1 iBudget Florida Stakeholders’ Meeting October 23, 2009

2 Assessment Instrument Main question: How should we get information about people to know their needs?

3 Assessment Instrument Current system: Previously used the Florida Status Tracking Survey (FSTS) and the Individual Cost Guide (ICG) Now uses the Questionnaire for Situational Information (QSI) Covers physical, functional, and behavioral areas

4 Assessment Instrument APD Recommendations: QSI be used as assessment instrument QSI improvements be ongoing

5 Assessment Instrument Decisions needed: How and when to request reassessment How and when to appeal results

6 Assessment Instrument Feedback so far: Want information on the QSI’s validity and reliability Concern that it does not identify certain needs of individuals

7 Assessment Instrument Your thoughts: What are your concerns about the QSI? How can we make people more comfortable with the QSI?

8 Services Main question: What services and flexibility should be available to consumers?

9 Services Current system: 27 services in Tiers 1, 2, and 3 13 services in Tier 4 Providers must be Medicaid enrolled (except for CDC+ program) Statewide rates with some geographic differentials Need for a service is determined through prior service authorization

10 Services APD Recommendations: Must use Medicaid enrolled providers Services allow more flexibility Rates be neutral Same set of services available to all individuals

11 Services Decisions needed: Potentially combining services for greater simplicity and flexibility Limits, if any, for each service –Dollar amount –Hours –Need proven (prescription or assessment) Provider qualifications

12 Services Feedback so far: Make additional services available in Tier 4 Want flexibility to use greater amounts of services

13 Services Your thoughts: How could service options meet consumers’ needs better? What limits on control or other safeguards might be important for health and safety?

14 Waiver Support Coordination Main question: What should the waiver support coordinator’s role be?

15 Waiver Support Coordination Current system: Waiver support coordination is a required service Children have limited waiver support coordination; adults have limited or full coordination Waiver support coordinators have lots of required paperwork – Very little is processed electronically—heavily paper based

16 Waiver Support Coordination APD Recommendations: Waiver support coordinator’s role will shift to more of a facilitator and guide Will be seeking to reduce paperwork

17 Waiver Support Coordination Decisions needed: Waiver support coordinators’ specific tasks What waiver support coordinator service options will be available How we will streamline forms and processes What additional training, if any, to require

18 Waiver Support Coordination Feedback so far: Questions about what the role should be

19 Waiver Support Coordination Your thoughts: What should the waiver support coordinator’s role be? What should the split of individual, family, and waiver support coordinator responsibilities be? What concerns are there about the waiver support coordinator’s role in a more self- directed system? What options would a waiver support coordinator have if he or she felt an individual was making bad choices?

20 Prior Service Authorization (PSA) Main question: How do we best ensure that individuals receive the services that they need within allowable waiver coverage?

21 Prior Service Authorization Current system: All services must be approved through prior service authorization Reviews are performed by area staff and a contracted provider –It’s time-intensive –It’s complex –It’s paperwork-intensive

22 Prior Service Authorization APD Recommendations: The process as we know it go away—be minimized or eliminated as much as possible while meeting federal requirements Streamlined paperwork More flexibility Personalized approach

23 Prior Service Authorization Decisions needed: Situations requiring a review The process for requesting reviews Who will perform reviews

24 Prior Service Authorization Feedback so far: Scaling back is great but we need something to meet federal requirements for assessing medical necessity of services

25 Prior Service Authorization Your thoughts: What service approval process is appropriate for: Medical services Therapies Behavioral services Extraordinary needs Meaningful day activities Residential habilitation Supports in the home

26 Consumer and Family Control Main question: What would be reasonable limits on individual control?

27 Consumer and Family Control Current system: Waiver support coordinators work with individuals and families to support choice Individuals and families have little insight into spending of funds for supports Prior service authorization is required before service amounts are increased

28 Consumer and Family Control APD Recommendations: Training be provided to consumers and families on choice-making Consumers and families have greater control over the amounts and types of services they get

29 Consumer and Family Control Decisions needed: Limits on spending to ensure that funds last through the year What to do if a person overspends but still needs services How to provide training on making good choices

30 Consumer and Family Control Decisions needed : What information consumers need to make good decisions How to help consumers track spending What support to give to consumers who don’t have unpaid help in decision-making If funds can be carried over to a future year like in CDC+

31 Consumer and Family Control Feedback so far: Some individuals don’t have sufficient support to exercise self-direction Concern that some providers may not cooperate or may be manipulative

32 Consumer and Family Control Your thoughts: What information and training do consumers and families need to make good decisions? How could they get that information? How can we help those who don’t have families or friends to help them make choices?

33 Consumer and Family Control Your thoughts: How might we limit spending to ensure that funds remain through the year? Should we do this? How are pro’s and con’s of allowing carryover of unused funds to another year? How can we find out if any providers are uncooperative or manipulative, and what penalties might be assessed?

34 Extraordinary and Changed Needs Main question: How do we ensure that people with extraordinary or changed needs get enough funding?

