OMH Children's HCBS Waiver 1915c Changes - … · Housekeeping ‣Slides will be distributed...
Transcript of OMH Children's HCBS Waiver 1915c Changes - … · Housekeeping ‣Slides will be distributed...
Housekeeping‣ Slides will be distributed electronically and posted to
the CTAC website following the meeting series
‣ A Q&A resource will be developed and distributed
‣Web-based support will be offered this summer to
review ongoing implementation and additional
questions
‣ Reminder: All information is current and accurate as of
the date of presentation
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Schedule of Offerings
‣Buffalo: Thursday, May 25th, 9:30 am - 12:30 PM
‣Syracuse: Wednesday, May 31st, 9:30 AM - 12:30 PM
‣Lake George: Thursday, June 1st, 9:30 AM - 12:30 PM
‣New York City: Monday, June 5th, 10 AM - 1 PM
‣Poughkeepsie: Thursday, June 8th, 1:30 - 4:30 PM
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Today’s Agenda
I. Administrative Concerns
II. Programmatic Concerns
III. Expanding Populations and Services
IV.Preparing for the Future
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PresentersNYS Office of Mental
Health:
◦ Meredith Ray-LaBatt
◦ Joyce Billetts
◦ Shannon Fortran
◦ Steve Vroman
Community Technical
Assistance Center of New
York:
◦ Boris Vilgorin
◦ Andrew Cleek
◦ Yvette Kelly
◦ Dan Ferris
◦ Caitlin Cronin
◦ Meg Baier
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Overview of Shift‣Why are these changes occurring?
• Renewal application to CMS of Waiver authority
• CMS requirements based on changes in federal policies
• Alignment and preparation for future initiatives (health homes, Medicaid managed care, Medicaid redesign)
‣What have we heard? Addressing your concerns:
• Impact on families
• Impact on staff and program model
• Fiscal viability
• Managing the multitude of concurrent system changes
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How Can Agencies Prepare?
I. Administrative Concerns
i. Organizational Restructuring
ii. Staffing Implications
iii. Billing, Rates, and Limitations
iv. Fiscal Implications
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Organizational RestructuringConflict Free Case Management (CFCM): The same agency but
NOT the same individual can provide unbundled services. ICC
agencies are required to:
‣ Create administrative and supervisory firewalls between care
coordination and HCBS Wavier services/functions (complete
separation of care coordination from direct service)
‣ Discontinue ICC from providing any other HCBS service to those
they are providing care coordination
‣ Ensure family choice of HCBS service provider and right to
change service provider if desired or dissatisfied
‣ Inform child/family of right to file complaint and/or grievance
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Example Organizational Chart
Executive Director/CEO
Cabinet or Executive Level Manager/
Program Director
Cabinet or Executive Level Manager/ProgramDirector
Cabinet or Executive Level Manager/
Program Director
Care Coordinator Supervisor
HCBS Wavier Services Supervisor
Quality Assurance and Quality
Management Supervisors
Care CoordiantorsHCBS Wavier Service
Provider StaffQuality Management
Staff
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Aligning Agency Services
Care Coordination Direct Services
HCBS State Plan Services
Health Homes IIHS Clinic
ICC – OMH HCBS Waiver CRS PROS
B2H HCIA Respite Day Treatment
Non-Medicaid Former TCM FPSS
New Services: YPA,
Pre-Voc., Supported
Employment
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Programmatic Changes
‣Staffing Implications
• Unbundling/CFCM
• Increase in ICC case ratios
• Repurposing/reassignment of staff
Slots ICC Now ICC Future Reassigned Staff
168 28 19 9
54 9 6 3
18 3 2 1
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Staffing Considerations‣ Multiple questions regarding whether ICC can also be part
time IIHS and/or CR for children for who they do not
coordinate care.
‣ This requires very clear FTE separations to ensure adherence
to CFCM, cost allocations and requirement for family choice
‣ Other considerations: Is this feasible with pending time and
motion study and cost reporting/reconciliation? Will this
create confusion in paperwork and documentation? How does
this impact CFCM compliance and supervisory structures?
