Appeals & Due Process (or Lack There Of)

I try very hard not to post a great deal of personal commentary. Though today I just couldn't help myself...

The North Carolina Department of Health and Human Services reached a settlement agreement with the US Department of Justice yesterday (8/23) regarding the State's ADA and Olmstead violations surrounding the improper placement and warehousing of mentally ill and developmentally disabled adults in adult care / nursing homes across the state. [ read more... ]

It is a victory. --However big or small it may seem is moot; it is nonetheless a victory in the recognition of a tremendous need and an acknowledgement of individuals deserving of a quality life and community interaction. Definitely a step in the right direction and I commend everyone involved for their diligence and efforts toward a just resolution.

Not to rain on the parade, but...

What continues to be of concern however, is that while we scurry to "deinstitutionalize" one vulnerable population and invest in services and programs to assure these individuals are properly supported in community environments as they are entitled, we are failing to bolster all the many thousands of other special populations who are already living in integrated settings, be it at home with their families or in supported living, etc. -- the ones who are not institutionalized and don't want to be -- whose loved ones desperately want to keep them in their homes... And yet, it seems that the very supports that allow that to happen, that they also are entitled to, continue to be trimmed away.

It's the human shell game: while we move one population toward community stability, we are pushing much of the rest, slowly but surely, straight into crisis. 

Without proper supports and proper funding for those supports, the reality is that many families will be forced to make the hardest decision of our lives - surrendering our loved ones to the state either because we will have to quit our jobs to provide full time care or we just cannot physically nor mentally do it anymore because we're already hanging on by a bare thread or both (which puts us right back where we started from and begs to question: where will they go? Can't put 'em in nursing homes, that's how we got into this mess to begin with.)

I had an exchange today with a weary and frustrated fellow mom in the eastern part of NC who is about to embark upon the grueling appeals process fighting for proper services and supports for her adult DD children that her family depends upon for their very existence. 

Yes, I said existence - not just the quality of life, certainly not for convenience and most definitely NOT for financial gain; EXISTENCE.

Like filing an appeal because services for your DD child(ren) are being drastically decreased and you simply cannot make do with less because you already are.

Through this dialogue I realized that the critical issues surrounding Medicaid appeals for DD recipients and Due Process, or lack of, are still not understood even on a basic level and misinformation continues to circulate.

Unless something has changed since June 2012 when I sent out and posted my Open Letter and Outline of Critical Medicaid Waiver Issues (with supporting documents), there remains NO FAILSAFE CONSTITUTIONALLY PROTECTED DUE PROCESS APPEALS PROCEDURE for Medicaid Waiver recipients and families! 

If something has changed, someone please let me know; I will be thrilled to update.

Otherwise, currently this is the way it works - or doesn't, as the case may be (from the outline):

What do we know about the Due Process / appeal procedures under the new 1915(b)(c) Medicaid Innovations managed care plan?

• The current appeals process reflects a consumer appeals process to a unilateral hierarchy with no third-party authority to fairly referee.
• As outlined in the PBH brochure and 2012 Provider Manual (pgs. 62-67) is as follows:
• If consumer caregiver has recipient service hours and / or benefits reduced, suspended or terminated,
• consumer caregiver will receive a letter 10 days prior to changes via US Certified Mail a letter, outlining instructions to request a ‘Reconsideration Review’ through PBH (or respective LME/MCO)’s ‘Reconsideration Review Process’ within 30 days of notification.
• If Reconsideration Review, does not yield a response in favor of consumer, consumer caregiver can appeal to both DHHS and the Office of Administrative Hearings (OAH) by filing a request for a State fair hearing within 30 days.
• Once appeal is processed, consumer caregiver may participate in an informal attempt to resolve the conflict through the Mediation Network of North Carolina;
• if the conflict cannot be resolved in mediation or if consumer declines mediation, the matter will be set for hearing before an Administrative Law Judge (ALJ) at the OAH.
• The ALJ will hear the matter and evidence and make a recommendation regarding the consumer’s matter and forward the decision to DMA,
• where DMA will review and make a final decision.
• What’s the point? More time and State financial resources wasted.
• The only recourse following a final decision by DMA is for the consumer to retain counsel and file suit in Superior Court - an extraordinary expense of tens of thousands of dollars that the vast majority of consumer families, including mine, could not afford.
• It should be noted that under the new PBH model, service eligibility for DD Medicaid Waiver recipients is determined by the Supports Intensity Scale (SIS) which arguably provides a more detailed client pictorial, however, the formula specifics which equates a recipient’s level of need by the State’s representative LME is deemed “proprietary information’:
• LME representatives are required to sign and enter into a “Non-Disclosure Agreement” with PBH to protect the SIS methodology.
• This non-disclosure further prevents a fair an adequate appeals process for consumers as how can one effectively challenge information which is withheld from them?
• Proprietary information as such held by an agent of the State providing public services to citizens on behalf of the State - services which are funded by Federal and State monies is, in fact, a conflict of interest.
• This is NOT transparency and only perpetuates mistrust.
• Also noteworthy: PBH recently had a federal lawsuit against acting NC DHHS Secretary Delia and Mann [5:12-CV-46] suing to not only remove final decision-making authority from the State government entity who is to oversee and govern the managed care operation and all LME’s, but to seemingly assure totalitarian authority.
• It is my understanding that this case has since been withdrawn.

OAH, ALJs and the Regulator Reform Act of 2011.

• NC SL 2011-398, commonly referred to as the Regulatory Reform Act, became State Law July 25, 2011, granting final authoritative ruling to OAH / ALJs over Medicaid cases, effective January 1, 2012 and applies to cases contested after that date.
• SECTION 32. G.S. 108A-70.9A(f) reads as rewritten: "(f) Final Decision. – After a hearing before an administrative law judge, the judge shall return the decision to the Department in accordance with G.S. 150B-37. The Department shall promptly notify the recipient of the final decision and of the right to judicial review of the decision pursuant to Article 4 of Chapter 150B of the General Statutes."
• SECTION 33. G.S. 108A-70.9B(g) reads as rewritten: "(g) Decision. – The administrative law judge assigned to a contested Medicaid case shall hear and decide the case without unnecessary delay. The judge shall prepare a written decision and send it to the parties in accordance with G.S. 150B-37."
• Despite the January 1, 2012 effective date for OAH final authority over recipient disputes in Medicaid matters, federally-funded Medicaid Waiver programs by design have a “single agency rule” which dictates that a single state agency makes final decisions in Medicaid issues which is somewhat conflicting given the design of the new statewide managed care waiver, therefore Centers for Medicare and Medicaid Services (CMS) must grant an exception waiver to the State of NC to permit alternate authority. Currently, NC governing officials and other interested stakeholders are working toward mutually agreeable waiver submission terms, though to date, an agreement has not be solidified.
• Thus there remains NO appropriate fail-safe due process for recipients and families save the unrealistic and unfeasible hardship of unnecessary legal expenses and lengthy court battles.

