Fact Based Analysis of Emmaus Board of Director's Decision to Transition Services from the Marthasville Campus

On May 19th, the Emmaus Homes, Inc. Board of Directors voted to transition all clients off of the Marthasville campus and into the community by 2020.  The vote was the culmination of more than a year of discussion and research regarding the changing regulatory environment, industry trends, future capital needs of the Marthasville facility, client demographic information for Marthasville, Emmaus and Missouri, funding projections for both services and facilities, and staffing requirements for the campus.

Beginning in September 2014, the Emmaus leadership team led by Cindy Clark, CEO and David Kramer, COO met with families numerous times to educate them on the potential regulatory changes that may require their loved one to relocate from the campus.  In addition, the Board of Directors held three public meetings with Marthasville families and interested parties to hear their concerns. 

Families have organized an advocacy group to oppose changes to the Marthasville campus.   They have been rigorous in their objection to the transition and since the decision have cited that the reasons for the decision, based on the organizational strategic plan, are baseless.  See the organization’s strategic plan HERE.

The purpose of this document is to share the information that the Board has reviewed over the past year, as well as some basic information about current trends for people with disabilities and the future workforce demands.  All of this is information that the Board receives as part of their orientation.

INDUSTRY TRENDS

 

Over the last 125 years, services for people with developmental disabilities, such as Down syndrome, Cerebral Palsy, and Autism Spectrum Disorders, have changed dramatically.  Emmaus Homes was perhaps one of the first private providers of services to people with disabilities in the State of Missouri, offering families from around the country a faith based alternative to state institutional care.  During this time, we have likewise evolved, modifying our services to reflect modern practices within the field.  Whether it was the elimination of barred windows, the transition of people from large dormitories, or similar historical practices, the leadership of Emmaus has recognized the need for change in providing services.  We are honored to be known as one of the leading providers of faith based services for people with disabilities in the State of Missouri. 

While we have always embraced our heritage of campus based communities, we can no longer ignore the clear trends and basic expectations in providing these services.

While there are decades of research showing the improved outcomes for people with disabilities in community-based settings, we are providing links to two recent studies. 

Community Living and Participation for People with Intellectual and Developmental Disabilities

Home and Community-Based Services: Creating Systems for Success at Home, at Work and in the Community

For the past several years Missouri has been focusing on improving its services to people with disabilities.  According to the Case for Inclusion, recently published by United Cerebral Palsy, Missouri has moved from 41st to 3rd nationwide over the past eight years in its inclusive practices for people with Intellectual and Developmental Disabilities (IDD).  The report uses the National Core Indicators (NCI), a standardized set of outcomes endorsed by the National Association of State Directors of Developmental Disabilities Services (NASDDDS).  Emmaus has established its agency outcomes to mirror NCI. 

EMMAUS DATA

Age & Residency

  • Emmaus serves on average an older population than Missouri’s total population with developmental disabilities.
  • More of our older population is served in community homes than on the campus, including 14 people over the age of 75.
  • Emmaus has successfully transitioned clients who have lived in campus based settings to community homes for more than 30 years. 
  • Younger clients, those under 35, overwhelmingly select community living options over the Marthasville campus.
  • While an average of 3 people have chosen Marthasville as their home each year for the past 15 years, we have also lost approximately 6 clients per year to natural death or other service options, including community homes. 

 

Level of Need

  • The state of Missouri utilizes the nationally recognized Supports Intensity Scale (SIS) tool to assess levels of needs for people receiving residential services.  Based on assessments by the Department of Mental Health (DMH), Emmaus serves more people with higher needs in the community than on the Marthasville campus.
  • The transition to the community from campus is a well-planned, supportive approach with family/guardian involvement and MORE individualized services. 

 

Service Model - Group to Individualized Services

  • The Group Home service model, as offered on the Marthasville campus, has seen a decrease nationally and, since 2011, has been made all but obsolete in Missouri.  According to the Missouri Department of Mental Health, Division of Developmental Disabilities Guideline ‘only people leaving state institutions may start a new Group Home and their size is limited to four or fewer residences.’  Nine out of the ten homes on the Marthasville Campus would not be in compliance if built today.
  • Even if fewer residents lived in each of the 10 group homes on the Marthasville campus, it would only further increase the funding gap as those homes were designed for capacities between 5 and 16 residents.
  • Though there is significant marketing for congregate Senior Living facilities, the trend for people with disabilities and the elderly clearly demonstrates a shift toward services provided in an integrated community versus an expectation to live in congregate housing (Olmstead vs L.C.).
  • The individualized service model offered in the community allows our clients to design personalized budgets with DMH.  Our clients have the opportunity to choose their own recreational activities, church services and preferences in employment.  

