1 iBudget Florida Stakeholders’ Meeting December 4, 2009.

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iBudget FloridaStakeholders’ Meeting

December 4, 2009

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Overview of Proposed System

•Budgets determined through algorithm •Service array revised to increase flexibility•Waiver Support Coordination better match to family needs, shift to emphasis on service coordination from service approval processing•Service review more limited, focused, & streamlined, focusing on health & safety issues

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•Consumer and family training and tools for managing budgets•Policies for limiting risk of overspending and options for corrective action plans•Behind-the-scenes reviews for health & safety, provider manipulation, and fraud•Process for determining budgets for consumers with exceptional needs

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• Electronic/automated as much as possible—virtually paperless• Phase-in over a reasonable time period—e.g., number of consumers (say by geography) and budget amounts

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Consumer and Family Control

Main question:

What would be reasonable limits on individual control?

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APD Recommendations:

• Training be provided to consumers and families on choice-making

• Consumers and families have greater control over the amounts and types of services they get

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Consumer and Family ControlFeedback so far:• System now does provide for adequate

consumer control• System now does not provide for

adequate consumer control• Some individuals don’t have natural

supports to help exercise self-direction

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Consumer and Family ControlFeedback so far:• Some families will be unable to manage

a budget• Concern that individuals’ natural

supports might not let them make desired choices

• Concern that some providers may not cooperate or may be manipulative

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Consumer and Family ControlFeedback so far:• Consumers may make poor choices

that put them at risk• Consumers need opportunities to make

choices and learn from the poor ones

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Decisions needed:• Limits on spending to ensure that funds

last through the year – Option A: Monthly allocation– Option B: 10% up front; 85%, spread over

12 months; 5% emergency reserve– Option C: 20% up front; 80% spread over 4

quarters

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Decisions needed:• Other methods to discourage

overspending – Monthly statements– Waiver support coordinator issues

service authorizations (consumer and family may do so in Option C)

– Swipe card system

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Consumer and Family ControlDecisions needed:• What to do if a person overspends but

still needs services– Require to adjust services to fit budget– Limit flexibility to make future changes– Require a representative to help– Temporary increase in funding to meet

critical health and safety needs– Require training or a mentor paid from

budget

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Decisions needed:• How to provide training on making

good choices– Web– Through Waiver Support Coordinator– In-person group trainings hosted by FCC

or Area Office– Paid service through person’s budget

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Decisions needed :• Caps on service amounts:

– Option A: Similar to current handbook– Option B: Only on limited services which

are related to health & safety– Option C: No

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Decisions needed :• Whether funds for certain critical health and

safety-related services must be reserved and may not be spent on other services:– Option A: Residential habilitation,

nursing, therapies– Option B: Residential habilitation only– Option C: None

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Decisions needed :• Who may issue service authorizations to

begin or end services:– Option A: Waiver support coordinator,

along with area staff for certain services– Option B: Waiver support coordinator– Option C: Consumer, family, and waiver

support coordinator

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Decisions needed :

• What information consumers need to make good decisions – Their own goals and needs– Traditional and innovative strategies for

achieving goals/meeting needs– Outcomes/performance data

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Decisions needed :

• How to help consumers track spending– Waiver support coordinator – Web-based budget tool– Service logs– Monthly statement

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Decisions needed :

• How to find out if any providers are uncooperative or manipulative– Analysis of service usage/spending

patterns– Reports from consumers/families– Quality assurance contractor reporting

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Decisions needed :• What support to give to consumers who

don’t have unpaid help in decision-making– Waiver support coordinators continue in that

role– Waiver support coordinators help find supports

to help– Quality assurance review– Behind-the-scenes audits

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Decisions needed :• If funds can be carried over to a

future year like in CDC+– Option A: No– Option B: 50% carry over for up to 1

year– Option C: 100% carry over, no time

limit

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Service Review

Main question:

How do we best ensure that individuals receive the services that they need within allowable waiver coverage?

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Service ReviewAPD Recommendations:The process as we know it go away—be

minimized or eliminated as much as possible while meeting federal requirements

• Streamlined paperwork• More flexibility• Personalized approach

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Service Review

Feedback so far:Scaling back is great but we need something to meet federal requirements for assessing medical necessity of services

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Service Review

Decisions needed:

• What are situations requiring a review?

• Who will conduct reviews?

