1. Commonwealth of Massachusetts Executive Office of Health and Human Services Chapter 257 of the Acts of 2008 Provider Information and Dialogue Session: Adult Long Term Care April 26, 2012 www.mass.gov/hhs/chapter257 eohhspospolicyoffice@state.ma.us

2. 2 Agenda Chapter 257 of the Acts of 2008 Overview of Adult Long Term Care Services Definition and Overview of Programs Meeting Objectives Review of Pricing Analysis and Methodologies Model Definitions Basic Adult Long Term Care: Staffing Patterns Model Budget framework Timeline and Key Milestones

3. 3 Chapter 257 of the Acts of 2008 Regulates Pricing for the POS System Chapter 257 places authority for determination of Purchase of Service reimbursement rates with the Secretary Of Health and Human Services under MGL 118G. The Division of Health Care Finance and Policy provides staffing and support for the development of Chapter 257 pricing. Chapter 257 requires that the following criteria be considered when setting and reviewing human service reimbursement rates: Reasonable costs incurred by efficiently and economically operated providers Reasonable costs to providers of any existing or new governmental mandate Changes in costs associated with the delivery of services (e.g. inflation) Substantial geographical differences in the costs of service delivery Many current rates within the POS system may not reflect consideration of these factors. Additional funding was not appropriated to finance any potential cost increases associated with the law. Chapter 9 of the Acts of 2011 establishes new deadlines for implementing POS rate regulation as well as requires that related procurements not go forward until after the rate setting process is completed. Jan 2012Jan 2013Jan 2014 Statutory Requirement: Percent of POS System with Regulated Rates 40%30% Spending Base Associated with Statutory Percentage (based on current projection of $2.278B POS Baseline to be implemented) ~ $880M~ $660M

4. 4 The Cost Analysis and Rate Setting Effort has Several Objectives and Challenges Objectives and Benefits Development of uniform analysis for standard pricing of common services Rate setting under Chapter 257 will enable: A.Predictable, reimbursement models that reduce unexplainable variation in rates among comparable, economically operated providers B.Incorporation of inflation adjusted prospective pricing methodologies C.Standard and regulated approach to assessing the impact of new service requirements into reimbursement rates Transition from “cost reimbursement” to “unit rate” Challenges Ambitious implementation timeline Data availability and integrity (complete/correct) Unexplained historical variation in reimbursement rates resulting from long-term contracts and individual negotiations between purchasers and providers Constrained financial resources for implementation, especially where pricing analysis warrants overall increases in reimbursement rates Cross system collaboration and communication Coordination of procurement with rate development activities Pricing Analysis, Rate Development, Approval, and Hearing Process Data Sources Identified or Developed Provider Consultation Cost Analysis & Rate Methods Development Provider Consultation Review/ Approval: Departments, Secretariat, and Admin & Finance Public Comment and Hearing Possible Revision / Promulgation

5. 5 Agenda Chapter 257 of the Acts of 2008 Overview of Adult Long Term Care Services Definition and Overview of Programs Meeting Objectives Review of Pricing Analysis and Methodologies Model Definitions Basic Adult Long Term Care: Staffing Patterns Model Budget framework Timeline and Key Milestones

6. 6 Adult Long Term Care Service Class Service Class Definition: Programs that provide individuals a place of overnight housing for a long- term period of time in a specialized residential facility with necessary daily living, physical, social, clinical and/or medical support. Transition to a less restrictive setting, while ideal, is not a common goal for individuals receiving services in these settings.