So essentially, if you disagree with an LME's decision regarding Medicaid services / supports, you pretty much are appealing to the person who instructed the decision to be made in the first place. If that doesn't work out, you can opt to undergo mediation and have a hearing before an ALJ who will then advise DMA of their opinion, but ultimately DMA still has final say.

The confusion seems to come from in between the State Law and the federal hang-up with CMS. 

Yes, NC State Law 2011-398 does in fact grant OAH final decision making authority BUT because of the federal "single agency rule," CMS must have a specific waiver from the State of NC in order for the federal government to allow another governing entity (e.g. OAH) to make decisions which affect federal monies. 

If North Carolina officials cannot agree on the waiver language for exception and this exception waiver is not submitted and approved by CMS before the final implementation of the statewide 1915(b)(c) managed care waiver, the period for appeals will have been exhausted and we may all be stuck with whatever decisions are made for us.

If you are in an appeals process, keep your representatives and advocacy groups informed - and as always, feel free to forward to me anything you wish to share.

*Update : More on Appeals and Due Process (feedback on this post) from Disability Rights NC.

From The Arc NC: Lessons from the Western Highlands Network overruns

From The Arc of North Carolina

Lessons from the Western Highlands Network overruns

[ view original posting ]

The cost overruns at Western Highlands Network (WHN), the first LME to become an MCO under a new law, are a serious issue. The solution to these overruns that the state and WHN has come up with is clear: further service cuts. Hopefully, these overruns are just a bump in the road and not the light of an oncoming train, indicative of a system-wide underestimation of managed care cost. Most likely it will be somewhere in the middle.

We can only hope that people with disabilities will not be harmed further by these overruns than they already have been by the shift to managed care. The Arc hopes WHN survives these problems and succeeds for the sake of the individuals they are in the business of supporting.

Regardless of the reasons for the problem, the State, meaning both the Administration and the Legislature, should be paying close attention. Though we do not yet know the specifics that led to these overruns, several things should be perfectly clear:

1. We need a real examination of the process. Regardless of why, no MCO should have such significant funding issues six months into operation. Some are understandably questioning the leadership of former CEO Arthor Carder, but it’s hard to believe anyone would question his commitment to the people WHN served, or the commitment of WHN’s staff. The fact that this MCO was allowed to go live without the tools to succeed is not only a mark on WHN, but more importantly a significant mark on the DHHS processes that deemed them ready.
2. We should not only examine the process that led to these overruns, but the 1915(b)(c) waiver model as a whole. It is no secret that The Arc does not believe this model is appropriate for people with IDD. The issues with WHN should cause public officials to question the model as well. As WHN looks for places to cut Medicaid rates, it becomes clear that the system prevents them from even considering state operated facilities [state institutions] for reductions comparable to community services. Managed Care was sold to legislators, and the public, on the assumption of MCOs’ ability to effectively manage all public resources. Clearly, that was not true then, nor is it now. This disconnect makes the state’s difficult transition to a new model of care even more difficult. If the 1915(b)(c) managed care model works for community-based services it should also work for state-managed facilities. This issue is just one of many model design questions that must be questioned.
3. State officials told the WHN Board that they should expect no additional state funds to make up for overruns. This begs the question: is the stated goal of “better access to services” just spin? When rate reductions, utilization reductions, and Medicaid paybacks are the primary tools used to eliminate deficits, it is difficult to take seriously that better access is a real goal. Better service access would more likely be achieved if the state were willing to adjust the capitation rate or infuse some money while WHN becomes better prepared to “manage.”

Though not enough details have been released yet to determine the specifics of the WHN overruns, we do know:

1. The only way “savings” will be achieved through this managed care model is through cuts. That should be clear as we review the differences in what WHN was paid and what they have said they needed to provide services. We know that Medicaid cost must be controlled but an honest discussion of how managed care achieves this is critical if people will have faith in this system.
2. The way “at risk” is used in this model is insulting to families, consumers and the people who provide the supports for them. Public MCO’s are not really “at risk” entities. They have raised no capital to fund their organizations; they receive generous administrative allocations separate from services funds, and have the ability to cut rates and services to consumers if they exceed budgets. Providers of services are the ones really at risk. With subjective decision making, constant rate reductions, no guaranteed “administrative” funds or excise payments to fund a MCO’s “risk” reserves, many providers will likely go out of business. Most importantly, people with disabilities and their families are the most at risk…at risk for another failed effort at reform jeopardizing their ability to live successful lives in the community.

I/DD Budget Cuts May Be Worse than Expected

From The Arc of North Carolina

I/DD Budget Cuts May Be Worse than Expected

[ original post here ]

In what is being described as a mistake, a budget transfer intended to move Guardianship funding from one division to another has created an additional 4.3 million dollar cut primarily to community services for people with I/DD.

Department officials and legislative leadership agreed to transfer $4.3 million in the Social Services block grant from the Division of MHDDSA to the Division of Social Services. The money was to be used by either Corporate Guardians or local DSS to provide guardianship services. The transfer was needed because, as LMEs transfer to MCOs, they will no longer be allowed to be guardian for individuals in their catchment areas.

Somehow the transfer of funding happened twice causing an additional cut of 4.3 million dollars to MHDDSA community services funding. Department officials tell us that this was never the intent and discussions with legislative staff point to a mistake, although we have no official confirmation. Unfortunately, the reduction has been included in the allocations to LME/MCO’s and several are taking immediate action to cut services. We are hearing reports that some programs face 20% reductions effective August 1st.

The Arc is calling on the DHHS to ask LME/MCO’s to hold off on implementing this reduction until all possibilities of fixing the problem have been exhausted. This reduction to an already fragile system is unwarranted and will harm individuals with I/DD.

