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Waiver Review Initiative. FINDINGS AND IMPLICATIONS June 21, 2011 Prepared by With the assistance of Minnesota Department of Human Services. Lead agency Comments.
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Waiver Review Initiative FINDINGS AND IMPLICATIONS June 21, 2011 Prepared by With the assistance of Minnesota Department of Human Services
Lead agency Comments • “The review process has been very organized from the State stakeholders with an attitude of working together with our County to improve services to our clientele…this process has resulted in improvements and process change that will definitely benefit our clientele.” – Clearwater County (Director of Human Services)
Agenda • Describe the waiver review initiative • Share findings from the waiver review • Describe changes in waivers across county agencies over previous 5 years • Share how counties change in response to reviews
About the waiver review initiative • A statewide project that began in 2006 to assure the Quality of Minnesota’s Home and Community Based Programs: • To identify promising practices • Assure compliance with program requirements • 75 lead agencies have been reviewed and as a result • Surveyed over 1,300 staff • Conducted almost 90 focus groups • Reviewed over 5,000 case files
Some changes in the initiative • Providing more services on-site to counties • Detailed report of what we looked for • Answering questions about requirements, practices • Follow-up process started • 48 counties had been through the follow-up process
Some changes in the initiative • Yahoo Group – save interesting tools collected from other counties • Instructions on how to find the Yahoo group with useful County tools. It can be found accessed at http://www.theimprovegroup.com/waivers/countytools.pdf • DHS data portal – reports published on the DHS website • Performance measures related to HCBS waiver programs • Updated quarterly • New reports get added as they are developed
Waiver review framework • The waiver review is designed & organized to examine the Center for Medicaid and Medicare seven quality areas;
Findings and themes: participant access • Promising practices • Counties build strong relationships with agencies such as schools, health clinics, hospitals & nursing homes • Increasingly, counties build strong regional collaboration to better serve communities • Counties serve a higher-need population than in 2004 • Limitations • Most counties (12 of 16) have fewer than 80% of screenings completed on time in one or more programs • Some counties are facing challenges serving culturally specific populations, notably Hispanic and Somali populations • Some counties are facing challenges in providing case management to participants who live outside the county borders
Findings and themes: person-centered 13 • Promising practices • DD ISPs nearly always exceed expected documentation of needs, goals & outcomes • Counties provide increasing employment opportunities for DD & CCT participants • Limitations • Not all CCT care plans are being developed within ten days of the assessment, as required by MN statute • Counties are not adequately addressing caregiver needs in care plans. Overall, only 41% of cases reviewed in the past year address caregiver needs
Findings and themes: provider capacity 15 • Promising practices • Nearly all contracts include basic participant outcomes and have a process to monitor if services are being provided • County staff are well connected and communicate regularly with providers • Limitations • More than 34% of all contracts reviewed were signed more than 60 days after the contract’s effective date • Some counties have a very residential provider base
Findings and themes: provider capacity *Statewide data ** Fee-for-Service data MMIS data
Findings and themes: participant safeguards 18 • Promising practices • In many counties participants are seen face-to-face on a monthly or quarterly basis • During assessments county staff take a look at kitchens, bathrooms, scatter rugs etc to ensure people are safe in their homes and to prevent falls • Limitations • Some counties had CCT participants that did not have biannual face-to-face visits over the past year • Some Counties had more than 20% of DD participants not visited in the previous six months
Findings and themes: rights/responsibilities 20 • Promising practices • Most counties had 100% documentation of participant rights for its DD cases • Limitations • Some counties had issues with public guardianship and case management roles being performed by the same person • Many counties do not regularly update participant rights forms
Findings and themes: outcomes/satisfaction • Promising practices • Some counties are systematically collecting participant satisfaction information • Counties are doing participant satisfaction surveys • Limitations • Goal setting continues to be a challenge in the LTC programs, in many counties goals are not individualized. • Participant satisfaction collected informally but not documented in case files
Findings and themes: system performance • Promising practices • Case management practices are very strong in all counties reviewed this year • Public Health and Social Services agencies and staff have good working relationships and work together to serve participants • Limitations • Staff capacity has been stretched as a result of budget cuts, and case managers report that keeping up with policy changes is a challenge • Contracting for culturally-appropriate services continues to be a challenge in many counties
Changes in waivers during review period • Technology is being used increasingly to support case management and other services through electronic case files, mobile laptops, and delivering services electronically. • CDCS services have been used in greater numbers in rural, suburban and urban communities alike; each community seems to have different reasons for its use of CDCS. • The majority of participants are being served in the community as opposed to institutions, and the percentage is increasing.
