The House Committee on Human Services met on October 23 to monitor the implementation of several bills passed during the session, including numerous Child Protective Services bills, as well as the status of procurements and managed care oversight at the Health and Human Services Commission.

This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. It is not a verbatim transcript of the hearing, but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

 

Courtney Phillips, Executive Commissioner, Health and Human Services Commission

  • Link to HHSC presentation
  • Phillips is the new HHSC Executive Commissioner as of Oct. 19, 2018
  • Rose – Welcomes Phillips to the state & wants to have a sit down
  • Raymond – Will do everything we can to make HHSC the most effective health agency

 

Victoria Ford, Health and Human Services Commission

  • Gives overview of recent procurement issues at HHSC, 20 procurements were of concern in April and May of 2018
  • Procurements were fixed or canceled, also put emergency processes in place to ensure future procurements followed all procedures
  • Created a team for procurement oversight, team has been monitoring procurements and working to update rules to comply with audit findings
  • Working with vendor on long-term reform plan to be released in mid-November
  • Raymond – Would any of these things require legislative changes?
    • Working through this issue now; largely did not have a failure of statute, but a failure of the agency to adjust to procurement changes & service delivery
  • Not surprised by outside audit as internal audit found similar issues, on track to update procurement policies/procedures and train staff appropriately
  • Evaluators now have limited ability to change scores & have worked to limit human error, but no modern scoring system
  • Frank – As we moved to an indirect provider of services where services are purchased, there should be a reduction in the number of staff, shouldn’t there be FTE reductions that could be redeployed?
  • Raymond – I think this has happened with HHSC
    • I believe this has happened with HHSC & can get the committee data over time
    • New staffing needs like IT, etc. are necessitating more staff
    • Tracking staff from legacy provision to modern provision may not be apples to apples
  • Raymond – As we moved into managed care there were savings identified in the budget, not sure what this means for FTEs, but these have been baked into the budget
  • Raymond – CPS is a different matter considering the ongoing lawsuit, kind of a moving target
  • Frank – More concerned about having FTEs in the right spots within the agency
  • Ernst & Young evaluated HHSC, recommended 29 areas for improvement, being vetted by the steering committee to divide into categories of immediate implementation and longer-term goals, still addressing staffing issues in the mean time

 

Stephanie Muth, Health and Human Services Commission

  • HHSC is transitioning into an agency that works effectively in the managed care environment, Rider 61(b) last session looked at HHSC oversight over managed care entities
  • Rider 61(b) report identified areas for improvement & HHSC is evaluating currently with 5 focuses: network adequacy, complaints process, clinical oversight practices, outcome-focused performance management, and service coordination
  • With network adequacy
    • Looking to improve provider directories, engaged in review
    • Also have ongoing access checks where staff try and make an appointment with providers, working to feed this info to MCOs so they can address the adequacy issue
    • Also looking at expanding rural access through telemedicine, etc.
    • HHSC does have an exceptional item
  • HHSC has added network adequacy standards for long-term services and support provider types from the report as of Sept. 1, rules are being finalized
  • On complaints trending and analysis, need to develop standard definitions and categories for complaints across the system as complaints can come in through many different vectors
  • HHSC has identified and will roll out 13 complaint categories to help aggregate, also looking at streamlining process, publicly sharing some complaints data, & incorporating into report cards
  • Raymond – I believe there will be legislation needed to help give you teeth on this, will likely be necessary for us to pass the Frank bill; also hearing about these issues from other members
    • Would be happy to work with legislature on this
  • Klick – Some complaints are more time sensitive, are you incorporating a health professional to review some that might be urgent?
    • We do have a priority process for access to care issue, not reviewed by a medical professional, but can look at doing this
  • HHSC also focused on strengthening clinical oversight through expanding utilization reviews to include STAR Kids and MDCP, analyzing PA data, creating Chief Medical Officer position, and improving guidance; intending to have a stratified sample by 2020
  • Working on adding a contract deliverable for PA data, also doing targeted reviews
  • Each managed care product has different service coordination requirements, terminology & definitions vary across contracts, looking at how to improve the coordination function
  • SB 894 – Codification of SAO recommendations from managed care audit in 2016, recommendations are implemented
    • SAO has engaged in a follow-up audit to review implementation, unsure of timeframe for final report
    • Also had EVV components; development & distribution of EVV client rights notice is still being finalized, deadline has been extended for implementation

