Transcript Developing Individual Budgets for Self

Self-Determination Leadership
Development Seminar
September 22, 2009
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From the Self-Determination Policy, the budget is:
 A fixed allocation of public mental health funds
 Derived from the costs of needed services &
supports
 May also include other public resources to be
accessed and integrated through the CMHSP
 Denoted in dollar terms as well as services
 Agreed to by the individual and the CMHSP as the
necessary cost of services and supports needed to
accomplish a consumer’s plan of
services/supports.
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In accordance with the Self-Determination Policy:
 The budget is expected or estimated costs of a
concrete approach to accomplishing the
consumer’s plan (Item II-C)
 Developed in conjunction with development of
a plan of specialty mental health services and
supports, using a person-centered planning
process (II-A)
 The amount of the budget shall be formally
agreed to by both the consumer and the
CMHSP before it may be authorized for use (IID)
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However it is derived:
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If the individual does not have direct control over a
fixed amount of resources so as to be able to select
and direct providers
If the individual does not know what the budgeted
amount is, and what it is intended for
It ain’t self-determination
An individual budget must be sufficient for the
consumer to accomplish the goals and
outcomes contained in their plan of services
and supports
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The pathways to achieving those may be varied
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We live & work in a world of limited resources
-For agency supports coordinators and
managers, gatekeeping is an expected role
Somewhere between the organization’s need to
conserve resources and the individual’s desire
for their own share is a middle ground
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How do we get there?
What is sufficient?
How do we assure fairness?
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When the individual knows what s/he has to work
with, and the basis for that amount, it is rather easy
to learn how to effect control, eventually
How do we empower participants?
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Authority over resources is not an end by itself
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The specific methods to assure direct participant
choice of and control over providers are not so
important
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But control over money is the central element of a power
shift from others being in charge of one’s life course, to
personal self-determination
But providing authority for choosing and influencing
provider behavior is the purpose of the mechanics
involving arrangements that support self-determination
An individual budget, therefore, is a central piece
of the machinery of those arrangements
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So is the manner in which the individual is supported to
apply the individual budget
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The budget must be:
Accessible
Flexible
Portable
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The amount and purpose of the budget is
known and understood by the participant
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The participant and his or her allies have been fully
involved in its development
The participant understands the options (and
limitations) for applying the budget
The participant knows has been oriented on
how to use those funds and provided with a
connection to where the funds are lodged
Ongoing information is provided to the
participant and chosen allies on the status of
the budget (monthly)
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Options are provided for modifying the budget
components within the overall amount, including:
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Planning is flexible in accordance with how a person
chooses to live day to day
 Scheduling the amounts of specific service/support may vary
day to day, week to week
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The actual use of a given service/support may be varied,
in the end, in comparison with the original plan
 i.e. the participant may adjust their own service “dose”
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There are opportunities to redirect savings that may
result from lower-than-planned use of services/supports,
to other more preferable services/supports options
 May be preliminarily authorized on a contingency basis in the
plan, or
 Plans may be adjusted later on
 Communication needs to be ongoing
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It must be possible for the participant to
manipulate and transfer budgeted resources,
from one provider arrangement to another.
Participant must be permitted change fiscal
intermediaries, with in a framework defined by
the PIHP/CMSHP
Budget savings can be maintained within a
reasonable framework
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Participants must be informed of the options for
flexibility and portability
 Participants must be provided with guidance
about the types of variations they may initiate and
the types that will require prior approval
 Including expectations that these must be
communicated to the PIHP/CMHSP
 Informed in writing
A how-to guide
 Ongoing guidance is easily accessible
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 A Specialist
 Peers
 Fiscal intermediary
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Prospective Method
 Benefit amount is
determined in advance
of PCP
 Objective assessment of
need determines IB;
 Participant determines
spending plan, services,
supports &
implementation strategy
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Retrospective Method
 Benefit amount is
determined in response
to PCP
 Participant Identifies
needs within PCP
 Agency (alone or in
concert with
participant) determines
benefit amount, services
& supports
 Participant determines
spending plan, &
implementation
strategy
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Participant Enters
System
Prospective
Budgeting
Assessment
completed using
PCP principles
Retrospective
Budgeting
PCP Completed
Total dollar amount of
benefit determined
Total dollar amount of
benefit determined
PCP completed
Amount of Budget
that is self-directed
Services &
support goals in
PCP
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Michigan uses a retrospective method to determine the
amount of an individual budget
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First, the plan of services and supports is developed
Then, the amount of the budget is determined based upon the
costs of services outlined in the plan
A prospective method typically involves using assessment
and other data to determine the amount of the budget,
following which a plan of services & supports is developed
that may not exceed the prospectively determined amount
