KATHIE KNOBEL-IVERSON:  I'm going 
to talk a little bit about,

we're a newer center compared 
to Dennis's center.

Our center was founded 
in 1994 and with 
$280,000 of state IL funds.

In three years of starting,

we were in somewhat 
of a financial crisis.

The demand, we were trying to meet 
the demand of our service area,

so we kept hiring people and 
realize that we're not –

we don't have enough money to 
even put a dent in the demand 
in our service area.

We have 13 counties.

They're very rural.

We drive and drive and drive and 
drive to get to somebody's home.

It's not unusual that you can 
spend six hours on the road to

spend an hour and a half or 
two hours at somebody’s home.

So it ties up a vehicle,
ties up staff,
all day long.

So we started to look for 
other opportunities.

And in 1997, we responded 
to a request for a proposal,

that is what the state 
does in Wisconsin.

They're called RFPs.

And it was for an 
employment program.

And I had from an 
employment background.

Where I worked at my previous job,

I thought, we can do this.

And we were awarded one of the 
three grants in the state and

we had it for five years and it 
changed our thoughts about money.

It really helped us figure out 
that bringing in additional money

that's not necessarily tied to IL,
but it was tied to employment of

the same folks that 
we were serving.

That it made a 
huge difference 
in our organization.

It also introduced us 
to benefit specialists.

Do any of your states have work-
related benefits specialists?

It was a new concept 
for Wisconsin.

But it happened statewide.

As the three sites, maybe it was 
four sites that got this grant.

Three of us, there were 
four, three of us were
independent living centers.

So we all developed 
benefit specialists.

It really changed consumers' 
ideas about working and 
getting off benefits.

And what a benefits specialist 
does is help a person figure out

how work is going to affect 
the benefits they get.

And it's not just 
Social Security benefits.

You can talk about 
subsidized housing,

you can talk about 
Medicaid or Medicare,

whatever a person has/there
depending on in their lives 
for benefits.

It also absorbed 15 percent 
of our administrative costs.

So it freed up more money 
to go into our IL program.

And I guess that was probably 
one of the most exciting things.

We have a very slim 
administrative staff.

Really small – if you 
get part of that paid,

then it frees up money to 
go into independent living.

In 2000, we responded 
and were awarded a

nursing home transition 
grant for the whole state.

Nobody wanted it.

And so we applied for it.

And were awarded that.

And again, some of this was 
happening simultaneously.

And we had the employment grant 
and the nursing home grant going

on at the same time and, again, 
picked up some more funds.

As all this happened, we had 
a personal care crisis 
in our service area.

Actually in Wisconsin,
a lot of counties and

hospitals used to 
do personal care,

and they were losing money 
so they stopped providing

personal care in people's homes.

And we had thought about doing 
personal care in 2000 and there 
was such competition out there,

we couldn't compete with 
the hospitals and we couldn't

compete with some of the 
other providers in the area.

While all of a sudden,
in less than three months,

three of the biggest 
providers in our service area,

closed their doors.

And they came to us and said,

Do you want our clients?

Well, do they want us?

We have never done this.

We don't know what we're doing.

And my board pretty much said,
you're going to do this.

And so it took us, we 
convinced the people

that were closing 
their doors to stay

open for a while to help us figure 
out what we wanted to do.

We had no money.

And I think we had 
$5,000 in the bank.

We were new.

We didn't have much going on.

So we wrote some startup grants 
and got two local foundations,

both affiliated with the hospitals 
that were ending their home care,

or their personal care programs,

gave us startup money 
and things just exploded.

Went from 25 consumers to 
250 in three months.

I would never, 
ever suggest doing that.

You have a question?  
Take the mic.

AUDIENCE MEMBER:  I was just 
curious.

How much did it cost for 
you to actually start 
up your PCP services?

KATHIE KNOBEL-IVERSON:  Not a lot but 
the biggie is delayed payroll.

I don't know how many of 
you have billed Medicaid.

They can deny your whole claim.

And you can be out.

Our payroll at that point was 
tremendous compared to the 
rest of our organization.

So we also needed to go to 
the bank and get a line of credit.

We wanted to be able to 
pay people in a timely fashion.

So that was what most of the funds 
were for was for cash flow for us.

Hiring people, we couldn't hire 
people fast enough at that point.

Things were just 
sort of out of control.

AUDIENCE MEMBER:  Yeah.

Here, looked into becoming a Medicaid 
provider, maybe the simplest way,

for maybe for HHS it's like 
$75,000 to start up – 
so I was just curious.

Kathie KNOBEL-IVERSON:  Is there 
like a buy-in?

AUDIENCE MEMBER:  It’s just – 
and I don't know a 
whole lot about that.

You have to have a 
substantial amount of funds.

So I don't know if startup funds 
actually added up to that much.

KATHY KNOBEL-IVERSON:  Again, 
you have to remember 
that – you have to

relate this to your 
experience in your own state.

In Wisconsin at that time,
we were getting $10.25 an 
hour for personal care.

When we started.

We got very involved and got 
the rate up to, I believe now,

it's $16 an hour 
for personal care.

It's still not enough to 
pay someone a living wage 
when you have to have RNs.

In Wisconsin, you have to 
have an RN on staff.

And they have to be on the 
person's home every 50 or 60 days.

So there are all kinds of 
complications to personal care.

But I would not do 
it the way we did it.

We sort of jumped into this.

I would really encourage people to 
do more of what we did on the rest

of the kinds of services 
that we picked up.

That's to plan better.

This was more of a 
response to a local crisis.

And you learn.

And we learned a lot from that.

We -- managed care became 
the new long-term care system 
in Wisconsin.

We have one little part of the state 
that still is not managed care.

But it changed the whole 
environment in long-term care.

I said in here, we now have 
15 or 20 home care providers.

