Wisconsin Department of Health Services Division of Long-Term Care

1. Developing a Comprehensive Approach to Systems Change: Increasing Integrated Employment Opportunities and Outcomes for Individuals with Disabilities in Wisconsin’s Managed Long-Term Care System Wisconsin Department of Health Services Division of Long-Term Care Financial Support for the Task Force is provided by the Centers for Medicare and Medicaid, Medicaid Infrastructure Grant (MIG), CFDA No. 93.768, through DHS’s Office of Independence and Employment/Pathways to Independence.

2. WI Department of Health Services: Major Systems Change Initiatives • Statewide expansion of the “Family Care” managed long-term care program • Statewide “Pathways to Independence” Medicaid Infrastructure Grant (MIG) initiative • Very little overlap of two systems change initiatives during early years (2000 to 2006)

3. “Family Care” Managed Long-Term Care • Began with five county pilot in 2000 • One system serving people with developmental disabilities, physical disabilities, and elderly • 2005 evaluation led to legislative support for statewide implementation • 75% of state now under managed care • Self-directed supports waiver offered as another option

4. “Family Care” Managed Long-Term Care • Entitlement created: ends waiting lists for community services • Outcome driven • Reduced per-person spending expected as the result of more cost-effective supports • Increased flexibility on how supports can be provided and who can provide them

5. “Family Care” and Employment • Little attention to employment outcomes in early years of implementation • Elderly as driving force • Facility-based employment “quick fix” for people with disabilities coming off waiting lists • Disability advocates concerned about lack of improvement in employment outcomes

6. Hard Look in the Employment Mirror • Most people with disabilities served by the long-term care system are currently unemployed or employed in non-integrated settings, making sub-minimum wages. • Just 25% of people with developmental disabilities in managed care involved in integrated employment (including crews/enclaves). [2006] • Just 5% of people with physical disabilities in managed care involved in integrated employment. [2006] • 9,416 individuals with disabilities in sheltered workshops making sub-minimum wage, with 35% earning less than $1.00 [2005].

7. State Agency Prioritizes Employment: Creates “The Managed Care and Employment Task Force” • Members appointed by Administrator for the Division of Long-Term Care. • Chaired by Deputy Administrator of the Division. • 28 highly respected members, including wide range of stakeholders: managed care entities, consumers and family members, advocates, providers, employers, colleges and universities, counties, and state agencies. • Seven issue committees, involving over 100 other contributors • 15 month process • Listening sessions held June, 2008 • Final report submitted July, 2008.

8. Task Force Areas of Focus • Through Issue Committees, the Task Force examined the following key program and policy areas: • Informed Choice and Member-Centered Planning • State/Managed Care Organization (MCO) Contracting and Funding Strategies • MCO Contracts and Strategies with Providers • Blending Funding Across Systems • Employment Service Provider Network Development and Support • Measuring Outcomes and Quality • Work and Employer Incentives, including incentives in Medicaid 84 Recommendations Made

9. DHS Response to Task Force Report and Recommendations “I support the findings and recommendations that this report contains. I have directed the management and staff in DLTC to proceed with implementation, which is likely to take several years to complete. We will continue to seek the support and engagement of partners in state and local government, as well as the private sector, to assist us in realizing these important objectives.” -Secretary Karen Timberlake WI Department of Health Services

10. DWD Response to Task Force Report and Recommendations “Our department was pleased to have representatives on the Task Force that developed vitally important, aggressive and detailed recommendations for systemic changes. We are delighted to continue in a cooperative role for positive life-sustaining changes for persons with disabilities…partnering to implement the Task Force recommendations is an exciting next step.” -Secretary Roberta Gassman WI Dept of Workforce Development

11. The Managed Care and Employment Task Force Download Full Task Force Report, Work Plans for Implementation, and Progress Reports at: http://dhs.wisconsin.gov/WIpathways/

12. Strategy for Systems Change A Multi-Faceted Approach

13. High Level Changes • Division of Long-Term Care adopted strategic priority to promote and support integrated employment outcomes • Revised contracts with Managed Care Organizations (MCOs) to include new language reflecting expectations around integrated employment. • Employment is featured prominently as one of the outcome areas that MCOs must help their members consider, and pursue if desired.

