Maine Department of Health & Human Services Office of Aging & Disability Services

1. Supporting Individual Success For People with Intellectual Disabilities & Autism Information for Service Providers Maine Department of Health & Human Services Office of Aging & Disability Services

2. Introductions • Human Services Research Institute • 7690 Mohawk StreetTualatin, OR 97062(503) 924-3783 • www.hsri.org • Vice President • John Agosta • jagosta@hsri.org • Policy Analyst • Alena Vazquez • avazquez@hsri.org Department of Health & Human Services Office of Aging & Disability Services 41 Anthony AvenueAugusta, ME 04333(207) 287-9200 www.maine.gov/dhhs/oads Supporting Individual Success web page www.maine.gov/dhhs/oads/disability/ds/sis/index.shtml Director Gary Wolcott Gary.wolcott@maine.gov Acting Associate Director Karen Mason Karen.mason@maine.gov SIS Manager Jennifer Fales Jennifer.fales@maine.gov

3. Supporting Individual Success Welcome, Introductions & Overview Implementation Plan • Overview • Phase-in sequence • Supplemental question verification • Supports level assignment & notification • Planning process & budget tool • Extraordinary review process • Grievance & appeal • Case examples

4. Purpose of Today’s Meeting Sharing information about the steps toward implementation of Supporting Individual Success.

5. What OADS is trying to do & why OADS is committed to ensuring that: People with intellectual disabilities & autism get the services & supports they need to live, love, work, play, and reach for their goals just as others do in their community.

6. Complementing Commitments This commitment requires us to establish a person-centered system that emphasizes that: People with intellectual disabilities & autism be in charge of their lives as much as possible. People with intellectual disabilities & autism have opportunities to use resources in ways that enhance their lives & help them participate in their communities. A shared responsibility for the wise use of public dollars & the contribution that people with intellectual disabilities & autism, & their families can make. That the system is managed in a way that is efficient & fair toeveryone, including those receiving or waiting for services.

7. Balancing Commitments Fair & efficient spending & management practices Services & supports preferred by people with ID & autism Sustainability Growing Wait List Making the System Fair for All Rates Paid to Providers for Delivered Services Person-CenteredApproaches Flexibility & Choice Self-direction EmploymentOpportunities A person-centered & sustainable system

8. Looking Forward • We have an opportunity to improve • the service delivery system. Supporting Policies, Rules & Regulations and Communication

9. New System RATES • Adjustments made to rates for some services, including community supports and work supports. • Rate-setting process involved provider survey, research of costs and rates for comparable services and public comment process. • Goals were to increase consistency in rates across providers and members and provide a range of living options. • Rates for Agency Home Support and Community Supports will be ‘tiered’ based on members’ levels of need according to the Supports Intensity Scale (SIS) (Medical Add-On rates are being eliminated)

10. New System AGENCY HOME SUPPORT • Agency home supports moved from an hourly to a per diem rate based on home size and members’ levels of support. • Residential support providers will manage staffing patternsbased on the needs of the home. • Rate models expect that members will spend some time in the community, but all rate models for homes with at least 2 members allow for 24/7 staffing.

11. New System OTHER RESIDENTIAL • No changes to Shared Living and Family Centered Support models. Enhanced rates still available for these services. • Semi-independentSupported Living residential option available.

12. New System OWN HOME or FAMILY HOME • Significant increase in the rate for Home Supports. • For individuals living with family or other caregivers, respite services have been increased to 350 hours annually. • Rate increases for Crisis Services, Psychological Consultation, and Therapies and the addition of a Skilled Nursing service to the waiver.