I did a survey, 
a call survey,
two weeks ago.

We now have 25 personal care 
and supportive home care 
providers in the 13-county area.

Some of them are 
really bad providers.

They will underbid 
anybody to get referrals.

They don't do background checks.

They don't do anything.

It's a really bad situation.

But managed care takes 
the lowest price.

And so we have been priced out 
of the market because we will 
continue to do how we do it.

We will follow the rules and make 
sure the consumers have a choice 
about who goes into the home.

They get to participate in 
interviews where you got to

have infrastructure to make 
those kinds of things happen.

So, again, I would not -- we're 
down to 70 people from 250.

And I would guess in a year,
year and a half,

probably won't be doing it at all.

Just because of how our 
environment has changed.

That is why we're incredibly 
motivated to continue to 
look for other things.

I was thrilled the other day.

Our IL director came to 
me the other day, and said,

we need to find another 
way to make money.

I was blown away.

She was more into program and 
doesn't think a lot about 
finance and we do.

We -- if we want to continue to 
grow and to meet the needs of the

people with disabilities 
in our service area,
we have to make money.

We had some wonderful 
opportunities and –

I put these in the wrong order.

If you would go to the next 
slide and then I'll come 
back -- go to page six.

We started doing some contract 
development because these RFPs,

these new programs 
worked out so well for us,

we thought, we're really 
good at starting new programs,

so let's see what else we can do.

We got asked by a local county 
that was so excited about the

fact that they found an 
organization that did advocacy.

And did systems change.

And they wanted to hire us to 
turn the mental health system 
in a county upside down.

They wanted house cleaning.

Wanted psychiatrists gone,
they wanted bad counselors gone,

and they wanted consumers to 
have control of their services.

And they came to us.

Gave us a contract -- for – 
page 6.

It's the CAC,
consumer affairs – 
here we go.

It's on page 5. 
I'm sorry.

And this person was a 
wonderful advocate.

She fit into the whole IL movement 
incredibly quickly and taught us

more than we ever knew about 
mental health services and the

crisis that individuals were going 
through in state institutions,

in psychiatric units at the hands 
of people who felt that they knew

what was best for them 
and within two years,

with this person and our advocacy,

we were able to make huge changes 
in the local mental health system.

Let me tell you, that 
endeared us to the county.

We are still reaping the benefits 
and this was ten years ago.

They love us for 
what we did for them.

This position now doesn't 
have to do systems advocacy,

the system is changed in 
La Crosse County and we've had 
this contract for ten years.

We have a staff person who comes 
in now and educates individual

consumers about their right to 
have control over their services

and about how important it is for 
them to develop their own goals,

not to listen to social workers 
who think they know what's best.

And those folks are retiring.

They're leaving.

Over the course of ten years,
people who aren't comfortable with

consumers being in control have 
been -- they have left the system

or been forced out of the system.

It's been a wonderful 
opportunity for us.

And for us to be able to 
tie that to advocacy was huge.

Now, you said this earlier, 
talking about advocacy and 
service providers.

We've had lots of people say,
You leave the advocacy hat at

home when we're paying 
you to do a service.

We will not do that.

That is the line 
in the sand for us.

We have lost some 
contracts because of that.

We will not NOT provide advocacy 
when we see somebody’s rights

being stomped on or not getting 
a choice or that they are being

placed in an environment 
that is more restrictive.

In the mental health system,
there is more abuse going on

to individuals -- have to 
not get on my soap opera.

They are the most abused group 
of folks with disabilities,

I think, in this country right 
now, with all the cuts that are

happening in the states in 
the mental health system.

It's going to get worse.

This opened up doors for us 
to -- we got asked to take over 
a mental health drop-in center.

And we said, Sure, we'll do it.

The county gave us a 
very generous contract.

We have been doing 
that for nine years.

We've responded to three 
requests for proposals.

Every three years,
they have to do it; 
it's a county rule.

No one has ever even 
competed against us,
so we get it every three years.

We have found other consistent 
funding sources for that site.

It provides a wonderful service.

It's really helped -- again,
reinforce the change in the

system because 
people have a safe,

supportive environment 
to be in during the day,

if they choose, no one is forced 
to come -- it's a drop-in center.

It is not something someone 
writes into someone's plan.

And it has changed the whole 
environment again in the county.

People come there instead 
of going to the ER.

They might end up in a crisis bed,
versus a hospital.

We have helped create a lot 
of really good alternatives

for people in the mental 
health system.

In the past year, we served 425 
people, unduplicated folks.

That use the center -- some of 
these folks -- the drop-in center.

Some of them come every day,
some of them come once a week,

some of them come 
for special events,

we have a series of support groups 
that we hold every evening.

We need a new building.

There's not a lot of privacy,
so we hold our support groups 
in the evening.

And we can't have more than one 
of them going on one at a time 
because there's no privacy.

We're starting to 
look for alternatives.

We've also been asked – 
we just competed for 
this for the fourth time.

We are going to get awarded and 
what they put into the RFP this

time was that we will open two 
more sites in other counties.

So we are excited about 
that opportunity.

We do follow-up for 
crisis and again,

it's a three-county area.

Three counties came together 
and developed an alternative 
to a hospital.

It's a crisis center.

It's licensed as a 
group home unfortunately.

The state insisted they do that.

But we provide services for 
folks who come there that 
don't have insurance.

There's a lot of them.

If you look at what's 
going on here, a lot of them

have no health insurance 
or most everybody we serve,

they're also -- many of 
them are homeless,

and typically a young 
male with no income,

they have been in a crisis,
either mental health or

mental health or alcohol 
and drugs situation.

And we provide case 
management and sort of 
a triage type of situation.

And we try to stay in 
their lives as long as we can.

But they're homeless,

20 to 30 years old.

And have no income.

It's very difficult to stay 
connected with this population.

