1. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing May 6, 2014 Barbara D. Ramsey, Director Lori Thompson, Assistant Director The Division for Intellectual and Developmental Disabilities Colorado Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 1 Advancing Community-Based Care: Serving Individuals with Intellectual and Developmental Disabilities in Colorado

2. Colorado Department of Healthcare Policy and FinancingColorado Department of Healthcare Policy and Financing Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resourcesImproving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources 2 Overview

3. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Governor Hickenlooper’s Executive Order D2012-027 Community Living Advisory Group Office of Community Living 3 Community Living Advisory Group

4. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing 4 Governor’s State of Health: Four Focus Areas

5. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Department Mission Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources. Triple Aim Improving the patient experience of care, including quality and satisfaction. Improving the health of populations. Reducing the per capita cost of health care. 5 Triple Aim & Department Mission

6. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Population of Colorado*:5,268,367 Total Medicaid Enrollees^: 923,526 Total DIDD/CHRP Enrollees (FY 2014-15)12,096 Waiver Enrollees FY 2014-15 DD Waiver:4,820 SLS Waiver: 5,318 State Only SLS Waiver: 632 CES Waiver: 1,204 CHRP Waiver: 122 *2013 Estimate, U.S. Census Bureau ^ April 2014 Monthly Report to the Colorado General Assembly/JBC 6 Colorado by the Numbers: People Served

7. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Division for Intellectual and Developmental Disabilities under Office of Community Living within the Department of Health Care Policy and Financing Community Centered Boards (CCBs) as Single Entry Points, Case Management Agencies and Providers Regional Centers – ICF/IDD for High Needs 7 Colorado: Care Continuum & Care Model

8. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Three Home & Community Based Waivers for People with Intellectual & Developmental Disabilities State-Only Supported Living Services Program Family Support Services Program Family Support Loan Program Colorado Choice Transitions 8 Colorado: A Programmatic Overview

9. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing CCBs responsible for determination of Developmental Disability. Supports Intensity Scale (SIS) Administered for two Adult Waivers (SLS &DD). Support Levels based on SIS & other identified risk factors. Support Levels determines rates. 9 Support Levels: Adult Waivers

10. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing 10 Support Levels Scores from SIS Sections Scores from SIS Sections Support Level (1 – 6) (Algorithm calculates data from the above factors) Support Level (1 – 6) (Algorithm calculates data from the above factors) +≤ HCBS – SLS Waiver Risk Factors for HCBS – DD Waiver Support Level (1 – 6) (Algorithm calculates data from the above factors) Support Level (1 – 6) (Algorithm calculates data from the above factors) Standard Rates Example: Group Home Levels 1-6 Standard Rates Example: Group Home Levels 1-6 Support Level 7 HCBS-DD Waiver HCBS-DD Waiver Scores from SIS Sections Scores from SIS Sections Algorithm Risk Factors for HCBS – SLS Waiver SPAL Amounts Levels 1-6 SPAL Amounts Levels 1-6 Standard Rates Example: Specialized Habilitation Levels 1-6 Standard Rates Example: Specialized Habilitation Levels 1-6

11. Colorado Department of Healthcare Policy and FinancingColorado Department of Healthcare Policy and Financing Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resourcesImproving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources 11 Community Living Initiatives

12. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Policy of least restrictive environment. Reserved for Colorado residents 18 and older. Admissions not permanent. Legal imposition of disability. Most complex medical and behavioral needs. Determined eligible by CCB. 12 Regional Centers: Admissions

13. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Short Term Treatment & Stabilization Model 13 individuals in short-term stabilization treatment model 18 community transitions YTD Intensive Treatment Model 21 individuals in intensive treatment model 111 community transitions YTD Long-Term Habilitation Model 72 individuals in long-term habilitation treatment model 29 community transitions YTD 13 Regional Centers: Transitions

14. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing 14 Regional Centers: Community Support Team Community Support Team Individuals transitioning to the community: Provides support and training to community provider Provides support to individuals in the community in crisis who without support may be admitted to the Regional Centers

15. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing 15 Regional Centers: Community Support Team – How it Works Individual in the community with behavioral, medical, or psychiatric crisis Individual is referred to the CST by contacting DRCO Transition Coordinator at 303-463-2698 Decision is made with referral agent for the services needed. If necessary a team is formed. As needed, a team responds. Individual is stabilized in their current environment or if appropriate is admitted to the RC for short term treatment & stabilization.

16. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Team launched in March 2014. Team support provided to four clients in March 2014. Team support provided to three clients in April 2014. Two clients able to remain in community because of team. 16 Regional Centers: Community Support Team – Clients Served

17. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Five Year, federal Money Follows the Person Demonstration Grant Eligible clients must:  Meet financial and functional eligibility requirements for SLS & DD Waivers  reside in a long-term care facility for a period of no less than ninety days;  have been Medicaid eligible for one day; and  must be willing to move to qualified housing as defined in federal statute. Eligible clients receive Waiver services (SLS & DD) in addition to Demonstration Services. Individual participation for up to 365 nonconsecutive days 17 Colorado Choice Transitions (CCT)

18. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Assistive Technology, Extended Caregiver Education Community Transition Services, Coordinator Community Transition Services, Items Purchased Home Accessibility Adaptations, Extended Intensive Case Management Peer Mentorship Substance Abuse Counseling Transitional, Group Substance Abuse Counseling Transitional, Individual 18 CCT: I/DD Demonstration Services

19. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Caregiver Education Community Transition Services, Coordinator Community Transition Services, Items Purchased Enhanced Nursing, RN Home Accessibility Adaptations, Extended Independent Skills Living Intensive Case Management Substance Abuse Counseling Transitional, Group Substance Abuse Counseling Transitional, Individual 19 CCT: SLS Demonstration Services

20. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Skilled Nursing Facility at Grand Junction Regional Center closed April 2010. 21 individuals moved to community settings. Guardian & Family responses very positive. 20 Success Story: Grand Junction Regional Center SNF Closure

21. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Family Community Case Management Agency & Provider Partnership Community Staff Training Support Community Provider Staff Hires 21 Success Story: Grand Junction Regional Center SNIF Closure – Community Engagement

22. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing “She is happier than when she was at Grand Junction Regional Center. She is completely different, more calm.” “She used to bite her hands but not any more. She can’t talk but jabbers with people now. She is happier now than at the regional center.” “Happy that they dye her hair, polish her nails and put on make- up. I believe I have seen a small increase in comprehension for her.” 22 Success Story: Grand Junction Regional Center SNF Closure

23. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Moved to Strive! Group Home in April 2010 after 16 years in Regional Center. Likes living in the Group Home. Loves to help cook meals for one of her housemates. Enjoys being able to participate in community day services. 23 Success Story: Grand Junction Regional Center SNF Closure - Judy

24. Colorado Department of Healthcare Policy and FinancingColorado Department of Healthcare Policy and Financing Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resourcesImproving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources 24 Supporting Complex Needs in the Community

25. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Residential Habilitation Services & Supports Group Residential Services and Supports  4-8 people living in a group home  Nursing Services bundled into daily rate Individual Residential Services & Supports  1-3 people living in a variety of settings  Access to State Plan Nursing Services Own home or leased apartment Host Home 25 Supporting Complex needs in the Community: Residential Habilitation

26. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Colorado statute authorizes exemptions from the Nurse Practice Act for clients with IDD receiving services in Residential Settings Medication Administration G-Tube Feeding 26 Supporting Complex needs in the Community: Nurse Practice Act Exemptions

27. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Community-based Individualized (not more than 2 people sharing living) Host Home Providers classified as Independent Contractors Adult Foster Care approach-allows for long-term stable family like living Cost-Effective 65% of clients in Adult waivers live in host homes 27 Supporting Complex Needs in the Community: Host Home Model

28. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing State Plan: Home Health Services Private Duty Nursing Skilled Nursing (provided by a Registered Nurse or Licensed Practical Nurse) Certified Nurse Aide (CNA) services Physical Therapy (PT) Occupational Therapy (OT) Speech/Language Pathology (SLP) services (or Speech Therapy) *Case Management duties include coordination of State Plan and HCBS service delivery to ensure no duplication of services 28 Supporting Complex needs in the Community Using State Plan Services to compliment HCBS Waiver Services

29. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Medically Fragile: environmental scan pre-transition to ensure adequate medical providers available, assess home for adaptation/modification needs Behaviorally Challenged: collaborative work with CST & early Behavioral Assessment through waiver, allow for longer transition period, visits, RC staff train HCBS staff, use of BHO for Mental Health Services *Execution of transition assessments and plans critical 29 Transitioning fragile clients: Keys to Success

30. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Three HCBS waivers for persons with IDD include Behavioral Services: Behavioral Consultation Counseling Behavioral Assessment Behavioral Line Staff When used in conjunction with RHSS, DHSS and Mental Health Services, provides additional support for complex needs Gap Analysis Study START Model 30 Dual Diagnoses: Mental Health & Developmental Disabilities

31. Colorado Department of Healthcare Policy and FinancingColorado Department of Healthcare Policy and Financing Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resourcesImproving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources 31 Tomorrow’s Path: Toward a fully integrated, conflict- free, choice-based community system

32. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Person-Centered Service Planning Process  Conflict of Interest Home and Community-Based Setting Requirements  Integrated in and Supports Full Access to the Greater Community  Selected by the Individual  Ensures an Individual’s Rights of Privacy, Dignity and Respect, and Freedom from Coercion and Restraint 32 New HCBS Rules

33. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Information and Referral Eligibility Determination Administration of the Waiting List Service Planning Case Management Provider Selection 33 Areas for Potential Conflict of Interest arising from the Multiple Roles of Colorado’s CCBs

34. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Conflict Free Case Management Management of Waiting List and Enrollment Third Party Eligibility for Waiver Services Waiver Redesign 34 Current Task Groups

35. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Current Legacy system is cumbersome, expensive, inflexible and contains inherent conflict of interest practices. Charge The Community Living Advisory Group directed the work group to explore a re-designed waiver for adults with IDD that will include flexible service definitions and easy access to enable participants to access services and supports when and where needed based on individual needs and preferences. 35 Waiver Redesign Group

36. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Life Domains Person-Centered focus Self-Directed and Self Determined Flexible Service Delivery Expanded Supported Employment Options to support Community residence 36 Waiver Redesign Group – Guiding Principles

37. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Self Direction & Self Determination Currently in EBD & CMHS Waivers FMS Employer of Record Model Targeting July 2015 for incorporation into SLS 37 Consumer Direction

38. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing 38 Success Story: Bobby “ I think he’s doing great, just wonderful. He really enjoys it there. He is a people person and he likes the people there.” Bobby’s mom, Ruth Weichselbaumer ▪ 53 years old; 47 of those spent at the Regional Center ▪ Lives at Imagine! ▪ Bobby enjoys outings with caregivers – wants to go tobogganing ▪ Has decided to grow a beard ▪ Gets out more since moving to Imagine! ▪ Sees his family more frequently.

39. Colorado Department of Health Care Policy and FinancingColorado Department of Health Care Policy and Financing Barbara D. Ramsey Director Barbara.Ramsey@state.co.us 303-866-5140 Lori Thompson Assistant Director 303-866-5142 39 Questions?