
the
14,
and
this
slide
just
so
informational.
You
know
who
your
cmhc
is
locally,
so
you
know
who
those
are,
hopefully
all
know
those
people
and
what
they
do.
F
The
cmhcs
again
there's
14
of
us
corpse
association
11.
We
spoke
about
175
000
people
annually,
8
000
people
employed
by
cmhcs.
If
you
throw
in
the
pds
piece
that
we
do
payroll
for
that
number
escalates
a
wide
range
of
folks
direct
support
professionals.
They
have
physicians,
lawyers,
doctors,
therapists,
300,
volunteer,
board
members.
I
point
that
out
because
we
are
community
based
and
we
are
led
by
dedicated
volunteers
in
their
community
and
I
say
cmhcs
make
all
communities
better
in
kentucky
and
I
believe
that
you've
seen
this
slide
already.
F
F
Hopefully
you
heard
this
before.
I
think
I
had
a
drum
roll
for
that
individuals
with
severe
mental
illness.
I
first
testified
of
this
effect
in
june
2019
at
the
interim
health,
welfare
and
family
services
committee,
and
that
testimony
clearly
at
that
point
we
laid
out
the
need
for
an
smi
waiver
should
be
noted.
The
navigant
report,
one
of
the
public
comments
they
received-
was
a
need
for
an
smi
waiver
as
well.
People
are
severely
mentally
ill
in
kentucky.
There's
a
task
force
on
this
issue.
Senator
meredith
serves
on
that
task.
Force
met
last
tuesday.
F
F
There
may
be
some
who
are
in
a
waiver,
but
not
because
they
are
severely
mentally
ill,
not
because
they
are
severely
mentally
ill.
It's
because
they
have
an
intellectual
disability,
have
a
physical
disability.
Maybe
elderly
may
have
acquired
brain
injury,
zero
dollars
spent
on
that
population.
In
kentucky
it's
about
time.
We
changed
that
nationally.
It's
twelve
dollars
for
every
ten
thousand
waiver
dollars
go
to
people
who
are
severely
mentally
ill.
I
think
it's
time
we
make
that
change.
Other
states
have
a
waiver,
so
one
of
my
recommendations
is
an
smi
waiver.
F
Any
group
that
invites
me
to
speak
I'm
going
to
lead
with
smi
waiver
residential
services.
People
need
a
place
to
live.
We
have
a
staff
residence
model
group
homes.
In-Home
supports
medication,
administration
support.
I
point
that
out
as
a
service,
because,
if
you're
in
a
waiver
today
and
if
you're
an
hour
late
for
your
medication,
a
multivitamin
or
aspirin
as
a
blood
thinner
that
gets
documented
if
you're
mentally
ill
severely
mentally
ill,
if
you're
an
hour
late
a
day
late
a
week
late
a
month
late.
F
Nobody
knows
nobody
knows
the
first
person
to
find
out
family
members
probably
know
they'll
tell
you.
Neighbors
law
enforcement
just
doesn't
seem
right
to
me.
Supported
employment
help
people
get
work,
there's
some
state
general
fund
dollars
for
employment,
some
grants
service,
some
states
have
his
tenant
skill
building,
and
this
is
really
teach
people
who
rent
an
apartment,
how
to
keep
an
apartment,
people,
I've
known
who
are
mentally
ill,
get
evicted
quite
often,
maybe
dirty
they
don't
maintain
it.
They
don't
pay
their
utilities
in
a
timely
manner.
F
We
had
one
guy
on
our
street
who
got
an
apartment
and
he
was
told
by
his
case
manager,
pay
your
utilities
on
time.
He
was
at
my
house
for
my
wife
to
write
a
check
in
his
checkbook.
We
didn't
pay
for
it.
She
helped
him.
Do
it
with
money
for
a
stamp
before
the
mailman
left
our
street.
We
only
have
about
eight
houses.
He
got
it
not
everyone's
that
good.
A
lot
of
folks
in
personal
care
homes
with
more
supports
could
live
in
the
community.
Smi
waiver
number
one
in
my
opinion.
F
Briefly,
pastory
devine
redesigned
efforts
navigate
heard
a
lot
about
it,
but
before
that
there
was
a
started
by
the
the
cabinet
as
well.
The
commissioner,
the
dale
commissioner,
led
we
met
three
times
that
ended
abruptly.
So
we've
talked
about
redesign
before
navigant
report
again
heard
it
earlier.
49
findings,
11
recommendations
and
a
rate
study
that
was
done.
I
think
that's
the
controversial
piece,
the
rate
study
I'm
going
to
be
a
little
different
than
my
predecessors.
F
I
support
budget
neutrality.
Budget
neutral
is
a
concern
for
me
budget
neutral.
When
I
define
budget
neutral,
it's
we
spent
857
million
dollars
on
six
waivers.
We
want
to
redesign
and
still
spend
857
million
dollars
on
waivers.
You
can't
do
both.
I
don't
think,
there's
enough
efficiencies
within
waiver
delivery
to
create
sufficient
dollars
to
move
the
needle
on
redesign
heard
it
before
three
of
the
waivers
lost
money.
Three
picked
up
money.
You
will
not
hear
from
the
winners.
F
They
will
not
call
you
and
say
wow.
This
is
awesome,
we're
getting
more
money.
My
friends
behind
me
with
the
abi
waivers
they'll
tell
you
more
about
this.
They
lost
one
in
seven
dollars
that
they
had
allocated
previously
on
the
rate
study,
one
out
of
seven
dollars.
14.25
percent,
that's
pretty
hard.
Michelle
p
lost
some
money
on
the
rage
study.
The
model
two
picked
up,
scl
picked
up
and
hcb
picked
up.
F
So
I
think,
and
when
that
document,
when
I
first
saw
it
because
I
was
on
the
rage,
study,
work
group
and
I
saw
the
migration-
I
said-
I'm
assuming
phones
are
ringing
right
now
because
those
dollars
so
the
the
task
to
navigate
and
previous
waiver
work.
I've
done.
We
can
do
whatever
we
want,
but
we
can't
spend
more
money.
F
It
just
doesn't
work
that
well.
I
think
we've
proved
to
ourselves
repeatedly
that
that's
problematic
and
I
just
don't
think,
there's
sufficient
efficiencies
to
create
impactful
change.
So
we've
got
to
evaluate
budget
neutrality.
I
think
we've
got
to
review
the
existing
recommendations
you
heard
about
11
today.
Keep
at
that
smi
waiver
keep
throwing
that
out
all
day
long
just
so,
we
all
know.
F
F
What's
your
turnover
rate
too
high,
we
need
to
look
at
that.
You
need
to
keep
people
in
place.
