1 iBudget Florida Stakeholders’ Meeting October 22, 2009

2 Introduction Jim DeBeaugrine APD Director Betty Kay Clements Family Care Council Florida Chairperson

3 The Meeting Process Facilitator Introduction –Keep the group focused and on track –Ensure stakeholder input is heard and recognized

4 Introductions Workgroup members Staff

5 Project Background APD Challenges to Overcome –System is complex –More consumer control possible –Managing funding is difficult –Wait list is growing

6 Why are individual budgets worth considering? Several states use similar models Individualized budgets can help with agency challenges Florida is well positioned to succeed Vulnerabilities no greater than current system Other options raise concerns Legislature told us to develop a plan

7 Why are Individual Budgets Worth Considering? Emerging best practice--several states use similar models –Examples: Georgia, Wyoming, Minnesota, Connecticut, Louisiana Florida is well positioned to succeed –Has key building blocks in place: statewide rates, fee-for-service, independent WSC’s, choice of providers, variety of services, etc.

8 Can help with agency challenges and achieve agency goals –Can increase self-direction, sustainability, equity Vulnerabilities no greater than current system –Agency & individual budget cuts can and do happen now Why are Individual Budgets Worth Considering?

9 Other options raise concerns –Managed care –Continued deficits, growing waitlist, awkward legislative cost-control measures Legislature told us to develop a plan

10

11 What is an individual budget? A formula –Computer calculates individuals’ budgets –Uses mathematical formula or algorithm –Uses consumer characteristics and assessment results –Funding is determined before services are decided upon A process –For selecting services

12 What is an individual budget? Chas Mosley, NASDDDS “In many states, the... budget is built through a developmental process in which people receiving support and their planning teams actively participate in a series of structured decisions.... The statistical analysis...essentially takes the place of the step-by-step decision-making procedure.”

13 Example of an individual budget 5,000 (Living setting) (age) +2,300 (subscore 1) +1,500 (subscore 2) = Total $15,000 (coded 3) + 3,000 (30 yrs old) + 4,600 (score of 2) + 4,500 (score of 3) = $27,100 ***This is for illustrative purposes only and is not a proposed formula.

14 Individual Budgets in Florida An idea that’s been around a while: –District 13 Model: 43 levels based on primary challenge, living situation, and level of need – Redesign Efforts: Envisioned valid & reliable assessment (ICG), cost prediction model, and flexible services system

15 Project Background Legislative Direction: Plan by February 2010 –Fair and equitable distribution of resources based on assessment process –Client choice of services and providers –Formulas to predict resource needs –Recommended roles for providers and support coordinators during the assessment process

16 Overall Goals Enhance: –Self-direction –Sustainability –Equity

17 1.Empower individuals 2.Funding is fair and equitable, yet responsive to individual needs 3.Protect health and safety Detailed Objectives

18 4.Transparent process 5.Operate within agency budget 6.Meet federal requirements Detailed Objectives

19 Additional goals and objectives? Revisions to stated goals and objectives?

20 Comparison CDC+ iBudget Waiver System

21 CDC+ vs. iBudget Florida vs. Flexible Benefit All are designed to give more flexibility to families, but in different ways They are in different stages of implementation Some are optional, some aren’t

22 CDC+ vs. iBudget Florida vs. Flexible Benefit CDC+ –Existing program being expanded –May hire own workers –Use fiscal employer agent service to pay workers and providers –Must opt into

23 CDC+ vs. iBudget Florida vs. Flexible Benefit Flexible benefit service –Amendment to all 4 waivers—in process –Must opt into –Choose from Medicaid enrolled providers –No fiscal employer agent service –More flexibility with meaningful day services –May be encompassed in iBudget FL

24 CDC+ vs. iBudget Florida vs. Flexible Benefit iBudget Florida –Plan in development – seeking Legislative direction –Not optional –All consumers would have funding determined –All consumers would have new service flexibility, except for CDC+ consumers (they keep their current broad flexibility) –Choose from Medicaid enrolled providers

25 Agency’s Approach in Developing iBudget Research—other states, studies Stakeholder and public review and comment Expert assistance

26 Generic System Elements Every system needs: –Way to gather information about peoples’ needs –Way to determine funding available for each person’s needs –Way to select services that may be paid for with the funding Different states & systems do each differently

27 Current System Determine needs through WSC review, assessment instrument Determine funding through WSC recommendation, prior service authorization (PSA) process, law/rule mandates Determine services through choice limited by handbook, PSA

28 High-Level Program Design Current System –Retrospective, complex iBudget System –Prospective, fair, reliable, and flexible

29 Key Differences Current System –Services decided first –Complex system: WSC writes plan Area & PSA review Rebasing affects Tiers affect –Change in services often requires new PSA review iBudget Florida –Funding decided first –Simpler, flexible system: Budget up to individual limit Limited service review Process for accommodating individuals with extraordinary needs

30 iBudget – A Self-Directed System Assessment Process & Consumer Characteristics Identification Algorithm Individual Budgets Service Delivery

31

32 Individual Budgets People who are similar will have similar iBudgets Flexible support systems Universal, not optional People with similar characteristics will have similar iBudgets –Will be process to accommodate those with truly unique needs Flexible support systems Everyone will have an iBudget

33 Individual Budgets Distributes appropriations fairly and equitably –Fits Florida’s data and experience –Model will consider funding patterns prior to tier implementation