The Arc is also concerned about how LME/MCO’s are implementing the one time $20 million reduction to community services. This cut is an extension of a reduction taken last year. While LME/MCO’s were encouraged to use fund balances to offset this reduction last year, we do not believe most did so. We are seeing a disturbing trend that has LME/ MCO’s passing on this entire cut to people with disabilities and their families. We believe a more responsive approach would be for LME/MCO’s to use fund balances to offset this reduction since it is a non-recurring cut. It does not seem appropriate for the Management Entities, who are charged with ensuring individuals have services, to use fund balances to become MCOs while the people they are created to serve lose services.

We will be tracking these reductions and will continue to encourage the State and LME/MCO’s to find alternatives to wholesale reductions for people with disabilities and their families.

Once we determine what steps the DHHS plans on taking, we will issue an action alert describing what actions people with disabilities and their families should take, if any, to influence these changes.

Related : 

• MCO Western Highlands Network estimates 3.5 Million Shortfall since January 2012.
• LME Smokey Mountain Center holds community forums regarding 3.4 Million Service Funding Reduction.
• Disability Rights NC Press Release : State fails to settle with DOJ but announces 8 year plan, 7/26.
• News and Observer article : LME Money Woes, from 7/18.

DMA 8M Public Comment on CAP-I/DD 361

ote: Below is a Public Comment submitted to DMA regarding the 8M Clinical Coverage Policy proposal for CAP-I/DD during the 15 day comment period from July 28 - August 11, 2011. This exert was pulled from it's original source, a public record, and is posted exactly as it appeared save the removal of the submitter's personal contact information and abbreviation of last name.

[ More on DMA Public Comments. ]

Comment 361

To: Webmedpolicy, Dma
Subject: Comments to proposed CAP MR/DD Manual
Sent: Friday, August 12, 2011 3:04 PM

I have two major concerns about the proposed CAP MR/DD Manual. My 20 year old daughter is profoundly physically and intellectually disabled. She requires 100% care and has special medical and behavioral needs.

Proposed Elimination of Enhanced Personal Care
I am very concerned about the proposed elimination of enhanced personal care. This has been an authorized service because of an identified need of a small segment of the CAP waiver recipients. What is the justification to eliminate this service? It is certainly not because there are no longer any CAP recipients "who have intense medical or behavioral needs." I thought the objective of the CAP MR/DD waiver was to keep individuals out of institutions. Cutting services to individuals with the most complex needs makes it more likely that some of these individuals will have to be placed in 24 hour residential settings. This will not improve the quality of life for these individuals nor will it save money. In fact, it will cost a lot more than providing these individuals with enhanced personal care.

At the pay rate for regular personal care services, it is impossible to find and keep good staff qualified to make decisions regarding behavior management, to carefully monitor seizures, to provide g-tube feedings, and to safely transfer my daughter who has had several major orthopedic surgeries. My daughter needs consistency and I need a break physically from 20 years of caring for my daughter. Frequent turnover of staff and/or going for long periods without staff because of the low pay for personal care services would be very detrimental to my daughter's quality of life and safety at home.

Limit of 129 hours/month of Habilitative Services
Again, a decision has been made not to differentiate between CAP recipients based on their level of need, currently measured by SNAP score. I believe providing the same limit of 129 hours/month to all CAP recipients discriminates against my daughter and others with high levels of need. For adults who are no longer enrolled in public schools, there should be a higher monthly limit for habilitative services, incremented by SNAP Level.

When my daughter ages out of public school, she will need opportunities to participate in the community. I hope to enroll her in a day program which operates 6 hours/day 5 days per week. That one program will use up all of the allowed habilitative service hours. But my daughter needs habilitative services for other community experiences such as weekly Special Olympics bowling, a weekly community drumming group and a monthly evening social gathering. In addition, she has habilitative goals to work on at home.

These two policy changes seem to completely disregard the quality of life of CAP MR/DD recipients for the sake of an easy way to save a relatively small amount of money. I ask that these two changes be reevaluated, with a sincere consideration of quality of life and safety. Please don't abandon the CAP recipients with the greatest needs.

Thank you,
Beth H.
Wilmington, NC

DMA 8M Public Comment on CAP-I/DD 323

Note: Below is a Public Comment submitted to DMA regarding the 8M Clinical Coverage Policy proposal for CAP-I/DD during the 15 day comment period from July 28 - August 11, 2011. This exert was pulled from it's original source, a public record, and is posted exactly as it appeared, including the commenter's highlights, save the removal of the submitter's personal contact information and abbreviation of last name. 

[ More on DMA Public Comments. ]

Comment 323

To: Webmedpolicy, Dma
Subject: 8M-CAP-I-DD
Importance: High
Sent: Friday, August 12, 2011 11:46 AM

To Whom It May Concern:
I am a parent of 3 adult males who receive services through the CAP-MR/DD program. They live at home with their Dad and me. I provide paid support services for each one of my sons under home supports ( 2 sons- 9 days mo. each, the 3rd son 12-13 days month) Plus me & their Dad put in countless hrs. of volunteer time. Home Supports has not worked well for my 3 sons. It is not designed for those who have more one person in the home receiving CAP services. I need the flexibility to work with which ever son needs me the most on a given day or divide up a day among 2, sometimes 3 of them for many different reasons (mostly lack of qualified, dependable outside CAP workers, sometimes medical reasons, etc.) “Everybody needs to be on the same page working by the hour so HCS & PC hours can be used by any CAP worker who works with the consumer..” The way things are now the hrs. in POC are divided into too many pots. I am locked in this HOME SUPPORTS POT I can only provide a pre determined days of service to each son per month. For instance say son number (no.) 1 has a need today and I am the only qualified CAP worker available to meet that son’s particular needs, and I have already worked all my allotted number of days with him. I can’t switch son no. 2 that I am working with today over to another CAP worker who is qualified to meet his needs because I have already used all my allotted days for son no. 1. The daily rate I am being paid comes from one pot and her hourly pay comes from another pot, she can meet son no. 2 needs, I can better meet son no. 1 needs, but with all this hoopla there are times when their medically necessary needs are not met, because I am locked in this HOME SUPPORTS POT Also there are times when son no. 3 doesn’t have a CAP worker for several days, I can find a Cap worker for son no.2 & dad volunteers with son no. 1. The problem here is, I am locked into pre alloted days I can work with him. What are we going to do to get their needs met? Another thing, what if something happened to me or another parent and we couldn’t provide HS services for a week or so. The hours locked up in this HOME SUPPORTS POT couldn’t be used by other hab techs to meet the consumer’s PC & HCS needs. Believe me it is virtually impossible to get a CAP worker to provide respite services especially for more than a few hrs.