You
need
to
give
people
an
opportunity
to
make
jobs.
One
point
in
my
life:
I
ran
an
agency.
I
knew
when
my
staff
person
visited
a
married
couple
that
worked
at
kroger's
bagging
groceries
their
intellectual
government
disability
because
they
made
more
than
my
staff
person.
F
F
Let's
focus
on
checklists
and
forms,
we
need
assistance.
I
represent
11
providers,
we
need
funding.
Today
I
mean
we're
really
concerned
about
our
ability
to
be
competitive
in
the
marketplace
and
hire
people
and
if
we
can't
adequately
staff
with
competent
people,
we're
not
in
a
position
to
go
forward
with
waivers
and
we've
talked
around
this
a
lot.
I
agree
with
senator
adams
it's
time
to
take
some
action.
We
need
to
figure
this
one
out
because
we're
just
not
competitive
in
the
marketplace.
F
We
got
some
great
great
people,
senator
carroll,
you
probably
experience
on
a
regular
basis,
great
people
who
leave
your
agency
because
they
can
go
someplace
else
and
make
more
money.
It's
a
real
concern.
We're
setting
ourselves
up
really
to
fail.
If
we
don't
do
that
to
look
at
the
cost
got
to
look
at
costs
going
forward
with
inflation.
We
talk
about
a
career
ladder.
F
F
We
do
the
we
cut
payroll
for
people,
millions
and
millions
of
dollars
of
payroll
for
people
and
one-
and
I
got
to
say
this-
is
an
interest-free
loan
to
the
commonwealth
because
we
get
reimbursed
afterwards.
These
are
not
our
employees.
We
are
an
employment
agency
essentially
and
doing
payroll.
It's
a
real
stressor
on
agencies
to
make
that
work
for
them.
F
I
think
using
mwma
with
pds
would
help.
I
have
some
people
express
concerns
about
that,
but
it's
a
hundred
dollars
a
month
we're
not
getting
rich
off
this.
If
you
have
enough
people
you
may
break
even
but
we're
cutting
checks
for
people.
We
have
recoupments
for
services
and
our
support
broker
gets
recouped.
It's
gotten
better,
but
we
get
recruit
for
those
services.
So
it's
a
real
hard.
F
It's
it's
financially
stressful
at
a
situation
that
pam
helped
us
with
last
week
with
someone
you
know,
and
we
do
we're
now
doing
it
for
hcb
waiver
deal
for
michelle
p
and
scl.
We
were
asked
to
join
those
as
the
fiscal
intermediary.
We
didn't
propose
that
as
a
model
they
came
to
us
years
ago
for
the
scl
michelle
p
and
the
last
six
nine
months
over
the
hcb.
F
F
I
also
think
we've
got
to
talk
about
redesign
across
what
can
we
do
across
all
waivers
and
smaller
pieces
kind
of
heard
earlier
that
the
scl
and
michelle
p
waivers
are
linked
serve
a
similar
population?
Does
it
make
sense
of
one
strategy
to
focus
on
those
things?
Initially,
the
abi
there's
two
of
them
focus
on
those
things
because
they
may
be
more
similar
and
the
redesigned
system
made
there
may
be
different
than
it
would
be
for
across
all
six
waivers
at
once,
so
focus
on
those
specific
things
pulling
expertise
around
those
areas
as
well.
F
Now
one
thing
did
happen,
consistent
language
across
all.
That's
that's
navigate
recommended
that
medicaid
has
done
that
kudos
to
them.
It's
really
beneficial,
because
now
families
and
individuals
understand
what's
what
it
means
previously.
It
wasn't
clear
wasn't
clear
to
me
and
I've
been
at
this
for
25
years,
but
now
it's
clear.
So
that's
a
step
in
the
right
direction,
but
are
there
scl
michelle
p
things
that
we
ought
to
pay
attention
to?
Michelle
p
does
not
have
a
residential
option.
Scl
does.
Could
michelle
p
be
a
feeder
to
seo?
We
need
residential,
you
go
there.
F
I
don't
know
it's
really
hard,
but
I
think
we've
got
to
look
at
those
things,
maybe
sit
across
all
six
for
everything
focus
on
those
specific
things
that
are
related
and
do
those
things
going
forward,
an
assessment
tool.
I
said
this
last
year
to
you,
chairman
reilly:
we
need
to
have
an
assessment
tool
to
identify
people's
needs.
F
There's
one.
I
don't
know
if
there's
a
universal
tool
across
all
six
wipers,
maybe
there's
an
introductory
tool
across
all
six
waivers.
Then
you
go
for
the
idd
population,
a
different
tool,
a
different
tool,
my
friends
from
the
abi.
I
could
probably
answer
that
better
than
I
can,
but
we
need
to
have
a
tool
that
measures
acuity.
You
need
acuity
to
really
determine
that
what
people's
needs
are
and
you
have
those
services
in
place.
It
also
becomes
a
planning
tool.
F
If
you
have
some
idea
what
to
expect,
you
can
better
budget
going
forward
what
those
needs
are
who's
coming
up
next,
people
who
are
really
have
greater
needs
their
next
they're,
going
to
cost
us
more
money
than
someone
who
may
be
next
in
line
has
less
support
needs.
So
we
need
to
have
that
police
as
well
got
addressed
the
waiting
list
been
at
this
for
a
long
time.
Scl
has
three
that
has
that
acuity
base
people
greater
needs
move
to
the
top
of
the
list.
Michelle
p
does
not
have
that.
F
It's
chronological,
you
know
if
you
got
on
the
list
early
on
you're
in
the
pool,
if
you're
not
you're,
going
to
wait
a
long
time
to
get
those
services.
Is
there
a
way
to
address
those
waiting
lists
to
give
people
an
expectation
that
there's
some
hope
of
getting
services
as
opposed
to
waiting
for
a
long
period
of
time?
Some
expectation?
How
do
you
do
that?
Some
idea?
F
I
also
think
it
needs
to
be.
The
system
needs
to
be
predictable,
flexible
and
address
the
needs
of
consumers.
First,
I
think
that's
key,
but
if
you
do
that,
you
take
care
of
providers,
funders
and
policy
makers.
I
think
we'll
be
okay,
but
I
think
we
need
to
look
at
that
start
out
with
the
consumer
needs
and
build
the
system
from
there.
F
This
I
like
a
two
by
two
grid,
the
only
four
bits
of
information
I
have
to
keep
up
with,
and
that
helps
me.
But
if
you
look
at
this
on,
the
y-axis
is
change.
Design
on
the
x-axis
is
dollars.
I
think
we're
in
the
bottom
left-hand
quadrant
right
now,
low
change,
load,
redesign,
low
dollar
status
quo.