So our outcomes aren't as high.

Our expectations aren't as high.

And neither is the funding source.

Our outcome is to stabilize this 
person and avoid recidivism.

So that they're not back 
in the hospital or back 
at the crisis center.

Those are our outcomes.

And then we were awarded 
a contract just a year 
and a half ago,

and this was probably one of 
the most exciting things that 
we've done in a long time.

We competed against 
a peer-run organization,

mental health consumers,
run the organization and

they had had the 
contract for ten years.

And we got the contract instead.

And it was -- it was 
really exciting for us.

It was also hard, because 
the same organization had

been involved with the 
consumers for years and a 
lot of people didn't trust us.

I'm sorry.
Page seven.

So we have this contract and it's 
providing technical assistance and

it's a really wonderful way for 
us to provide --

we sing the IL song 
every place we go.

It's a great opportunity to get 
people introduced -- not only

to -- in Wisconsin we use a model 
called a mental health recovery.

I don't know how many 
of you are familiar,

but it is so close 
to the IL philosophy,

that in our agency you can't 
distinguish between the two.

It was probably one of 
the best partners that we

ever -- philosophy that was just 
so close to what we were busy

practicing every day that 
it hit us over the head.

They are so similar that 
this is going to make us 
a better organization.

Right now, we have -- we're 
in our second year of this

contract and we have accomplished 
more than the other agency did in 
ten years in a year and a half.

We have a lot of these sites,
they were not run well,

they were not accountable 
for the money they got.

Terrible things were happening 
at some of these sites.

And that's all been cleaned up.

The consumers are -- who run these 
places are really empowered about

developing their own 
benchmarks statewide.

And they are now developing 
a peer review tool.

So they can monitor themselves.

It's been really fun 
to watch this happen.

And part of it is because 
we have high expectations.

We don't take care 
of things for people.

We expect people -- if you're 
going to have this organization,

you need to run it; 
you need to run it ethically,

and you need to be responsible for 
the money the state is giving you.

Can't just spend it and not have 
receipts and so people have really

come around and the state is 
thrilled with what we're doing.

And of course we have personal 
and supportive home care,

which is -- I don't want 
to talk that much anymore.

It's really not probably going 
to last long in Wisconsin.

We have some centers and 
similar to what Dennis does.

Huge centers that do 25 
or $35 million of personal 
care in a year.

And some of the rest us 
got on the bandwagon and 
are not doing the same.

One's in Milwaukee and 
one's in Racine.

They're huge population bases.

It's a harder sell in our 
rural areas and much harder 
with managed care.

One of the things that we got 
to do in 2006 And if you go

to page 9 -- I was talking 
to somebody earlier,

comprehensive community 
services is a fancy word 
for skill training.

It's a service that every one of 
you provide in your organization.

It's targeted for folks 
with mental illness and 
it has a recovery,

the recovery philosophy 
is at the base of this.

We got an opportunity to 
participate in a pilot,

again, in La Crosse County,
and now we do this in 3

counties and we're going to 
be in 5 counties soon.

There was no competition.

If you can ever become
a part of the pilot,

jump at the opportunity.

If it fits what you're doing.

There's no competition.

Great opportunity to 
work out the kinks.

It's a test to see 
if it's going to work.

We had a wonderful experience.

We are still the primary 
provider in two of the 
counties of this service.

Medicaid has changed what 
they're paying for.

All of a sudden, they 
weren't paying for travel,
so we upped the rate,

so they started to pay for travel 
again because it was not very

popular when they 
pulled travel off.

So we can now drive three hours to 
provide an hour and a half of

time with a person and three hours 
back and get paid for the entire 
time that our staff person is there.

All our IL staff do CCS.

It's skill training.

That's what it is.

Some of our staff, are persons 
living with mental illness,

and there are certified peer 
specialists, some are not.

It's not required.

It's preferred that we have 
a person living with a mental 
illness providing that service,

but it's not required,
in Wisconsin,
at least.

We do a wide array 
of skill training.

A lot of them -- it can be not any 
different -- could be budgeting,

it can be cooking,
it can be household management,

but we also do a lot of mental 
health skill training.

Symptom management,
wellness management,
medication management,

do a lot of that 
with the individual,

so they have more control 
over what happens to them.

One of the things that -- during 
this whole process,

our staff got so excited about 
the opportunities for consumers 
that we now have three staff

trained -- national trainers to 
train certified peer specialists.

We have a WRAP, which is a 
Wellness Recovery Action Plan.

We have two staff that are 
certified WRAP trainers.

And we have seventeen peer 
specialists on staff.

So we can respond to need.

One of the things we are 
doing is -- in Wisconsin,

they are asking people to do 
multi-county services so we

are also at the table and 
part of that process.

We have done benefits 
assessments for 12 years.

That was all part of 
that -- helped us get our foot

in the door 12 years ago as 
part of the employment 
program that we did.

We get $65 an hour for that 
from counties and from division

of voc rehab,
we get $750 per assessment.

That's okay.
That's ten hours.

We have staff -- three staff 
that are certified or do we have

two staff and trying to 
get a third one trained?

A lot of 504 assessments.

We've been doing this 
almost since day one.

We get $65 an hour for that.

And how many of you are aware if 
a small community is going to get

a rural development loan,
to change their infrastructure,

can be sidewalks,
sewer systems,
new buildings,

that they have to have a 504 
assessment of every building 
in their community,

before they can apply 
for the loan?

That's nationwide.
Huge opportunity.

Last year, we got -- and the 
cycles, they cycle.

Some of the loans last 
three years and some last five.

So every three years 
or every five years,
we're inundated.

Last year, we had over a hundred 
requests for 504 assessments.

We had to give some of them away.

We couldn't do them all.

We didn't have the capacity.

Yes?

