1 iBudget Florida Stakeholders’ Meeting December 4, 2009

2 Overview of Proposed System Budgets determined through algorithm Service array revised to increase flexibility Waiver Support Coordination better match to family needs, shift to emphasis on service coordination from service approval processing Service review more limited, focused, & streamlined, focusing on health & safety issues

3 Overview of Proposed System Consumer and family training and tools for managing budgets Policies for limiting risk of overspending and options for corrective action plans Behind-the-scenes reviews for health & safety, provider manipulation, and fraud Process for determining budgets for consumers with exceptional needs

4 Overview of Proposed System Electronic/automated as much as possible— virtually paperless Phase-in over a reasonable time period—e.g., number of consumers (say by geography) and budget amounts

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

6 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

7 Consumer and Family Control Feedback so far: System now does provide for adequate consumer control System now does not provide for adequate consumer control Some individuals don’t have natural supports to help exercise self-direction

8 Consumer and Family Control Feedback so far: Some families will be unable to manage a budget Concern that individuals’ natural supports might not let them make desired choices Concern that some providers may not cooperate or may be manipulative

9 Consumer and Family Control Feedback so far: Consumers may make poor choices that put them at risk Consumers need opportunities to make choices and learn from the poor ones

10 Consumer and Family Control Decisions needed: Limits on spending to ensure that funds last through the year –Option A: Monthly allocation –Option B: 10% up front; 85%, spread over 12 months; 5% emergency reserve –Option C: 20% up front; 80% spread over 4 quarters

11 Consumer and Family Control Decisions needed: Other methods to discourage overspending –Monthly statements –Waiver support coordinator issues service authorizations (consumer and family may do so in Option C) –Swipe card system

12 Consumer and Family Control Decisions needed: What to do if a person overspends but still needs services –Require to adjust services to fit budget –Limit flexibility to make future changes –Require a representative to help –Temporary increase in funding to meet critical health and safety needs –Require training or a mentor paid from budget

13 Consumer and Family Control Decisions needed: How to provide training on making good choices –Web –Through Waiver Support Coordinator –In-person group trainings hosted by FCC or Area Office –Paid service through person’s budget

14 Consumer and Family Control Decisions needed : Caps on service amounts: –Option A: Similar to current handbook –Option B: Only on limited services which are related to health & safety –Option C: No

15 Consumer and Family Control Decisions needed : Whether funds for certain critical health and safety-related services must be reserved and may not be spent on other services: –Option A: Residential habilitation, nursing, therapies –Option B: Residential habilitation only –Option C: None

16 Consumer and Family Control Decisions needed : Who may issue service authorizations to begin or end services: –Option A: Waiver support coordinator, along with area staff for certain services –Option B: Waiver support coordinator –Option C: Consumer, family, and waiver support coordinator

17 Consumer and Family Control Decisions needed : What information consumers need to make good decisions –Their own goals and needs –Traditional and innovative strategies for achieving goals/meeting needs –Outcomes/performance data

18 Consumer and Family Control Decisions needed : How to help consumers track spending –Waiver support coordinator –Web-based budget tool –Service logs –Monthly statement

19 Consumer and Family Control Decisions needed : How to find out if any providers are uncooperative or manipulative –Analysis of service usage/spending patterns –Reports from consumers/families –Quality assurance contractor reporting

20 Consumer and Family Control Decisions needed : What support to give to consumers who don’t have unpaid help in decision-making –Waiver support coordinators continue in that role –Waiver support coordinators help find supports to help –Quality assurance review –Behind-the-scenes audits

21 Consumer and Family Control Decisions needed : If funds can be carried over to a future year like in CDC+ –Option A: No –Option B: 50% carry over for up to 1 year –Option C: 100% carry over, no time limit

22 Service Review Main question: How do we best ensure that individuals receive the services that they need within allowable waiver coverage?