I
don't
believe
we're
satisfied
with
the
status
quo
or
we
wouldn't
be
here
now
we'll
be
figuring
out.
What
happens
next?
So
that's
where
we're
at.
I
think.
F
If
you
go
above
it,
I
think
what
we've
done
to
date
is
high
change,
low
dollar,
not
less
dollars.
I
mean
we're
not
moving
the
dollar
needle
right
and
that
hasn't
worked
so
far
right,
navigating
it
didn't
work
for
them
didn't
work
previously.
Other
things
they've
been
involved
with,
we
can
make
changes,
can't
change
the
dollar.
So
I
think
we
got
to
have
a
real
conversation
about
what
those
costs
are
and
the
46
million
at
857.
F
That's
about
5
percent,
senator
meredith
five
percent,
not
a
whole
lot
of
money,
but
got
to
find
it.
I
understand
that
bottom
right,
low
change,
high
dollar.
I
think
the
system
today
without
change
is
in
a
dollar
crisis.
I
don't
believe
we're
going
to
be
in
a
position
to
maintain
our
workforce,
keep
the
good
ones.
F
Okay,
that's
what
we
really
want
to
do.
We
want
to
keep
the
best
workers,
keep
them
and
hire
ones
like
them.
That's
the
goal!
If
we
don't
have
a
way
to
do
that,
I
don't
know
we
can
keep
the
best
ones
and
we
end
up
with
workers.
Shifts
will
be
staffed,
but
are
the
best
workers
and
the
goal
was
the
top
right
hand.
Quadrant
high
change.
F
F
We
want
to
make
changes,
but
we
got
to
go
forward
with
understanding
that
those
changes
will
be
priced
and
we'll
figure
out.
If
you
have
to
do
it
incrementally
how
we
do
that
based
on
the
budget
number.
Otherwise
we're
going
to
be
we'll
have
struggles
if
we
just
make
change
without
dollars,
and
those
are
just
a
summary
of
those
four
slides
again.
We
want
to
support
individuals
today,
folks
on
the
waiting
list
and
folks
you
don't
know
about,
because
there's
people
out
there
not
on
waiting
lists
that
we
have
to
figure
out.
F
I
believe
again,
it's
my
waiver.
It's
the
third
time.
I've
said
that,
hopefully
you
walk
away
knowing
this
in
my
waiver
or
I
haven't
done
my
job.
I
think
we
can
figure
this
out.
I
really
do.
I
think
we
have
enough
people
around
the
room
in
the
room
that
can
do
this.
We
got
to
balance
the
needs
of
all
players.
E
G
Thanks
dave,
thomas
good
presentation,
your
part
very
eye
opening.
I
think
we
have
some
more
discussions.
Budget
neutrality-
I
get
what
you're
trying
to
get
at.
That's,
probably
not
the
right
term.
We
may
have
to
invent
another
one,
but
I
still
think
we
got
to
recognize
that.
What
what
we're
not
doing
right
now
is
costing
us
money
yeah.
G
G
C
F
I
think
one
we
got
to
talk
about
workforce,
we
have
to
talk
about
workforce
and,
and
other
folks
are
going
to
raise
that
issue.
We
work
really
hard
to
get
people
in
place,
but
in
reality
some
don't
aren't
very
good
employees
and
they
don't
last
very
long.
I
think
we
got
to
focus,
and
that
goes
over
the
pds
program
as
well.
They
need
competent
workers,
so
we
got
to
have
a
good,
solid
workforce.
F
F
2000
there
was
people
on
the
waiting
list
for
sel
for
seven
eight
nine
ten
years,
and
we
started
moving
towards
that.
Okay,
we
made
that
commitment
over
time.
We
have
to
figure
out
that
piece
as
well.
Those
two
things
I
think
is
is
where
we
have
to
get
to
and
then
go
forward,
and
I
like
to
see
the
data
comparing
us
nationally,
because
maybe
we're
doing
things
other
states
aren't
doing
that's.
My
first
answer
is
that
maybe
we're
better
than
those
states.
I
I
So
that's
that
is
a
that
is
a
service
for
michelle
p,
but
yet
a
12
year
old
kid
can't
get
that
and
I'm
not
even
sure
we're
going
to
test
that
because
we're
going
to
be
opening
up
a
summer
program,
basically
a
a
juvenile
adt
program
and
you
know,
is
medicaid
going
to
cover
that
is
the
waiver
going
to
cover
it
for
those
kids
that
have
it.
But
right
now,
as
far
as
I
know
in
the
state,
there
is
nothing
like
that.
So
for
us,
as
a
group
to
really
make
informed
decisions
this.
I
I
My
daughter
has
michelle
p
waiver
she's
on
pds
we're
able
to
pay
twenty
dollars
an
hour
to
the
people
that
work
with
her.
So
those
are
those
are
just
some
of
the
details
at
so
many
different
levels
that
you
can
get
in
with
this.
So
my
question
is
as
a
task
force.
What
is
our
plan
moving
forward
and
how
deep
are
we
going
to
get
into
these
services
to
really
be
able
to
understand
it,
and
I
don't
know
that
we'll
have
time
during
the
interim
to
really
do
that.
E
Well,
I
think,
obviously
we're
looking
this
six
month
period
and
I
think
we
need
to
do
as
deep
a
dive
as
we
possibly
can
do
in
that
in
that
time
frame
and
like
you
say,
this
can
go
so
many
ways
with
so
many
variables
and-
and
I
think
we've
just
got
to
dig
in
as
deep
as
we
can
and
see
where
we
go
from
there.
Senator
adams,
you
have
any
comment
on.
E
I
You
know
those
those
types
of
things,
but
it
gets
very
complicated
and
there
are
some
inequities.
The
commissioner
I've
had
this
conversation
with
some
of
the
other
programs.
There
are
some
true
inequities
for
the
same
types
of
services,
but
with
that
being
said,
there
are
some
or
providers
that
rely
on
those
inequities
to
survive.
G
G
Yeah
and
it's
like
how
many
people
can
you
get
in
the
lifeboat
at
one
time?
It's
just
just
tough
to
do
and
I'm
afraid.
If
we
take
too
much
on
at
one
time,
then
nobody
succeeds
where
if
we
can
do
it
incrementally,
maybe
that
makes
sense.
But
again
I
think
that's
part
of
the
reason
for
this
task
force.
We
have
the
discussion,
but
I
appreciate
what
the
senator
carol
has
said
in
person.
I
And
you
know
I
think
a
review
of
all
the
waiver
services
has
to
come
before.
We
do
that
and
then
we
look
at
where
are
the
places
to
find
the
savings
with
the
juvenile
population
again,
how
many
respite
hours
are
used
by
that
population?
