i. Budget Florida Stakeholders’ Meeting December 4, 2009 1
Overview of Proposed System • Budgets determined through algorithm • Service array revised to increase flexibility • Waiver Support Coordination better match to family needs, shift to emphasis on service coordination from service approval processing • Service review more limited, focused, & streamlined, focusing on health & safety issues 2
Overview of Proposed System • Consumer and family training and tools for managing budgets • Policies for limiting risk of overspending and options for corrective action plans • Behind-the-scenes reviews for health & safety, provider manipulation, and fraud • Process for determining budgets for consumers with exceptional needs 3
Overview of Proposed System • Electronic/automated as much as possible— virtually paperless • Phase-in over a reasonable time period—e. g. , number of consumers (say by geography) and budget amounts 4
Consumer and Family Control Main question: What would be reasonable limits on individual control? 5
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 6
Consumer and Family Control Feedback so far: • System now does provide for adequate consumer control • System now does not provide for adequate consumer control • Some individuals don’t have natural supports to help exercise self-direction 7
Consumer and Family Control Feedback so far: • Some families will be unable to manage a budget • Concern that individuals’ natural supports might not let them make desired choices • Concern that some providers may not cooperate or may be manipulative 8
Consumer and Family Control Feedback so far: • Consumers may make poor choices that put them at risk • Consumers need opportunities to make choices and learn from the poor ones 9
Consumer and Family Control Decisions needed: • Limits on spending to ensure that funds last through the year – Option A: Monthly allocation – Option B: 10% up front; 85%, spread over 12 months; 5% emergency reserve – Option C: 20% up front; 80% spread over 4 quarters 10
Consumer and Family Control Decisions needed: • Other methods to discourage overspending – Monthly statements – Waiver support coordinator issues service authorizations (consumer and family may do so in Option C) – Swipe card system 11
Consumer and Family Control Decisions needed: • What to do if a person overspends but still needs services – – Require to adjust services to fit budget Limit flexibility to make future changes Require a representative to help Temporary increase in funding to meet critical health and safety needs – Require training or a mentor paid from budget 12
Consumer and Family Control Decisions needed: • How to provide training on making good choices – Web – Through Waiver Support Coordinator – In-person group trainings hosted by FCC or Area Office – Paid service through person’s budget 13
Consumer and Family Control Decisions needed : • Caps on service amounts: – Option A: Similar to current handbook – Option B: Only on limited services which are related to health & safety – Option C: No 14
Consumer and Family Control Decisions needed : • Whether funds for certain critical health and safety-related services must be reserved and may not be spent on other services: – Option A: Residential habilitation, nursing, therapies – Option B: Residential habilitation only – Option C: None 15
Consumer and Family Control Decisions needed : • Who may issue service authorizations to begin or end services: – Option A: Waiver support coordinator, along with area staff for certain services – Option B: Waiver support coordinator – Option C: Consumer, family, and waiver support coordinator 16
Consumer and Family Control Decisions needed : • What information consumers need to make good decisions – Their own goals and needs – Traditional and innovative strategies for achieving goals/meeting needs – Outcomes/performance data 17
Consumer and Family Control Decisions needed : • How to help consumers track spending – Waiver support coordinator – Web-based budget tool – Service logs – Monthly statement 18
Consumer and Family Control Decisions needed : • How to find out if any providers are uncooperative or manipulative – Analysis of service usage/spending patterns – Reports from consumers/families – Quality assurance contractor reporting 19
Consumer and Family Control Decisions needed : • What support to give to consumers who don’t have unpaid help in decision-making – Waiver support coordinators continue in that role – Waiver support coordinators help find supports to help – Quality assurance review – Behind-the-scenes audits 20
Consumer and Family Control Decisions needed : • If funds can be carried over to a future year like in CDC+ – Option A: No – Option B: 50% carry over for up to 1 year – Option C: 100% carry over, no time limit 21
Service Review Main question: How do we best ensure that individuals receive the services that they need within allowable waiver coverage? 22
Service Review 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 23
Service Review Feedback so far: Scaling back is great but we need something to meet federal requirements for assessing medical necessity of services 24
Service Review Decisions needed: • What are situations requiring a review? • Who will conduct reviews? 25
Service Review Decisions needed: • Situations requiring review – Under all options: • Newly-enrolled in waiver • If overspent budget within last 12 months • First time in a licensed home 26
Service Review Decisions needed: • Situations requiring a review – Under all options: • Temporary significant change in needs requiring additional funds • Permanent significant change in needs requiring additional funds • Extraordinary need request 27