13. New System DAY ACTIVITIES • Changes to rates and billing policies estimated to increase work supports. • Community Supports rates will vary depending on the members’ level of need and location of service. • Annual caps on services eliminated and members can determine the services they want to access within their supports budget. • For more information about rates please reference the Burns & Associates documents on the Supporting Individual Success web page: http://www.maine.gov/dhhs/oads/disability/ds/sis/index.shtml

14. New System FOR MEMBERS • Based on their support needs, members will receive a supports level and corresponding budget that will guide their service choices and planning. • Members living in a residential setting (agency group home, family centered support, shared living) will have flexibility with their supports budget for day and work support options. • Members who live at home with their family or other caregiver will have flexibility with their home supports, and day and work support options. There are also respite hours available. • Members who live on their own will have flexibility with how they use their home supports, and day and work support options.

15. Implementation timeline • Individuals receiving Section 21 services will be phased in based on their annual effective personal plan date. • It will take a full year to transition all current members into the new service model. • In July 2015, OADS will begin sending notification letters with supports level and budget information to members with an annual effective personal plan date of January 2016. • Roll-out will continue with notifications to members in August 2015 who have an effective personal plan date of February 2016.

16. Implementation timeline • Jan 2016 • Feb 2016 • Mar 2016 Effective Personal Plan Date Notification

17. Phase-in sequence • Authorization & services begin • SIS completed • SQ Verification if needed • Supports level determined SIS Report generated & sent to CM • Example for member with effective personal plan date January 2016 • Notification of supports level & budget July 2015 November 2015 December 2015 January 2016 August 2015

18. Agency Home Support Phase-in • For agency homes serving two or more members, phase-in process will be slightly different. • Per agency home: • Each member will phase-in to their day supports (community & work supports) based on their annual effective personal plan date, but their residential rate model will remain under the old system. • Once the last person reaches their annual plan effective personal plan date, then all members in that home will switch to the new residential rate model.

19. SIS Report • SIS Interviewer will send SIS report to case manager within 10 days of the SIS interview. • Case manager will share the SIS report with member (and guardian) within 10 days of receiving report. • Service providers can request the SIS Report for members they serve if there is a signed release in place. • SIS report is different than supports level and budget notification (described later). SIS Report generated & sent to CM

20. Supplemental questions • SQ Verification if needed • Not part of the SIS instrument, but are asked during the SIS interview for some individuals. • Triggered by responses to items related to medical and behavioral support needs (Section 3A & 3B of the SIS). • Used to identify individuals who may require extensive supports to manage medical and behavioral needs. • For some individuals, responses to the SQ’s will need to be verified by the Supplemental Verification Team (SVT).

21. Supplemental Verification Team • SQ Verification if needed • Made up ofOADS staff and the SIS Manager. • Meets every other week to review cases. • Reviews documents to verify the existence of higher behavioral or medical need. • May result in a higher supports level assignment for some members. • Safeguard to ensure that people are assigned to a supports level that meets their needs.

22. Supplemental documentation • SQ Verification if needed • Case managers will receive a form from the SVT requestingdocumentation. • Documentation needs to be sent within 2 weeks of request. • Case managers may request documentation from service providers. • Most current documentation (6 months prior to the SIS interview) for areas related to medical and/or behavioral needs.

23. Supports levels • Supports level determined Members will be assigned to a Supports Level (1-5) based on support needs. 5 4 3 2 1 LowSupport NeedsHigh

24. Supports Level Assignment Calculating a Supports Level: The Standardized Scores* for Section 1,Part A + Part B + Part E = SUM ABEHome Community Health & Living Living Safety Total Score of Section 3A Medical Total Score of Section 3B Behavioral *Standardized scores are calculated by AAIDD

25. Supports level assignment

26. Supports budget table

27. Supports level notification • Notification of supports level & budget • Members and/or guardians will receive a notification letter with their supports level and budget information. • In July 2015, OADS will begin sending letters to members with an annual effective plan date of January 2016. • Service providers can request supports levels and budget information for members they serve if they have a current signed release.

28. Service planning • Planning team discussions • Anticipated that implementation year would be more complex, therefore additional 30 daysprovided. • During phase-in, highly recommend starting initial discussions with members & their team soon after notification. • Particularly important for members with extraordinary needsas might require Extraordinary Review Process.