Is
that
you
know,
being
you
know
with
with
or
without
a
disability?
I
That's
what
you
use,
granny
and
uncles
and
aunts
to
to
babysit,
so
how
many
hours
are
being
spent
for
these
children
with
with
respite
you
know,
is
there
a
savings
to
be
had
there
and
maybe
look
up
front
where
what
are
the
areas
where
we
can
find
the
most
efficiencies
to
so
we
can
kind
of
know
what
we
have
to
work
with
moving
past.
That
and
and
that's
just
a
thought-
and
this
this.
I
E
Thank
you,
senator
carroll,
carol,
steve.
We
we
appreciate
your
report.
Thank
you
very
much,
and
our
next
presenter
is
amy
stade
executive
director
of
the
kentucky
association
of
private
providers.
Please
make
your
way
amy.
Please
make
your
way
to
the
table
once
you're
ready.
Please
introduce
yourself
for
the
record
and
you
may.
E
B
B
Cap
is
a
trade
association
representing
providers
of
services
to
individuals
with
intellectual
and
developmental
disabilities
generally.
This
is
through
the
supports
for
community
living
waiver
and
the
michelle
p
waiver,
but
individuals
with
disabilities
also
get
services
to,
on
a
certain
extent
through
the
home
and
community-based
waiver.
B
Before
I
begin,
I
really
just
want
to
thank
commissioner
lee
and
director
smith
just
for
their
hard
work
on
this
issue.
They've
really
been
willing
to
listen
to
stakeholder
feedback
when
they
came
in,
and
you
know
they
paused
the
rate
study
and
have
really
wanted
to
work
on
this,
and
I
commend
them
both
for
that
oops
briefly.
B
I
just
want
to
talk
about
the
waivers
you've
heard
about
all
of
them,
but
I
did
want
to
take
a
chance
to
explain
the
difference
a
little
bit
between
the
michelle
p
and
the
scl
waivers
so
the
seo.
Yes,
we
serve
the
same
population.
Generally
speaking
on
the
michelle
p
waiver,
you
have
individuals
who
either
live
with
a
family
member
or
can
live
independently
on
their
own.
With
some
support
on
the
scl
waiver
we
have
generally.
Most
of
these
people
are
actually
have
state
guardians.
B
They
generally
don't
have
a
family
that
they
can
live
with
and
they
need
the
key.
Is
they
really
need
that
residential
piece?
That's
in
the
sel
waiver.
They
can't
live
by
themselves
and
they
cannot
there's
no
family
for
them
to
live
with.
They
need
that
residential
care
for
the
scl
waiver,
and
that's
generally,
why
they're
on
the
scl
waiver?
B
B
I
won't
talk
about
that.
That
date
is
outdated.
I
did
want
to
kind
of
again
just
talk
about
exactly
how
much
we're
spending
in
our
waivers.
If
you
look
at
the
state
share
for
stl-
and
this
is
2019
data,
I
chose
that
because
it's
non-coveted
data
I
figured
it
was,
the
costs
were
a
little
bit
more
accurate
scl.
Our
state
chair
is
about
116
million
in
michelle
p.
It's
about
102
million
note
that
michelle
p
waiver
services
are
limited
to
40
hours
a
week
in
an
annual
expenditure
limit
of
63
000..
B
B
B
B
Kentucky's
hcbs
spend
accounts
for
only
42.8
percent
of
our
long-term
support
services
spend
which
places
us
in
the
bottom
quartile
we're
in
the
bottom.
25
percent
of
all
state
of
all
states
with
our
spend,
the
national
average
per
resident
hcbs
spend
is
298
dollars
and
18
cents,
kentucky's
average
per
resident
https
spend
is
200
and
21
cents.
B
Nationally
72
of
all
1915
c
waiver
spend
is
on
idd
services,
we're
a
little
bit
higher
we're
at
74
percent
of
our
sun,
but
still
kind
of
within
that
national
average
we're
middle
of
the
road
there.
Additionally,
kentucky's
per
enrollee
spending
for
1915
sea
waiver
services
for
individuals
with
idd
is
slightly
below
the
national
average.
The
national
average
is
46
thousand
dollars.
B
So
there's
been
a
lot
of
conversation
about
quality
and
what
are
we
getting
for
our
money
and
I
just
want
to
say
from
the
outset:
the
waivers
are
the
cost
savings
with
this
population.
We
would
be
supporting
them
in
providing
them
24-hour
care,
no
matter
what
except
it
would
be
in
an
icf
or
a
nursing
facility.
If
we
were
in
an
icf,
this
care
would
cost
us
twelve
hundred
dollars
a
day
with
the
scl
waiver
we're
at
about
two
hundred
and
fifteen
dollars
a
day.
B
So
the
waivers
in
and
of
themselves
are
the
cost
savings
we.
We
have
to
provide
this
care
to
this
population,
no
matter
what
it's
just
now
we're
coming
to
the
point
where
we
choose,
where
we're
providing
the
care
and
how
we're
providing
the
care-
and
I
would
you
know-
remind
members
of
this
task-
force
that
the
olmsted
decision
requires
that
states
provide
community-based
alternatives
for
these
kinds
of
services.
And
we
definitely
don't
want
a
doj
investigation
in
our
state
about
not
providing
community-based
care.
B
Additionally,
kentucky
we've
increased
our
waiver
spend
from
2007
to
present
and
kentucky
has
increased
our
case
for
inclusion,
ranking
which
kind
of
rate
states
about
how
they're
providing
these
services
the
quality
of
the
services,
et
cetera.
Our
ranking,
has
increased
from
number
40
to
number
five,
so
our
investment
has
really
truly
improved.
The
quality
of
services,
we're
providing
in
the
state.
B
I'll
kind
of
go
through
these
quickly,
we
have
comments
just
specifically
about
the
sel
and
the
michelle
p
applications.
I
want
to
be
clear
that
these
comments
relate
only
to
the
scl
and
michelle
p
waiver
applications.
Well,
they
may
apply
to
other
applications.
They
are
limited
to
the
scl
and
michelle
p
waiver
applications.
B
So
in
the
applications,
the
service
definitions
processes.
All
of
that,
it's
it's
vague,
so
essentially
it's
impossible
for
a
provider
to
accurately
evaluate
how
the
proposed
changes
are
going
to
affect
them.
Unless
we
see
the
regulations,
because
these
regulations
drive
the
program
and
we
have
no
idea-
if
you
know
the
service
definitions
or
the
rates
proposed
are
actually
going
to
be
sufficient
to
sustain
the
system.