THIS 8M-CAP-I-DD WAIVER ISN’T DESIGNED TO MEET THE NEEDS OF CONSUMERS WHO ALSO HAVE OTHER PARTICIPANTS LIVING IN THE SAME HOME. “This 40 hour per week thing would really put a hardship upon our family.” . We are always diligently seeking for qualified, dependable CAP workers to work with our 3 sons. Even with me working 7 days per week under home supports we cannot find enough outside help to meet all the hours of their plan of care. It is very difficult to find qualified, dependable CAP workers to work with adult males who are dual diagnosed with some behavior issues at times, plus the job doesn’t pay enough, no benefits and staff have to use their own vehicles & insurance with very little mileage pay. When we can find help someone has to be off a day or 2, a week, sometimes longer, come in late or leave early. Right now I have one worker who is quitting Aug. 27, another one who comes to work very sick and in a few days is going to have to have part of her bowels removed, the other one says she can work 3 days a week. We have no good prospects in sight. It usually takes at least 6 mo. sometimes a year to fill a position. Because of this I can’t seek employment outside the home. Even when I have help I am always on call. Somebody asking me questions, training new staff, juggling everybody’s schedule, the schedule changes several times a month. Also a CAP worker who can work with one of my sons usually isn’t qualified or won’t work with one of the others. There are times if I can get a neighbor or family member to help me a few hours I have paid them out of my own pocket. WE CAN’T LEAVE THEM WITH JUST ANYONE. One of my sons was RAPED, the other 2 SEXUALLY MOLESTED by another CAP worker. My sons have been HIT, VERBALLY & EMOTIONALLY ABUSED, LEFT IN THE CARE OF SOMEONE NOT EMPLOYED BY AGENCY, LEFT IN PARKED CAR WITH MOTOR RUNNING, & LEFT UNATTENDED WHILE HAB TECH TOOK A NAP. “Other parents, grandparents can tell you HORRORS like these also. “ That is why we family members started providing services so our adult children could be taken care of . WE DESPERATELY NEED TO BE PERMITTED TO PROVIDE EVER HOW MANY HOURS OF SERVICES THAT IS NECESSARY TO MEET THEIR MEDICALLY NECESSARY NEEDS ACCORDING TO EACH ONES POC. Other CAP workers are not limited to 40 hrs. per week and it isn’t going to add cost to their POC. Why would any one object to parents/relatives providing "excellent” services over 40 hrs.per week when we can’t find qualified, dependable outside CAP workers to do so? “ Which in our case is every week.” OUR SONS VERY MUCH WANT TO LIVE AT HOME WITH US. IT ISN’T THE EASIEST ROAD FOR US TO TRAVEL. HOWEVER, WE WANT THEM TO BE CARED FOR IN THE LEAST RESTRICTIVE ENVIRONMENT POSSIBLE AND FOR THEIR RIGHT TO MAKE A CHOICE FOR THEIR CARE NOT BE VIOLATED.Here we are devoting our whole lives to our adult children, who have been violated by CAP workers and it seems like you expect us to volunteer more and more of our time. There are parents who have put their adult children in state care 24/7 who are able to keep them at home. If you expect all this volunteer time from us then you should send those adult children back home for their parents to take care of them also. What about AFL Homes they are paid 24/7. Our 3 sons are going to be in danger of being put into state care 24/7 if I am cut to 40 hrs. per week. PLEASE BAN THIS 40 HR. LIMIT ON FAMILY CAP WORKERS OR PLEASE MAKE AN EXCEPTION FOR FAMILIES LIKE OURS WHO HAVE EXTENUATING CIRCUMSTANCES. Even when I have to provide 84 hrs. per wk. of CAP services among 3 adult sons. I & their Dad are still volunteering dozens of hrs. per wk. I can provide letters from others about the quality of care I provide and the endless effort I make to keep them included in the community. I travel 500 + hrs. per month to make sure their POC is met. Both you and I don’t want them to be socially isolated. I don’t provide care so I can profit. Everything I do & everything I have is for them. However, if I am restricted to 40 hrs. per week there is going to be a lot of social isolation here because of lack of qualified, dependable, outside of family, CAP workers available to provide services. Even now there are times when we have 2 CAP workers besides me I am the one who has to provide the transportation for everybody. I cannot continue to do this if I am limited to 40 hrs. per week.

The 8M-CAP-I-DD waiver section H d. states that the PERSON CENTERED PLAN shall outline measures that ENSURES THE PARTICIPANT’S CHOICE and CONTROL OVER HIS DAILY LIFE and PROMOTE COMMUNITY INTEGRATION. In our case when I, the mother am the only qualified CAP worker available to provide services (this happens every week) and if 8M-CAP-I-DD won’t let me provide paid services (over 40 hrs. per wk.) then my 3 SONS CHOICE & CONTROL OVER THEIR DAILY LIVES WILL BE VIOLATED & THEY WILL BE SOCIALLY ISOLATED.

The issue of CAP workers not providing respite services if they accompany family on out of state on vacation because , family caregiver, is present. In our case we desperately need staff to accompany us. We have 3 sons who need one on one attention therefore, we are technically not really there for the son who has a CAP worker with him. We are there for the other 2 sons. Words cannot articulate how extremely important it is for the boys to get to go on vacation. How much it helps them emotionally . It is getting more difficult for us to handle it. Especially if we have an emergency. For our SONS’ SAFETY & WELLBEING Will you PLEASE! PLEASE! reconsider this policy especially for families with multiple CAP recipients and make an exception

PLEASE DON’T VIOLATE OUR ADULT CHILDREN’S RIGHT TO HAVE CHOICE & CONTROL OVER THEIR DAILY LIVES, NOR IMPOSE REGULATIONS (like limit family members to 40 hrs. per week) THAT WILL CAUSE SOCIAL ISOLATION, BECAUSE THEY CHOOSE TO LIVE AT HOME WITH THEIR PARENTS AND CHOOSE FAMILY MEMBERS TO PROVIDE “EXCELLENT” CAP SERVICES TO MEET THEIR MEDICALLY NECESSARY NEEDS ACCORDING TO THEIR PLAN OF CARE. PLEASE REMEMBER THE DECISIONS YOU MAKE EFFECT VENERABLE PEOPLE’S LIVES WHO CAN’T HELP THEMSELVES
YOUR DECISIONS CAN GIVE THEM GOOD QUALITY OF LIFE OR MAKE THEM MISERABLE. MAY GOD HELP US ALL !!!
I know I have rambled a bit. I hope you can understand our unique situation. If you have any questions Please Contact Me.

