Transcript MA_Reform2020_BIconf_4-12-13_no notes

REFORM 2020
HCBS REDESIGN
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Alex Bartolic, Director of Disability Services
Jean Wood, Director of Aging and Adult Services
Brain Injury Alliance Conference
April 12, 2013
Brooklyn Center, MN
WHAT IS “REFORM 2020”?
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Bi-partisan initiative to reform MA
Effort to meet the challenges of rising MA costs and
growing demand
Opportunity to develop/test new ways of operating;
successful models will be expanded and in place by
2020
Several foundational transformation projects,
already underway, set the platform for other
reform efforts
Some initiatives require approval and/or
participation of the federal government
Several initiatives require state legislative action
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CURRENT ENVIRONMENT FOR REFORM
Minnesota is building on a history of
improvements to the system to address core
values
 Changing demographics and economic pressures
put future of current system at risk of not being
sustainable
 Opportunities have arisen at the federal level to
support innovation and reform at the state level
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VALUES AND VISION
Long Term Services and Supports (LTSS)
support people in having a meaningful life at all
stages of life, according to their own goals,
providing opportunities to make meaningful
contributions, and built upon what is important
to them.
 Minnesota’s long-term supports and services
system is flexible, responsive and accessible by
people who have an assessed need for LTSS.
 The LTSS system is well-managed to ensure its
sustainability in order to be available to those
who need it in the future.
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GOALS OF HCBS REDESIGN
1) Better Individual Outcomes
Increased flexibility to better meet the needs of
each individual
 Increased stability in the community
 Better-informed individual decision-making
about LTSS options
 Promotion of person-centered planning - life-long
and crisis
 Improved transitions between settings and
programs, preventing avoidable health crises.
 Recognize and address the social determinants of
health care need and cost
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GOALS OF HCBS REDESIGN
2) Right Service at the Right Time
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Low-cost, high-impact services reach people earlier
Decreased reliance on more costly services
HCBS, not institutional care, is the entitlement
3) Ensuring the Future of LTSS
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Increased sustainability of the LTSS system
Increased efficiency in the use of public LTSS
resources
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CONCEPTUAL FRAMEWORK:
HCBS SYSTEM NOW
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CONCEPTUAL FRAMEWORK:
NEW HCBS SYSTEM
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BUILDING ON A HISTORY OF REFORM
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1997-present:
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Development of integrated health/long-term care
products for seniors (MSHO, MSC+)
Demonstration for disabilities (MnDHO) and Special
Needs Basic
2001: Many significant legislated LTSS policy
changes
2006-2007: Quality Architecture
2009: Nursing Facility Level of Care Legislative
Changes
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BUILDING ON A HISTORY OF REFORM
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2009-2014: Transformation Projects
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MnCHOICES
Elderly Waiver Customized Living Rate Development Tool
Disability Waivers Rates System
HCBS Waiver Provider Standards
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2011-2015: Dual Demonstration
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2011 – 2015: Money Follows the Person
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2014-2018: Demonstrations to test out reform strategies;
State plan changes; 1915(c) waiver amendments; additional
reform initiatives (outlined in following slides)
2019-2020: Future LTSS system, informed by learnings from
previous phases
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REFORM STRATEGIES
Improve navigation and streamline access to
services and support
 Redesign and improve services
 Increase service coordination and service
integration
 Increase efficiency and sustainability of
administrative systems
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STRATEGY ONE:
IMPROVE NAVIGATION AND STREAMLINE
ACCESS TO SERVICES AND SUPPORT
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MnCHOICES
First Contact Simplification
Expanding access to transition supports
Home and community-based services report
card
Employment supports
Statewide, centralized common entry point for
vulnerable adult reports
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NAVIGATION/ACCESS:
MNCHOICES
Web-based comprehensive assessment and
service planning application for access to all long
term services and supports
 Reduces the need for multiple assessments
 Person-centered – tailored to individual
strengths, goals, preferences and assessed needs
 All ages; across disability types
 Data collection system will better inform
evaluation, policy and service development
 Supports life planning
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NAVIGATION/ACCESS:
FIRST CONTACT SIMPLIFICATION
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Redesign and streamlining of the Pre-admission
Screening (PAS) process for people entering
nursing homes.
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Enhances opportunities to provide decision support,
assessment, and follow-up strategies, which help
people avoid unnecessary nursing home admissions,
or return home when they are ready.
