Transcript iBudget Florida Stakeholders’ Meeting

iBudget Florida
Stakeholders’ Meeting
October 23, 2009
1
Assessment Instrument
Main question:
How should we get information
about people to know their needs?
2
Assessment Instrument
Current system:
• Previously used the Florida Status
Tracking Survey (FSTS) and the
Individual Cost Guide (ICG)
• Now uses the Questionnaire for
Situational Information (QSI)
• Covers physical, functional, and
behavioral areas
3
Assessment Instrument
APD Recommendations:
• QSI be used as assessment
instrument
• QSI improvements be ongoing
4
Assessment Instrument
Decisions needed:
• How and when to request reassessment
• How and when to appeal results
5
Assessment Instrument
Feedback so far:
• Want information on the QSI’s
validity and reliability
• Concern that it does not identify
certain needs of individuals
6
Assessment Instrument
Your thoughts:
• What are your concerns about the
QSI?
• How can we make people more
comfortable with the QSI?
7
Services
Main question:
What services and flexibility
should be available to consumers?
8
Services
Current system:
• 27 services in Tiers 1, 2, and 3
• 13 services in Tier 4
• Providers must be Medicaid enrolled
(except for CDC+ program)
• Statewide rates with some geographic
differentials
• Need for a service is determined
through prior service authorization
9
Services
APD Recommendations:
• Must use Medicaid enrolled providers
• Services allow more flexibility
• Rates be neutral
• Same set of services available to all
individuals
10
Services
Decisions needed:
• Potentially combining services for
greater simplicity and flexibility
• Limits, if any, for each service
– Dollar amount
– Hours
– Need proven (prescription or
assessment)
• Provider qualifications
11
Services
Feedback so far:
• Make additional services available in
Tier 4
• Want flexibility to use greater amounts
of services
12
Services
Your thoughts:
• How could service options meet
consumers’ needs better?
• What limits on control or other
safeguards might be important for
health and safety?
13
Waiver Support Coordination
Main question:
What should the waiver support
coordinator’s role be?
14
Waiver Support Coordination
Current system:
• Waiver support coordination is a required service
• Children have limited waiver support coordination;
adults have limited or full coordination
• Waiver support coordinators have lots of required
paperwork
– Very little is processed electronically—heavily paper
based
15
Waiver Support Coordination
APD Recommendations:
• Waiver support coordinator’s role will
shift to more of a facilitator and guide
• Will be seeking to reduce paperwork
16
Waiver Support Coordination
Decisions needed:
• Waiver support coordinators’ specific
tasks
• What waiver support coordinator service
options will be available
• How we will streamline forms and
processes
• What additional training, if any, to require
17
Waiver Support Coordination
Feedback so far:
Questions about what the role should be
18
Waiver Support Coordination
Your thoughts:
• What should the waiver support coordinator’s
role be?
• What should the split of individual, family, and
waiver support coordinator responsibilities be?
• What concerns are there about the waiver
support coordinator’s role in a more selfdirected system?
• What options would a waiver support
coordinator have if he or she felt an individual
was making bad choices?
19
Prior Service Authorization
(PSA)
Main question:
How do we best ensure that individuals
receive the services that they need within
allowable waiver coverage?
20
Prior Service Authorization
Current system:
• All services must be approved through prior
service authorization
• Reviews are performed by area staff and a
contracted provider
– It’s time-intensive
– It’s complex
– It’s paperwork-intensive
21
Prior Service Authorization
APD Recommendations:
The process as we know it go away—be
minimized or eliminated as much as
possible while meeting federal
requirements
• Streamlined paperwork
• More flexibility
• Personalized approach
22
Prior Service Authorization
Decisions needed:
• Situations requiring a review
• The process for requesting reviews
• Who will perform reviews
23
Prior Service Authorization
Feedback so far:
Scaling back is great but we
need something to meet federal
requirements for assessing
medical necessity of services
24
Prior Service Authorization
Your thoughts:
What service approval process is
appropriate for:
•Medical services
•Therapies
•Behavioral
services
•Extraordinary
needs
•Meaningful day
activities
•Residential
habilitation
•Supports in the
home
25
Consumer and Family Control
Main question:
What would be reasonable
limits on individual control?
