Waiver Review Initiative

1. 2013 Minnesota Age & Disabilities Odyssey June 17, 2013 Waiver Review Initiative Using Data to Drive Improvements

2. Today’s Agenda: • Purpose of the Waiver Review Initiative • Waiver Review Round II • Findings & Best Practices for Better Results • Using WR Data to Drive DHS Improvements • Concluding Items

3. Purpose: • Goals • History

4. Goals: • Supports CCA vision and strategic plan • Helps ensure that the long term care programs continue and are sustainable over time. • Helps ensure that long term care programs improve the quality of life of Minnesotans.

5. Goals: • Assure compliance by lead agencies with federal and state requirements. • Identify best practices and/or barriers, track local improvements, and share best practices amongst lead agencies. • Obtain feedback about DHS resources.

6. History: • Waiver Review Initiative began in 2006 and reviews of 89 lead agencies, including 87 counties and two tribes, completed in early 2012. • Waiver Review Initiative – Round II began in April 2012 and will be completed in 2015. • DHS continues to partner with the Improve Group.

7. Waiver Review Round II • Tools & Methods • Enhanced Focus on Quality Improvement • Sharing Performance Data with Lead Agencies

9. Tools & Methods of Analysis: • The waiver review process uses a comprehensive, mixed-method approach. • The data collection methods are intended to glean supporting information, so that recommendations and corrective actions are supported by multiple sources of data. • The data collected is analyzed and the findings are put in a report for each agency. All reports and the LAs’ responses are posted on the DHS website.

11. Focus on Quality Improvement: Examination of qualitative factors during case file review • Moving from “compliant” to “best practices” to improve quality of care for waiver participants: • LTCC/Screenings, Care Plans (CSP/ISP), and Case Notes/Documentation

12. Focus on Quality Improvement: Case specific list of non-compliant case file documentation • Improving our ability to track remediation for CMS. • 100% of non-compliant cases reviewed on-site must be corrected in 60 days. • Allows LAs to see which programs and which staff may need additional supports.

13. Focus on Quality Improvement: Project website created to share lead agency resources and best practices • Similar size LAs have similar strengths and barriers. • Allows for easy access to share LA documents and information considered “best practices”

14. www.Minnesota.HCBS.info

15. Focus on Quality Improvement: Increased availability of county specific performance data • Promote internal QA and monitoring of compliance. • New data sets being created and shared based on LA requests: • Earned income data • Participant needs vs. Residential settings

16. Focus on Quality Improvement: • Reports available include: • Average LTC spending per person • Percent of LTC spending in HCBS • Percent of people who receive HCBS • Percent of people who receive HCBS at home • Percent of people with low needs with waiver services in a residential setting • Percent of people with high needs • Percent of people with high needs who receive services at home • Working-age people with monthly earnings • Working-age people earning $250 or more per month • Percent of nursing facility resident days for people with low needs • Housing type at initial or last assessment • Initial assessments or screenings completed on time http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_144803

17. Sharing Performance Data:

18. Sharing Performance Data: • Discussion with lead agency about what is driving its outcomes or results • Comparison of lead agency to its cohort and statewide data • Let’s review an example: Handout from Wright County

20. Findings & Best Practices: • Case Management • Assessment & Care Planning • Case File Technical Compliance • Internal & External Relationships • Provider Service Capacity & Development • Waiver Allocations

21. Case Management: Data: • Case managers visited participants 3.6 times in the 18 months prior to the waiver review. • Nearly half (48%) of providers indicated that a top strength of the lead agency they work with is good, open communication between case managers, consumers, and providers.

22. Case Management: Recommendation forBetter Results: • Frequent visits and contacts with participants and their families allows a case manager to build strong relationships and monitor health and safety needs.

23. Assessment & Care Planning: Data: • 78% of care plans reviewed contained the required health and safety information. • 87% of care plans provided information on the services the participant was receiving to address their needs. • 98% of care plans were current at the time of review, and 96% were signed by the participant and/or guardian.

24. Assessment & Care Planning:

25. Assessment & Care Planning: Recommendation forBetter Results: • Reminder: CSP/ISP is the only document the participant receives. It should be person-centered, outline his/her needs and how services will address those needs, and use clear language. • Consider developing a single care plan for CADI waiver participants also receiving Rule 79 MH TCM that includes all the required elements.

26. Case File Compliance: Data: • The areas where lead agencies were frequently found to be compliant are • DD screening documents are current (98%), • OBRA Level One document (99%), • Choice questions are answered by participants (95%).

27. Case File Compliance: Recommendation for Better Results: • LA’s that incorporate other requirements into the care plan are more likely to be compliant (e.g. the DD ISP includes information on one’s rights to appeal). • LA’s who use standard formats for all documents across programs are more likely to have all required documents in place

28. Case File Compliance • Corrective Actions are issued when patterns of non-compliance are found. • For example all CADI cases are missing a back up plan • LAs are required to develop a corrective action plan to resolve the issue for all cases. • Corrective action Results from year one…..

30. Internal & External Relationships: Data: • A majority of LAs (88%) indicated in the QA survey that they always have case managers document provider performance, and always provide oversight to providers on a systematic basis (75%). • 76% of providers surveyed indicated they submit monitoring reports to the lead agency, and 83% indicated that they received the needed assistance when it was requested from the lead agency most or all of the time.

31. Internal & External Relationships: Recommendation for Better Results: • Use visit sheets to document satisfaction and to monitor provider performance to ensure consistency across programs.

32. Service Capacity & Development: Data: • 75% of LAs said that they recruit service providers to address gapsby working with existing providers or use of RFPs. • Common service gaps for LAs: providers of specialized services including psychiatry, crisis beds, dental, and transportation. • 12% of Provider Survey respondents indicated increased opportunities for community based employment as a service need (3rd overall).

33. Service Capacity & Development: Recommendation for Better Results: • Partner to increase purchasing power. • Develop in-home service packages to move low needs participants out of CFCs and repurpose those beds for high behavioral participants. • Expand community-based employment opportunities for participants with disabilities, that results in higher wages in CCB and DD.

34. Waiver Allocations: Data: Recommendation for Better Results: • 10 of 24 LAs received recommendation to reduce their reserve. • Include accounting staff on team to provide added analysis above and beyond WMS, allowing LAs to manage more closely.

35. Waiver Review Data Driving DHS Improvements: • Using data to improve CCA • Feedback on DHS

36. DHS Improvements: • Requests from lead agencies: Model contract changes • Waiver Review Team observations during reviews: CDCS care plan components • Data analysis of case file results: • QET • Technical assistance DHS provide to LA’s • Reports to CMS

37. Feedback on DHS: • Supervisors and case managers are asked to share feedback on DHS tools and resources. • 278 case managers • 92 supervisors • Sharing results within CCA to prompt state improvements and better serve LAs.

38. Case manager feedback on DHS

39. Concluding Items: • Q&A • Resources • Contact Information

40. Q& A: Discussion Questions: • How do these issues or measures align with what you see in your community? • What additional information would be helpful for DHS to share with LAs? • Was your Waiver Review experience informative and did it prompt any changes at the LA?

41. Resources: • Waiver Review Project Website: www.MinnesotaHCBS.info • DHS Waiver Review Initiative – Lead Agency Reports: http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_136600 • DHS CCA Performance Reports: http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_144803

42. Contact Information: Jean Martin, DHS Jean.M.Martin@state.mn.us 651.431.2578 Julia Wallis Holmoe, DHS Julia.Holmoe@state.mn.us 651.431.2168