Simplification of reimbursement to lead agencies
for MnCHOICES assessments for people 65+
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NAVIGATION/ACCESS:
EXPANDING ACCESS TO TRANSITION SUPPORTS
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Build on existing efforts:
Return to Community transition support for people in
nursing homes
 Long Term Care Options Counseling about
community-based housing options
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Expand access to transition supports for targeted
group of older adults
Identified by Senior LinkAge Line® or by nursing
home, hospital, or health care home
 At-risk of institutionalization, but not yet eligible for
Medicaid
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NAVIGATION/ACCESS:
HOME AND COMMUNITY-BASED REPORT CARD
Makes available to the public a home and
community-based services report card at
www.minnesotahelp.info.
 Modeled on Minnesota’s successful Nursing
Home Report Card
 Provides information to consumers about
differences among HCBS services and service
providers. Good and timely information leads to
better decision-making.
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NAVIGATION/ACCESS:
WORK: EMPOWER AND ENCOURAGE
INDEPENDENCE
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Early intervention strategy for better outcomes
Successful transition to adulthood (target groups 1826)
 Community integration, participation, contribution
 Delay or prevent significant disability
 Delay prevent or reduce use of public services
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Builds upon proven approaches
 Services:
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Navigation for medical, MH and employment support
 Person-centered planning , referral and support
 Benefits education/planning and options counseling
 Problem-solving assistance to reduce barriers
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NAVIGATION/ACCESS:
ENHANCING PROTECTIONS FOR VULNERABLE
ADULTS
Number of older adults and people with disabilities
receiving services in the community is growing. A
strong adult protection system guards against their
abuse, neglect, and exploitation.
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Establish a single common entry point to receive
reports of suspected maltreatment of vulnerable
adults through a statewide, toll-free number and webbased reporting tool.
Would replace current county-designated common
entry point system.
Increase support to counties for investigating
allegations of maltreatment and providing protective
services.
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STRATEGY TWO:
REDESIGN AND IMPROVE SERVICES
Planning and service development
 Community First Services and Supports
 Essential Community Supports
 Services for individuals with autism diagnosis
 Enhancements to HCBS waivers and home care
 Mental health redesign
 Community-based services to address
homelessness and barriers to housing
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REDESIGN AND IMPROVE SERVICES:
PLANNING AND SERVICE DEVELOPMENT
LTSS Gaps Analysis: biennial survey to assess the status
of LTSS for older adults. Expanded by the 2012 legislature
to include services for people with disabilities, including
mental health services.
 Needs determination (foster care): Conduct a survey to
assess capacity needed and licensed capacity available, by
county. Results will inform legislatively required closure
process.
 Critical Access Study for home and community-based
services: Will build on past work to assess HCBS use and
availability at the community level. Will identify potential
strategies to build HCBS capacity where needed.
 Future Reform: Redirect residential and nursing facility
services, using information from the above planning and
service development activities.
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REDESIGN AND IMPROVE SERVICES:
COMMUNITY FIRST SERVICES AND SUPPORTS
(CFSS)
 Flexible
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service can include:
Assistance with ADLs, IADLs, health-related tasks
including skills maintenance/enhancement to
complete creating plans and/or supporting plans
Coaching
Prompting
Home modifications to replace human assistance
Technology to replace human assistance
Transition services
Provider standards to promote access to
agencies and staff with appropriate skills.
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REDESIGN AND IMPROVE SERVICES:
COMMUNITY FIRST SERVICES AND SUPPORTS
(CFSS), CONT.
 Assessment
looks comprehensively at a
person’s situation (MnCHOICES)
 Eligibility based on functional ADL needs
and behaviors
 Person-centered Support Plan aligns
services with the goals
 Individualized service budget based on
current PCA home care ratings.
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REDESIGN AND IMPROVE SERVICES:
COMMUNITY FIRST SERVICES AND SUPPORTS
(CFSS), CONT.
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Participants can choose the service model:
Agency-provider model
 Self-direct and assume greater flexibility and
responsibility for employing and managing staff and
support plan
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Financial management entities will provide administrative
functions
New financial management structure for selfdirected options
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Will be used for CFSS and the waiver service of
Consumer Directed Community Supports
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REDESIGN AND IMPROVE SERVICES:
COMMUNITY FIRST SERVICES AND SUPPORTS
(CFSS), CONT.
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Outcomes for CFSS
Individuals will:
 Recover and/or gain skills to increase and maintain
community stability
 Access the right service by the right provider at the
right time
 Use technology or modifications to decrease need
for human assistance when appropriate
 Delay or avoid the need to access other programs
 or more costly services
 Avoid use of inappropriate services
 Increasingly direct their own services
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REDESIGN AND IMPROVE SERVICES:
ESSENTIAL COMMUNITY SUPPORTS
ECS provides specific services for people with relatively
low needs who will not meet the new Nursing Facility
Level of Care (NF LOC) criteria, when implemented.