Margaret H.
Mount Airy, N.C.

P.S. What if I mother/legal guardian move out of family home or into apartment B. Would I still be limited to 40 hrs. per week? Do you think this will help the CAP recipients in our home?

DMA 8M Public Comment on CAP-I/DD 294

Note: Below is a Public Comment submitted to DMA regarding the 8M Clinical Coverage Policy proposal for CAP-I/DD during the 15 day comment period from July 28 - August 11, 2011. This exert was pulled from it's original source, a public record, and is posted exactly as it appeared save the removal of the submitter's personal contact information and abbreviation of last name.

[ More on DMA Public Comments. ]

Comment 294

To: Webmedpolicy, Dma
Subject: 8M-CAP-I-DD
Importance: High
Sent: Thursday, August 11, 2011 10:01 PM

Attached, please find a document detailing my concerns regarding the new 8M-CAP-I-DD policy.

The new proposed 8M CAP Policy to take effect in November 2011 is a devastating blow to families affected by a developmental and/or physical challenge. It is incomprehensible how my daughter, Chelley, age 12, diagnosed with Autism, will escape being institutionalized. How is it that this great government of ours will rush to the aid of other countries in need, but cannot recognize the great need in THIS country? I have an enormous amount of concern about how inhumane this new policy will be towards those not classified as “typical”. It’s almost as if we are living in a Hitler regime, where those not deemed to fit a certain class or characteristic should be punished is some way, because they are looked upon as degrading the race or inferior to what they call “normal”. What kind of world have we become when compassion and humanity can only be expressed in the public eye to impress other nations, and not an actionable standard at home? I am ashamed to say that this country’s standards/motives reflect nothing that our forefathers fought for.

Below, I have outlined how this new policy will negatively impact my child, my family, my life (if that’s what one would even call it).

Concerns with the proposed 8M CAP Policy:

• Enhanced Care: In 2010, Chelley had 100+ appointments. She was in the ER a few times and was hospitalized 6 times during the latter part of 2010. As a result of battling with an array of illnesses, she was only able to attend school SIXTEEN (16) days this past academic year. I am twice divorced to 2 cowardly men. I work two steady jobs, and during tax season, that goes up to 3 steady jobs. I am the primary caretaker of my 87 year old widowed father, and my 23 year old daughter, Christine, still in college, who we recently informed me, is expecting a child in October! (This just means another dependent to care for in the very near future). Because of my busy schedule and family responsibilities (both physically and financially), I am dependent of professional care for my daughter Chelley. Her health is very fragile, and the need for quality care is essential. Without the right enhanced services in place, I would have to quit all my jobs and stay home and care for her myself. And that would only lead me to be dependent on public assistance, which in turn would not be able to pay for her care, our home, basic standard of living...so that’s not an option. So the only alternative would be to institutionalize Chelley, which would NOT provide her with quality of life, and where she feels most acclimated and safe. This option is also against Chelley’s wishes and the family’s wishes. And that would be a tremendous cost to the government in the end. Eliminating Enhanced Care would have a tremendous NEGATIVE impact!
• Home Supports: The change back to coupled services is the best thing going in this new waiver!
• Habilitation Limitation: The maximum habilitative limit coupled with maximum personal care limit is clearly not enough for me to work my 2-3 jobs. The purpose of my working these additional jobs is to be able to supplement for Chelley’s care....which to me...is doing the government a favor. Because if she is institutionalized, that financial burden will fall in the good old US government’s lap. (Reminder: an institution is against Chelley’s and the family’s wishes) A typical family working member is required to work a 40 hr week outside of the home and come home from work and provide another 80 hrs a week to care for a disabled loved one. Because I don’t have a typical work week, my number of hours is substantially greater. Chelley is in need of consistent long-term person centered care!! Children with disabilities learn at a slower rate than the average person but yet the highest need individual can only receive 129 hrs per month? And I understand that there will be no exceptions? Whatever happened to the person centered approach??? These limitations surely support my belief of us living in a Hitler society. How can anyone deem that one set amount of time is suitable to everyone....regardless of their limitations, their dependencies, their abilities, etc.? Our children, both adults and minors, need additional care for a lifetime and it needs to be person centered so they can become productive in their community! Our children’s needs are great!!! Many individuals, specifically my daughter, will lose their freedom and possibility their life if this new waiver should take effect!
• Personal Care Limitation: Please refer to my notes in Habilitation Limitation. Just to reiterate....The UR limits will cause many to be institutionalized!!!! My daughter will be one of them! This negative impact will be the detriment of not only my daughter, but my family....society will miss out of gaining a wonderful viable member; the government will be greatly impacted financially, etc. But more importantly, an institution is against Chelley’s and the family’s wishes.
• Family Member: If it were not for the love of family, I think that my daughter would be a forgotten person in our society. We are quick to sweep problems under the rug so to speak and ignore people who are truly in need. But thank God that Chelley is loved by her family, and we are willing to stand up for her and protect her and provide her with the individual care that she needs. The BEST care that Chelley receives is from her family, because we have the patience, and the knowledge of her individual care, and always make the decisions which best fits her individual requirements. But this new policy seeks to limit the individual care provided by family members. This is not even logical!! What external staff will be willing to stay up hours upon hours each and every night when a child’s sleep patterns is only 3-5 hours? What external staff will be willing to sacrifice their time to fill out endless paperwork, attend grueling appointments/meetings, sacrifice not ever taking a vacation, etc.? External staff will not endure the pain and heartache that family members endure for the sake of caring for a loved one? And what about when qualified staff cannot be found, or are in transition? Who picks up the slack? How in anyone’s right mind would it be a good idea to punish the work and time that families put in for the care of their loved one?
• Home Modifications: How is the 15,000 factored into the budget? Does it go toward the total cost of the current budget year? For example, participant current budget is 125000 without home modifications. Home modification is 13,000. This puts current budget 138000 but less than 15000 in 5 years. Would this case a denial in Home Modifications/Services? Although this does not personally apply to my daughter, it is still concerning. For example a specialized bathroom for a person who truly needs it, is not a luxury item and but rather is needed for health and safety. Adding an assessable bathroom into an existing bedroom should be added to the inclusive list. This would not be needed or provided for another child in an average home. Without this it would jeopardize the health and safety of the individual and put an individual at risk of institutionalization.
• Respite: Restricting how Respite is to be used is purely inhumane! I work 2-3 jobs, work countless additional hours in the home caring for my daughter, don’t have options for vacation because of my unique family situation, have daily interruption of sleep, etc....and yet the state dares to think that I should not be entitled to some occasional respite to get some relief at my discretion???? Currently there is no other service that would be appropriate....and the reason why I and other families cherish every moment that can be had from respite care. And if I may add, those respite hours are not always spent resting...which is a novel idea....but I use those hours to give me time to grocery shop, to clean my house, to fill out paperwork, to cook, to do laundry, to care for other family members in my home, etc. It is impossible to accomplish all that I do for my daughter without having some occasional free time (if I can even call it that). With the past waiver, how many “typical” families can say they could survive on just 576 hrs per year of down time? It would be unfathomable!!!! I’d like to meet the person or committee who agreed to enforce this restriction. I would love to have them visit me and stay for a while to truly evaluate whether their decision was conscionable!!!
• 2.0 Eligible Participants: for the CAP waiver notes “Waiver-Specific Requirements” A person with mental retardation, developmental disabilities, or both may be considered for CAP-I/DD funding if s/he fulfills all of the following criteria: Can maintain his or her health, safety, and well-being in the community with the program”. Please clarify! If I am reading this correctly it states that individuals with great need will no longer be eligible for wavier services and will have no choice but to live in an institution. What does this mean for current participants that have high needs? Is there specific criteria that drives this statement? Who and or what makes that determinations; an individual; a committee; a dollar amount?

