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Waiver Development Update NYSACRA 10 th Annual Leadership Conference. November 30, 2012. Today’s Agenda. Managed Care Transition Timeline & Milestones Targeted Work Teams Update Access, Enrollment & Advocacy Care Coordination Modernizing the Fiscal Platform Next Steps

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Waiver development update nysacra 10 th annual leadership conference

Waiver Development UpdateNYSACRA 10th Annual Leadership Conference

November 30, 2012

Today’s Agenda

  • Managed Care Transition Timeline & Milestones

  • Targeted Work Teams Update

    • Access, Enrollment & Advocacy

    • Care Coordination

    • Modernizing the Fiscal Platform

    • Next Steps

  • Update on Needs Assessment – Kate Bishop

Doh duals demonstration
DOH Duals Demonstration

  • Up to 10,000 people with developmental disabilities, enrolled in 1-3 plans.

  • Voluntary enrollment (July 2013), then passive enrollment (January 2014) into comprehensive care

  • Many protections built into the model:

    • Person-centered care coordination

    • Interdisciplinary care coordination team

    • Independent enrollment broker

    • Independent ombudsman

    • Choice of providers and plans

    • Integrated grievances/appeals process

    • Continuity of Care

    • Participant Advisory Committees & Feedback Sessions

Doh duals demonstration1
DOH Duals Demonstration

  • Fully-Integrated Dual Advantage programs (FIDAs)

    • Capitated managed care program

    • provides comprehensive array of Medicare, Medicaid, and supplemental services including DOH long-term care, acute healthcare, OMH, OASAS andall OPWDD People First Waiver Services (state plan and 1915c)

  • Both FIDA and the People First waiver have the same objectives, but the FIDA is the first demonstration of comprehensive care.

  • Following the 3 -year demonstration, FIDAs will transition to DISCOs.

Doh duals demonstration how it will work
DOH Duals Demonstration – How it will work

  • July 2013 (Phase 1) – Voluntary enrollment into MLTC Plans - individuals will not experience any changes in OPWDD services.

  • January 2014 (Phase 2) – Voluntarily enrolled members will automatically transition to FIDAs through which they will receive all of their supports and services.

  • There will only be up to 3 FIDAs in New York State.

Managed care transition timeline
Managed Care Transition Timeline

MLTCP: Managed Long-Term Care Plan

FIDA: Fully Integrated Duals Advantage

DISCO: Developmental Disabilities Individual Support and Care Coordination Organization

Draft request for applications rfa posted
DRAFT Request for Applications (RFA) Posted

  • Draft RFA for pilot project DISCOs available at www.opwdd.ny.gov/opwdd_services_supports/people_first_waiver/home

  • Provides a more in-depth understanding of what will be required of organizations that wish to apply to operate a pilot DISCO

  • DRAFT will be revised to reflect recommendations of targeted work teams and continued discussions with federal Centers for Medicare & Medicaid Services (CMS)

Further shaping waiver design
Further Shaping Waiver Design

  • Targeted Work Teams providing guidance for pilot DISCOs.

  • Revised Draft RFA will soon be posted online

  • Further Implementation Planning – OPWDD will establish planning groups to further define implementation details.

  • CMS will respond to NYS’s waiver applications, draft RFA and draft DISCO contract.

Targeted work teams update
Targeted Work Teams Update

  • In August, OPWDD assembled three (3) targeted work teams to define specific details of system reform.

    • Access, Enrollment & Advocacy

    • Care Coordination

    • Modernizing the Fiscal Platform

  • Teams met frequently from August to October 2012.

  • Deliverable: Recommendations for Pilot DISCOs

    • To enhance Request for Applications (RFA) for pilot DISCOs, waiver applications and draft DISCO contract

    • Inform providers and others on many details of how a DISCO will operate

  • Access enrollment advocacy work team
    Access, Enrollment & Advocacy Work Team

    • Focused on DISCO enrollee rights, due process and provision of independent advocacy within DISCOs:

      • Ensure Communication of Individual Rights

        • Effectively communicate the rights of each individual enrolled in a DISCO

      • Evaluate the DISCOs’ Grievance and Appeals Process

        • Due process protections for DISCO enrollees

      • Ensure Independent Advocacy

        • Strong independent advocacy for individuals

    Access enrollment advocacy work team recommendations
    Access, Enrollment & Advocacy Work Team Recommendations

    Involvement of Individuals in DISCO policy-making:

    • 1/3 of DISCO Board members should be people with DD, family members or advocates.

