Restructuring DD Budgets, Assessments and Rates in Oregon

1. 1 Restructuring DD Budgets, Assessments and Rates in Oregon

2. 2 HSRI’s “Ten Issues to Consider” Oregon’s Answers Goals Choice of Assessment Tool Full Population or Random Sample? Cost Data & Building the IBA Improving the Relationship: Need & Allocation What Waivers/Services are Covered? Exceptional Support Needs & Costs Reassessment of Support Needs Rolling Out the Model New People & Budget Challenges “Takeaway” Thoughts from Our Experiences Resources

3. 3 1. Goals Differently-funded waves of deinstitutionalization, “project-based” variations in slot funding, & failure to update rates left a “legacy” of inconsistency, inequity, and barriers to meeting individual goals. Funding was not consistently based on needs. We lacked data on individual needs & costs. (Gary Smith called us a “data-free environment”) We lacked the tools to objectively assess support needs & link this to funding. Funding variations interfered with portability & choice. County and provider “negotiations” over rates prevented individuals from choosing where they wanted to live or who would serve them.

4. 4 The number of people demanding Crisis support was growing, & more than half of these were already in Comprehensive services. Often moving into “crisis” was the only way to get an adjustment of rates. Reactive, not proactive. Lack of information about consumer needs & provider costs, & of consistent, valid rate-setting methodologies, made it difficult to compete for scarce resources, credibly forecast budget needs & effectively target what we have.

5. 5 In 2005 we launched ReBAR to: Replace “legacy” rates with a fair, equitable, understandable system Target funding to assessed need, making best use of scarce resources Enhance portability and choice Be credible, consistent, cost-effective Improve ability to plan, budget & forecast Involve Stakeholders from Day One

6. 6 Choice of Assessment Tool Oregon had no statewide assessment process or trained assessment personnel Stakeholders helped set criteria & select SIS Existing tool, don’t reinvent wheel (or rely on IT) Support focus, not deficit based Address behavioral, medical & life skills areas Independent, nationally recognized, validated Strong ongoing training and support structure Modern technology: automated, web-based Stakeholder involvement in tool selection critical to later acceptance and support

7. 7 Full Population or Random Sample? “Three-Legged” Pilot Sample 400 People SIS Assessment done by AAIDD interviewers No existing Oregon assessment infrastructure Stakeholders liked independence of AAIDD PCS - Provider Cost Study: actual cost variables ISS – Individual Services Survey: actual staff service hours provided to individuals in sample “Three Legs” of Pilot allowed matching assessed need, staff hours, & costs HSRI compared Oregon sample results with other national data to strengthen analysis

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9. 9 4. How is cost data used to build IBA? Oregon created what HSRI calls an “Individual Budget Level,” or “IBL” The Oregon system uses six Support Tiers & four different setting sizes – resulting in a matrix with 24 possible monthly budget amounts We think this is simpler to understand and implement than a multitude of individual rates The individual’s Support Tier is portable from provider to provider and location to location Although the system is intended to enhance individual choice, it is not a voucher & payment is made to providers of authorized services

10. 10 5. Improving the Relationship of Need & Allocation: Making Model Stronger With Stakeholder input, we determined that setting size is a significant cost factor From a policy standpoint, we also wanted to provide a “pathway” for larger homes to downsize, without destabilizing current system Licensed Capacity of the setting in which the individual lives was added as a model variable Also with Stakeholder input, some variables of the otherwise “budget neutral” model were adjusted to address key issues: direct salary, benefits, training The model allowed “what if” prediction of impact

11. 11 How Does the ReBAR Process Work? The individual receives a ReBAR assessment Includes SIS & Oregon Supplemental Questions Assessments are done by State Assessment Specialists Assessment info is uploaded to AAIDD for processing SIS results are matched to one of 6 support tiers Matching done by HSRI, using Oregon ReBAR algorithm 3. Licensed setting capacity is entered into matrix Support dollars are adjusted by size of residential setting 4. Residential Individual Budget Amount is Determined The support tier and residential setting size are combined 5. Tier 7 Additional Support Review In unusual cases DD may authorize funding beyond Tier 6 Tier 7 eligibility is determined by Supplemental Questions

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13. 13 Does Model Cover Multiple Waivers? Currently the ReBAR model applies only to adult Comprehensive Waiver 24-Hr Residential settings The next Comprehensive Waiver services to be added are Supported Living & Employment/Day Other DD services such as Adult Foster Care and Host Homes have recently begun to use a needs-based rate tool developed by the state called the Oregon Support Needs Assessment Profile. This is also administered by ReBAR Assessment Unit. Oregon’s Supports Waiver has its own rate structure, and is not covered by ReBAR

14. 14 Exceptional Support Needs & Costs? Oregon developed 4 “Supplemental Questions” Severe Medical Safety Risk Severe Community Safety Risk – Convicted Severe Community Safety Risk – Not Convicted Severe Risk of Injury to Self The SIS addresses these, but does not provide as much detail for rate-setting as in other areas These questions are triggered by answers in SIS Exceptional Medical & Behavioral sections When results indicate especially high levels of support need, documentation is reviewed: Oregon’s Risk Tracking Record, Behavior Support Plans, medical protocols, legal orders, etc.

