Dear Concerned Friends,
Because of your efforts, Nashville has "reconsidered" it's decision to fire all of the TIPS full-time teachers. Commissioner Seivers met with TIPS Regional Lead Teachers on April 9th and heard their concerns. Representative Doug Overbey was there. So was Rick Nicholson from Finance Ways & Means Committee, TEA, and a representative from the Governor's office. About 2 weeks later, the RLTs, state secretaries and business manager got letters saying that they would have jobs in the "new" program. Thank you for making the calls, e-mails, etc. We're glad Commissioner Seivers changed her mind about the RLTs.
We don't know what the RLTs will be doing, though, because they may be assigned different job duties. We contacted Don Thompson and asked him if everyone was being kept. He said that TIPS contracts for some staff through the Center on Deafness at UT. These people may get to keep their jobs until the end of September, but they don't know that for sure. When we asked about the numbers of people involved, he said there are 3 RLTs, 2 computer people and 7.5 secretaries currently employed who are paid by UT but work for TIPS. Don Thompson still has a RIF letter, too.
Nashville is still planning on taking away the "special school" title from TIPS School, but they are moving the TIPS program under the Tennessee School for the Blind so the TIPS teachers can still be teachers. Posted on this site (in the next comment) is a letter written by Sarah Willis. She is the lady who started TEIS, helped to get TIPS set up as a special school and worked very hard to get Tennessee's early intervention program going well. She retired several years ago and moved to Washington to work for the US Office of Special Education Programs. Ms. Willis KNOWS Tennessee's program, and she knows federal law. In her letter, she tells Commissioner Seivers that our state needs to put all of this change on hold and fix the problems within the current system, not try to reinvent the airplane while it is flying. As a parent with a child in our state's program, I encourage you to let your legislators know these things:
1) you appreciate their help in saving the jobs of TIPS RLTs
2) our state needs to stop trying to implement a new program and just fix the problems in the current program
3) give people who KNOW early intervention a chance to help plan the future.
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May 7, 2007
Commissioner Lana Seivers
Tennessee Department of Education
Andrew Johnson Tower – 6th Floor
Nashville, Tennessee 37243-0375
RE: Governor’s Office of Children’s Care Coordination’s (GOCCC) Study and Recommendations on Tennessee’s Early Intervention System (TEIS)
Dear Commissioner Seivers:
On April 11, 2007, I received the GOCCC’s report and recommendations relative to TEIS. I have studied the report carefully; although I agree with some of the report and support some of the recommendations, I am disappointed at the extent to which the report contains incorrect, unclear, distorted, incomplete statements and perhaps illegal recommendations. Even though there was no public review and comment period (nor were comments requested), I have chosen to share my personal comments and offer recommendations of my own.
I have experience in both Tennessee’s early intervention system and the Office of Special Education Programs (OSEP), the federal administering office for the program. During my tenure in the Monitoring and State Improvement Planning Division (MSIP) at OSEP, I visited many states and assisted in a comprehensive review of each of these state’s Part C systems. During the time I served as the policy consultant in MSIP, I became familiar with the program in even more states. As a result, I am in a unique position to critique the contents of this report.
Many of the needs, issues and concerns cited in the GOCCC report have a long history. Some were present or emerging when I left the position as Director of the Office of Early Childhood (OEC) nearly 10 years ago. I stayed in contact with personnel in OEC during the years I was employed at OSEP and was aware of issues in the program. After retiring from OSEP in 2003, I thoroughly examined concerns and issues related to TEIS while I worked as a consultant for the program and served on the “Birth to Five” and the “Financial Task Force” in 2005.
Please understand my comments are not intended to assign blame to any present or former employee of DOE. In fact, I would submit that some of the existing problems may have begun while I was Director of OEC, and therefore, any responsibility could be assigned to me. I recognize that the current Director of OEC assumed the position after the GOCCC began this study and, to date, has not had the time or the manpower to address issues existing when he assumed the position. I do not believe that he will have time to address current issues when he must spend the majority of his time resolving the issues related to implementing the changes recommended in this document. It will be much like the situation in 1991 when the states were required by federal statute to implement the entitlement program without adequate time to plan all aspects of the program. We were forced, as will the OCE, to “fly the airplane while you are still building it”. A dangerous situation and one that is not necessary in the early intervention program at this time.
I have strong feelings about both the right and the responsibility of the state to evaluate and make program changes as needed. However, I have equally strong feelings about those decisions being based on correct information and data.
1 If the recommendations in the report are based on the information provided in the report, then the basis for program changes is suspect.
2 If any additional information exists that influenced the recommendations, that information should be made public.
I have strong feelings as well about the involvement of parents of children eligible for early intervention services under Part C in the discussions about changes to the system and an opportunity for adequate review of recommended changes by parents, early intervention providers, etc. I believe that a reform effort of this magnitude should:
1 involve more than the small number of parents who responded to the written survey and/or participated in the group discussions,
2 ensure the significant inclusion of those most affected by the changes (parents of children with disabilities currently receiving TEIS services or have recently exited services), and
3 afford ample time for review and comment by the general public (including parents of children with disabilities).
Although I agree with many conclusions and recommendations contained in the report, I have major concerns regarding much of the data presented, conclusions drawn and recommendations presented.