26
Consumer and Family Control
Current system:
• Waiver support coordinators work with
individuals and families to support choice
• Individuals and families have little insight
into spending of funds for supports
• Prior service authorization is required
before service amounts are increased
27
Consumer and Family Control
APD Recommendations:
• Training be provided to consumers
and families on choice-making
• Consumers and families have
greater control over the amounts
and types of services they get
28
Consumer and Family Control
Decisions needed:
• Limits on spending to ensure that funds
last through the year
• What to do if a person overspends but
still needs services
• How to provide training on making
good choices
29
Consumer and Family Control
Decisions needed :
• What information consumers need to
make good decisions
• How to help consumers track spending
• What support to give to consumers who
don’t have unpaid help in decision-making
• If funds can be carried over to a future
year like in CDC+
30
Consumer and Family Control
Feedback so far:
• Some individuals don’t have sufficient
support to exercise self-direction
• Concern that some providers may not
cooperate or may be manipulative
31
Consumer and Family Control
Your thoughts:
• What information and training do consumers
and families need to make good decisions?
• How could they get that information?
• How can we help those who don’t have families
or friends to help them make choices?
32
Consumer and Family Control
Your thoughts:
• How might we limit spending to ensure that
funds remain through the year? Should we do
this?
• How are pro’s and con’s of allowing carryover
of unused funds to another year?
• How can we find out if any providers are
uncooperative or manipulative, and what
penalties might be assessed?
33
Extraordinary and Changed
Needs
Main question:
How do we ensure that people with
extraordinary or changed needs get enough
funding?
34
Extraordinary and Changed
Needs
Current System:
• Individuals are assigned to tiers, which
cap spending
• If needs are believed to have changed,
the waiver support coordinator requests a
prior service authorization review for
additional services and/or a tier change
35
Extraordinary and Changed
Needs
Decisions needed:
• Process to identify people with
extraordinary needs and set their
budgets
• Process to handle requests for
funding due to changed needs and
determine the funds required
36
Extraordinary and Changed
Needs
Decisions needed:
• How to identify people with extraordinary or
changed needs
–
Statistician will help when the model is more developed
• How to set their budgets
• How to decide if needs have changed
• How to calculate funds needed for changed needs
37
Extraordinary and Changed
Needs
Feedback so far:
Want to ensure that funds are available
for people with changed needs or
extraordinary needs
38
Quality Assurance
Main question:
How do we monitor to ensure health,
safety, and good outcomes?
39
Quality Assurance
Current system:
• Contracted provider (Delmarva) performs quality
assurance activities in conjunction with APD staff
• Contracted provider uses desk reviews, on-site visits, and
consumer interviews to assess provider performance and
consumer outcomes
• Medical Case Management Team and/or WSCs determine
if additional review is required for health and safety
• Support planning, annual reports, and quality assurance
contractor determine if individuals are progressing toward
goals
40
Quality Assurance
APD Plans:
• New quality assurance contract uses
different measures
• Florida is joining National Core Indicators
initiative
41
Quality Assurance
Decisions needed:
• What might change under a new contract
in a more self-directed system
• What might trigger any special health and
safety reviews
42
Quality Assurance
Feedback so far:
Support revision of the quality assurance
system to be more understandable, less
bureaucratic, and more person-centered
43
Quality Assurance
Your thoughts:
• What are your concerns regarding quality
assurance in a more self-directed system?
• How should consumer outcomes be
assessed in a more self-directed system?
• What should be done if the consumer is
making poor choices and their health and
safety are at risk?
44
Overall System Financing
Main question:
How do we make budgets
predictable and sustainable for
consumers and the agency?