Service Review Decisions needed: • Situations requiring a review – The first i. Budget Florida plan: • Option A: Yes • Option B: Yes • Option C: Only if using different services than previous plan 28
Service Review Decisions needed: • Situations requiring a review – Every 3 years: • Option A: Yes • Option B: No • Option C: No 29
Service Review Decisions needed: • Situations requiring a review – If adding new service family: • Option A: Yes • Option B: Yes • Option C: No 30
Service Review Decisions needed: • Situations requiring a review – If increasing amounts of certain services within budget amount: • Option A: Yes--behavioral services, nursing services, therapies • Option B: Yes—intensive behavioral services, nursing services, therapies • Option C: No 31
Service Review Decisions needed: • Situations requiring a review – If decreasing amounts of certain services within budget amount: • Option A: Yes--behavioral services, nursing services, therapies • Option B: No • Option C: No 32
Service Review Decisions needed: • Situations requiring more frequent review: – If meets certain criteria: • • • Current or previous forensic involvement Extraordinary medical needs Extraordinary behavioral needs Community based care child Only paid supports in person’s life 33
Service Review Decisions needed: • The process for requesting reviews – Computer-based • Who will perform reviews – Option A: Contracted provider, Central Office, and Area Offices – Option B: Central Office and Area Offices – Option C: Area Offices 34
Quality Assurance and Quality Improvement Main question: How do we ensure health, safety, and good outcomes? 35
Quality Assurance and Quality Improvement APD Plans: • New quality assurance contract uses different measures – Increasing percentage of support coordination records reviewed to 50% – Will review about 25% of consumers individually • Florida is joining National Core Indicators initiative 36
Quality Assurance and Quality Improvement Feedback so far: • Support revision of the quality assurance system to be more understandable, less bureaucratic, and more person-centered • Concern that individuals may make poor choices that put their health and safety at risk • Concern that individuals may be at risk of exploitation by providers and natural supports 37
Quality Assurance and Quality Improvement Key Areas: • Health & safety • Budget management • Outcomes • Compliance 38
Quality Assurance and Quality Improvement Participants in QA/QI System: • Consumers & families • Waiver Support Coordinators • Providers • Family Care Councils • Advocacy & provider organizations • APD Central Office staff 39
Quality Assurance and Quality Improvement Participants in QA/QI System: • APD Area staff – – – – Certified Behavior Analysts Nursing staff Questionnaire for Situational Information Administrators Licensing Group home monthly monitoring Provider enrollment Supported living coordinator 40
Quality Assurance and Quality Improvement Examples of key activities: • • Assessment Planning Training Standard setting/process determination Monitoring/data analysis Information sharing Problem identification Corrective action 41
Quality Assurance and Quality Improvement Decisions needed: • Options: – Health & safety: • Requirement for use of full or enhanced waiver support coordination by certain individuals (e. g. , those with forensic involvement) • Competency-based training • Utilization reviews to identify service patterns of concern 42
Quality Assurance and Quality Improvement Decisions needed: • Options: – Health & safety: • Review by area certified behavior analysts and nursing staff based on QSI scores • Limits on certain flexibility in selecting and changing services 43
Quality Assurance and Quality Improvement Decisions needed: • Options: – Budget management: • Training for all levels of skill • Timely information through web-based tools – – Consumer & family Support coordinator Area office Contracted Quality Assurance reviewers 44
Quality Assurance and Quality Improvement Decisions needed: • Options: – Budget management: • Policies to deter overspending • Corrective action plans to address overspending • Data analysis of spending patterns 45
Quality Assurance and Quality Improvement Decisions needed: • Options: – Outcomes: • Training on outcomes under a more selfdirected system • Training for support coordinators on handling issues of poor choice-making • Central Office review of support plans to assess consumer goals under new system 46
Quality Assurance and Quality Improvement Decisions needed: • Options: – Outcomes: • Procedures for waiver support coordinators to access area office support and direction in addressing problematic consumer choicemaking 47
Quality Assurance and Quality Improvement Decisions needed: • Options: – Compliance: • Training for consumers/families on provider responsibilities • Revise relevant assurances and the handbook to clarify expectations and responsibilities under self-directed system 48
Quality Assurance and Quality Improvement Decisions needed: • Options: – Compliance: • Review service patterns to identify provider non-compliance • Review service delivery against budget/support plan • Publicly share information about non-compliant providers 49
Services Main question: What services and flexibility should be available to consumers? 50
Services APD Recommendations: • Must use Medicaid enrolled providers • Services allow more flexibility • Rates be neutral • Same set of services available to all individuals 51