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Rate Rationale & Methodology
• NYS provided CMS with the Time and Motion study; found
75% of ICC time devoted to care coordination – informed
the proposed unbundled rates
• Services outside of the bundle comparable to current
rates with trending for inflation
• Proposed rates are interim, with the understanding the
State has agreed to a retrospective cost reconciliation
process and time and motion study, as well as the
expectation the 1915c Waiver will transition to Medicaid
managed care & ICC would convert to Health Homes
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Billing Rates (Current Services)SERVICE UNIT UPSTATE DOWNSTATE
1a. Intensive Care Coordinator Monthly $1,173.33 $1,232.01
2a. Respite Care, Individual 15 min $14.82 $15.61
2b. Respite Care, Group 15 min $8.15 $8.59
2c. Respite Care, Group of Three 15 min $5.92 $6.24
3a. Family Support Services, Individual 15 min $17.04 $17.50
3b. Family Support Services, Group of 2 15 min $9.38 $9.63
3b. Family Support Services, Group of 3 15 min $6.81 $7.00
3b. Family Support Services, Group of 4 15 min $5.11 $5.25
3b. Family Support Services, Group of 5-8 15 min $4.27 $4.38
4a. Intensive In Home, Brief, 30 min minimum 30 min $102.65 $110.86
4b. Intensive In Home, Full, 60 min minimum 60 min $124.04 $133.96
4c. Intensive In Home, Extended, 90 min minimum 90 min $166.81 $180.16
5a. Crisis Response, Brief, 30 min minimum 30 min $128.31 $138.58
5b. Crisis Response, Full, 60 min minimum 60 min $158.25 $170.92
5c. Crisis Response, Extended, 90 min minimum 90 min $187.34 $202.33
5d. Crisis Response, Triage - by telephone 15 min $23.17 $25.99
6a. Skill Building, Individual 15 min $17.04 $17.50
6b. Skill Building, Group of 2 15 min $9.38 $9.63
6c. Skill Building, Group of 3 15 min $6.81 $7.00
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Billing Rates (New Services)
SERVICE UNIT UPSTATE DOWNSTATE
7a. Youth Peer Advocate, Individual* 15 min $14.82 $15.61
7b. Youth Peer Advocate, Group of 2* 15 min $8.15 $8.59
7c. Youth Peer Advocate, Group of 3* 15 min $5.92 $6.24
8. Supported Employment, Individual * 15 min $17.04 $17.50
9a. Pre-Vocational Services, Individual* 15 min $17.04 $17.50
9b. Pre-Vocational Services, Group of 2* 15 min $9.37 $9.63
9c. Pre-Vocational Services, Group of 3* 15 min $6.80 $7.00
Transitional Case Management (TCM) 15 min $32.32 $34.02
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Billing CodesCode Description
4650 ICC Full Month
4651 ICC Half Month
4653 Respite – Individual, 15min
4655 Family Support Individual, 15mins
4656 Skill Building – Individual, 15min
4657 Intensive In–Home Brief, minimum 30min
4658 Intensive In–Home Full, minimum 60min
4652 Intensive In-Home Extended, minimum
90min
4659 Crisis Response Brief, minimum 30min
4660 Crisis Response Full, minimum 60min
4654 Crisis Response Extended, minimum 90min
4372 Respite – Group of 2, 15min
4373 Respite – Group of 3, 15min
4374 Family Support – Group of 2, 15min
4375 Family Support – Group of 3, 15min
4376 Family Support – Group of 4, 15min
4377 Family Support – Group of 5-8, 15min
4378 Skill Building – Group of 2, 15min
4379 Skill Building – Group of 3, 15min
New Services
4380 Youth Peer Advocate Individual
4381 Youth Peer Advocate – Group of 2
4382 Youth Peer Advocate – Group of 3
4666 Pre-Vocational Services Individual
4667 Pre-Vocational Services – Group of 2
4668 Pre-Vocational Services – Group of 3
4665 Supported Employment Services Individual
4398 Flexible recipient service dollars (state
funded only as of 1/1/15)
1148 Crisis Response by Telephone, 15min
1149 Transitional Case Management, 15min
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Limitations
‣ Case ratio for the HCBS Waiver under the 1915c for the ICC
service is 1:9 (will move to 1:12 for children scoring high acuity
when HCBS services move to Medicaid Managed Care and ICC
to Health Homes)
‣ ICCs will maintain number of required contacts to assure quality
of care, monitoring of child and family through programmatic
shifts
‣ ICC Agencies must also stay within overall budget limits per
year and slot/child enrolled in Waiver as outlined in the fiscal
worksheets supplied by OMH and follow required procedures for
approval of budgets that exceed annual limits
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LimitationsChildren’s HCBS
Wavier Service
Current OMH Waiver
Service Limitations
Proposed OMH Waiver Service Limitations
Individualized Care
Coordination
One billed case rate a
month per participant
One billed case rate a month per participant
Respite Maximum billing of 6
hours a day
Limit of 6 hours a day
Skill Building None Limit of up to 4 hours a day not to exceed 10 hours a week
Family Peer
Support
None Limit of up to 4 hours a day not to exceed 10 hours a week. One billable
service a day
Intensive In Home N/A - Bundled Limit of up to 4 hours a day not to exceed 24 hours a month
Crisis Response N/A – Bundled Limit of 2 Face to Face units per day (pre-authorization for billing if more
is needed). Limit of up to Two (2) -15 minute units for telephone contact
and no more than two units daily
Youth Peer
Advocate
N/A Limit of up to 4 hours a day not to exceed 10 hours a week. One billable
service a day
Pre-Vocational
Services
N/A Limit of up to 4 hours a day not to exceed 8 hours a week. One billable
service a day. Child must be 14 or older.