Marie P.

DMA 8M Public Comment on CAP-I/DD 257

Note: Below is a Public Comment submitted to DMA regarding the 8M Clinical Coverage Policy proposal for CAP-I/DD during the 15 day comment period from July 28 - August 11, 2011. This exert was pulled from it's original source, a public record, and is posted exactly as it appeared save the removal of the submitter's personal contact information and abbreviation of last name.

[ More on DMA Public Comments. ]


Comment 257

To: Webmedpolicy, Dma
Cc: Marty Johnson; marysam@westernhighlands.org
Subject: comment on cap changes for I/DD
Sent: Thursday, August 11, 2011 1:35 PM

To whom it may concern,

The changes that maybe made to CAP for l/DD will greatly impact my "son'. Especially, the changes to Residential. lf the changes go into effect, my wife and I will probably have to seek ICF/MR placement for him.
This is a long story. My "son" came to live with us when he was five. He had already been assessed at Amos cottage in Greensboro twice which recommended that he be institutionalized. The foster home that he was in could only contain him by locking him in his room. He came to us with CAP services and we were his foster parents. During the first eighteen months, we had a habilitation worker for 6 non-consecutive months. No afterschool or summer program would work with him without a worker. Both my wife and I were taking off work to cover his care which started to put us in trouble at work. At this point, the local Area Program helped my wife to become his CAP provider. This solved the
problem for us for a long time. Our "son" made a great deal of progress. We had wanted to adopt him, CAP made several back and forth decisions on parents providing CAP services for their children. And given our experience with not being able to keep CAP workers(which put our jobs at risk), we decided not to adopt him to be able to continue to have him live with us. I could not see giving him our name, if he then had to live outside our home. Overall CAP has worked well for him and made a different prognosis from the earlier one possible. When my "son" became a teenager, it became necessary for my wife and I to switch roles. She now works outside the home and I work with my "son". My "son" has autism and mental retardation. And despite medical intervention, he does not sleep through the night. When he gets up, I have to get up with him as he willget into the kitchen, etc. without regard to his safety.
The proposed changes to residential with limits to day supports and respite v0ill impact us greatly. I have experienced working around the clock with our "son" during the last three summers of high school when no summer programs where available or would take him because of his activity level. When he left school and started a year round day program with day supports, lwas able to recover from being worn out. Now I am able to prepare for my "son" while he is at the day program.
For many years we had a couple who provided overnight respite for our "son" in spite of his not sleeping. But two years ago, they had to stop. Since then I have had one ovemight break, despite numerous requests for service providers. To keep going I have used hourly respite during the day to take a break. Without this it will be difficult to keep going and will place a financial hardship on our family.

Thank you for listening.

Martin J.
Asheville, NC

Medicaid Reforms May Leave Developmentally Disabled in the Cold

Note: highlights, links, italicized quotes as well as comments in *purple are entirely my own mark-up and not reflective of the author nor original posting, link below. 


--For more information in a detailed outline with supporting documents regarding critical issues facing NC's DD populations and families, CLICK HERE. 


This is why we MUST PAUSE!

Medicaid Reforms May Leave Developmentally Disabled in the Cold

Unintended consequence of 2011 law to improve treatment of mentally ill

By Barry Smith
Jun. 11th, 2012

[ Original article from Carolina Journal Online ]

RALEIGH — Developmentally disabled North Carolinians could slip through the cracks as mental health services across the state transition into a new health care delivery system.

Advocates for developmentally disabled patients fear that thousands of patients might lose case management services as local and regional mental health organizations (often called local management entities, or LMEs) begin implementing a managed care system of health care delivery. Time is running out for lawmakers to make the statutory changes if they want to fix the problem before the transition is complete the first of the year.

People with developmental disabilities include people with autism, cerebral palsy, Spina bifida, Down’s syndrome, and intellectual disabilities.

A law that passed last year changes the delivery of patient care to Medicaid recipients of mental health, developmental disability, and substance abuse services. The effort seeks to expand a service-delivery model employed by Piedmont Behavioral Health Services, headquartered in Cabarrus County, statewide.

Lawmakers hope the change, when complete, will result in increased efficiencies for the Medicaid-related services.

The primary emphasis of the new law was to improve services for the mentally ill. But in what may have been an unintended consequence of the legislature’s actions, advocates for the developmentally disabled worry that the patients and families they serve may have been overlooked.

Julia Adams, assistant director of government relations for The Arc of North Carolina, said that case management is key to making sure developmentally disabled patients and their families get the health care and support services that they need.

Case managers are “experts in understanding the needs of this specific community and how to best help this community,” Adams said, noting that a lot of people with developmental disabilities often have difficulty figuring out the complexities of their care on their own.

