New Episode Alert: Order of Selection – A Candid Look Inside Kentucky’s VR Challenges and Solutions

In this episode of Manager Minute, host Carol Pankow sits down with Cora McNabb, Executive Director of Kentucky Combined, for an honest, in-depth conversation about how her agency is responding to the rising fiscal pressures in vocational rehabilitation.

Facing skyrocketing service costs in the wake of the pandemic, McNabb shares how Kentucky made the tough but necessary decision to implement an Order of Selection. She walks through the agency’s strategic approach, including cost containment measures like staffing freezes, policy changes, and clear, consistent communication.

Listeners will gain valuable insights into:

·       Using data to drive timely and effective decisions

·       Building transparency and trust through fiscal openness

·       The power of collaborative leadership in times of change

·       Why engaging RSA early and assembling diverse internal teams makes a difference

This episode offers practical advice and real-world examples for VR leaders and decision-makers working to maintain service delivery in a rapidly evolving landscape.

Tune in and be inspired to lead with clarity, collaboration, and a commitment to sustainability.

Listen Here

 

Full Transcript:

 

Cora: How quickly things can accelerate, because you can be okay one month and then a lot of case service costs hit in the next month. Oh, you're not looking so good.

 

Carol: Having that bigger group. Looking at the situation, I think more minds make for better observations about what's happening in perspective. You can't do this by yourself

 

Cora: moving forward, I think that we're going to have deeper dives into the programmatic and fiscal data at our meetings than what we were having.

 

{Music}

^{Intro Voice: Manager Minute brought to you by the VRTAC for Quality Management, Conversations powered by VR, one manager at a time, one minute at a time. Here is your host Carol Pankow.}

 

Carol: Joining me in the studio today is Cora McNabb, director of Kentucky Combined. Cora, it's so great to see you. Thanks for being here.

 

Cora: Thanks for having me.

 

Carol: Well, so over the last five years, the fiscal landscape for the VR program has been shifting, and the pandemic had led to a slowdown in spending as customer demand decreased. But now things are ramping up again, including inflation. In March, I recorded a podcast featuring RSA in Indiana, combined director Theresa Kolezar on this very topic. CSAVR also highlighted it in a general session, and the VRTAC-QM released a tool to help state VR agencies navigate order of selection. Today, I want to have a real time discussion with Cora about how she and her team are navigating the order of selection process in Kentucky. As one of our more seasoned state directors, she's in the midst of working through these challenges, and I think it's important to hear firsthand what that looks like. So let's dig in. So, Cora, can you tell our listeners a bit about yourself and your journey into VR?

 

Cora: Sure. I started out in the early 90s in a nonprofit organization. I never finished college. And so about that time, my mom died and I decided to go back to college and finish. And I did a practicum in the nonprofit, and from there on, I was hooked. And it was actually a sheltered workshop at that time. And I started out in vocational evaluation. That was around the time, if you remember, supported employment started to grow. And so I had the privilege of starting that and taking over the oversight of the supported employment program. And I was there for about 14 years, and then we moved from Indiana to Kentucky. And I really didn't even want a job right away. But there was an opportunity to be an administrator for the blind agency. And I took that job. And so 20 years later, here I am and I've been the executive director. This is my sixth year.

 

Carol: Wow. You have a very similar background to me because I started out in that world too, of sheltered work, and then when supported employment came around, ended up leading actually in our state hospital, one of the programs to get our folks out into the community working in supported employment. It was so crazy. I look back at that and how far we've all come. That's pretty cool. So how big is the VR program in Kentucky? Like how many staff and customers do you serve and what's your budget look like to give people kind of a sense of scope?

 

Cora: Our budget is probably around 90 million. That includes everything. Last year we served about 40,000, and that would be also including pre-employment transition services in there. And so currently we have about 480 staff, of which around 140 of them are VR counseling staff.

 

Carol: Wow, you are not a small program. I didn't realize you were quite as big as you are. So how has the fiscal landscape changed for your agency over the last five years.