34

35 Questions?

36 How well do individual budgeting systems generally work?

37 Human Services Research Institute staff –States can implement in a budget-neutral manner and have been able to constrain costs Florida District 13 Pilot –Increased predictability of costs, accepted by families Former Wyoming Staff Member: –“Families love it” Individual Budget System Outcomes

38 Individual Budget System Outcomes Wyoming DOORS—since 1998: Evaluation by Navigant Consulting DOORS “...continues to perform as it was originally intended: distributing waiver funds equitably across the population of individuals enrolled in the HCBS waivers while matching consumer needs with available supports.” Increases in costs are due to increased enrollment and exceptional/changed need funding process

39 Individual Budget System Outcomes Wyoming DOORS—since 1998: Evaluation by Navigant Consulting Consumers and families generally satisfied Providers generally satisfied

40 Individual Budget System Outcomes Implementation Recommendations –Evaluate individual impacts Can phase in new amounts Have special process for exceptional needs –“New system issues” Can phase in geographically or other method

41 Assessment Instruments What is an assessment instrument? A standardized method for collecting important information about people

42 Assessment Instruments What makes a good assessment instrument? Reliable—the way it measures will give the same result when results should be the same Valid—it measures what it’s supposed to measure Predictive – assessment information and other factors yield fair and equitable budget amounts

43 Assessment Instruments What makes a good assessment instrument? Also need to think about: What consumers assessment is intended for Time it takes to administer Who can administer Training required for administration Nature of assessment Cost of assessment

44 Assessment Instruments What assessment instruments do states use for individual budgeting? –ICAP—Indiana, Wyoming –SIS—Georgia, Colorado, Oregon –“Home-grown”—Connecticut, Minnesota States using national instruments often add a state-specific supplement

45 QSI in Use Now… Validity and reliability studies indicate the QSI is comparable to similar instruments Can revise to meet state needs About 50,000 assessments completed –Large sample size is great for algorithm development Administered by trained and certified APD staff

46 Algorithm What is an algorithm? –Mathematical formula that considers data (consumer characteristics) and determines a budget amount –Captures patterns of spending for similar consumers from previous years –Used in many other contexts: Amazon.com recommendations—data on product views Credit scores—data on accounts, payment history

47 Algorithm What makes a good algorithm? High “r-square”—a measure that tells us how well a formula fits its data Higher r²Lower r²

48 Algorithm 1.0 is perfect fit to data; but unattainable due to unique circumstances Wide range of “goodness of fit” Louisiana:.46 Georgia:.75 Colorado:.26 &.51 (two waivers) Oregon:.45 Wyoming: about.80 (started at.50)

49 4 Western States’ Variables Factors that explain costs and the percent of variance each explains

50 Algorithm What makes a good algorithm? Fewer variables Valid and reliable data Useable—can collect data, run it Refined over time (ex: Wyoming)

51 Algorithm Models from other states –Levels Determine budget ranges—typically 6-7 levels Used by states with complex administrative systems, problem rates, or data that won’t work Used in Colorado, Connecticut, Oregon –Individual budgets Potentially thousands or more possible budget amounts (depends on variables used) Used in Wyoming, Georgia, Minnesota

52 Algorithm What are other states’ algorithms like? Use different variables—examples: –Subscales or sections from assessments –Overall scores from assessments –Individual questions from assessments –Diagnosis –Age –Living situation –Services received –Chronic conditions –Mental health status –Community safety risk States may use just a subset of these

53 iBudget Algorithm In Development Expert Consultant Hired Preliminary Details Upon Completion of Analysis

54 Questions?

55 Service Delivery Process What is a service delivery process? –The “roadmap” that is followed from budget determination to service delivery and beyond –Includes planning, service identification, provider selection, monitoring, and more

56 Service Delivery System What makes a good service delivery process? –Responsive –Simple –Supports self-direction

57 iBudget Service Delivery System Greater flexibility in choosing services –Example: broaden services by combining similar services Maximize personal control

58 Developing a New System How do you develop a new system?

59 Developing a New System Four main steps: Step 1: Prepare Step 2: Collect data Step 3: Set individual budgets Step 4: Implement

60 Developing a New System Step 1: Prepare Set policy goals Engage stakeholders Choose assessment

61 Developing a New System Step 2: Collect data Collect information on individuals and the system –Full population is best –Ensure it is accurate Compile the collected information

62 Developing a New System –Step 3: Set individual budgets Set individual budgets –Put data into the computer –Use regression analysis to create formula that is best fit model Review findings in relation to policy goals –Health and safety –Equity

63 Developing a New System –Step 4: Implement Consider potential implementation issues Plan for implementation –Modify rules –Build awareness –Provide training –Modify operating procedures, forms, IT systems Implement new practices

64 Proposed Plan Development Timeframe October: Gather stakeholder ideas November and December: Statistical analysis, policy option development January: Stakeholders review draft plan, second round of public meetings February: Plan to Legislature

65 Pending feedback from Legislature: –Draft to Legislature: February 1, 2010 –CMS approval sought as soon as possible –Phase-in begins Summer/Fall 2010 –QSI improvements/algorithm refinement: Through Spring/Summer 2011 –Wider phase in begins Summer/Fall 2011 Suggested High-Level Implementation Plan

66 Questions?