Supported
Employment
N/A Limit of up to 4 hours a day not to exceed 8 hours a week. One billable
service a day. Child must be 14 or older.
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Billing Rules for ICCCURRENT RULES:
(*May be subject to change pending CMS approval):
‣ ICC Full Month Billing: 6 required face-to-face contacts per
month at least 3 with child and other 3 can be family member or
other service provider (collateral).
✓Minimum of 15 minutes each.
✓Must be enrolled for at least 21 consecutive days in the calendar
month
‣ ICC Half Month Billing: at least 3 face to face contacts, 2 with
child and 1 with collateral. Minimum of 15 mins each and enrolled
at least 11 consecutive days in the calendar month.
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Transitional Case Management
‣ Transitional Case Management (TCM) is designed to
provide coordination and continuity of care by supporting
youth and family/natural support system in transition from
an inpatient or residential setting to a community setting.
TCM provides case management prior to transitioning to
Waiver from an inpatient or residential setting, and also to
youth enrolled in Waiver that require temporary inpatient
care.
‣ Previously referred to as “ICC inpatient”
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Transitional Case Management
‣ As part of the shift and unbundling, providers to bill case-
by-case transitional care management for youth in
inpatient or residential settings
• TCM prior to enrollment in waiver can be claimed for a
maximum of 30 days (between the signing of the Waiver
Application and enrollment date)
‣ Taking over what would previously be billed as ICC in-
patient
‣ Billed in 15 minutes increments in one claim AFTER
discharged from setting and back in the community
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Billing Rules: IIH and CRSCurrently:
‣ IIH & CRS telephone and face to
face: reimbursement for an average
of 65 IIH and/or CRS contacts per
slot included in the monthly case
payment
‣ IIH and CRS face to face: Billed
monthly per 15 minute
contacts(contacts must be minimum
of 30 minutes each to bill)
‣ CRS telephone calls: billable for up
to 48 phone contacts annually per
slot of a minimum of 15 min. each
contact
Moving Forward:
‣ IIH
• Face to face to the child or child
and family
• Minimum of 30 mins for brief, 60
mins for full, 90 mins for extended
• Limit of up to 4 hours a day not to
exceed 24 a month
‣ CRS
• Face to face or telephone contact
◦ 30 min, 60 min, or 90 min units
for face to face
◦ 15 min unit for telephone
• CRS cap to bill twice per day up
to 90 minute units 25
Billing Rules: Crisis Response
‣Up to two 15 minute telephone contacts are
allowed to be billed per day, if needed
‣CR face-to-face can be provided in 30, 60 or 90
minute units for up to two a day (up to a 90 minute
contact each)
‣ If an additional face-to-face contact is needed, the
agency must receive pre-authorization prior to
billing, once verifying documentation has been
provided to the state
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CMS Requirements
‣Although CMS modified rates significantly, in order
to get the interim rates and enhance fiscal
integrity, CMS required a number of actions to
consider renewal of the Waiver, including:
◦ Audits by the Office of the Medicaid Inspector General
(OMIG)
◦ A Retrospective Cost Reconciliation to CFR Reports
◦ A Time and Motion Study of the ICC service
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OMIG Audit‣OMH worked with the OMIG to develop audit
protocols based on the HCBS Guidance
Document
‣Case records will be reviewed based on existing
HCBS Waiver requirements
‣Audits for the calendar year 2014-2015 will begin
June 2017
‣Some agencies may have already been contacted
and notified they will subject to audit
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Clear Documentation‣ Initial planned delivery of service and annual recertification must be
authorized by LGU and documented in the child's service plan. Quality
reviews at 90 days by ICC supervisor.