I have attached a more complete discussion on items of agreement (see appendix 1) and concern (see appendix 2).
I have grave reservations about beginning to implement the recommended changes before the federal State Plan has been amended. Many of the recommended changes could be implemented without federal approval; however, it would be ridiculous for the state to create a compliance problem for not amending their plan in those areas that are required (for example, see 34 CFR §303.145(b)).
Generally, I support the following recommendations but feel there are areas of concern inherent in each category:
1.1 Administration
· “TIPS is a valuable DOE program, committed to strengthening families and reaching well into rural areas of the state” and “TIPS’ training and mentoring functions are important for sustaining quality services.
· DMRS should be relocated to DOE for administration.
1.2 Fiscal
· Eligibility Determination in the present system is unnecessarily costly and therapists performing eligibility evaluations frequently recommend clinic-based therapy for children they evaluate.
1.3 Program Implementation+
· The ratio of service coordinators to families should be one service coordinator for every 40 families.
· Implementation of consultative approaches to direct services is a key in the system.
· IFSPs should become more family oriented and functional for the child.
· Clarification describing the appropriate use of service definitions should be provided by OEC to the service community.
· Using estimated prevalence and TEIS data to target counties for child find purposes and incorporating the activities of START into child find plans should strengthen the TEIS child find system.
Generally, my major concerns and comments fall into the following categories.
2.1 Process
· Many issues and concerns used to support the decision to disband the present TEIS offices and dismantle the TIPS program could and should have been addressed by State OEC staff; doing so could possibly have eliminated the need for this study and the resulting disrupting recommendations.
2.2 Data
· Some of the data collected by the outside consultants and utilized to support the disbanding the TEIS offices and dismantling the TIPS program are not an accurate representations due to multiple competing assignments from OEC such as CIMP, TEIDS, etc.
2.3 Conclusions
· The contents of the report are misleading, incorrect, confusing, and unclear. The contents are largely unsupported by facts and some of the recommendations are highly likely to be inconsistent with federal statute and regulations.
2.4 Fiscal
· Taking funds appropriated for services to infants and toddlers with disabilities and their families to establish “a new program of state Early Intervention services for families whose children are not eligible for Part B services at age 3 years when TEIS services are no longer available to them under the existing model, and who await entry into Pre-K programs” (report, page 5) is reprehensive, possibly inconsistent with federal standards, and may establish a pattern of services that may in the future require significant state dollars to maintain.
Based on my over-whelming concerns with this report, I suggest that the Department:
· “table” the unsettling implementation efforts that are already underway;
· concentrate the efforts of OEC staff to addressing systemic issues identified which can be corrected immediately and with relatively little cost;
· after corrective actions have been implemented, reevaluate the status of the system in relation to fiscal and programmatic issues;
· based on the status reevaluation, consider the appropriateness of the recommendations in this proposal; and
· if indicated, completely plan and implement a new service design.
If you would like to contact me regarding any of my comments or suggestions, I would be pleased to talk with you. I can be reached by calling 931-268-8262. I hope that I can be of assistance as these problems are addressed.
Sincerely,
Sarah Willis
Attachments
Cc: Joseph Fisher
Jamie Kilpatrick
Dr. Don Thompson
Dr. Dean Richey
Attachment 1
Generally, I support the following recommendations or statements but feel there are areas of concern inherent in most:
1.4 Administration
· “TIPS is a valuable DOE program, committed to strengthening families and reaching well into rural areas of the state” and “TIPS’ training and mentoring functions are important for sustaining quality services” (p. 34).
TIPS is a valuable DOE program with staff that is highly trained and experienced in working with part-time staff and children with disabilities and their families. Over the years, TIPS has recruited, developed and mentored highly trained staff, including personnel trained in working in low incidence disability areas. Tennessee, like most states, has a shortage of personnel trained to work with infants and toddlers, especially in the low-incidence areas. By using a consultative approach, TIPS full-time teachers can help the state meet federal personnel standards for serving children who present needs in vision, hearing, deaf-blindness and other significant disabilities, since within the cadre of full-time teachers employed by TIPS there are experts in deaf education, vision, autism, deaf-blindness, orientation and mobility, speech pathology, early childhood special education, early literacy and audiology. Since its inception as a special school under my leadership in 1994, TIPS has demonstrated the capacity to serve children at a very reasonable cost. In 2006, TIPS served 3,786 children with a total budget expenditure of $9,381,708 or $2,478 per child. This expenditure compares favorably to the cost of $4500 reported for direct services in the study (p. 5).
In the Individuals with Disabilities Improvement Act of 2004, Congress stipulated that early intervention services must be based on scientifically based research (see Sec. 635(a)(2) of the Act) and peer-reviewed research (see sec. 636(d)(4) of the Act). We do not know yet how OSEP will interpret these requirements, if indeed they do. However, the curricula utilized by TIPS staff are likely to meet these requirements. All the curriculums are based on research and are peer reviewed, thus would meet the requirements in IDEA 2004.
TIPS Regional Lead Teachers are trained to provide mentoring and to model strategies for part time staff. The report (p. 36) discussed the importance of both mentoring and modeling strategies and indicated that statewide personnel will be employed to perform those functions in the proposed service system. What I fail to understand, though, is why the state would dismantle a system that has demonstrated the capacity to accomplish these tasks and turn over the responsibility for developing an alternative plan to other agencies which do a good job of accomplishing the activities for which they were created to accomplish, but which are NOT equipped to provide the services required for the birth to three population with disabilities (e.g., TECTA).