Services will support people with an assessed need for
one of the ECS services to maintain their community
living.
Eligible groups:
 MA ineligible seniors (65+)
 Transition group: individuals of any age who were
receiving LTSS under MA and lose eligibility for those
services, and are not eligible for CFSS. (DHS
proposes to serve this group in the Long Term Care
Realignment Waiver, submitted February 13, 2012
and resubmitted November 21, 2012).
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REDESIGN
AND IMPROVE
SERVICES:
SERVICES TO INDIVIDUALS WITH AUTISM
SPECTRUM DISORDER
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DHS worked with people in the community to design new
services and/or approaches to services for children with
ASD
Built on belief that intensive services early in life will
result in improved long-term outcomes for children and
reduce family stress
New intensive, early intervention benefit set will provide
medically necessary:
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Multidisciplinary diagnostic evaluations
Developmental and behavioral treatment services
Rigorous progress monitoring
Services will be:
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Individualized to each child
Culturally responsive and family centered
Flexibly developed/ meet diverse needs of population
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REDESIGN AND IMPROVE SERVICES:
ENHANCEMENTS TO HCBS WAIVERS AND
HOME CARE
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Service menu redesign
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New in-home support service
Technology
Employment
Consumer-Directed Community Supports
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Evaluate and test new allowable/unallowable services
Evaluate and test new budget methodologies
Evidence-based health promotion
 Future Reform: Individual service budgets of
people using disability waiver services
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REDESIGN AND IMPROVE SERVICES:
MENTAL HEALTH REDESIGN
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Anoka Metro Regional Treatment Center
Demonstration
Seeking waiver of federal law prohibiting Medicaid
coverage for persons “residing in institutions for
mental diseases”
 Allow for continuity of care during a person’s
transition from the community to a inpatient setting
and back to community
 Specific to AMRTC
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REDESIGN AND IMPROVE SERVICES:
MENTAL HEALTH REDESIGN, CONT.
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Transition out of Anoka
People with multiple and complex needs, including
serious mental illness and co-morbidities
 Unable to leave AMRTC within two weeks of
determination they no longer need that level of care
 Services to support transition back into the
community
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REDESIGN AND IMPROVE SERVICES:
MENTAL HEALTH REDESIGN, CONT.
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Service System Gap: A treatment service for
adults living in the community who need daily
supervision/monitoring
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Complex diagnostic picture includes bipolar disorder,
sexual disorder, cognitive impairment
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Typically hasn’t been charged with criminal sexual
offense
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Requires long-term service to meet complex needs.
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REDESIGN AND IMPROVE SERVICES:
MENTAL HEALTH REDESIGN, CONT.
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Intensive Residential Treatment Services
Helps adults discharged from inpatient psychiatric
stays who need 24 hour clinical supervision before
returning home
 Can also prevent more costly inpatient stays
 Service gap exists to meet treatment needs that
include medical conditions and/or aggressive
characteristics
 Workgroup to provide recommendations to DHS
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REDESIGN AND IMPROVE SERVICES:
MENTAL HEALTH REDESIGN, CONT.
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Continuity of Care for Children under 21 who
need Residential Psychiatric Care
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No 1115 waiver sought at this time
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DHS is seeking technical guidance from CMS on this
issue
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REDESIGN AND IMPROVE SERVICES:
COMMUNITY-BASED SERVICES TO ADDRESS
HOMELESSNESS AND BARRIERS TO HOUSING
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Housing Stability Services
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Two groups to be enrolled
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Target Group One:
 MA participant
 Eligible for General Assistance due to
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Advanced age or basis of eligibility related to illness, incapacity or
disability pending/ in appeal
Homeless
Target Group Two:
 MA participant
 Eligible for Group Residential Housing and living in certain
types of housing
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Services:
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Service coordination
In-reach/Outreach
Tenancy supports
Community living assistance
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REDESIGN AND IMPROVE SERVICES:
COMMUNITY-BASED SERVICES TO ADDRESS
HOMELESSNESS AND BARRIERS TO HOUSING, CONT.
