BILL ANALYSIS Ó
AB 1231
Page 1
Date of Hearing: April 16, 2013
ASSEMBLY COMMITTEE ON HUMAN SERVICES
Mark Stone, Chair
AB 1231 (V Manuel Perez) - As Amended: March 21, 2013
SUBJECT : Regional centers: telehealth and teledentistry
SUMMARY : Requires the Department of Developmental Services
(DDS) to inform all regional centers of their authority to use
telehealth and teledentistry for service delivery, as defined,
for regional center consumers with autism spectrum disorders or
pervasive developmental disorders.
Specifically, this bill :
1)Declares the following legislative findings:
a) Autism spectrum disorders (ASD) now affect one in every
88 children of all ethnic, racial, and socioeconomic
backgrounds;
b) ASD is now the fastest growing developmental disability
in California and the nation and is more common than
childhood cancer, juvenile diabetes, and pediatric AIDS
combined;
c) Approximately two-thirds of all new consumers who are
entering the regional center system are now diagnosed with
ASD;
d) Behavioral health treatment (BHT), also known as early
intervention therapy or applied behavior analysis, is
established to improve brain function, cognitive abilities,
and activities of daily living for a significant number of
individuals with ASD, but may not be accessible or
available in underserved communities; and
e) A significant number of individuals with ASD suffer from
inadequate dental care.
1)States the Legislature's intent to do the following:
a) Improve access to treatments and intervention services
for individuals with ASD or other developmental
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disabilities and their families in underserved populations;
b) Provide more cost-effective treatments and intervention
services for individuals with ASD or other developmental
disabilities and their families;
c) Maximize the effectiveness of the interpersonal and
face-to-face interactions that are utilized for the
treatment of individuals with ASD or other developmental
disabilities;
d) Continue maintenance and support of the existing service
workforce for individuals with ASD or other developmental
disabilities; and
e) Utilize telehealth and teledentistry to improve services
for individuals with ASD and other developmental
disabilities.
1)Requires DDS to do the following:
a) Inform all regional centers that behavioral health
treatment may be provided through the use of telehealth and
that dentistry may be provided through the use of
teledentistry;
b) Request regional centers to consider the use of
telehealth and teledentistry in each individual program
plan (IPP) and individualized family service plan (IFSP)
that includes a discussion of behavioral health treatment
or dental health care; and
c) Provide technical assistance to regional centers through
the use of existing resources, and in partnership with
other organizations and stakeholders.
1)Requires the use of telehealth and teledentistry services to
be considered for inclusion in training programs for parents
of regional center consumers, including group training.
2)Authorizes DDS to implement vendorization subcodes for
telehealth and teledentistry services and programs.
3)Requires providers of telehealth and teledentistry services to
maintain the privacy and security of confidential consumer
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information.
4)Provides that a consumer may receive behavioral health
treatment and teledentistry services through the use of
telehealth or teledentistry for a provisional period of 12
months, during which a consumer may return to his or her
preexisting services, as defined in the consumer's IPP or
IFSP, as specified.
5)Provides that services provided through telehealth and
teledentistry shall be done so on a voluntary basis and may be
discontinued at the request of the consumer or the consumer's
representative, as specified. Requires the regional center,
upon receiving such a request, to convene a review to
determine alternative, appropriate means for continuing to
provide a service previously delivered through telehealth or
teledentistry.
6)Requires DDS, on or before December 1, 2017, to forward to the
fiscal and appropriate policy committees of the Legislature
any information provided by regional centers to assess the
effectiveness and appropriateness of providing telehealth and
teledentistry services to regional center consumers through
the IPP and IFSP processes.
7)Provides that a provider of telehealth or teledentistry
services shall be responsible for all expenses and costs
related to the equipment, transmission, storage,
infrastructure, and other expenses related to telehealth and
teledentistry.
8)Specifies a sunset date of January 1, 2019 for the provisions
included in this bill, as specified.