 

Victoria Ford, Health and Human Services Commission

  • HB 2025 – Relating to the regulation of certain long-term care facilities
    • Gave regulatory division a good opportunity to look at all policies and procedures
    • Will be providing training required by rule, facilities have until May 1 of next year to implement bill items in their facilities
  • Rose – Asks that HHSC makes sure her office and Rep. Davis’ office is updated once rules are adopted
  • SB 1021 – Reports on consolidation & advisory committees
    • Report issued this Summer, in process right now of establishing two advisory committees between HHSC, DSHS, and DFPS to ensure efficient operation of agencies
    • Assessment still ongoing on effectiveness of current advisory structure
    • Also transferring Consumer Rights unit to ombudsman’s office by the end of the year

 

Mike Maples, health and Human Services Commission

  • Highlights SB 547, provides access to specialized services in SSLCs and makes them available to community providers, rules have been implemented
  • Going to ease into this even without funding, opportunities to make capacity available soon; will be working to get Medicaid reimbursement in the Spring & have an exceptional item to expand the program
  • Raymond – Do you have some idea of how many will utilize this?
    • Not yet, we have met with providers and have seen some interest, will have more data heading into session; starting with dentistry and wheelchair fabrication
  • Raymond – Did we have a lot of pushback on this where people said they don’t want the state to competing?
    • No, conversation has surrounded where we will locate, focusing on places without many providers
  • Frank – Asks for clarification on wheelchair manufacturing?
    • Correct, fabrication & modification of wheelchairs; our facilities work with individuals on what modifications or specialty wheelchairs are needed
  • Raymond – And some of these individuals have trouble finding this service off campus?
    • Absolutely
  • Klick – Will it be like an FFS arrangement, are you contracting with an MCO?
    • Could be both, not there yet, but will start with contracting with community providers
  • Miller – Asks Dr. Phillips what she has heard today?
    • Phillips, HHSC – That we have a lot of work to do, great strides have been made recently, but much work to do
  • Miller – Need the right processes and people to accomplish our goals, my advice is to have all of this in place

 

Hank Whitman, Commissioner, Department of Family and Protective Services

  • Link to DFPS presentation
  • More than 90 bills affected the CPS system last session & improved protections for clients, grateful for the influx of funds & FTEs
  • Turnover has decreased in investigation, family-based safety, and conservatorship by around 20%; caseloads are also down
  • Have seen large number of priority intakes this month; have worked to improve priority intake processes
  • Intakes, investigations, and removals have gone up slightly over last 3 years, but consistent with population growth
  • Frank – Asks for clarification on data, slide 8 shows decrease in number of children removed in 2017, but slide 7 does not; trying to reconcile the two
    • Kristene Blackstone, DFPS – Between 2017 and 2018 we had a 3% increase overall in removals
  • Frank – But the data shows 20%
    • Not sure if it is the fault of the chart, or average monthly number, can get more info
    • Blackstone returned later in the hearing to report that the slide 8 number was an error, FY17 is 19k removals
  • DFPS has also improved on long-term outcome metrics, highlights slide 9
  • HB 5 transformed DFPS as an agency, created DFPS as an independent agency, established investigations and HR divisions, continuing to contract with HHSC on admin services
  • HB 5 also established joint steering committee between HHSC and DFPS

 

Kristene Blackstone, Department of Family and Protective Services

  • HB 4 allowed a monthly stipend for kinship care, funding has helped caregivers with critical resources to stabilize placements
  • Raymond – And we see that this is helping children & permanency placements
    • Whitman – Also promoting better outcomes
  • Frank – Are we also going to look at kinship effect on reducing foster homes, hoping to see this somewhere
    • Blackstone – We’ve been steadily growing kinship placements, this year @46% and the national average is around 32%, doing a good job & does free up foster placements
  • Wu – Would also expect a decrease in DFPS seeking termination with more relative placements, do you know if there is a trend for that?
    • No numbers currently, have had an increase in relatives adopting
  • Raymond – Also want you to be sure and follow up with LBB, I believe there will also be significant savings with these placements
    • Whitman – We definitely want to catch the metrics, but more importantly is the outcome of the children

