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Dohn Hoyle

MICHIGAN’S EXPERIENCE

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Justice Thurgood Marshall described past practices as a “…regime of state mandated segregation and degradation…that in its virulence and bigotry rivaled, and indeed paralleled, the worst excesses of Jim Crow.”

City of Cleburne v. Cleburne Living Center 1985

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THE HOWELL GROUP

Values Based Systems Change

VOW - to effect systems change causing the system(s) to fund and do what we already know is right & what people want.

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PRINCIPLES OF MICHIGAN’S WAIVER RENEWAL AND TENETS FOR MANAGED CARE

• The honoring of each person’s preferences and choices including the presumption of competence and interpreting behavior as communication

• Doctors and other professionals would serve in consultative roles and their involvement would be only as desired or needed.

• Regular individual feedback and a focus on the outcomes the individual wants would form the basis for quality assurance.

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PRINCIPLES OF MICHIGAN’S WAIVER RENEWAL AND TENETS FOR MANAGED CARE CONTINUED

• Self-determination would govern peoples’ lives and they would have choice and control over their own budgets according to their desires.

• The person who coordinates supports would play a personal agent role to help an individual achieve the outcomes they wished.

• Informal and generic supports would be considered prior to the implementation of supports through the Waiver

• External people and anyone unwanted would not intrude in the lives of the individuals served by the waiver

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DESIRABLE ELEMENTS OF MANAGED CARE ARE:

• A single funding stream

• Capitation with growth

• Local discretion

• Shared risk or stop loss

• People on waiting lists must be served

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HOWELL GROUP PREMISES FOR MANAGED CARE

• We welcome change

• We want what the waiver promised

• Since prospects for new money are low, the re-direction of public dollars offer the most efficient possible use of public dollars

• Control the growth rate of expenses

• Carve out presents an opportunity

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HOWELL GROUP PROPOSAL ON MANAGED CARE IMPLEMENTATION

Goals

• Fulfill the promise of the Code

revisions

• Individualize Supports

• Eliminate barriers

• Contain the rise of costs for services

that do add value

• Provide needed and desired services

for those on waiting lists

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Person Centered Planning + A Support Model of Services can = Persons with Disabilities “Getting a Life”

“Person-Centered Planning means a process for planning and supporting the individual receiving services that builds upon the individual’s capacity to engage in activities that promote community life and that honors the individual’s preferences, choices, and abilities. The person-centered planning process involves families, friends, and professionals as the individual desires or requires.”

-Michigan Mental Health Code Sec. 700g

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MANAGED CARE IN MICHIGAN

• Medicaid Comprehensive Health Care

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• Carved out

• Administered through local entities

• Separate from physical health care

• State is provider of last resort

• Shift from state to county

• Constitutional mandate for CMHSP

MANAGED CARE SYSTEM FOR DEVELOPMENTAL DISABILITIES

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VALUES MICHIGAN’S PUBLIC MENTAL HEALTH SYSTEM FOR PERSONS WITH DEVELOPMENTAL DISABILITIES SHOULD PROMOTE INDIVIDUALS TO BE:

• Empowered to exercise choice and control over all aspects of their lives

• Involved in meaningful relationships with family and friends supported to live with family while children and independently as adults

• Engaged in daily activities that are meaningful, such as school, work, social, recreational, and volunteering

• Fully included in community life and activities

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STATE OF MICHIGAN1915 (B) WAIVER

Freedom of Choice Waiver – Managed Care Waiver• Serves anyone with a developmental disability (no

requirement for institutional level of care and not limited to slots)

The Federal Government recognizes Michigan as having a 1915 (b)(c) Combination Waiver

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MICHIGAN’S SYSTEM

• Designated CMHSPs will administer general fund appropriations for developmental disability services. They also participate through a Prepaid Inpatient Health Plan (PHIP) in administering nearly all Medicaid funded developmental disabilities benefits on a Capitated, Prepaid, Shared Risk, basis.

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MICHIGAN’S SYSTEM

• The plan incorporates the elements of an insurance paradigm (i.e. enrolled recipients or covered lives) with the traditional safety net model (covering a target population with statutorily mandated access to funded programs and services).

