Waiver Development Update NYSACRA 10 th Annual Leadership Conference

1. Waiver Development UpdateNYSACRA 10th Annual Leadership Conference November 30, 2012

2. 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

3. Managed Care Transition Milestones

4. 1915 b/c Waiver Application Process

5. 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

6. 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.

7. 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.

8. Managed Care Transition Timeline MLTCP: Managed Long-Term Care Plan FIDA: Fully Integrated Duals Advantage DISCO: Developmental Disabilities Individual Support and Care Coordination Organization

9. 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)

10. 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.

11. 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

12. Targeted Work Team Partners

13. 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

14. 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

15. 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

16. 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.

17. 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.

18. 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

19. Core Functions of Care Coordination

20. 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

21. 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

22. 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.

23. 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.

24. 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.

25. 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

26. Modernizing the Fiscal Platform Work Team:Principles of Payment Reform • Fairness and Equity • Portability • Efficiency/Economical • Structural Reform • Simplicity and Practicality • Network Stability

27. 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

28. 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

29. 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

30. Needs Assessment UpdateGoals of Needs Assessment

31. 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

32. 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

33. Overview of Coordinated Assessment System

34. 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)

35. 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

36. New York State-specific interRAI DD New York State OPWDD Coordinated Assessment System (CAS) interRAI Intellectual Disability (ID)

37. 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

38. Coordinated Assessment System

39. 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.

40. 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

41. 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

42. 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

43. 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

44. Questions and Answers