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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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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
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 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