23 Service Review 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

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

25 Service Review Decisions needed: What are situations requiring a review? Who will conduct reviews?

26 Service Review Decisions needed: Situations requiring review –Under all options: Newly-enrolled in waiver If overspent budget within last 12 months First time in a licensed home

27 Service Review Decisions needed: Situations requiring a review –Under all options: Temporary significant change in needs requiring additional funds Permanent significant change in needs requiring additional funds Extraordinary need request

28 Service Review Decisions needed: Situations requiring a review –The first iBudget Florida plan: Option A: Yes Option B: Yes Option C: Only if using different services than previous plan

29 Service Review Decisions needed: Situations requiring a review –Every 3 years: Option A: Yes Option B: No Option C: No

30 Service Review Decisions needed: Situations requiring a review –If adding new service family: Option A: Yes Option B: Yes Option C: No

31 Service Review Decisions needed: Situations requiring a review –If increasing amounts of certain services within budget amount: Option A: Yes--behavioral services, nursing services, therapies Option B: Yes—intensive behavioral services, nursing services, therapies Option C: No

32 Service Review Decisions needed: Situations requiring a review –If decreasing amounts of certain services within budget amount: Option A: Yes--behavioral services, nursing services, therapies Option B: No Option C: No

33 Service Review Decisions needed: Situations requiring more frequent review: –If meets certain criteria: Current or previous forensic involvement Extraordinary medical needs Extraordinary behavioral needs Community based care child Only paid supports in person’s life

34 Service Review Decisions needed: The process for requesting reviews –Computer-based Who will perform reviews –Option A: Contracted provider, Central Office, and Area Offices –Option B: Central Office and Area Offices –Option C: Area Offices

35 Quality Assurance and Quality Improvement Main question: How do we ensure health, safety, and good outcomes?

36 Quality Assurance and Quality Improvement APD Plans: New quality assurance contract uses different measures –Increasing percentage of support coordination records reviewed to 50% –Will review about 25% of consumers individually Florida is joining National Core Indicators initiative

37 Quality Assurance and Quality Improvement Feedback so far: Support revision of the quality assurance system to be more understandable, less bureaucratic, and more person-centered Concern that individuals may make poor choices that put their health and safety at risk Concern that individuals may be at risk of exploitation by providers and natural supports

38 Quality Assurance and Quality Improvement Key Areas: Health & safety Budget management Outcomes Compliance

39 Quality Assurance and Quality Improvement Participants in QA/QI System: Consumers & families Waiver Support Coordinators Providers Family Care Councils Advocacy & provider organizations APD Central Office staff

40 Quality Assurance and Quality Improvement Participants in QA/QI System: APD Area staff –Certified Behavior Analysts –Nursing staff –Questionnaire for Situational Information Administrators –Licensing –Group home monthly monitoring –Provider enrollment –Supported living coordinator

41 Quality Assurance and Quality Improvement Examples of key activities: Assessment Planning Training Standard setting/process determination Monitoring/data analysis Information sharing Problem identification Corrective action

42 Quality Assurance and Quality Improvement Decisions needed: Options: –Health & safety: Requirement for use of full or enhanced waiver support coordination by certain individuals (e.g., those with forensic involvement) Competency-based training Utilization reviews to identify service patterns of concern

43 Quality Assurance and Quality Improvement Decisions needed: Options: –Health & safety: Review by area certified behavior analysts and nursing staff based on QSI scores Limits on certain flexibility in selecting and changing services

44 Quality Assurance and Quality Improvement Decisions needed: Options: –Budget management: Training for all levels of skill Timely information through web-based tools –Consumer & family –Support coordinator –Area office –Contracted Quality Assurance reviewers

45 Quality Assurance and Quality Improvement Decisions needed: Options: –Budget management: Policies to deter overspending Corrective action plans to address overspending Data analysis of spending patterns

46 Quality Assurance and Quality Improvement Decisions needed: Options: –Outcomes: Training on outcomes under a more self- directed system Training for support coordinators on handling issues of poor choice-making Central Office review of support plans to assess consumer goals under new system

47 Quality Assurance and Quality Improvement Decisions needed: Options: –Outcomes: Procedures for waiver support coordinators to access area office support and direction in addressing problematic consumer choice- making

48 Quality Assurance and Quality Improvement Decisions needed: Options: –Compliance: Training for consumers/families on provider responsibilities Revise relevant assurances and the handbook to clarify expectations and responsibilities under self-directed system

49 Quality Assurance and Quality Improvement Decisions needed: Options: –Compliance: Review service patterns to identify provider non-compliance Review service delivery against budget/support plan Publicly share information about non-compliant providers

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

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

52 Services Feedback so far: Make additional services available in Tier 4 Want flexibility to use greater amounts of services Use algorithm to determine level and intensity of services (e.g. Res Hab)