B
Unless
we
can
see
the
regulations,
implementation
of
the
waiver
applications
as
written
and
the
proposed
rates
as
written
will
result
in
individuals
with
idd
experiencing
a
reduction
in
services
in
the
wave
in
our
waiver
application.
It
specifically
states
that
the
intention
and
availability
of
service
do
not
change.
Therefore,
the
department
for
medicaid
services
does
not
anticipate
that
participants
will
experience
a
reduction
in
service.
B
Ultimately,
the
reduction
of
scl
and
michelle
p
service
reimbursement
and
the
reduced
service
limits
proposed
in
the
applications
will
result
in
participants
experiencing
a
significant
reduction
in
services.
Further,
it
will
make
it
impossible
for
providers
to
adequately
provide
and
coordinate
program-wide
supports
that
address
the
needs,
conditions
and
or
some
symptoms
which
will
negatively
impact
participants
ability
to
participate
fully
in
his
or
her
community.
B
We
have
service
specific
comments,
you
have
them
in
your
packets.
I
won't
go
through
them,
but
if
you're
curious
they're
in
there,
my
next
comments
are
related
to
the
navigate
rate
study.
These
apply
probably
to
all
waivers.
But
again
my
comments
are
limited
to
the
scl.
Michelle
p
waivers.
The
right
study
was
not
transparent.
B
I
served
on
the
right
task
on
the
right
study
work
group.
We
were
not
permitted
to
share
information.
We
were
not
permitted
to
talk
about
information
outside
the
work
group.
We
couldn't
solicit
stakeholder
feedback,
so
it
was
just
eight
people
in
a
room
trying
to
figure
out
rates
for
an
entire
system
of
care
it
just
it.
The
stakeholder
feedback
was
not
there.
B
B
They
don't
reflect
the
actual
cost
of
doing
business,
but
instead
reflect
the
strict
budget
neutrality
parameters
that
were
placed
upon
navigate.
When
we
talk
about
budget
neutrality,
cms
does
have
a
requirement
of
cost
neutrality
and
that
kentucky
cannot
spend
more
on
our
waiver
services
than
we
would
on
institutional
care.
B
There's
a
lot
of
wiggle
room
there
between
the
twelve
hundred
dollars
a
day
that
we
would
spend
on
institutional
care
in
the
215
a
day
that
we
spend
on
the
community-based
care,
and
I
know
that
a
lot
more
factors
go
into
it,
but
we
do
have
wiggle
room,
we
can
spend
more
money
and
cms
would
approve
it.
It
is
a
possibility.
B
B
B
Additionally,
there
is
a
national
direct
support,
professional
wage
crisis
in
the
country,
their
wages
are
low
across
the
country,
so
they
based
the
wages
off
of
artificially
low
wage
rates
across
the
country
because
they're
all
medicaid
reimbursed
and
then
additionally,
they
tried
to
create
with
the
reimbursement
parity
across
the
waivers
which
we
agree
with
you
know.
If
a
service
is
the
same
service
and
is
provided
in
three
different
waivers,
it
should
be
paid
the
same.
You
know
if
you're
doing
the
same
thing.
B
Unfortunately,
they
did
not
consider
the
provider
tax
and
one
waiver
pays
a
5.5
percent
provider
tax
off
of
gross
receipts.
That
is
the
supports
for
community
living
waiver.
No
other
waiver
pays
that.
So,
if
we're
paying
people
equally,
the
sel
waiver
providers
automatically
make
5.5
percent
less
for
the
same
service,
so
outstanding
issues
that
I
we
believe
that
need
to
be
addressed
by
the
work
by
the
task
force.
B
B
These
providers
have
no
other
income
stream.
They
can't
go
out
and
increase
the
price
of
the
hamburger
so
that
they
can
pay
their
employees
more.
The
only
way
they're
going
to
be
able
to
pay
their
employees
more
is
if
we
increase
reimbursement
rates
and
I'll
tell
you
you
know,
the
federal
government
is
likely
going
to
increase
the
minimum
wage
pretty
significantly
here
soon,
and
these
providers
aren't
going
to
be
able
to
keep
up.
They
already
can't
they're,
already
paying
less
than
walmart
mcdonald's
fast
food
restaurants
starbucks
our
reimbursement
rates
in
general.
B
Also,
we
just
need
to
take
a
look
at
our
regulations.
As
I
said,
these
services
are
100
regulation
driven
and
right
now
our
regulations
focus
a
lot
on
documentation
entering
data
etc,
and
it
takes
a
lot
of
time
away
from
just
actually
providing
the
care
and
making
sure
people
are
cared
for.
So
anyway,
we
can
take
a
look
at
that.
B
B
I
understand
that
we
can't
today,
but
we
need
this
money
just
to
keep
waiver
services
afloat
number
two:
we
need
to
implement
a
long-term
funding
solution
based
upon
accurate
data
to
establish
a
sound
rate
structure
that
includes
a
wage
component
that
is
adjusted
for
cost
of
living
regularly
to
senator
carroll's
point.
I
think
it
is
a
possibility
for
this
task
force
to
extend
itself
into
the
next
interim,
and
I
we
would
support
that
to
take
a
real
look
at
the
rate
structure
in
next
year.
B
B
We
need
to
address
the
scl
and
michelle
p
waiver
waitlist,
the
michelle
p
waiver
waitlist
needs
to
include
emergency
and
urgent
categories
like
scl.
We
need
a
way
to
essentially
triage
some
of
these
individuals
on
the
waitlist
we're
exploring
if
this
is
a
possibility,
but
if
it
is,
we
need
to
allow
for
immediate
realification
reallocation
of
a
slot
when
an
individual
dies,
as
miss
smith
alluded
to
you.
B
So
if
we
would
also
support
that
change,
we
need
to
address
the
gap
in
care
for
individuals
with
significant
support
needs.
We
had
a
lot
of
recommendations
in
the
exceptional
supports
task
force
related
to
that
and
again
that
gap
in
care
exists
in
multiple
waivers.
It's
not
just
the
scl
and
michelle
p
waiver
overhaul
the
referral
and
involuntary
termination
process
so
that
individuals
do
not
remain
with
providers
who
are
no
longer
able
to
support
their
needs.
B
So
right
now,
for
example,
if
a
residential
provider
has
an
individual
who's
having
extreme
crisis,
extreme
behaviors
is
a
danger
to
self
and
his
or
her
roommates
and
that
provider.
You
know,
calls
the
state
and
says
we
don't
have
the
resources
to
keep
this
individual
safe
and
his
or
her
roommates
safe.
G
I
think
everyone
would
agree
that
we've
got
to
see
the
workforce
issue
addressed.
I'd
probably
take
issue
with
your
statement
that
we
are
going
to
see
a
federal
minimum
wage
of
15
an
hour.