29. Extraordinary review process • A memberor guardian, through thecase manager, can request a formal review: • If they feel the member’s support needs will not be met by their available service package or • If the member has had a major life change. • Requests will be reviewed by the Extraordinary Review Committee (ERC).

30. Extraordinary Review Committee • The ERC cannot change a member’s assigned supports level but is able to approve services such as Qualified Extra Support Services (QESS) or Skilled Nursing. • ERC is also responsible for reviewing requests for SIS reassessment due to major life change. • Approval will be granted on a case by case basis. • Amount of approved services will depend on the documented and verified need of the member. • Case managers must submit referral form and supporting documentation.

31. Extraordinary Review Committee MORE SUPPORT REQUESTED • Approval granted on a case by case basis and depends on documented and verifiable need. • Case managers must submit required supporting documentation. • Case managers may request documentation from service providers in order to meet this request.

32. Supporting documentation Required • ERC referral form • Person Centered Plan • Functional Assessment • Budgetary expenditure or current level based budget • Proposed budgetary usage (in accordance with allowances) Included if applicable • IST • Historical Behavioral Documentation and patterns • Other supporting documentation- clinical or behavioral assessments, relevant evaluations, behavior logs, safety plans, severely intrusive plans (SIP), crisis interventions, reportable event information, forensic history, et al

33. Extraordinary Review Committee MAJOR LIFE CHANGE • Reviews requests and determines if a new SIS assessment is necessary outside of the usual 3 years. • Includes significant impacts to member’s support needs: • Change in natural home/family living situation including loss of natural supports • Loss of living situation • New/change in diagnosis of Dementia or related condition • New/change in diagnosis or condition of serious mental health or behavioral need

34. Extraordinary review notification • Notification of the results of the ERC will be sent to the case manager for the member within 5 business days of the final decision. • Notification will also be sent to the member’s resource coordinator for any necessary service authorizations.

35. Person-centered planning • Person-centered planning What will stay the same with person-centered planning? • The member and their team will discuss their support needs, goals, and opportunities to access their community. What is new to the person-centered planning process? • Everyone at the meeting will know the annual supports budget amount that the member has available to them. • The member can choose the type and amount of services they want to meet their needs and goals within their annual supports budget.

36. Planning with a budget • Services should help the member to lead the life they want with the support they need. • Planning teams can use a supports budget tool to help plan services within the member’s supports budget.

37. Supports budget tool • Web-based application to use during planning. • Enter member’s supports level assignment (1-5) and residential placement. • Calculations for rates of services available by living setting and supports level will auto populate. • Enter services by hour in the calendar to reflect a typical week according to member’s stated wants and needs. • Last column will show Total Remaining in the annual budget.

38. Supports budget tool

39. Authorization • Authorization & services begin • At least 30 days prior to the Person-Centered Plan effective date, case manager submits plan to Resource Coordinator for authorization. • Once authorized, services begin!

40. Grievance & Appeal Process • Notification of supports level & budget • Authorization& services begin Appeal rights issued Referral to ERC Appeal rights issued No Yes Extraordinary Review Service package meets needs Yes No or not enough Skilled nursing or QESS approved Appeal rights issued

41. MaineCare appeal process • Appeal rights are issued at three points in the process: • After notification of supports level and budget • After ERC decision • After services are authorized • Members will need to file an appeal within 10 days of the notification of final PCP. • Members can file an appeal through their case manager or Disability Rights Maine. • Case managers will follow current process for assisting members to file appeals.