Adams said that approximately 6,000 such patients could slip through the cracks.

While a handful of area mental health organizations already have made the move to the new managed care model, most have not. However, state law requires all of them to shift to the new model by Jan. 1, 2013.

*Whoa Nelly! WE ARE NOT READY.

Patients and family members already are reporting problems they’ve encountered from the changeover in some parts of the state.

Jane Lindsey, whose 21-year-old child suffers from a number of disorders, has encountered problems getting a psychiatrist for her child.

Lindsey’s family took guardianship of their child when she was 4 months old.
“She was a shaken baby,” Lindsey said. The adult child sees about 12 different specialists. “She has three immune disorders,” Lindsey said. “At times, she can have a list of 40-plus medications.”

Lindsey, who lives in Hendersonville, said that on Feb. 14, when her child was headed home from a doctor visit, she experienced a panic attack. Despite having numerous meetings with and calls to area officials, Lindsey has been unable to get a psychiatrist to see her child for clinical intervention.


Procedures stipulate that the managed care entity must authorize such services before they are delivered.

“According to her neurologist, if she continues to have these panic attacks, she will die,” Lindsey said.

Targeted management had been provided by for-profit and nonprofit private organizations. Those businesses will close down, Adams said. She said 150 people within the Arc of North Carolina will no longer work for the private sector.

*Small agency owners and providers - some of the best, most honorable, passionate professionals in the field - are being set up for failure! 

Jim Jarrard, deputy director of the state Division of Mental Health, Developmental Disabilities, and Substance Abuse Services, said that responsibilities of former case management workers will be divided among care coordinators and community guides.


*Care Coordinators will be accessible via central call center (unless there has been a recent change?) while the minimum qualifications for Community Guides include: 18 years of age, high school diploma, and valid NCDL.

While the new coordinators and guides won’t be as “robust” as the former case managers, Jarrard said that “they certainly help you navigate the system.”

Jarrard said he understands the concerns that have been raised about case management. “We’re trying as hard as we can to try to allay fears,” Jarrard said. “I think change is always hard for people.”

*Mr. Jarrad: We are NOT afraid of change; our lives ARE change... this is not our first rodeo. --We are afraid of losing wonderful staff who are payed nothing for the jobs they do; of losing the invaluable support of case managers we've built trusting relationships with; of having to quit our jobs to fill in gaps that shouldn't be there; of not being able to care for the children we love AND survive; of having to surrender our children to salvage the rest of our family members... 


And we're afraid no one is listening  - and too little too late is just too much to risk our lives for.

Adams counters that fear of change isn’t the problem. “People are actually getting into crisis because the system is not functioning,” Adams said.

Adams said she is working with lawmakers in an effort to make sure developmentally disabled patients get the treatment plans and service referrals they need.

Two legislators — Sen. Ralph Hise, R-Mitchell, and Tom Murry, R-Wake — said they are working on legislation to resolve the problem.

“We know what we want to do,” Murry said. “We’re just trying to see if we can get it done in the time remaining.”

“We’re in the drafting process,” Hise said. But he noted that Senate committees are shutting down and legislative leaders have set a June 19 target date for adjournment.

Adams said the changes need to be made this session, and if legislators believe it’s a priority, it can be accomplished.

“I think they need a green light from the leadership,” Adams said.

If they wait until the 2013 session, which would start in late January, case management services would have already ceased, she said.


*Why are we in such a hurry to race this through haphazardly? Shouldn't we want to make absolutely, positively certain that this is done RIGHT? That no one falls through the cracks? That no one ends up with egg on their face and the State is not opening itself up to more federal lawsuits and yet another DOJ investigation? 


“By the time the fix comes, there may be nobody left to work with these people,” Adams said.

*What if this were your child? Would you leave these issues hanging 'til next session?

Barry Smith is an associate editor of Carolina Journal.

Years of CAP Service vs. No. of CAP Workers

I posed a question today in the Facebook group, "For those receiving CAP services: How long have you received services?... and to the best of your recollection, how many CAP workers have been employed to work with your child in that time?"

Responses:

• Crystal (me) = 19 CAP employees over 10 years
• JC. = 2 CAP employees over 7 years
• PF. (child 1) = 6 CAP employees in less than 3 years
• PF. (child 2) = 6 CAP employees in less than 3 years
• CT. = 23 CAP employees over 8 years
• LB. = 3 CAP employees over 3 years
• BF. = an estimated 50 CAP employees over 7 years
• TH. = 5 CAP employees over 7 years
• SG. = 9 CAP employees over 5 years
• LW. = 6 or 7 CAP employees over 2 years
• AC. = approximately 15 CAP employees over 5 years
• RB. = 3 CAP employees in 3 years
• KF. (child 1) = 9 CAP employees in 7 years
• KF (child 2) = 12 CAP employees in 6 years

Can you guess the lucky exception? 

Care to speculate the reasons behind such extreme turnover rates?

The implementation of the new 1915(b)(c) Medicaid / Innovations Waivers and the service cuts it brings, will steepen and compound the improbabilities of finding and retaining reliable, trustworthy and professional direct-care staff to aid in the care, supports and life-skill goals of our children. 

While for most families, the bulk of service hours allotted will remain in the same ballpark, many others will have their hours cut due to a maximum ceiling, irrespective of individual level of need. Of the total service hours for an individual recipient, much of those hours will be shifted from the  higher paying Home and Community Supports (HCS) rate to the much lower Personal Care Services (PCS) rate, essentially resulting in a very substantial pay cut (in some cases, nearly half a worker's salary) for direct-care staff who already make less than peanuts for the important and vital work that they do - and with no benefits.

From my letter to Governor Perdue:

In the last 10 years, I can recall no less than 19 CAP Workers / care providers to whom I have entrusted my helpless little girl; I cannot even remember all their names as the turn-over rates for these positions is quite high. (In special parent circles, a CAP Worker who sticks around past one year is Gold.) Consider the emotional and developmental damage that such constant inconsistency creates in the daily life of a child with special needs; learning a new person, loving a new person, and losing that person – over and over again (never mind what it does to the parent). And while there have been some wonderful trustworthy care providers in our life, I wish that were the only issue... During this parade of CAP Workers, practical strangers in my home and personal space, I have experienced: the physical abuse of my child when an employee pinched my 3 ½ year old numerous times leaving dark purple and green bruises on her tiny body, thousands of dollars worth of property stolen from my home, and a week’s worth of groceries devoured that I could not afford to replace; I had an employee who took my daughter on a date with her ex-husband she’d previously had a DVPO against who was unaware she was living with a new guy; I once had two employees who became friends and later found that they spend quite a bit of time hanging out together in bars smoking and drinking with my child in their care; one girl who was fired for drug abuse; and last but not least, yet another who filed a DSS complaint against me for “abuse and neglect” in retaliation for being terminated – an incident that wasted the time and resources of 5 separate agencies, including the Morrisville Police Department, Cedar Fork Elementary School, Wake County Human Services, and the Department of Social Services. And that’s just the stuff I know about; anything else that has happened throughout the years, my daughter is unable to tell me. 