· DMRS should be relocated to DOE for administration (p. 37).
I do agree that shifting the early intervention resources in DMRS to the lead agency would assist in streamlining administration and assure long term availability of those resources for EI services. Consolidation of EI services designed to provide services to infants and toddlers with developmental delays could ensure the state’s resources worked in concert as a system to meet the needs of children and families. In addition, it could also insure similarity of eligibility, rates for services, personnel qualifications, etc. Whether those private agencies will still compete for matching grants, if the agencies will be required to provide identical services, if the employees of those agencies will become state employees, etc., will determine the amount of state resources needed to implement the changes.
1.2 Fiscal
· Eligibility Determination in the present system is unnecessarily costly and therapists performing eligibility evaluations frequently recommend clinic-based therapy for children (p. 18).
The eligibility determination requirements currently in place for TEIS are more rigorous than are required in federal regulations. The previous director of OEC communicated to me a belief that the evaluation must yield information that would permit measurement of child progress to meet federal outcome requirements, thus, requiring a more burdensome and costly eligibility determination process. Permitting evaluators that are associated with a child-serving agency to recommend clinic-based services is an issue that can and should be resolved immediately without commitment of state resources.
1.3 Program Implementation
· The ratio of service coordinators to families should be one service coordinator for every 40 families (p. 35).
The role of service coordination (34 CFR §303.23) and the provision of service coordination service (see 34 CFR §303.12(a)(11)) which is required to be provided without cost to every eligible child unless their parent refused the service is complex and labor-intensive. The Quarterly Caseload Report for June 15, 2006 indicated the three districts with the lowest ratio of families per service coordinator (33, 40, 43) had the highest percentages (99, 97, 95) of conducting initial IFSP meetings within 45 days required in federal regulations (see 34 CFR §303.342) and conducted a high percentage (88, 96, 97) of transition planning conferences not less than 90 days before the child’s third birthday as required in federal regulations (see 34 CFR §303.148(b)(2)(i)). In contrast, the districts with the highest ratio of families per service coordinator (66, 59, 58) had the lowest percentages (79, 79, 77) of conducting the initial IFSP meeting within 45 days and conducted a much lower percentage (96, 84, 71) of transition meetings according to the mandated timelines. These data alone are sufficient to indicate the need to lower the state’s ratio of families per service coordinator. Currently, there are approximately 100 service coordinators employed in the TEIS district offices. The report proposed to employ 123 service coordinators, almost a 25% increase in the current number of service coordinators, under the new service plan. However, if the number of children identified increases because of greater attention to child find activities proposed in this report, this number will soon be insufficient. It is unclear how there will be sufficient funds to support the expansion plans included in this report.
· Implementation of consultative approaches to direct services is a key in the system (p.26).
There are many reasons why consultative approaches are important in the design of a state’s early intervention system. The use of a consultative model causes less intrusion for families; makes available staff with specific and low-incidence expertise to children living in remote areas; reduces cost for the system and family (if the state has a system of payment), etc. The report states that TIPS is of high quality (p. 26). Even though TIPS is not usually described as such, it is primarily a consultative approach. TIPS employs full time highly qualified specialists in working with children who are hearing impaired, visually impaired, speech delayed, etc. These individuals in turn mentor part time employees who are implementing scientifically based curricula for children with disabilities. The approach has been highly successful in Tennessee as well as many other states. It is unclear why highly trained, efficient and experienced TIPS staff would be terminated or reassigned to a different position in order for the state to create another consultative model which may not be efficient or have the expertise and experience TIPS currently has.
· IFSPs should become more family oriented and functional for the child (p. 20).
The report states that the Pathways Project, a research project of TEIS principal investigators from UT and TTU, revealed a high level of satisfaction with service coordination and that IFSPs are meaningful to professionals but substantially less so for families. Training should be provided to the service community on developing functional IFSPs. It should be noted, however, that the results of the Pathways research has not been completely utilized by the state. I would recommend that a conversation occur immediately with these PIs to discuss the most appropriate dissemination of the findings of the project.
· Clarification describing the appropriate use of service definitions should be provided by OEC to the service community (p. 22).
Many of the definitions of early intervention services contained in the federal regulations are confusing and difficult to understand. However, those definitions cannot be ignored. A state can provide guidance and technical assistance to the provider community to clarify what definition should be used with what type of service. For example, special instruction could be defined as a service provided to a child without modeling and mentoring a parent in replicating the activities with the child later. Parent training could contain the requirement for modeling and mentoring. Both services should require parent information.
Assistive technology (AT) is a more complex issue. The report recommends partnering with CSS to get required AT. Historically, the state bid process to obtain AT was so lengthy and cumbersome that AT equipment could not be obtained in a timely manner to meet federal standards for timely delivery of services (see 303.344(f)(1) and 303.525). Hopefully, that issue has been resolved. A recommended list and the maximum payment for AT devices are included in the report. OEC staff should ensure that all items on the list are required by federal standards which do not require the purchase of quotidian or life sustaining equipment; if non-required equipment is included, the benefits for purchasing should be examined carefully.