 

Cora: Our consumer services has really seen an unprecedented increase in cost after Covid 19. The pandemic and in the last several years since 2021, we have seen increases in all areas, applications, eligibilities, cases, employment outcomes as well as the numbers served. And obviously if you've got increases there, you've got increases in expenditures and you have to take into account how the cost of services have increased. Our applications from 2021 till 2024 increased 95%. Our eligibility is 102% and our expenditures increased 72%. Of course, that also meant our employment outcomes increased as well. So we've increased a lot.

 

Carol: Holy smokes I haven't heard numbers that big? That is huge. You know, I wonder too. Some people have been telling me that the customers that they're seeing now coming in the door are also different than kind of pre-pandemic that they said, folks that they're serving when they're looking at case characteristics are tending to be more complex. And so in addition to kind of everything going up, the individuals needing service need more things. And so the cost per case has also gone up. Has that been the case for you all?

 

Cora: Yes. The cost per case has also gone up.

 

Carol: Interesting. So, you know, during the times of plenty when the message was spend, spend, spend. What kind of strategies did you implement at that time? Because I remember you back then going like, oh my gosh, we gotta, we have to spend all this money.

 

Cora: Yes we did. We had a lot. We had like a full year of carryover. We increased tuition costs. You know what we paid for tuition. We suspended cost sharing or the financial needs testing. We suspended that we gave raises and we hired additional staff because the demand and, you know, we had long wait times in some of our more urban areas. And so we added additional staff to handle the caseloads.

 

Carol: Yeah. I remember you saying way back when, I think you had a region where you couldn't get counselors for quite some time. It was way over a year, and you were just dying to get those salary increases to see if you could get folks in. So are you now covered statewide with staff?

 

Cora: Yes. Since we have implemented the wages and then staff got additional wages as well, you know, annually through the state fiscal year, our turnover went from around 44% to about 2 to 3%. So we have a very stable workforce, which I think also contributed to how many people we were serving in cases that we were seeing.

 

Carol: So that's pretty amazing. So you can see all the, how the strategies are playing out. You know you are keeping your staff. That's been good. But then all the other pieces that you put into play, like suspending, cost sharing and all of that. What are you finding is happening today?

 

Cora: Well, we know that agencies rising costs against the estimated expenditures that we have in the available funding has what has pressed us to look at entering order of selection, because we know that at the end of the year, we will have spent more than what we have if we don't.

 

Carol: So what steps have you been taking to implement the order of selection?

 

Cora: A lot. We looked at both fiscal and programmatic. We did fiscal forecasting from 2021 through 2024. We looked at four years and we analyzed that data for all areas, referrals for applications. We looked at attrition costs. We looked at the applicants in each priority category by their status. We looked at our assessment cost for that time period. We looked at our attrition cost. We have consulted with our state rehab council. We've held public hearings. We're currently waiting for approval from RSA through the process for the state plan amendment. Through that process, RSA identified that we had duplicative language in our priority categories. For category one and two. We use the word most in both of those categories, but we defined it out by functional capacity. And they had not noticed that before. So they came back and told us we would have to either close one and two, or leave one and two open. And leaving two open is not an option for us. We have to close category two, so we are going to have to close all four categories while we work on addressing the issue with those priority definitions. So that's going to require obviously additional public hearings and a policy and regulatory change. So that has kind of complicated the process for us. But we need to correct that. And we started that process with our state rehab council. On Monday, we had a session where we're beginning to look at those priority categories. We also held training of staff. We've held one training and we have another one scheduled for next week. We've worked collaboratively with our cabinet leadership and the governor's office. They both have been very supportive, developed communication plan. So it's a lot. It's a long process really.

 

Carol: Well, it is a lot. I was thinking about that kind of the political piece of it because sometimes folks forget, you know, there's the mechanics of it. Do you have your policy in place, you know, and how's that all rolling in training of staff and doing your amendment. But politically, sometimes you will get pushback from the higher ups going, we don't want you to do this. We don't want you to go on an order, but you're not experiencing that. You are getting support.