 

Audrey Carmical, Department of Family and Protective Services

  • HB 7 made several changes regarding DFPS suits affecting parent-child relationship, increased protections for parents by prohibiting certain removals, created a defense for parents acting in good faith, made dismissal of cases automatic and jurisdictional
  • Supreme Court additionally organized an HB 7 task force to study jury instructions, current recommendation is to move to narrow form submission, but rules have not yet been adopted
  • Also required study of attorneys ad litem and report is available on web, created new license types
  • Raymond – Thanks Rep. Wu for his work on this
  • Wu – Would expect appellate cases resulting from this bill due to new law, have there been any court cases?
    • Haven’t heard about these yet, but will likely see them eventually
  • Wu – Especially on good faith exception, legislature tussled over the language for 3 weeks; would expect a quick appeal
  • Wu – In the bill there was a provision that said family service plans would no longer include restatement of allegations as it causes unnecessary fighting between parties, but I believe many caseworkers are still including this in plans
  • Raymond – Can one of you commit to check that provision & get back to us on status?
    • Yes, can look into this

 

Kristene Blackstone, Department of Family and Protective Services

  • SB 11’s largest part surrounded community based care, also required an annual foster care needs assessment, added a 3-day exam upon removal, required performance-based contracts, and created a pilot program for case management
  • Recently released FY18 capacity needs assessment, have lost 568 actual beds in residential treatment centers, shelters, etc. since FY17, due to contract modifications, provider action, and some to Hurricane Harvey
  • Saw a 50% reduction in HCS waiver slots and elimination of DFPS residential operation diversion slots; HHSC has requested that these slots be restored in LAR
  • In FY 18, gained 351 residential operation beds from 13 new providers and some existing providers
  • Regional leadership has been working to develop strategic plans as a result of assessment
  • Also established treatment foster care rate
  • Created a 30-day initial medical exam, which joins Health Steps and CANS assessment; developed with help of stakeholders, bill also established requirements upon removal for abuse, chronic conditions, etc.
  • Children cannot receive a vaccination at this exam unless medical professional determines tetanus shot is necessary, biological parents can also give permission for vaccination
  • Frank – I don’t feel like DFPS has implemented this in the way the legislature intended, could you tell me who the stakeholders were that helped in the implementation of the 3-day examination plan
    • Primarily worked with medical community
  • Frank – It’s my opinion that it should be based on the way the bill is written, this bill was negotiated very tightly & trying to consider parental rights
  • Frank – Stakeholders had one perspective without regard for parental rights, CPS should not get together with one organization and disregard legislative intent
  • Frank – I don’t feel like we should have to go back with legislation to clarify what is there, still trying to figure out what I can do about this
  • Frank – I feel like CPS went with stakeholders over the parental concerns
  • Klick – I agree with this as the author of this amendment
  • Raymond – Could you clarify what happened?
    • When we implemented the 3-day initial exam, implemented for every child as they come into care; bill prioritized certain children victims of abuse, with complex medical conditions, etc.
    • CPS struggled to figure out how to operationalize this assessment & how caseworkers were supposed to assess conditions or abuse as they were making a removal and not be at risk of making a bad decision
  • Frank – The stakeholders consulted in implementation, did they include those involved in passing the bill; I believe the stakeholders working on implementation were only on one side, was that true?
    • What we had a difficult time figuring out was how to operationalize, it was our assessment that caseworkers would not be able to do this
  • Frank – In some ways the medical community was a vendor in this case, I looked at this as a vendor bill
  • Raymond – Still not clear to me what CPS did and how it didn’t match up to bill language
    • Bill says we shall secure the 3-day exam for a child who is removed as a result of sexual abuse, physical abuse, with obvious physical injury, or has a chronic medically complex condition or diagnosed mental illness
    • Looking at this, we were worried that we would overlook certain children, wanted to err on the side of caution in terms of who gets the exam
    • CPS doesn’t believe the language prohibits our construction
  • Frank – I would fully acknowledge that you were within the reading of the bill
  • Raymond – What should they have done differently?
    • Frank – Essentially the vendors wanted a 3-day medical every time, discussion on the floor determined not to have medical exams used as a fishing expenditure against parental rights
    • Frank – The list in the bill is what was determined to be appropriate
  • Raymond – But what would you have them do?
    • Frank – Would have them determine if there was abuse, condition, etc.
  • Raymond – So the caseworker would need to make this determination, how well trained are they?