‣ The services provided must align with the definition and description of the
service in the guidance document and support the achievement of the
Waiver child’s identified goals.
‣ A Progress Note must be written for every contact and all fields must be
completed.
‣ Clear documentation of what service is provided, by whom, and for which
goal must be noted.
‣ A qualified individual providing multiple services must delineate between
services, goals, timeframes, and those served in documentation.
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Time & Motion Study‣ The objective of the survey is to account for all time spent
by the care coordinators in delivering services, traveling,
performing non- billable activities AND personal time
during a specified timeframe.
‣ The State will employ an independent evaluator to conduct
the above referenced time and motion study to be
completed and reported in summary to CMS no later than
December 31, 2017.
‣ The study will help to substantiate the rate request and
demonstrate the time and effort spent by care coordinators
per child enrolled in the HCBS Waiver
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Cost Reconciliation‣ CMS is requiring that OMH engage in a retrospective
reimbursement reconciliation process using service provider
cost of all services compared to the final allowable Medicaid
reimbursement rate by service.
‣ FFP would be limited to the actual cost of the service(s) at the
service provider level.
‣ If service providers received reimbursement in excess of their
cost, the State would (1) reduce reimbursement to the service
providers actual cost (2) any excess of actual cost could not be
claimed for FFP and any excess would have to be refunded to
CMS.
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New Program Codes for CFR Reporting2230 Children’s HCBS Waiver Individualized Care Coordination (includes
transitional case management (TCM)– anticipate to be the same person)
2240 Children’s HCBS Waiver Respite
2250 Children’s HCBS Waiver Family Support
2260 Children’s HCBS Waiver Crisis Response
2270 Children’s HCBS Waiver Skill Building
2280 Children’s HCBS Waiver Intensive In-Home
2350 Children’s HCBS Waiver Supported Employment
2360 Children’s HCBS Waiver Pre-Vocational Services
2370 Children’s HCBS Waiver Youth Peer Advocate
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How Can Managers Prepare?
II. Programmatic Concerns
i. Orienting Children and Families to a “new way”
ii. Operationalizing New Staff Roles
iii. Opportunities for Staff Assignments
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Messages for Families
‣ The Waiver program is intended to “wrap” services
and supports around a child and family.
‣ Families must be aware that Waiver involves a “team”
of providers working together to support their
individualized needs
‣ Through collaboration and coordination, families have
access expert staff that specialize in particular areas
focused on helping to address their unique needs
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Services Review
‣Unbundled Services
• ICC, Crisis Response, and Intensive In-Home
‣Existing Services
• How do the unbundled core services interact with and
compliment the additional available services below
• Current Services: Family Peer Support, Respite, and Skill
Building
• New Services: Prevocational, Supported Employment,
Youth Peer Support (Transitional Case Management)
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ICC – Care Coordination
• ICC will be responsible for the overall coordination
of the services for the child.
