Chapter II

CLA Profile

Providers and Homes

• CLAs are homes where DMR clients reside, located in communities throughout the state.
• CLAs range in size from one to 10 residents, with six being the most common residence size. All have 24-hour staffing.
• There are currently 771 CLAs -- 623 (81 percent) are run by private providers under contract with DMR; 148 (19 percent) are operated by DMR. (See Chapter IV for discussion on contracting of private providers).
• The range in the number of homes per private provider varies widely. The largest operates 78 homes, while a number of providers have only one home each. The top five providers have more than 20 homes each and together manage almost 30 percent of all CLAs statewide. There are 41 providers with four or fewer homes.
• There are 81 private provider agencies -- 17 unionized and 64 non-unionized. DMR homes are unionized.
• Figure II-1 shows the number of homes run by DMR increased from 119 in FY 92 to 155 in FY 97 - or 30 percent. However, between FY 97 and FY 01 the number decreased to 148. Private homes continued to increase during that time, from 509 homes to 623 - or 22 percent.
• CLAs are located in 138 of the 169 towns in Connecticut. Several towns have just one; Windsor has the most with 27.
• CLAs must be licensed by DMR, while DMR's own homes are "certified" by the department. (See Chapter IV for a discussion of licensing requirements.)
• Sixty-five CLAs are Intermediate Care Facilities for Mentally Retarded (ICF/MR). This designation is issued by the federal Centers for Medicare and Medicaid (much like is done with nursing homes), and entitles these homes to receive Medicaid funding through the state Department of Social Services.

• ICFs/MR are licensed by DMR, but also subject to additional federal regulation and oversight, which in Connecticut is implemented by the state public health department.

Clients (as of June 2002)

Overall Client Capacity

• 3,434 DMR clients live in either public or private community living arrangements

_ 79 percent live in privately run homes (2,698 clients)

_ 21 percent live in CLAs operated by DMR (736 clients)

Clients by Region

• Table II-1 shows the number of CLA clients by region (see Figure I-4 in Chapter I for a listing of towns within each region).
• The North Central region serves the most clients with 1,043 (30 percent), while the Southwest region serves the fewest with 421 (12 percent).
• Over half (54 percent) of the department's CLA clients reside in the North Central and South Central regions.

• Table II-2 shows the number and percent of CLA clients by region and whether they reside in private or public homes

• Almost 80 percent of DMR's group home clients statewide reside in CLAs operated by private providers.
• The Southwest region has the greatest percentage of clients living in private CLAs (89 percent)
• The Eastern region has the largest proportion of clients living in publicly operated CLAs (44 percent). This is most likely due to towns in this region housing the bulk of clients previously residing in the now-closed Mansfield Training School.

Overall CLA Client Characteristics (as of July 4, 2002 - active clients only)

Summary

• A comparison of CLA client characteristics with those of clients living in all other DMR residential settings, including family homes, shows:

_ both populations tend to be roughly 60 percent male and 40 percent female;

_ CLA clients are older than non-CLA clients, with average ages of 45 and 34 respectively (median ages are 44 and 34);

_ as a proportion of the type of residence, three times as many DMR-CLA clients are profoundly retarded, and twice as many are severely retarded than clients living elsewhere;

_ as a proportion of the type of residence, almost twice as many CLA clients use wheelchairs or have no mobility skills, than non-CLA clients; and

_ almost twice as many CLA clients are blind, compared to non-CLA clients as a proportion of residence type.

• It should be noted, in the client characteristic data given to committee staff by DMR, over 23 percent of mobility and vision data for non-CLA clients were missing, compared to less than one percent for CLA clients.

Sex

• Of the 3,434 clients residing in CLAs, 58 percent are male and 42 percent are female.

_ These percentages are very comparable to DMR's overall population (excluding CLA clients), where the breakdown is 55 percent male and 45 percent female.

Age

• CLA clients are older, on average, than DMR clients living in other settings.

_ The average age for CLA clients is 45, while the average age for DMR's total population (excluding CLA clients and including clients living at home) is 34.

_ The median ages are 44 and 34, respectively.

Mental Retardation Level

• Figure II-2 shows the mental retardation severity level (MR level) of CLA clients by percentage. The figure also shows MR levels of DMR clients in all other types of living arrangements (again, excluding CLA clients and including clients living at home). "NR" means the client was not retarded and "ND" means the mental retardation level was not determined.

_ As a proportion of residential type, over three times as many clients with an MR level of "profound" live in CLAs than other living arrangements housing DMR clients, and over twice as many clients have an MR level of "severe."