7. 7 Adult Long Term Care Services: Meeting Objectives Review operating model definitions –Gain provider feedback on the scope and adequacy of model definitions –Articulate the similarities and differences among the three purchasing agencies (DDS, MRC, MCB) Demonstrate a draft staffing pattern for the ‘basic’ model for each of the three purchasing agencies –Determine if the staffing levels assumed in the basic model are fair and adequate to meet the needs of the clients –Discuss what additional staff would be needed for the more medically, behaviorally or otherwise intensive services Review draft model budget construct –Discuss staffing assumptions for Basic Services, utilizing the agency provided definitions and staffing patterns Address any other outstanding questions among providers

8. 8 Agenda Chapter 257 of the Acts of 2008 Overview of Adult Long Term Care Services Definition and Overview of Programs Meeting Objectives Review of Pricing Analysis and Methodologies Model Definitions Basic Adult Long Term Care: Staffing Patterns Model Budget framework Timeline and Key Milestones

9. 9 Proposed program models The purchasing agencies developed distinct model structures to appropriately serve the diverse needs of their clients. Staffing levels and expertise will vary among models dependent on the specific needs of the purchasing agency. Proposed model types include:

10. 10 Proposed Model Definitions: Basic ModelDefinition Basic (Staffing patterns and levels of expertise will vary among agencies) The basic adult long term care group home will provide services and supports to individuals who need daily intervention with care, supervision, and skills training in activities of daily living, home management and community integration. Individuals will be provided with a home environment that meets their needs and insures their safety and well being and are assisted in making choices and decisions and in planning their futures. Program staff will explore as needed the individual consumers interests, abilities, cueing, compensatory strategies and orientation to task. Program staff are expected to have a working knowledge of the disability and/or brain injury. Services must be flexible and able to change to meet the individual’s changing needs.

11. 11 Proposed Model Definitions: Behavioral Support Services ModelDefinition Behavioral (Staffing patterns and levels of expertise will vary among agencies) All services and goals contained in the basic model apply. In addition: Behavioral/clinical supports provided by a psychologist or appropriate clinician or behavioral consultant Staff training and consistent implementation of clinical/behavioral procedures and physical interventions including holds, enforced de-escalation strategies and restraint in accordance with behavior plans Staff skilled at working with individuals who: – have complex presentations – may be aggressive, assaultive, self-injurious or likely to exploit others – have a history with substance abuse – may have interfering sexual behaviors

12. 12 Proposed Model Definitions: Medical Support Services ModelDefinition Medical (Staffing patterns and levels of expertise will vary among agencies) All services and goals contained in the basic model apply. In addition: Direct nursing, nursing consultants, and regular overnight nursing to address chronic and acute client- specific needs Staff with the capacity to: – support individuals with G/J tubes and other extraordinary procedures as necessary – provide transfers and physical assistance – address both brain injury and medical management needs (MRC) Enhanced transportation needs

13. 13 Proposed Model Definitions: Forensic Support Services ModelDefinition Forensic (Staffing patterns and levels of expertise will vary among agencies) All services and goals contained in the basic model apply. In addition: A commitment to maintain public safety through the provision of appropriate individual supports and limits Staff to provide close supervision in accordance with individual needs and desire to manage community access Capacity to work with the criminal court system including the implementation of probationary agreements Experienced Clinical supports and appropriate staff training for: – Sexual offences – Fire starting – Physical Assault – Criminal behaviors – Substance Abuse

14. 14 Proposed Model Definitions: Blind, Deaf & Hard of Hearing Support Services ModelDefinition Blind, Deaf & Hard of Hearing (Staffing patterns and levels of expertise will vary among agencies) This is the basic model for our blind consumers. All attributes of the standard ‘basic’ model also apply. In addition: Staffing to support Deaf Blind consumers in all aspects of total communication needs including: – Sign Language – Tactile Objects – Etc. Structural support to enable and enhance the interpretive needs of each client

15. 15 Proposed Staffing Structure: DDS Basic Model The DDS Basic 1 staffing pattern assumes 5.1 direct careFTEs The 4 person Basic 1 staffing pattern increases direct care staffing from 1 to 2 FTEs during the 7-9am and 3-11pm weekday shifts and from 1 to 2 FTEs for both weekend daytime shifts

16. 16 Proposed DDS Program Models 2-3 person4 person5+ person 1Basic Level 1 2Basic Level 2 3Behavioral Support Services Level 1 4Behavioral Support Services Level 2 5Support Services to the Deaf and Hard of Hearing Level 1 6Support Services to the Deaf and Hard of Hearing Level 2 7Forensic Support Services 8Medical Support Services Level 1 9Medical Support Services Level 2 10Medical Support Services Level 3

