1. May 8, 2013
Developmental Disabilities Individual Support and Care Coordination Organizations and Accountable Care Organizations: A New Service Delivery Model for the Intellectually and Developmentally Disabled
YAI International Conference
May 6-9, 2013
Presented by
David A. Gregory, FACHE
Partner, Presscott Associates
A Division of ParenteBeard LLC

2. Presentation Overview
ACOs
­Healthcare reform
­Commercial
Developmental Disabilities Individual Support and Care Coordination Organizations (DISCOs) – definition
Synergy: ACO and DISCO service delivery models
DISCO implementation/requirements
DISCO – Core Elements of new service delivery models
Guiding principles for service improvements
Presscott Associates –
A Division of ParenteBeard LLC 2 2

3. Accountable Care Organizations (ACOs)/ Healthcare Reform
Introduced through the federal Patient Protection and Affordable Care Act (PPACA) of 2010
Definition: Physicians, hospitals and other health care professionals working together to coordinate care and share in savings or losses for traditional Medicare beneficiaries assigned to the ACO
Part of Medicare through the Medicare Shared Savings program in 2012
Payment tied to achieving healthcare quality goals and outcomes that result in cost savings
Create incentives for healthcare providers to work together to treat individuals across various healthcare settings
Providers receive a share of the savings beyond a predetermined threshold amount
Presscott Associates –
A Division of ParenteBeard LLC 3

4. ACOs and Commercial Health Plans
Commercial health plans have emulated healthcare reform
Commercial health plans have implemented various value-based contracting models
Health plans goals
­Collaboration among providers in delivery system/integrated delivery systems
­Coordination of patient care among the continuum of care
­Accountability and shared risk among providers
­Increased quality and improved patient outcomes
­Cost savings
­New payment models
­Patient satisfaction
Presscott Associates –
A Division of ParenteBeard LLC 4

5. Developmental Disabilities Individual Support and Care Coordination Organizations (DISCOs)
Created by the New York Office for People With Developmental Disabilities (OPWDD) People First Waiver of the Social Security Act
Non-profit organizations that provide individualized supports/services, care coordination to individuals with developmental disabilities and/or to their families
Function as fiscal intermediaries (manage care/reimbursed on an individual budgeting, global budgeting or capitation basis)
Serve individuals with all levels of need by providing supports/services directly or indirectly through sub-contracts with provider agencies.
Initially, monthly capitation payments based on the disabled individual’s assessed needs, with the state sharing some financial risk
DISCOs will evolve to full financial risk for meeting service needs within the capitation revenue
Presscott Associates –
A Division of ParenteBeard LLC 5

6. People First Waiver
Develop/implement creative service delivery and payment models that integrate acute and long-term care to achieve improved health outcomes and quality of care while lowering health care costs for the developmentally disabled population
Target population: 100,000 New Yorkers enrolled in Medicaid who have substantial developmental disabilities as defined in New York State Mental Hygiene Law
­80% of these assessed to need an institutional level of care through either an ICF/MR or nursing home
Presscott Associates –
A Division of ParenteBeard LLC 6

7. People First Waiver will Demonstrate
Better care coordination for developmentally disabled individuals with extremely complex medical/behavioral health needs can be achieved through specialized systems of care management/coordination
A transformed long-term care delivery system that places person-centered planning, individual responsibility and self-determination at the forefront can enhance care and individual satisfaction and lower Medicaid costs
New reimbursement models for institutional and community-based care systems can encourage efficiency, improve accountability and reduce costs
The continued provision of essential mental hygiene services through the establishment of a safety net care pool will provide lower-cost services that meet individuals’ needs and defer entry into higher costs Medicaid services
Presscott Associates –
A Division of ParenteBeard LLC 7

8. Synergy: ACOs and DISCOs
ACOs: Timely model of healthcare delivery for disabled people with complex care needs
DISCOs
­New person-centered goals/comprehensive plan of care for individuals with intellectual and developmental disabilities
­Care coordination/case management designed for individual’s unique needs/circumstances
Community/home-based alternatives replacing old systems of institutionally-based care
Presscott Associates –
A Division of ParenteBeard LLC 8

9. ACO Development: First Steps
Form an organization/infrastructure
Define organizational Mission, Goals and Objectives
Establish leadership/governance
Identify population to be served
Define services and service area
Develop/contract with a provider network
Address legal/compliance issues
Identify financial resources
Develop an operating budget
Presscott Associates –
A Division of ParenteBeard LLC 9

10. ACO Development: First Steps (cont.)
Develop a marketing plan
Establish clinical integration/care coordination/ management
Develop information systems for data collection/ management/sharing
Address patient engagement
Draft implementation agenda and timing
Presscott Associates –
A Division of ParenteBeard LLC 10