EXISTING LAW
1)Establishes the Lanterman Developmental Disabilities Services
Act (Lanterman Act), under which the Department of
Developmental Services (DDS) is authorized to contract with
private non-profit regional centers to provide case management
services and arrange for, or purchase, services that meet the
individual needs and choices of each person with developmental
disabilities, regardless of age or degree of disability, and
at each stage of life, to support their integration into the
mainstream life of the community.
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2)Grants all individuals with developmental disabilities, among
all other rights and responsibilities established for any
individual by the United States Constitution and laws and the
California Constitution and laws, the right to treatment and
habilitation services and supports in the least restrictive
environment.
3)Requires the development of an Individual Program Plan (IPP)
for each regional center consumer, which specifies services to
be provided to the consumer, based on his or her
individualized needs determination and preferences, and
defines that planning process as the vehicle to ensure that
services and supports are customized to meet the needs of
consumers who are served by regional centers.
4)Requires that the planning processes to create an IPP include:
a) A statement of the individual's goals and objectives, a
schedule of the type and nature of services to be provided
and other information and considerations, as specified;
b) Review and modification, as necessary, by the regional
center's planning team no less frequently than every three
years; and
c) Statewide training and review of the IPP plan creation,
as specified.
1)Establishes that an infant or toddler under age 3 who is
eligible for regional center services shall have an
individualized family service plan (IFSP) to direct services,
as specified, and defines the types of services, supports and
staffing that should be considered when creating the plan.
2)Enacts, through federal law, the Early Intervention Program
for Infants and Toddlers with Disabilities of 1986 under the
Individuals with Disabilities Education Act (IDEA).
3)Enacts the Telehealth Advancement Act of 2011, and defines
telehealth as the mode of delivering health care services and
public health via information and communication technologies
to facilitate the diagnosis, consultation, treatment,
education, care management, and self-management of a patient's
health care while the patient is at the originating site and
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the health care provider is at a distant site, as specified.
4)Defines behavioral health treatment as professional services
and treatment programs, including applied behavior analysis
and evidence-based behavior intervention programs, which
develop or restore, to the maximum extent practicable, the
functioning of an individual with pervasive developmental
disorder or autism, as specified.
5)Defines teledentistry as the use of information technology and
telecommunications for dental care, consultation, education,
and public awareness, as specified.
6)Prohibits health care service plans, health insurers, and the
Medi-Cal program from requiring in-person contact to occur
between a health provider and a patient before payment is made
for covered services appropriately provided through
telehealth, subject to the terms and conditions of plan
contract or the reimbursement policies adopted by the
Department of Health Care Services.
FISCAL EFFECT : Unknown
BACKGROUND
The Lanterman Developmental Disabilities Services Act (Welfare &
Institutions Code § 4500 et seq.) guides the provision of
services and supports for Californians with developmental
disabilities. Each individual under the Act, typically referred
to as a "consumer," is legally entitled to treatment and
habilitation services and supports in the least restrictive
environment. Lanterman Act services are designed to enable all
consumers to live more independent and productive lives in the
community.
The term "developmental disability" means a disability that
originates before an individual attains 18 years of age, is
expected to continue, indefinitely, and constitutes a
substantial disability for that individual. It includes
intellectual disabilities, cerebral palsy, epilepsy, and autism
spectrum disorders. Other developmental disabilities are those
disabling conditions similar to an intellectual disability that
require treatment and management similar to that required by
individuals with an intellectual disability. This does not
include conditions that are solely psychiatric or physical in
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nature, and the conditions must occur before age 18, result in a
substantial disability, be likely to continue indefinitely, and
involve brain damage or dysfunction. Examples of such
conditions might include intracranial neoplasms, degenerative
brain disease or brain damage associated with accidents.
Direct responsibility for implementation of the Lanterman Act
service system is shared by the Department of Developmental
Services (DDS) and 21 regional centers, which are private
nonprofit entities, established pursuant to the Lanterman Act,
that contract with DDS to carry out many of the state's
responsibilities under the Act. The principal roles of regional
centers include intake and assessment, individualized program
plan development, case management, and securing services through
generic agencies (e.g., school districts, In-Home Supportive
Services) or by purchasing services provided by vendors.
