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Person Centered Care in Managed Care – Myth or Reality?

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Presentation on theme: "Person Centered Care in Managed Care – Myth or Reality?"— Presentation transcript:

1 Person Centered Care in Managed Care – Myth or Reality?
YAI Conference Monday May 6th, 2013 Presentation by Jerry Huber Deputy Commissioner OPWDD

2 The Amazing Race

3 Coordinated Assessment System (CAS)
Care Coordination Case Studies RFA Front Door ICS DISCO Coordinated Assessment System (CAS) RFI People First Waiver InterRAI Pilots CQL Managed Care Personal Outcome Measures

4 THEMES Equity Balance Person Centered Needs Based Outcomes Driven
Incentivized THEMES

5 OFF TO THE RACES Improving how we meet needs - expanding self direction and employment to provide opportunities for everyone, launching CAS Improving quality of our care through workforce support and measuring individual outcomes Participating in NYS Olmstead Plan – creating more housing opportunities & moving people out of institutions Launching managed care through pilot DISCOs – moving toward integrated, holistic care Continuing health and safety reforms –

6 AGENDA FOR TODAY 1. Discuss 4 Essential aspects of Person-Centered Practice as a Foundation for Managed Care 2. Discuss similarities and differences within managed care for people with ID/DD as compared with mainstream managed care 3. Outline milestones and time tables for the transition in managed care here in NY

7 Assessment Planning Access Evaluation Standardized Comprehensive
3/13/2013 Assessment Standardized Comprehensive Planning Person Centered Assessment Based Measurable Outcomes Access Access to Services “Front Door” Consistency Evaluation Outcomes Based

8 Assessment Planning Access Evaluation

9 Goals of Needs Assessment
Standardized needs assessment that identifies individual needs and strengths to inform Person-centered care planning An assessment tool that can inform acuity levels for resource allocation. Ability to draw on individual or aggregate level data for quality monitoring purposes.

10 New York State-specific InterRAI DD
Items from Child and Youth ID and Mental Health tools Items from Community Mental Health (CMH) tool Items from the Correctional Facilities tool New York State OPWDD Coordinated Assessment System (CAS) interRAI Intellectual Disability (ID)

11 Coordinated Assessment System
CAS Core Child and Adolescent Supplement Mental Health Supplement Forensic Supplement Medical Management Supplement Substance Use Supplement

12 CAS and the Case Study 18 Assessment Specialists hired to complete CAS for the case study Assessment Specialists received extensive training specific to the CAS CAS summary and CAPs will be used by agencies to inform care planning Ongoing review of the CAS, protocols and manual will continue throughout the case study Reliability and validity testing will be conducted

13 Long-Term Vision New Coordinated Assessment System will be phased in thoughtfully over the next several years: Beginning with year long case studies, Moving next to DISCO pilot projects, Next into use with all newcomers to the service system, Eventually, over time, will be used with those currently receiving services. We will be careful not to disrupt lives, but instead identify opportunities for greater integration and independence based on needs, strengths and desires.

14 For More Information… InterRAI Integrated Assessment Suite: CAS specific questions:

15 Assessment Planning Access Evaluation

16 Essential Elements of Person Centered Care
3/13/2013 Essential Elements of Person Centered Care Person-Directed Person-Centered Outcome-Based  Information, Support and Accommodations Wellness and Dignity of Risk Participation of those that individual selects Community Integrated

17 3/13/2013 FUTURE The DISCO will be responsible for ensuring that they have organizational characteristics that support person centered planning Person centered planning is expected to be part of and integrated into the entire culture of an agency and managed care entity

18 Assessment Planning Access Evaluation

19 What Is the Front Door Initiative?
3/13/2013 What Is the Front Door Initiative? The Front Door Initiative is: A person centered approach to developing plans of support for people - not a program or a service Part of the fundamental process by which people access supports and services through OPWDD - providing a broader array of individualized service options to give individuals and families more flexibility and choice of supports and services that meet their needs

20 3/13/2013 Why Now? – 3 Factors The sustainability factor - how do we sustain appropriate service provision within fiscal realities? The relevancy factor - are the services we currently offer those that families and individuals coming into our service system are seeking? The compliance factor - in light of Olmstead and recent federal decisions on ADA, will the menu of service options we provide allow us to meet the goals of Olmstead and federal requirements?

21 OPWDD’s Front Door Initial Contact Assessment of Skills
Eligibility Determination Assessment of Skills Support Needs Identified Informed Decision Making and Individualized Plan Development Service Authorization and Implementation

22 3/13/2013 Front Door Goals Facilitate OPWDD’s approach to the delivery of services based on: A focus on the values of self determination and self-direction Resources to individuals based on needs, rather than the programs currently available More informed choice of supports and services Holistic use of paid and community supports Statewide consistency and availability of individualized and self-directed service options

23 3 Approaches to Achieve Goals
Simplify Access to Self-Direction Streamline Internal Processes OPWDD & Provider Partnership Through Change

24 OPWDD & Provider Partnership Through Change

25 Areas for Increased Partnership
Reinvestment Planning and Implementation Communication in Service Planning

26 Reinvestment Reinvestment is one or more methods for individuals to maintain service dollars but change service type to be able to purchase services in a more integrated setting.

