Changes in state policy and funding have put a strain on Multnomah County’s Intellectual and Developmental Disability Services Division (IDDSD), a new county audit released Wednesday finds.
IDDSD’s case managers help connect adults and children who have intellectual and developmental disabilities with the services and resources needed to live healthy and connected lives. According to the most recent satisfaction survey, conducted in 2016, clients are generally satisfied with the services IDDSD provides. But the audit finds that in recent years, the division has been suffering from a newly complicated financing system, an increase in caseloads and case turnover, and a “one size fits all” state approach to working with different counties.
“We found the Division’s ability to provide quality care is at risk because of the number and pace of significant changes mandated by the state,” reads the audit. “The destabilizing impact of these changes and funding pressure at the county level have resulted in high caseloads and turnover, case manager strain and burnout, morale issues, and complaints from clients and their families.”
One of the biggest strains, the audit adds, is a new state process for determining which services clients qualify for, called the Oregon Needs Assessment (ONA). The state mandates that both new and existing clients need to go through the ONA, and assessments cannot be conducted by clients’ individual case managers.
Last year, Multnomah County dedicated 12 former case managers (of about 90 managers total) to be ONA assessors, leaving the remaining case managers to pick up the assessors’ former clients. This came at the same time that new Medicaid eligibility standards opened the door for more people to qualify for IDDSD services, meaning “the number of children who are eligible to receive services significantly increased.”
But the increase in eligible individuals wasn’t accompanied by an increase in state funding—and IDDSD relies on the state for about 85 percent of its budget.
“With the Affordable Care Act, it just opened up who could qualify for Medicaid,” Multnomah County Auditor Jennifer McGuirk told the Mercury. “So expanding that definition increased, in theory, people’s access to those services, but it didn’t increase the money that was available.”
As a result, the average case load for each case manager jumped from 45 clients to 60 clients.
That increase in workload put pressure on case managers, and it was compounded by changes in how the state disperses funding. IDDSD used to receive equal monthly payments from the state. But now the state reimburses the division based on how many “billable contacts”—or client interactions, either via email or an in-person visit—that case managers perform each month. This new focus on meeting a contact quota takes focus away from quality of care, McGuirk said.
“The focus on billable [contacts] has meant that case managers have to focus on getting their billables in,” she said. “The increase in caseload means they’ve got more people to serve. At what point are you maybe serving a larger quantity of people, but not giving them the quality you would like?”
That concern is reflected in the audit’s data. McGuirk’s team conducted a case study of 61 clients between January 2017 and September 2018, finding that case managers missed 23 required quarterly visits, and that more than two-thirds of the cases were missing at least one monitoring checklist (a tool case managers use to make sure clients are getting all the services they need). These missed visits and checklists occurred despite the fact that some case managers worked extra hours without reporting overtime, saying they were under pressure to perform enough billable contacts.
High case turnover is also an issue; 13 percent of clients in the case study had four or more case managers in the year-and-a-half period the auditors studied.
A quote from the 2016 IDDSD client satisfaction survey shows how disruptive that turnover can be for a client:
“It would be nice to have the same case manager for more than just a couple of months,” the client said. “They change multiple times during the year and we have to start all over again getting to meet and know them.”
Knowing they are unable to provide their clients with the best possible services, the audit found, has resulted in low morale among case managers. As the deputy director of the county’s Department of County Human Services, Mohammad Bader helps oversee IDDSD. He told the Mercury that the audit’s findings about case manager morale were “not surprising,” and that he believes change needs to happen at the state level.
“It’s important to know that our workers have a huge heart, and they’re really very dedicated,” he said. “[IDDSD is] not a cookie cutter kind of system. We could use all the help we can get, through funding and system improvements.”
McGuirk said that many case managers approached her office directly while it was conducting the audit—a sign to her that “they were feeling desperate enough that change needed to happen, that they were going to come talk to the auditors.”
IDDSD has since started working to revamp its case manager training system, Bader noted. He said he knows it’s important for case managers to have a space to express their frustration and exhaustion.
“I really appreciate that the division appears to be taking morale issues seriously,” McGuirk said, “but there needs to be a constant push on that, and a push to decrease their caseloads.”
Both McGuirk and Bader told the Mercury that while the state’s changes in policy and funding apply to every Oregon county, the modifications likely affect Multnomah County more than less-populous counties, which can be flexible with smaller staffs and fewer clients to serve.
“Multnomah County is different,” McGuirk said. “We’re a bigger county, and we’re able to have a bigger scale of offered services. If people can’t access those services in other counties, they might come here for it. That’s not necessarily acknowledged at the state level.”
County leaders have been working with state legislators and the Oregon Office of Intellectual and Developmental Disabilities with the hope that some of these problems might be fixed during the next legislative session. Multnomah County is also networking with other counties—particularly Washington and Clackamas counties, the most populous ones after Multnomah—to see how they might be able to work together to create change at the state level.
In a written response to the audit, Multnomah County Chair Deborah Kafoury noted that IDDSD did see a $4 million bump in biannual funding this year, and that “the program is in the process of hiring new positions to decrease workload.” Kafoury also wrote that the county “has streamlined other processes to maximize productivity,” such as adopting electronic signatures for paperwork and other technological advances.
Bader is optimistic that more help will come from the state soon, and said he believes it “should be on their shoulders” to ease the strain on IDDSD.
“But absent of that,” he said, “I think we should try to solve these problems locally.”
