Implementation of Self-Direction within the CAP-MR/DD Supports Waiver

1. Implementation of Self-Direction within the CAP-MR/DD Supports Waiver Presented by: Rose Burnette, Waiver Project Manager Division of Mental Health/Developmental Disabilities/Substance Abuse Services Susie Eguez, Clinical Instructor DDTI/School of Social Work/UNC – Chapel Hill 11/19/10 NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

2. Today’s Presentation • Provide an overview of the Self-Direction option • Provide a description of operational details of the option with a focus on the Roles and Responsibilities of all parties • Explain the processes involved in Self-Direction • Provide an update on implementation of the option NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

3. Self-Direction A Philosophy And Orientation To Service Delivery Whereby Informed Individuals Assess Their Service Needs, Determine How And By Whom These Needs Should Be Met, And Monitor The Quality Of Services Received. NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

4. Self-Directed Supports in NC • Independent Living Programs in NC communities Division of Vocational Rehabilitation Division of Services For The Blind • Centers For Independent Living • CAP Choice Medicaid Waiver for Disabled Adults • Division of Aging and Adult Services: Home and Community Care Block Grant Family Caregiver Program NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

5. To increase individuals choice and control over their services, as much as possible To be flexible in the use of public funds to meet each individual’s needs To spend public money wisely and appropriately To support individuals in their homes and communities To encourage and support individuals with developing meaningful relationships and community membership Goals of Self-Direction in the Supports Waiver NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

6. Benefits to the System • Offers flexibility, choice and control as a trade off for limited resources • Research indicates when families are involved in the development of a budget they tend to spend less than families who receive what’s typically on the menu.  • Cash and Counseling evaluation completed by Kevin Mahoney, researcher, found that individual control yielded lower costs.  NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

7. Benefits to the system • Less turnover in staff because of self selection • Strengthens and sustains natural support networks that will reduce paid supports • Reduces movement into facility based services NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

8. Self-Direction is an Option • Individuals may choose to participate in Self-Direction, it is not a requirement! • At any point the participant may choose to stop Self-Direction and use only provider directed services. NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

9. Agency With Choice • The model of self-direction within the Supports Waiver is the Agency with Choice model. • In general, an individual that chooses to participate in Self-Direction is considered the managing employer of employees they hire to work for him/her and to provide services that are designated as being self-directed. • Requires the support of the Financial Management Services agency and the Community Resource Consultant NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

10. Service Delivery Options Compared Self-Directed Option For Individuals But May Not Be For Everyone • May Be The Only Option Some People Select In Which To Receive Services • May Be An Option Some People Select In Combination With Traditional Service Components • Has Safeguards In Place For Participants And For Public Funds Accountability Traditional Remains An Option For Individuals • May Be The Only Option Some People Select In Which To Receive Services • May Be An Option Some People Select In Combination With Self-Direction Components • Has Safeguards In Place For Participants And For Public Funds Accountability NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

11. Components of Self-Direction The Person Centered Plan The Budget Self-Directed Services The Team of People Providing Supports Protections and Safeguards Communication-Communication-Communication… NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

12. Person Centered Plan Evolves from a process led by the participant and reflects what is “important to” the person Reflects what is “important for” the participant, such as life-enriching goals, preferences, needs, strengths, and desired outcomes Identifies unpaid and paid services/supports Identifies services, equipment, and supplies, etc. Specifies time, place and ways to receive services/supports NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

13. The Budget The budget is based on the Cost Summary Involves participant, case manager, CRC, FMS and other team members Identifies all of the participants’ resources (e.g. public funding, employment income and other sources) Outlines how funds will be spent on services, supplies, equipment and other needs Receives funding agency approval for public funds Follows funding agency rules NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

14. Individuals Have Budget Authority • Have decision making authority over an individual budget from which the individual purchases supports and services authorized in a person centered plan. • The person centered planning process is primary to insuring that individuals receive the services and supports needed within their identified budget. • Have the flexibility to shift funds among authorized services within the total amount of the budget. NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

15. Self-Directed Services Whom to select to provide services/supports How, when and where services/supports are provided What equipment and supplies to buy From which supplier, store or vendor to purchase some items Within funding rules, the participant decides… NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