27 Steps to Achieve Reinvestment Models
Review and modify existing processes, procedures and templates or develop new ones that enable providers to reinvest dollars associated with existing services that support more choice and better outcomes for people while also serving more people Develop consistent policies, procedures and reports that OPWDD Regional Offices can utilize to better manage base resources Create policies that can be put in place that shift management of current resources away from vacancy management and toward capacity management and more integrated settings

28 Communication in Service Planning
OPWDD and partners must communicate about individual level of need and how that need impacts service planning. Services in traditional supervised IRA and day habilitation settings will not be authorized by OPWDD simply because a program opportunity is available. An individual must have a level of need significant to require the level of support offered in these services and must choose these options as opposed to an option in a more integrated setting

29 Assessment Planning Access Evaluation

30 HCBS Quality Framework
3/13/2013 HCBS Quality Framework Eligibility (Level of Care) is carried out in a valid, reliable, and equitable fashion Individual Plans include services and supports that align with individual goals, strengths and needs Provider qualifications are regularly checked and monitored Individual health and well being is maintained Financial accountability is maintained The Medicaid agency maintains administrative authority

31 CMS Increasing Expectations
3/13/2013 CMS Increasing Expectations Using Data to drive systems improvements Evidence Based Performance Measures for Federal Waiver Assurances Regulatory Compliance CMS expects states to remediate individual situations but also to respond to trends in the data. In reviewing evidence, CMS looks to see if continuing compliance issues are identified through quality improvement initiatives. Must show how we review trends, develop and evaluate quality improvement strategies. Health and Safety

32 How do we make this Shift?
3/13/2013 How do we make this Shift? Evolving system Historically – Compliance/QA focus Shifting from site-based “bricks & mortar” inspections to reviews focused on individuals and achievement of outcomes “The measure of Quality is not the delivery of a support or service, but the results that services or supports provide for each person” Source: Designing Quality—Responsiveness to the Individual. CQL 1999 Outcome measures emphasize responsiveness to individual needs rather than compliance with organizational process or program requirements. Supports and services are not the outcomes. The supports and services are the practices, activities, and processes that enable people to achieve their prioritized outcomes. As such, organizational systems, policies and procedures create frameworks for enabling people to achieve outcomes. Systems, policies and procedures are not ends in themselves. The measurement of quality is shifting from a focus on compliance with organizational process to a focus on responsiveness to personal outcomes.

33 What are CQL Personal Outcome Measures?
Valid and reliable personal outcome measures that focus on what is meaningful to the person served. Provides a methodology to assess how well the organization’s provision of supports and services facilitate outcomes that are meaningful to each individual. Different than National Core Indicators (NCI) which are system outcome measures.

34 My Focus: What is most important to me now.
3/13/2013 CQL The Council on Quality and Leadership My Self My Focus My World My Dreams My Focus: What is most important to me now. 34

35 CQL The Council on Quality and Leadership
3/13/2013 CQL The Council on Quality and Leadership My Self 1. People are connected to natural supports. People have intimate relationships. People are safe. People have the best possible health. People exercise rights. People are treated fairly. People are free from abuse and neglect. People experience continuity and security. People decide when to share personal information. 35

36 My World CQL The Council on Quality and Leadership
3/13/2013 CQL The Council on Quality and Leadership My World 1. People choose where and with whom they live. 2. People choose where they work. 3. People use their environments. 4. People live in integrated environments. 5. People interact with other members of the community. 6. People perform different social roles. 7. People choose services. 36

37 People choose personal goals. People realize goals.
3/13/2013 CQL The Council on Quality and Leadership My Dreams People choose personal goals. People realize goals. People participate in the life of the community. 4. People have friends. 5. People are respected. 37

38 Proposal for Operationalizing POMs in DISCO Pilots – Components
3/13/2013 Proposal for Operationalizing POMs in DISCO Pilots – Components Care Coordination Framework Practice Guidelines Communication and Learning throughout the OPWDD system QI Plan—Use of CQL Data in Quality Improvement


Concepts of care management are rooted in the development of managed care principles Care Management has a focus on the best outcomes for individuals served Managed Care’s history has had a focus on cost containment Each rely on concepts of health promotion and disease prevention

41 CMS’s “Triple Aim” Better Health for the Population Better Care
for Individuals Lower Cost Through Improvement

42 Where does Person Centered Planning Fit In?
Since much of the Medicaid cost for those with long term care needs is outside of traditional health care, the emphasis needs to be on planning for all aspects of the individual needs for each person enrolled in a managed care plan

43 Variations in Managed Care Strategies for those with LTC Needs
1. Population already has complex medical and social needs 2. Due to these needs utilization of resources including specialty care is often quite extensive 3. Cost for services most often tied into daily living needs, including housing and day activities in addition to medical needs

44 Integrated Care is a Must
To really provide comprehensive Person Centered planning and care to the DD population, there is a need to integrate good care coordination that includes all aspects of medical, behavioral and social needs of the individual

45 Where Does Self Directed Care Fit In?
Different models of Self-Direction under Managed Care: Carved Out Models (ex. WI) Carved In Models (ex. Michigan) With either model, MC organizations in NY will need to provide Self-Directed Options for those enrolled

46 Person Centered Care in Managed Care – Myth or Reality?
It will be what we make it Concepts of good care coordination, Person Centered Planning and quality Managed Care are not mutually exclusive concepts Managing one’s complete care is the requirement of the individual, his or her circle of support and the provider network It Takes a Village but we need to create that Village

47 Enhancing Individualized Services in New York – A RECAP
The Need for Reforms of Financial and Service Platforms prior to going into Managed Care: 1. The Sustainability Factor 2. The Relevancy Factor 3. The Compliance Factor

48 OPWDD Transformation As OPWDD pursued development of the People First Waiver, we worked with CMS to define priority elements of system transformation: Expanding opportunities and supports for EMPLOYMENT Expanding COMMUNITY SERVICE OPTIONS – supportive housing, community-based services Expanding SELF DIRECTION options OLMSTEAD PLAN- Creating opportunities for people to move from institutions to integrated settings

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