EIPA Comments on EIP Home Concept Paper

EIPA Comments on EIP Home Concept Paper

The Early Intervention Providers Association (EIPA) appreciates the opportunity to review and comment on the Concept Paper related to an EIP Home.Our member agencies have reviewed the Concept Paper and raised a series of questions related to process for developing an EIP Home (including the timeframe for implementation), the structure for the system (including the roles and responsibilities for Service Coordinators under this new system), and how agencies will be designated/re-designated as Comprehensives, Service Vendors, and Specialty programs.

As we reviewed the Concept Paper we kept in mind the questions raised by the Department. The framework of our comments are to: 1) respond to the questions raised by the Department and 2) lay out additional questions and comments raised by EIPA Member agencies.

We are concerned that the Provider Network Workgroup’s recommendations upon which this Concept Paper is based were made in May 2006. There have been many changes to the New Jersey Early Intervention System (NJEIS) since that time and it is not clear to us that any or all of the recommendations are still relevant. In addition, the Concept Paper mentions that the Department of Health and Senior Services (DHSS, “the Department”) sought input from the Provider Forum on Assignment Policy. This was a one-time meeting asking for input related to catchment areas that, to our knowledge, did not provide specific recommendations.

 EIPA is concerned that there is no clear plan with which to implement this type of a concept, and that the description of the proposal for various changes in processes and procedures in the Concept Paper is fragmented and imprecise.  The proposal needs to clarify the roles of the different provider agencies as well as the roles of Service Coordination and the REICs.  We believe that without answers to the questions raised in this paper we cannot fully comment on the pros/cons of this system. We recommend that the Department convene a series of meetings with providers and other stakeholders to more fully explain the Concept Paper and to receive adequate input from all.

Responses to Questions Raised by the Department

  • The Concept Paper delineates no significant difference between a comprehensive agency and a service vendor except for the number of Full Time Equivalent Staff. We believe that a comprehensive agency should have the capacity to provide more than one service that is delineated in the IFSP. We further believe that if the Department maintains the different provider designations between a comprehensive agency and a service vendor, a transparent process, with clear criteria for service vendors to become a comprehensive agency must be outlined. ABCD and the EIPA have for a number of years recommended that the State develop provider standards. Provider standards should include the State’s requirements for a comprehensive agency. We recommend that New Jersey explore what other states’ criteria are for agencies and provide recommendations to all stakeholders based upon their review.
  • For further comments and questions with regard to this issue, please see section I. below under Questions and Comments from EIPA Member Agencies.
  • Clinical supervision levels should be developed based upon a layered model, depending upon experience, training and skills of practitioners.  A core set of competencies should be developed and the levels of supervision should be based upon a practitioners’ capacity to be expert in specific competencies. It is difficult to provide any comment on team meeting time since that terminology has not been defined. In reading the Concept Paper, it is unclear as to how an agency (comprehensive or service vendor) will have authority over team members and require practitioners, including service coordinators, to attend team meetings.
  • For further comments and questions with regard to this issue, please see section II. below.
  • Criteria and documentation for agencies to be designated as having specialized expertise is needed. We recommend that a workgroup be convened with stakeholders in each of these specialty areas to develop standards and competencies.
  • For further comments and questions with regard to this issue please see section III .below.
  • Service delivery areas/rotations are currently used with agencies designated as primary, secondary, and tertiary for specific locales within counties.  We recommend that the State examine historical and current data on referrals in the counties, which are available through the Service Coordination Units,
  • For further comments and questions with regard to this issue please see section VI. below
  • New Jersey should explore what other states have done to determine the need for new service vendors and/or comprehensive agencies.  Many EIPA agencies have seen a reduction in the number of children being referred and question whether New Jersey needs additional agencies (comprehensives and service vendors) at this time. Performing a needs assessment as recommended above in answer to question 4 is a good way to determine the needs in specific locales and counties.
  • For further comments and questions with regard to this issue please see section VI. below.
  • Reasons for agencies to decline EIP Home assignment could include:  no staff available, no staff appropriate to the needs of the child, and distance of agencies (and its practitioners) to the family.
  • For further comments and questions with regard to this issue please see section VII. below.
  • Prior to any discussion of enforcement sanctions, we believe that provider standards are needed that include a basic performance expectations for agencies. Standards should include guidelines for all EI service providers in order to facilitate and ensure their success in acting within full compliance of EI Regulations and laws, pursuant to the terms of their respective Letters of Agreement with the Department. Such standards are necessary to create a uniform set of stated expectations and guidelines for providers who are responsible for meeting state-mandated outcomes in EI service delivery. Provider standards create a quality framework of obligations and expectations for agencies with approved staff that are already providing services within the NJEIS, or could potentially provide services, on a contractual basis. We recommend that the State, working with providers, develop these standards and expectations to hold all providers, including service coordination, accountable for services.
  • For further comments and questions with regard to this issue please see sections I. and II. below.
  • There are a number of terms that must be defined or more fully defined including: specialized programs, service coordination capacity, team meeting, state established rotation, quality supervision, and negotiation among providers, to name just a few.
  • For further comments and questions with regard to this issue please see sections III.and VI. below.
  • To improve communication for the assignment of EIP Home and/or ensuring the full complement of services are provided timely, we recommend that a system be developed to track children and families from the point of referral to the services being provided at the EIP Home.  We also suggest that the State work with counties currently having difficulties rather than in the whole EIP system which is generally working well. We are concerned that the Concept Paper was developed as a solution to eliminate the waiting list for EI Services ( mostly speech therapy) to children/families in the certain areas, where it was difficult for agencies to secure practitioners. The state in collaboration with all of the Stakeholders should develop a plan/ incentive or creative EI Service programming idea/s for provision of EI Services in these areas including other service models that are securing practitioners to work in these areas.
  • For further comments and questions with regard to this issue please see sections IV. And VII. below.