16. Self-Directed Services Services that can be self-directed are: • Personal Care • Respite Services • Transportation • Home and Community Supports • Individual Goods and Services • More to be added in the new waivers NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

17. Self-Direction The Team Supporting the Participant NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

18. The Team Every team will be different based on the participants’ circumstances, and will generally include: • Participant and /or family • Friends or others as the decided by participant • Representative (if needed) • Case Manager • Direct Support Worker (Employees) • Community Resource Consultant (required) • Financial Management Service Agency (required) NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

19. Communication-Communication-Communication… • It is absolutely critical that all team members communicate with each other on a regular basis. • The Team must have regular interaction with the participant, Representative, CRC, Case Manager, FMS, etc. to ensure the health, safety and success of the individual! NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

20. The Participant-“Managing Employer” • The individual and/or their representative have lead responsibility and authority for; • Finds, selects and trains people to provide services/supports, • Decides pay and benefits within approved range • Schedules direct support workers/ employees • Evaluates job performance and replaces direct support workers/employees as needed NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

21. The Representative The representative is chosen by the participant and can be a trusted friend The representative may NOT also be a paid caregiver (i.e. Case Manager; Community Resource Consultant, Personal Care staff/ worker); guardian (any type), family member of the participant may make all or just part of the decisions, depending on how much help is needed Appointment as a Representative is a formal process Not all participants will have/need a representative NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

22. Financial Management Service (FMS) The FMS’s role is: • to work with the individual and/or his/her representative: • FMS is responsible as the employer of record. • in conducting employer related tasks, such as obtaining background checks, payroll functions ( taxes etc.), unemployment compensation fees, accounting, etc. NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

23. Financial Management Service (FMS) • When an individual decides to participate in Self-Direction the FMS meets with the individual, CRC and Case Manager to complete the Enrollment packet. • The FMS provides face to face support in addition to phone support and Customer Assistance. NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

24. Community Resource Consultant (CRC) The CRC’s role is to work with the individual one-on-one: • to guide and support the individual throughout the process of self-directing their services • to provide information on recruiting, hiring, managing, training, and evaluating employees • to assist with developing schedules and outlining duties of employees • to provide QDDP functions with the participant NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

25. Community Resource Consultant (CRC), cont. • Helps the participant to understand and monitor the budget. • Identifies resources and options in the community to expand community membership. • Communicates with other team members when changes in plan or budget are needed. NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

26. Case Manager The Case Manager’s Role is: • To facilitate the person centered planning process. • To assess needs, coordinate and link services, and monitor service delivery. The case manager working with the individual, collaborates with the Financial Management Service agency, and the Community Resource Consultant to monitor the expenditure of funds authorized in the individual budget. NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

27. The Direct Support Worker (Employee) Is employed by the participant Must meet qualifications and requirements of the funding source The employee work assignments are directed by the participant The employee schedule is directed by the participant The participant selects the methods, material, equipment NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

28. Local Management Entity (LME) The LME is responsible for the following: • Serves as the “point of entry” into Self-Direction • Provides information to individuals who are interested in Self-Direction • Reviews the Participant Choice Agreement with the participant/guardian and secures signatures NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

29. Local Management Entity (LME), cont. • Provides CRC vendor contact information • Notifies the DMH-DD-SAS of participant entry and transitioning from Self-Direction • Maintains contact with the participant and other Team members and responds appropriately to any potential health and safety issues or other triggers NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

30. Traditional Providers Continue to play an important role: • Many people will continue to receive services from traditional providers in addition to services they choose to Self-Direct • Traditional providers can provide “back-up” staff if desired by the participant NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

31. Roles and Responsibilities Please refer to the Roles and Responsibilities document…this handout provides specific detail about each person’s responsibility in specific categories! NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

32. Roles and Responsibilities The areas detailed in the Roles and Responsibilities document: • Transition to Self-Direction • Health and Safety • Plan Development • Developing Non-Traditional Service Options NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

33. Roles and Responsibilities cont’ • Selecting Traditional Providers • Staff Hiring and Supervision • Payment of Services • Monitoring • Additional circumstances that trigger notification to the LME NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