35 Extraordinary and Changed Needs Current System: Individuals are assigned to tiers, which cap spending If needs are believed to have changed, the waiver support coordinator requests a prior service authorization review for additional services and/or a tier change

36 Extraordinary and Changed Needs Decisions needed: Process to identify people with extraordinary needs and set their budgets Process to handle requests for funding due to changed needs and determine the funds required

37 Extraordinary and Changed Needs Decisions needed: How to identify people with extraordinary or changed needs –Statistician will help when the model is more developed How to set their budgets How to decide if needs have changed How to calculate funds needed for changed needs

38 Extraordinary and Changed Needs Feedback so far: Want to ensure that funds are available for people with changed needs or extraordinary needs

39 Quality Assurance Main question: How do we monitor to ensure health, safety, and good outcomes?

40 Quality Assurance Current system: Contracted provider (Delmarva) performs quality assurance activities in conjunction with APD staff Contracted provider uses desk reviews, on-site visits, and consumer interviews to assess provider performance and consumer outcomes Medical Case Management Team and/or WSCs determine if additional review is required for health and safety Support planning, annual reports, and quality assurance contractor determine if individuals are progressing toward goals

41 Quality Assurance APD Plans: New quality assurance contract uses different measures Florida is joining National Core Indicators initiative

42 Quality Assurance Decisions needed: What might change under a new contract in a more self-directed system What might trigger any special health and safety reviews

43 Quality Assurance Feedback so far: Support revision of the quality assurance system to be more understandable, less bureaucratic, and more person-centered

44 Quality Assurance Your thoughts: What are your concerns regarding quality assurance in a more self-directed system? How should consumer outcomes be assessed in a more self-directed system? What should be done if the consumer is making poor choices and their health and safety are at risk?

45 Overall System Financing Main question: How do we make budgets predictable and sustainable for consumers and the agency?

46 Overall System Financing Current system: Legislature appropriates funding Complex rules control individual cost plans and spending to seek to stay within the appropriation –Individuals are assigned to one of four tiers –Rebasing for those with changed cost plans –PSA determines medical necessity

47 Overall System Financing Current system: Legislature cuts services and imposes other requirements to control spending About 25% of APD customers had cost plan reductions under the tiers

48 Overall System Financing APD Recommendations: System be fairer to consumers and be sensitive to individual needs Important to Remember: State constitution requires balanced budget—APD must stay within its appropriation Legislature makes decisions on how to fund the wait list

49 Overall System Financing Decisions needed: How much funding to reserve for extraordinary and changed needs How tiers will mesh with this system –Will be designing it without tiers

50 Service Providers Main question: Who may provide services?

51 Service Providers Current system: Any provider meeting Medicaid requirements can be enrolled and provide services Must use Medicaid-enrolled providers unless in CDC+ Currently more than 10,000 providers statewide Range from single-person entities to large-scale operations with multiple sites and hundreds of employees

52 Service Providers Current system: Under waiver requirements, consumers must have choice of providers WSCs submit service authorizations to begin or end services with a specific provider Providers must complete paperwork: annual reports, quarterly reports, individual plans, service logs, etc.

53 Service Providers APD Recommendation: CDC+ option continue, although participants will get iBudgets Everyone else use Medicaid-enrolled providers Rates be neutral

54 Service Providers Decisions needed: What competencies and standards that providers would need to meet What information or notice is given to providers to begin or end services

55 Service Providers Feedback so far: Ensure consumers have support and training Need timely notice and payment Self-directed system could pose management challenges –Staffing, regulation compliance, revenue projections

56 Service Providers Your thoughts: What opportunities does a more self- directed system pose for providers that are creative and innovative? How can providers, consumers, and families work more cooperatively in a self-directed system?

57 Administrative Issues Main question: How will the system work to make all this happen day-to-day?

58 Administrative Issues Current system: Area office staffs manage at the local level Cost plans run with the fiscal year ABC is the main computer system Paper-based

59 Administrative Issues APD Recommendation: Wish to pilot or phase-in as CMS allows – This will allow us to fine-tune before full implementation

60 Administrative Issues Decisions needed: When during the year an annual budget begins How iBudgets will be phased in –Need to see range of impacts after algorithm is developed further Changes required to computer systems and other supporting processes What specific staff roles will be –Service approval? Calculating budgets?

61 Administrative Issues Feedback so far: Support for phasing in over time Concern that implementing this on top of other recent changes might be too much Concern that if we don’t do this soon, the system will be in trouble

62 Administrative Issues Your thoughts: How might we phase in iBudgets across the state? What is a reasonable implementation timeframe, recognizing potentially strong interest in the Legislature for action?

63 Algorithm Main Question: What factors should be considered in the algorithm to determine funding?

64 Algorithm Current system: Waiver support coordinators request services for individuals Complex system for approving requests – Law requires use of certain factors to make tier assignments (such as living situation) –For Tiers 2, 3, and 4, spending is capped –Rebasing –Limits in handbook Funding is total of services approved

65 Algorithm APD Recommendations: Use regression model Dependent variables are previous years’ expenditures Seeking individual budgets

66 Algorithm APD Recommendations: Data for variables must be reliable and valid Variables will make appropriate contribution to model predictiveness Review model to ensure that health and safety are not at risk Rates be neutral

67 Algorithm Decisions needed –Specific variables and their contribution –How often to rerun and revise algorithm

68 Algorithm Feedback so far: Build a model tailored to Florida Concern that funding for meaningful day activities will be eroded or insufficient Concerns on using diagnosis in the model

69 Algorithm Feedback so far: Want to know the model details, including statistical details How to ensure validity and reliability of data used in model Fairness to those living at home

70 Algorithm Your thoughts: Factors that might be correlated with costs Data we might use

71 Conclusion Questions? Comments? Suggestions?

72 Conclusion Adjourn Thank you for your time and input!