Waiver development update nysacra 10 th annual leadership conference
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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

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Waiver development update nysacra 10 th annual leadership conference

Waiver Development UpdateNYSACRA 10th Annual Leadership Conference

November 30, 2012


Waiver development update nysacra 10 th annual leadership conference

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


Managed care transition milestones

Managed Care Transition Milestones


Waiver development update nysacra 10 th annual leadership conference

1915 b/c Waiver Application Process


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


  • Targeted work team partners

    Targeted Work Team Partners


    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


    Waiver development update nysacra 10 th annual leadership conference

    Core Functions of Care Coordination


    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

    “THE BRICK”

    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


    Waiver development update nysacra 10 th annual leadership conference

    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/

    Supports

    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


    Coordinated assessment system

    Coordinated Assessment System


    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


    Waiver development update nysacra 10 th annual leadership conference

    Questions and Answers


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