      Individuals’ Rights: DISCO contracts should reference specific rights of individuals to:

      • Lead decision-making about his/her plan, not simply participate

      • Update service plans as needed

      • Self-direct services

      • Receive information in understandable format and manner

      • Request an advocate

      • Receive assistance to understand information

      • Access an enrollment broker

      • Access records via health IT

      • Complain without fear of reprisal

      • Receive personal hygiene supports from same sex staff person

      • Choose someone to assist in decision-making

    Access enrollment advocacy work team recommendations1
    Access, Enrollment & Advocacy Work TeamRecommendations

    Grievance and Appeals Processes:

    • Look for following best practices in pilot DISCOs:

      • Informal process to resolve complaints prior to formal process

      • Availability of independent ombudsman to assist with grievance process (with a hotline)

      • Means to ensure the correct level of assistance for individuals is available

      • Opportunity for individuals and families to report satisfaction (or not) with grievance process

    • OPWDD should measure and analyze:

      • satisfaction with grievance process

      • how well DISCO meets required timeframes for settling grievances

      • data re: DISCO grievances

    Access enrollment advocacy work team recommendations2
    Access, Enrollment & Advocacy Work TeamRecommendations

    Grievance and Appeals Processes:

    • Advisory councils/committees should assist OPWDD to review the effectiveness of DISCO grievance practices and identify best practices.

    • Continuation of supports/services during grievance should be automatic.

    • Expand list of parties who can file grievances/appeals to those allowed under OPWDD regulation.

    • OPWDD should review grievance history of DISCO applicants.

    Access enrollment advocacy work team recommendations3
    Access, Enrollment & Advocacy Work TeamRecommendations

    Independent Advocacy:

    • DISCOs should be required to ensure that each person has a circle of support that includes people who are not paid to provide support.

    • OPWDD Regional Offices should continue to serve as a resource to individuals/families.

    • OPWDD should establish an oversight group to evaluate the effectiveness of independent advocacy within the pilot DISCOs and provide training.

    • Independent advocacy must exist at two levels (system and individual) and be coordinated by one statewide advocacy organization that uses existing local advocates to assist individuals.

    • OPWDD should develop training for independent advocacy.

    • DISCOs must be required to disseminate information regarding availability of independent advocates.

    • DISCOs should use internal review boards with advocacy representatives to review program outcomes and enrollee satisfaction.

    Care coordination work team
    Care Coordination Work Team

    • Develop quality measures, in collaboration with Delmarva, a consultant group with experience in formulating quality outcomes in other states, and outline the parameters for the qualifications of the lead care coordinator by making recommendations to:

      • Customize and integrate care management/care coordination

        • Shape a customized and integrated care management/care coordination system that employs true person-centered planning

      • Focus on Full Range of Services

        • Support the full range of service needs for persons with developmental disabilities

    Important to remember
    Important to Remember

    • Care Coordination is an overall function, or entity. It is not a person; it is a team.

    • There will be a Lead Coordinator role with required minimum responsibilities and qualifications.

    • Overall Care Coordination and the Core Functions may be delivered according to how the Care Coordination entity designs it.

    • Plan of Care will contain:

      • Description of the person (e.g. skills, strengths, interests)

      • Individual’s outcomes and the measurable action steps taken to achieve those outcomes

      • Services and supports needed

      • Wellness and safety supports

      • Documentation expectations related to individual’s progress

    Core responsibilities of the lead care coordinator
    Core Responsibilities of the Lead Care Coordinator

    • Team leader

    • Responsible for the oversight and coordination of the entire Care Coordination team and the person’s services

    • Ensures the plan of care is properly implemented and the person’s needs are met

    • Cost Management

    Lead care coordinator qualifications
    Lead Care Coordinator Qualifications

    • Bachelor’s degree (in any field)

    • At least one year of experience with people with developmental disabilities

    • “Grandfathering” will not be allowed.

    Face to face service meetings
    Face-to-Face Service Meetings

    • Minimum of three times per year, and

    • As needed according to the assessed needs of the person

    • The person may request fewer face-to-face meetings.

    Person centered planning requirements
    Person-Centered Planning Requirements

    • Plans must be person-centered, and updated as needed with at least two reviews per year.

    • Hallmarks of person-centered-planning must be provided by DISCO:

      • Individual Awareness – individuals understand their right to person-centered planning and what it entails

      • Person-Centered Culture - DISCO actively establishes a person-centered culture at all levels in the organization.

      • Training - DISCO trains staff in person-centered planning.

      • Roles & Responsibilities - DISCO establishes staff roles and responsibilities within the planning process and for plan monitoring.

      • Quality Management – DISCO measures effectiveness of the planning process, identifies and implements best practices.

    Modernizing the fiscal platform work team
    Modernizing the Fiscal Platform Work Team

    • Focus on principles of rate reimbursement reform under DISCOs and the various approaches to structural rate reform by making recommendations to :

      • Ensure Equity

        • Promote equity, sustainability, and alignment of financial incentives with program outcomes for the developmental disabilities services system

      • Develop New Concepts, Philosophies and Incentives

        • Blueprint for reimbursement to providers in the managed care network

      • Develop Interim Payment Strategies

        • Facilitate the transition to reimbursement under managed care

    Modernizing the fiscal platform work team principles of payment reform
    Modernizing the Fiscal Platform Work Team:Principles of Payment Reform

    • Fairness and Equity

    • Portability

    • Efficiency/Economical

    • Structural Reform

    • Simplicity and Practicality

    • Network Stability

    Modernizing the fiscal platform work team proposed component based approach option
    Modernizing the Fiscal Platform Work Team:Proposed Component-based Approach Option


