1. DBHDS Virginia Department of Behavioral Health and Developmental Services Improving Discharge Processes Updates on Waiver Changes Heidi Dix Assistant Commissioner of Development Services, DBHDS October 13, 2011

2. Page 2 DBHDS Virginia Department of Behavioral Health and Developmental Services DOJ Findings Lack of adequate care within the Training Centers Insufficient waiver slots to transition individuals to the community Limited ID waiver program capacity to serve everyone in need Current waiver rate structure and design does not allow the flexibility needed to serve individuals with the most complex needs in the community Many day programs do not provide individuals with opportunities for meaningful work. The Commonwealth’s Treatment and Discharge Planning process does not meaningfully identify people’s needs, barriers to discharge, and ways to address those barriers Specialized community services (medical, dental, crisis) are not adequate to serve those in the community Lack of sufficient oversight of community providers.

3. Page 3 DBHDS Virginia Department of Behavioral Health and Developmental Services CATEGORIESEXPECTATIONS Family Reluctance & Family Education/Support -ARS should be involved in treatment planning and support -If AR is opposed to moving, the TC should document the steps taken to ensure that they are making informed choice and implement strategies -Educate individuals and ARs about the community and various community living options on a routine basis. Staff Education/Training Staff must be knowledgeable of available community services and coordinate with providers to ensure support needs are met Person-Centered Planning Process Virginia’s PCP should be consistently applied, and discharge planning process should meaningfully indentify people’s needs, barriers to discharge and ways to address those barriers Collaboration with CSBs CSBs must closely coordinate with TC to develop Person-centered discharge plans that address most integrated setting Providers Providers must be given information necessary to plan supports to serve individuals in TCs,and participate in educating staff Community Capacity/Resources State should develop and implement a plan to expand supports needed to move individuals into the community, including individuals with complex health care needs, behavior problems and/or mental health diagnosis. Post Monitoring Develop and implement a system, to monitor community-based homes and supports to ensure that they are in accordance with PCP and the individualized discharge plan.

4. Page 4 DBHDS Virginia Department of Behavioral Health and Developmental Services Components of Discharge Assessment Gathered written procedures and protocols Reviewed job descriptions Met with key members Discussed what has/has not worked Discussed how key players envision Virginia’s system Discussed how data is collected

5. Page 5 DBHDS Virginia Department of Behavioral Health and Developmental Services Overall Strengths Great Attendance & Candid input Best Practices Creative thinking Increased focus on educating staff Increased focus on family reluctance Increased coordination between TC and CSB

6. Page 6 DBHDS Virginia Department of Behavioral Health and Developmental Services Areas for Improvement PCP/PCT implemented in varying degrees ISPs varied in relation to supports needed for movement Barriers addressed inconsistently Large variation in knowledge of community options Large variation in discharge processes and timelines Lack of PST cohesiveness and role clarity

7. Page 7 DBHDS Virginia Department of Behavioral Health and Developmental Services Next Steps Develop a consistent discharge process across TCs/regions Clarify key players and responsibilities Implement system to identify supports needed to move individuals and match them with providers/supports Identify gaps in services & work with regions to develop capacity building strategies and address system barriers to moving Improve system of training and supports Improve system of checks and balances (accountability)

8. Page 8 DBHDS Virginia Department of Behavioral Health and Developmental Services Current System: Training Center Census Trend Training Center Average Daily Census (ADC) FY 1976-FY2009 There is a shift in what families are choosing Average discharges = 70 per year Average long-term admissions = 16 per year

9. Page 9 DBHDS Virginia Department of Behavioral Health and Developmental Services 9 Waiver Capacity Data from DMAS alpha claims report & wait list for DD & DBHDS 7/1/11 Variance between capacity and enrollment resulted from 1 month lag in data processing Slots approved by CMS & GA

10. Page 10 DBHDS Virginia Department of Behavioral Health and Developmental Services Current System: Persons with ID/DD Awaiting Services by Type of Service, FY10* Community waiting lists – 5,472 for ID waiver (2,940 urgent need) and 1,100 for DD waiver

11. Page 11 DBHDS Virginia Department of Behavioral Health and Developmental Services Re-Examining Waiver Programs Item 397, paragraph BBBBB of the 2011 Appropriations Act mandates a study of waiver programs due October 1, 2011 Revised submission date – December 1, 2011 In July 2011, a meeting was held with stakeholders to discuss: –Creating a waiver(s) that matches needs to services, not diagnosis to waiver –Ensuring people with the most complex medical and behavioral needs can be served –Expanding capacity for those on the wait list for services –Modifying waiver rate structure for residential care and encourage placement in the most integrated setting –Enhancing waiver payment rates for critical services (behavioral, nursing, etc.) –Reducing documentation requirements –Moving self-direction further towards individual budgets and individual resource allocation

12. Page 12 DBHDS Virginia Department of Behavioral Health and Developmental Services 12 Medicaid Waiver Strengths Less restrictive home environment More cost effective, in the aggregate, than alternate institutional settings Cost sharing with CMS (50%) Offer individualized services Maintains individuals homes in communities Coordination of services

13. Page 13 DBHDS Virginia Department of Behavioral Health and Developmental Services 13 Medicaid Waiver Challenges Inadequate capacity (e.g. slots) Rates inadequate in some service categories Service categories need updating Not set up to serve those with the most complex medical and behavioral needs

14. Page 14 DBHDS Virginia Department of Behavioral Health and Developmental Services 14 Data Shows Variation in Costs to Meet Different Levels of Need FY2010RecipientsAverage Per Person Expenditure Training Center (Public ICF/MR)1,296$160,964 Private, Community ICF/MR391$137,552 ID Waiver Recipients8,010$75,465 ID Waiver Recipients -- NOT Using Congregate Residential 3,186$46,266 ID Waiver Recipients -- Using Congregate Residential 4,824$95,279 Training Center Discharges to ID Waiver25 (sample)$104,255

15. Page 15 DBHDS Virginia Department of Behavioral Health and Developmental Services Budget- Item 297, BBBBB 15 Short Term OptionsLong Term Options Adjust Medicaid provider rates to increase availability of smaller residential settings Create an exceptional rate for individuals receiving residential support services (high medical and/or behavioral needs) Increase number of services available in the Day Support Waiver Modification of target population Modification of the case management structure Adjustment to the waiting list process