    • Frank – Prior to this we were not hitting 30 days for a medical in most cases
  • Raymond – Was it Chairman Schwertner who introduced this?
  • Klick – I was the one who authored the amendment
  • Raymond – Whose idea was the 3-day?
    • Whitman, DFPS – Caseworkers have an overwhelming workload, if they missed something in the exam it would be caught in the media; too much responsibility to place on the caseworkers
    • If caseworkers don’t get all the information this is a tough call
  • Wu – I think I understand, to clarify: This was a provision I had asked for in HB 39 that did not end up moving, came from a work group well before session, also something the judges and ad litems had asked for
  • Wu – On the negotiations on my bill, the discussion was that DFPS was already working on, but they were not confident they could do so; my bill said every child victim of abuse and neglect would get a 7-day exam
  • Wu – DFPS was not sure they could meet the “shall” requirement, my suggestion was to reduce the range of kids that shall be seen and then you try and get it done for everyone else
  • Raymond – This is what I recall as well
  • Klick – I think some pediatric providers were interested in 3 days, but at that point we were not even successful with a majority of exams in 30 days
  • Klick – 7 days was too long for children who were diabetic or asthmatic, language also requires children with injuries or signs of sexual abuse to be seen sooner
  • Wu – This was not supposed to be intensive investigation, was intended to get an exam for conditions that are obvious and apparent; these are children already moved for abuse and neglect; in terms of fishing, this is post removal & a cursory examination
  • Frank – In terms of loading work onto caseworkers, you’ve loaded more on if every kid needs an exam, there is already a certain amount of this that the caseworker needs to do
  • Frank – Need to ensure that intent of bill is followed, I’m alright with filling a bill to tighten this up; a caseworker has to make some decisions on removal already
  • Wu – I want to clarify that the bill passed included a minimum protection
  • Frank – If you look at the way this discussion was negotiated, that’s not what resulted; may need to write cleaner bills, because there was clearly a bias with who put this together in the stakeholder meeting
  • Raymond – What was your interpretation of the wording?
    • Frank – I thought you would only do a 3-day medical on the children listed, it was a question of parental rights versus medical needs & not wanting these done before show cause hearing
  • Wu – I think you are mixing this up with the vaccines provision
    • Frank – No, this was part of the discussion
  • Wu – We were not part of that discussion
  • Klick – This was part of the discussion, this was highly negotiated; 3 days is too long for some children
  • Frank – We talk about piling on, look at what is happening to foster homes; DFPS had the ability to do this, but I’m just expressing my opinion
  • Raymond – If you would tell us your concern that this would lead to in terms of unfairness
    • Frank – Creates unnecessary trauma on the kid, there is a bias that every kid should get a 3-day medical; this is also the bias of DFPS, and the way to fix this would be to mandate that the exams only be given to the children listed
    • Blackstone, DFPS – We have seen some pretty dramatic cases where injuries weren’t visible to us
    • Frank – Without a doubt, I think we would also find cases where medical providers caused removals that were unnecessary
  • Frank – When you are putting implementation together, the stakeholders have a bias, I don’t think everyone was represented
  • Frank – DFPS had a right to do this, I do not like it & I’m going to try and get it changed
    • Blackstone, DFPS – We have made a PA policy that the list includes the child must have it & clarified to staff, made sure the list of children receive first priority with the exam
    • Whitman, DFPS – This is a problem for us in the rural areas and telemedicine could help, watched Dr. Lakey’s presentation on telemedicine, $20k unit could allow for exams
  • SB 11 also expanded community-based care, Stage 1 rolled out in Fort Worth & conducting readiness assessments in other areas, have come to an agreement on Stage 2 for case management;
  • Klick – Do we know when approximately this will be?
    • Blackstone, DFPS – We have submitted a request to exceed appropriation, if we get approval will take about 6 months to go through; plan is in place
  • DFPS requested exceptional item for the next biennium to expand and sustain community-based care
  • SB 11 also expanded use of performance-based contracting, Slides 28 and 29 have performance measures for CBC contracts
  • SB 11 required Family-Based Safety Services case management pilots in two regions of the state, Pathways operating in El Paso as of June, working to procure for second site with evaluation due by end of year
  • Raymond – How much is the exceptional item cost? How much was the request to exceed?
    • Exceptional item request is $59 million, request to exceed is roughly $9.5 million
  • Frank – How much of the $9.5 million is increased population compared to cost overrun?
    • Over $3 million is one-time start up
  • Frank – How much of the remaining $6.5 million is part of the legacy system
    • Legacy system is still ongoing, have submitted a 14/1 child ratio for this system and this is as close as we could get

