HomeMy WebLinkAboutHawaii County Case Management (CM)Hawaii County Case Management (CM)
The Advisory Committee on Aging is pleased to have the opportunity to make recommendations
on the delivery of Case Management (CM) services in Hawaii County. We first want to affirm
our support for Executive Dr. Kimo Alameda, who had brought expertise, experience, and peo-
ple -skills to the Office. He is a hands-on leader who himself spent many weeks helping with dis-
aster relief during the volcano eruption. Under pressure from the state ever since he arrived, he
has sought to comply with their demands while preserving the best practices that have made the
HCOA the best AAA in the state.
In that spirit, we respectfully disagree with his proposal to bring CM in-house and to disband our
longstanding and successful model of contracting out those services. Our duty is more to the ku-
puna of this island than to the state Department of Health, which is pushing for a one -size -fits -all
model when in fact each island is very different in its demographics, urban/rural mix, relation-
ship between their county councils and their Offices on Aging, history of services, resources,
numbers of vendors, philosophies and business models. A size 13 foot will hurt both foot and
shoe if it is required to wear a size 9!
I. What does Hawaii County Office on Aging (HCOA) have that we value most and do
not want to lose?
A. The identity and function of the HCOA. Is it an area agency that does planning and
oversees service provision to implement the plan? Or is a resource center that delivers di-
rect services? We feel we should keep our focus on planning, not service delivery. We
contract with other agencies for service, and monitor and evaluate their work. Because we
are not both provider and evaluator, we can be objective, which ensures the quality of the
services and avoids self-dealing; sometimes government agencies provide poor services
and low accountability and we want to avoid that outcome. We also have more flexibility
since we do not have to hire and fire service providers ourselves.
B. County financial support. Almost all our staff are funded by Hawaii County. Therefore,
we have competent, committed and stable employees who do not have to worry about los-
ing their jobs because their grant funding will run out. The choice of the HCOA has been to
use those unrestricted dollars to hire a staff with expertise in planning. Other counties must
chase short-term grant dollars and have staff whose jobs are tied to those grants. We do not
see the wisdom of hiring our own case managers whose jobs are dependent on Kupuna
Care grant funding, while most of the rest of the staff are permanent.
C. We have a large vendor pool. When an elder needs services, there are a number of ven-
dor options that can be offered. For example, we know which agency has staff who speak
different languages, or who may be particularly good at dealing with people with mental
disabilities; we can contract for services with a variety of vendors.
D. We see Kupana Care as a short-term program. Other counties and the state consider KC
as a long-term program; once someone is on KC they are on it forever. We emphasize hav-
ing clients and caregivers create a support network of their own, to move to private pay op-
tions if they can, and/or help them fill out the extensive paperwork to apply for Medicaid if
they become eligible (other counties have used KC dollars for Medicaid -eligible elders
which we see as a waste of money). Our model requires more intensive CM, but moving
people off KC after 1 to 6 months allows us to serve more people and reduce the wait list
(our KC model means people are less likely to die either in KC or on the wait list).
IL What are the problems we see with how Kupuna Care Case Management is currently
delivered?
A. Services are not delivered equitably to all parts of the island. 47% of case management
services are in South Hilo. Rural areas are not as well served.
B. It takes too long from a client's initial call to getting services. In looking at the chart on
the administrative process, we saw that there are numerous ways to cut the wait time. To
start with, using volunteers to take the initial calls, fill out an information sheet, and then
wait for Intake specialists to pick up the sheets wastes several days. If I&R staff who are
like "walking Rolodexes" took the calls, they could immediately refer to other agencies
(VA, transportation..) or to Case Management.
C. Client satisfaction is our main concern - and this is NOT a problem. Both HCOA and
Services for Seniors which provides Case Management services do evaluations, and Advi-
sory Committee hear from residents. All agree that clients are satisfied.
III. Compliance with the State 5 year plan
The 5 year plan has come and gone. It was from 2011 to 2016, and while we are technically out
of compliance, no sanctions were ever placed on us. The plan requested that we bring Case
Management in-house. There were three parts to that request.
* Intake and assessment: "Hawaii County... must establish the HCOA as the single point of en-
try by bringing -house the intake and assessment functions currently performed by the Coordi-
nated Services division of the County Department of Parks and Recreation ...." (p. 43) This
was accomplished.
* Case Management: "Each County will need to get county executive and legislative approvals
to restructure case management into an in-house agency function." (p.22) We have not gotten
that approval, and the Advisory Committee would not recommend such approval.
* Case Management services are to be brought in-house, to conform to the new "common oper-
ational model" for all Counties. We disagree that a common model is in the best interests of
our Hawaii County kupuna, and would want a chance for our Mayor to negotiate a different
model with the state.
IV. Advisory Committee recommendations
We offer a third option that would resolve some of the problems listed in Section I and also help
with the compliance issue:
A. We recommend against hiring 5 in-house CMs after the SFS contract runs out at the end of
June, 2019. We feel that would be too drastic and rapid a change, disruptive in terms of
services, and based on an untested assumption that in-house would work better.
B. We recommend one in-house CM/Care Coordinator. This staff person would assign them-
selves some cases, and oversee CM and case coordination overall. Preferably, they would
not be grant (Kupuna Care) funded, but County funded to make their employment security
and benefits the same as other HCOA employees. The state is mostly interested in generat-
ing uniform data to report to the federal offices, and we have already complied with adopt-
ing their (less user-friendly!) database. We can let them know we want to preserve pro-
cesses that have worked well for our clients for over 30 years.
C. We recommend ending the practice of awarding a single contract for all CM services; in-
stead, use different agencies as we do with other services in our vendor pool. For example,
during the lava crisis, Neighborhood Place of Puna was selected to provide case manage-
ment (there were also many referrals to Services for Seniors). Different vendors who pro-
vide specialty services, such as staff who speak other languages or know the culture of a lo-
cal area, could be selected to better meet the needs of clients. This flexibility could help
serve seniors more equitably across the island rather than being Hilo -centric.
D. Given the 30 year relationship with SFS which was created at the request of HCOA and
which has always been responsive to its needs, we do not want to lose that relationship and
the expertise that agency has developed over the years specifically serving kupuna. We
worry too that bringing CM totally in-house leaves us open to liability issues as well as Hu-
man Resource burdens.
In sum, our recommended mixed model preserves the connection to SFS while giving us more
vendor options, gives us time to test out streamlined internal processes that could improve the
timeliness of services, and continue our short-term Kupuna Care model that allows us to serve a
greater number of seniors. As a transition, we might need to extend the SFS contract for another
6 months or more, depending on what the county procurement allows. Such a transitionary pe-
riod should allow HCOA to identify and secure interested agencies that may be well suited in the
provision of case management services on a per referral basis.
Mahalo,
HCOA Advisory Committee on Aging