14. Clarified Policies • Either/Or policies prohibited; mixed services encouraged • 25% rule must end • Transportation services should be based on need, not based on type of service someone is receiving

15. Changing Service Definitions • Revised what’s permitted under Supported Employment to include and encourage: -Customized Employment -Self-Employment -Ability to pay employers/co-workers for supports -Ability to pay natural supports for transportation -Ability to use workplace personal assistance for longer term on-the-job supports

16. Revised Prevocational Services Definition • Service is intended to contribute to a participant’s employability in paid employment in integrated, community settings • Participants may be compensated in accordance with applicable Federal laws and regulations, but the provision of prevocational services is intended to lead to a permanent integrated employment situation • The services should enable a participant to attain the highest possible wage and work which is in the most integrated setting and matched to the member’s interests, strengths, priorities, abilities, and capabilities • Services recipients are expected to make reasonable and continued progress toward participation in at least part-time integrated employment.

17. Assessing Performance • Improving data systems to allow for better tracking of employment outcomes, services and expenditures. • An annual report on performance will be produced by state agency. • Performance data will be used to establish benchmarks (goals) for progress.

18. Accurately assessing cost-effectiveness • Collection of wage and hour data allows for accurate assessment of cost-effectiveness of supported employment • Documenting cost-effectiveness of supported employment is critical for buy-in to policy of ‘zero exclusion’ • Long-held assumptions die hard!

19. Managed Care Organizations • Have formal policies, principles or guidelines on employment that reflect the Department’s values regarding integrated employment. • Added source of employment expertise to their staff. • Establishing cooperative relationships with local Vocational Rehabilitation offices

20. Managed Care Organizations • Training care managers and nurses -Outlining specific expectations on how to ensure informed choice in member-centered planning process -Care Managers are expected to regularly offer and fully support members to pursue integrated employment -By doing this, MCOs are expected to increase both the number and percentage of long-term care recipients who are supported to pursue and maintain integrated employment at a competitive wage.

21. Managed Care Organizations • Expanding and diversifying their provider networks for integrated/supported employment services. • Encouraging use of customized employment • Exploring use of outcome payments and incentive payments so providers that deliver good outcomes, fade supports, and serve the most challenging individuals do not lose out financially.

22. Managed Care Organizations • Hiring members so MCOs are leading by example • Some are doing performance improvement projects on employment • Some are becoming EN’s • Some are doing peer-to-peer outreach with other employers in their areas

23. Integrated/Supported Employment Providers Are being assisted to learn and implement the most promising, evidence based practices: • Customized Employment Pilot • Systematic Instruction Training

24. Facility-Based Service Providers Are being assisted with organizational change through a Rebalancing Initiative • Started in 2009 with 10 CRPs • Modeled after DOL’s T-TAP Initiative • Mentoring + Grants + TA + CE Training • 18 CRPs (25%) now involved

25. What is CRP Rebalancing? • Emphasizes shifting the balance of organizational resources (esp. staff) in favor of integrated employment • % of people served in integrated employment expected to rise • % of people served in facility-based employment and day programs expected to decrease

26. What is CRP Rebalancing? Primary Strategies: • Enabling new referrals to go directly into at least part-time integrated employment • Assisting facility-based participants to transition to at least part-time integrated employment

27. What is CRP Rebalancing? • Does not require a commitment to conversion Allows the CRP and individual consumers to “Live into the answer…” [J. O’Brien] • “Accelerated progression” toward community integration and real jobs

28. Personal Care Providers • Being engaged to provider workplace personal care and assistance • Developed toolkit to help providers add workplace personal care and workplace personal assistance as new service lines • With Wisconsin APSE, developing core training for individuals hired to provide workplace personal care and/or assistance

29. Accountability for Change • Two key state agencies (DHS and DWD) jointly charged a body of external, well-qualified stakeholders with monitoring progress and reviewing outcomes. • This body is a sub-committee of the Governor’s Council on Workforce Investment • DHS has developed multi-year work plans for implementation of each of the recommendations made by the Managed Care and Employment Task Force

30. Resources for Change Center for Medicaid Services has approved MIG funding to support implementation of these strategies. Time-limited nature of MIG funds has created sense of urgency around getting changes implemented.

31. The Value of High Expectations “The greatest danger may not be that our aim is too high and we miss it, but rather that it is too low and we reach it.” -Michelangelo

32. For More Information: Lisa A. Mills, PhD Consultant WI Department of Health Services Lisa.Mills@dhs.wisconsin.gov (608) 225-4326 The Glass is Always Half Full