53 Services Feedback so far: Start from scratch with new handbook Like the very broad services, but if they’re in service families, make sure they are logically grouped Very broad services might be more challenging for consumers to navigate—hard to know how to meet needs

54 Services Decisions needed: Design of service array –Broader services—allow to meet changing needs day-to-day (current worker can switch between similar tasks) –Service families—allow to meet changing needs over time (can get a new worker to do new tasks)

55 Services Option 1: Modified Status Quo Option 2: Modified MercerOption 3: Minimalist No Service Families Residential ServicesPlaces to Live Wellness Therapeutic Supports Personal Supports Life Skills Development Transportation Support Coordination Environmental and Adaptive Equipment Equipment Comparison of Service Families in Options

56 Services Comparison of Services in Options Option 1: Modified Status QuoOption 2: Modified MercerOption 3: Minimalist Residential Habilitation Services Residential Habilitation (Standard)Basic Residential Residential Habilitation (Behavior Focused) Enhanced Residential Residential Habilitation (Intensive Behavior) Specialized Medical Home Care Nursing Residential Nursing Meaningful Day Adult Day Training Flex Benefit Companion Services In-Home Support Services Personal Care Assistance Respite Care

57 Services Comparison of Services in Options Option 1: Modified Status QuoOption 2: Modified MercerOption 3: Minimalist Support CoordinationSupport Coordination (Limited) Basic Supports Transportation Behavior Analysis Behavior Analysis Services Enhanced Supports Behavior Assistant Services Community Training and Supports Family & Guardian Training Mentoring Person Centered Planning Support Coordination Support Coordination (Transitional) Support Coordination (Full) Meaningful Day Supported Employment In-Home Support ServicesSupported Living Coaching

58 Services Comparison of Services in Options Option 1: Modified Status QuoOption 2: Modified MercerOption 3: Minimalist Adult Dental Services Basic Wellness Dietician Services Enhanced Wellness Occupational Therapy Physical Therapy Respiratory Therapy Nursing Private Duty Nursing Skilled Nursing Specialized Mental Health Services Speech Therapy Durable Medical Equipment and Supplies Equipment Environmental Accessibility Adaptations Consumable Medical Supplies/PERS Personal Emergency Response Systems (Unit and Services) Consumable Medical Equipment

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

60 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 Allow more customized level of service

61 Waiver Support Coordination Feedback so far: Desire for greater flexibility in choosing level of support coordination Waiver support coordinators play an important and multifaceted role in the APD system. Need to ensure they are still available to help consumers and families.

62 Waiver Support Coordination Decisions needed: What waiver support coordinator service options will be available: –Limited –Full –Enhanced (currently transitional)

63 Waiver Support Coordination Decisions needed: Situations which may indicate need for full (or enhanced) waiver support coordination: –Newly-enrolled in waiver –Forensic involvement –Complex medical needs –Complex behavioral needs

64 Waiver Support Coordination Decisions needed: Situations which may indicate need for full (or enhanced) waiver support coordination: –Transition from school –Change in residential setting to group home or supported living –Verified abuse or neglect –Dual diagnosis –Alcohol or drug abuse history

65 Waiver Support Coordination Decisions needed: Waiver support coordinators’ general tasks –Annual plan, level of care determination, and maintenance of Medicaid eligibility (required by CMS) –Handle exceptional/changed needs requests –Providing information about, access to, and coordination of services

66 Waiver Support Coordination Decisions needed: Waiver support coordinators’ general tasks –Help create social connections –Increase access to community resources –Training consumers and families in self-direction and budget management

67 Waiver Support Coordination Decisions needed: Waiver support coordinators’ general tasks –Budget management in consultation with consumer and family –Monitoring of health and safety –On call 24/7

68 Service Providers Main question: Who may provide services?

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

70 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

71 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

72 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?

73 Implementation Feedback so far: How to ensure that calculation of iBudgets is understandable to consumers and their families Need to carefully communicate with any consumers and families from the wait list when they do join

74 Implementation Your thoughts: How can we communicate with stakeholders: –Individually –Through providers –Through organizations

75 Implementation Your thoughts: What should we tell them? –Consumers –Families –Waiver Support Coordinators –Providers –Advocates

76 Conclusion Questions? Comments? Suggestions?

77 Conclusion Public Comment Plan Next Meeting Adjourn Thank you for your time and input!