· Using estimated prevalence and TEIS data to target counties for child find purposes and incorporating the activities of START into child find plans (p. 15).
The survey results of activities of START during 2006 produced excellent results from the 30 physicians who responded to the survey. If physicians continue to use the standardized instrument with routine clinical surveillance and follow with a referral for children with suspect developmental or behavioral status, the appropriateness of referrals from physicians to TEIS should improve in the future. The state should also look at other efforts underway in the state which could, with expansion, assist with increasing appropriate physician referrals. One example is the East Tennessee Infant Toddler Help Line where volunteers delivered information to 1600 physicians during the last year. Using a cadre of volunteers to visit physician offices and the START training could produce an increase in physician referrals with a high probability of a higher rate of eligibility, thus reducing program costs.
ATTACHMENT 2
Following are specific comments regarding each of the major concern categories.
2.1 Process
· Many issues and concerns used to support the decision to disband the present TEIS offices and dismantle the TIPS program could and should have been addressed by State OEC staff which may have eliminated the need for this study and the resulting disrupting recommendations.
Since the OEC failed to address and correct critical problems such as payor of last resort, the 45 day timeline, duplication issues between DMRS, TIPS and TEIS contract personnel, the system is suffering from fiscal and programmatic concerns. In this report, these unaddressed concerns are used as justification for termination of the present TIPS and TEIS district locations. If these issues had been addressed in a timely fashion, the study and resulting recommendations would likely have not been necessary. It could, therefore, appear that TIPS and TEIS are being punished for the lack of state action, supervision and oversight.
In addition, even with the issues in the current service delivery system which need to be addressed and corrected, the report does not clearly outline the parameters of the recommended new service delivery plan. We are not provided any data or explanation to demonstrate how the proposed system would be more efficient in ensuring that children achieve maximum developmental gains and that parents are provided quality parent support. On April 17, 2007, at the UC LICC meeting, OEC staff stated that many aspects of the proposed system are unknown at this time. It appears that again the state will be building the airplane as they are flying it. I do believe that, for the most part, children in the present service delivery system are receiving appropriate developmental services to ensure the maximum developmental growth and parents are receiving the information and support for parent empowerment. Yet, it is evident the staff of OEC have spent much of the last year and will have to devote most of the upcoming years to implementing a new service delivery system without any guarantees that the same or similar services will be available to children and their families. There are no assurances provided that the unintended consequences of changing the current system in haste without a well-developed plan will not produce problems similar to those present now and create ones that are more costly to correct. This time could better be spent correcting the problems in the present service delivery system and gathering correct information and data on which to make systemic changes.
We do not know what unintended consequences associated with implementation of the recommendations in the report will arise due to:
1. a poorly developed implementation plan,
2. a lack of an input process, and
3. an overly ambitious implementation plan.
We do know that, at this time, parents are nervous and afraid their child will lose services. They wonder if they will have the service coordinator and service providers they trust. Many professionals, some who have been employed in the early intervention system for many years, fear that they will lose their jobs and thus insurance benefits. Many of these people have developed health problems and may not be able to get insurance in the future. Indeed, I understand that the TIPS staff received termination notices and a later letter notifying them that they would be reassigned to different positions. What they were not told is the duties of the reassigned position; apparently they will have no input into selecting a position in which they will feel competent to perform and feel they can make a difference for children and families. Surely DOE and OEC can do better than this.
2.2 Data
· Some of the data collected by the outside consultants and utilized to support the disbanding the TEIS offices and dismantling the TIPS program are not an accurate representation due to multiple competing assignments from OEC such as CIMP, TEIDS, etc.
(1) The time sample to determine the proportion of time service providers spent in administrative tasks and direct service was scheduled in such a manner to misrepresent the work of TEIS and TIPS. For the district TEIS offices, the time sample which would clarify the amount of time staff was engaged in administrative or service coordination activities was schedule for October 1 – 14, overlapping the time of two heavy, unusual administrative assignments:
o The TEIS offices were notified in September to begin the administrative process of entering data into the state’s new data system, (TEIDS). The data input was to be complete by the December 1, 2006 deadline for federal reporting requirements. Compiling the federal data forms using TEIDS was to serve as a “field-test” of the accuracy of the data system. For comparative purposes, the offices were required to complete the data collection process according to the previous years’ procedures. This process resulted in necessary but duplicative parallel administrative data reporting assignments.
o In some TEIS districts, (i.e., UC) the CIMP process required the review of 100 IFSPs for inclusion of the federal APR report.
At the time the Regional Lead Teachers participated in the time study, some TIPS offices were receiving TEIDS training, had just began implementation of TEIDS or were problem-solving the computer issues related to using non-state of Tennessee provided equipment on this web-based program. CIMP reports were also approaching due dates during the Regional Lead Teacher data collection. Regional Lead Teachers were required by the DOE to participate in this administrative activity. This resulted in heavier than usual administrative tasks as well as less face to face time with parent providers and/or families and children.
Thus, during the fall of 2006 the TEIS district and TIPS staffs were more heavily involved in administrative functions than would be customary. It is not, therefore, surprising that the time sample shows the TEIS and TIPS staffs spending a majority of time in administrative duties (data provided by the outside consulting group and Report, p. 34).