In Michigan, use of an assessment to determine services
authorization may not be substituted for the person-centered
planning process
 The prospective method involves a budget cap; we do not cap
budgets on the front end
 But limits on each individual budget developed are going to come
form somewhere
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In the end, the agreement by the participant is to implement
the plan within the overall budget amount
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Value ($) of services & supports under
the control & direction of the
participant
May include Medicaid & NonMedicaid services/supports but must
have clear audit trail of Medicaid $
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Describes the method for calculating based on reliable
costs or services utilization;
Developed using a consistent methodology for all
involved participants;
Reviewed & monitored according to a specified method
& frequency;
Provides participant ability to move money around;
Methodology is open to public inspection;
Informs participant of amount that is authorized to be
self-directed;
Defines a process for making adjustments & informs
participant;
Provides procedures to evaluate over & under
expenditures;
Provides prompt mechanisms to adjust funding in
response to individual situations;
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First, the plan is developed using a personcentered planning process
Second the budget amount is determined from
the plan, calculating costs per unit of service at
specific rates and aggregating these costs
Finally, the specific arrangements the
participant will, or may, utilize to control and
direct providers are determined
Then, the budget may be authorized in
companionship with the plan
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Person-centered planning
Involves the person’s whole life
Addresses health, welfare and opportunity for
integration, participation and productive
activity
Services needed are authorized with equity in
mind
Service authorizations are provided in specific
form with respect to the amount, duration and
scope of each service
Bringing in the cost issues too soon will corrupt
the process of determining and fairly meeting
individual needs
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Person-centered planning
About the person’s whole life (NOT just the services to
be obtained through the MH system)
Planning a budget takes into account the person’s
whole resource picture
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Saving money is not a primary goal
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Entitlements
Earnings
In-kind contributions from allies
CMHSP-provided resources
Ratcheting down on opportunity or working outside of fairness
and equity is not acceptable
Obtaining better value is ongoing
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Examining costs versus outcomes
Facilitating a learning process whereby new options for
achieving outcomes are at the heart of improving value
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In simplest case:
 Services authorized are at a static, known level, and the
person is not seeking a change
 Services are to be provided from among a group of
known providers with known rates
 The budget is rather straightforward
 Choice and control may be contracted through the
CMHSP
 But, there is a defined individual budget, the person
has participated in its development, has agreed to the
amount, and may access the budget, based upon
agreements reached in the planning process, using a
fiscal intermediary
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PLANNING GRID
PLANNING GUIDE SUPPORTS
FOR COMPANIONS
& OTHER SUPPORT
HOURS
SUN.
MON.
TUES. WED.
THU.
FRI.
SAT.
6-9 AM
9-1 PM
1-6 PM
6-10PM
10-6AM
TOTAL
HOURS
CODE
F=FAMILY
Fr=FRIENDS
HOURS
CODE
P=PAID
S=SELF
HOURS
CODE
HOURS
C=COMPN
TOTAL
More complicated
 The person is moving into a role that is new (e.g.
independent living)
 The services are to be consumer-controlled via direct
contracts that the consumer will negotiate
 Providers are not looking so “traditional”
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Innovative provider arrangements are sought
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E.g. individual personal assistance providers rather than
agency-provided Pas
Rates to be authorized do not include the same cost factors
Incentivised approaches to obtaining work
Companionship models that provide some of the personal
assistance
Peer support services
Rates are different
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They may not be excessive
They must be sufficient for the participant to
acquire qualified and capable providers
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Wage rates
 Must be sufficient
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Necessary add-ons
 Worker’s compensation
 Training needs
 Health care if possible
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Guidance must be provided to the participant
regarding the range of applicable rates
Maximum amounts that the consumer may
spend to pay specific providers may be
specified by the CMHSP (III-B-3-e)
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There shall be a written agreement between the
consumer and the PIHP/CMHSP delineating the
responsibilities and authority of each party
The agreement shall include a copy of the
participant’s plan and individual budget
The directions and assistance necessary for the
participant to properly use the budget shall be
provided to the consumer in writing when the
agreement is finalized. (II-E-2)
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Goods and Services are available only to individuals
participating in arrangements in self-determination
whose Individual Budget is lodged with a fiscal
intermediary. Projected savings from the use of the
Individual Budget can be used to acquire goods and
services that (1) increase independence, facilitate
productivity, or promote community inclusion and (2)
substitute for human assistance (such as personal care
in the Medicaid State Plan and community living
supports and other one-to-one support described in B3
Alternative Service definitions) to the extent that
Individual Budget expenditures would otherwise be
made for the human assistance.
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The purpose of the Goods and Services is to
promote individual control over and flexible use of
the individual budget by the individual using
arrangements that support self-determination, to
promote savings and the prudent use of Medicaid
funds, and to facilitate creative use of funds to
accomplish the goals identified in the individual
plan of services through achieving better value or
an improved outcome.
A Goods and Services item must be identified
using a person-centered planning process, meet
medical necessity criteria, and documented in the
individual plan of services. Goods and Services
may not be used to acquire goods or services that
are prohibited by federal or state laws or
regulations.
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