Making Services Work for People Analysis Paper
May 4 2000
This paper is an attempt to collect all the summaries of various discussions and current perspectives of the Board and Committees of the Kenora Association for Community Living (KACL) on various issues that have arisen in discussions on making Services Work for People. The paper will serve as an internal record of our positions as they evolve and as a communication instrument to our families and other interested parties. Since the paper was commenced in mid-stream of the discussions it is not complete. Sections will be added as time permits.
Making Services Work for People, April 1997 available on the Internet at http://www.gov.on.ca/CSS
Since the release of the Ministry of Community and Social Services Paper there have been many Board meetings, Committee Meetings," Input Sessions" and other forums of discussions.
The Association's attempts to have meaningful and satisfactory input to the Making Services Work for People process has been futile. The process has been viewed as a top down exercise from Toronto, where a policy decision is made and subsequently follows a window dressing exercise where the goal has been to place a spin on decisions already made. The degree to which local MCSS officials had any influential is uncertain. Some decision-making may have been left to the locals but given the similarity of decisions elsewhere it is believed that the process has been essentially Toronto driven. There is little evidence that any input that KACL has had to the process, has made any differences to the decision making process.
The Ministry of Community and Social Services (referred to as MCSS) is the Government Ministry charged with the responsibility of providing services to persons with developmental handicaps.
MCSS is the representative of the elected government and thus must be held accountable for structures that they set up. The Social Services Advisory Committee and its successor Social Services Implementation Advisory Council were two committee appointed by MCSS. The two committees have had little or no credibility with KACL as its members have had little or no experience in the field. Of the original 5 members from the Kenora, three resigned before the final statement of the committee and we have been informed by a member of the first committee that the remaining two did not endorse the recommendation. A member of the second committee Lloyd Johnson, while from Kenora, has had no discussions with KACL or its families and does not represent KACL, its families or the community of Kenora. While MCSS has attempted to suggest that persons with DH backgrounds have had some part in the design process, the two most likely to be referred to, indicated that they did not take part in the design and do not know where it came from. Such expertise that was available to the committee came from the MCSS. MCSS is listening to MCSS advice.
Different Issues have been identified by MCSS
Making Services Work for People, Pages 26
Proposed MCSS answer: a telephone information system operating out of Atikokan called 310 Info systems.
Projected cost to KACL $1000. Projected value: $0.
The view of KACL on the proposed issue of a co-ordinated information system was that it is a Southern Ontario issue. Local MCSS officials were required to get a check mark. The system is a waste of taxpayer's dollars that could better be used to provide direct services to persons with developmental handicaps. However, it is cheaper than alternative systems proposed, hence KACL has ceased to object for fear that more monies will be wasted in this MCSS project.
Making Services Work for People Page 27, 28
Former proposals:
The first Social Services Advisory committee proposed that approximately $2 million out of approximately $16 million be used to fund a new agency (referred to as a Brokerage agency) to provide a single point access. Even MCSS choked on this $2 million extravaganza. It was rejected by KACL as a waste of money, an extra and unnecessary layer of bureaucracy, concerns about gatekeeper functions, perceived entrance into a US style managed care and an undesired district approach.
The current proposal has been nicked named Straw Dog, ISNC Virtual Agency that is proposed to have a head office with one program and one clerical staff, 7 community offices with 13 full time equivalence case managers. MCSS says benefits to families are district approach and outside accountability.
The almost unanimous view of KACL Board, Families and Staff who engaged in discussions and input sessions is negative for similar reasons as the earlier proposal. Little appears to have been changed. The method of implementation is to employ funds of the ISNC organization; APSW funding which was earlier removed from KACL budget (and other APSW Programs) and additional funds from Children Service Providers. How much will be removed from KACL Children Services budget is not certain.
Issues
Both MCSS and KACL are quite clear and opposite on the views of the issue of District approach. Families want services to be provided on a local community basis by a provider that they know and on whose policies and directions they believe they can have some influence. Local MCSS officials attempt to sell the district approach on the basis that some vacant "beds" in one community could be used by some needy persons in other communities who are without beds. They attempt to sell the notion of a district approach with the spin "the North Western Ontario Community".
KACL has refused to be reduced to the level of discussion of "beds" believing it is not in the commodity market but rather in the service business - serving people who have in varying degrees, families and friends in local communities, having different dreams, desires and aspirations and want to be connected to a their local community.
KACL along with most other participants agree that there are community and culture differences across the district and that these should be respected rather than seen as obstacles for MCSS to over come.