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INDIVIDUALIZED SUPPORTS AND SERVICES

Many people receiving services want:

• To receive individualized supports

• Services targeted toward their specific needs and preferences

• To receive their services in typical community locations

• A benefit package including only their desired/needed supports and services

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SUPPORTS AND SERVICESThe reason for defining the “alternative”

supports and services is to:

• Identify an acceptable array of service/support options

• Which can be provided on an individualized and very flexible basis

• Depending on the desires and needs of the person

• To establish mechanisms to track what services/supports are delivered

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INDIVIDUALIZED SUPPORTS AND SERVICES

To accomplish this ALL planning must be person centered’

Each person’s “benefit package” will look different because people have different:

• needs• desires• natural supports• community supports

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ELIGIBILITY

• Eligibility established by the Mental Health Code

• DD Definition parallels federal definition

• Mental Health Code specifies that:• priority shall be given to the provision of services to

individuals in urgent or emergent situations” (Chapter 2, 330.1208)

• Eligibility for Medicaid establishes an entitlement

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ACCESS

• Individuals will engage in a person-centered planning process to identify how DD Specialty Supports and Services can respond to the identified needs.

• Persons in emergency situations will receive immediate crisis stabilization response without having to first proceed through access steps

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B3 SUPPORTS & SERVICES

• Assistive Technology

• Community Living Supports

• Enhanced Pharmacy

• Environmental Modifications

• Family Support & Training

• Housing Assistance

• Peer-Delivered or Operated Support Services

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B3 SUPPORTS & SERVICES

• Prevention – Direct Service Models

• Respite Care Services

• Skill-Building Assistance

• Support and Service Coordination

• Supported/Integrated Employment Services

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DEFINITIONS OF GOALS THAT MEET THE INTENTS & PURPOSE OF B3 SUPPORTS & SERVICES:

• Community inclusion and participation means: The individual uses community services and participates in community activities in the same manner as the typical community citizen.

• Independence means: “freedom from another’s influence, control and determination.” (Webster’s New World College Dictionary, 1996) Independence in the B3 context means how the individual defines the extent of such freedom for him/herself during person-centered planning.

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DEFINITIONS OF GOALS THAT MEET THE INTENTS & PURPOSE OF B3 SUPPORTS & SERVICES:

• Productivity means: engaged in activities that result in or lead to maintenance of or increased self-sufficiency. Those activities are typically going to school and work. The operational definition of productivity for an individual may be influenced by age-appropriateness.

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2.5A MEDICAL NECESSITY CRITERIA

• Mental health and developmental disabilities services are supports and services: designed to assist the beneficiary to attain or maintain a sufficient level of functioning in order to achieve his goals of community inclusion and participation, independence,

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MICHIGAN SYSTEMS HAVE…• Person Centered Planning

• Self-Determination Policy & Practice Guideline

• 1915 (b) (3) Supports & Services

• Choice Voucher

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Michigan’s Policy & Practice

SELF-DETERMINATION

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POLICY GUIDELINE

“Consumers shall have access to self-determination upon request.”

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CORE VALUES OF SELF-DETERMINATION POLICY

• Freedom

• Authority

• Support

• Responsibility

• Confirmation

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POLICY GUIDELINE

• “Arrangements that support self-determination must… assure methods for the person to exert direct control over how, by whom, and to what ends they are served and supported.”

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POLICY GUIDELINE

• “Person-centered planning (PCP) is a central element of self-determination… self-determination recognizes the rights of a person… to have a life with freedom, and to access needed supports that assist in the pursuit of their life, with responsible citizenship.”

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POLICY GUIDELINES

• “The person determines and manages needed supports in close association with chosen friends, family, neighbors, and coworkers as a part of an ordinary community life.”

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POLICY GUIDELINE

• “The funder shall offer and support easily accessed methods for consumers to control and direct an individual budget including providing them with methods to authorize and direct the delivery of services and supports from qualified providers selected by the consumer.”

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FY 2012ANNUAL REPORT

CLS BOARD OF DIRECTORS MEETING

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2005 2006 2007 2008 2009 2010 2011 20120

200

400

600

800

1000

1200

1400

1600

1800

People have Control over Their ResourcesSelf-Determination

Wayne +

Oakland*

# of

Peo

ple

*Self-Determination is the only model of support CLS offers in Oakland County.

+Wayne count does not include ~360 Respite Only Budgets.

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1 2 3 4 5 60

50

100

150

200

250

300

350

400

450

230

366

402

344

215

126

# Persons by Household Size

Household Size

# p

eo

ple

Wayne

Living a Life of Opportunity91 licensed homes remain as of 1/1/13, 159 returned

Licensed Own Home

2002 2003 2004 2005 2006 2007 2008 2009 2011 2012500

700

900

1,100

1,300

1,500

1,009 972

925 880

845 817

746 688 574

545 652 667 722

804

884 1,000

1,105

1,153 1,080

1,127

Wayne

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Personal Autonomy

20022009

20102011

2012

0

100

200

300

400

500

600

700

800

900

Legal Guardian No Guardian

Per

100

0

WAYNE

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INTEGRATED CARE COORDINATOR