Incorrect characterizations of activities as administrative tasks vs. direct service tasks contributed to the elevated percentage of time being spent on administrative duties. For example, the report (p. 18) provides a listing of administrative responsibilities for service coordinators under the Targeted Case Management plan. These duties are “accessing insurance, assisting the family in obtaining other appropriate supports and identifying other sources of financial resources for the family.” These duties are included as part of the requirements for service coordination in the federal regulations (see 34 CFR §303.23 and note following 34 CFR §303.344).
(2) Numbers provided on page 34 of the report seem inconsistent with my understanding of the TIPS program. A total of 35 Regional Lead Teachers are supporting the work of a 450-600 core part time staff, resulting in a ratio that approximates 1:13 or 1:17. Each part time staff could be working with several children and families. So a Regional Lead Teacher could be supporting the direct services of 50 to 100 families. The report states on page 34 that “TIPS’ training and mentoring functions are important for sustaining quality services” and that TIPS core providers are of high quality (page 26). Maintaining this ratio of Regional Lead Teachers to part-time staff and families would ensure that activities such as mentoring, modeling, training, parent support activities, linking with other resources, information research, etc., continue to assist part time staff to provide high quality services. If part time staff has to perform these necessary functions on behalf of families, they will have to be compensated for many more hours of direct service and may not have modeling available from an experienced professional.
2.3 Conclusions
· The contents of the report are misleading, incorrect, confusing, and unclear. The contents are largely unsupported by facts and some of the recommendations are highly likely to be inconsistent with federal statute and regulations.
State Oversight
(1) The report states “Last, it is the policy of the Administration to manage state government effectively and efficiently” (p. 8). It would be difficult to disagree with this statement and I do not. I do question if this program has been managed effectively and efficiently in the past. I do question if it is efficient and effective for the state to convene and financially support task forces to make recommendations, fail to act on those recommendations, then support out-of-state consultants and GOCCC staff to make the same recommendations. One example of this is the list of identified conditions by which a child is automatically eligible for early intervention services (p. 45). I served as a member of the Finance Task Force of 2005 which recommended and provided a prototype of such a list. The report states that the recommendation was not implemented (p. 13). It should be noted that it would have been appropriate for the state to have saved money and extensive staff time by simply implementing this recommendation. Instead, the state chose to pass up the opportunity to do so and leave this area to the Governor’s Office of Children’s Care Coordination to recommend again. It is interesting that the report states that two TEIS district offices had developed and were using such a list (p. 12), indicating that the districts were trying to compensate for the lack of state action. In doing so, these districts have contributed to a criticism of TEIS. To my knowledge, however, NO task force or group has, prior to this, recommended dismantling the TIPS program and disbanding the district level TEIS offices.
(2) The report discusses TEIS’ practice of payment for “services that it ought not (pay for), when other fund sources are available” (p. 31). While the recommended practice is in non-compliance with federal standards, the federal guidelines do permit that practice if it is necessary to “prevent a delay in the timely provision of services to an eligible child or the child’s family” (see 34 CFR §303.527(b)). Therefore, if an appropriate payor (i.e., TennCare, DOH, private insurance, etc.) does not agree to provide the service in a timely manner and the service is not provided, TEIS would be in violation of the federal requirement for the provision of services in a timely manner (34 CFR §303.340(c)). If TEIS does agree to provide the service, TEIS is in violation of the requirement for payor of last resort (see 34 CFR §303.527). The state could resolve this bind by creating a mechanism for “reimbursement from the agency or entity that has ultimate responsibility for the payment” (see 34 CFR § 303.527(b)). To not utilize TEIS funds when services would otherwise be delayed would create a due process/non-compliance issue with timely provision of services and would impede the child’s maximum developmental outcomes. The GOCCC could have been instrumental in assisting OEC in formulating agreements with other agencies and entities to insure reimbursement from appropriate payors when EI funds were used to support a service in a timely manner.
(3) By including a goal (p. 15) which states that in the future, the system should “establish and maintain consistent relationships with” interagency partners, the report implies the current TEIS districts have not established and sustained positive relationships with local health agencies and other health providers. It is clear in the Upper Cumberland that there is an extremely good relationship between the TEIS office and health providers. However, it is not likely that any district TEIS office would attempt to establish a relationship with the Tennessee Chapter of the American Academy of Pediatrics or the Tennessee Perinatal Association but would concentrate their efforts on the practicing health care providers within their district. It would be appropriate for the OEC to establish relationships with these Associations and I strongly suggest that this occur. The District TEIS offices should not be criticized for failing to have relationships with statewide agencies, since it would appear to me that this should have been handled by OECS.
(4) Much of the information (p. 33-34) concerning the District TEIS Point of Entry Offices and Roles of Principle Investigators (PIs) is incorrect or misleading. The establishment of district-level entities occurred at the suggestion of the National Early Childhood Technical Assistance Center utilizing a Request for Proposals (RFPs) as the tool to locate entities with an interest in working on the establishment of an early childhood system. Contracts were awarded to the eight academic settings and one DMRS community program, (now located in a community hospital), not because early intervention services were considered “investigational” but because these sites developed the winning proposals in response to the RFPs. Each district was asked to do a study of the state landscape in one aspect of a statewide early childhood system required in federal statute: service coordination, personnel standards, public awareness, central directory, etc. Following the initial year, the state continued to utilize these contact agencies because of their knowledge of the requirements and the state’s capacity to meet those standards. When federal statute required states to move to full implementation, the contracts were continued as POEs for several reasons: they were independent from service agencies (except for the one DMRS provider agency), thus, avoiding the type of potential conflict of interest discussed in the report in regard to evaluators being associated with agencies (p. 19); they afforded in-kind services not available in other agencies; and most importantly, no other state agency was willing to administer an under-funded entitlement program that required services outside their scope of services.