Regional centers also share primary responsibility with local
education agencies for provision of early intervention services
under the California Early Intervention Services Act (e.g.,
Early Start Program). The regional center caseload includes
over 250,000 consumers who receive services such as residential
placements, supported living services, respite care,
transportation, day treatment programs, work support programs,
and various social and therapeutic activities. Approximately
1,600 consumers reside at one of California's four Developmental
Centers-and one state-operated, specialized community
facility-that provide 24-hour habilitation and medical and
social treatment services.
Services provided to people with developmental disabilities are
determined through an individual planning process. Under this
process, planning teams-which include, among others, the
consumer, his or her legally authorized representative, and one
or more regional center representatives-jointly prepare an
Individual Program Plan (IPP) based on the consumer's needs and
choices. The Lanterman Act requires that the IPP promote
community integration and maximize opportunities for each
consumer to develop relationships, be part of community life,
increase control over his or her life, and acquire increasingly
positive roles in the community. The IPP must give the highest
preference to those services and supports that allow minors to
live with their families and adults to live as independently as
possible in the community.
Autism
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Autism is defined as a group of neurodevelopmental disorders
linked to atypical biology and chemistry in the brain and
generally appearing within the first three years of life.
Autism is further characterized by delayed, impaired or
otherwise atypical verbal and social communication skills,
sensitivity to sensory stimulation, atypical behaviors and body
movements, and sensitivity to changes in routines. While
symptoms and severity differ among individuals with an autism
diagnosis, all individuals affected by the disorder have
impaired communication skills, difficulties initiating and
sustaining social interactions and restricted, repetitive
patterns of behavior and/or interests. Autism spectrum
disorders (ASD), is one of the commonly-used terms to describe
autism and other pervasive developmental disorders (PDD), and it
more appropriately captures the array of symptoms and varying
levels in the severity of symptoms experienced by individuals
with a diagnosis within ASD.
According to the Centers for Disease Control (CDC) Autism and
Developmental Disabilities Monitoring (ADDM) Network, the
estimated prevalence of ASD for children born in 2008 was 11.3
per 1,000 children, which translates to one in 88 children.
This is a drastic increase from the average prevalence for 2006,
which was 9.0 per 1,000, or one in 110 children. ASD continues
to be 4 to 5 times more prevalent for boys than for girls.
Quarterly DDS data from March 2013 shows that 59,852 regional
center consumers have an autism diagnosis, which is nearly
double the number of individuals with the same diagnosis served
by regional centers in 2007. Among the individuals with autism
served by the regional centers, 11,484 are female and 52,930 are
male, and 40% of the population with an autism diagnosis is 0 to
9 years old. DDS additionally administers the Early Start
program in California, which provides a broad scope of
behavioral intervention and family support services to infants
and toddlers under the age of 3 who are 'developmentally
delayed' or have an 'established risk' or are 'at high risk' of
a developmental delay.
Early Intervention Services
Research shows that a child's development can be greatly
impacted by early intervention treatment services, especially
when provided during a child's first three years. During that
time, a child is developing motor skills and language, and
begins to socialize with others. Early intervention services
for babies and toddlers that have been diagnosed with, or seem
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to be at risk for, a developmental delay or disability often
include physical, cognitive, communication, social/emotional and
self-help skill building. While there is no proven cure for
ASD, early intervention can dramatically change the trajectory
of a child's life over time, including his or her ability to
learn new skills throughout childhood and the ability to
integrate into, and have a positive relationship with, his or
her community.
Behavioral health treatment (BHT)
As defined in statute, BHT includes behavioral analysis and
interventions that can develop or restore the functioning of an
individual with pervasive developmental disorder or autism.
Applied Behavior Analysis (ABA)
Whereas behavior analysis is the experimental analysis of
behavior and focuses on the principles that explain how learning
takes place, applied behavior analysis involves the design,
implementation and measurement of environmental variables and
modifications to the environment that can produce improvements
in behavior. ABA therapy has been used for decades as an
intervention therapy for individuals with autism and related
disorders, and ABA therapy approaches have been developed over
time to improve learning ability, skill building and overall
quality of life for individuals with autism.