34. Self-Direction Vendor Selection NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

35. CRC Selection DMH-DD-SAS has selected, through a RFA process, two vendors to provide the services of Community Resource Consultant (CRC). • The Arc of North Carolina and, • Central State of the Carolinas • Both vendors have many years of experience providing services and supports to individuals who receive CAP-MR/DD funding. • Through the application process both vendors demonstrated the knowledge and ability to be successful in the role of Community Resource Consultant. NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

36. FMS Selection • In collaboration with DMA an RFP process was conducted to select 1 vendor to perform the functions of a Financial Management Service (FMS). • The vendor selected as the Financial Management Service is G.T. Financial Services. • G.T. Financial Services • owned and operated by individuals who have over 10 years of experience as financial administrators • have been operating as a family business providing fiscal intermediary services • for individuals participating in self-direction in Wisconsin and Michigan • Have served over 3500 people with disabilities NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

37. Self-Direction Protections and Safeguards NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

38. Protections In any program, there are risks. • Self-directed supports value the security of… • Participants • Direct support workers (employees) • Public funds NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

39. Protections for Participants • Resources and training for participants, families, representatives, case managers, provider staff and LME(s) • Option for participants to choose a representative • Grievance processes within human service agencies • Option to return to traditional/provider-directed services • Maintenance of confidentiality • Monitoring by team members, LME(s), DMH-DD-SAS and DMA NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

40. Protections for Employees (Direct Support Workers) Training for participants on how to manage services/supports Hiring agreement between the participant and employee State and federal laws and regulations for employers Support and assistance from the CRC and other Team members NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

41. Protections for Public Funds Procedures for determining allocations Rules on allowable services and expenditures Approval of paid services and budgets Requirements for service and financial reporting Requirements of the Financial Management Service Agency (FMS) Audits of financial records Monitoring by the LME and DMH-DD-SAS and DMA NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

42. Other Safeguards • The individual’s support team • Case manager contact and monitoring • CRC face to face contact and support • Transitioning from traditional agency directed services to self-directed services and supports • Withdrawal from self-directed services and supports • Ongoing monitoring by the LME • Ongoing monitoring by the DMH-DD-SAS and DMA NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

43. Communication-Communication-Communication… • It is absolutely critical that all team members communicate with each other on a regular basis. • The Team must have regular interaction with the participant, Representative, CRC, Case manager, FMS, etc. to ensure the health, safety and success of the individual! NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

44. Self-Direction How do Participants Become Enrolled in Self-Direction? NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

45. How do Participants Choose to Self-Direct? • Participating in the Supports Waiver • After entering the Supports Waiver, a person will have a choice about what type of services to receive, either: • provider-directed services or • self-directed services, or • combination of the two *To make the decision the participant must be informed of all the risks and benefits of their choices NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

46. How do Participants Choose to Self-Direct? • Individuals who have an interest in the Self-Direction option contact their LME • LME staff will provide information about the Self-Direction option • Individuals are provided a choice in selecting a Community Resource Consultant • Participants can NOT receive case management and CRC services from the same provider/vendor. NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

47. Participant Flow Chart The Participant Flowchart Document provides the step by step process for a participant to become enrolled and actively self-directing! NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

48. PCP Approval Process • PCPs will be processed via the Utilization Review vendor. • The Utilization Review vendor will complete a first level review and send the PCP to the DMH-DD-SAS. • DMH-DD-SAS will review and approve/process the PCP. • The authorization letter will be sent to the TCM from the Utilization Review vendor. NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

49. Agreements, etc. • There are multiple documents required for the participant and the representative to review and sign. • These documents are intended to provide information and ensure the participant and Representative understand what Self-Direction means. • Participant Choice Agreement • Appointment of the Representative NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services

50. Processes and Documents There are multiple processes and documents for which the participant/Representative must be to knowledgeable…these are intended to provide information necessary for Self-direction. • Involuntary/voluntary termination • Self-Direction Guide-reflects all components & processes • Participant Handbook-use as a Daily Reference NC Division of Mental Health, Developmental Disabilities and Substance Abuse Services