I
don't
think
it's
going
to
happen
if
it
does,
kentucky
is
going
to
have
a
whole
lot
of
problems
that
are
going
to
exasperate
this
even
more
because
bear
in
mind.
Six
percent
of
our
economy
is
based
on
small
business
in
kentucky
and
this
will
devastate
them
and
there
goes
the
tax
revenue
we
need
to
do
this.
G
I
think
the
best
statement
that
you've
made
so
far
is
that
waivers
are
the
cost
savings.
I
think
we
do
have
to
keep
that
central
to
this
discussion,
but
I
think
what's
missing.
Is
we
don't
know
how
much
petition
potential
there
is
for
additional
cost
savings?
If
we
do
the
very
things
you're
talking
about
and
that's
where
I
think
we
need
a
really
deep
dive
to
see
where
this
is
going
to
be,
and
he
goes
to
steve's
presentation
earlier
about.
G
You
know
if
we
need
to
provide
additional
funding
to
make
this
bridge
in
order
to
provide
these
additional
services
under
the
waiver
program.
Then
I
think
that
may
be
the
the
focus
and
what
we
could
do
most
immediately,
but
we
don't
know
what
that
is,
but
I
think
there
definitely
is
tremendous
savings
potential
there,
but
we
have
to
identify
that
cost.
G
Also,
even
though
you
are
the
cost
savings
you
you
noted
that
if
we
modify
the
regulations
and
make
it
more
flexible
and
I'm
all
about
that
always
have
been
that
there's
a
savings
there
as
well,
and
I
think
it
goes
back
to
japan's
presentation
earlier
that
you
know
we
build
more
accountability
into
the
system
that
helps
us
all.
So
I
think
we
have
to
just
address
this
on
additional
fronts.
G
But
to
me,
what
should
be
the
priority
is:
how
much
potential
is
a
savings
there
by
expanding
the
services
and
not
just
look
at
it
as
a
call
center,
but
a
savings
center,
but
again
accountability
within
your
cost
savings
for
this
entire
program.
So
I'm
I'm
with
you,
but
again.
I
think
we
really
need
to
focus
on
where's
the
potential
savings
to
the
medicaid
program
by
expanding
these
services
and
then
attempt
to
try
to
do
something
immediately.
So
thank
you
appreciate
your
presentation.
I
B
So
we
are
in
line
nationwide
states
spend
about
70
percent
of
their
hcbs
budgets
on
caring
for
individuals
with
I
with
idd.
You
know
it's
expensive
I'll.
Just
give
you
the
lifespan
of
some
someone
with
idd
an
individual
generally
can
come
onto
the
scl
waiver
when,
let's
say
21
years
old
for
the
rest
of
their
life,
they
are
going
to
be
cared
for
on
the
scl
waiver.
B
It
does
happen
and
it's
amazing,
and
that
is
a
testament
to
our
amazing
waiver
providers,
but,
generally
speaking,
this
is
a
lifetime
of
care
for
this
individual
and
there's
just
not
a
lot
of
ways
around
that,
and
that
is
why
this
population
is
so
expensive
to
support.
Additionally,
a
lot
of
people
with
intellectual
and
developmental
disabilities
have
some
health
problems.
We
some
of
them,
have
co-occurring
mental
health
issues
which
which
makes
this
all
the
more
complicated,
and
so
it's
just
a
complex
population,
and
it's
a
complex
population
nationally.
I
I
B
For
example,
in
lexington
louisville
15
an
hour
has
kind
of
become
standard,
that's
just
the
going
rate
right
now
or
around
there,
these
residential
providers,
the
rate-
does
not
support
that
wage,
and
so
they
had
to
look
at
other
care
models,
the
family,
home
provider
and
the
adult
foster
care
model,
utilizes,
independent
contractors.
So
obviously
there's
not
the
overhead
is
not
there
and
they
have.
They
all
have
different
contracts
to
pass
through.
B
You
know
a
certain
amount
of
reimbursement
that
has
been
a
great
service
for
a
lot
of
individuals
and
it
is
expanding
in
the
state.
You
know
not.
Everyone,
though,
is
appropriate
for
that
service.
Some
some
individuals
do
need
the
staff
residence
model
with
more
oversight
et
cetera.
It's
just
you
know
whatever
it
is
suited,
though
well
for
a
lot
of
individuals.
I
B
B
Additionally,
you
know
the
staff
residence
model
is
declining
and
it's
unfortunate
because
a
lot
of
individuals
in
the
sports
for
community
living
waiver
do
need
that
level
of
care
do
need.
You
know
the
true
24-hour
care
that
we
get
with
the
staff's
residence
model.
The
family
home
provider
is
a
lot
more
flexible,
more
family,
like
environment
et
cetera,
and
it
is
great
but
yeah
it,
and
a
lot
of
it
has
to
do
with
the
wage
piece
with
the
staff
residence
model.
B
B
E
And
at
this
time
we
will
ask
for
our
last
presenters
for
this
afternoon
are
diane
schermer
and
mary
haas
with
the
brain
injury
association
of
america.
Kentucky
chapter
miss
schumer,
miss
haas.
Please
make
your
way
to
the
table
once
you
are
ready,
please
introduce
yourselves
the
record
and
you
may
proceed.
J
K
J
J
The
report
cites
national
trends
and
best
practices
repeatedly.
However,
there
are
no
evidence-based
best
practices
cited
pertaining
specifically
to
brain
injury
or
any
other
specific
disability
group.
In
fact,
there
is
a
recommendation
to
reduce
services
in
the
abi
waivers,
which
we
strongly
oppose.
The
fact
is
that
rates
have
not
increased
in
well
over
10
years,
yet
inflation
and
costs
of
providing
services
have
continued
to
climb
to
medicaid.
Waiver
providers
are
charged
with
carrying
our
nation's
most
vulnerable
individuals,
yet
rates
don't
allow
wages
to
be
competitive,
and
you've
heard
this
from
all
of
us.
J
This
afternoon,
I'd
like
to
talk
a
little
bit
specifically
about
brain
injury,
because
it
seems
to
be
that
everybody
wants
to
lump
it
together
with
all
the
other
categories.
Brain
injury
is
not
a
one-time
event.
It
can
be
a
chronic
condition
that
impacts
an
individual
throughout
his
or
her
lifetime.
J
J
Typically
in
brain
injury
programs
across
the
country,
there
is
a
continuum
services
that
extends
from
the
acute
to
the
community-based
services.
I'm
a
carf
surveyor,
which
is
the
commission
on
accreditation
of
rehab
facilities,
carf
accreditates
programs
across
this
country
and
probably
12
to
15
other
countries,
and
unlike
other
programs
in
behavioral
health
or
perhaps
for
cancer
care.