 

Cora: No. And of course, we don't want to go into order selection either. So we're going to work as quickly as possible to get those definition changes done. And our policy changed, you know, the regs. But we want to make sure we do that in a quality manner because how you define those priority categories is important.

 

Carol: Yeah absolutely. So where are you at then in the process with getting your state plan amendment approved by RSA?

 

Cora: We're just waiting on it. We have sent it back and now we're waiting. We're hoping to implement by May 1st. So we're just waiting to get that back.

 

Carol: Yeah. So you're coming on kind of quick, too. There's, uh. Well, I shouldn't say quick. You've been working on this for a while. There's a number of states that are in the throes of various stages of working it through. One thing you said is this takes a lot of time. And I know people have called as of late, like, even in the last week or two, and they're like, we need to implement an order right away. Like, we need to go on by May 1st. And this is like an April 1st timeframe. And I'm like, that's not even possible.

 

Cora: No. And it is a cumbersome process. But when you think about how important the decisions are that you make, I guess it would be hard not to have a process that takes time and a lot of thought, and you need to look at everything thoroughly.

 

Carol: I know one of the big pieces that folks from the feds, you know, RSA will talk about is cost containment strategies, trying to look at any kind of cost containment strategies you can put in place first, or kind of alongside as you're looking at implementing an order to help, kind of rein in the expenditures. So what kind of cost containment strategies have you put into place, or are you guys looking at putting into place?

 

Cora: Yeah, back in I guess probably September in the fall was a telling month. We looked at that and went, whoa, our costs were way up. And of course we knew there was tuition in there. But even in spite of that, they were way up. And we saw that trend beginning to be there. And so we started to look at more data. And so in January, we stopped all out of state travel. That was, you know, funded through the VR grant. All personnel actions were put on hold. We are now in the process of looking at our contractual agreements and reducing them where we can. We also, here in Central Office, are going to consolidate some of our space, give up some of the vacant cubes that we have. And another thing that we've been looking at off and on for the last several months, our hearing aid costs, and we did release some temporary staff and some initial probation staff, which was very hard.

 

Carol: That is hard. None of these things are easy to do for sure. It's very painful. I've been hearing from people all over where they're having to do very similar types of things, and you've had a little bit longer on ramp because you've been noticing this since last fall. It isn't like, hello, today you just got this notice, like, say from Jake going, Cora, you don't have any money, which is happening. Other people, they're not having access to any financial information about the program. And it's really super troublesome because you can't be in control of the allocation and expenditure of your funds as the VR director, when you don't even get a financial report.

 

Cora: Right. That would be very concerning.

 

Carol: And you've really had to navigate that because you've had many different structural changes in Kentucky with where that fiscal folks land. I mean, they used to be with you, and then now you've got them way at the cabinet level. So it's a whole different picture.

 

Cora: Yeah. Through looking at those, we get a weekly report, we get a lot of reports. And it was looking at that where we begin to see the percentage of differences start to change. And I think, you know, if you get regular reports controlling your administrative costs are not that difficult. It's those case services costs because plans are written and money is obligated. And once that starts, unless you're running that data and really looking at it ongoing, in which this is something that we've learned, we will be looking at more data and different data going forward as we maneuver through this. You know, how many plans are in place implemented. All of that is really important to look at ahead of time, because you can see what's coming, because once they're implemented and those services are on the plan, the trains on the track and it's going.

 

Carol: That's right. You're talking about this and looking at this, who's the we? So I know it's you and Susie, but who's the we that's looking at the data? Do you have an expanded team looking at it? Who do you include in that?

 

Cora: Our leadership team, my division directors. And then also the cabinet fiscal staff.

 

Carol: This is sage advice because I think some leaders have had a tendency to want to keep this close to the vest, like they know there's a problem, but they're not wanting to include a bigger group. And I just need to, like, make a pitch right here. Having that group involved, like your leadership team and the fiscal people in the cabinet and having that bigger group looking at the situation, I think more minds make for better, you know, observations about what's happening in perspective.