 Project for Assistance in Transition from
Homelessness (PATH) Critical Time Intervention
(CTI) Pilot
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Group to be enrolled:
Adults with serious mental illness (SMI) or SMI with a cooccurring substance use disorder
 Homeless or at imminent risk of homelessness
 Being served by PATH program
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Model:
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Links outreach, in-reach, and other PATH services with a
CTI evidence-based practice framework (time-limited
intensive case management with specialized support)
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STRATEGY THREE:
IMPROVE SERVICE COORDINATION AND
INTEGRATION
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Innovative approaches to service coordination children with CFSS
Case Management Redesign
Alzheimer’s Health Care Home
Health Home Demonstration – Inclusion of
LTSS in the integration of behavioral and
physical health care
Technical assistance to divert commitments
and address crisis
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SERVICE COORDINATION/INTEGRATION:
INNOVATIVE APPROACHES TO SERVICE
COORDINATION FOR CHILDREN
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Children with CFSS
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IEP/IFSP that includes health-related MA services,
and at least one of the following:
More than 2 complex health-related needs
 Receiving mental health services
 Demonstrates physical aggression towards oneself or others
or destruction of property that requires immediate
intervention of another person
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RFP process will encourage local entities to
design models appropriate for their area; must
have cooperation of a school in their models
 Test service coordination model for 1,500 children
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SERVICE COORDINATION/INTEGRATION:
INNOVATIVE APPROACHES TO SERVICE
COORDINATION FOR CHILDREN, CONT.
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NOTE: Adjunct activities not included in 1115
Technical assistance will be provided to help existing
service coordinators learn to incorporate CFSS into
their plans
 Intention to implement at some future point Home
Care targeted case management for people on CFSS
who don’t otherwise have case management
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SERVICE COORDINATION/INTEGRATION:
CASE MANAGEMENT REDESIGN
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Recommendations are not finalized but among
the changes being considered are:
Defining the service and activities for all Medicaid
paid case management in collaboration across DHS
divisions
 Increasing opportunities for consumer choice
 Creating consistent standards with a focus on quality
outcomes
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SERVICE COORDINATION/INTEGRATION:
ALZHEIMER’S HEALTH CARE HOME
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Support the development of Health Care Homes
that are especially equipped to serve people with
Alzheimer’s and other dementias.
Leads to better screening and earlier identification of
Alzheimer’s and other dementias
 Individuals with Alzheimer’s and dementia and their
family caregivers will have ongoing access to a
Health Care Home model of primary care – better
partnerships between provider, patient, and family;
better continuity of care; increased coordination
between primary care and community-based services.
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SERVICE COORDINATION/INTEGRATION:
HEALTH HOME DEMONSTRATION
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Targets adults with serious mental illness with other health
conditions (including substance abuse); and, children with severe
emotional disturbances and health conditions
Integrates behavioral and physical health and long term services,
with referral to other supports.
Tests new model of comprehensive care management and
coordination
Addresses access barriers to:
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Preventative and routine health care
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Treatment of health conditions
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Wellness supports
Offers choice of “behavioral health home”; lead behavioral services
entity maintains coordination agreements with primary care
providers
Improves use health information technology to share info and
coordinate care
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SERVICE COORDINATION/INTEGRATION:
TECHNICAL ASSISTANCE TO DIVERT
COMMITMENTS AND ADDRESS CRISES
Create regional capacity through technical
assistance
 Quality Improvement Triage specialists will work
to create person-centered community-based crisis
plans for individuals who have previously used
psychiatric hospital services during crises
 Support regional quality assurance stakeholders
who will be responsible for discovery, remediation
and quality improvement
 Use tele-presence technology to get clinical
expertise anywhere in the state
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STRATEGY FOUR:
ADMINISTRATIVE EFFICIENCY AND
SUSTAINABILITY
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Nursing Facility Level of Care implementation
Provider Standards
Rate Methodologies for waiver services
Consumer-Directed Community Supports:
Redesign Fiscal Support Entities
New budget methodology for vent-dependent
seniors
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ADMINISTRATIVE EFFICIENCY/SUSTAINABILITY:
NURSING FACILITY LEVEL OF CARE CRITERIA
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Changes authorized by the 2009 Legislature.
Affects eligibility for MA payment of nursing facility
services and HCBS waivers that provide alternatives
to nursing facility services.
 Change is needed to ensure that highest cost services
are targeted to individuals with the highest needs,
and long-term sustainability of the system is
maintained.
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DHS is prevented from implementing until
January 2014 for adults and October 2019 for
children, due to federal maintenance of effort
requirements.