45
Overall System Financing
Current system:
• Legislature appropriates funding
• Complex rules control individual cost plans and
spending to seek to stay within the
appropriation
– Individuals are assigned to one of four tiers
– Rebasing for those with changed cost plans
– PSA determines medical necessity
46
Overall System Financing
Current system:
• Legislature cuts services and imposes other
requirements to control spending
• About 25% of APD customers had cost plan
reductions under the tiers
47
Overall System Financing
APD Recommendations:
• System be fairer to consumers and be
sensitive to individual needs
Important to Remember:
• State constitution requires balanced
budget—APD must stay within its
appropriation
• Legislature makes decisions on how to
fund the wait list
48
Overall System Financing
Decisions needed:
• How much funding to reserve for
extraordinary and changed needs
• How tiers will mesh with this system
– Will be designing it without tiers
49
Service Providers
Main question:
Who may provide services?
50
Service Providers
Current system:
• Any provider meeting Medicaid requirements
can be enrolled and provide services
• Must use Medicaid-enrolled providers unless in
CDC+
• Currently more than 10,000 providers statewide
• Range from single-person entities to large-scale
operations with multiple sites and hundreds of
employees
51
Service Providers
Current system:
• Under waiver requirements, consumers must
have choice of providers
• WSCs submit service authorizations to begin or
end services with a specific provider
• Providers must complete paperwork: annual
reports, quarterly reports, individual plans,
service logs, etc.
52
Service Providers
APD Recommendation:
• CDC+ option continue, although participants
will get iBudgets
• Everyone else use Medicaid-enrolled
providers
• Rates be neutral
53
Service Providers
Decisions needed:
• What competencies and standards that
providers would need to meet
• What information or notice is given to
providers to begin or end services
54
Service Providers
Feedback so far:
• Ensure consumers have support and training
• Need timely notice and payment
• Self-directed system could pose management
challenges
– Staffing, regulation compliance, revenue
projections
55
Service Providers
Your thoughts:
• What opportunities does a more selfdirected system pose for providers that
are creative and innovative?
• How can providers, consumers, and
families work more cooperatively in a
self-directed system?
56
Administrative Issues
Main question:
How will the system work to make all
this happen day-to-day?
57
Administrative Issues
Current system:
• Area office staffs manage at the local level
• Cost plans run with the fiscal year
• ABC is the main computer system
• Paper-based
58
Administrative Issues
APD Recommendation:
Wish to pilot or phase-in as CMS allows
– This will allow us to fine-tune before full
implementation
59
Administrative Issues
Decisions needed:
• When during the year an annual budget begins
• How iBudgets will be phased in
– Need to see range of impacts after algorithm is
developed further
• Changes required to computer systems and
other supporting processes
• What specific staff roles will be
– Service approval? Calculating budgets?
60
Administrative Issues
Feedback so far:
• Support for phasing in over time
• Concern that implementing this on top of
other recent changes might be too much
• Concern that if we don’t do this soon, the
system will be in trouble
61
Administrative Issues
Your thoughts:
• How might we phase in iBudgets across
the state?
• What is a reasonable implementation
timeframe, recognizing potentially strong
interest in the Legislature for action?
62
Algorithm
Main Question:
What factors should be considered
in the algorithm to determine
funding?
63
Algorithm
Current system:
• Waiver support coordinators request services for
individuals
• Complex system for approving requests
– Law requires use of certain factors to make tier
assignments (such as living situation)
– For Tiers 2, 3, and 4, spending is capped
– Rebasing
– Limits in handbook
• Funding is total of services approved
64
Algorithm
APD Recommendations:
• Use regression model
• Dependent variables are previous
years’ expenditures
• Seeking individual budgets
65
Algorithm
APD Recommendations:
• Data for variables must be reliable and valid
• Variables will make appropriate contribution
to model predictiveness
• Review model to ensure that health and
safety are not at risk
• Rates be neutral
66
Algorithm
• Decisions needed
– Specific variables and their contribution
– How often to rerun and revise algorithm
67
Algorithm
Feedback so far:
• Build a model tailored to Florida
• Concern that funding for meaningful day
activities will be eroded or insufficient
• Concerns on using diagnosis in the model
68
Algorithm
Feedback so far:
• Want to know the model details, including
statistical details
• How to ensure validity and reliability of data
used in model
• Fairness to those living at home
69
Algorithm
Your thoughts:
• Factors that might be correlated with
costs
• Data we might use
70
Conclusion
Questions?
Comments?
Suggestions?
71
Conclusion
• Adjourn
• Thank you for your time and input!
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