AUDIENCE MEMBER:  Under the 
benefits assessment,

does that include 
pass plans as well?

KATHIE KNOBEL-IVERSON:   Yes,
it does.

If someone is going to 
do a pass plan,

we get paid additional for that.

We have four staff that 
are trained in the 504.

Need to be able to do 
a good 504 assessment.

These get sent in with 
an application package.

It's a plan of correction,
for -- you go into a

township and their 
courthouse is not accessible,

they have to have a plan of 
how they're going to make it 
accessible.

So we put in -- and we get 
paid hour by hour for that.

Last week, somebody was 
late getting their 504 
assessments done.

And so they had turnover 
in their county.

It was a small county that applied 
for the rural development funds

and they were going to lose all 
their money that they put into

a new water system in 
their entire county.

And they called us in a panic.

We are doing 25 buildings and 
sites and we have three weeks 
to get them done.

And we're going to do them.

We freed up everybody that we 
could to go do those for people.

People don't blink.

Because they're getting 
millions of dollars.

They will lose 16 million 
dollars in that county if they 
don't get this plan in.

They aren't going to 
blink at paying $65 an 
hour for that service.

We also do a lot of 
home modifications.

In Wisconsin, we have a really 
strong state association.

And so when we find something,
we share,

we try to figure out how we can 
make this a statewide thing.

For example, the rural 
development thing,
all of us do that.

The home mods, we have 
always done home mods,

but in the last couple years,
we have a self-directed managed

care program called IRIS and 
there's been big changes

nationally in the children's 
waivers and I don't know how

many of you are familiar 
with the children's waivers,

but it's money that supports 
kids with any type of disability 
to stay at home.

And so -- our staff person,
Maureen Ryan,
who is wonderful,

met with Department of Health 
Services and the IRIS folks

and these folks can't go 
any other place else but us.

Because there's nobody else 
in the state that's trained.

So we get every IRIS referral 
and we get every children's 
waiver referral.

I'll talk about those more 
at length some other time.

The statewide agreement with the 
children's waivers is interesting

because some of the social 
workers want us to do things 
that we aren't comfortable with.

So we just had to have a 
meeting with three counties,

all their social workers and said,

okay, here's what we're 
comfortable doing.

We're not going to order a bed 
that's a cage for a child.

So they can't get out.

If there's an emergency 
in your family.

We will not do that.

We will not get into 
behavioral management.

We will deal with physical 
access in people's homes.

That means we're probably 
going to get less referrals.

That's okay.

It's things that 
we're comfortable with.

We do a lot assistive technology,
as Dennis does in his state.

That's another thing,
when we opened our center,

we already had an $80,000 
grant waiting for us.

Because nobody in the region 
was doing it to do assistive

technology so Wisconsin has a long 
history of accessing part of the

Rehab Act accessing, um,
let me get this here.

Assistive technology for whatever 
purpose a person needs,

whether it's work-related,
home-related,
travel-related,

we get involved in helping that 
person find what they need.

We do not sell equipment.

We don't recommend any 
particular equipment.

We give all that information 
-- we have a try-out -- do you 
have a try-out?

DENNIS FITZGIBBONS:  We don't have it,
but there is a try-out in Maine.

KATHIE KNOBEL-IVERSON:  Okay.

We have -- all the eight centers 
have a try-out loan closet and

people can come in too 
and do demonstrations,

we let people take things home,

so they don't spend money on 
things that aren't going to work.

And then we do the skill training 
tied to that assistive technology.

If a person is going to work and 
they have an open file with VR,

we get paid for that.

And counties are now, 
managed care, is paying us –

not nearly as much as we'd like,
but they hired their own

assistive technology specialist 
who -- how do I say this nicely?

Doesn't know very much about 
assistive technology.

And so we end up sometimes 
redoing assessments after 
they've done their own.

So assistive technology is 
interesting, we have three staff 
that are RESNA certified.

They are ATPs.

Assistive Technology 
Professionals.

And we wrote a grant to DVR.

And I don't know --do you have 
innovation -- I&E grants in 
your states?

Innovation and expansion grants?

We don't know?  
You might want to ask.

Wisconsin does.
I thought they were 
a national opportunity.

Sometimes those get 
targeted for certain things.

In Wisconsin, they always 
went to two technical colleges 
and nobody ever got access.

And so we asked why.

And DVR was a little 
embarrassed and they said,

oh, we don't know why these two 
colleges get millions of dollars.

And so now all the centers,
every year, we work on a project

with the local VR office and 
the whole idea is that eventually,

this will be a fee-for-service 
when we're done.

And our work-related assistive 
technology program,

that has gone wild in our region.

We can't keep up with the referrals.

It's -- whether you're going 
into someone's work site and 
assessing what they need.

We order the equipment they need,
which speeds up the outcome 
about four months.

Because the VR was 
going to order it.

They have to go through the 
purchase order process,

they have to get bids,
they have to do the whole thing.

So the consumer gets 
to pick what they want,

we purchase it and we get 
reimbursed for it from VR.

That changed the whole 
relationship with VR.

Their outcomes are 
improving drastically.

And their staff are freed 
up from all kinds of red tape.

And that was part of the I&E,
innovation and expansion grant

with DVR and we only did that 
under that auspices for two years.

Took us two years to get 
our staff trained as ATPs,

but now -- we probably get 
close to a hundred referrals.

Maybe 120 a year for 
that at $65 an hour.

And mental health, again,
I was just talking about CCS,

Comprehensive Community Services.

Mental health wellness curriculum 
is a wonderful curriculum,
it -- it instills hope.

A lot of folks with mental illness 
don't have the same level of hope

that people do with 
other disabilities.

And it's a wonderful way 
for people to understand 
that they can get well.

They may never have the 
diagnosis changed,

but they can live a decent life.

