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D B H D S Virginia Department of Behavioral Health and Developmental Services The New Exceptional Rate for the ID Waiver Lee Price, Sr. Policy Advisor.

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Presentation on theme: "D B H D S Virginia Department of Behavioral Health and Developmental Services The New Exceptional Rate for the ID Waiver Lee Price, Sr. Policy Advisor."— Presentation transcript:

1 D B H D S Virginia Department of Behavioral Health and Developmental Services The New Exceptional Rate for the ID Waiver Lee Price, Sr. Policy Advisor for the Office of the Settlement Agreement Executive Advisor & Dawn Traver, Community Resource Manager, Division of Developmental Services

2 Page 2 DBHDS Virginia Department of Behavioral Health and Developmental Services The Underlying Issue DBHDS recognizes that there are individuals in the training centers and the community who have greater needs than can be adequately met through the existing rate of reimbursement. –High medical support needs –High behavioral support needs

3 Page 3 DBHDS Virginia Department of Behavioral Health and Developmental Services Intent of an Exceptional Rate The “exceptional rate” was conceived to be a stopgap measure to address this problem – not a final solution –DBHDS is hopeful that the waiver study currently underway will assist in crafting long-term improvements to the service system

4 Page 4 DBHDS Virginia Department of Behavioral Health and Developmental Services General Assembly Action The 2013 General Assembly included a budget bill item to provide funding for an exceptional rate for ID Waiver Congregate Residential Support services: –Provided $3,682,880 in state general funds to support the exceptional rate

5 Page 5 DBHDS Virginia Department of Behavioral Health and Developmental Services Budget Bill Language The exceptional rate is designed for those –“currently residing in an institution and unable to transition to integrated settings in the community due to the need for services that cannot be provided within the maximum allowable rate AND –whose needs present imminent risk of institutionalization and enhanced waiver services are needed beyond those available within the maximum allowable rate.”* *Budget Bill Item 307 #3c

6 Page 6 DBHDS Virginia Department of Behavioral Health and Developmental Services General Assembly Intention Budget bill intent: –Provide a temporary (i.e., until waiver redesign) exceptional rate for those with complex medical or behavioral needs –Enable those individuals to receive enhanced waiver services beyond those provided through the existing maximum rates

7 Page 7 DBHDS Virginia Department of Behavioral Health and Developmental Services Extent of Impact The approved funding is estimated to provide additional supports to approximately 250 people. It is anticipated that the exceptional rate will be 25% more than the current Congregate Residential Support rates –NoVa:$21.70/hour –ROS:$18.88/hour

8 Page 8 DBHDS Virginia Department of Behavioral Health and Developmental Services Current Status DBHDS & DMAS staff have drafted criteria for the new rate and sent to CMS for approval: –Individual eligibility – will involve, among other factors, SIS® scores –Special review process before service authorization –Provider requirements Will release the details once CMS approves the Waiver amendment

9 Page 9 DBHDS Virginia Department of Behavioral Health and Developmental Services Current Status (cont’d) Waiting to hear back from CMS State regulations are being drafted, but their approval process begins after CMS Waiver amendment approval

10 Page 10 DBHDS Virginia Department of Behavioral Health and Developmental Services Hopeful Timeline CMS Waiver amendment approval by early October 2013 ID Waiver regulations about the exceptional rate in place by early January 2014 The first individuals approved for exceptional rate funding by mid-February 2014

11 Page 11 DBHDS Virginia Department of Behavioral Health and Developmental Services Some Possible Examples of Individuals Who May Need the Exceptional Rate

12 Page 12 DBHDS Virginia Department of Behavioral Health and Developmental Services MT

13 Page 13 DBHDS Virginia Department of Behavioral Health and Developmental Services Things That Are Important To/For MT TO: Playing my keyboard/listening to music Being outside; going on vacations Being lifted up and down on the ARJO lift Watching the hands of a clock move Water Visiting with family/friends FOR: Maintaining optimal positioning for respiratory health Adequate nourishment and hydration Visual, auditory and tactile stimulation Total assistance with ADLs Engaging in many social, recreation and leisure activities

14 Page 14 DBHDS Virginia Department of Behavioral Health and Developmental Services MT’s Recent Hospitalizations Hospitalized seven times in between January April 2013 for –Pneumonia –Respiratory difficulties Each hospitalization lasted 5 to 15 days for a total of 70 days

15 Page 15 DBHDS Virginia Department of Behavioral Health and Developmental Services Knowledge/Expertise MT’s Provider Must Have Pneumonia prevention plan of care NPO – Nutrition/hydration/medications via G- tube DNR (parents wish no CPR/chest compressions) Knowledge of dysphagia Bowel movement protocol Repositioning protocol Weight and fluid intake protocol