MCSS say district approach is a benefit: families see it as a curse.
Accountability is a difficult concept. Whatever accountability is, there is accountability to consumers, to family of consumers, to community, and to the taxpayer. MCSS argue that a third party brokerage or case management will provide greater accountability. It would be hard to argue that there will not be greater face validity. Whether there is in fact greater accountability will ultimately depend upon the performance of the second agency.
The Association and the families it serves see no benefit to the new proposed agency. The general view held by the Board, Families and Staff is that existing ACL's will require the same amount of case managers (Personal Planners) as before and the additional layer of case management will merely serve an additional layer of bureaucracy. MCSS's assumptions regarding case management and the degree that case management can be separated from direct services are not realistic. While MCSS official claim the existing system is "uncoordinated", "wasteful", "inefficient", "unresponsive to needs of consumers and families" and "duplication of system" its hard to see that the new proposed system will not be doubly so. KACL has no serious idea as to the actual expense of the new agency. Based on data currently available to KACL, one would have to look beyond a cost- benefit analysis to determine why anyone would proceed with setting such an agency.
An earlier proposal, proposed by the Social Services Advisory Committee was costed by Catherine Heinrich, an MCSS Consultant in October 1998 to cost just under $2 Million dollars. The current proposal has never been costed out. The total costs of the existing Integrated Services for Northern Children (ISNC) and new proposed revisions would surely cost in excess of $2 million. It is impossible to guess whether the cost of the additional services would cost more or less than the previous proposal. The expenditure of money for little perceived benefit should upset taxpayers in general and specifically persons and families who must do with out services to pay for the proposed increased bureaucracy and government inefficiency.
KACL was informed by one committee member who supports the MCSS initiative, that he bought into it because he was informed that no funding would be withdrawn from existing Associations for Community Living. Time will prove this commitment true or false. Concern is expressed as to the total costs of the project and the better utilization of dollars that could be made by using dollars to serve persons with developmental handicaps and children.
At the moment when new applicants apply for services, KACL makes an assessment as to whether they will be able to support new consumers - given existing load. There is a heavy bias against setting up a waiting list and to date, new consumers have been able to receive some level of service. As consumer service load increases, risk of under supervision and lack of minimally acceptable support levels increases. The Association has chosen this path rather than totally excluding new clients from time to time. To do this consumer service loads must be managed carefully. If there is no funding for new consumer, KACL must retain the right to choose acceptable risk level for consumer service load.
Obviously the new agency has a great potential to act as a gatekeeper directing consumers where it wishes. Concern is expressed that case managers will end up with some consumers being forced into segregated services.
Will my child's files with KACL be shared with ISNC and other Children Service Providers? Presently KACL policy and procedures would require your consent. It is not clear what attitude either MCSS or ISNC would take in the new order.
Does KACL wish to become a sponsoring agency if this role is offered?
Two views have been expressed by families and Board members:
No: if the sole purpose of doing this exercise is to create external accountability then KACL should not participate in sponsorship to avoid a conflict of interest.
Yes: if gatekeeper function becomes a role of a new agency then KACL must protect the rights of its consumers and families to choose.
Balancing these two conflicting interests, KACL has decided to adopt a negative position with respect to sponsorship to permit it to play an advocacy role.
It is not entirely clear what the new agency will determine? However, it would appear to play some significant role.
It is our understanding that MCSS has momentarily dropped the idea of proceeding with a level of support tool that would classify individuals according to levels of needs and deficiency. However the new agency would be able to invent its own similar tools.
It is not clear how long this would take place. Certainly not as early as before as a lengthy intake process must take place. For Infant Development Program, KACL could commence services within two days and continue with collecting additional data as necessary.
To centralization of services and allocation of resources. It is unclear at this moment if MCSS has a clear idea where it is leading. Once a certain degree of centralization has been achieved two possibilities present themselves: (1) a global bidding for services as in the recent taking over of Homemaker Services away from Red Cross and reassign it to a private company from London, Ontario. (2) A bidding on services for individuals that may be bid on by individual service providers.
Present indications would lead KACL to believe that it will be providing fewer services at some point in the future. If it is required to terminate staff the expenses of termination will generally exceed the 60 days notice required to be given by MCSS. The Association will have to bear the additional expense unless it is successful in arguing that such costs are in fact part of the cost of providing services prior to the 60 days notice and caused by MCSS actions.