They can be parents, they can be 
aunts and uncles and they can

work and they can be on boards 
and do all sorts of things.

And this is a curriculum 
we found through SAMHSA,

the National Association 
for Mental Health.

And if you get on their website,
they just have oodles.

Just wonderful.

That's one of if things we 
might want to put on WIKI,
just the link to SAMHSA.

And we also have developed a way 
to monitor how fee-for-service

has changed our organization,
especially the people we serve.

In Wisconsin, we have what's 
called a peer review.

Where we have a copyrighted tool 
that I was part of developing

and five or six people from other 
centers come and they look at

everything you do and they want 
to make sure that you're staying

on target with the IL philosophy,

that we're staying fiscally sound 
and it's a really wonderful tool.

And during one of ours, people 
were really worried that we were

serving too many people 
with mental illness.

Yes.

So we wanted to prove that 
what we were doing was 
really a good thing.

And we -- asked the person 
that developed -- we use MyCIL 
at our center.

Any of you use MyCIL?

And we asked -- I can't 
remember her name now.

In Hawaii.
Michelle.

To change some of what we can 
collect so that we can prove that

so many of the people we were 
already serving had a mental 

health diagnosis,
we just weren't asking.

And I am guessing that's the 
same at your centers,

is that you're serving a lot 
of folks with dual diagnoses.

And sometimes you're helping 
somebody find housing and not

asking the right questions 
about what their biggest 
barrier is to housing.

Is it because they have 
schizophrenia and they

hallucinate and they're not

medicated and people are afraid of 
them in the building they're in.

And that's why they need housing 
every eight months because their 
neighbors get afraid of them.

They need to move.
Or they're evicted.

And so part of what we 
decided to do is really 
figure out -- who we serve.

And it's -- through our CSRs 
and -- everybody knows what that 
is -- consumer service record?

And I&Rs

We monitor that quarterly,
we still do.

We started that ten years ago.

And we still monitor who we serve on 
a real regular basis so we don't

feel like we are out 
of balance with disabilities.

But certain services target 
certain disabilities.

And CCS is strictly for folks 
with – you have to have 
a mental health diagnosis.

Benefit specialists is 
for any disability,

assistive technology,
typically,

but now we're getting into 
some assistive technology.

Even for folks 
with mental illness.

Because other things are 
complicating or are

barriers -- learning disability,
a brain injury,

on top of a mental health issue.

So it's really attractive; 
we're starting to spread more into 
the mental health world too.

Home modifications are typically 
physical disabilities,

elderly and children 
with physical disabilities.

And then, of course,
the comprehensive community 
services.

Overall, we saw some 
increases in who 
we were serving.

And one was children.

Which we don't serve 
very well at all.

And just this opportunity 
for us lately to do home 
mods for families.

When our staff go in there,
they don't just go in there

and do that home mod,
they talk about all our

other services and that's,
I think, probably the 
most exciting thing.

And home care, it's harder.

We try.

We try really hard to get our 
staff trained so that they

can say, I think maybe you 
need to call somebody 
about an advocacy issue.

These families that have the 
kids and some of the consumers'

households that we go into are 
desperate for access to other

services and so -- children 
are really underserved 
in Wisconsin.

With this waiver change,
they won't be.

There won't be any waiting list.

Yes, yes?
AUDIENCE MEMBER:  My center does,
much what you're talking

about -- when we go out and 
whether they're asking for

a home mod or skill 
training or whatever,

we do a complete 
needs assessment.

But the point you made,
made me think.

It's just the person that
we got to request on.

We're not looking at 
the entire family unit.

Everybody living under that roof.

So you have given me 
something to think about.

Its more that needs assessment,
we applaud ourselves for doing

everything that person needs 
besides the home mod that they

asked and I think we need to be 
looking at more as the family unit

and all of the diagnosis 
and not just something that 
we have within the box.

KATHIE KNOBEL-IVERSON:  The thing 
you just have to remember,

we can go into a home 
and people are wondering,

what the hell are 
you doing in here?

You're supposed to be in here,
you're supposed to do a ramp,
get out of our house.

So you have to be in an 
environment that people 
want you to be there.

If they want the assistance,
I would say, yeah.

We don't do needs 
assessments unless,

you know, a formal 
needs assessment 
unless people ask.

And not many people say, 
would you come in and 
assess my family?

They don't.

If there's an opportunity 
to do that, who pays for 
the assessment then?

Is that just your IL funds?  Okay.

I think sometimes at our center,
we're maybe a little quick 
sometimes to move on and don't

take a look -- as good a 
look at environments as 
we should sometimes.

But other times people are 
desperate for services.

We all know that 
people come to your 
center for one thing.

Is that always the thing 
they need or want?

It's not.

They might come to you 
because they're getting evicted 
and you find out they have lost

their job, that they have 
no health insurance,

that they don't know 
where they're going to 
eat from day to day.

So there's a whole 
bunch of things going 
on with that person.

So one of the things that 
we have really tried to 
do is try to figure out,

who's coming to us and 
why are they here?

And so we are really, really 
working hard to identify 
co-occurrence of disabilities

and MyCIL is not very co-
occurrence friendly.

You can put that they have 
multiple disabilities,

but it will not filter what 
those disabilities are.

So we are working to 
change that in our state.

Our whole state is trying to 
identify -- do a better job of 
identifying who we're serving.

Some of the positive 
characteristics of the

people we serve, it's been so 
refreshing working with folks

in the mental health system 
because people are totally thrilled

and excited about not 
just our approach,

but the whole IL 
approach to services.

We've had people,
numerous times say,

no one has ever,
in my life,
asked me what I want.

No one has ever said,
What would you like to do,

what kind of job 
would you like do?

Where would you like to live?

Who would you like to live with?

And that was -- made us so sad 
to hear that and the majority

of it was out of the 
mental health system.