Changes in waivers during review period • Care plan documentation of participant health and safety and participant goals is improving. • Compliance with technical requirements is improving. • In 2006, 9% of CCT cases had a completedocumentation of a backup plan, while 74% of the CCT cases we reviewed in the past year had this documentation • In 2006, 67% of LTC cases had a completed OBRA level one, while 98% of LTC cases we reviewed in the past year had this documentation
Changes in waivers during review period • Contracting practices are improving; most counties moved to the DHS model contract over the last 30 months, and now contracts meet all requirements and in general are in place for all services, with a few incidental exceptions. • The proportion of participants earning income is increasing. In the DD program, 49% of participants earned income in 2005, and 56% earned income in 2009. In CCT, 20% of participants earned income in 2005, while 21% earned income in 2009.
Continuing challenges • Some issues continue to challenge counties; these could be considered when working with counties and/or supporting their work: • Counties are facing increasingly limited budgets, particularly for travel, staff reductions and training. They are addressing these limits by using internal cross-training whenever possible. • Some counties struggle when switching between different waivers and/or health plans to meet the various care plan and documentation requirements. They have frequently requested tools resources such as requirement checklists to support their work
Continuing challenges • Keeping up with the pace of program changes remains difficult for counties; some have assigned staff to be internal “experts” on specific issues, but others do not have a system for adapting to change. • While DHS offers a number of resources, the resources are not available to all programs; county staff continue to ask that Regional Resource Specialists or similar support be available for AC and EW programs.
Lead agency Comments • “The review confirmed many areas SLC [St. Louis County] has known are challenging areas with room for improvement. The difficulty has been with limited resources and the need for greater direction and consistency locally and from DHS. On a positive note, in the intervening 3 years, both DHS and SLC are moving forward step by step to improve the overall waiver administration and service delivery.” (Deputy Director, St. Louis County)
Follow – up • The follow up summarizes the results of the waiver review follow up activity from 2008 through 2010. • Results are organized into the following sections: • Individual Case Compliance • Cohort Compliance • Lead Agency Service Improvements
Follow-up results Purpose The follow-up review: • Confirms lead agency compliance with corrective action plans; • Tracks local improvement efforts; • Obtains feedback on the helpfulness of the review.
Follow-up results Process • The lead agency submits documentation to verify planned changes to their programs were implemented as stated in their corrective action plan • A list of cases and required documentation is sent to the lead agency that includes cases previously found non-compliant, along with additional cases to ensure that the practice has been consistently implemented and not only applied incidentally. • Lead agencies are also asked about recommendations that were included in the waiver review report.
Follow-up results Process. • The submitted documentation is reviewed for compliance with state and federal requirements. • A draft report is sent to the lead agency for review • Report is finalized • Additional corrective actions re-issued if necessary
Follow-up results Conclusions • The follow-up process continues to be an effective mechanism to assure compliance and secure feedback on recommendations. • Most lead agencies have made significant progress in achieving compliance. • Frequency of face-to-face case manager visitation, timing of screenings and care plans continue to be major challenges for lead agencies. • Lead Agencies implemented over three-quarters of all recommendations made by the Department relating to service improvements.
Follow-up results Adjustments Made to the Process Include: • Reduce the time interval between the Initial Waiver Review visit and the Follow-Up Process to between 15 and 18 month intervals. • Planning to implement phase II of the follow-up process after the initial follow-up reviews are completed.
