Self Direction and Resource Allocation September 9, 2014 at 12:00 pm ET

1. John Agosta, PhD JAgosta@hsri.org Katie Howard, MPH KHoward@hsri.org Self Direction and Resource AllocationSeptember 9, 2014 at 12:00 pm ET

2. Presentation Outline • Objectives • Goals of Resource Allocation • Steps in the Process • Evaluation • Managed Care and other State Plan options • Questions 2

3. Objectives • Identify issues that Resource Allocation addresses • Familiarize participants with methods of Resource Allocation • Identify steps to implementing Resource Allocation • Understand how assessment instruments can be used to set budgets

4. Challenges in the Field • Accelerating service demand • Budget stress • Reliance on legacy and inefficient systems • Workforce shortages • Need for continued community integration and self direction

5. Goals of Resource Allocation • Enable policy makers to make disciplined fiscal choices • Allocate resources based on assessed support level • Accommodate people with extraordinary needs in HCBS waiver programs • Can create flexibility in individual service planning

6. A Lot We want to move from a low correlation like THIS… $ $ Little Little Little A Lot Little A Lot Support Needed A Lot Support Needed …to a high correlation like THIS

7. Blending Together Principles Related to Service Delivery and System Management Services and supports preferred by people with developmental disabilities A Person-Centered and Sustainable System Disciplined fiscal and management practices

8. Exemplar States that Use Assessment InformedResource Allocation for People with IDD • Colorado - Supports Intensity Scale (SIS) • Connecticut – Level of Need (CT-LON) • Indiana - Inventory for Client and Agency Planning (ICAP) • Louisiana – SIS • New Mexico - SIS • Oregon – SIS • Rhode Island – SIS • South Dakota – ICAP • Washington – SIS • Wyoming – ICAP States in process: • North Carolina - SIS • Virginia -- SIS 8

9. Steps in the Process • Establish guiding policy goals and a communication plan • Identify and implement an assessment tool to measure support needs accurately and reliably. • Determine what services will be included in the model • If possible, review historical utilization for services that will be included in the model • Establish a supports level framework and assign individuals to their appropriate level • Identify “service packages” for each level (service and expected use) • Consider rates paid for services and calculate impacts • Validate the model with a review of individual records • Revise model as warranted then implement the model • Evaluate based on policy goals once full implementation has occurred

10. Policy Goals • Establish guiding principles for the plan • Integration • Self direction • Equity and efficiency • Sustainability • Assess the current system: • Service array • Rate structure • Policies • Determine future goals for the system • Stakeholder input

11. Assessment Tool • Identify an assessment tool • Valid • Reliable • Time and intensity of supports • Align closely with ADLs/IADLs • Identify other data need to be collected • Identify random stratified sample of service population • Create an assessment plan

12. Included Services • Examine current waiver services • Determine if any need to be added to aid inclusion in the community • Establish which services will be a part of the resource allocation model • Examine historical utilization patterns in relationship to support assessment data and other factors

13. Tying Supports to Budgets

14. Framework • Groups individuals with similar needs • Reflects current support needs • Based on supports needed for every day activities as well as supports for behavioral or medical conditions • Includes exceptions process

15. Establishing Supports Available Those above the authorization levels are reduced (and may be stepped down over time); those below may or may not increase based on their decisions. The system must take exceptional support needs into account.

16. Factors to Consider • Assessment level framework • Using the instrument to inform design of a person centered plan. • Exceptions process • Per person costs in relation to the cost of implementing a resource allocation system • Child versus Adult differences • Living setting and impacts on anticipated costs • Specific state or jurisdiction factors

17. Rates • Level of Support Framework can inform how much providers are reimbursed for certain individuals • Reimbursement rates for services should be fair and sufficient • Consider whether to incentivize services that increase community involvement and independence (i.e., employment)

18. Service Packages • Identify factors that effect service packages • Group services together when establishing budgets • Create budgets for each combination of factors based on desired outcomes for support level with that combination of factors • For example, service packages are developed for adults that include an expectation of use of Supported Employment. • Consider base budgets versus add-on budgets

19. Provider Networks • Identify gaps in service • Create policy for attracting providers • Establish service packages that allow providers to support individual at the person’s support level • Use rates to strengthen provider network in a way that aligns with system goals

20. Validate Model • Pull a sample of records • Gather case files and other information • Verify that the person meets the criteria of the Level of Support • Confirm that the Service Package is adequate • Make adjustments to model based on issues identified during validation process

21. Implementation • Communicate with Stakeholders throughout the process • Appeals process • Planning process • Protection against conflict of interest in case management • Person centered planning • Services used

22. Evaluation Once system implemented: • Check reliability of assessors • Look at new service utilization patterns • Gather feedback from service recipients • Establish whether change has occurred related to original policy goals • In time, modify the model to address identified issues

23. Resource Allocation within Managed Care and Other CMS Authorities • Commonly used with 1915(c) waivers • MLTSS for people with I/DD • 1915(b)/(c) • 1115 • Other State Plan options 1915(i)(j)(k) • Functional assessment • Flexible • Self-directed 23

24. Where to Find Help • To request TA: http://www.hcbs-ta.org/request.aspx • For additional information:http://www.hcbs-ta.org 24