Mobility Level

• Figure II-3 shows the mobility levels of DMR clients living in CLAs by percentages. The figure also shows mobility levels of clients in all other types of living arrangements.

_ Overall, almost 87 percent of CLA and 70 percent of non-CLA clients can walk, either independently or with assistance of a device like a cane or walker.

_ As a proportion of residential type, almost twice as many CLA clients use wheelchairs or have no mobility skills (13.2 percent), than non-CLA clients (7.7 percent.)

_ Mobility data for 23 percent of non-CLA clients were unknown, compared to 0.4 percent for CLA clients.

• Figure II-4 illustrates the visual acuity of DMR's CLA clients as a separate group and compared with clients living in other settings.

_ Almost 6 percent of CLA clients are blind, compared to 3 percent of non-CLA clients.

_ Approximately 60 percent of CLA clients have no visual impairments, compared to 50 percent of non-CLA clients.

_ No data exist for 23 percent of non-CLA clients, while less than 1 percent of CLA clients have missing data.

Length of Stay

· The average length of stay in a CLA placement is 8.5 years (as of June 2001). It should be noted, CLAs -- as a residential option -- have only been operating in Connecticut since the late-1980s.

· The median length of stay is six years.

Funding and Expenditures

· Table II-3 shows how CLAs are funded and the total amounts for FY 01.

Home and Community Based Waiver Funding

• Ninety percent of the clients who live in CLAs are enrolled in the federal Home and Community-Based Waiver program, which seeks to have Medicaid clients remain in the community, rather than being cared for in institutions.
• Enrollment in the program ensures that Medicaid will reimburse half of the program costs, as well as half of the room and board expenditures. The ICFs/MR group homes are funded entirely through the Department of Social Services, as mentioned above.
• Of the total 2,698 clients living in privately run CLAs, 2,170 (80 percent) are enrolled in the Home and Community Based Waiver program.
• Of the 736 clients living in CLAs operated by DMR, 698 (95 percent) are enrolled in the waiver program.
• CLA clients' medical care is provided in the community. Residents see local physicians, therapists, and dentists at the practitioners' offices. The costs are reimbursed through the individual's Medicaid assistance.

Public and Private Comparison

• Figure II-5 shows the total amounts expended on CLAs (both ICF and non-ICF) by both DMR and private providers from FY 95 through FY 01. These expenditures include program, room and board, and other administrative expenses. The private expenditures increased about 34 percent, while DMR expenses grew 32 percent.

• Private providers receive more of the total funding for CLAs (almost two-thirds); however, private CLAs care for about 80 percent of the clients in those settings.
• In terms of costs per client, DMR expenditures have risen 45 percent in the seven-year period and private provider expenses increased about 19 percent.
• Figure II-6 shows the comparison of the annual cost per client between DMR homes and privately operated homes. In FY 01 it cost about $95,000 a year to provide services for a client in a private CLA (both ICF and non-ICFs/MR) and about $190,000 for a client in a DMR CLA -- twice as much.

Regional Comparison

• Figure II-7 shows the DMR contract totals to fund privately run CLAs in each region for FY 01. The amounts ranged from $27.3 million in the Southwest Region to $55.6 million in the North Central Region. Much of that variation is due to the size of the regions and the number of clients served as discussed above.

• There is variation among the regions in the average private annual per-client costs from $69,688 in the Southwest region to $89,478 per client in the Eastern region.
• Homes run by unionized providers tend to be more expensive overall than non-unionized. The average daily rate for all homes is $232; for unionized homes the average cost is $254 and $225 for non-unionized homes.
• Older homes and longer-established providers tend to have lower rates than more recently established providers with newer homes. This is due to the fact that newer providers receive initial rates that more closely reflect higher costs while older facilities receive flat percentage increases year after year. Thus, the longer a provider's homes have been operating the greater the gap is likely to be between actual costs and payments made by DMR (similar to the committee's finding in the 2001 Medicaid Rate Setting in Nursing Homes study).
• There is also variation among the private CLA per-person program costs based on the number of clients per home. Figure II-8 shows the average daily rate for clients in the most common-sized homes. Generally, the greater the number of clients in a home, the less expensive the daily rate to care for the client. The most expensive is the 3-person home, with a daily cost per person of about $293.

Staffing

• All CLAs must provide 24-hour, 7-day a week staffing as long as clients are at home. There are no required staffing ratios in any homes. Instead, staffing requirements are based on individual homes, the needs of the clients in a home, the initial licensing application that lays out staffing patterns, and the contracted amounts paid the provider to operate the home.

