Transcript Wisconsin Medicaid Infrastructure Grant

Developing a Comprehensive Approach
to Systems Change:
Increasing Integrated Employment
Opportunities and Outcomes for
Individuals with Disabilities in
Wisconsin’s Managed
Long-Term Care System
Wisconsin Department of Health Services
Division of Long-Term Care
Financial Support for the Task Force is provided by the
Centers for Medicare and Medicaid, Medicaid Infrastructure Grant
(MIG), CFDA No. 93.768, through DHS’s Office of Independence and
Employment/Pathways to Independence.
WI Department of Health Services:
Major Systems Change Initiatives

Statewide expansion of the “Family Care” managed
long-term care program

Statewide “Pathways to Independence” Medicaid
Infrastructure Grant (MIG) initiative

Very little overlap of two systems change initiatives
during early years (2000 to 2006)
“Family Care” Managed Long-Term
Care

Began with five county pilot in 2000

One system serving people with developmental
disabilities, physical disabilities, and elderly

2005 evaluation led to legislative support for
statewide implementation

75% of state now under managed care

Self-directed supports waiver offered as another
option
“Family Care” Managed Long-Term
Care

Entitlement created: ends waiting lists for
community services

Outcome driven

Reduced per-person spending expected as the
result of more cost-effective supports

Increased flexibility on how supports can be provided
and who can provide them
“Family Care” and Employment

Little attention to employment outcomes in early
years of implementation

Elderly as driving force

Facility-based employment “quick fix” for people with
disabilities coming off waiting lists

Disability advocates concerned about lack of
improvement in employment outcomes
Hard Look in the Employment Mirror

Most people with disabilities served by the long-term care
system are currently unemployed or employed in nonintegrated settings, making sub-minimum wages.

Just 25% of people with developmental disabilities in managed
care involved in integrated employment (including
crews/enclaves). [2006]

Just 5% of people with physical disabilities in managed care
involved in integrated employment. [2006]

9,416 individuals with disabilities in sheltered workshops
making sub-minimum wage, with 35% earning less than
$1.00 [2005].
State Agency Prioritizes Employment:
Creates “The Managed Care and Employment Task Force”

Members appointed by Administrator for the Division of Long-Term
Care.

Chaired by Deputy Administrator of the Division.

28 highly respected members, including wide range of stakeholders:
managed care entities, consumers and family members, advocates,
providers, employers, colleges and universities, counties, and state
agencies.

Seven issue committees, involving over 100 other contributors

15 month process

Listening sessions held June, 2008

Final report submitted July, 2008.
Task Force Areas of Focus

Through Issue Committees, the Task Force examined the
following key program and policy areas:
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Informed Choice and Member-Centered Planning
State/Managed Care Organization (MCO) Contracting and
Funding Strategies
MCO Contracts and Strategies with Providers
Blending Funding Across Systems
Employment Service Provider Network Development and Support
Measuring Outcomes and Quality
Work and Employer Incentives, including incentives in Medicaid
84 Recommendations Made
DHS Response to Task Force Report
and Recommendations
“I support the findings and recommendations that this
report contains. I have directed the management and
staff in DLTC to proceed with implementation, which
is likely to take several years to complete. We will
continue to seek the support and engagement of
partners in state and local government, as well as
the private sector, to assist us in realizing these
important objectives.”
-Secretary Karen Timberlake
WI Department of Health Services
DWD Response to Task Force Report
and Recommendations
“Our department was pleased to have representatives
on the Task Force that developed vitally important,
aggressive and detailed recommendations for
systemic changes. We are delighted to continue in a
cooperative role for positive life-sustaining changes
for persons with disabilities…partnering to implement
the Task Force recommendations is an exciting next
step.”
-Secretary Roberta Gassman
WI Dept of Workforce Development
The Managed Care and Employment
Task Force
Download Full Task Force Report, Work
Plans for Implementation, and Progress
Reports at:
http://dhs.wisconsin.gov/WIpathways/
Strategy for Systems Change
A Multi-Faceted Approach
High Level Changes

Division of Long-Term Care adopted strategic priority
to promote and support integrated employment
outcomes

Revised contracts with Managed Care Organizations
(MCOs) to include new language reflecting
expectations around integrated employment.