11. DISCO Goals 1
Provide individualized planning for all enrollees that focuses on individual outcomes
Promote OPWDD’s four valued outcomes for individuals:
­Live and receive services in the most integrated settings
­Meaningful and productive community participation, including paid employment;
­Develop meaningful relationships with friends, family, and others in their lives
­Experience personal health, safety and growth
Ensure that each individual who chooses to do so can self-direct his or her services including the option for budget and employer authority
Maintain a well trained workforce that minimally meets all OPWDD requirements and is culturally competent to meet the needs of the individuals seeking or receiving supports and services in the communities in which they live.
1 OPWDD Application
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A Division of ParenteBeard LLC 11

12. DISCO Organization and Management/ Governing Board
Governing Board to establish/oversee DISCO policies
Participate in OPWDD-required abuse and training
Meet 4 times per year
Within 1 year of becoming operational, have 20%+ individual/advocate board membership, or advisory council with board input
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A Division of ParenteBeard LLC 12

13. DISCO Organization and Management/ Service Delivery Network
Contracted provider network
Providers with specialized expertise for individuals with developmental disabilities/special populations
Choices of at least 2 providers for each provider type
Responsive to community cultural considerations, including language
Presscott Associates –
A Division of ParenteBeard LLC 13

14. DISCO Organization and Management/ Contract Management
Established service contracts with network providers
Policies and Procedures for contract monitoring
Contracts must include:
­Service standards
­Staff/agency qualifications
­Provider compliance monitoring and remedies
­Reportable events (“Unusual Incidents”) and processes
­Billing processes and rates for service units
­Appeals/grievance processes for resolution of payment issues
Presscott Associates –
A Division of ParenteBeard LLC 14

15. DISCO Organization and Management/Enrollment Monitoring and Disenrollment Reporting
Qualified individual, all ages, will be eligible to enroll in DISCO pilot with authorization of OPWDD Regional Office
Qualifications
­Qualifying developmental disability
­Meets ICF/DD level of care
­Medicaid enrolled (included dually eligible)
Not included during pilot phase
­OPWDD state operated residential and day services
­SNF, OASAS/OMH or private psychiatric hospital residents
Enrollment, disenrollment, service utilization, encounter data, enrollee satisfaction, marketing, grievance/appeals, fiscal data
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A Division of ParenteBeard LLC 15

16. DISCO Organization and Management/ Assessment of Prospective Members
OPWDD developing an assessment tool (CAS)
State will complete initial assessments
DISCOs will use assessment tool to support care plan development and monitoring
Current instrument (DDP2) must also be completed for enrollees
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A Division of ParenteBeard LLC 16

17. DISCO Organization and Management/ Care Management
Establishment/implementation of written care plan
Assistance to enrollees to access services reflecting person’s communicated choices/needs
Application process assesses DISCO’s readiness to provide care management, health/safety monitoring, OON referrals (as needed)
Primary care manager and care management team
Quality assessed by qualifications of care coordinators, quality outcome measures
Presscott Associates –
A Division of ParenteBeard LLC 17

18. DISCO Organization and Management/ Financial Requirements
Initial capital to comply with DOH Regulation Part escrow and contingent reserve requirements
Must identify sources of initial capital
Reserve and escrow requirements (exception for “start-up” period)
Minimum net worth equal to greater of escrow requirement or contingent reserve
Presscott Associates –
A Division of ParenteBeard LLC 18

19. DISCO Organization and Management/ Accounts Receivable-Payable
Receivable: Management of capitation revenues (based on member months)
Payable: Payment of claims received from the subcontract network providers
OPWDD examining methodologies for establishing standardized fees for cap rate and provider payments
Presscott Associates –
A Division of ParenteBeard LLC 19

20. DISCO Organization and Management/ Budget-Finance-Accounting
Monitoring and reporting of all financial aspects of the DISCO operation
Budgets
­Number of enrollees
­Service delivery costs
­Administrative operating costs
Required reports
­Annual Financial Statements: Medicaid Managed Care Operating Report
­Quarterly Financial Statements
Presscott Associates –
A Division of ParenteBeard LLC 20

21. DISCO Organization and Management/ Utilization Management and Review Systems
Assure maximum system use of available community-based and integrated services
Direction/link to care coordinators, enrollee/advocates, caregivers regarding services promoting objectives of People First Waiver
Aggregate reporting of uses and costs of services and trends
Recommendations based on utilization data/reports
Presscott Associates –
A Division of ParenteBeard LLC 21

