Department of Human Resources Budget Proposal Fiscal Year 2009 August 15, 2007

Department of Human Resources Budget Proposal Fiscal Year 2009 August 15, 2007

Governor’s Instructions DRAFT PROPOSAL

Division of Aging ServicesFY2008 Budget DRAFT PROPOSAL Note: Budget Amounts Include Anticipated Reductions to Federal Funds of $4,750,000. In Addition To Required State Match, Some Programs Require Local Matching Dollars Which Are not Reported In the Annual Budget.

Division of Aging ServicesFY2009 Reductions DRAFT PROPOSAL

Division of Aging ServicesFY2009 Reductions (continued) DRAFT PROPOSAL

Division of Aging ServicesFY2009 Enhancements DRAFT PROPOSAL

Division of Aging ServicesFY2008 Supplemental Budget Request DRAFT PROPOSAL

Division of Aging ServicesFY2008 Supplemental Budget Request • Title of Project Replace Discontinued Federal Targeted Case Management Funds With State Funds • Population Served At risk elderly Georgians including the majority of clients for which DHR has been appointed guardian by the courts. • Problem Statement Adult Protective Services is experiencing a shortfall of $3.5 million Targeted Case Management funds which had, in prior years, been budgeted for APS. Targeted Case Management is a Medicaid fund source that is declining due to more stringent federal regulation by CMS. Potential loss of 78 positions without replacement funding. • Project Goal(s) Maintain funding levels for Adult Protective Services by appropriating state funds sufficient to replace federal funds no longer available. To maintain staffing levels sufficient to comply with state law, State funds are requested in the amount of $3.5 million to offset the decrease to federal funds. • Describe how goal(s) will be achieved and measured State Funds, if appropriated in the supplemental FY08 and subsequent budgets will be applied to the APS budget. Comparison of Adult Protective Services staffing and caseloads by region will indicate that service levels are appropriately funded statewide. DRAFT PROPOSAL

Division of Family & Children ServicesFY2008 Budget DRAFT PROPOSAL

Division of Family & Children ServicesFY2009 Reductions DRAFT PROPOSAL

Division of Family & Children ServicesFY2009 Enhancements DRAFT PROPOSAL

Projected FY08 Supplemental Action • Title of Project Replace Discontinued Federal Targeted Case Management Funds With State Funds • Population Served Children under age 18 for whom abuse or neglect has been reported or confirmed. • Problem Statement Child Protective Services (CPS) is experiencing a shortfall of $8.8 million in Targeted Case Management funds which had, in prior years, been budgeted for CPS. Targeted Case Management is a Medicaid fund source that is declining due to more stringent federal regulation by CMS. Potential loss of 175 child welfare casemanagers. • Project Goal(s) Maintain funding levels for Child Welfare Services by appropriating state funds sufficient to replace federal funds no longer available. To maintain staffing levels sufficient to comply with state law, State funds are requested in the amount of $8.8 million to offset the decrease to federal funds. • Describe how goal(s) will be achieved and measured State Funds, if appropriated in the supplemental FY08 and subsequent budgets will be applied to the Child Welfare budget. Comparison of Child Welfare staffing and caseloads by region will indicate that service levels are appropriately funded statewide. DRAFT PROPOSAL

DMHDDAD FY2008 Budget DRAFT PROPOSAL

DMHDDAD FY2009 Reductions NOTE: $196,196,091 inn DMHDDAD State general funds appropriations exempt from 2% adjustment. DRAFT PROPOSAL

DMHDDAD FY2009 Enhancements DRAFT PROPOSAL

DMHDDAD FY2008 Supplemental Budget Request DRAFT PROPOSAL

Division of Public HealthFY2008 Budget DRAFT PROPOSAL

Division of Public HealthFY2009 Reductions DRAFT PROPOSAL

Division of Public Health FY2009 Enhancements DRAFT PROPOSAL

Projected FY08 Supplemental Actions New Born Screening Expansion • Fee created to fund the activity • Currently fees go to the State General Revenue FY 08 Supplemental request = $5.6M DRAFT PROPOSAL

Office of Child Support Services FY2008 Budget *Includes $2,841,500 in fees DRAFT PROPOSAL

Office of Child Support Services FY2009 Reductions DRAFT PROPOSAL

Office of Child Support Services FY2009 Enhancements DRAFT PROPOSAL

Office of Regulatory ServicesFY2008 Budget ** FY08 Fiscal Affairs- pending approval of moving ORS Admin from DHR Admin to Facility and Provider Regulation DRAFT PROPOSAL