So we – combine the 
recovery philosophy,

if you Google recovery,
you will find just an immense 
amount of information.

And you have to distinguish 
between AODA and mental 
health recovery.

Wisconsin also are has a great 
website for that is for peer specialists

that -- I can bring that 
to you tomorrow.

If anybody wants to get in there 
to find out more about our 
approach to mental illness.

And then we have 
consumers that 
are so motivated,

because we have high 
expectations of them.

We expect them to figure 
out how to control whatever 
they want in their lives,

whether it's their services,

whether it's their relationship 
with the overzealous parents,

whether it's the sheltered 
workshop where they work and

that we have expectations 
that they can learn and 
they can succeed.

And a lot of people have never, 
ever, had those expectations before.

We also have consumers 
who, again, become aware 
of our services.

And we get involved with people 
for many many different 
reasons and then they go,

oh, my God, you can help with 
me with this person at work 
who is bullying me?

Sure we can.

We can help you figure out 
how to resolve that issue.

So I think that's the other thing is
that our staff do a really good job

of sharing what else 
we can do for folks.

And we're excited because 
consumers develop self-reliance,

confidence and they have 
very successful outcomes.

The challenge to some of 
the fees-for-service,

and again it's the type of 
fees-for-service that we do,

especially folks living 
with mental illness,

it's a more transient,
mobile population of folks.

Homelessness is more prevalent 
than you could ever imagine,

to the point where we have 
developed a homelessness 
program and believe me,

there's no money out 
there for homelessness.

Nobody wants to pay you to deal 
with this population so we do 
fundraising and United Way.

Last year, we served 110 people 
that were homeless and it can 
suck the life out of a center.

It's a really difficult 
group of folks to serve,

especially if there's a chronic 
mental illness involved.

And so we have had to step back 
and decide that we can't serve

everybody that walks 
through our doors.

We just don't have the 
capability we don't have the funds.

People were lined up at the 
doorway in the morning with 
all their belongings.

Because they had heard we 
helped people find housing.

And we had to make it clear 
to people that we are not 
an emergency agency.

Your emergency cannot 
be our emergency.

There are places that 
are emergency agencies,

we can refer you there.

But we can't do that.

A lot of folks that come 
to us don't have any kind 
of documented history.

They don't have 
employment history,

they don't even have a history of 
their mental illness documented.

They don't have housing history or 
their housing history is terrible.

They've been evicted more 
times that you can imagine.

They might have a criminal 
record; those all come with 
a lot of the folks we're serving.

We have youth who are 
struggling with the acceptance 
of their disability.

I was talking earlier to 
somebody today about,

we just really struggle with 
getting youth involved 
-- I think it was Tim

youth involved in the 
disability movement.

Because a lot of the youth 
we're dealing with are kids 
with mental health issues.

And they're really struggling.
And so as an agency,

we are trying to figure out 
what are we doing wrong?

We need to hire some youth,
some yute we call them,

and to help figure out how 
to connect with these kids.

So that they're not a statistic 
20 years from now.

Five years from now,
they can be graduated from

college and have a family,
just like any other 18-year-old.

Under -- a lot of these folks 
are under or unemployed.

They have co-occurring disability 
complications and one of the

things if you are going 
to start to think 
about fees-for-service,

there's a much higher 
cancellation rate.

You can drive a long ways,
you can call before you leave

and you get to their house 
and they're not there.

So you have to take 
that into consideration.

How am I doing for time, Tim?

One of the things I want to talk 
about next is how we staffed and

administered some of the changes 
in our organization.

And this is really,
really,
going to depend –-

I talk about this ad nauseam 
at our state association,

is every one of your 
organizations has a culture,
whether you recognize it or not.

And it depends on how things 
happen in your organization.

Our organization is -- been 
accused of sharing way too much 
information with everybody.

That's my fault.
I don't like secrets.

I think everyone has the 
right to know what's going on.

And so I share everything 
that is not confidential.

People know about our finances.

And I'm talking about our staff,
consumers,
our board,
the community,

lots of our partners,
community partners know what's 
going on in our organization.

So this is really, really 
important to me and to our

board that everyone stayed 
informed and was part of the 
transition into fees-for-service.

Everyone had a role in the change 
and it was -- what people wanted 
to do as part of the change.

We understood what 
requirements 
there were for staff

and now again, it depends 
on which fee-for-service 
you're talking about,

but some folks had to 
have special training.

I think about assistive 
technology, our ATPs,

our Assistive Technology 
Professionals have to have

40 hours of training a year 
to keep their certification.

We have to make sure that happens.

Our peer specialists have to have 
20 hours of very specific training 
over the course of the year.

Some folks have to 
maintain their

certifications,
the ATPs.

We have actually, social 
workers in our agency,

they don't act as social workers,
but they want to maintain

the license, so we maintain 
that license for them.

And we had to develop some 
referral processes for folks.

We also needed to identify the 
staff to provide the services

and I'm going to use the -- CCS,

which is the skill training service 
for folks with mental illness.

You have to have somebody.

You can't just pick somebody 
and go, okay, you're going 
to do skill training.

And you're not 
a good skill trainer.

Has to be someone that you 
know is very good at their job.

When we got the pilot for that,

I knew -- there was no 
question about who I was 
going to put in that position.

She's the best skill 
trainer we've ever had.

She's now our IL 
director and still fills in.

She is exceptional 
at what she does.

And so that's who we 
picked to do the pilot.

She was  the only person -- and then
she was going to train someone

else if we got more referrals 
than we could handle.

So I think it's really important 
that whatever service it is that

you're going to do that you find 
someone that is going to be good

at that particular service.

They have to be 
enthusiastic and willing.

But they also have to be 
very good at what they do.

I have wonderful, enthusiastic,
and willing staff, that 
aren’t good skill trainers.

