Transcript MA_Reform2020_BIconf_4-12-13

REFORM 2020
HCBS REDESIGN
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Loren Colman, Assistance Commissioner, Continuing Care Administration
Alex Bartolic, Director of Disability Services
Jean Wood, Director of Aging and Adult Services
Age and Disabilities Odyssey Conference
June 18, 2013
Duluth, 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
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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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Development of integrated health/long-term care
products for seniors and people with disabilities
Many significant legislated LTSS policy changes,
including nursing facility level of care legislative
changes
Dual demonstration project (Medicare and Medicaid)
“Transformation Projects”
MnCHOICES
 Elderly Waiver Customized Living Rate Development Tool
 Disability Waivers Rates System
 HCBS Waiver Provider Standards
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Moving Home Minnesota (aka Money Follows the
Person)
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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
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Web-based comprehensive assessment and service
planning for access to all long term services and
supports; all ages; across all disability types
On-line training for assessors is now available
(assessors will be selected by each lead agency)
Beta 3 testing this summer
Roll-out begins 11/04/13, starting with new
assessments
By June 2014 all lead agencies will be using
MnCHOICES for new assessments
Phased approach to bringing counties on-line
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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, effective October 1,2013.
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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+,
effective October 1, 2013
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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
Effective January 1, 2014
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Navigation/Access:
Home and community-based “Report Card(s)”
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Makes available to the public information about home
and community-based services 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 decisionmaking
DHS to work with advisory group to make
recommendations by August 1, 2014
Report card(s) to be available July 1, 2015
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Navigation/Access:
Work: Empower and Encourage
Independence
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Target implementation date: July 1,2014
Early intervention strategy for better outcomes
Successful transition to adulthood (target five specific
groups ages 18-26)
 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:
Telephonic navigation for health care, mental health care,
community services 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
New legislation to modernize the Adult Protection
System:
Establishes a single common entry point to receive
reports of suspected maltreatment of vulnerable adults
through a statewide, toll-free number and a web-based
reporting system, effective July 1, 2014
Increases support to counties for investigating
allegations of maltreatment and provide protective
services
Provides a tool for counties that supports clear
decision making and consistency in protective services
(required use by counties August 1, 2013)
Creates a public outreach campaign to raise
awareness on identifying and reporting maltreatment
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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
Critical to the goal of “right service at the right
time” is matching capacity with need
 We currently have a few tools for assessing need
and capacity. Working to bring these together in
a more coordinated way.
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LTSS Gaps Analysis
Needs determination survey (foster care)
Critical Access Study for home and community-based
services
These studies and analyses are used to inform
future service development
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Redesign and Improve Services:
Community First Services and Supports
(CFSS)
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Target implementation date: April 1, 2014
Desired outcomes for CFSS are that 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:
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 (helping people acquire, enhance and
maintain skills)
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:
Essential Community Supports
ECS will provide specific services for people with relatively
low needs who will not meet the new Nursing Facility Level
of Care (NF LOC) criteria, when implemented, effective
January 1, 2014 for adults.
Services will support people with an assessed need for one of
the ECS services to maintain their community living.
Services include caregiver support, homemaker, chore,
personal emergency response, home-delivered meals,
community living assistance, and case management.
Eligible groups:
MA ineligible seniors (65+); authorized in 2009
Transition group: individuals of any age who were receiving
LTSS under MA and lose eligibility for those services, and are
not eligible for CFSS. This group is eligible for an additional
onetime case management benefit; authorized in 2013
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REDESIGN
AND IMPROVE
SERVICES:
SERVICES TO INDIVIDUALS WITH AUTISM
SPECTRUM DISORDER
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New benefit set will provide medically necessary:
Multidisciplinary diagnostic evaluations
 Developmental and behavioral treatment services
 Progress will be tracked and data collected in order to build body of
evidence
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Services will be:
Individualized to each child
 Culturally responsive and family centered
 Flexibly developed/ meet diverse needs of population
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By July 2013:
Develop the implementation details
 With the Department of Education, develop the capacity to
coordinate services and information across health and
education sectors
 Receive federal approval
 Implementation date, no earlier than March 1, 2014
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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.