• Controls the flow of information
• This will include regular contact with the child/family
as well as frequent collateral contacts
• Utilization of community resources
• Documentation
• The ICC role includes the services provided under
Transitional Care Management
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HCBS Waiver TransformationCategory of
Change
PAST: Current
1915c
NOW: 1915c
Application
Renewal
FUTURE: SPA/
Health Home/
Managed Care
Service Bundled (ICC/ IIH/
CRS)
Unbundled
Services
Individual
Services
Rates ~$2300
downstate/
bundled
~$1200
downstate/ ICC
~$800 downstate/
high acuity
Conflict of Interest
Requirement
N/A Conflict Free
Case
Management
Conflict of Interest
Case Ratio 1:6 1:9 1:12 (High Acuity)
Care Coordination Service: bundled
with other
services
Coordination of all
care
Coordination of all
care
Staff
Qualifications
Preferred Masters Align with Health
Home (Bachelors)
Bachelors Degree
Proposed New Protocols ‣ Required Monthly Contacts and Activities
• Submitting proposal to modify contacts and activities
• Reduce face-to-face requirements
• Increase other required contacts with collaterals and
providers
‣ Required Documentation for Service Plans
• Considering removing requirement for 30-day review
• Enhance expectations for Initial Service Plan
• Utilize addendums for updating Service Plans and
modifying needs and services
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ICC – Care CoordinationRedefining the Role of the ICC: Considerations
‣ Expanding to include Transitional Aged Youth (TAY):
Knowing community resources
‣ Increased attention to health care needs
‣ Increased facilitation role in accordance with
Wraparound approach
‣ “Warm hand-off”: Introducing family to Waiver providers,
community resources, discharge planning/ options
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Intensive In-Home
‣ IIH works with family on the goals outlined in the
Waiver Service Plan, with consideration to the existing
Treatment Plan (implemented by clinical provider).
‣The Intensive In-Home (IIH) worker provides services
that support the child's social and emotional
development and learning.
‣Articulating the needs, strengths and priorities of the
family back to the ICC
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Intensive In-Home (cont.) Redefining the Role of IIH: Considerations
‣ Conceptualizing the role
• Relationship
• IIH provider is providing clinical interventions (e.g., coping
strategies, behavior de-escalation, etc.)
‣ IIH has a unique role in providing interventions that address
the clinical aspects of the child and family’s needs which
requires the highest qualified and trained provider (as well as
Crisis Response) in the Waiver program.
‣ Time Management
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Crisis Response‣ Crisis Response Services (CR) reinforce the agreed upon safety
plan that the child and family have developed and attempts to
stabilize occurrences of child/family crises when they arise.
‣ These services may include:
• assessment
• consultation
• linkage
• immediate intervention wherever necessary, for example, in
schools, at home and work.
‣ This service is available 24 hours a day, seven days a week.
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Crisis Response (cont.)Considerations:
• Service provider’s role when a crisis develops while
with the family/ youth: Skilled in behavioral de-
escalation, updated on Safety Plan
• When to call Crisis Response or emergency services
• Fluid communication with ICC: Follow-up
• Parameter of service provision: billing considerations,
best practice
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Family Support‣ Family Support is designed to enhance the health and growth of
children and adults in the family unit to ultimately develop safe, stable, and supportive families who are connected to their communities.
‣ Family Support Services:
• provide resources, including, but not limited to education, training, advocacy and supports
• assist the family by introducing and connecting them to activities in the community (e.g., educational, cultural, recreational) which would foster family cohesion
• may be provided to Waiver parents/guardians and family members who have frequent and regular caretaking responsibilities for the Waiver child
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Skill Building‣ Skill Building Services (SBS) focus on helping the child be
successful in the home, community and school by acquiring
both social and environmental skills associated with his/her
current developmental stage.
‣ Utilizes an individualized, strength based approach to assist
the child recognize functional assets/strengths and those that
need developing.
‣ Skill Building may also assist youth to develop skills for
independent living and by facilitating access to, monitoring
and supporting vocational training.
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Respite Services‣ Respite Services (RS) provide a needed break for the family
and the child to ease the stress at home and promote
overall wellness for the child and his/her family.
‣ Activities include: providing supervision and recreational
activities that match the child's developmental stage and/or
community outings with child
‣ Respite care may be provided on a planned or emergency
basis, day or night, in the child's home or in the community
by trained respite workers with one Waiver child or a group
of Waiver children
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How Can Expansion Help?
III. Expanding to New Populations/Services
i. Serving TAY in Expanded Enrollment Age
ii. Providing New Waiver Services
a. Youth Peer Advocates
b. Pre-Vocational Services
c. Supported Employment
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New ServicesNYS working through amendment and waiver process with
CMS with the intent to:
‣ Expand the allowable age of enrollment from up to the age
of 18 to up to 21 years old
‣ Add three new services: Youth Peer Advocate, Pre-
Vocational Services, and Supported Employment
**No designation process for current waiver providers, they
can elect to provide if they have qualified staff and follow
subcontractor approval process
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New Services‣ Youth Peer Advocate
• Offer positive youth development-centered services for a waiver participant who is at a developmentally appropriate age with a resiliency/recovery focus.◦ Promoting skills for coping and symptom management and the use of available resources.
