DDS System Transformation

1. DDS System Transformation AWA Conference July 17, 2014

2. What is the current situation • Who is being served? • What are their needs? • What services do they receive today?

3. Over 14,000 individuals are currently served by Home and Community-Based (Waiver) services (HCBS) Current Situation Program focus Person’s Needs Population • 4,173 served • 2,800 on waitlist due to cap • Individuals of all ages with developmental disabilities • Supportive Living2 • Assistive technology and adaptive equipment • Relief care services • Consultation services • Positive behavior support services • Specialized medical supplies • Stacy is 14 years old and lives in Jonesboro. She has a developmental disability and a mental illness. She requires support to address behavior issues and adaptive living skills so that she can stay at home with her family

4. Over 14,000 individuals are currently served by Home and Community-Based (Waiver) services (HCBS) Current Situation Program focus Population Person’s Needs • Elderly persons with physical, cognitive or medical conditions • 7,318 served • Attendant care and supports4 • Home delivered meals • Relief care services • Adult Day Care/Adult Day Healthcare • Adult Family Home • Joseph is 76 years old and lives in Cabot. He has Parkinson’s disease. He requires attendant services and meals delivered 5 days a week so that he can remain in his home and be more independent

5. Over 14,000 individuals are currently served by Home and Community-Based (Waiver) services (HCBS) Current Situation Program focus Population Person’s Needs • 2,690 served • Attendant care and supports • Assistive technology and adaptive equipment • Case Management and Counseling Support • Adults with physical disabilities • Dennis is 32 years old and lives in Hope. He had a motor vehicle accident and is readjusting to life at home. He needs assistance in accomplishing tasks of daily living so that he can continue to live in his own home

6. Existing services for individuals with developmental disabilities • Alternative Community Services (ACS) Waiver • 4200 individuals served • Developmental Day Treatment Clinic Services (DDTCS) • approximately 4600 adults served • Personal Care Services • approximately 1200 individuals with DD served

7. Alternative Community Services (ACS) Waiver • Case Management • Supportive Living (includes Residential Habilitation) • Respite Services • Non-Medical Transportation • Consultation Services • Personal Emergency Response System (PERS) • Crisis Intervention • Supplemental Support Service • Community Transition • Specialized Medical Supplies • Adaptive Equipment • Environmental Modifications

8. Why do we have to change our system: Due to limitations on the number of people that can be served under ACS Waiver program, Arkansas is unable to serve all eligible individuals: • DDS Waiting list: 2800 individuals • Average wait time: 8 years Existing system is fragmented with different programs serving different populations.

9. Example of fragmented system for HCBS

10. What does success look like All eligible individuals who need services and supports are able to receive them in the setting of their choice: • In all parts of the state • In the most integrated setting chosen by the individual • Based on person’s individual needs • Without regard to age, type or severity of disability • No Waiting list

11. How can we achieve success? The State and stakeholders developed the Community First Choice Program that will: • Fill the service gaps • Eliminate DD Waiting list: program provides HCBS services to the 2,800 individuals on waitlist • Enable individuals with disabilities to receive services in the most integrated care settings CFCO is projected to save$365M of State General Revenue (SGR) over the next 12 years

12. Projected State General Revenue (SGR) expenditures for HCBS services under three scenarios $M spend • Status Quo • CFCO Implementation • Olmstead enforcement  • SGR Expenditure$M • $924.5M of avoided expenditures over next 12 years compared to Olmstead scenario • 350 • 300 • 250 • 200 • 150 • $365.5M of savings over next 12 years compared to Status Quo scenario • 100 • 50 • 0 • 2014 • 15 • 16 • 17 • 18 • 19 • 20 • 21 • 22 • 23 • 24 • 25 • 2026 • State Fiscal Year Olmstead enforcement (2016) Source: FMS Analysis. Analysis of Net Effect of CFCO Program on State General Revenue, Jul 10 2014

13. CFCO will provide access to comprehensive package of services: Services that will remain in DD HCBS Waiver: Case Management Supported Employment • Services Transitioned from ACS Waiver: • Supportive Living • Respite Services • Non-Medical Transportation • Consultation Services • Personal Emergency Response System (PERS) • Crisis Intervention • Supplemental Support Service • Community Transition • Specialized Medical Supplies • Adaptive Equipment • Environmental Modifications • Services added from other Waiver or State Plan Programs: • Attendant Services and Supports (Personal Care Services) • Developmental Day Treatment Clinic Services (DDTCS) • Home Delivered Meals • Chore Services • Goods and Services • New Services • Assistive Technology • Positive Behavior Support Services • Participant Directed Support Services: • Counseling Services • Financial Management Services

14. CFCO provides new way for individuals to access services: What is participant-direction: • Is a “consumer controlled” method of selecting and providing services and supports; • Allows the individual maximum control of the home and community-based attendant services and supports; • Individual acts as the employer of record; • Afforded necessary supports to perform that function.