J
When
you
go
for
brain
injury
specialty,
which
differs
from
stroke,
you
have
to
have
the
full
continuum.
So
if
you
take
on
brain
injury-
and
you
say
I
want
to
do
acute
brain
injury,
you
have
to
show
that
you
have
the
full
continuum
services,
which
means
you
go
from
acute
all
the
way
through
community-based
services.
J
We
were
told
in
that
meeting
that
that
was
just
a
training
issue,
that
that
was
something
that
needed
to
be
retrained.
That
scans
were
not
needed,
so
we
provided
information
to
the
state
to
list
the
people
that
were
involved
in
that,
so
that
they
could
do
retraining
about.
Two
days
later,
I
had
a
call
from
two
case
managers
who
said,
but
yet
I've
been
told
by
the
state
that
the
documentation
that
I
submitted
is
insufficient,
that
I
need
to
give
a
scan
so
where's
the
training
needed.
J
There
is
also
a
need
for
comprehensive
standardized
training
for
personnel
working
in
the
waivers
that
should
be
evidence-based
and
ongoing,
whether
you
work
in
paducah
lexington
or
in
bowling
green.
There
should
be
standardized
training
that
all
of
us,
as
providers
providing
services
to
individuals
with
brain
injury,
should
have
it
should
be
consistent
across
all
of
us.
One
example
of
this
would
be
considered
the
academy
of
certified
brain
injury
specialists.
J
What
makes
brain
injury
unique
our
roots
are
deep
in
physical
medicine
and
rehab.
This
is
not
just
a
physician.
It
means
that
we
are
slated
in
physical
medicine,
which
involves
therapy
services,
as
well
as
the
team
that
provides
the
services
and
the
care
that
we
provide.
It's
an
interdisciplinary
treatment
team,
in
which
all
members
provide
a
coordinated
effort
toward
a
central
goal
to
benefit
the
person
served.
J
The
team
brings
a
diversity
of
expertise
to
benefit
the
individual
being
served
that
may
include
physicians,
clinicians
rehabilitation
and
general
practitioner:
nurses,
nurses,
skilled
therapists,
direct
care
staff
and
many
other
unique
providers
of
brain
injury
services.
The
whole
program
is
person.
Centered
rehabilitation
therapy
is
delivered
in
the
context
of
real
life
situations.
J
That
individual
doesn't
remember
who
his
therapists
are
on
that
given
day
any
day,
he
still
doesn't
remember
what
he
had
for
breakfast.
So
you
have
to
help
him.
Remember
my
dad
had
a
brain
injury
after
I
started
in
rehab
and
five
years
post
injury.
When
his
wife
took
him
to
walmart
to
go
grocery
shopping,
he
wasn't
allowed
to
drive.
J
He
went
to
the
bench
to
wait
for
her.
While
she
finished
shopping,
he
thought
she
left,
so
he
picked
up
a
cab
and
he
gave
the
cab
driver
their
address.
What
he
thought
was
their
address.
It
was
his
previous
address
20
miles
outside
of
houston
when
he
got
to
that
address.
He
had
no
money
to
pay
for
the
cab,
and
so
he
became
belligerent
with
the
cab
driver.
Also,
other
people
were
living
in
the
home
which
he
couldn't
understand,
and
so
then
he
was
taken
to
the
jail.
I
was
the
emergency
contact
in
the
wallet.
J
J
Cognitive
rehabilitation
therapy
is
the
basis
of
all
that
we
do
in
brain
injury,
rehab
cognitive
problems,
change
over
time
with
individuals
with
brain
injury
and
may
evolve
at
a
different
pace
for
each
person,
with
many
interacting
factors
that
affect
affecting
initial
recovery
and
recovery
over
time.
Cognitive
cognitive
disorders
make
it
difficult
for
individuals
with
brain
injury
to
monitor
changes
in
their
daily
routine,
their
daily
health,
or
to
even
comply
with
their
medication.
J
Our
outcomes
are
done
through
rehab
teams
across
the
country.
When
we
focus
on
increasing
function
after
illness
and
injury,
the
team
develops
a
series
of
functional
performance
indicators
and
targets,
just
as
we
set
measurable
goals
and
objectives
for
those
we
serve.
We
love
to
graduate
individuals
from
our
programs
that
have
regained
some
quality
of
life.
Again,
there's
nothing
more
rewarding
to
us
as
we
watch
somebody
walk
out
of
our
program
to
regain
some
degree
of
quality
of
life,
and
actually
we
have
someone
who
just
moved
out
of
state
after
graduating.
From
the
from
the
waivers.
J
K
K
K
I
don't
know
I
just
know
in
real
life,
it's
upsetting
when
you're
trying
to
provide
that
consistency
and
someone
who's
telling
her
when
she
gets
up
in
the
morning
you
have
to
shower.
You
have
to
take
your
medicines,
so
that's
that's
real
life.
What
not
having
that
workforce
that
we
can
depend
on
and
value
the
people
and
are
both
vulnerable,
that
I
know
everyone
in
this
room
that
we
want
to
serve.
We
want
to
serve
them.
We
want
them
to
have
that
quality
of
life.
K
I
think
amy
spoke
about
appendix
k,
k
again,
making
these
changes
flexible
for
all
providers
and
going
back
to
senator
meredith.
I
do
think
there
could
be
some
things
where
we
could
re
lock
some
regulations
and
get
some
efficiencies
and
things
that
we
want
to.
We
want
to
be
involved
in
this
process,
and
anyone
knows
me
I'll
do
whatever
it
takes
to
make
this
go
forward
and
to
really
serve
the
people.
We
all
care
about.
K
Person-Centered.
I
know
we've
all
said
this
too
again
and
I've
talked
to
pam
on
many
occasions.
We
want
this
to
be
person.
Centered
one
size
does
not
fit
off,
because
there
is
no
two
brain
injuries
alike.
I've
spoken
with
many
families,
one
person
who
has
had
a
very
severe
brain
injury,
their
son's
back
working
doing
what
we
all
want
them
to
achieve.
We
have
someone
else
who
maybe
what
would
be
considered
a
mild
brain
injury.
K
They
will
never
be
able
to
live
on
their
own,
so
that's
what's
different
about
abi
and
and
probably
all
our
disabilities.
I
don't
want
to
just
section
them,
because
this
is
all
about
serving
all
of
our
people
in
the
waivers
gaps
in
care
address
the
issues
relating
to
the
gaps
across
all
the
waivers,
such
as
patients
and
one
of
the
things
that's
near
and
dear
to
my
heart,
is
neural
behavioral.