Early Start Denver Model (ESDM)
As established by the creators of the model, the primary goal of
the ESDM, developed by Dr. Sally Rogers and Dr. Geraldine
Dawson, is to "improve the quality of life for each person with
ASD, characterized by personal feelings of efficacy, meaningful
inclusion in community, individual exploration of interests and
use of talents, and satisfying relationships." ESDM
intervention takes place in a child's home, and is a
relationship-based intervention that is provided by trained
therapists, which involves parents and families during natural
play time and other daily routines. While there is currently no
cure for ASD, behavioral interventions like the ESDM have been
developed to improve overall functioning and learning while
decreasing the symptoms of ASD.
Telehealth and Teledentistry
The Telehealth Advancement Act of 2011 was established in AB 415
(Logue) Chapter 547, Statutes of 2011. One of the primary goals
of telehealth under the Act is to expand health care consumers'
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access to convenient and quality care in an effort to maintain
or improve the physical and economic health of medically
underserved communities. Telehealth is meant to enhance the
overall health care delivery system while saving money,
preserving health-related jobs, and increasing meaningful and
positive interactions between patients and providers.
As with the more general application of telehealth,
teledentistry gives individuals with developmental disabilities
who may not otherwise be able to receive care in a regular
dental office setting-due to distance or discomfort, for
example-the opportunity to interact with care professionals
while they're in their own homes, schools, or other comfortable
and familiar settings. Allowing local health providers to
interact with other health providers in another location
remotely can be useful in obtaining additional input on what
might be complex and otherwise unaddressed conditions, therefore
increasing the quality of care provided to a patient and
potentially improving long term oral health outcomes.
COMMENTS :
This bill is part of a package that arose from a hearing in 2012
by the Senate Select Committee on Autism & Related Disorders
that focused on disparities in available services and service
delivery in underserved communities. As a result of the
hearing, the Select Committee convened a taskforce to address
disparities in the allocation of regional center resources
across different racial and socio-economic groups. In order to
reach underserved communities as effectively and efficiently as
possible, the report recommends alternatives to customary
service provision, such as the use of center-based therapy, home
and community-based therapy and the use of
telehealth/telemedicine for parent training and direct service
delivery.
While the legislative findings and declarations in the bill
focus on ASD, promoting the use of telehealth and teledentistry
to provide better access to services and to provide treatment
and services in the most competent, equitable, and
cost-effective manner possible are appropriate goals for all
individuals served in the regional center system. It may be the
case that some services frequently, though not exclusively, used
for individuals with ASD are especially amenable to delivery
through telehealth, including training for parents on behavior
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intervention techniques.
Need for the bill
The author states, "Approximately two-thirds of all new regional
center consumers are diagnosed with autism spectrum disorders
(ASD) and require 25-40 hours per week of behavioral health
treatment (BHT). Additionally, poor dental care is an ongoing
problem for developmentally disabled individuals whose
challenges may prevent them from following typical dental
protocols and increase the likelihood that unfamiliar faces
(dental professionals) and noises (dental tools) will be
difficult to tolerate. Many regional center consumers do not
have adequate access to BHT and dental care. When regional
center consumers forego dental care or sufficient hours of
behavioral health treatment, the cost to the state is
significant. Often, telehealth is a viable, affordable
alternative to in-person care and treatment. AB 1231 offers a
way to increase access to vital healthcare, maintain a high
standard of care, and decrease transportation costs that are
crippling regional center budgets."
A prior version of this bill (SB 764, Steinberg) was vetoed by
the Governor, who stated the goals of the bill could already be
accomplished under current law. However, while the Lanterman
Act grants regional centers the authority to use innovative
service delivery mechanisms, and there is nothing in statute
precluding regional centers from promoting service delivery
through the use of telehealth or teledentistry, the author has
noted that providers have perceived reluctance on the part of
regional centers to integrate telehealth into their treatment
models without explicit authorization from DDS. This bill is,
in part, intended to clarify scope and process for regional
centers, which the author hopes will result in an increased
willingness to seek appropriate and desired services for
regional center consumers through the use of telehealth and
teledentistry.
