D EVELOPMENTAL D ISABILITIES A DMINISTRATION R ESOURCE C OORDINATION S ERVICES Training #1 June 5,...

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DEVELOPMENTAL DISABILITIES ADMINISTRATION

RESOURCE COORDINATION SERVICES

Training #1June 5, 2012

Community

Employment

Holistic

CoordinationQuality

Assurances QualityMonitorin

g

Performance Outcomes

RCFunding

Serv

ices

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AGENDA Welcome

Quality Framework and Continuous Quality Improvement

Resource Coordination Service Framework FY 2013

Process, Policies, and FormsUpdatesHelpful StrategiesRemindersPerformance Measure Links

*Please make a note or flag topics you would like to see more in-depth training

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WELCOMEBy: Stanley Butkus

DDA Deputy Director

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RESOURCE COORDINATION

Helpful information What resource coordination is (and isn’t) How it works Key functions Connections to services Interagency activities Responsibilities

Stanley Butkus

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RESOURCE COORDINATION – THE

WHY Assist and support individuals in leading life

of quality and meaning to them.

Be realistic but understand that a person is not the sum of their deficits and diagnosis.

We deal with the whole person and the standard is how would we want to be treated in similar circumstances.

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WHY For all the good work of agencies, networks and

systems and the wise guidance of policies, procedures and funding formulas; we are ultimately dealing with people’s lives, individual biographies. And we do it one person at a time.

Resource coordination is: the face of the service system for the person

and those people who are important in their lives;

the eyes and ears of our system; and the first level of monitoring.

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WHY No two people or those in their lives are the

same.

There may not be agreement between the person and their family members about what is best or appropriate which can be a source of conflict.

Some are very involved some are distant, even disengaged in some situations.

There may be some situations where you are as close as it gets to being a family member.

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RESOURCE COORDINATION – THE WHY

The resource coordinator is the agent of the person, an advocate and problem solver.

A connector through the individual plan to their communities.

One expert in our field ( David Pitonyak) has said that the biggest problem people with intellectual and cognitive disabilities face is loneliness.

You may be able to think of situations in your own life where something was just beyond your grasp intellectually and when there is no one there to check in with you can feel alone-IT does this to me.

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Resource coordinators are independent of agencies providing other services.

This provides the opportunity to act and advocate in concert with the wishes and best interests of people when there are issues that need to be addressed.

The resource coordinator serves expressive and instrumental roles that vary by time and circumstance.

Expressive in the sense of providing emotional and empathic support and instrumental in making sure that as needed the person is supported appropriately residentially, in day and employment situations and for related needs.

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Essential role is the resource coordinator’s connection to the plan.

Developing a plan that is authentic to the person, identifying how life goals will be met taking needs and preferences into account and overseeing, and monitoring progress is at the heart of resource coordination.

In other words, assuring that people get what they need, when they need it, by people who know what they are doing. Matching person needs with care and service provider strengths/preferences for those they serve and support is the key to success. Cross training has its place but everybody cannot work well with everybody.

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RESOURCE COORDINATION DAILY COMMITMENT

Listen to understand the person’s story

Hold the person in positive regard- because any of us are capable of doing anything (good or bad) that anybody else did in human history if we were in a similar circumstance.

Begin where the person is

Use a positive behavior supports frame

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Expectations-overtime we have as a field systematically underestimated what people with disabilities can achieve. As we have learned better approaches they have done better. Conversely, with the best of intentions we have expected them to be better citizens than the rest of us-not make any mistakes-creating the unintended consequence of increasing dependency.

Sensitivity to diversity, and socio-economic factors, e.g. 49% of waiver recipients in the US have a family income of less than $25,000 per year

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These are stressful jobs. You need to take care of yourself. Burnout

occurs when what you want to is out of reach with what you can do.

Be clear on what your functions are and stick to those.

Seek guidance from your supervisor on how to prioritize when you get overloaded.

Know the rules, processes, assurances, and resources and seek additional training or advice.

Someone once said the only place in town where there is no conflict is in the cemetery so if you get a chance get some training in conflict resolution and mediation.

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DDA PHILOSOPHY People with developmental disabilities are

valuable and contributing members of their community.

People and families should have access to necessary services and supports, from various resources, in the least restrictive, most appropriate, and most effective environment possible.

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DDA SERVICE DELIVERY OVERVIEW

DDA provides a coordinated service delivery system so that people with developmental disabilities receive appropriate services oriented toward the goal of integration into the community.

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DDA services are provided through both State and federal funding and programs provided by a wide array of community-based services delivered, State Residential Centers (SRC), and Forensic Residential Centers (FRC).