 

Cora: Right.

 

Carol: You know, you can't do this by yourself.

 

Cora: No you can't.

 

Carol: Yeah. I'm really glad that you're doing that. So what kind of advice would you have for your colleagues across the country who are wrestling with these similar issues? What are things that you found that have been helpful for you working through this?

 

Cora: Well, I think to know that you're not alone in it, and it is a very difficult decision. Once you make the decision, I think it's important to act quickly and be confident, because it's really easy to blame yourself that you know you didn't do a good job, or that you have let the disability community down in your state. The grants very complicated and all the processes surrounding it, I think are complicated and challenging. I think the more people that you surround yourself with and making all those decisions, the better. It's very important. It's kind of like we ran a data set today and sent it to Jake, and I didn't think about did it have pre edits in it? And Jake came back and said, does this have presets in it? Because the data can be deceiving in itself too. And then know that how quickly things can accelerate, because you can be okay one month and then a lot of case service costs hit in the next month. Oh you're not looking so good. And the fiscal forecasting group has been great to be a part of all of those groups. The new fiscal forecasting tool. There's all kinds of tools that are out there. And then I know I always say this for those states where they don't have those relationships somehow be working on them, because without them you're not going to be successful.

 

Carol: Yeah, that's all very good advice. I do want to dig in for a minute on the data, because I know folks like to look at different things. What have you found to be most helpful to you and the leadership team when you're talking about the data? What are the kinds of things you guys are looking at that have been really impactful? And is there any way that they're displayed or something that has been more helpful to you?

 

Cora: Well, I think the annual cost of services over time, looking at that historical data, how many referrals that you have, how many applications that are currently in the hopper, the attrition cost, looking at those help. Because if you know about 38% of your cost, that is going to you know, those authorizations are not going to go to payment. That helps just all kinds of data, really. And looking at it by priority category. And one of the things Susie and I have talked a lot about is, and RSA mentioned to us is, are we too top heavy in one priority category over another one? Because then that makes it difficult as you are looking at closing. And that's kind of what happened to us, by the way, that we define those functional limitations. Now we're kind of stuck until we get our definitions changed. We have to close both one and two, and that's not what we wanted to do. We wanted to leave one open and just close two.

 

Carol: How many categories do you have?

 

Cora: We have four.

 

Carol: Okay. Because I know I've seen people have even like 5 or 6. And I feel like the more you finely slice and dice those, they end up almost becoming irrelevant in a way, because you might have a half a percent of people in a category. So you go, you're closing this. And it's confusing to the counselors, like, how am I finally finding this? It makes it harder to implement and it's causing you more grief really.

 

Cora: Yes. I think that we're going to try to simplify ours as we move forward.

 

Carol: Yeah, that sounds really good. Have you had to do anything in particular to help people get comfortable, like in understanding and interpreting the data? Because I know sometimes folks, you know, everybody's minds just work differently. And so you could have a report. And for some people it's super obvious. Oh yeah. Like you can interpret that and it says x, y, z. Other folks are like it just looks like Greek on a page. Have you had to do anything to help kind of with like data literacy?

 

Cora: Well, it's interesting that you say that because informing the public and the public hearings, I think that was difficult for individuals because and part of that is probably they just don't simply want to see it because they don't want us to close the categories. You know, because it's not it's not a good thing to do. But I think once we presented the data and would show what large percentages of increase that we had, that people would go, oh yeah, and our state rehab council, they were very supportive and could see that. But I think just the general public, it's more difficult, probably because it's their child or their, you know, grandchild and it's just more difficult. So that has been difficult getting everyone to understand it. That's a good point, though. The data sometimes is difficult to accept.