 

REGULATORY ENVIRONMENT

 

More than 95% of the clients served by Emmaus Homes are funded through Medicaid’s Home and Community Based Waiver Program (HCBS). The Center for Medicaid Services (CMS), which manages the HCBS program, issued its final ruling in January 2014 in regards to their standard of living. The state of Missouri must comply with the final ruling by March 2019. The state of Missouri was required to submit its transition plan to CMS by April 2015. As part of the transition plan, approximately 800 individuals receiving HCBS services in Missouri will be interviewed to determine compliance with the HCBS final ruling. A copy of the transition plan and a summary of the more than 300 comments DMH received from Emmaus supporters can be found here.

DMH began visits to providers beginning with those living in larger congregate settings such as the Emmaus Marthasville campus. Several of our clients on the Marthasville campus were interviewed. DMH provided feedback to both the families and the organization, citing situations that would require remediation in order to be in compliance with the new ruling.  Emmaus submitted its Corrective Action Plan to DMH in response to the feedback and is waiting for approval or rejection.  As part of the response, Emmaus indicated that the Board of Directors voted to transition clients from this site over 5 years.  Because the Marthasville campus is owned by Emmaus, who is also the service provider, the corrective action plan may also be sent by DMH to CMS for final approval of the state’s overall transition plan.

To date, Emmaus has still not received feedback indicating that the Marthasville campus would or would not have been allowed under the new final ruling.

STAFFING

 

It has always been challenging to provide an adequate workforce on the Marthasville campus.  During times of economic growth, staffing becomes even more challenging.  There is not a natural source of qualified candidates in the immediate Marthasville area.  Many of our staff travel as much as 30 miles or more to work on the Marthasville campus.  As both the economy improves and the communities in western St. Charles County and Washington experience growth, we are once again having difficulty recruiting in this area.  Potential employees can find work for similar pay closer to their home, often times with fewer evening and weekend hours, which is typically required of our employees. 

Emmaus recently adjusted its base wage for entry level employees to $10/hour.  In addition, we have guaranteed wage increases to direct support professionals during their first 4 years of employment, a time when we experience the highest turnover.  This is a competitive wage for our industry.  As with many professions, such as teaching, society does not express its appreciation for the care of our most vulnerable citizens by providing an adequate payment structure to support a living wage for our employees.   Emmaus remains active in our advocacy efforts with state legislators to increase funding for services to people with IDD so that we may continue to recruit and retain a talented workforce.  Studies indicate that there is a growing “care gap”.  As baby boomers age and people with disabilities continue to live longer lives, there will be more people requiring assistance with their daily lives and fewer people to provide that service. Emmaus currently provides approximately 1.2 million hours of direct service to its clients each year.    

We monitor several metrics related to our workforce and have highlighted them in the chart below.  As we have made our transition to community-based settings, our data indicates that staff prefers to work in smaller settings.  Emmaus staff that have worked both in campus and community settings anecdotally report that their work is more rewarding in a community home.  They report that clients are happier, it feels more homelike and that they can see the progress our clients are making by being actively engaged in the community. 

With our community homes, clients receive more individualized supports, which requires more staffing.  As a result, our direct support workforce has grown by nearly 200 employees since 2009, with most of these employees choosing to work in community homes.  About 1/3 of our direct support professionals who have been with us for more than 5 years work in Marthasville with the remaining 2/3 of our employees working in our community homes.  This is consistent with the number of clients served in each location.     

As Emmaus continues to expand into the community, the gap in turnover and open positions between the two service areas continues to widen.  Much of this is due to the satisfaction that staff report with community settings.  Open positions in Marthasville take longer to fill which results in significant overtime and staff fatigue.

RESIDENTIAL SERVICES FUNDING MODELS

 

Our homes located on the Marthasville Campus are classified as Group Homes for funding purposes by the State of Missouri under the Medicaid Home and Community Based Waiver.  Each Group Home is categorized/classified based on a defined acuity level that does not change for that home.  Under the Group Home funding model, each client living in the Group Home is expected to have the same general acuity level (and support needs).  Over time, if a client’s needs change and more support hours are required, the Group Home funding model expects that the client should move from their current Group Home to another Group Home with an acuity level classification that more closely meets their needs.   If the client does not move to a more appropriate Group Home, there is no increase in the client’s Medicaid funding to help cover the cost of additional support hours (that Emmaus would provide in the home).  As the acuity level of clients increase with aging, the result for Group Homes is an increasing number of support hours that are provided by Emmaus with no direct reimbursement by the client’s Medicaid Funding.