The report states (p. 33) the TEIS district offices have inconsistencies “all with varying salary and benefits policies, administrative costs above those identified in contract line items, and numerous idiosyncrasies”, and “PIs are considered an under-utilized resource in the areas of Early Intervention curricula development, Early Intervention focused research and best practice guidance” , and “PIs have assumed different levels of hands-on responsibility for administrative oversight of the offices”. I agree with each of these statements; OEC, however, should have not submitted a contract for state approval if there were undue administrative costs included in the proposed budget, and the PI was not performing the administrative and supervisory functions at a level expected by the state, nor should the contract/grant personnel in DOE and F&A have approved such. The OEC staff should also have used the cadre of PIs with their professional expertise in an appropriate way and apparently, they did not.
(5) It is misleading for the report to state that the early intervention system has “fallen short in …Systems of Payment” (p. 41). Historically, the State Interagency Coordinating Council (SICC) has recommended that the state have a system where services are provided at no cost to families rather than propose that families be required to support a portion of the cost for the provision of services to their child permitted under the System of Payment provision in federal regulations (see 34 CFR §§303.520 and 303.521)). In a meeting to present the findings of the Financial Task Force, DOE officials indicated a desire to maintain the current “no cost to families” plan. Therefore, it is not appropriate to criticize OEC for not instituting some type of System of Payment. The Financial Task Force recommended that DOE consider what type of a System of Payment would be most important in Tennessee (i.e., requiring use of private insurance, parent fees, etc). I do strongly believe it is time for TEIS to consider a system of payments.
Fiscal
(6) The bases for projected cost savings or costs for recommendations are not provided in the report. The report should clearly explain how the purported cost savings or estimated cost expenditures were calculated in order that the reader could totally understand what will be changed, eliminated, or terminated in the present system. Restructuring DMRS rates (p. 26) may require significant funds, but no explanation of the process or anticipated financial effect is provided. It is not clear if the restructuring of rates is intended to relieve the current responsibility of DMRS agencies to raise a portion of their operating cost. One way to keep the costs to the system as low as possible would be change the eligibility for DMRS service to the TEIS eligibility. Currently, DMRS agencies serve children with a 20 percent delay whereas TEIS eligibility requires a 40% delay in one developmental area or a 25% delay in two or more developmental areas. Therefore, when rates are restructured, the new rate will be applicable to children not eligible for TEIS. It appears that DMRS services may be provided for a maximum of 10 hours per week in addition to all other required service hours (p. 54). From the information provided in the report, it appears this would be duplicative of any other required service.
(7) The report (p. 4 & p. 7) states “It costs approximately $4500 per child for Direct Service from all fund sources, for the 8000 children served with IFSPs throughout the year.” If these figures are accurate, the total amount spent for direct services would have been $36 million; however, the total funds available for the program are reported to be $34.2 million. These data are confusing since the reported expenditures are greater than the available funds. Also, these data do not report any expenditure for administrative costs. Since the report uses an incorrect cost per child for direct services, it is unclear if projected savings or expenditures are accurate.
(8) It is unclear when the anticipated $10M revenue from Medicaid dollars (p. 5) will be available or even if these funds are guaranteed to become available. If the funds are not expected immediately, or if there is no guarantee of their availability, it is imperative that this possible fund source not be considered in the restructuring of the present system or the financing of a new system. The report does specifically mention in relation to revenue that OEC has engaged in a cooperative arrangement with another state agency to secure Medicaid reimbursement for targeted case management (p. 18). The effort does mandate monthly face-to-face visits with all TEIS enrolled children, even those not eligible for Medicaid. It is not yet clear if the system will experience increased revenue compared to the cost associated with the increased demands for face-to-face visits with children (e.g., number of staff required for complying with the requirement, travel costs, etc.). Of equal concern is the undue burden on families for professionals to visit them when there is no obvious need.