‣ Pre-vocational
• Individually designed to prepare a youth age 14 or older with serious emotional disturbance to engage in paid work, volunteer work or career exploration. ◦ Not job-specific
◦ Geared toward facilitating success in any work environment
‣ Supported Employment
• Provide assistance to waiver participants age 14 or older with severe disabilities as they perform in a work setting.
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How Will This Prepare Me?
IV.Readying Staff for Future Services
i. Future of Care Coordination
ii. New SPA Services
iii. Opportunities of New HCBS services Array
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Future of HCBS Waiver‣ Moving to Health Homes
• Integrated Care
• Focus on Whole Health
• Collaboration/Coordination with Array of Healthcare
Providers
‣ Moving to Medicaid Managed Care
• Assuring Quality of Care
• Demonstrating Outcomes
• Value Based Payments
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Updated Children’s System Transformation Timeline
‣ Updated Children’s Behavioral Health and Health Medicaid
Redesign Implementation dates as submitted to CMS as part
of amendment to the 1115 New York Medicaid Redesign
Waiver
• July 1, 2018
◦ Transition 1915(c) Children’s Waivers to Health Home
◦ Align Children’s Home and Community Based Services for Level of Care
Population
◦ Children’s Behavioral Health Benefits Transition to Managed Care
• January 1, 2019
◦ Foster Care Population Transitions to Managed Care
◦ Expansion of Children’s HCBS for Community Eligible and Family of One Level
of Need Population
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What the transition timeline means for Waiver Services?
‣Moving towards new structures and processes that
align with redesign and managed care
‣Creating more seamless programmatic and fiscal
transitions to new services
‣Preparing for changing ways of “doing business” that
focus more on individualized service arrays and less
on programs
‣Develop capacity and specializations in areas that will
continue in new services and models
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Moving to Health Homes‣ Aligned staffing qualifications of ICC to be commensurate
with Health Home high acuity
‣ Create opportunities for specialization in care coordination
efforts and approaches to whole health
‣ Orient staff to the wide array of available services from
multiple child-serving systems
‣ Establish relationships with common health care practices
and providers to better integrate care
‣ Move towards value based approaches focused on
outcomes correlated with research
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Staff QualificationsICC Staff qualifications now align with required qualifications for staff
serving Health Homes “High Acuity” youth:
• Bachelor’s degree or a NYS Teacher's Certificate and two years’ experience*
providing direct services for children in the children’s service system with a
preference for the mental health field/working with children with SED
-- OR -- a Master’s degree and one year experience* providing direct services
to children, or providing linkage to services, for children, in the children’s
service system with a preference for the mental health field/working with
children with SED.
‣ Also applies to Transitional Case Management
*Qualifying experience may be pre-or post-degree. Candidates may qualify
by meeting the qualifications for the NYS Intensive Case Manager position
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Readying Staff for Future
Waiver Service Redesign Service Qualifications
ICC HHCM Same
IIHS SPA - CPST Bachelors/Masters
Skill Building PSR/ Habilitative SB High School Diploma
FPSS/YPA SPA - FPSS/YPSAT Training/Credential
Crisis Response SPA - Crisis Intervention Licensed Practitioner
Respite HCBS - Respite High School Diploma
B2H – F/CSS HCBS - C/FSS ------
B2H - SNCAS HCBS- CSATS ------
There will be many opportunities for staff at varying levels in the Waiver
program to provide an array of services under the new State Plan
services and expanded array of HCBS services.
Technical Assistance‣ Slides will be distributed electronically following the
series
‣ A Q&A resource will be developed and distributed
‣ A web-based office hour will be offered in late
June/July to talk through ongoing implementation and
additional questions
‣ Please send questions to: [email protected]
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Ongoing OMH Updates
‣Regular Monthly Webinars
‣ Impromptu Webinars, as needed
‣ Issuance of New Guidance Document with CMS
Approval of Waiver renewal
‣Policy Change Notices
‣Notification emails
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Thank you! Discussion/Q&A
HCBS Waiver Unit Email & Main Division Phone
Number:
(518) 474-8394
Contact the Community Technical Assistance
Center at [email protected]
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