My Life, My Community! Waiver Redesign Update with HSRI Recommendations

1. My Life, My Community! Waiver Redesign Update with HSRI Recommendations Connie Cochran Assistant Commissioner & Dawn Traver Waiver Operations Manager Virginia Department of Behavioral Health and Developmental Services

2. Virginia is Shifting the Array of Services More Integration and Options for Independence Nursing Facilities, ICF, Day Support Group Homes Prevocational Sponsored Residential Family Home Group Supported Employment Individual’s Own Home or Apartment, Individual Supported Employment Current Array of Services Future Array of Services

3. Four Main Areas of Settlement Agreement Serving individuals with DD in the most integrated setting and building quality community-based alternatives for individuals, particularly individuals with complex needs Quality and risk management system, including monitoring and evaluating services, and implementing quality improvement processes at an individual, provider, and state-wide level Transitions from training centers Supporting independent housing and employment options for individuals with DD

4. Individuals Served By Virginia’s Developmental Disability SystemFebruary 5, 2014 674 8,115 10,797

5. Waiver Transformation Activities • On July 1, 2013, DBHDS & DMAS awarded a contract to the Human Services Research Institute (HSRI) to study Virginia’s HCBS Medicaid Waivers for persons with ID and DD. • The study was named “My Life, My Community!”

6. Goals of My Life, My Community! • Evaluate the efficiency, effectiveness and flexibility of the current waivers. • Recommend approaches for system changes including waver enhancement, and the potential efficacy of one comprehensive waiver and one supports waiver. • Conduct a study of current Medicaid rates. • Recommend new rate structure based on the study and exploring an individual resource allocation system for efficient distribution of waiver funds. • Aid in implementing the new system.

7. My Life, My Community: Two Phases Phase I • Evaluate the waivers • Hold public stakeholder forums and report on results • Evaluate SIS administration and create process for data use • Develop a plan to reduce the number of waivers • Review policy changes • Report on findings

8. My Life, My Community: Two Phases (cont’d) Phase II • Conduct a cost study and propose a more appropriate rate structure • Explore a resource allocation framework • Create a rate structure • Evaluate SIS data • Analyze the potential impact of the proposed waiver system • Align with the Quality Management System • Develop a communication plan

9. Public Forums • HSRI held 8 stakeholder meetings across the state between 9/23 and 10/10/13 • All were welcome: self advocates, family members, providers, CSBs, advocacy reps • The resulting report is available at: http://www.dbhds.virginia.gov/MLMC.htm • The information gathered helped inform the Phase I report

10. My Life, My Community Public Forums Conclusions Primary Principle: One Unified, Needs-Based Waiver • The waiver needs to address the increasing demand for services in the state • The waiver should offer a flexible array of services that allow for choice, control & creativity to meet individual needs & preferences

11. My Life, My Community Public Forums Conclusions (cont’d) • Waiver rates need to be commensurate with the costs of providing services • The waiver needs a uniformly implement, sound infrastructure for screening, providing case management/service coordination services that enable users to access services free of conflict of interest

12. December 20, 2013: HSRI Phase I Recommendations • Phase I report included a series of short and long term recommendations • Available at http://www.dbhds.virginia.gov/MLMC.htm • DBHDS will evaluate each of these recommendations, in conjunction with stakeholder input, before making policy decisions or final recommendations • Final recommendations to Governor for General Assembly consideration at 2015 session

13. Major HSRI Recommendation VA should initiate the development of two new 1915(c) Waivers that include eligibility for people with ID, DD and related conditions • Comprehensive waiver with wide service array, including residential • Support waiver with similar supports array but no 24-hour residential option

14. Waiting List Recommendations Long Term Recommendation • A single set of waiting list criteria should be created Short Term Recommendations • DD Waiver emergency slots should be available on a continual basis • DBHDS/CSBs should perform continual outreach to ensure people know how to apply for services/WL • Review WL data to determine which individuals are receiving services through other sources/not receiving any services • Stakeholders should contribute to revised policies that integrate WLs

15. CSB Recommendations Long Term Recommendations • Clarify & strengthen the oversight role of the state in contract with CSBs & practice related to Medicaid funded activities • CSBs as single point of entry for individuals with DD added to statute • Expand role of CSBs as case management entities for those with DD & related conditions • Develop long-term plan for transitioning CSBs into case management providers vs. Waiver services providers

16. Case Management Recommendations Long Term Recommendations • Address conflicts of interest within the current case management system • Shift all case management to the public CSB system • Develop 2 new State Plan Amendments • Case management for those on I/DD waivers • Case management for those not receiving waiver services

17. Case Management Recommendations (cont’d) Short Term Recommendations • Enable ID & DD Waiver case managers to bill for activities up to 6 months prior to transition to the community • Administration of the SIS should be done by an independent entity

18. Service Array Recommendations Long Term Recommendations • Enhance and encourage Positive Behavioral Support services • Remove restrictions on “general supervision” in Congregate and In-home Residential Support services • Consider stakeholder forum feedback on transportation services

19. Service Array Recommendations (cont’d) Long Term Recommendations • Consider adding Caregiver Retention payments or vacancy factor to rates • Consider adding a “Community Guide” service to promote community integration • Add dental services to the waivers

20. Service Array Recommendations (cont’d) Short Term Recommendations • Streamline the process for preventing and addressing crises for those served in the community • Ensure access to Skilled Nursing services for those with significant medical issues • Continue to support self-directed service options

21. Employment Recommendations Long Term Recommendations • Revise employment service definitions to align with CMS 2011 employment informational bulletin • Make discussions about individuals’ career interests a priority before determining day/employment services

22. Quality Improvement Strategies Recommendations Long Term Recommendation • DMAS & DBHDS should create a unified Quality Improvement System for the two new waivers to safeguard individuals and improve their quality of life Short Term Recommendation • VA should proceed with revisions to the ID Waiver QIS for the 2014 renewal per draft guidance issued by CMS in August 2013

23. Incident/Risk Management Recommendations Long Term Recommendations • Develop a critical incident manual that clarifies the roles and responsibilities of everyone in the system • Automatically notify SCs/CMs of critical incidents reported in CHRIS • Clarify DBHDS role & responsibility for conducting certain types of investigations

24. Incident/Risk Management Recommendations (cont’d) Long Term Recommendations • Expand Death Reporting and Mortality Reviews to all I/DD waiver recipients whose death is unanticipated or unexplained

25. Next Steps Response to Phase I recommendations • Stakeholder meetings to further discuss DBHDS’/DMAS’ response to major issues Phase II began in January • Burns & Associates to met with a committee of provider stakeholders for input into the development of a survey for all providers regarding ID/DD Waiver rates • “Provider Advisory Committee”

26. Stakeholder Groups Being Formed Waiver Development Advisory Committee • Overarching committee to provide input to the process of new waiver development Subcommittees: • Provider Advisory Committee • Eligibility Requirements • Waiting Lists • Case Management

27. SIS Related Next Steps • ID support coordinators no longer administering the SIS to individuals receiving ID and DS Waiver services • DBHDS contracted with an external vendor (AAIDD) to complete the SIS on individuals receiving ID, DD & DS waiver • Approximately 1,450 SIS interviews to be completed through June, 2014 • The information will be used to inform the rate study.

28. Timeline for Implementation of My Life, My Community • Renew Intellectual Disability (ID) Waiver (January 2014 – July 2014) • only make small modifications to the current program • Design New Developmental Disability Waiver(s) (January 2014 – January 2016) • The WDAC and subcommittees will provide consultation and guidance in development of these solutions

29. Questions?