 

Carol: Well, it definitely lends to that whole when you have a communication plan, you're really talking differently to different groups because you've got obviously kind of your higher ups in the politicals and you've got your own staff and the consumers and then the other stakeholders. So the messaging may look different just because you're trying to communicate in a way that people can understand what's going on. Right? Absolutely. Yeah. So what are you projecting for the future? Now we've gotten the, you know, continuing resolution came, the money came, which is good. What are you looking at when you look out a year or two? What are you thinking.

 

Cora: In my crystal ball? I don't know really what to expect. So hoping that our funding stays stable. The cola was great. That was a great surprise for all of us. And getting that and you know, moving forward, I think that we're going to have deeper dives into the programmatic and fiscal data at our meetings than what we were having, making sure that we're marrying those two together. Because if you just look at one and goodness, if you're not looking at it at all, then you really are having difficulty. I feel like we have some hope knowing that the rest of the award did come, and we need to build that carry forward money back up, not to the point where we had it, but we have to have that.

 

Carol: Yeah, I know RSA said recently about, you know, building that money up, but they were like, you really should in this time of continuing resolutions, their rule of thumb is you should have at least two months of kind of cash available so that you're not scrambling when we're waiting to see what's happening with the CR or whatever. And I know some of the agencies have been closer to the vest, like they're kind of right on the penny with every dollar that's come in is getting spent. So it is good to have a little bit of a reserve.

 

Cora: I think this is the first time in six years that we've gotten to the, you know, and I imagine there are other states that have really expended almost all their money because we were, what, six months in?

 

Carol: Yeah.

 

Cora: Yeah.

 

Carol: People cried. People cried. When the new GAN came out. I talked to over a dozen directors. People were yelling and had tears of joy. People were just overwhelmed because it has been so stressful. And folks, not sleeping at night. You know, it's it's been tough, very tough. So I definitely think you have great advice for folks. So if you're not looking at your data, you need to. And if you're only looking at it one way, and I know a couple folks were caught off guard that way, they really weren't kind of marrying up what was happening programmatically with the fiscal data. They weren't looking at both sides of the picture. And like you said, you had that just Ginormous increase of applications and eligibilities and all these folks coming in the door and the people have changed. If you aren't looking at all of that through that lens and then looking at what's happening over here financially, you're kind of missing a really critical piece. And it does bring your fiscal side of the house together with the program people, which is so important.

 

Cora: Right.

 

Carol: Yeah.

 

Cora: When you see those increases, then you should mentally note right away you're going to see expenditures increase.

 

Carol: Yeah. Well, and I like that you said to Jake was able you weren't sure on the one data. You know, did it include the Pre-ETS or not. And Jake, at the cabinet level, RSA knew enough because he's gotten so involved in the program, knows enough to call you and go, hey, Cora, does this data include the Pre-ETS? That's what we want across the country. We want fiscal staff to understand enough about the program that they can have that realization to ask a darn question like, what is this inclusive of? Above, right? Yeah, that is great.

 

Cora: And care.

 

Carol: And care. Absolutely. Like that leads to a lot. Oh my gosh. Well, Cora, I just I think the world of you, you've been one of our longer term standing directors, even at the amount of years you've had in now doing this. We've just had such a turnover, and I continue to see that, we had two more directors leaving last week. It just does not stop. So I think one great piece of advice from you, though, is including that leadership team. You can't just have one person in the agency that understands everything going on because that person walks out the door. It is tough to recover because everybody else left behind has no clue what's going on.

 

Cora: Right.

 

Carol: Well, thank you, Cora, I really appreciate you having this conversation. And for folks that are listening, definitely remember, you can always reach out to us at the QM. You can also reach out to your RSA state team. They are super helpful as you're facing these really tough decisions you're making. And if you're considering going on an order of selection, I say involve RSA early. Early in the process. Cora knows it's a long road to hoe. There's a lot of things that have to be covered, but it's important because you're making a very important decision, so you don't want to leave any stone unturned for sure.

 

Cora: No. They've been a great support for us. We have a great team at RSA that we work with.

 

Carol: I love that. Well, thanks, Cora, I hope you have a great day.

 

Cora: Appreciate it. Bye bye.

 

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