And I have folks who are 
very good at other things,

but not very enthusiastic 
-- didn't want to do it.

So you have to figure out 
who is going to match that.

They have to be very 
professional,

they have to be very 
good at documentation

and they had to know 
how to use MyCIL very 
effectively to collect

the outcomes that 
we needed 
for the service.

Also had to identify some managers 
and because we had -- we still do.

We have a very slim 
administrative structure.

For a long time,
it was me and a bookkeeper.

Now it's me,
a bookkeeper and 
a fundraiser.

We are very slim.

So when you start to talk 
about identifying managers,

I took to heart -- I can't 
remember how many years ago,

at a NCIL conference,
people talked about the fact

that there's going to be 
a crisis in this country soon,

because, a lot of us directors and 
assistant directors -- we're going

to retire and we have to start 
looking at who in the organization

has the desire and the 
skill set to be managers.

About four years ago,
we took a huge risk.

We had an all-staff meeting 
and I laid it out there.

I'm going be gone, I'm going 
to leave and I need to know

that we have good managers 
in this organization.

I need to know who's interested.

And we poured hundreds 
of hours into mentoring,

training and 
educating these folks.

Along the way, lots of people 
fell off because they weren't

really that interested 
or they realized they 
didn't have the skill set.

I now have three of the best 
managers I have ever had.

I have an IL coordinator, I have 
an IL director and I have 
a mental health—I have four.

We took three people that 
had never thought about 
being managers.

And they became managers.

And it took a long time.

That was what we needed to 
do as an organization.

Now I feel I could leave 
tomorrow and IL would be fine.

Not personal care,
but IL would be fine.

So you need to find 
strong supervisors,

they need to understand the 
parameters of whatever project 
you're going to do,

they need to be a strong 
communicator and they need 
to value quality services.

I have it written down here 
that I need to share a story.

We have -- good communicators 
have to be able to tell people 
what you do effectively,

how good you do it and 
what kind of outcomes you have.

And we have a new staff person.

Five minutes?  
Ten?  Okay.

She was pretty new.
Been around a year 
or so and we thought,

She's such a good 
communicator.

We are going to send her to this 
committee and we are going to let

her be there and we got 
feedback about the fact that

this woman can't 
talk off the cuff.

That she pretty much -- 
had a terrible time.

We had to bring her back and
asked what's going on?

And she said I thought 
I was doing a good job,
and then I got so nervous,

and I couldn't do this -- so 
now she has a little spiel that

she can do, she practices 
it and we decided to do 
that with everybody.

That everybody, in their own way 
needs to give the same message 
to the entire community.

So our marketing and 
fundraising person calls 
it the elevator speech.

Everybody should be able 
to tell you the same thing.

And poor Sadie,
bless her heart,

now she is able to – 
off the cuff,

she is doing it just like that.

She wasn't self-aware 
enough about what she 
could speak about effectively.

We also had to make sure 
that the accountant 
understood the billing process,

to set up tracking of costs 
and we have -- Dennis and 
I were talking about this.

I had to fire our 
bookkeeper because 
she just didn't want to do it.

And the billing process 
was really going to change.

And she just didn't want 
the complications that 
came with it.

So we had to replace her 
and at that point,

we went from a bookkeeper 
to an accountant.

So -- it was wonderful.

People who could run reports,
and I feel that was one of

the transitions we made 
-- eight years ago,
almost nine now,

if you can not have a bookkeeper 
and have someone really

professional in that position,
it's really helpful to get good 
reports and good information.

Because I have to tell you.

It's gotten more 
and more complicated.

Some of the services that 
we're providing and some of 
contracts that we're doing,

we have to report 
information that,

eight years ago, it
wouldn't have mattered

if whether we wanted to 
report it or not, we couldn't.

It just wasn't there.

And now you need a really 
good accounting 
software and you need a

really good data collection 
system for your programs.

Those are imminent if you're 
going to start to go out and

go after contracts or
try to do fee-for-service.

We have set up some benchmarks.

This, again, was back to our skill 
training that we were selling.

We set benchmarks for when 
we could increase staff.

Because when we 
had Alicia do the 
skill training,

she was the 
skill trainer 
extraordinaire,

she was already 
working 
full-time for us.

She was already doing IL.

And so we pulled her 
out and said,
you're probably going

to eventually be doing 
20 hours a week.

And so we had this 
void that was going to 
happen in our organization.

So she said, when can 
we hire somebody?

So we immediately set 
benchmarks about 
income and the cost it

would take to bring 
somebody into our 
organization to fill that void

and then she would 
supervise them, versus 
do the direct service.

We had -- at that point,
we hadn't -- we don't have

an assistant director right now.

We had myself and the 
assistant director did 
all the monitoring of all

the outcomes for all the new 
contracts and the services.

In Wisconsin, they're 
program outcome-crazy.

It's -- we don't have 
any contract that doesn't 
have outcomes tied to it.

It's been that way for 
years in Wisconsin.

That was easy.

We had to track actual 
costs versus income.

We had to monitor complications.

And believe me, there's going to 
be complications of a new service.

And we had to continue to work 
at providing staff recognition,

kept the board informed 
and the kinds of 
complications that we

had were that lots of referrals 
just didn't fit, the program that 
we were running.

Social workers still thought they 
knew what was best for consumers,

and we tried to get them 
working on a project,

like, I don't want to lose weight.

I don't want to exercise.
That wasn't my idea.

My social worker thought 
I should do that.

And we had to make it really 
clear to the referral source

that we weren't going to take 
these kinds of referrals.

And it's really made 
a huge difference in 
how they get goals and

objectives developed 
with consumers.

We also have a mental 
health drop-in center.

It's, again, another contract 
that we were asked to take over.

It was a horrible old building.

It's now really nice place.

We've pumped in -- I 
have about $30,000.