For other processes and procedures that need clarification, please see below Sections I through VIII. below under Questions and Comments for EIPA Member agencies.

Questions and Comments from EIPA Member Agencies

I. Capacity and Service Vendor Status

  • Who completes DHSS Self Assessment Observation Reports/ Chart Documentation if vendors are utilized to fulfill IFSP services?
  • It is not clear as to the process by which a Service Vendor attains Comprehensive Status.
  • In this same regard, the document states that “ a Comprehensive agency accepting assignments as an EIP Home must have the capacity to provide at least one service in accordance with the frequency and duration of the IFSP”.  How can a Comprehensive agency only have to provide one minimum service to be considered as the EIP Home, but a SV is required to meet the full complement of services in order to become an EIP Home?
  • How does a Service Vendor meet the full complement of IFSP services without arranging services through “any other NJEIS contracted agency”?  This provision makes it much more difficult for the Service Vendors to serve as an EIP Home than Comprehensives even though a Service Vendors’ capacity is less than that of a Comprehensive.

II. Capacity and Comprehensive Status

  • What will be the new extent of the role of Comprehensives as EIP Homes under this proposal? Will Comprehensives need to supervise vendors (i.e. to ensure timely services, etc.)?
  • Will Comprehensives now be able to and responsible for conducting trainings for employees?
  • What should Comprehensives do if a subcontracting agency is not in compliance or a Procedural Safeguards issue arises?

III. Specialty Status

  • How will agencies be assured that they will be identified as a Specialty program for ASD or other specialty populations, and how will all Service Coordination Units (SCUs) be aware of their capacity to serve these children?
  • How did DHSS arrive at designation of 3 special populations, and why are other populations not considered for specialties, such as Down’s Syndrome Specialty, Feeding Specialty, Apraxia Specialty?
  • The State has often indicated that a family cannot request a “methodology”, and has sometimes gone out of its way to discourage the perception among families of being able to access specific types of instructional methods. How will the State make clear that the designation of “specialties” does not imply that if a family is not receiving services from the “specialists” then the service is somehow inferior.

IV. Concerns about Service Coordination and Meeting IFSP Services

  • How will DHSS maintain neutrality and fairness in assignments if SCUs are no longer in charge of coordinating services, and prevent potential power struggles amongst organizations?
  • The Concept Paper explains that the EIP Home assumes lead responsibility for coordination of direct early intervention services. Will Comprehensives be paid for Service Coordination (since new staff such as Administrative and Social Workers will need to be in place to accommodate these new responsibilities)?
  • If so, how will this new billing system be integrated into the current billing structure, as it seems that agencies would need to submit their billable hours in order to be reimbursed for Service Coordination services rendered. How will the State quantify and track these billable hours?
  • In addition, it is unclear how shifting the duties of Service Coordination Units (SCUs) to individual providers will result in a cost savings to the State. If agencies are providing direct services specified in an IFSP in addition to Service Coordination services, will there not be more so-called “run-away costs” incurred by the State? In addition, how would the State budget for the cost of Service Coordination if agencies are providing Service Coordination services, as this would presumably involved multiple agencies in some cases?
  • The Concept Paper is unclear as to the role of Service Coordination: what will SCUs be doing while EI providers are performing this new role?

Has DHSS considered using State dollars to hire more support staff for SCU case managers in addition to this proposal?  It seems that the responsibilities designated under EIP Home (items 2, 3, 4, & 8) are a good starting point for the formulation of an administrative job description for support staff.  In addition to these tasks, designated support staff could be required to manage the information provided by case management for generation and dispersal of the lists, modifications of forms for IFSP’s, coordination of meeting schedules, tracking of services, etc.