15. 15 When review of Supplemental Questions shows need for more support, two outcomes are possible: Adjustment upward within the 6-level rate matrix to a higher support tier HSRI algorithm combines SQ & SIS Exceptional Medical/Behavioral scores This captures high intensity/low incidence issues which the SIS may not “flag” strongly Referral for Tier 7 funding review Tier 7 focuses on very intensive staffing needs beyond the top tier of the rate matrix Tier 7 review is not done by ReBAR, but by DD state program staff & the service coordinator

16. 16 How Often to Reassess? Oregon plans to do reassessments: Every 5 years An earlier reassessment may be provided if there is a substantial change in a person’s support needs (especially medical or behavioral)

17. 17 Rolling Out the Model Oregon needed to address four key issues in implementing its new ReBAR process: Developing assessment infrastructure Strategy for applying assessments & rate changes Impact on multiple state and county systems A method to fund the new system

18. 18 Assessment Infrastructure The only existing resource for doing assessments was a group of nearly 200 county case managers Their workload was already maxed out Training, monitoring, assuring consistency would be hard Stakeholders worried about conflict of interest A state-operated Assessment Unit was created 10 Specialists & 2 Supervisors are distributed statewide All Specialists were trained by AAIDD AAIDD does Interviewer Reliability Reviews annually AAIDD does quarterly conference call updates Supervisors monitor interviewer performance regularly QA surveys go to UofO evaluators after every interview Consistency & credibility of this unit is critical

19. 19 Implementation Strategy Oregon is using a “bottom up” approach, beginning with people with the lowest existing rates, regardless of location or provider. Gets quick relief to those whose rates haven’t changed for up to 20 years, except sporadic COLA Gave the system a chance to “warm up” with folks who mostly have less complex and intensive support needs Allows pacing the work by sequencing rate levels to be done to match number of interviews possible A major benefit: This approach engenders a lot of initial support from consumers & providers A drawback: It means things get tougher as we work our way up the rate scale.

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22. 22 Results: First Year of “Bottom Up” Approach

23. 23 Impact on Multiple Systems Rate Restructuring impacted systems far beyond the development of rate models: Billing & Payment: ReBAR could not have been implemented without Oregon’s new eXPRS automated payment system Intergovernmental relationships: ReBAR reduces the autonomy of counties to set rates; but it also allows them to focus on other areas like service quality instead of haggling dollars Scheduling & preparing consumers, provider, county and state staff for interviews requires lots of hard work. DD Council & providers help.

24. 24 Funding the System Change Oregon tapped two major sources: CMS Real Choice System Transformation Grant 5-year grant funded strategic planning, core staff, TA Redirection of positions and funding from closure of Eastern Oregon Training Center Oregon DHS Asst. Director James Toews and DD Administrator Marylee Fay nurtured a multi-year plan to see that positions & savings from closing Oregon’s last ICFMR would be directed to community DD services – specifically the development of the ReBAR Assessment Unit & funding to implement new rates. Many of our original timelines and plans to be “perfect” before implementing were shortened to capture political & economic opportunities. That “opportunism” allowed the project to be born. Stakeholder support allows it to live and grow.

25. 25 New people & budget challenges ReBAR started by doing “conversions” of people already in stable services. Recently it began assessing people new to the Comprehensive Waiver, or who are in “crisis” within that system. A logistical challenge is finding knowledgeable SIS interview respondents in new or unstable situations A goal of ReBAR is to reduce the number of people who move into “crisis” due to a mismatch between needs and resources – to be proactive, not reactive. In times of budget reduction, ReBAR provides a strong platform for planning, forecasting and justification of resource needs, and increased credibility for the Division

26. 26 Some “Takeaway” Thoughts Lots of talk today about importance of Stakeholders. Believe it. No system change is hotter than one that reaches into everyone’s pocketbook. Involve them early, often & always (even they disagree) When things get tough, it is crucial to be able to say, “OK, we did this, so how will we fix it?” Credibility: Hard to gain, easy to lose Make the credibility of the assessment and rate tools and processes an absolute priority Get as many boats floating with your tide as early as you can. Incorporate this in your rollout strategy. Be Opportunistic. There is no single “right way” to do this (yet). So be ready to grasp the possibilities.

27. 27 The Rate Restructuring 80/20 Rule Rate Restructuring is 20% about the Numbers It is 80% about the People – who need to buy into it, wrestle with it, live with it, & support it.

28. 28 Resources Oregon’s ReBAR Website (Lots of Info) www.oregon.gov/DHS/dd/rebar Oregon Council on Developmental Disabilities Training videos/brochure for consumers, families, provider http://ocdd.org/index.php/ocdd/trainings/129/ Contacts Marylee Fay, SPD/ODDS Administrator marylee.fay@state.or.us 503-945-9787 Bob Clabby, ReBAR Director bob.clabby@state.or.us 503-385-7144 Jan Morgan, ReBAR Program Manager jan.m.morgan@state.or.us 503-945-6409

29. 29 The End The Last ICFMR Bed in Oregon 10-27-2009