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The New Exceptional Rate for the ID Waiver. Lee Price, Sr. Policy Advisor for the Office of the Settlement Agreement Executive Advisor & Dawn Traver, Community Resource Manager, Division of Developmental Services. The Underlying Issue.

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the new exceptional rate for the id waiver
The New Exceptional Rate

for the ID Waiver

Lee Price, Sr. Policy Advisor for the Office of the Settlement Agreement Executive Advisor

& Dawn Traver, Community Resource Manager, Division of Developmental Services

the underlying issue
The Underlying Issue
  • DBHDS recognizes that there are individuals in the training centers and the community who have greater needs than can be adequately met through the existing rate of reimbursement.
    • High medical support needs
    • High behavioral support needs
intent of an exceptional rate
Intent of an Exceptional Rate
  • The “exceptional rate” was conceived to be a stopgap measure to address this problem – not a final solution
    • DBHDS is hopeful that the waiver study currently underway will assist in crafting long-term improvements to the service system
general assembly action
General Assembly Action
  • The 2013 General Assembly included a budget bill item to provide funding for an exceptional rate for ID Waiver Congregate Residential Support services:
    • Provided $3,682,880 in state general funds to support the exceptional rate
budget bill language
Budget Bill Language
  • The exceptional rate is designed for those
    • “currently residing in an institution and unable to transition to integrated settings in the community due to the need for services that cannot be provided within the maximum allowable rate


    • whose needs present imminent risk of institutionalization and enhanced waiver services are needed beyond those available within the maximum allowable rate.”*

*Budget Bill Item 307 #3c

general assembly intention
General Assembly Intention
  • Budget bill intent:
    • Provide a temporary (i.e., until waiver redesign) exceptional rate for those with complex medical or behavioral needs
    • Enable those individuals to receive enhanced waiver services beyond those provided through the existing maximum rates
extent of impact
Extent of Impact
  • The approved funding is estimated to provide additional supports to approximately 250 people.
  • It is anticipated that the exceptional rate will be 25% more than the current Congregate Residential Support rates
    • NoVa: $21.70/hour
    • ROS: $18.88/hour
current status
Current Status
  • DBHDS & DMAS staff have drafted criteria for the new rate and sent to CMS for approval:
    • Individual eligibility – will involve, among other factors, SIS® scores
    • Special review process before service authorization
    • Provider requirements
  • Will release the details once CMS approves the Waiver amendment
current status cont d
Current Status (cont’d)
  • Waiting to hear back from CMS
  • State regulations are being drafted, but their approval process begins after CMS Waiver amendment approval
hopeful timeline
Hopeful Timeline
  • CMS Waiver amendment approval by early October 2013
  • ID Waiver regulations about the exceptional rate in place by early January 2014
  • The first individuals approved for exceptional rate funding by mid-February 2014
things that are important to for mt
Things That Are Important To/For MT



Maintaining optimal positioning for respiratory health

Adequate nourishment and hydration

Visual, auditory and tactile stimulation

Total assistance with ADLs

Engaging in many social, recreation and leisure activities

  • Playing my keyboard/listening to music
  • Being outside; going on vacations
  • Being lifted up and down on the ARJO lift
  • Watching the hands of a clock move
  • Water
  • Visiting with family/friends
mt s recent hospitalizations
MT’s Recent Hospitalizations
  • Hospitalized seven times in between January 2012 - April 2013 for
    • Pneumonia
    • Respiratory difficulties
    • Each hospitalization lasted 5 to 15 days for a total of 70 days
knowledge expertise mt s provider must have
Knowledge/Expertise MT’s Provider Must Have
  • Pneumonia prevention plan of care
  • NPO – Nutrition/hydration/medications via G-tube
  • DNR(parents wish no CPR/chest compressions)
  • Knowledge of dysphagia
  • Bowel movement protocol
  • Repositioning protocol
  • Weight and fluid intake protocol
mt s staffing needs
MT’s Staffing Needs
  • Two hours of nursing services per shift
  • Monitoring vital signs and assessing for signs of illness.
  • Assessing respiratory status; administering Albuterol nebulizer for severe wheezing
  • Checking G-tube integrity/patency and stoma site condition every shift
  • Monitoring positioning during enteral feeding and optimizing positioning at all times
  • Oropharangeal suctioning as needed
  • Monitoring oxygen support via nasal cannula continuously from bedtime to 7AM
things that are important to for rh
Things That Are Important To/For RH