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Technology
Employment
Evidence-based health promotion
Consumer-Directed Community Supports
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Individual Community Living Service will be added to EW and
AC upon federal approval
Evaluate and test new allowable/unallowable services
Evaluate and test new budget methodologies
Individual service budgets of people using
disability waiver services
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Redesign and Improve Services:
Mental Health Redesign
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Several proposals under consideration for mental
health redesign (at different stages)
Enhanced services to help people transition out of
Anoka Regional Treatment Center
 A treatment service for adults living in the
community who need daily supervision/monitoring
 Intensive Residential Treatment Services to help
adults discharged from inpatient psychiatric stays
who need 24 hour clinical supervision before
returning home
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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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STRATEGY THREE:
IMPROVE SERVICE COORDINATION AND
INTEGRATION
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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
Future reform: Innovative approaches to
service coordination
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Service Coordination/integration:
Case Management Redesign
Report to Legislature due February 2014 with
proposed legislative language
 Recommendations are not finalized but among
the changes being considered are:
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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
Support the development of Health Care Homes
that are especially equipped to serve people with
Alzheimer’s and other dementias
 Proposals were submitted in response to fiscal
year 2014 Community Service/Community
Services Development (CS/SD) application
 Selected grantees to be announced when all
contracts are complete (estimated July 2013)
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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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Related Service Coordination/integration project:
Health Care Delivery Systems (HCDS)
Demonstrations
Focus is on the whole person and accountability
for all services a person receives and their health
outcomes/experience, not just what the provider
delivers
 Provider choice remains, implemented for
enrollees across FFS and managed care; excludes
duals initially – “attribution” not enrollment
 Provider organizations of all sizes and types can
form an HCDS, but primary care must be
included
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Related Service Coordination/integration project:
Demonstration to Integrate Care for Dual
Eligibles
Goals
Improved
platform for dual eligibles to align with and support State
Payment and Delivery Reforms as developed through stakeholder efforts
Provide
State a clearer joint role with CMS in Medicare SNP oversight
in order to preserve/enhance integrated administrative and operational
features and reduce reliance on informal CMS Medicare SNP policy
agreements which often change and threaten disintegration
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learning laboratory for State and CMS efforts to improve
integrated D-SNP administrative efficiency and alignment for
beneficiaries
Provide
access to Medicare data to create and maintain an integrated
Medicare and Medicaid data base for performance metrics and risk
adjustment
Phase 1: Seniors enrolled in MSHO SNPs, waiting for final MOU
Phase 2: People with Disabilities, ongoing discussions with CMS for
2014
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Service Coordination/integration:
Divert Commitments and Address Crises
Target implementation: October 1, 2013
 Quality Improvement Triage specialists will work
to create person-centered community-based crisis
plans for individuals who have previously used
emergency rooms. psychiatric hospital services or
commitment during crises
 Flexible service to prevent and address crises
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From training family or other support people on
crisis planning and management, to
 Specialist team providing intervention services
during a crisis
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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
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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NF LOC changes will go into effect January 2014
for adults and October 2019 for children.
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Administrative Efficiency/Sustainability:
Provider Standards
Implementation date: January 1, 2014
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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:
Disability Waivers Rate System
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Statewide architecture for calculation of disability
waiver service rates
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Individualized
Equitable
Consistent
Transparent
Allows choice and portability for recipients
Promotes quality
Key Dates (pending CMS approval)
Rolling implementation begins January 1, 2014
2014-2015 rates banded to vary no more than 0.5% from
the rate in each previous year
 2016-2018 rates banded to vary no more than 1% from the
rate in each previous year
 2019 rates will be set by DWRS with no further banding
 Analysis and value refinements are specified and
scheduled
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Administrative Efficiency/Sustainability:
Budget Methodology for High-cost Seniors
Will assist people 65+ who are vent-dependent
and who want to receive services in their home
 Effective July 1, 2013 and provides an 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
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With enhanced state plan options, future role of waivers will change
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Flexibility in the system will enable people to receive the right
service at the right time by the right provider
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Service delivery will be driven by functional needs, strengths and
goals, informal, family and community support
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Redesigned, effective delivery models will be used
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Nursing facilities will primarily serve people for less than 90 days
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Quality management system will be implemented across all HCBS
to identify issues, assure timely remediation, provide data for
continuous improvement and informed decisions
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CONTACT INFORMATION
Alex Bartolic, Director of Disability Services
[email protected]
 651/431-2381
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Jean Wood, Director of Aging and Adult Services
[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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