iBudget Florida Stakeholders’ Meeting

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iBudget FloridaStakeholders’ Meeting

October 23, 2009

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Assessment Instrument

Main question:

How should we get information about people to know their needs?

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Current system:• Previously used the Florida Status

Tracking Survey (FSTS) and the Individual Cost Guide (ICG)

• Now uses the Questionnaire for Situational Information (QSI)

• Covers physical, functional, and behavioral areas

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APD Recommendations:

• QSI be used as assessment instrument

• QSI improvements be ongoing

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Decisions needed:• How and when to request reassessment• How and when to appeal results

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Feedback so far:• Want information on the QSI’s

validity and reliability• Concern that it does not identify

certain needs of individuals

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Your thoughts:• What are your concerns about the

QSI?• How can we make people more

comfortable with the QSI?

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Services

Main question:

What services and flexibility should be available to consumers?

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Services

Current system:• 27 services in Tiers 1, 2, and 3• 13 services in Tier 4• Providers must be Medicaid enrolled

(except for CDC+ program)• Statewide rates with some geographic

differentials• Need for a service is determined

through prior service authorization

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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

Decisions needed:• Potentially combining services for

greater simplicity and flexibility• Limits, if any, for each service

– Dollar amount – Hours – Need proven (prescription or assessment)

• Provider qualifications

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Services

Feedback so far:• Make additional services available in

Tier 4• Want flexibility to use greater amounts

of services

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Services

Your thoughts:• How could service options meet

consumers’ needs better?• What limits on control or other

safeguards might be important for health and safety?

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Waiver Support Coordination

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

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Current system:• Waiver support coordination is a required service• Children have limited waiver support coordination;

adults have limited or full coordination• Waiver support coordinators have lots of required

paperwork – Very little is processed electronically—heavily paper

based

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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

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Decisions needed:• Waiver support coordinators’ specific

tasks• What waiver support coordinator service

options will be available• How we will streamline forms and

processes • What additional training, if any, to require

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Feedback so far:

Questions about what the role should be

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Waiver Support CoordinationYour thoughts:• What should the waiver support coordinator’s

role be?• What should the split of individual, family, and

waiver support coordinator responsibilities be?• What concerns are there about the waiver

support coordinator’s role in a more self-directed system?

• What options would a waiver support coordinator have if he or she felt an individual was making bad choices?

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Prior Service Authorization (PSA)

Main question:

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

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Prior Service Authorization

Current system:

• All services must be approved through prior service authorization

• Reviews are performed by area staff and a contracted provider – It’s time-intensive

– It’s complex

– It’s paperwork-intensive

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Prior Service AuthorizationAPD 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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Decisions needed:• Situations requiring a review• The process for requesting reviews• Who will perform reviews

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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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Prior Service AuthorizationYour thoughts:

What service approval process is appropriate for:

•Medical services•Therapies•Behavioral services•Extraordinary needs

•Meaningful day activities•Residential habilitation•Supports in the home

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Consumer and Family Control

Main question:

What would be reasonable limits on individual control?

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Current system:• Waiver support coordinators work with

individuals and families to support choice• Individuals and families have little insight

into spending of funds for supports• Prior service authorization is required

before service amounts are increased

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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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Decisions needed:• Limits on spending to ensure that funds

last through the year • What to do if a person overspends but

still needs services• How to provide training on making

good choices

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Decisions needed :• What information consumers need to

make good decisions • How to help consumers track spending• What support to give to consumers who

don’t have unpaid help in decision-making• If funds can be carried over to a future

year like in CDC+

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Feedback so far:• Some individuals don’t have sufficient

support to exercise self-direction• Concern that some providers may not

cooperate or may be manipulative

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Consumer and Family ControlYour thoughts:• What information and training do consumers

and families need to make good decisions?• How could they get that information?• How can we help those who don’t have families

or friends to help them make choices?

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Consumer and Family ControlYour thoughts:• How might we limit spending to ensure that

funds remain through the year? Should we do this?

• How are pro’s and con’s of allowing carryover of unused funds to another year?

• How can we find out if any providers are uncooperative or manipulative, and what penalties might be assessed?

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Extraordinary and Changed Needs

Main question:

How do we ensure that people with extraordinary or changed needs get enough funding?