I
think
that's
one
thing
when
someone
when
we
say
well
right
now,
we
don't
have
a
waiting
list
for
brain
injury.
K
Well,
that's
because
we're
not
able
to
really
serve
those
neural,
behavioral
clients,
a
provider
is
just
not
going
to
be
able
to
provide
the
care
that
they're
going
to
need
to
sustain
them.
If
we
have
somebody
who's,
truly
neurally,
behavioral
challenge,
the
good
news
is
it's
not
a
big
percentage
of
our
population,
but
it's
probably
our
most
in
need,
part
of
the
abi
population.
K
Again,
we've
heard
flexibility
provide
that
flexibility
for
patients
to
be
able
to
transition
among
the
waivers
again,
I
have
some
brain
injury
clients
who
are
in
scl.
You
know
I
had
to
have
some
abi
clients
from
michelle
p.
Again,
let's
look
at
the
needs.
If
we're
really
going
to
do
person
saying
let's
look
at
the
needs
and
if
there's
some
ability,
I
think
amy
said
if
we
can
transition
across
waivers.
That
would
be
great
and
again
short
term.
K
It's
funding
provide
a
rate
increase
for
the
waivers
to
address
the
critical
workforce
issues
long-term,
implement
a
long-term
funding
strategy
in
the
next
budget,
designed
to
address
our
workforce
crisis
going
forward
and
provide
sustainability
in
all
the
waivers.
And
again
I
thank
you
for
your
attention
and
diane
and
our
welcome
to
any
questions
you
may
have.
Thank
you
thank
you,
representative
riley,
and,
if
julie's
on
the
think,
thank
her
also.
G
K
Well,
it
could
vary,
it
used
to
be
motor
vehicle
accidents,
but
right
now
we're
seeing
an
increase
in
falls
with
children.
It's
false.
The
other
one
is
violence,
diane
and
I
both
work
with
individuals
due
to
they
suffer
their
brain
injury,
domestic
violence.
I
mean,
if
you
have
any
more
national
diane,
does
more
on
the
national.
I
would
say
in
kentucky
it's
still
motor
vehicle
and
gun
violence.
J
And
actually,
the
leading
cause
of
traumatic
brain
injury
would
vary
by
state
in
oklahoma.
It
might
be
that
you're
kicked
by
a
horse,
but
nationally
it
is
falls,
and
it's
because
the
the
group
that's
getting
injured
most
by
tbi
is
many
of
us
in
the
room.
The
aging
population,
the
older
american,
is
actually
falling.
G
I
appreciate
that
because
one
of
the
things
I
think
could
influence
this
is
and
we'll
be
talking
about
it
in
one
of
our
committees.
I'm
sorry
forget
which
one
but
the
lack
of
a
trauma
network
in
kentucky,
and
we
funded
that
many
years
ago,
but
never
have
I
mean
we
approved
that
many
years
ago,
but
having
fun
of
that
either
and
I'm
looking
to
see
if
that
could
potentially
impact
the
situation
as
well.
So.
K
One
thing
that's
not
available
in
the
other
waivers
that
is
available
in
the
abi
is
the
counseling
having
the
true
counseling
directed
at
the
person
with
the
brain
injury
again,
the
way
you
would
set
my
sister
up
for
counseling,
because
again,
hers
was
due
to
domestic
violence,
so
she
has
also
suffers
from
post-traumatic
stress
so
having
someone
skilled
in
the
counseling
piece
that
addresses
both
the
abi
and
the
other
dual
diagnosis.
A
lot
of
our
people
do
have
dual
diagnosis.
I
know
steve
talked
about
severe
mental
illness.
My
brother
was
schizophrenic
before
his
brain
injury.
K
So
you
know
again.
A
lot
of
our
people
are
dual
diagnosis,
so
I
think
the
other
service
that
people
really
appreciate
in
the
abi
waivers
is
the
therapies
is
especially
occupational
therapy
and
diane.
Diane,
actually
is
the
one
who
provides
the
direct
care,
but
again
my
sister's
recipient,
but
again
the
way
you
would
set
my
sister
up
for
occupational
therapy.
You
may
have
to
take
15
minutes
at
the
first
part
of
just
reminding
her
of
what
you
did
in
the
last
session
or
whatever.
So
getting
someone
with
that.
J
There
are
many
circumstances
that
change
at
that
individual
ages,
based
on
the
differences
that
change
in
their
body
and
the
progression
of
their
brain.
That
will
cause
them
to
need
those
therapy
services
again,
so
they
may
name
them
periodically
and
there's
one
thing
that
comes
in
with
their
therapy
services
behavioral
services
through
a
certified
behavior
analyst.
It
makes
no
sense
that
the
therapist
develops
the
plan
or
it
doesn't
touch
the
individual.
J
Day,
treatment
is
meant
to
have
people
work
on
skills
that
are
their
functional
skills
that
they
need,
and
that
might
be
three
people
working
with
someone
on
cooking.
While
four
people
go
over
here
and
work
on
mechanical
skills,
it's
not
putting
20
people
in
one
room
and
they
all
do
something
together,
and
I
think
unfortunately,
somehow
we've
gotten
there
for
a
variety
of
reasons
and
I'm
not
pointing
fingers
and
I'm
not
criticizing
it's
just
that
day,
treatment,
whether
it's
brain
injury
or
idd,
should
be
really
directed
toward
the
individual
and
what
their
needs
are.
J
The
distinction
that
we've
tried
to
make
today
is
that
rehab
is
really
different.
We
are
rehabilitating
someone
to
get
them
back
to
a
certain
point
in
their
level
of
function
versus
habilitative
care
and
that's
the
distinction
we
wanted
to
make.
Thank
you
for
that.
Thank
you,
ladies.
Thank
you.
Thank.
E
You
senator
carol
and
talking
about
brain
injuries.
My
mom
passed
away
about
three
months
ago
from
a
brain
injury
that
she
had
suffered
about
four
years
before
you
know,
I
think
you
I
saw
some
stats.
You
had
that
sometimes
it's
less
than
five
years
and
I
think
she's
a
little
bit
over
four
years,
and
you
know,
we've
talked
here
a
lot
about
the
difficulties
of
workers
and
and
a
lot
of
that,
it's
because
of
pay
and
a
lot
of
is
because
these
jobs
are
extremely
difficult.
E
E
Well,
thank
you,
ladies.
We
sure
do
appreciate
your
presentation,
appreciate
what
you
do.
This
concludes
our
business
for
this
afternoon.
As
a
reminder,
the
next
meeting
of
the
1915
c
home
community-based
services
waiver
task
force
scheduled
for
1
pm
on
monday
july
26th.
If
there's
no
further
business,
come
before
the
task
force
today,
this
meeting
is
adjourned.