Employment is featured prominently as one of the
outcome areas that MCOs must help their members
consider, and pursue if desired.
Clarified Policies

Either/Or policies prohibited; mixed services
encouraged

25% rule must end

Transportation services should be based on
need, not based on type of service someone
is receiving
Changing Service Definitions

Revised what’s permitted under Supported
Employment to include and encourage:
-Customized Employment
-Self-Employment
-Ability to pay employers/co-workers for supports
-Ability to pay natural supports for transportation
-Ability to use workplace personal assistance for
longer term on-the-job supports
Revised Prevocational Services
Definition

Service is intended to contribute to a participant’s employability in paid
employment in integrated, community settings

Participants may be compensated in accordance with applicable
Federal laws and regulations, but the provision of prevocational
services is intended to lead to a permanent integrated employment
situation

The services should enable a participant to attain the highest possible
wage and work which is in the most integrated setting and matched to
the member’s interests, strengths, priorities, abilities, and capabilities

Services recipients are expected to make reasonable and continued
progress toward participation in at least part-time integrated
employment.
Assessing Performance

Improving data systems to allow for better
tracking of employment outcomes, services
and expenditures.

An annual report on performance will be
produced by state agency.

Performance data will be used to establish
benchmarks (goals) for progress.
Accurately assessing costeffectiveness

Collection of wage and hour data allows for
accurate assessment of cost-effectiveness of
supported employment

Documenting cost-effectiveness of supported
employment is critical for buy-in to policy of
‘zero exclusion’

Long-held assumptions die hard!
Managed Care Organizations

Have formal policies, principles or guidelines
on employment that reflect the Department’s
values regarding integrated employment.

Added source of employment expertise to
their staff.

Establishing cooperative relationships with
local Vocational Rehabilitation offices
Managed Care Organizations

Training care managers and nurses
-Outlining specific expectations on how to ensure informed
choice in member-centered planning process
-Care Managers are expected to regularly offer and fully
support members to pursue integrated employment
-By doing this, MCOs are expected to increase both the number
and percentage of long-term care recipients who are supported
to pursue and maintain integrated employment at a competitive
wage.
Managed Care Organizations

Expanding and diversifying their provider networks
for integrated/supported employment services.

Encouraging use of customized employment

Exploring use of outcome payments and incentive
payments so providers that deliver good outcomes,
fade supports, and serve the most challenging
individuals do not lose out financially.
Managed Care Organizations

Hiring members so MCOs are leading by example

Some are doing performance improvement projects
on employment

Some are becoming EN’s

Some are doing peer-to-peer outreach with other
employers in their areas
Integrated/Supported Employment
Providers
Are being assisted to learn and
implement the most promising, evidence
based practices:

Customized Employment Pilot

Systematic Instruction Training
Facility-Based Service Providers
Are being assisted with organizational
change through a Rebalancing Initiative

Started in 2009 with 10 CRPs

Modeled after DOL’s T-TAP Initiative

Mentoring + Grants + TA + CE Training

18 CRPs (25%) now involved
What is CRP Rebalancing?

Emphasizes shifting the balance of organizational
resources (esp. staff) in favor of integrated
employment

% of people served in integrated employment
expected to rise

% of people served in facility-based employment and
day programs expected to decrease
What is CRP Rebalancing?
Primary Strategies:

Enabling new referrals to go directly into at
least part-time integrated employment

Assisting facility-based participants to
transition to at least part-time integrated
employment
What is CRP Rebalancing?

Does not require a commitment to
conversion
Allows the CRP and individual consumers to
“Live into the answer…” [J. O’Brien]

“Accelerated progression” toward community
integration and real jobs
Personal Care Providers

Being engaged to provider workplace personal care
and assistance

Developed toolkit to help providers add workplace
personal care and workplace personal assistance as
new service lines

With Wisconsin APSE, developing core training for
individuals hired to provide workplace personal care
and/or assistance
Accountability for Change

Two key state agencies (DHS and DWD) jointly
charged a body of external, well-qualified
stakeholders with monitoring progress and reviewing
outcomes.

This body is a sub-committee of the Governor’s
Council on Workforce Investment

DHS has developed multi-year work plans for
implementation of each of the recommendations
made by the Managed Care and Employment Task
Force
Resources for Change
Center for Medicaid Services has
approved MIG funding to support
implementation of these strategies.
Time-limited nature of MIG funds has
created sense of urgency around
getting changes implemented.
The Value of High Expectations
“The greatest danger may not be that
our aim is too high and we miss it,
but rather that it is too low and we
reach it.”
-Michelangelo
For More Information:
Lisa A. Mills, PhD
Consultant
WI Department of Health Services
[email protected]
(608) 225-4326
The Glass is Always Half Full