Community homes are eligible for the Medicaid funding model known as Individualized Supporting Living (ISL).  In ISL Homes, the support needs (hours) of each client are identified on an individual basis and funded based on an individual contract unique to each client. As  needs change for a client, the ISL funding model enables the  contract to change as well, allowing for more or less support hours depending on client need.  As a result, if Emmaus adds more staffing hours to support a client’s changing needs, direct reimbursement by the client’s Medicaid funding is possible through approved changes to a the contract.

The State of Missouri has communicated to Emmaus that our Group Homes on the Marthasville Campus are not eligible for conversion to the ISL funding model.  In addition, the rate rebasing (establishing a new base rate) project in the State of Missouri which is designed to increase daily rates for Group Homes and hourly rates for ISL Homes, is also not expected to significantly impact the daily rates of our Marthasville Group Homes.  Also, for Group Homes, rate rebasing represents a one-time increase in daily client rates and does not include a mechanism for addressing the future cost of providing additional support hours as the needs of Group Home clients increase with aging.  As a result, the likely future addition of support hours to meet the increased needs of our Marthasville Group Home clients will not be eligible for direct reimbursement by Medicaid which will create additional financial deficits that will need to be funded through other revenue sources.    

MARTHASVILLE CAMPUS BUILDINGS AND GROUNDS

 

The Marthasville Campus is in a valley of approximately 600 acres of land owned by Emmaus, located approximately 4 miles from the town of Marthasville, Missouri.

Currently there are nine Group Homes and three apartments that serve as homes for 77 Emmaus clients.  These homes were originally built between 1965 and 1991.   Five of these homes are multi-level, non-accessible houses which currently serve 25 Emmaus clients.  The four remaining homes provide for single-level living and currently serve 48 Emmaus clients.  Three of these homes are designed to serve up to 16 clients with shared bedrooms of either 2 or 4 roommates.

The Campus also includes two administration buildings that were built in 1918 and 1926, a facilities maintenance building, chapel and three employee rental homes.  An additional building constructed in the 1850’s is closed to daily activity but continues to be used for storage.  Two other buildings have been closed in recent years and are no longer used.  A pond and three cemeteries are also located on the grounds.

The Campus is served by a private clean water system and a private waste water system that is owned and maintained by Emmaus.  Emmaus also maintains the private roads, parking lots and walking paths that are necessary to support the Campus homes and activities.  In addition to the general maintenance of the homes and buildings, Campus infrastructure operation and maintenance activities funded by Emmaus include the following:

  • Roads, Parking Lots & Walking Paths
  • Wells, Water Tanks & Distribution Pipes
  • Waste Water Lagoon & Lift Stations
  • Night-time Safety Lighting for Campus Grounds
  • Mowing & Grounds Maintenance

 

The costs of operating and maintaining client homes and the Campus infrastructure are not funded by the Center for Medicaid Services (Emmaus Homes’ largest provider of funds.)  Rather, these facility costs are paid for with client Social Security benefits and subsidized with non-operating or donated funds.  (The average room & board rate for Marthasville clients is currently $21 per day.) Emmaus subsidizes a portion of the housing costs for all of its current clients but due to the nature of the Marthasville Campus (age of homes, Campus infrastructure and large grounds), the current housing subsidy  for Marthasville clients is more than  50% higher than Emmaus clients who live in community homes.   

Due to the fixed nature of the costs to operate and maintain the Campus infrastructure and grounds, as the number of clients served on the Campus declines the subsidy needed to fund these costs will increase.  During the past 10 years, Emmaus has experienced a drop in clients served on the Campus by approximately 20%, due to a decline in new clients choosing the Campus and also due to the normal attrition of clients as they age.  Based on this trend, the following graph estimates both the decline in census and increase in subsidy that are projected for Marthasville by July 2020.

In addition to the housing subsidy, the operation and maintenance of the two Campus administration buildings represent an additional annual cost of more than $260,000.  This cost to provide office space for staff represents program overhead cost for Emmaus.  Due primarily to the higher cost of operating and maintaining the older, larger administration buildings, program overhead cost for Marthasville clients is 25% higher than similar costs required to serve other Emmaus clients.

Additional financial detail for both the housing subsidy and administrative building costs in Marthasville can be viewed here.

CONCLUSION

 

For more than 120 years, Emmaus has been providing high-quality services to adults with developmental disabilities.  In recent years, Emmaus has undergone many changes in where we provide our services, however what remains unchanged isour unwavering commitment to our clients.  Ultimately, the Board’s decision was not based on the interpretation of the Center for Medicaid Services Final ruling, but rather on careful research of the best way to provide services for both the clients that we serve today and in the future. Emmaus has always been a leader in our industry by creating national best practices and standards for adults with developmental disabilities.  As we continue to expand our services into the community, our mission remains clear; to provide the highest quality services with a continued focus on our faith-based tradition.  We are committed to preserving our mission for many generations to come.