Office of Regulatory ServicesFY2009 Reductions *2% of ORS budget DRAFT PROPOSAL

Office of Regulatory ServicesFY2009 Enhancements *The additional $748,000 in Enhancements will be funded from new licensure fees to be collected for first time in FY2009 DRAFT PROPOSAL

Reductions Summary DRAFT PROPOSAL

Enhancement Summary DRAFT PROPOSAL

DHR Concept Papers DRAFT PROPOSAL

Concept Paper FY 09Division of Family & Children ServicesRoom, Board, and Watchful Oversight (RBWO) • Population Served: Children age 18 or younger whose families are unable or unwilling to care for them. DFCS purchases residential care in family group homes or facilities. • Problem Statement: CMS mandated that Georgia “unbundle” the Level of Care (LOC) per diem effective July 1, 2007. DFCS will now purchase Room, Board, and Watchful Oversight (RBWO). A new rate system was developed based on a cost model. Overall rates under RBWO will be less than under LOC. The number of children in LOC have declined over the last year. However, there will be a significant state fund impact because no Medicaid revenues are accessible to support the RBWO system. DFCS will be using state and Title IV-E funds as the primary fund sources for the RBWO system. • Project Goal(s): • Retain adequate placement resources for children in DFCS custody. • Utilization of services will drop an additional 10%. • There will be a significant increase in the IV-E penetration rate. • Describe how goal(s) will be achieved and measured: • Add $28 million in additional state funds to support RBWO. DRAFT PROPOSAL

Concept Paper FY 09MHDDAD DRAFT PROPOSAL

Concept Paper FY 09MHDDAD DD Waivers DRAFT PROPOSAL

Concept Paper FY 09MHDDAD Crisis Services State Dollars $9,300,000 annualized Population Served Adult Mental Health and Adult Addictive Diseases Problem Statement The lack of community-based crisis services forces consumers to seek services in our inpatient settings (state hospitals and crisis stabilization units). Large numbers of these consumers could be better served with community-based crisis services. Currently, DMHDDAD funds mobile crisis teams that cover all of Region 1 and parts of Regions 2 and 3. Though many substance abuse consumers in crisis could be served in outpatient settings, DMHDDAD lacks a way to divert consumers with substance abuse issues to community locations where they can be assessed prior to being referred to the hospital and /or the crisis stabilization programs. Project Goals The proposal will expand mobile crisis services to the upper section of Region 2 and to the remaining 6 counties in Region 3, as well as Regions 4 and 5 and it will introduce community-based crisis triage programs into each of the five Regions. Mobile crisis services will be performed in schools, homes, streets, jails, emergency rooms, and other places in communities. Regional triage centers will provide intake, assessment and outpatient/inpatient treatment referral as well as Drug and Alcohol Detoxification. Performance Measures • State hospital admissions for Adult Mental Health services by adult MH / AD consumers. • Adult MH / AD consumers readmitted to state hospitals. DRAFT PROPOSAL

MHDDAD Concept Paper FY 09 Forensic Diversion Coordinators State Dollars $450,000 annualized Population Served Adult Forensic Services Problem Statement SB 190, which became effective July 1, 2007, gives judges the authority to divert Incompetent to Stand Trial defendants to community services. Superior and State courts are unlikely and unable to seek out resources for defendants and the default for courts is generally commitment to state hospitals. Providing the courts with access to forensic diversion coordinators will increase judges’ willingness to divert forensic consumers, who do not pose a significant safety risk, to community services. Project Goals The program will consist of forensic diversion coordinators to act as liaisons between the court system and community mental services by providing judges information about alternatives to hospitalization for defendants with mental illness. The forensic diversion coordinators will provide linkage to services and monitor targeted defendants for three to six months. In addition, these case managers will provide outpatient competency restoration training, if needed, to defendants who are Incompetent to Stand Trial and are diverted from hospital commitment. Performance Measures • Number of defendants served • Number of defendants diverted to community mental health services • Hospital utilization of defendants DRAFT PROPOSAL

