1. Community First Services and Supports (CFSS)
June 14, 2013
Pam Erkel, Diane Benjamin, Jeanine Wilson

2. Current Environment For Reform
Minnesota is building on a history of improvements to the system to address core values.
Changing demographics and economic pressures put future of current system at risk of unsustainability.
Opportunities have arisen at the federal level to support innovation and reform at the state level.

3. Values and Vision
With Long Term Services and Supports (LTSS), people can live meaningful lives at all stages of life, according to their goals and priorities; people can contribute in a way that is meaningful to them.
Minnesota’s long-term supports and services system is flexible, responsive and accessible to people who have an assessed need for LTSS.
The LTSS system is well-managed to ensure future sustainability for those who will need it.

4. Goals of HCBS Redesign 1) Better Individual Outcomes
Increased flexibility to better meet the needs of each individual;
Increased stability in the community;
Better-informed individual decision-making about LTSS options;
Promotion of person-centered planning: life-long and crisis;
Improved transitions between settings and programs, preventing avoidable health crises;
Recognize and address the social determinants of health care need and cost.

5. Goals of HCBS Redesign 2) Right Service at the Right Time
Low-cost, high-impact services reach people earlier.
Decreased reliance on more costly services.
HCBS, not institutional care, is the entitlement.
3) Ensuring the Future of LTSS
Increased sustainability of the LTSS system;
Increased efficiency in the use of public LTSS resources.

6. Reform Strategies
Improve navigation and streamline access to services and supports;
Redesign and improve services;
Increase service coordination and service integration;
Increase efficiency and sustainability of administrative systems.

7. Community First Services and Supports
A redesign of the Personal Care Assistance Services benefit in order to:
better meet the needs of each individual;
increase and support each individual’s independence and recovery;
support the stability of the individual;
promote the ability of the individual to direct and his/her own services.

8. Community First Services and Supports
A redesign of the Personal Care Assistance Services benefit in order to:
reduce service barriers, gaps and duplication;
serve people earlier with less intensive services, in some cases delaying or avoiding need for more intensive services;
be more flexible and responsive and better able to adjust quickly to changing circumstances without high-intensity services;
simplify administration of services; and
create a more sustainable system.

9. Community First Services and Supports (CFSS) – replaces PCA
Flexible service can include:
Assistance
Teaching
Coaching
Prompting
Home modifications to replace human assistance
Technology to replace human assistance
Transition services
Provider standards to promote access to agencies and staff with appropriate skills.

10. Community First Services and Supports
Outcomes for CFSS
Individuals will:
Recover and/or gain skills to increase and maintain community stability
Access the right service by the right provider at the right time
Use technology or modifications to decrease need for human assistance when appropriate
Delay or avoid the need to access other programs
or more costly services
Avoid use of inappropriate services
Increasingly direct their own services

11. Summary of 1915(k) Regulations
Scope: Make home and community-based attendant services and supports available to eligible individuals, as needed, to assist in accomplishing ADLs, IADLs, and health-related tasks through hands-on assistance, supervision, or cueing. Services and supports must be provided statewide and in the most integrated manner possible.

12. 1915(k) Regulations
Implementation Council: A Development and Implementation Council must be established with a majority of individuals with disabilities, elderly individuals and their representatives. States must consult and collaborate with the Council when developing and implementing a State plan amendment to provide 1915 (k) services and supports.

13. 1915(K) Regulations Included Services:
Assistance with ADLs, IADLs and health-related tasks;
Acquisition of skills necessary for the individual to accomplish ADLs, IADLs, and health-related tasks
Back-up systems to ensure continuity of services and supports
Voluntary training on selecting, managing and dismissing attendants
Optionally, expenditures for transition costs and expenditures related to increasing independence or substituting for human assistance, if assistance would otherwise be needed.

14. 1915 (K) Regulations
Assessment: Assessments must be conducted annually, and generally face-to-face, although telemedicine may be allowed, and must support the development of a person-centered service plan and, if applicable, service budget. Person-centered Service Plan: The planning process must be driven by the individual and include people selected by the individual. It must provide the information and support needed to ensure the individual directs the process to the greatest extent possible.

15. 1915 (K) Regulations
Service Models: States may choose one or more service-delivery models, including:
Agency-provider models, which operate under contract or provider agreement with the State,
Self-directed models with service budget, which may operate with several financial management options, including a financial management entity, a cash system, or a voucher system.
Other models as developed by the State and approved by CMS.

16. 1915 (K) Regulations
Support System: must provide adequate information, counseling, training and assistance, as needed, to ensure that the individual is able to choose and manage their services, models and budgets. This support must include information on:
person-centered planning
the range and scope of individual choices
the process for changing plans, services and budgets
the grievance process
individual rights
identifying and assessing appropriate services
risks and responsibilities
and risk management.

17. 1915 (K) Regulations
Service Budget Requirements: The service budget for the self-directed model with a service budget must include the specific dollar amount the individual can use for services and supports as well as the procedures for:
informing the individual about the budget before the person-centered service plan is finalized
adjusting the budget
determining circumstances that may lead to a change in the budget
determining transition costs
requesting a fair hearing if the individual’s request for a budget adjustment is denied or the budget is reduced.

18. 1915 (K) Regulations
Provider Qualifications: For all service delivery models, the individual retains the right to
train their attendant care providers to meet their specific needs and in the manner that meets their personal, cultural and/or religious preferences
establish additional staff qualifications based on their needs and preferences
access other training provided by the State.
For the agency-provider model, the State must define adequate qualifications for providers.
For the self-directed model with service budget, an individual has the option to hire family members or others, provided they meet the qualifications established by the individual.

19. 1915 (K) Regulations
Quality Assurance System: The State must establish a comprehensive, continuous quality assurance system, which includes:
A quality improvement strategy
Methods to continuously monitor the health and wellness of each individual receiving services and supports
Outcomes measures
Standards for all service delivery models
Methods for maximizing individual independence and control, and
Methods for eliciting and incorporating feedback from individuals and their representatives, disability organizations, providers, families, community members and others to improve the quality of the services and supports benefit.

20. 1915 (K) Regulations
Data Collection: The State must collect and provide information annually on the number of individuals served and the types of services and supports provided.
Increased Federal Participation: Federal Medical Assistance Percentages applicable to the State will be increased by 6% under an approved State plan amendment.

21. 1915 (K) Regulations State Assurances: The State must
must meet or exceed previous levels of State expenditures for home and community-based attendant services and supports provided to individuals with disabilities or elderly for the first year
take necessary safeguards to protect the health and welfare of enrollees

22. Self-Direction & Risk Management
The risk assessment and mitigation plan (or risk plan) is a written document for the participant that
initially identifies risks for him/her living in the community with supports
Outlines how these risks will be addressed/mitigated
Is periodically reviewed and modified so that it is responsive to changing risks over time.
The risk plan should be a component of the participant’s person-centered service plan

23. Risk Assessment & Mitigation Plan
Customized and person-centered
Identifies and documents all risks a participant might encounter when living in the community with supports
Includes the participant and his/her designated representative, as appropriate, in the process
Honors the participant’s preferences and appreciates his/her values

24. Risk Assessment & Mitigation Plan
Allows participants the right to assume risk
Conducted in the spirit of facilitating the participant to live successfully in the community, not as a way to prevent/discourage community living
Provides an opportunity for the participant and his/her designated representative, as applicable, to review and provide feedback