While the language in this bill addresses many of the concerns
that were expressed with respect to the previous version, there
are still some provisions in the bill that don't fit within in
the current context of the IPP process. In particular, the
subdivision allowing a consumer to receive services through
telehealth and teledentistry "on a provisional basis" for 12
months, during which "any consumer who receives services through
the use of telehealth or teledentistry may return to his or her
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preexisting services" is inconsistent with the structure of the
IPP process. In some cases, the service that is delivered to a
consumer through the use of telehealth or teledentistry will be
a new service for the consumer, and there will be nothing for
the consumer to "return" to in the IPP. In other situations in
which a consumer is receiving behavioral health therapy, for
example, and has a new IPP developed to include receipt of
behavioral health therapy through the use of telehealth rather
than through the previously authorized mechanism, nothing
precludes the IPP from including more than one service delivery
mechanism for a particular service. While some IPPs have
contingency plans in place for potential emergencies, IPPs can
also address shifts in a particular service or service delivery
method if, for example, the service a consumer is receiving is
not beneficial and the turnaround time for a new IPP process
would delay an immediately necessary service. Furthermore, if
there is not a contingency plan related to telehealth or
teledentistry in a consumer's IPP, subdivision (f) in Section 2
of the bill addresses the right to terminate the use of
telehealth or teledentistry as a mechanism for service delivery
and reengage in the IPP development process to determine more
suitable and agreed upon services and delivery mechanisms.
Subdivision (f) is consistent with current statute allowing a
consumer or the consumer's appropriate representative to request
an IPP review.
PROPOSED AMENDMENT
Considering the aforementioned inconsistency between language in
the bill and the current statute and practice related to the
IPP, staff recommends the following amendment to WIC Section
4686.21(e), which would strike the language on page 4, lines 1
through 12:
1 (e) A consumer may receive behavioral health treatment and
2 dentistry services through the use of telehealth or
teledentistry on
3 a provisional basis with the consent of the consumer or, as
4 appropriate, the consumer's parent, legal guardian, or
5 conservator, as set forth in the consumer's IPP or IFSP. The
6 provisional period for receiving services through the use of
7 telehealth or teledentistry shall not exceed 12 months.
During the
8 provisional period, any consumer who receives services
through
9 the use of telehealth or teledentistry may return to his or
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her
10 preexisting services, as defined by the consumer's IPP or
IFSP,
11 that were in place prior to the commencement of the
telehealth or
12 teledentistry services, subject to subdivision (f).
PRIOR LEGISLATION
SB 764 (Steinberg), 2012, was substantially similar to this
bill. As introduced, the measure addressed the use of telehealth
to provide services to individuals with ASD. It was later
amended to address individuals with ASD and other developmental
disabilities, similar to this legislation. Vetoed by the
Governor.
AB 415 (Logue), Chapter 547, Statutes of 2011 repealed the
Telemedicine Development Act of 1996, changing the reference
from "telemedicine" to "telehealth", revising confidentiality
and privacy standards, consent requirements, and other health
provider and insurance requirements for telehealth.
SB 1665 (M. Thompson), Chapter 864, Statutes of 1996 enacted the
Telemedicine Development Act of 1996, which imposed several
requirements governing the delivery of health care services
through telemedicine. Prohibited health insurers from requiring
face to face contact between a health care provider and patient
for covered services appropriately provided through
telemedicine.
REGISTERED SUPPORT / OPPOSITION :
Support
ACT Today
Association of Regional Center Agencies (ARCA)
Autism Research Group
Institute for Behavioral Training (IBT)
The Children's Partnership
Opposition
None on file
Analysis Prepared by : Myesha Jackson / HUM. S. / (916)
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319-2089