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Service Review

Decisions needed:

• Situations requiring review– Under all options:

• Newly-enrolled in waiver• If overspent budget within last 12

months• First time in a licensed home

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Service Review

Decisions needed:

• Situations requiring a review– Under all options:

• Temporary significant change in needs requiring additional funds

• Permanent significant change in needs requiring additional funds

• Extraordinary need request

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Service Review

Decisions needed:

• Situations requiring a review– The first iBudget Florida plan:

• Option A: Yes• Option B: Yes• Option C: Only if using different

services than previous plan

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Service Review

Decisions needed:

• Situations requiring a review– Every 3 years:

• Option A: Yes• Option B: No• Option C: No

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Service Review

Decisions needed:

• Situations requiring a review– If adding new service family:

• Option A: Yes• Option B: Yes• Option C: No

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Service Review

Decisions needed:• Situations requiring a review

– If increasing amounts of certain services within budget amount:

• Option A: Yes--behavioral services, nursing services, therapies

• Option B: Yes—intensive behavioral services, nursing services, therapies

• Option C: No

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Service Review

Decisions needed:• Situations requiring a review

– If decreasing amounts of certain services within budget amount:• Option A: Yes--behavioral services,

nursing services, therapies• Option B: No• Option C: No

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Service ReviewDecisions needed:• Situations requiring more frequent

review:– If meets certain criteria:

• Current or previous forensic involvement• Extraordinary medical needs• Extraordinary behavioral needs• Community based care child• Only paid supports in person’s life

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Service ReviewDecisions needed:• The process for requesting reviews

– Computer-based

• Who will perform reviews– Option A: Contracted provider, Central

Office, and Area Offices– Option B: Central Office and Area

Offices– Option C: Area Offices

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Quality Assurance and Quality Improvement

Main question:

How do we ensure health, safety, and good outcomes?

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APD Plans:• New quality assurance contract uses different

measures– Increasing percentage of support coordination records

reviewed to 50%– Will review about 25% of consumers individually

• Florida is joining National Core Indicators initiative

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Feedback so far:• Support revision of the quality assurance system

to be more understandable, less bureaucratic, and more person-centered

• Concern that individuals may make poor choices that put their health and safety at risk

• Concern that individuals may be at risk of exploitation by providers and natural supports

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Key Areas:• Health & safety• Budget management• Outcomes• Compliance

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Participants in QA/QI System:• Consumers & families• Waiver Support Coordinators• Providers• Family Care Councils• Advocacy & provider organizations• APD Central Office staff

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Participants in QA/QI System:• APD Area staff

– Certified Behavior Analysts– Nursing staff– Questionnaire for Situational Information Administrators– Licensing– Group home monthly monitoring– Provider enrollment– Supported living coordinator

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Examples of key activities:• Assessment• Planning• Training• Standard setting/process determination• Monitoring/data analysis• Information sharing• Problem identification• Corrective action

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Decisions needed:• Options:

– Health & safety:• Requirement for use of full or enhanced waiver

support coordination by certain individuals (e.g., those with forensic involvement)

• Competency-based training• Utilization reviews to identify service patterns

of concern

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Decisions needed:

• Options:– Health & safety:

• Review by area certified behavior analysts and nursing staff based on QSI scores

• Limits on certain flexibility in selecting and changing services

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– Budget management:• Training for all levels of skill• Timely information through web-based tools

– Consumer & family – Support coordinator – Area office– Contracted Quality Assurance reviewers

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Decisions needed:

• Options:– Budget management:

• Policies to deter overspending• Corrective action plans to address

overspending• Data analysis of spending patterns

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– Outcomes:• Training on outcomes under a more self-

directed system• Training for support coordinators on handling

issues of poor choice-making• Central Office review of support plans to

assess consumer goals under new system

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Decisions needed:

• Options:– Outcomes:

• Procedures for waiver support coordinators to access area office support and direction in addressing problematic consumer choice-making

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Decisions needed:

• Options:– Compliance:

• Training for consumers/families on provider responsibilities

• Revise relevant assurances and the handbook to clarify expectations and responsibilities under self-directed system

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– Compliance:• Review service patterns to identify provider

non-compliance• Review service delivery against budget/support

plan• Publicly share information about non-compliant

providers

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Services

Main question:

What services and flexibility should be available to consumers?

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Services

APD Recommendations:• Must use Medicaid enrolled providers• Services allow more flexibility• Rates be neutral• Same set of services available to all

individuals

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Services

Feedback so far:• Make additional services available in

Tier 4• Want flexibility to use greater amounts

of services• Use algorithm to determine level and

intensity of services (e.g. Res Hab)

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Services

Feedback so far:• Start from scratch with new handbook• Like the very broad services, but if

they’re in service families, make sure they are logically grouped

• Very broad services might be more challenging for consumers to navigate—hard to know how to meet needs

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Services

Decisions needed:• Design of service array

– Broader services—allow to meet changing needs day-to-day (current worker can switch between similar tasks)

– Service families—allow to meet changing needs over time (can get a new worker to do new tasks)

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Services

Option 1: Modified Status Quo

Option 2: Modified Mercer Option 3: Minimalist

No Service Families

Residential Services Places to Live

WellnessWellness

Therapeutic Supports

Personal Supports

Personal SupportsLife Skills Development

Transportation

Support Coordination

Environmental and Adaptive Equipment

Equipment

Comparison of Service Families in Options

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ServicesComparison of Services in Options