 

Trevor Woodruff, Department of Family and Protective Services

  • 5th Court of Appeals has issued a ruling, determined that plaintiff claims should be sustained in caseload and oversight/monitoring, but not in placement array and foster group homes
  • District court injunction was determined to be half valid and half invalid, currently in remand state
  • Briefs due at end of the month, will then again be reviewed by the appellate court
  • Frank – One of the finding discusses CPS caseloads and inconsistencies in determining them, can DFPS decide to set caseworkers based on number of children in the system instead of tracking cases for children, cases for parents
    • This has been ongoing since the court’s initial ruling, report every month tracks this
  • Frank – Will it require a bill to have LBB understand we should look at this a different way?
    • I don’t think it would require a bill
  • Raymond – If we did a pass a bill requiring this, then it wouldn’t need a discussion
  • Wu – We’re talking about taking total children and dividing by caseworkers?
  • Frank – It would be divided according to stage/type, trying to simplify this number & have one instead of two
  • Wu – Agree with having consistency, but I think you would run into problems as parent and children numbers vary on every case

 

Public Testimony

Bria Huber, Fractured Families

  • Seeking refinement of HB 2848, shares experience of husband blamed for injuries to daughter that were caused by Ehlers-Danlos syndrome (EDS)
  • Intent of bill was to have multi-disciplinary team of practitioners evaluate children when they present with fractures
  • Raymond – How far into the process did it get?
    • Husband was indicted and then charges were dropped 8 months after
  • Raymond – How quickly can a hospital determine if a child has the condition that caused these fractures?
    • No blood test currently, clinical diagnosis
  • Raymond – So what could have been done differently in your case?
    • A review of medical family history
  • Raymond – Were you diagnosed at this time?
    • No
  • Raymond – So it’s one of those issue where they would’ve had a difficult time knowing
    • If I had had the opportunity to discuss personal issues, it could have been discovered
    • Difficult to do this when parents are assumed to be abusers, information is lacking

 

Rana Tyson, Fractured Families

  • Part of the issue is that EDS is not included in list of conditions to consider with infant fractures
  • Share experience of CPS scrutiny after daughter presented with symptoms consistent with Ehlers-Danlos

 

Jennifer Brown, Fractured Families

  • Shares personal experience of child with Ehlers-Danlos syndrome
  • Frank – How much did you have to spend on lawyers?
    • Around $15k
  • Learned that HB 2848 was passed into law during her experience, loophole exists allowing hospitals and DFPS to repeatedly ignore medical evidence of EDS
  • Frank – I think without financial resources, these cases would not have been successfully fought
  • Frank – Hospitals have tremendous financial incentives that go against the parents, guessing that the state paid for the multitude of tests done to confirm
    • Tyson, Fractured Families – We paid for the tests, had to file bankruptcy
  • Frank – need balance in this system and private interests are financially incentivized to find problems
  • Raymond – Was not aware of this issue, will call CPS to speak on this shortly; usually we are criticized for not reaching children suffering abuse, challenge is to balance the approach
  • Rose – Since Fractured Families has begun, are you aware of families without resources to fight cases and are in jail?
    • Tyson, Fractured Families – Yes, there a significant number of cases with public defenders, many have taken plea bargains
    • Huber, Fractured Families – Have seen that it is much easier to convince judge or jury that the partner caused the injury, results in families set against each other
  • Klick – Would like to visit with families after the hearing, certain that we will fix the loophole next session