V. EIP Home Concept

  • What will be timeframe to launch the new EIP Home policy and training for SCU?
  • Why are other Comprehensive agencies not contacted when assigned agencies cannot meet services?  Why does assignment then go to SV? Are catchment areas eliminated?
  • Who assumes liability for training, timely service provision of subcontracted agencies and SV agencies used by Comprehensives? How will the NJEIS ensure adequate training for SV agencies? Are Comprehensive agencies responsible for assuming training SV staff?
  • When an SV agency functioning as an EIP Home can’t meet all service needs, the SCU assigns a Comprehensive agency to meet or arrange new services. What happens if a Comprehensive is already providing services? Who remains to provide those services?
  • Who is assigned as the EIP Home when no Comprehensive or SV agencies can fill all of the services?
  • Are SV’s held to same reporting standards as Comprehensives and who completes observations and record reviews for SV staff?

VI. EIP Assignment and Rotation

  • There have been historical inconsistencies across SCU of implementation of new policies and procedures issued by DHSS. What will be the enforcement mechanism of these policies and procedures if/when they are not followed by SCUs?
  • The term "state established rotation" must be defined. Will this rotation be conducted by referral, which has been suggested by some NJEIS staff?
  • Also, in question #4 of the Concept Paper Memo, it is stated that "NJEIS intends to designate one or more service delivery areas per county with corresponding rotation lists." Does this imply the formation or reconfiguration of multiple zones each with their own rotation?
  • We do not understand the meaning of the final paragraph of this subsection.The first sentence says: "The EIP Home subcontracts or negotiates directly with an SV agency." Then the last sentence says: "To eliminate conflict of interest, an EIP home cannot subcontract with an agency that has an NJEIS LOA. It is our understanding that Service Vendors do currently have LOA’s. We need clarification of this part of the paper in order to understand and comment on it.
  • If the assumption is that “negotiates” means giving another willing provider the referral for a specific service, then it does not mean that there is any fee-splitting going on. Any fee-splitting would be difficult to perform.There should be some clarification on what this means.  Since billing is never mentioned, the assumption is that that each agency would bill separately for services rendered.
  • With respect to rotations, the Concept Paper states that there will be a rotation but does not take into account within the rotation process the fact that agencies vary greatly by size and capacity. How will the state ensure that a sense of fairness in the rotation of assignments is maintained for larger, medium, and smaller agencies that will need to sustain a certain number of clients in order to remain in compliance with the Concept Paper’s designated number of full time employees for each agency?
  • How long is a rotation? The Concept Paper does not delineate the length of a rotation. How will agencies of any size be able to maintain adequate staffing, especially with the capacity requirement of maintaining at least 91 face to face hours at all times? How can the rotation list be determined in a fair and equitable fashion for the first round of assignments, especially for agencies waiting farther down the list?
  • The agency that is the EIP Home is required to take on a lot of administrative responsibility to ensure that all services are delivered. Also, if we are to believe the system’s reasoning for creating an EIP Home, it is incumbent upon the EIP Home to ensure sound team process/coordination, training, and supervision. That can only be done if the EIP Home requires staff from other agencies to submit copies of their documentation, has the authority to require contact among all staff, and is involved in supervision at some level whenever an SV or another Comprehensive is utilized.

VII. No Practitioner Available (NPA) at EIP Home

  • It is not clear what the time frame will be for the EIP Home to notify the SCU and REIC of NPA.
  • With regard to the overall issue of underserved areas, we feel that in order to make progress on the significant issue of NPA, the State must allow organizations to develop creative solutions. Currently, there are some areas within the State of New Jersey in which practitioners simply do not feel comfortable providing services. While we understand that the State must comply with the requirement for services to be provided in a natural environment when possible, there must be allowances for alternative models of service delivery to make any progress on this matter in which the safety of practitioners is a consideration. The State needs to consider the safety and environment in which it is placing providers as well as the needs of the family, and realize that some practitioners are not going to be able to go into a home in which he or she feels uncomfortable.

VIII. Implications for Children and Families

  • How many potential agencies will families need to interface and coordinate services with under this new proposal? Given the current confusion inherent in this Concept Paper from a provider perspective, this could cause frustration for families from the consumer perspective as well.
  • There is no mention of the definition and responsibilities of an EIP Home agency in this proposal in terms of its responsibility to families and the quality of care.

Conclusion

The EIPA has many critical concerns regarding proposals laid out in the EIP Home Concept Paper, as mentioned above. Many of our concerns center around issues of fairness to children and families served by the NJEIS, the ability of provider agencies to maintain compliance with current rules and regulations under the proposed changes, and the ability for providers to navigate the new system that would be created by these changes, the description of which is still unclear.

The EIPA has in the past, and will continue in the future, to articulate creative solutions to the issues addressed by the EIP Home Concept, including  provider standards, consistency and continuity of services, no practitioner available, improvements to service coordination, etc. We feel that the current changes proposed in the EIP Home Concept Paper do not effectively address these issues, nor do they provide the fundamental change that is necessary to tackle the complex root causes of these issues.  In light of our concerns, we reiterate our recommendation for DHSS to convene a series of provider and stakeholder meetings to tackle these issues in a comprehensive and transparent manner that will bring sustainable and transformative changes to the NJEIS.