Services Feedback so far: • Make additional services available in Tier 4 • Want flexibility to use greater amounts of services • Use algorithm to determine level and intensity of services (e. g. Res Hab) 52
Services Feedback so far: • Start from scratch with new handbook • Like the very broad services, but if they’re in service families, make sure they are logically grouped • Very broad services might be more challenging for consumers to navigate —hard to know how to meet needs 53
Services Decisions needed: • Design of service array – Broader services—allow to meet changing needs day-to-day (current worker can switch between similar tasks) – Service families—allow to meet changing needs over time (can get a new worker to do new tasks) 54
Services Comparison of Service Families in Options Option 1: Modified Status Quo Option 2: Modified Mercer Option 3: Minimalist Residential Services Places to Live Wellness Therapeutic Supports Wellness Personal Supports No Service Families Life Skills Development Personal Supports Transportation Support Coordination Environmental and Adaptive Equipment 55
Services Comparison of Services in Options Option 1: Modified Status Quo Option 3: Minimalist Residential Habilitation (Standard) Residential Habilitation Services Option 2: Modified Mercer Basic Residential Habilitation (Behavior Focused) Residential Habilitation (Intensive Behavior) Enhanced Residential Specialized Medical Home Care Nursing Residential Nursing Adult Day Training Meaningful Day Companion Services In-Home Support Services Personal Care Assistance Respite Care Flex Benefit 56
Services Comparison of Services in Options Option 1: Modified Status Quo Option 2: Modified Mercer Support Coordination (Limited) Transportation Option 3: Minimalist Basic Supports Behavior Analysis Services Behavior Analysis Behavior Assistant Services Community Training and Supports Family & Guardian Training Mentoring Person Centered Planning Enhanced Supports Support Coordination (Transitional) Support Coordination Meaningful Day In-Home Support Services Support Coordination (Full) Supported Employment Supported Living Coaching 57
Services Comparison of Services in Options Option 1: Modified Status Quo Option 2: Modified Mercer Option 3: Minimalist Adult Dental Services Basic Wellness Dietician Services Occupational Therapy Physical Therapy Respiratory Therapy Nursing Private Duty Nursing Enhanced Wellness Skilled Nursing Specialized Mental Health Services Speech Therapy Durable Medical Equipment and Supplies Environmental Accessibility Adaptations Consumable Medical Supplies/PERS Equipment Personal Emergency Response Systems (Unit and Services) Consumable Medical Equipment 58
Waiver Support Coordination Main question: What should the waiver support coordinator’s role be? 59
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 • Allow more customized level of service 60
Waiver Support Coordination Feedback so far: • Desire for greater flexibility in choosing level of support coordination • Waiver support coordinators play an important and multifaceted role in the APD system. Need to ensure they are still available to help consumers and families. 61
Waiver Support Coordination Decisions needed: • What waiver support coordinator service options will be available: – Limited – Full – Enhanced (currently transitional) 62
Waiver Support Coordination Decisions needed: • Situations which may indicate need for full (or enhanced) waiver support coordination: – – Newly-enrolled in waiver Forensic involvement Complex medical needs Complex behavioral needs 63
Waiver Support Coordination Decisions needed: • Situations which may indicate need for full (or enhanced) waiver support coordination: – Transition from school – Change in residential setting to group home or supported living – Verified abuse or neglect – Dual diagnosis – Alcohol or drug abuse history 64
Waiver Support Coordination Decisions needed: • Waiver support coordinators’ general tasks – Annual plan, level of care determination, and maintenance of Medicaid eligibility (required by CMS) – Handle exceptional/changed needs requests – Providing information about, access to, and coordination of services 65
Waiver Support Coordination Decisions needed: • Waiver support coordinators’ general tasks – Help create social connections – Increase access to community resources – Training consumers and families in self -direction and budget management 66
Waiver Support Coordination Decisions needed: • Waiver support coordinators’ general tasks – Budget management in consultation with consumer and family – Monitoring of health and safety – On call 24/7 67
Service Providers Main question: Who may provide services? 68
Service Providers APD Recommendation: • CDC+ option continue, although participants will get i. Budgets • Everyone else use Medicaid-enrolled providers • Rates be neutral 69
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 70
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 71
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? 72
Implementation Feedback so far: • How to ensure that calculation of i. Budgets is understandable to consumers and their families • Need to carefully communicate with any consumers and families from the wait list when they do join 73
Implementation Your thoughts: • How can we communicate with stakeholders: – Individually – Through providers – Through organizations 74
Implementation Your thoughts: • What should we tell them? – Consumers – Families – Waiver Support Coordinators – Providers – Advocates 75
Conclusion Questions? Comments? Suggestions? 76
Conclusion Public Comment Plan Next Meeting Adjourn Thank you for your time and input! 77
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