And I would guess we did about 
$50,000 now of improvements in

the building and it really 
has increased our exposure 
to the community.

We've had really nice 
articles in the newspaper,

and we can do fundraising around 
it and people basically say,

How much do you want?

And we are talking, again,
about expanding our hours

there because the people see 
the outcomes that happen there.

When we decided to do 
examples of fees-for-service, 
go to page 23 here.

We took a lot of information 
from our board and staff.

We got a lot of input and again,
this is a -- back to the culture

of your organization; 
we were able to get 
wonderful ideas from our

staff that helped us resolve 
some of our issues with the 
drop-in center.

And the county said, 
of course we will do that for you.

And this can be any service,
but it was so easy to do 
for our drop-in center.

The drop-in center we took 
over had a terrible reputation.

Awful, awful things were 
going on in that building.

So we decided to do a publicity 
blitz with a very positive focus 
about the outcomes there.

And we had to have 
neighborhood meetings,

to make sure that people knew 
that it was under new management

that we weren't going 
to allow these kinds 
of things to happen.

There was drugs and 
sex and all sorts of things 
going on there, it was awful.

And then we did press releases 
constantly until we felt

like people were sort of 
sick hearing about it.

And they were okay with it.

We worked with our 
accountant to make 
sure -- we actually negotiated

with the county and got an 
advance, a start-up advance,

if you get that 
opportunity, take it.

If you're billing for fee-for-services,
then at the end, you -- they might

not pay you but you'll 
have money in the bank.

We trained staff and we learned 
a lot at the drop-in center.

It was interesting to find out 
what people's visions of 
consumer control was.

Now all we do at that drop-in 
center is I make sure they 
enough money to run.

Consumers and staff run the place.

And they just love 
the opportunity.

They have an advisory board.

We have committees over there 
and they tell me what they want.

If they want me to go 
after more money, then 
we go try to find more

money so they can -- they want 
a recreation program started now.

So now we're trying to figure out 
how we can fund that for them.

I want to talk about, 
just quickly and then
I'll be done here.

Marketing tools, your 
best marketing tool is 
high quality services.

If you don't provide 
a quality service,

doesn't matter -- doesn't matter 
what else you put in the paper

or in your newsletter 
if the word starts to 

spread that your service
isn't a quality service.

And you need to have 
positive outcomes.

And need to know how 
to share those.

I heard everybody telling 
wonderful stories this morning.

I think in IL, we are so focused 
on getting the job done,

that we don't take the 
time to collect stories.

How many of you collect 
stories on a regular basis?

Do you do it on a closed 
site on your computer or 
something or how do you --

Mike. Can use the

AUDIENCE MEMBER:  We have 
a consumer success story

template that we have 
made accessible for

those with visual 
impairments in

our agency as well as others.

They put the client's picture in,
they sign a release,

they put the success story 
and they write it in their own

words with the assistance,
if needed, of staff.

And I make sure that they 
put what goals they 

are working toward,
which ones they accomplished,

which ones they're still 
working toward.

It's a one page thing that 
is helpful in doing outreach

to funders and others 
and for fundraising.

And that was one of the first 
things I made them do when 
I came on board.

KATHIE KNOBEL-IVERSON:  Good job.
That's fantastic.

One of the things that you need 
to know -– I was talking

about the elevator speech,
you need to do presentations 
whenever you can.

And you need to include the 
fact you do fee-for-service.

People need to understand 
that the free service

that we're talking about,
are for folks that don't

have any funding 
connected to them.

We really value what we 
do and if you value it,

it's worth being paid for.

So I think -- we have 
everybody trained,

but I have about six people
-- they are just the best 
at presentations.

We refer to them as 
the dog and pony show.

Any time we get the opportunity,
we are out doing a presentation.

And I just listed some of the 
folks, but it can be to United Way,

it can be, when we're 
out doing like a health 
fair or something,

we just make sure that we 
have other things there.

Not just specific 
to the population.

Get invited to a lot of 
elder fairs in Wisconsin,

health and safety types of issues 
and so we go there and talk about

all of the other 
services that we provide.

You need to go to consumer 
groups, professional groups.

We have decided one of our -– 
we've really changed our

relationship with the 
Division of Voc Rehab.

And we now insist that 
every three months,

we come in and do a two-hour 
presentation about who we 
are and what we do.

Whether they want it or not.

They like it.
They want us to come in.

But it's really amazing how many 
councilors don't show up for those 
mandatory training requirements.

And then they miss 
out on what's going on.

So we do them quarterly 
now with VR.

A lot of our fee-for-services,
IL services are so closely 

related -- in Wisconsin,
again, the whole peer support 

thing, if anyone's interested,
if you have that going on 

in your state, we have a 
lot in Wisconsin we'll share.

We have a certified test that 
I believe the state would be

willing to share if any state 
wanted to go that route.

We do skill training,
assistive technology.

We make sure that all 
our referrals are aware 
of all our services.

We talked about that a little bit.

And the consistent language 
that we make sure staff have.

Because our best marketing tool,
besides the positive services 
is the consumers.

Information spreads 
through their grapevine.

It's amazing.

And to have good 
consumer outcomes.

We need to make sure that 
the consumer owns their goals,

that they expect success from us,
that we keep an open dialogue

with consumers, so that they know 
what our expectations are and we

know what theirs are and that you 
collect good data and that you

provide monthly 
consumer-specific 
documentation.

That's probably was one of a barrier.

I had no idea how many people 
couldn't write good documentation.

We had to have skill 
training for our staff,

to make sure they knew 
how to document correctly.

And then our agency outcomes was 
to have good data collection and

to provide thorough and timely 
reports and that people are satisfied

with whether it's the buyer or the 
recipient of the service that they

are both very satisfied.

We talked about that earlier,
with the service that we provide.