17. 17 Proposed Staffing Structure: MRC Basic Model The MRC Basic 1 staffing pattern assumes 4 direct care FTEs The staffing needs for each individual will be considered in the assigned rates and included as add-ons The 4-5 person Basic 1 staffing pattern increases direct care staffing from 1 to 2 FTEs during the 3-11pm weekday shifts and from 1 to 2 FTEs for both weekend daytime shifts

18. 18 Proposed Staffing Structure: MCB Basic Model The MCB Basic 1 staffing pattern assumes 6.25 direct care FTEs The 4-5 Person Home assumes the same staffing pattern with an additional overnight direct care employee.

19. 19 Draft Model Budget – DDS Basic FTEs reflect staffing models recommended by the purchasing agencies. Relief calculated at 15.4% of Direct Care Staff FTEs (including DCI+II+III, Overnight Asleep, and Overnight Awake). Tax & Fringe, Admin Allocation percentages are blended across all purchasing agencies data. Transportation Expenses include staff mileage, vehicle expenses, and vehicle depreciation. An estimated cost adjustment factor (Source: Health Care Cost Review from Global Insights Massachusetts CPI Forecast- Fall 2011) is applied to account for inflation between the FY11 base year through the prospective rate period FY14-FY15. Basic Level 1 Model Budget (Capacity 2-3) Beds:2.5Bed Days:913 FTE Expense as a % of Total Management0.204% DC Supervisor0.7511% DCI + DCII + DC III2.9531% Overnight Asleep1.4010% Overnight Awake0.000% Relief A0.455% Relief B0.221% Support0.081% Total Program Staff 6.0562% ExpensesFactor Tax and Fringe21.71%13% Total Compensation 75% Occupancy $ xx8% Food $ xx3% Client Transportation $ xx1% Transportation Expenses $ xx1% Other Expenses - (Food +CT+TE) $ xx2% Direct Admin Expenses $ xx1% Total Reimb excl M&G 91% Admin. Allocation9.89%9% TOTAL 100% CAF: x.xx% $ xxxx,xxxx UNIT RATE: TBD

20. 20 Proposed Models: Provider Feedback What are the specific medical, behavioral, forensic or adaptive needs of your clients that should be considered in rate development? What are the staffing patterns necessary to maintain a site that adequately meets the varied needs of these clients? How does your agency determine its relief rate? How does your agency allocate management costs across your organization? What are cost drivers that need to be included in our analysis and rate development? (i.e.: Transportation, health insurance, etc.) What data sources does your organization reference to determine the true costs of these drivers over time?

21. 21 Agenda Chapter 257 of the Acts of 2008 Overview of Adult Long Term Care Services Definition and Overview of Programs Meeting Objectives Review of Pricing Analysis and Methodologies Model Definitions Basic Adult Long Term Care: Staffing Patterns Model Budget framework Timeline and Key Milestones

22. 22 Department Service Design Finalized: All service components, staffing ratios, staff qualifications, other program inputs have been decided by the purchasing department. Provider Sessions: For each rate setting project, EOHHS conducts an average of 3 provider input sessions prior to Executive Sign-Off and the Public Hearing Process to allow for greater depth in understanding core program components, cost drivers, and procurement considerations. Executive Sign-Off: Commissioner and C257 Executive Committee sign-off on draft rates and implementation plan. EO485 Submitted to ANF: Draft rate regulation to ANF; Will better align the rate regulation proposal with budget planning. Public Hearing: DHCFP and purchasing departments consider testimony in advance of rate adoption. Procurement Process: The procurement will be issued after the rates have been adopted. Rates Effective: Where possible, reimbursement under regulated rates will align with beginning of SFY to minimize mid-year contract amendments for both purchasing Departments and providers. Updated Implementation Timeline and Key Milestones for Adult Long Term Care July 1

23. 23 Questions/Feedback Please Email Questions & Comments to: eohhspospolicyoffice@state.ma.us Please Visit the Chapter 257 Website: www.mass.gov/hhs/chapter257