 

Chad Tyson, Fractured Families

  • If these conditions are determined quickly, can remove the burden from the state’s resources
  • Also puts a heavy burden on families and marriages

 

Kristene Blackstone, Department of Family and Protective Services

  • Bill was implemented, entered into contract with MedCare to provide review, amended contract with FACN to reflect that they could seek second consultation & trained caseworkers
  • Hearing a request from parents to be able to request additional review themselves, can be done
  • Frank – In the implementation, the FACNs can request additional expertise to help protect the rights of children and parents, but the FACN is the one alleging abuse; does this not strike you as a conflict?
    • Would think there are times when medical professionals turn to other medical professionals to consult, this opens the door for that and promotes that

 

Liz Kromrei, Department of Family and Protective Services

  • In case of difference of opinion, the bill also directed a blind peer review of the process
  • Raymond – Are you familiar with cases now & if we are doing a better job already?
    • Can look into this and provide information
  • Frank – When you were doing the implementation, what stakeholders were at the table?
    • Blackstone, DSHS – This was implemented by the Investigations Division, not aware of process; normally we would involve all relevant stakeholders
  • Frank – My understanding is that stakeholders are drawn from a narrow set of people who all think the same way
    • Normally we try to involve parents, children: depends on scope and nature of the bill, often depends on the bill
  • Raymond – You can enumerate the necessary stakeholders in the bill; find out who made up the group and get us this info as well

 

Jesse Booher, Texas Alliance of Child and Family Services

  • Alliance members are the direct service and care organization around the state
  • Important component of SB 11 was community readiness & engagement, TACFS worked with state and stakeholders to hold informational meetings in different communities
  • Testified in support of good data for CBC readiness, TACFS is working to promote CBC readiness in Harris County to prepare for possible roll out in the future

 

Amanda Fredriksen, AARP

  • Appreciates work down recently on nursing home quality, especially on HB 2025 from the 85th, anticipates a change in regulatory trend, hoping that legislature will monitor implementation going forward
  • Concerned about inappropriate use of antipsychotics
  • Klick – Have seen reports in the Dallas area hat we are still seeing spikes in use of these drugs, was presented to me that some senior citizens would develop schizophrenia, but thi sis not generally a condition that develops later in life
    • We are seeing these diagnoses as rates of inappropriate use go down & we know that these don’t show up typically this late in life
  • Frank – So there are 15k people taking drugs without a diagnosis?
    • This is off-label use, often requested by facility staff to manage outbursts to manage disruptive residents, often written PRN & sits on file indefinitely
    • Interested in looking at the consent piece, difficult portion is that this population is mostly not in a position to give consent & legally authorized representative consent is not required to be in writing
    • Looking to beef this up

 

Anais Biera Miracle, The Children’s Shelter

  • Testifying on implementation of CBC in Region 8A, DFPS announced the SSCC contract for a division of The Children’s Shelter; developed a vision of CBC that reflects the organization’s vision
  • Looking at possibly 31 foster care organization partners, with a youth advisory care component
  • Have worked extensively with the community
  • Minjarez – Is there anything else in terms of support that you need?
    • Currently hiring, working alongside with partners and proceeding well
  • Frank – Given that part of the responsibility is transferring to you, what do you think you can improve?
    • Focused on children without placements & timely care
  • Frank – And starting Feb. 1 it’s on you
    • Yes, we understand that County needs to grow capacity by possibly 21%; will be recruiting for specific needs of children

 

Christina Green, Children’s Advocacy Centers of Texas

  • Testifies to improved metrics, Children’s Advocacy Centers (CACs) have served significantly more numbers of children than previous years; dedication of resources, SB 1806 routing high risk cases to CACs, consolidation of investigations, etc. have helped improved metrics

 

Closing Comments

  • Raymond – Will see some legislation as a result of this hearing, will have one more hearing before session, likely mid-November