(9) The report states that administration costs in TIPS are attributable to an erroneous characterization of the program as a State Special School (p. 34). This may not be true. At the time of the creation of the TIPS program as we know it today, the early intervention programs from the three State Special Schools were pulled out and merged into the new program: Tennessee Infant Parent Services School. These programs had provided direct service to approximately 320 children and employed 3 administrators (two secretaries and one supervising teacher) and 12 full-time Regional Lead Teachers during the year that ended on June 30, 1994. Since that date, TIPS has provided home-based early intervention services to thousands of children, growing from 320 children in FY 1994 to 3,786 in FY 2006. The home intervention service that TIPS provides is modeled after the type of programming that the TIPS program was providing when it was still under Tennessee School for the Deaf. The service is labeled on the IFSPs as either Special Instruction or Family Training. At the present time, TIPS School has a total of 17.5 persons who are performing purely administrative functions. Per Don Thompson, a portion of these staff are regular state employees employed by TIPS School and a portion are University of Tennessee employees who work for TIPS School under a Grant Agreement. The breakdown of these persons is as follows: DOE STAFF -- 1 TIPS School Director, 1 Business Manager, 4 Secretaries; UT-K Grant Agreement Staff -- 9.5 Secretaries and 2 Information Technologists. In addition, two of the Regional Lead Teachers are heavily involved in educational program supervision. Their positions are: Statewide Supervisor and Special Projects Coordinator. Two of the other Regional Lead Teachers provide supervision to the Regional Lead Teachers in two offices, but they also provide direct service to families and function as Consulting Teachers. TIPS grew because the model allows growth to occur. Federal law states that to the maximum extent appropriate, children should be served in “natural environments.” As our state moved to serve more children in natural environments, TIPS expanded services and established office locations in each of the nine TEIS districts. Support staff was added to these locations to handle clerical/teacher assistant duties. This was done to insure that Regional Lead Teachers would NOT be tied to their offices as administrators, but would spend the majority of their time performing consultative teaching duties as they served families, coached and mentored part-time teachers, evaluated children, did child-find, etc. I believe it is a misnomer to label RLTs as administrative staff. To do so would be equivalent to saying subject area department chairs in local high schools are not instructional personnel.
(10) I do not believe the district TEIS contracts contain a significantly high level of administrative and supervisory costs. Page 34 of the report states that “Only $7M of the POE’s total budget of $17.2M is spent on direct IFSP services” (approximately 40%). This amount appears to omit service coordination from calculations of direct service. Service coordination is the only direct service required to be offered/provided to all eligible children; families can reject the provision of any direct service. Therefore the service coordination staff and associated costs must be considered as direct service. Dr. Dean Richey, the PI for the UC contract, reported that 70% of their 2005-2006 contract funds (contracted direct services and salaries and associated costs for the provision of service coordination) were expended for direct services and 30% were expended for administration. Their administrative cost is within the range of the 22% administrative cost reported by DMRS (p.52).
Processes
(11) The report (p. 34) states” TIPS has historically provided only one of the 16 required services of IDEA Part C whereas TEIS has the responsibility of all Part C required services”. The state administered early intervention system is mandated to ensure the provision of all required services; the district-level TEIS offices were, at the time of required implementation, established to provide one service, service coordination. The state, however, needed a process to purchase services when they were not available from another source. Because of the lack of OEC staff (and a state freeze on hiring) to negotiate rates for services with local providers, to verify the accuracy of reimbursement claims, etc., funds for direct services were put in contracts and the district offices were asked to process reimbursement claims from contract providers. TIPS provides a home based service that can be coded as either family training or special instruction. It should be noted that family training/special instruction provided by TIPS and service coordination provided by TEIS offices are the two most frequently required services in IFSPs. In 2006, over 80 percent of the children served were provided family training or special instruction. Speech/ language services were the next most required service. See the following link for verification of this information: http://www.state.tn.us/education/speced/TEIS/doc/06_Web_CC_Statewide_final_3_16_07sm.pdf
(12) The report states that TEIS offices are not visible in the community and therefore self-referral is difficult (p. 34). I do not believe the POE offices need to be “visible” in the community. The method for referral, whether by a parent or by another primary referral source, is by calling a toll-free number. What is important to parents and primary referral sources is not the “visibility” of the office but what happens as a result of the call. Since early intervention activities should occur in natural environments, most parents do not ever need to visit the TEIS office, negating the importance of the location of the service coordinator’s or the service provider’s office. Utilizing an academic setting is a neutral location, free of stigmatizing beliefs of some people (e.g., “DCS staff comes to your home to take your children away”, or “Only poor people go to the health department”, etc.).
(13) A perceived duplication of services between TIPS and TEIS with a “laundry list” of examples is discussed on page 34 of the report. It should be noted that in an effort to assist the TEIS offices in meeting the 45 day federal requirement, TIPS staff have, with agreements between the two entities, assisted TEIS service coordinators in the initial eligibility process. It is unclear from the statements in the report if both agencies performed the exact same tasks for the same child; if not, no duplication exists. If these agencies are performing duplicative services, OEC has the responsibility to issue a policy directive as to which agency performs what function for which children under what conditions and provide oversight to ensure its implementation. OEC has abandoned its supervisory oversight responsibility by allowing such a practice to exist, if in fact it does exist.
Any duplication which may currently exist between DMRS, TEIS contract providers, and TIPS is not discussed in this report. If duplication does exist, part of the issue is the confusion between the definitions of services, discussed elsewhere in this document. Certainly this is an issue on which OEC could and should provide guidance and ensure duplication ceases. However, the recommendations included in report (p. 54) do allow for duplicative services to be provided in the future. The recommendations are for the terms family training and special instruction will be changed to developmental therapy (p. 22). Each eligible child will then be provided with a developmental therapist for a maximum of one hour per week. The report further recommends “group services for developmental therapy may be provided in addition to all other required services hours for a maximum of 10 hours per week per child….This requirement would include a minimum of one 15 minute individual parent consult per week” (p. 54). In order to receive group services, the IFSP team would have “to agree that the child and family goals could not be satisfactorily met without this intensive service provision” (p. 55). I am unclear as to why both the one hour per week of developmental therapy and the 10 hours per week of group developmental therapy would be recommended and seems duplicative. If the IFSP teams feels that a child needs 10 hours of developmental services per week and the one hour was then discontinued, the state would save significant funds (of the 8000 children served last year, over 80% received the equivalent of developmental therapy). It should be noted that it may be illegal to place a “cap” on the amount of service an eligible child may receive (one hour of developmental therapy per week; a maximum of 48 service hours over six months, p. 55) without a procedure to over-ride the cap for a child whose IFSP team recommends the need for more services. Also, requiring parents to sign a transportation agreement to document their understanding that any transportation to and from a group service is the responsibility of the parent (as specified on p. 55) may be illegal. Under IDEA, if a child’s IFSP indicates the need for a service, the service must be provided with the frequency, intensity and duration as specified.