Screening

• There are no regulatory requirements that staff meet certification or minimum educational levels -- providers may set their own.
• In March 2001, DMR issued a number of human resources policies requiring the following screening measures prior to hiring new employees by DMR or private providers (effective date in parenthesis):

_ employer references are checked, and where applicable professional credentials are reviewed and verified (7/1/01);

_ a documented review of the Connecticut Registry of Sex Offenders (7/1/01);

_ motor vehicle license and record review to verify that any person who is to transport clients has a valid motor vehicles license (7/1/01);

_ demonstrated employee participation and proficiency in 14 separate areas of staff training (9/1/01); and

_ a documented review of potential employee's criminal history record. Whenever possible, this history shall be based upon a biometric/fingerprinting analysis conducted by the Connecticut State Police Bureau of Identification (7/1/02).

• If a person is terminated from a provider agency or DMR because of substantiated abuse or neglect, that person's name must be placed on a registry of persons prohibited from working in direct care services again. Agencies must also screen a potential employee to ensure his/her name does not appear on the registry before the person can be hired. The use of the registry is currently facing a legal challenge and its use is suspended until new regulations can be developed.

Training

• All direct care staff must be trained within 30 days of being employed and retrained every two years. New employees must work with other employees until they have received training in:

_ signs and symptoms of disease and illness;

_ communicable disease control;

_ resident basic health;

_ routines of the residents; and

_ emergency procedures of the residents.

• The training content and duration, method of training, and qualifications of the trainers must be documented by the provider. Written summaries of the training content must be available to DMR upon request.
• All direct care staff must be trained within six months, and retrained every two years in the following areas:

_ first aid for accidents;

_ agency policy and procedures;

_ abuse and neglect prevention and reporting (now required annually);

_ planning and provision of service; and

_ behavioral emergency techniques.

• At least one staff person for each shift shall be certified in cardiopulmonary resuscitation (CPR), and any person who administers medication shall be certified and possess a valid card attesting to the certification.
• Screening and training of staff is subject to review by a licensing inspector when a home is being relicensed.
• In addition to direct care staff, provider agencies and DMR also employ other persons such as nurses, psychologists, behaviorists, and occupational, speech, and physical therapists. Most of these professionals work on a consultant basis, providing planning, assessment, and monitoring of clients' programs rather than direct care services.
• For some nursing responsibilities, licensed nurses may delegate to direct care staff in certain situations (as explained in Chapter III).

Levels and Salaries

· Committee staff analyzed direct care staffing ratios and salaries for public and private homes for FY 01. These are shown in Table II-4.

· The resource data show a substantial gap between DMR and the private agencies in the staffing and salaries of DMR and the private providers who operate CLAs under contract. The ratio of staff to clients is higher in DMR homes where it is almost two staff for each client; in private homes there is a better than 1:1 ratio. The numbers of FTEs equal or exceed the number of clients because of the three-shift coverage; it does not mean that each client has one direct care staff taking care of him or her.

· The salary gap between DMR and private agencies continues to widen -- from a 23 percent difference found in program review's 1992 study of group home staffing to 33 percent in FY 00 to 39 percent in FY 01. In FY 01, private providers expended $78.5 million in salaries for 2,863 (FTE) direct care staff including substitutes. This translates to an average salary of $27,397. DMR homes expended about $48 million for 1,253 (FTE) staff, resulting in an average salary of $38,369.

Turnover

• Until recently, staff turnover was not information the department requested from private providers. Earlier this year, regional DMR contracting staff began collecting turnover data as part of the contract. However, that data have not yet been analyzed, and it is not clear whether they will be aggregated or will be used in each region as a monitoring tool for individual agencies.
• Recent national figures of staff employed in residential support programs showed a turnover rate of 35.2 percent.² In Connecticut, December 2001 figures collected from 30 private provider member agencies of the Connecticut Community Providers Association indicated a median turnover rate in FY 00 of 22 percent .³
• DMR's turnover rate among direct care staff, which includes workers at Southbury Training School, regional centers, as well as CLAs and is for both full-time and part-time staff was 6.4 percent in FY 01 and 5.8 percent in FY 02.

² Turnover rate reported from 14 states included in the Core Indicators Project, a quality improvement endeavor sponsored by the National Association of State Directors of Developmental Disabilities Services. This is a similar to the turnover rate program review found in its study of CLAs in 1992.

³ This is similar to the private provider turnover rate of 24 percent program review found in its 1992 study.