Change should only be forced where an increased benefit is likely. The opposite seems quite evident in the new proposal. The status quo structures are not static but rather are continually and dynamically evolving. No member of KACL believe that KACL has remained unchanged over the past 5 or 10 years but rather has had to evolve to changing circumstances including declining government supports to persons with developmental handicaps. In its current effort to satisfy a political agenda imposed from the South, MCSS distracts from the real issue of lack of funding, un-serviced client base to the north and the enviable problems that flow from a desire to maintain existing costs levels for an ever-increasing client load.
KACL recommends to local MCSS officials that they attempt to negotiate greater freedom from Toronto to recognize northern realities, to permit the more effective and efficient existing systems to continue to evolve with real meaningful dialogue with existing service providers and respect the unique aspects of northern communities and cultures.
KACL recommends to Toronto MCSS officials that they respect that the North is not Toronto and that structures that may make some sense to solve Southern Ontario problems simply create greater inefficiencies and waste when applied unthinkingly to the North.
Appendix A KACL's Advice To MCSS on Fewer access points and Single Point of Access
The Association acknowledges the MCSS definition of an “access point” as “ a service provider (or program of a service provider) or collaborative intake process that determines which specific families or individuals will receive services. KACL believes that the number of multiple access points is not a “problem” for the North. Most certainly it is not a problem in the Northwest as few communities have more than one alternative service provider at the moment. Particularly, this is so in the developmental services sector.
KACL would like to emphasize the benefit of choice of service providers and the range of value options that would be available by increasing service options in the North. KACL has a history of being at one end of the spectrum of various valued options. For example, KACL at times has been seen to take extreme positions with respect to deinstitutionalization, integration, individualization, principle of, self-determination, and dignity of risk, least restrictive alternative and social role valorization. In terms of a global perspective, KACL is nowhere near the end of any value spectrum. In the North it probably represents the end of the limited options available. We believe that forcing fewer access points would have the detrimental effect of reducing the already too limited options.
Consequently, the Association would recommend no less than the one access point for Adult Developmental Services that presently exist in the Kenora - Rainy River District for each of the 6 existing service centres, being, Atikokan & District, Dryden and District, Fort Frances, Kenora and District, Red Lake, and Sioux Lookout & District. Each of these service centres knows the geographical area served by it with few problems.
As indicated above it categorically rejects the notion of treating the entire district as a unitary catchment area. This notion runs counter to the notion of “local services” and the shift to a greater acceptance of responsibility by family, friends and community. A district is not a community.
In Children services, KACL has been appalled at the lack of respect that some professionals and possibly government as well, have paid to the different functions provided by different programs. For example, at the two service forums attended by staff of KACL, comments were heard, that a child development, or child mental health program staff would withdraw if a child apprehension program staff became involved – all said in the honest (but KACL believes mistaken belief) that the child’s interest was thereby served. On more than one occasion, KACL has remained involved supporting families whose child was ultimately apprehended. In such cases KACL does not have problems with the final apprehension, but yet believes it plays a valuable role prior to apprehension and at times after. Further, the Association is appalled that this province allows the same agency that is required to apprehend children to be allowed to be the sole agency providing residential support and services such as specialized foster care.
In one other area the Association believes the interest of children would be served. The Kenora Association for Community Living has served its catchment area with an Infant Development Program, “Community Integration” Program, Respite as well as an integrated nursery and “Kids Zone” program. Up to 3 years of age, it is very difficult to diagnose children with the medical designation “mental retardation”. By having this program with the Association the Association has been able to start early in selling the benefits of integration to parents and educate parents to the difference they can make in the lives of their children. An added benefit is that the Association, through its home based programs, is better able to service out laying regions then the centre board philosophy of children mental health.
In the older children’s program areas, an advantage that Kenora has over the other Association, is that having the Community Integration program it is able to start vocational and residential readiness training as early as Grade Seven, rather than have to wait until the students graduate from high school. Kenora believes this is a decided advantage in providing effective and efficient services. When the children reach 18 they are ready to take on the task of employment and moving into more independent living. By transferring such developmental support services to associations, better use will be made of the special services at home program, a program that is predominantly used by children (under 19) living still living in the family home.
Another benefit of moving developmental services for children over to existing providers for adult developmental service is to eliminate the alleged problems of “cross-over” from children to adult services. However, the Association wishes to make it clear that its view respecting the desired transfer of specialized foster care over to the same provider as the adult developmental services provider is not based on this alleged problem of “cross-over” as it has never existed in Kenora. KACL has always enjoyed the co-operation of the local children’s aid society in smooth transfers from that agency to adult service.