(14) The report states that “the research funded by TEIS in the academic settings has been defined at the discretion of the PIs and has not necessarily benefited the Early Intervention system” (p.33). To my knowledge, none of these projects has ever contained a provision for research; the Pathways project was funded via a separate contract to two of these universities. I am aware of activities which may have been discussed in terms of research (i.e., at one point the East Tennessee TEIS office wanted to “research” if physicians would respond better to written public awareness materials or to information provided on CDs which they could listen to in their vehicle, an activity requiring no additional contract funds). To characterize this as research is questionable; the benefit of the activity to TEIS is not.
(15) The report contains many statements about the screening, evaluation and assessment processes. In many cases, the terms “eligibility determination” (which is called “evaluation” in the federal regulations) and “assessment” appear to be used interchangeably. The terms have different definitions in federal regulations (see 34 CFR §303.322(b)(1) and (2)). It may be incorrect, however, to state that OSEP has endorsed assessment by a developmental specialist (p. 18), or that to comply with OSEP requirements, the state would need to limit the number of assessment tools (p. 14).
(16) The statement “Variability in Eligibility Determination processes contribute to low rates of children served” (p. 12) is not supported by data or other information. It may be that a policy with a lack in variability would be problematic. There is little similarity is conducting an eligibility evaluation for a child whose family does not speak English and a child who is suspected of having autism. Being able to vary the eligibility processes to ensure that appropriate eligibility processes are followed with each child may make it possible for the appropriate inclusion of more children.
2.4 Fiscal
· Taking funds appropriated for services to infants and toddlers with disabilities and their families to establish “a new program of state Early Intervention services for families whose children are not eligible for Part B services at age 3 years when TEIS services are no longer available to them under the existing model, and who await entry into Pre-K programs” (report, page 5) is reprehensive, possibly inconsistent with federal standards, and may establish a pattern of services that may in the future require significant state dollars to maintain.
“The option became available in the federal law to extend services up to age five for children who are eligible for Part B, however without additional federal resources for that purposes” (p. 8 ). It is not clear what option is being addressed in the above quote but it is likely the option made available in IDEA Improvement Act of 2004 which provided States an opportunity to create a birth through five early intervention system. At age three, parents would have an option for their children to attend a Part B program, if eligible; thus, the state and LEAs would both be required to administer a program for children with disabilities age three through five. Funds were provided by Congress to help support the program in any state that adopted that option, but the amount would be significantly insufficient to support adopting this option.
In 2005, the Tennessee Department of Education convened a large task force that was charged with considering whether Tennessee should consider this option. Largely due to the cost of such a program, the task force recommended the state NOT consider this option until the state had adequate financial resources to support TEIS.
This report does recommend creating a new state program for 1200 children (p. 8), while discussing the cost overruns in the present program. It is interesting to note that the report states a cost of $2000 to serve each non-eligible three year old; but, the report also states an average cost of $4500 for these same children before their third birthday. What the report does not tell us is what service(s) these same children will NOT receive when they turn three and how the loss of the service(s) will be explained to parents, creating a “now you need it, now you don’t” scenario on a child’s third birthday.
The children to be served by the new state program are children who are not eligible for services at age three when TEIS services are no longer available to them. The report states (p. 25) that the most visible gap in services is for children
o Served by TEIS who achieve IFSP goals prior to age three.
o Who are ineligible for Part B Special Education services when they exit TEIS at age three; or
o Who are not assessed for Part B eligibility and leave TEIS services without referrals.
Those children are certainly in need of continuing services to ensure that developmental gains are not lost during a period where they do not receive service.
Usually, however, parents are empowered to continue infusing appropriate developmental activities into ongoing family activities and to locate appropriate services after age three, even without the benefit of service delivery. If this happens, these children may not be the state’s children who are in the most need of receiving services. Children age birth through three who have a less than 40% delay in one developmental area and who have never been eligible for developmental services may well be the group with the greatest likelihood of needing services if the state has the funds to expand services. The state needs to carefully consider the creation of another service system (non-eligible three year olds) in terms of future costs to maintain and expand to other similar children.
It should also be noted that taking funds from the present service delivery system and expending those funds on a non-eligible population may constitute a non-compliance issue with federal regulations. 34 CFR §303. 124(b) states “the total amount of state and local funds budgeted for expenditures in the current fiscal year for early intervention services for children eligible under this part and their families must be at least equal to the total amount of State and local funds actually expended for early intervention services for these children and their families in the most recent preceding fiscal year for which the information is available. “ If funds which have been expended in this and previous fiscal years are utilized for services for non-eligible children, the state could create a non-compliance situation.
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