22. DISCO Organization and Management/ Quality Assurance System
QA/PI program and approved written quality plan addressing
­Ongoing assessment
­Implementation
­Evaluation of overall quality of care and services
­Specific measurable activities
­Meet requirements of Article 44 of PHL and regulations of 42 CFR (QA/PI)
­Approved by Commissioner of OPWDD
­Board-level accountability
­Objective, measurable and relevant quality indicators
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A Division of ParenteBeard LLC 22

23. DISCO Organization and Management/ Management Information System
Compliant with Statewide Policy Guidance – common information policies, standards and technical approaches governing health information exchange
Maintenance of health information system that collects, analyzes, integrates and reports data
Data available to State and upon request to CMS
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A Division of ParenteBeard LLC 23

24. DISCO Organization and Management/ ADA Compliance Plan
Compliance with Americans with Disabilities Act
Compliance plan to be submitted with Application
State guidelines addressed
SDOH guidelines found in the Model Contract
Must be approved by OPWDD
ADA checklist must be completed
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A Division of ParenteBeard LLC 24

25. DISCO Service Area
Geographic area for certificate of authority to operate a DISCO
Sufficient provider network
­Services availability to enrolled population
­Services accessibility to enrolled population
Presscott Associates –
A Division of ParenteBeard LLC 25

26. DISCO Marketing Strategy
Marketing plan must be submitted
­Goals
­Strategy
­Address information needs of eligible persons
Limitations on marketing activities defined
Monitoring to ensure compliance with state/ federal requirements
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A Division of ParenteBeard LLC 26

27. DISCO Self-Direction Services
Self-directed services must be available
DISCO must provide description of how it will offer self-direction
Education and supports for self-direction
Presscott Associates –
A Division of ParenteBeard LLC 27

28. DISCO Person-Centered Planning
Individualized Service Plan (ISP) developed by the care coordinator, person and person’s circle of support
DISCO must describe process and principles for ISP
Training for care management staff, individuals and families
Measurement of outcomes
Presscott Associates –
A Division of ParenteBeard LLC 28

29. Productive Community Participation and Competitive Employment
Support individual with I/DD to fully participate in their communities, including employment
DICSO must describe process/methods for increasing volunteerism and employment for enrollees
Presscott Associates –
A Division of ParenteBeard LLC 29

30. Core Elements of New Service Delivery Models
Integrated primary/acute care, behavioral health, long-term services
Stakeholder input in design/management of care models
Addressing individuals’ support/caregivers’ networks
Maintenance of provider relationships
Integrated funding (Medicare, Medicaid, State)
Presscott Associates –
A Division of ParenteBeard LLC 30

31. Core Elements of New Service Delivery Models (cont.)
Risk assessment for individual-centered goals for resource allocation
Performance measurement
Information technology for data collection and measurement
Reimbursement design (EOC, risk, P4P)
Life-long planning for persons with I/DD
Presscott Associates –
A Division of ParenteBeard LLC 31

32. Guiding Principles for I/DD Service Improvements
Consistent with Developmental Disabilities and Civil Rights Act and ADA of 1990
Access to services and supports
Ability to have choices/make decisions
Achieve outcomes (e.g., independence, meaningful work, dignity, well-being)
Service delivery that integrates/coordinates programs and funding
Systems demonstrate value to consumers and purchasers (need data and measurements)
Presscott Associates –
A Division of ParenteBeard LLC 32

33. Essential Elements for Success
Strong leadership
Provider input
Clear Mission Statement (addresses integration)
Realistic Goals
Objectives that are tangible, measurable, can be validated
Provider commitment/engagement
Presscott Associates –
A Division of ParenteBeard LLC 33

34. Essential Elements for Success (cont.)
Care management
­Evidence-based clinical guidelines
­Clear, concise processes
­Provider accountability
­Preventive care and wellness orientation
­Performance goals/measurements
IT: EHR, data sharing for informed decision-making
Communication, feedback (internal, external)
Presscott Associates –
A Division of ParenteBeard LLC 34

35. Essential Elements for Success (cont.)
Organizational culture
Strategy: Formal Business Plan, Implementation Agenda and timeframes
Presscott Associates –
A Division of ParenteBeard LLC 35

36. Summary
Essential elements in provider integration are part of a Business Plan
Integration is relationship-building
Relationship building required concerted effort
Successful relationships beyond affiliation are crafted by having a Plan of Action
Result: Achievable accountability and competitive positioning for the DISCO
Presscott Associates –
A Division of ParenteBeard LLC 36

37. Contact Information
David A. Gregory, Partner Presscott Associates – A Division of ParenteBeard LLC office The Empire State Building 350 Fifth Avenue, 68th Floor New York, NY 10118
Presscott Associates –
A Division of ParenteBeard LLC 37 37