In only one regard does this Association believe that some benefits might flow from the elimination of choice – the wrap up of ISNC (Integrated Services for Northern Children). Regardless of what the stated mandate of that agency might appear to be, ISNC provides services in some of the same areas as Child Development Centre (CDC) but is not prepared to provide service on First Nation communities. Since the bulk of CDC staff are not prepared to provide services on First Nations Community many such communities go without service. This Association believes that existing staff could be re-allocated to various communities over the district to other service providers saving administrative costs.
In the developmental services sector this is simply not a problem in the North West. To force less than the existing one point of access in the existing services areas that currently is to force unnecessary and costly bureaucracy that will direct dollars away from direct service.
Appendix B Excerpts from Straw Dog Report
Single Point of Access to Residential Services
· Responsible for administering the single point of access for residential services for both the children's and developmental services sectors
Functions of Community Offices
Functions of Case managers:
Information and Referral:
· In response to public inquiries received directly or referred to the office, provide information on children's and developmental services; refer other inquiries to appropriate resources
Initial Intake:
· Complete intake form with basic information regarding names, birth dates, address, etc.
· Note presenting problem
· Note referral source
· Explain service delivery
· Explain the forms, privacy and confidentiality
· Describe services available
· Explain the difference between assessment, consultation and intervention
· Explain the service delivery process/model
· Address any questions or concerns
· Presenting problem: describe the severity, history and frequency of the problem
· Report on diagnoses, school identification, medical and psychiatric history, medications,
· Report on developmental milestones, cognitive, physical, emotional and behavioural functioning
· Report strengths and weaknesses of the child
· Report on the family place of residence, family history, structure and functioning, siblings
· Report family response to the difficulty being presented and what remedies have been tried
· Report on current and past services already received and/or offered
· Discuss additional services under consideration
· Discuss additional information that may be required, and consent from the family to obtain it
· Report professional concerns or impressions
· Note observations of family interactions, client's presentation during interview
· Report on family level of commitment to the service and/or treatment
· Note specific goals/outcomes as related by family/client and their priority for services, as reflected in the single agreement of service/ISA
· Report any specific request(s) or concerns identified by the parent/client
· Determine eligibility for service(s)
· Determine need for clinical assessment(s)
· Determine if service is required pending further assessments
· Arrange for clinical assessments as required
· Complete Single Agreement for Service/Individual Service Agreement
Case Management
· Contact the service provider(s) and confirm service delivery
· Connect the family/client directly to the appropriate service provider(s)
· Co-ordinate services as needed
· Case management activities can be minimal, active, or intermediate, depending on the situation
· Keep the family informed on an ongoing basis
· Receives and distributes assessment and follow-up reports
· Monitors progress and/or need for additional/modified services
· Determines sequencing and planning of services
· Provides resource and/or adjustment counselling as required
· Liaises with service providers and schools as authorized
Case Closures
· Completes discharge form
· Reports on results of assessments completed, services and interventions requested and provided, case management provided
· Reports on reasons for closure, provide any concerns about closure
· Obtain closure reports from every service provider
· Provide information to family about reactivating service if required/requested
· If case transferred to another locality, obtain consents and transfer relevant information/files
· Conducts or sends out evaluation form
Administrative Functions:
· Responsible for recording of data electronically through data input and word-processing and manual filing of hard copy reports
· Responsible for office functioning at the district level (office supplies, machine functioning, maintenance of office hours, etc.)
· Professional development and training
Case Resolution Functions
· Where a family/client contests the service offered or denial of service, prepares documentation for submission to head office
· Provides information and attends hard to serve conference upon request by either the family or a service agency or the head office
Appendix C
Agreements of DH Support Servers ED:
1. The proposed system will cost a lot more than MCSS presently believes it will.
2. MCSS projection of required case managers is in accurate.
3. There is a lack of understanding as to what district approach means and the effect on clients and families
4. All DH Organizations wish to take over DH Children's programs believing existing children's agencies are not providing adequate servicing. (KACL believes this is a problem of lack of adequate funding.)
5. Each community has its own unique problems and culture.
6. The new approach will merely add another layer of bureaucracy for no value added.
7. All existing ACLs are single service providers in each community known by that community.
8. The whole process is motivated by a Southern Ontario's Issues agenda.
9. There are too many issues outstanding issues and lack of information to adequate respond to any specific proposal that might come forward.