During the last Bush Administration, the federal Medicaid reimbursement rate was cut by eight dollars ($8.00) per hour, a significant amount when one considers the cost of overhead and employee salaries. Today, the average CAP Worker makes between nine to twelve dollars ($9.00-12.00) per hour when performing “Home and Community Supports” (HCS) services (this is the minimal time designated for working on pages and pages of specific life-skill goals and continuation of therapies, not unlike an IEP) and minimum wage to eight dollars ($7.15-8.00) per hour for “Personal Care Supports” (PCS) services (the bulk of allotted hours which includes bathing, grooming, toileting, etc.) and “Respite” (time built in for unscheduled relief). Comparatively, a Certified Nurse Aide 1 working in a long-term care environment in Wake County makes roughly $13.03 hourly, while a Wake County Teacher Assistant in Special Education averages $10.27 per hour and a Wake County Public Schools Custodian, $12.80 per hour, not including benefits or shift differential. For the record, the average Garbage Collector in the State of North Carolina is paid an average hourly rate of $11.75. A CAP Worker receives only their hourly wages with no benefits whatsoever when working consistently less than 30 hours weekly, not even mileage reimbursement to offset the cost of driving their clients around in their personal vehicles attending community activities as dictated by their care plan.

Suffice it to say that the vast majority of families not utilizing the maximum amount of service hours allotted are not choosing not to do so because the need is not present. Quite the contrary, there is a critical need that cannot be staffed with competent, quality, reliable, professional care providers dedicated to a profession that includes a daily routine of cleaning feces, urine, and vomit; preparing special foods and feeding; heavy lifting; changing G-tubes and catheters and diapers; administering medications; bathing and dressing; utilizing sign language and specialized communication devices; and completing endless amounts of paperwork tailored to a non-applicable medical model to justify their existence all while being subjected to nerve-racking and often abusive behaviors such as hitting and biting, because frankly, people can make a better salary emptying garbage cans than caring for an innocent human being unable to do for themselves.

* If you would care to share your stats regarding years your loved one has received CAP direct-care services and the number of CAP workers that have been employed in your home to care for your child, likewise any related stories regarding difficulties in direct-care coverage, experiences, etc. please feel free to respond to this blog post, post in our Facebook group or contact me privately via no2nchb916@gmail.com.

Family Stories Video

A very moving presentation and just a tiny glimpse into the challenging lives of families caring for children (and adults) with Intellectual and Developmental Disabilities... faces of families whose services and supports, and thus daily survival, will be and are detrimentally impacted by the implementation of the new 1915(b)(c) Innovations Medicaid Waivers...

Raleigh Trip Presentation of IDD Caregiver Voices and The Breakfast Club.

* If you are a parent or caregiver with a story to contribute, have correspondence exchanges with legislative members you would like to share, please contact me at no2nchb916@gmail.com.

Parent Perspective: Parent Letter from K.Feller

A couple of months back, I received a heartfelt letter from a local special mom of two boys with Autism to deliver and share with Dr. Pat Porter in one of my meetings. I am posting with her permission. Thank you Kimberly!

Parent Perspective

March 1, 2012

RE: Concerns with NC HB 916

My name is Kim Feller and I live in Wake County. I am writing to you because I have two sons who both have autism and are covered by the Medicaid CAP Waiver program. Nick is 14 years old and James is 11 years old. I am concerned about the NC HB 916 which will greatly affect services. Both of my boys participate in several different therapies including occupational, speech, and social skills therapies. Also, they both take different medications for the treatment of aggressive behaviors, anxiety, and seizures. My youngest son who is 11 years old recently had a temporary residential placement at the Murdoch Developmental Center in Butner, NC where he stayed for three months. He was placed there due to aggressive behaviors which we were unable to handle at home. He is living back home again only because we have home staff provided through the Medicaid CAP Waiver program. We feel very fortunate that both our sons are currently covered by the Medicaid CAP Waiver program. The CAP Waiver program has been critical in providing our boys Home and Community services as well as funding for the aforementioned therapies, medicines, and residential services. These services support individuals in their home and community and avoid more costly institutional settings. Provider agencies just took an almost 3% rate cut on November 1, 2011, in addition to a 5% cut a few years ago. We are concerned that the cut to Home & Community service hours will make it difficult to retain the quality service providers we need to care for our boys. Working with children who have autism requires a certain level of commitment, sensitivity, and resilience which must be compensated accordingly. Also, the DHHS has recently implemented new limits on the number of hours our sons can receive. This concerns us a great deal because our youngest son needs constant supervision. If we don’t have enough home support hours the chances of our son reverting back to his prior aggressive behaviors will be greatly increased. It is much more economical to pay home staff than it is to pay for a residential placement!

The 1915 (b)(c) managed care waiver proposes that a single entity with a financial interest to keep funding low will determine eligibility for services, control who can provide services, develop the Person Centered Plan, and decide the level of funding. This is of concern to us because the decision makers would work for the Local Management Entity (LME) which has a financial interest to contain costs. There needs to be a decision maker representing solely the interests of the person with the disability as is currently happening with the Case Managers. The new plan should recognize the integrity of the Developmental Disability model by excluding Case Management from the Managed Care Entity and separating Developmental Disability from Mental Health and Substance Abuse. Developmental Disability is not an illness, and therefore should not be combined with Mental Health and Substance Abuse.

We appreciate any efforts you can make toward avoiding cuts in Home & Community Service hours as well as excluding Case Management services from the Managed Care Entity.

Thank you for your time and efforts.

Sincerely,
Kimberly H. Feller
contact info...

* If you are a parent or caregiver with a story to contribute, have correspondence exchanges  with legislative members you would like to share, please contact me at no2nchb916@gmail.com.