MHDDAD Concept Paper FY 09Basic Technology State Dollars $2.84 million ($1.1 million annualized) Population Served Supports all MHDDAD Programs Problem Statement MHDDAD has no base budget for to support technology hardware and special software systems within the state hospitals and the service system. This lack of budget has caused 73% of MHDDAD computers to become obsolete as they currently exceed 8 years in age. Project Goals The proposal will support the purchase of 1,245 new computers to complete refreshment of 4,225 computers MHDDAD wide; cost to provide these new computers is $776,880. Additional technology shortcomings to be addressed by proposal include: • $2 million for complete network refresh for MHDDAD hospitals. This will allow all clinical personnel to have quick and reliable access to patient medical records, lab results, allergy and drug interactions information, computerized training, and consumer data to improve patient care. • $1.5 million for monitors to complete refresh. MHDDAD system has about 30 monitors fail each month. Many (over 2000 monitors) were bought in 1999 and are failing rapidly. Clinicians, social workers, forensics staff, and management need reliable monitors to view patient information and make decisions on care, community placement, and hospital utilization. • $290,000 for Physicians Order Entry: MHDDAD’s pharmacy operations currently rely on faxes and person to person communication and interventions. To reduce drug error, get the right medicine to the right consumer and at the right time requires modern technology. A Physicians Order Entry system keeps doctors, medical staff and pharmacists in sync and will greatly improves patient care. Performance Measures • $1.1 million each year and percentage of annual tech refresh (25% per year for 4 years). DRAFT PROPOSAL

MHDDAD Concept Paper FY 09 Care for Medically Complicated and Community-Based Acute Care State Dollars $7,200,000 Population Served C & A Mental Health, Adult Mental Health, Adult Forensic, Adult Nursing Home Problem Statement Currently there are no internal resources that will allow the Division to provide appropriate medical care or supports for severely challenging consumers within the hospital system. In addition, most acute psychiatric care is provided in one of seven state hospitals. Project Goals Through this proposal the Division will purchase resources within a private facility for those consumers with chronic medical conditions or otherwise challenging behaviors. This facility will have the expertise to treat consumers with needs beyond the scope of the hospital system. This proposal will fund the purchase of 40 specialty beds within this private facility that will be located in Georgia . Through this proposal and with the repurposing of state hospital acute care beds, the Division will also establish local, 16 bed inpatient care units that provide short term, 24-hour psychiatric care . Expectation is that care provided by these units would be Medicaid reimbursable. Performance Measures • Mortality rates • Cost for outside hospitalization • Occupancy rate for adult psychiatric units • Number of critical incidents (deaths, injuries, accidents, assaults, elopements, etc.) at state hospitals DRAFT PROPOSAL

MHDDAD Concept Paper FY 091,500 New DD Waivers State Dollars $16,657,454 6 months funding ($30,194,908 annualized) Other Funds Amount $25,819,305 includes administrative and direct services federal match for 6 months funding ($51,638,611 annualized) Population Served Adult Developmental Disabilities Services, Child & Adolescent Developmental Disabilities Services Problem Statement The most current DD Planning List data indicate that a total of 5,465 Georgians with DD are waiting for services. Of these individuals, 3,255 need a residential service. Also, at the beginning of FY08, there were 1,024 people living in state operated DD hospitals. Over 17,000 Georgians with DD live with caregivers age 60 and over and approximately 1,800 individuals with MR/DD live in nursing facilities in Georgia. These demographics indicate that the demand for residential services will increase over the next decade. Approximately 700 young adults with DD exit special education programs each year. Without new day/employment resources, most of these young people would go home to no services. Many Georgia families rely on the availability of dependable day and employment services for their family member with disabilities in order for parents to be able to work and support the family. Due to the expansion of community services and especially the increased cost of transportation, the need for additional transportation resources has reached crisis levels in Georgia’s DD services system. Without additional resources for transportation, many consumers will not be able to access services that otherwise would be available to them. Project Goals This proposal requests 1,500 DD waiver service slots: These 1,500 new service slots are expected to serve at least 1,300 unduplicated individuals, including 150 people transitioning from institutional to community services. The proposal includes 525 residential type services, 834 day and employment services and 112 family support type services. To support and implement the 1,500 new resources, this proposal includes additional funding aimed at increasing DD system capacity including funding to: respond to challenging consumer behaviors, increase staff and provider competency, identify and address complex consumer medical needs, increase transportation services and strengthen statewide system administration and oversight. Performance Measures • Number of individuals on the DD waivers. • Number of individuals in State operated DD hospitals. • Number of people with DD in employment. DRAFT PROPOSAL