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Current System:• Individuals are assigned to tiers, which

cap spending• If needs are believed to have changed,

the waiver support coordinator requests a prior service authorization review for additional services and/or a tier change

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Decisions needed:• Process to identify people with

extraordinary needs and set their budgets

• Process to handle requests for funding due to changed needs and determine the funds required

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Decisions needed:• How to identify people with extraordinary or

changed needs – Statistician will help when the model is more developed

• How to set their budgets• How to decide if needs have changed• How to calculate funds needed for changed needs

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Feedback so far:

Want to ensure that funds are available for people with changed needs or extraordinary needs

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Quality Assurance

Main question:

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

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Quality Assurance

Current system:• Contracted provider (Delmarva) performs quality

assurance activities in conjunction with APD staff• Contracted provider uses desk reviews, on-site visits, and

consumer interviews to assess provider performance and consumer outcomes

• Medical Case Management Team and/or WSCs determine if additional review is required for health and safety

• Support planning, annual reports, and quality assurance contractor determine if individuals are progressing toward goals

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Quality Assurance

APD Plans:• New quality assurance contract uses different

measures• Florida is joining National Core Indicators

initiative

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Quality Assurance

Decisions needed:• What might change under a new contract

in a more self-directed system• What might trigger any special health and

safety reviews

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Quality Assurance

Feedback so far:

Support revision of the quality assurance system to be more understandable, less bureaucratic, and more person-centered

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Quality Assurance

Your thoughts:• What are your concerns regarding quality

assurance in a more self-directed system?• How should consumer outcomes be

assessed in a more self-directed system?• What should be done if the consumer is

making poor choices and their health and safety are at risk?

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Overall System Financing

Main question:

How do we make budgets predictable and sustainable for consumers and the agency?

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Current system:• Legislature appropriates funding

• Complex rules control individual cost plans and spending to seek to stay within the appropriation – Individuals are assigned to one of four tiers

– Rebasing for those with changed cost plans

– PSA determines medical necessity

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Current system:• Legislature cuts services and imposes other

requirements to control spending• About 25% of APD customers had cost plan

reductions under the tiers

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APD Recommendations:• System be fairer to consumers and be

sensitive to individual needsImportant to Remember:• State constitution requires balanced budget—

APD must stay within its appropriation• Legislature makes decisions on how to fund

the wait list

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Decisions needed:• How much funding to reserve for

extraordinary and changed needs • How tiers will mesh with this system

– Will be designing it without tiers

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Service Providers

Main question:

Who may provide services?

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Service ProvidersCurrent system: • Any provider meeting Medicaid requirements

can be enrolled and provide services• Must use Medicaid-enrolled providers unless in

CDC+• Currently more than 10,000 providers statewide• Range from single-person entities to large-scale

operations with multiple sites and hundreds of employees

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Service Providers

Current system: • Under waiver requirements, consumers must

have choice of providers• WSCs submit service authorizations to begin or

end services with a specific provider• Providers must complete paperwork: annual

reports, quarterly reports, individual plans, service logs, etc.

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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

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

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

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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Administrative Issues

Main question:

How will the system work to make all this happen day-to-day?

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Current system:• Area office staffs manage at the local level• Cost plans run with the fiscal year • ABC is the main computer system• Paper-based

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APD Recommendation:

Wish to pilot or phase-in as CMS allows

– This will allow us to fine-tune before full implementation

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Decisions needed:• When during the year an annual budget begins• How iBudgets will be phased in

– Need to see range of impacts after algorithm is developed further

• Changes required to computer systems and other supporting processes

• What specific staff roles will be – Service approval? Calculating budgets?

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Feedback so far:• Support for phasing in over time• Concern that implementing this on top of

other recent changes might be too much• Concern that if we don’t do this soon, the

system will be in trouble

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Your thoughts:• How might we phase in iBudgets across

the state? • What is a reasonable implementation

timeframe, recognizing potentially strong interest in the Legislature for action?

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Algorithm

Main Question:What factors should be considered in the algorithm to determine funding?

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AlgorithmCurrent system:• Waiver support coordinators request services for

individuals• Complex system for approving requests

– Law requires use of certain factors to make tier assignments (such as living situation)

– For Tiers 2, 3, and 4, spending is capped – Rebasing – Limits in handbook

• Funding is total of services approved

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Algorithm

APD Recommendations:• Use regression model • Dependent variables are previous

years’ expenditures• Seeking individual budgets

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Algorithm

APD Recommendations:• Data for variables must be reliable and valid• Variables will make appropriate contribution

to model predictiveness• Review model to ensure that health and

safety are not at risk• Rates be neutral

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Algorithm

• Decisions needed

– Specific variables and their contribution

– How often to rerun and revise algorithm

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Algorithm

Feedback so far:• Build a model tailored to Florida• Concern that funding for meaningful day

activities will be eroded or insufficient• Concerns on using diagnosis in the model

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Algorithm

Feedback so far:• Want to know the model details, including

statistical details• How to ensure validity and reliability of data

used in model• Fairness to those living at home

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Algorithm

Your thoughts:• Factors that might be correlated with

costs• Data we might use

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Conclusion

Questions?

Comments?

Suggestions?

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Conclusion

• Adjourn • Thank you for your time and input!

iBudget Florida Stakeholders’ Meeting

Documents

Transcript of iBudget Florida Stakeholders’ Meeting