Option 1: Modified Status Quo Option 2: Modified Mercer Option 3: Minimalist

Residential Habilitation Services

Residential Habilitation (Standard) Basic Residential

Residential Habilitation (Behavior Focused)

Enhanced Residential

Residential Habilitation (Intensive Behavior)

Specialized Medical Home Care Specialized Medical Home Care

Nursing Residential Nursing

Meaningful Day

Adult Day Training

Flex Benefit

Companion Services

In-Home Support Services In-Home Support Services

Personal Care Assistance Personal Care Assistance

Respite Care Respite Care

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Support Coordination Support Coordination (Limited)Basic Supports

Transportation Transportation

Behavior Analysis

Behavior Analysis Services

Enhanced Supports

Behavior Assistant Services

Community Training and Supports

Family & Guardian Training

Mentoring

Person Centered Planning

Support CoordinationSupport Coordination (Transitional)

Support Coordination (Full)

Meaningful DaySupported Employment

In-Home Support Services Supported Living Coaching

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Adult Dental Services Adult Dental Services Basic Wellness

Dietician Services Dietician Services

Enhanced Wellness

Occupational Therapy Occupational Therapy

Physical Therapy Physical Therapy

Respiratory Therapy Respiratory Therapy

NursingPrivate Duty Nursing

Skilled Nursing

Specialized Mental Health Services

Specialized Mental Health Services

Speech Therapy Speech Therapy

Durable Medical Equipment and Supplies

Durable Medical Equipment and Supplies

Equipment

Environmental Accessibility Adaptations

Environmental Accessibility Adaptations

Consumable Medical Supplies/PERS

Personal Emergency Response Systems (Unit and Services)

Consumable Medical Equipment

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Waiver Support Coordination

Main question:What should the waiver support coordinator’s role be?

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APD Recommendations:

• Waiver support coordinator’s role will shift to more of a facilitator and guide

• Will be seeking to reduce paperwork• Allow more customized level of

service

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Feedback so far:• Desire for greater flexibility in choosing

level of support coordination• Waiver support coordinators play an

important and multifaceted role in the APD system. Need to ensure they are still available to help consumers and families.

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Decisions needed:• What waiver support coordinator

service options will be available:– Limited– Full– Enhanced (currently transitional)

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Decisions needed:• Situations which may indicate need for

full (or enhanced) waiver support coordination:– Newly-enrolled in waiver– Forensic involvement– Complex medical needs– Complex behavioral needs

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Decisions needed:• Situations which may indicate need for full (or

enhanced) waiver support coordination:– Transition from school– Change in residential setting to group home or

supported living– Verified abuse or neglect – Dual diagnosis– Alcohol or drug abuse history

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Waiver Support CoordinationDecisions needed:• Waiver support coordinators’ general tasks

– Annual plan, level of care determination, and maintenance of Medicaid eligibility (required by CMS)

– Handle exceptional/changed needs requests

– Providing information about, access to, and coordination of services

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Waiver Support CoordinationDecisions needed:• Waiver support coordinators’ general

tasks– Help create social connections– Increase access to community

resources– Training consumers and families in

self-direction and budget management

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Waiver Support CoordinationDecisions needed:• Waiver support coordinators’ general

tasks– Budget management in consultation

with consumer and family– Monitoring of health and safety– On call 24/7

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Service Providers

Main question:

Who may provide services?

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Service Providers

APD Recommendation:• CDC+ option continue, although participants

will get iBudgets• Everyone else use Medicaid-enrolled

providers• Rates be neutral

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Service Providers

Feedback so far:• Ensure consumers have support and training• Need timely notice and payment• Self-directed system could pose management

challenges – Staffing, regulation compliance, revenue projections

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Service Providers

Decisions needed:• What competencies and standards that

providers would need to meet• What information or notice is given to

providers to begin or end services

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Service Providers

Your thoughts:• What opportunities does a more self-

directed system pose for providers that are creative and innovative?

• How can providers, consumers, and families work more cooperatively in a self-directed system?

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Implementation

Feedback so far:• How to ensure that calculation of iBudgets is

understandable to consumers and their families

• Need to carefully communicate with any consumers and families from the wait list when they do join

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Implementation

Your thoughts:• How can we communicate with

stakeholders:– Individually– Through providers– Through organizations

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Implementation

Your thoughts:• What should we tell them?

– Consumers– Families– Waiver Support Coordinators– Providers– Advocates

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Conclusion

Questions?

Comments?

Suggestions?

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Conclusion

Public CommentPlan Next MeetingAdjourn

Thank you for your time and input!

1 iBudget Florida Stakeholders’ Meeting December 4, 2009.

Documents

Transcript of 1 iBudget Florida Stakeholders’ Meeting December 4, 2009.