MHDDAD Concept PaperDD Provider 7% Rate Increase State Dollars $2,015,357 6 months funding ($4,030,713 annualized) Other Funds Amount $3,559,895 6 months funding - federal match of state funds ($7,137,792 annualized) Population Served Adult Developmental Disabilities Services, Child & Adolescent Developmental Disabilities Services Problem Statement Mental Retardation Waiver Program (MRWP) service rates were last adjusted for actual accessed costs in FY’94 (based on FY’93 Medicaid cost reports). There have been two increases in DD waiver services since FY’04 - a 4% DD increase in FY’02, and a 4.5% increase in FY’06. During that period, the Consumer Price Index has risen by approximately 29%. The number of people served in DD waivers has increased by more than 400% in the last decade. Even more significant than the growth in numbers of people served in our system is the change in the type and complexity of services that are being provided. An aging consumer population and our decreased dependence on state operated DD hospitals are resulting in significant changes in Georgia’s DD consumer population. Increasingly, consumers are entering community services with complex medical or behavioral challenges that require staff with special skills and/or licensing. When the ability of provider agencies to pay competitive wages is reduced, the quality of the services they deliver is likely to suffer. The health and safety of the people served in DD services is directly related to providers’ ability to attract and retain the best direct care staff and first line supervisors. Project Goals This proposal would provide a 7% rate increase for all DD Medicaid Wavier Services including the 1500 new services requested for FY’09. Although a 7% increase will not reconcile the difference between rate increases since FY’94 and the rise in the Consumer Price Index over that period this request increase is seen as a positive step toward narrowing the gap, attracting quality staff and decreasing staff turnover. Performance Measures • Number of individuals on the DD waivers • Number of individuals in State operated DD hospitals • Number of people with DD in employment. DRAFT PROPOSAL

Concept Paper FY 09Division of Public HealthGrant in Aid • Problem: Grant in Aid funds: • Based on historical funding • 48 counties have a funding inequity • Proposal: Bring counties to the state average • Calculated shortfall is $11.4 M in FY08: • $5.7 M to the “shortfall” counties in FY09 & 10 • Use formula (population & poverty) from FY11 • No decrease more than 20%/year • From FY11, award 20% of funds competitively DRAFT PROPOSAL

Concept Paper FY 09Coordinated Transportation • Population Served: • Clients/consumers of the Divisions of Aging, MHDDAD, DFCS and OCSS • Problem Statement: • There is a lack of adequate transportation for the consumers of DHR who need to access DHR services • Increasing aging population needing services • DHR serving more of DD population in community; they need transportation services • OCSS Fatherhood Program participants need transportation to training • DHR currently serving 47% of clients who need services • Project Goal(s): • Provide funding for four-year plan to meet the needs of growing aging & DD populations & OCSS • Maximize increased state funding to draw down federal dollars wherever possible • Describe how goal(s) will be achieved and measured: • Additional funding in the amount of $4,350,000 for FY09 to begin plan • 4-year plan addresses the most needy client groups; will meet 90% of the current unmet need and provide services to an additional 16,500 clients and provide approximately 3.3 million additional one-way trips over the four year period of FY09 through FY12. • Matching state funds with Medicaid funds will more than double funds available to both OCSS Fatherhood participants and developmentally disabled clients. • New Federal Transit Administration Grants can serve both the developmentally disabled and aging populations. • Measures would include: • Needs assessment surveys • Customer service evaluations • Number of clients served and trips provided • Cost per trip DRAFT PROPOSAL

Concept Paper FY 09Coordinated Transportation DRAFT PROPOSAL

Concept Paper FY 09DHR Rental Deficits • Population Served: All DHR clients/consumers and employees • Problem Statement: • DHR Real Estate Rental expenditures have steadily increased since FY99 with no corresponding regular increase in appropriations • This puts a strain on program budgets to cover the increased costs for rental space • Project Goal(s): • To obtain additional state appropriations to cover the projected continuing increases in rental costs; • Describe how goal(s) will be achieved and measured: • Additional funding in the amount $1,300,000 ($650,000 State) in FY09 and each year thereafter to keep up with the costs of annual increases in rent. • Measures for these projects would include: • Cost per square foot for rented space, total costs for leased facilities. • Number of county DFCS offices relocated, number of new co-located facilities leased, number of square feet per position. DRAFT PROPOSAL

Concept Paper FY 09Office of Regulatory ServicesLicensing Fees Proposal: Collect fees to support improving the quality of regulatory oversight • 38 states (including 11 southern states) have licensing fees for all or most licensing programs • Georgia charged licensing fees in FY ’07 for 4 provider types generating $700,000, 19 types of providers pay nothing for regulatory services • Businesses voluntarily choose to operate in a regulated setting • Providers will take more ownership of decision to become a regulated provider • Georgia Certificate of Need fees range from $1000 to $25,000 (Generate estimated $750,000 to support improved regulatory activities if fees range from $100 to $1000.) DRAFT PROPOSAL

Department of Human Resources Budget Proposal Fiscal Year 2009 August 15, 2007