    Direct Care State Driven Model -- Foundation:

    • Direct Care Staff Wage

    • Employment Related Expenditures

    • Program Support

    • General & Administrative

    Modernizing the fiscal platform work team potential timeline for payment reform process
    Modernizing the Fiscal Platform Work Team:Potential Timeline for Payment Reform Process

    • September: Establish sample of agencies for General Ledger analysis

    • October: Begin gathering General Ledgers

    • November – January: Analysis of component percentages

    • February: Open discussion of component percentages and service differentials based on differences

    • March: Standard fees in draft

    Next steps fall 2012
    Next Steps: Fall 2012

    • Targeted Work Team Recommendations for Pilot DISCOs posted online in October.

    • Refine the Draft Request for Applications (RFA) for Pilot DISCOs, post new version.

      • Submit 1915 b and c waiver applications to CMS

      • Plan a structure/process for Implementation Planning

      • Develop DRAFT DISCO contract

      • Continue negotiations with CMS to finalize agreements

      • Coordinate with DOH on preparation for Pre-FIDA MLTCPs for people with developmental disabilities

    Needs assessment update goals of needs assessment
    Needs Assessment UpdateGoals of Needs Assessment

    Final design team recommendations
    Final Design Team Recommendations

    A statewide needs assessment tool should be:

    • Person-centered while identifying individual strengths, needs, and interests

    • Standardized, normed and validated

    • Comprehensive and holistic including multiple domains

    • Flexible with an ability to be adapted to fit individuals’ changing needs

    • Able to inform a person-centered care plan

    • Supportive of “no wrong door” approach

    Critical reform needs assessment
    Critical Reform: Needs Assessment

    • Create a “universal” assessment system across New York State

    • Enhance the quality of life and care of persons with DD receiving Waiver services by:

      • Accurately identifying the characteristics and needs of individuals to better inform person-centered care planning

      • Discovering changes and trends in health status and their relationship to the types of supports and services utilized

      • Analyzing data across regions of the state on whether individuals with similar needs receive similar supports/services, regardless of where they reside

    Overview of Coordinated Assessment System

    Overview of interrai dd
    Overview of interRAI DD

    • 16 “domains”

    • Each domain has specific “items” (NOT questions)

      • Items identify information to be gathered

    • Interview with individual and other sources:

      • Direct observations

      • Staff/clinicians

      • Family and friends

      • Records (e.g. ISPs, habilitation plans, IPOPs, medical records)

    Interrai dd core domains
    interRAI DD Core Domains

    A. Identification

    B. Intake/Initial History

    C. Community/Social Involvement

    D. Strengths/Relationships/


    E. Environment

    F. Communication/Vision

    G. Cognition

    • Health Conditions

    • Independence in Everyday Activities

    • Oral/Nutritional Status

    • Mood/Behavior

    • Medications

    • Service Utilization/Interventions

    • Diagnostic Information

    • Assessor Information

    New york state specific interrai dd
    New York State-specific interRAI DD

    New York State OPWDD Coordinated Assessment System (CAS)

    interRAI Intellectual Disability (ID)

    Cas supplements
    CAS Supplements

    • Specific answers to items will trigger the need to complete special supplements, on an as needed basis:

      • Child and Adolescent Supplement

      • Substance Use Supplement

      • Mental Health Supplement

      • Forensic Supplement

      • Medical Management Supplement

    Critical reform needs assessment1
    Critical Reform: Needs Assessment

    • New Coordinated Assessment System will be phased in thoughtfully:

      • Starting with case studies,

      • Moving next into DISCO pilot projects,

      • Next into use with all newcomers to the service system, and

      • Eventually, over time, be used with those currently receiving services.

    • We will be careful not to disrupt lives, but instead identify opportunities for greater integration and independence based on needs, strengths and interests.

    Focused case studies
    Focused Case Studies

    Purpose – to immediately begin to test key reform concepts on a small scale

    Tested concepts – assessment tool, care planning process, documentation practices, new measures of individual outcomes, flexible funding environment

    Participating Agencies – high performing agencies

    Schedule - One year of study beginning January 1, 2013

    Who will complete assessments
    Who will complete assessments?

    • Assessment specialists

      • For case study, recruiting from current state MSC workforce

      • Bachelor’s in Social Work or another Human Services Field

      • At least one year of experience with individuals with DD

    • Responsible for completing assessments and implementation of surveys to gather feedback

    Where are we now
    Where are we now?

    • Finalized draft NYS CAS core tool and supplements

    • Selected a technology vendor to automate the tool for use during the case studies

    • Recruited and trained 18 Assessment Specialists

    Long term vision
    Long-term Vision

    • Recruit additional state staff to assess individuals statewide

    • Incremental rollout of statewide assessment

    • Develop a case mix and acuity levels

    • Use of needs assessment to inform resource allocation

    • Use data to enhance evidence-based policy decisions and valid quality measures