16 Page 16 DBHDS Virginia Department of Behavioral Health and Developmental Services MT’s Staffing Needs Two hours of nursing services per shift Monitoring vital signs and assessing for signs of illness. Assessing respiratory status; administering Albuterol nebulizer for severe wheezing Checking G-tube integrity/patency and stoma site condition every shift Monitoring positioning during enteral feeding and optimizing positioning at all times Oropharangeal suctioning as needed Monitoring oxygen support via nasal cannula continuously from bedtime to 7AM

17 Page 17 DBHDS Virginia Department of Behavioral Health and Developmental Services RH

18 Page 18 DBHDS Virginia Department of Behavioral Health and Developmental Services Things That Are Important To/For RH To: Making his own choices about mealtimes, snacks and TV Personal space/private time Sporting activities Socializing with family and friends Warm water activities Playing games, listening to music and looking at books For: Structure Something constructive to do during the day Being encouraged to participate in ADLs Maintaining good health through regular medical and nutrition management Managing his challenging behaviors and communication

19 Page 19 DBHDS Virginia Department of Behavioral Health and Developmental Services Other Important Things Per RH & His Authorized Representative Home designed for individuals on the autism spectrum; quiet with sensory items available Home where the others can tolerate RH when he chooses to be loud Space to roam while still being supervised Own room Home with no more than 4 other individuals Fenced in back yard Structured environment Being close to his family

20 Page 20 DBHDS Virginia Department of Behavioral Health and Developmental Services RH’s Behavioral Data: 2012 – episodes of aggression – 7 episodes were documented – 53 episodes were managed with proactive intervention  Attacked parents in vehicle  Bit, hit and kicked staff  Bit peers He had 40 events of property destruction  1 event was documented  39 events were managed with proactive intervention

21 Page 21 DBHDS Virginia Department of Behavioral Health and Developmental Services RH’s Behavioral Data: 2012 – 2013 (cont’d) 214 episodes of self injurious behavior – 18 episodes were documented – 196 episodes staff were managed with proactive intervention  Biting self to the extent of drawing blood  Hand banging on windows and doors  Slapping self in face to the extent of drawing blood  Hitting his face on his knees, blacking his eyes and bruising his face TOVA interventions were implemented 4 times Chemical restraint was utilized 1 time during an episode of especially challenging behavior

22 Page 22 DBHDS Virginia Department of Behavioral Health and Developmental Services RH’s Staffing Needs Staff trained and practiced on his positive behavioral support plan 24 hour awake supervision with two staff awake at night Follow communication plan Two staff for medical appointments to assist with his aggression toward medical professionals Supervision in bathrooms if others are nearby to reduce the risk of aggressive episodes

23 Page 23 DBHDS Virginia Department of Behavioral Health and Developmental Services PJ

24 Page 24 DBHDS Virginia Department of Behavioral Health and Developmental Services Things That Are Important To/For PJ To: Listening to country music Taking trips Talking to people about trips I’ve taken Looking at pictures in magazines Watching a movie or television with others from time to time For: Being reminded to take small bits so I don’t choke Intense supervision to make sure I don’t hurt myself

25 Page 25 DBHDS Virginia Department of Behavioral Health and Developmental Services Current Challenges for PJ I will sometimes leave where I am supposed to be and will “wait” for someone to come find me. I enjoy this game and I laugh when I am found. When I become upset I may remove my clothes and throw feces. I often pull clothes, hair, and jewelry and scratch or kick support partners. I struggle with transportation and often grab the steering wheel, open doors, jump out or squeeze through windows, while riding in a vehicle. I will often destroy things in my home and other environments such as the community or at my day program.

26 Page 26 DBHDS Virginia Department of Behavioral Health and Developmental Services PJ’s Staffing Needs Having 1:1 support for transportation to prevent elopement, SIB or other challenging behaviors Having 1:1 support when walking around in the community, as he will drop to the ground, roll around in parking lots and disrobe in public Having an effective Behavior Support Plan, Nutritional Management Plan, Having supports for oral and personal hygiene and with taking needed medications

27 Page 27 DBHDS Virginia Department of Behavioral Health and Developmental Services PJ’s Staffing Needs (cont’d) Having a Positive Behavior Support Facilitator to develop and monitor Behavior Support Plan Instances of serious physical aggression should be addressed by following his BSP and involving START services to support acute and on-going concerns A structured and active employment or day support setting where line of sight supervision is provided


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