Something constructive to do during the day

Being encouraged to participate in ADLs

Maintaining good health through regular medical and nutrition management

Managing his challenging behaviors and communication

  • Making his own choices about mealtimes, snacks and TV
  • Personal space/private time
  • Sporting activities
  • Socializing with family and friends
  • Warm water activities
  • Playing games, listening to music and looking at books
other important things per rh his authorized representative
Other Important Things Per RH & His Authorized Representative
  • Home designed for individuals on the autism spectrum; quiet with sensory items available
  • Home where the others can tolerate RH when he chooses to be loud
  • Space to roam while still being supervised
  • Own room
  • Home with no more than 4 other individuals
  • Fenced in back yard
  • Structured environment
  • Being close to his family
rh s behavioral data 2012 2013
RH’s Behavioral Data: 2012 – 2013
  • 60 episodes of aggression
      • 7 episodes were documented
      • 53 episodes were managed with proactive intervention
    • Attacked parents in vehicle
    • Bit, hit and kicked staff
    • Bit peers
  • He had 40 events of property destruction
      • 1 event was documented
      • 39 events were managed with proactive intervention
rh s behavioral data 2012 2013 cont d
RH’s Behavioral Data: 2012 – 2013 (cont’d)
  • 214 episodes of self injurious behavior
      • 18 episodes were documented
      • 196 episodes staff were managed with proactive intervention
    • Biting self to the extent of drawing blood
    • Hand banging on windows and doors
    • Slapping self in face to the extent of drawing blood
    • Hitting his face on his knees, blacking his eyes and bruising his face
  • TOVA interventions were implemented 4 times
  • Chemical restraint was utilized 1 time during an episode of especially challenging behavior
rh s staffing needs
RH’s Staffing Needs
  • Staff trained and practiced on his positive behavioral support plan
  • 24 hour awake supervision with two staff awake at night
  • Follow communication plan
  • Two staff for medical appointments to assist with his aggression toward medical professionals
  • Supervision in bathrooms if others are nearby to reduce the risk of aggressive episodes
things that are important to for pj
Things That Are Important To/For PJ



Being reminded to take small bits so I don’t choke

Intense supervision to make sure I don’t hurt myself

  • Listening to country music
  • Taking trips
  • Talking to people about trips I’ve taken
  • Looking at pictures in magazines
  • Watching a movie or television with others from time to time
current challenges for pj
Current Challenges for PJ
  • I will sometimes leave where I am supposed to be and will “wait” for someone to come find me. I enjoy this game and I laugh when I am found.
  • When I become upset I may remove my clothes and throw feces.
  • I often pull clothes, hair, and jewelry and scratch or kick support partners.
  • I struggle with transportation and often grab the steering wheel, open doors, jump out or squeeze through windows, while riding in a vehicle.
  • I will often destroy things in my home and other environments such as the community or at my day program.
pj s staffing needs
PJ’s Staffing Needs
  • Having 1:1 support for transportation to prevent elopement, SIB or other challenging behaviors
  • Having 1:1 support when walking around in the community, as he will drop to the ground, roll around in parking lots and disrobe in public
  • Having an effective Behavior Support Plan, Nutritional Management Plan,
  • Having supports for oral and personal hygiene and with taking needed medications
pj s staffing needs cont d
PJ’s Staffing Needs (cont’d)
  • Having a Positive Behavior Support Facilitator to develop and monitor Behavior Support Plan
  • Instances of serious physical aggression should be addressed by following his BSP and involving START services to support acute and on-going concerns
  • A structured and active employment or day support setting where line of sight supervision is provided