15. Traditional vs. Participant-Directed • Traditional Services • Participant-Directed Services

16. CFC Support System Counseling Financial Management Services (FMS) Provides information, Practices putting the participant as center Explain the program Completes enrollment Collaborates with participant to complete the assessment, service plan, spending plan and reassessments Offers skills training Partners with participant Must be available to all participants with a service budget Collect and process timesheets Process payroll, withhold and file taxes Separately track budget funds and expenditures for each individual Track and report disbursements Assures that spending plan is followed Pays invoices including timesheets Figures tax liability and pays taxes Provides accounting reports Pays for atypical goods and services not covered by a Medicaid provider

17. Where are we today with CFCO • March 14, 2014: State submitted CFCO proposal to Centers for Medicare and Medicaid Services (CMS) for approval • August-September 2014: projected Federal Approval

18. What is the plan and next steps in the process? • July 2014: DHS finalizes work with stakeholders to develop draft of program manual, standards, etc. • August 2014: Draft program manuals, descriptions, regulations for CFCO are submitted for public comment • September 2014: Revise drafts based on feedback from public • October 2014: legislative review by the Joint Public Health Committees and Rules and Regulations Committee • November 2014: Legislative review by Arkansas Legislative Council • Implementation: January 1, 2015

19. What does this change mean to the individuals and families • Individuals who receive services today under ACS Waiver will continue to receive services through Community First Choice Program • New options may become available: • Participant-directed model • New services, such as assistive technology

20. Transition of Individuals on the ACS Waiver to CFCO: CURRENTLY NEXT YEAR ACS Waiver Services: Case Management Supported Employment Supportive Living Adaptive Equipment Crisis Intervention DDTCS Day Services Personal Care Services ACS Waiver Services: Case Management Supported Employment Community First Choice: Supportive Living Adaptive Equipment Crisis Intervention Day Services Attendant Services and Supports

21. Enrollment of Individuals on the Waiting List • Individuals will be enrolled in order they were placed on the Waiting List – individuals waiting the longest enrolled first • Estimated enrollment time for all: 12-18 months

22. What assistance will be provided to the individuals and families • DDS is partnering Arkansas Waiver Association (AWA) to conduct outreach and training to individuals and families • DDS is partnering with Developmental Disabilities Provider Association (DDPA) to provide training to Case Managers and providers

23. New Quality Strategy • Quality Assurance process supports System Change • QA process – 3 components

24. Federal opportunities vs. federal requirements

25. CMS Final Rule of HCBS Settings

26. Supported Employment Current situation, ACS Waiver Supported employment service: • 2013 – 97 people • 2014 – 106 people Individuals who are eligible for DDTCS services only, do not have access to Supported Employment services through Medicaid.

27. Supported Employment Why do we have to change: • Employment is essential part of social life • More people want and can be employed • Current supports are outdated

28. Assessment States are required to use a person-centered service plan that is based on an assessment of functional need: • Assessment will determine if the individual requires assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), or health-related tasks • Information from the assessment can be used for better care planning for each person. • Periodic assessment will provide valuable information for quality improvement.

29. Assessment • InterRAI Assessment instrument - scientifically scaled and validated instrument • Assessments are conducted by independent 3rd party and qualified staff • DDS has contracted with Pine Bluff Psychological Associates to conduct assessments • Assessments will be conducted by Qualified Developmental Disability Professionals (QDDP).

30. DDS ASSESSMENT PROCESS TIMELINE • Assessments of adults began in November 2012 and were completed in November 2013 (adults receiving ACS Waiver services or residing in public or private Intermediate Care Facilities (ICFs)) - COMPLETED • In October 2013 DDS started assessment of additional groups listed below. These assessments are projected to be completed by December 2014. 1) Children receiving ACS Waiver services or residing in public or private Intermediate Care Facilities (ICF) - COMPLETED 2) Adults & Children on ACS Waiver wait list – IN PROGRESS 3) Adults receiving DDTCS services - -IN PROGRESS

31. Contact Information regarding assessments • DDS: Eugenia Brandon at (501) 682-8678 or at harriett.brandon@arkansas.gov • PBPA: (870)534-2830 if you have questions about assessors, assessment appointments and assessment results

32. 65% of all program participants have been assessed PRELIMINARY • DD assessments progress by program (June 2014) • Assessed Number • In Progress • 2,179 • 10,657 • 461 • 961 • 109 • 352 • 2,883 • 4,173 • 1143 • Waiver • HDC • Private ICF • DDTCS • Total • Waiver wait list Each program includes both adults and children % of children are as follows: waiver 11%, waiver waitlist 50%, HDC 3%, Private ICF 24%, DDTCS 0%.