42. OADS grievance process • The current OADS grievance process will remain in place. • For grievance information, go to the link below. http://www.maine.gov/dhhs/oads/disability/ds/grievance/home.html

43. Robert • Robert is 52 years-old and lives in a group home with two other housemates. • He been assigned to Supports Level 2, and based on where he lives his annual Supports Budget is $114,519. • He is close with his younger brother Paul, who visits once a week. • He is fairly independent with home living activities, but may need reminders for house cleaning, personal hygiene, and grooming. • He can get frustrated with complex tasks, such as preparing a meal, but does well if someone supports him step-by-step. • He needs assistance getting around in the community, and currently goes to a day program 5 days a week. • Loves to talk about carsand trains, and is excited about the possibility of working with cars.

44. Robert • Fairly independent with home living • Can follow step-by-step instructions • Interest in cars and trains • Brother • Housemates • Home staff • Day program staff • Case manager • Auto repair • Oil change • Car wash • Car dealership • Train station • Section 21 • MaineCare • Social Security Income • iPhone call/ text • Email • Digital watch

45. Robert • Goals: • I would like to find a paying job. • I would like to do more activities outside the house and make new friends. • I would like to take a vacation with my brother and go to a car racing event.

46. Robert • During his planning meeting, Robert decided to use a combination of community supports and work supports to reach his goals. • He will use 4 hours per week for work supports with one-on-one staff to help him learn and maintain a job that fits with is interests and career goals. • He will spend 5 hours per week using work supports in a group setting (3 people). • He will use 4 hours of community supports one-on-one to explore opportunities in the community with the hopes of meeting new people who share his interests. • He would also like to keep going to his day program 4 days a week for 3 hours. • On Saturdays, he will spend time with is brother planning their vacation. • This is a total of 25 hours of community and work supports.

47. Morgan • Morgan is 58 years-old and lives in a group home with one other person. He has a SUM ABE of 35. • He requires constant verbal prompting to complete home living activities. He can dress and bathe independently but needs monitoring and assistance to complete tasks as he often gets distracted. • He can become frustrated when things don’t go as planned. • He requires constant support while in the community. He tends to approach female strangers with inappropriate touch if he is left unmonitored. If he is not supported by familiar male staff, he becomes violent and extremely aggressive. • He does have some self-injurious behaviors that include picking at his skin, scabs or scratches. If left unattended, he also has a tendency to rip clothing and smear feces. • Morgan enjoys watching TV, looking at magazines and listening to his iPod.

48. Morgan • Morgan’s Supports Intensity Scale assessment had a SUM ABE of 35. • His responses to items on the Supports Intensity Scale Section 3B triggered the Supplemental Questions. • His case was automatically referred to the Supplemental Verification Team (SVT). (Members who are already assigned to the highest levels based on their SUM ABE score do not need to go through the SQ verification process) • The SVT requested documentation from Morgan’s case manager regarding his behavioral support needs. • The SVT reviewed the documentation and verified that Morgan has significant behavioral needs. • He will be assigned to Supports Level 5 to best meet his behavioral support needs.

49. Morgan • Goals: • I would like to find more things to do outside my home. • I would like to learn ways for me to be more involved in planning things so that I know what is coming up. • I would like to find more to do with music (find new songs for my iPod, watch concerts – live or on Netflix, go to a music store, etc.) • In order to reach his goals, Morgan has decided to use primarily community supports with one-one-one staff for 23 hours over the a week.

50. Teresa • Teresa is 29 years-old and lives in a group home with one other housemate. • She has complex behavioral needs that cause her to need full physical support to complete home living activities. She needs full support with taking care of clothes, food preparation, and housekeeping. Her food is pureed for her to avoid a choking risk, and she can feed herself with some assistance. • She is capable of dressing herself, but if left unattended would opt not to wear clothes. • She requires full physical support to safely engage in the community. This often includes needing 2:1 support as she often runs away. She is often aggressive and violent in public toward staff. • She has self-injurious behavior that include hitting her head on objects and cannot be left alone with sharp objects. She needs support in prevention of pica as she will drink cleaning supplies, cologne, or other household items. Alarms are on doors as she has a risk of elopement.