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ADMINISTRATIVE EFFICIENCY/SUSTAINABILITY:
PROVIDER STANDARDS
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Intentions:
Help assure appropriate care for persons served
 Create more consistency of service while allowing for
specialization
 Enabling participant choice
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Strategies
Creating foundational, statewide set of standards for
all providers
 Soliciting and responding to stakeholder input
 Developing common, statewide oversight and
compliance of providers
 Creating voluntary certifications for providers
seeking to specialize
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ADMINISTRATIVE EFFICIENCY/SUSTAINABILITY:
RATE METHODOLOGIES FOR WAIVER SERVICES
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Create a statewide system that:
Will establish provider payment rates that are based
on a uniform process but also capture the
individualized nature of the services and the
individual’s needs
 Is transparent, fair and generates consistent pricing
across the state
 Promotes quality and participant choice
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ADMINISTRATIVE EFFICIENCY/SUSTAINABILITY:
CONSUMER-DIRECTED COMMUNITY SUPPORTS
(REDESIGN OF FISCAL SUPPORT ENTITIES)
Implement a new financial management
structure across all self-directed options in order
to have a more efficient system.
 Shift fiscal support from a service to an
administrative function.
 DHS will issue an RFP and enter a contractual
arrangement with fewer entities than currently
operating, giving DHS more direct oversight and
quality management of the these functions.
 DHS assumes there will be fewer agencies under
contract, but will ensure that regardless of
location, people will have at least two agencies
from which to choose.
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ADMINISTRATIVE EFFICIENCY/SUSTAINABILITY:
BUDGET METHODOLOGY FOR HIGH-COST
SENIORS
Will assist people 65+ who are have high-cost
needs, specifically those who are vent-dependent
and who want to receive services in their home.
 Enhanced Elderly Waiver (EW) budget to support
individuals in the community, avoiding
unnecessary nursing facility admissions and
readmissions.
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ADMINISTRATIVE EFFICIENCY/SUSTAINABILITY:
QUALITY
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To support reform values and goals we are building
mechanisms for a quality-driven system
Various mandates related to quality:
CMS corrective actions
CMS requirements
 State legislation
 Legal actions, settlements and decrees
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Working towards improved and integrated quality
activities:
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State Quality Council
Waiver Provider Standards
Positive Support Strategies and Emergency Use of Manual
Restraints
Needs assessment (foster care)
Gap analysis
Olmstead Plan
Technology grants
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VISION FOR 2020
Demonstrations and changes to 1915(c) waiver will
inform additional changes and identification of
appropriate vehicles
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With enhanced state plan options, future role of 1915(c)
waivers will change:
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Service menus
Provider standards
Service access thresholds
Flexibility needed to access right service at the right
time by the right provider will be driven by assessment
information:
Functional need
 Strengths and goals
 Informal, family and community support
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VISION FOR 2020, CONT.
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Redesigned support and care coordination and effective
delivery models will be incorporated into the system
Role of nursing facilities will change to primarily serve
people for less than 90 days
Money Follows the Person will successfully have achieved
goals of moving people to community settings and
demonstrating needed community services
Quality Management System will be implemented across all
HCBS to identify issues, assure timely remediation, and use
data for continuous improvement, and informed decisions
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WHERE WE ARE NOW
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In negotiation with CMS
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Submitted request for Long-Term Care Realignment in February 2012 and again in
November 2012
Submitted request for Reform 2020 to CMS in November 2012
2013 Minnesota legislative proposals
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Alternative Care and Essential Community Supports (Slide 22)
Enhance vulnerable adult protection (Slide 15)
HCBS Critical Access Study and service development (Slide 17)
CFSS (Slides 18-21)
First Contact (Slides 14-16)
Work: Empower and Encourage Independence (Slide 14)
Housing Stability Services Demonstration (Slide 30)
Individual Community Living Support added to Alternative Care and Elderly Waiver (Slide
24)
Crisis diversion and discharge planning (Slide 38)
Improved access for ≥65, vent-dependent (Slide 47)
Transition to the Community [package of proposals] (Slide 29)
 Mental Health Specialty Treatment Service
 County share of costs for Anoka- Metro Regional Treatment Center and Minnesota State
Hospital
 Transition initiatives for certain populations
Intensive Services for Autism Spectrum Disorder (Slide 26)
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CONTACT INFORMATION
Alex Bartolic, Director of Disability Services
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[email protected]
651/431-2381
Kristine Davis, Group Residential Housing Policy Specialist
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[email protected]
651/431-3845
Glenace Edwall, Director of Childrens Mental Health
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[email protected]
651/431-2326
Cynthia Godin, Director of Adult Mental Health
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[email protected]
651/431-2237
Jean Wood, Director of Aging and Adult Services
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[email protected]
651/431-2563
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RELATED WEBSITES
Information on MA Reform
www.dhs.state.mn.us/mareform
Information on services and DHS policy
development around
Autism Spectrum Disorder:
www.dhs.state.mn.us/autism
Reports available through the DHS website
(eDocs):
http://www.dhs.state.mn.us/main/id_000100
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