Community-Based

Services*Waivers*State Funded

State Residenti

al Centers

Forensic Residenti

al Centers

State $

Federal

$

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Resource coordinators must: Be familiar with and maintain compliance

with these State and federal laws and regulations, which may be amended during the upcoming fiscal year;

Be knowledgeable and trained in DDA’s: Waiver and State funded procedures and

quality assurances; and Priorities and initiatives.

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DDA IS COMMITTED TO COORDINATING SERVICES AND SUPPORTS THAT ARE:

Individualized, reflecting a continuum of services and/or supports, both formal and informal, based on the unique strengths of each person and their family/caregivers;

Provided in the least restrictive, most natural setting appropriate to meet the needs of the person and family;

Person directed;

Family-driven and child/youth-guided, with families, children, and youth engaged as active participants at all levels of planning, organization and service delivery;

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Community-based, coordinated and integrated with various services and supports including generic (i.e. services available to the public at large), community, local, federal, and State programs for needed medical, social, educational, and other services including community housing agencies, connecting the person with self advocacy groups, recreation, social, and DDA services;

Culturally and linguistically competent, with agencies, programs, services and supports that are responsive to the cultural, racial and ethnic differences of the populations we serve;

Prevent and reduce crisis, emergencies, hospitalization, and institutionalization;

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Holistic including generic, local, State, federal, and other resources and funding beyond DDA;

Promote integration with the community at large;

Protective of the rights of children, youth, adults, and their family/caregivers; and,

Collaborative across long term services and support systems, involving Medicaid and other insurances, mental health, child welfare, juvenile services, education, substance abuse, somatic health and other system partners who are responsible for providing services and supports to people eligible for DDA funding.

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Waiver Roles & Responsibilities Person – self determination and self-directed (if

desired) Resource Coordinator

Initial application Service planning – holistic Monitoring – proactively monitoring services, due

dates (plan, LOC, financial redetermination, etc.) circumstances, and needs

Eligibility –annual requirements including Medicaid Financial documentation, LOC, annual plans within 365 days,

Support Broker – Human Resource functions FMS – Accounting and payroll functions Service providers – staff that work for the waiver

participant

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CONTINUOUS QUALITY IMPROVEMENT

The DDA is committed to conduct ongoing system-wide reviews of ways to improve the effectiveness of services and supports so people can achieve personally developed outcome through: better coordination and delivery of

services; accountability of funding; federal assurances; and alignment of priorities and strategies.

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This commitment includes strategies to continuously support DDA’s system of highly qualified and resourceful resource coordinators that are knowledgeable of community resources and creative problem solvers to assist people with becoming fully integrated in their communities.

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Linking people and families to natural and informal networks leads to improved outcomes and reduced reliance on formal services.

These linkages are essential to be fully integrated in one’s community.

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Quality and the cost of service are both important and inter-related.

Services

Cost

Quality

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Lack of monitoring of quality of services may negatively impact health and safety and progress toward goals.

Poor planning and lack of brokering community resources, to include natural supports, may over commit funding for one person which deprives another person of needed services.

It is also true that failing to seek funding in the interest of “cost savings” may impede health and safety, quality, and increase cost pressures in other parts of the system (such as emergency rooms and institutions).

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DDA RESOURCE COORDINATION

CORE SERVICE CATEGORIES

Eligibility &

Access

Waiting List

Community

Coordination

Transitioning to Commu

nity

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SYSTEM GOVERNANCE AND REGULATIONS

State and federal statutes and regulations govern the DDA service delivery system.

• Health General• COMAR 10.22

DDA CMS stands for the Federal Center for Medicaid and Medicare Services

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MEDICAID WAIVER BASICSBackground Community Pathways and New Directions are

both Medicaid programs referred to as 1915 (c) Home and Community-Based Service (HCBS) waivers.

Medicaid is a joint federal/State funding program that pays for most long term care provided to low income, older persons and persons with disabilities.

The HCBS waiver allows states to use Medicaid funding to provide services and supports to persons living in their homes or in other community-based settings (e.g. group homes, alternative living units, IFC (DDA’s adult foster homes)).

Reference: CMS Training for Case Managers on HCBS Waiver Assurances

Link: http://www.hcbsassurances.org/index.html

http://www.hcbsassurances.org/index.html

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WAIVER BASICS - CONTINUED Persons are eligible to receive HCBS waiver

services if they meet federal qualification criteria.

A state must apply to the CMS through an HCBS waiver application for permission to operate an HCBS waiver.

Regardless of the HCBS waiver design, every application must address how a state intends to meet specific CMS requirements known as the HCBS waiver assurances.

The assurances were put into place by Congress to address the unique challenges of assuring the quality of services delivered to vulnerable persons living in their community.


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WAIVER BASICS - CONTINUEDHCBS Waiver programs must include the following:


Waiver Design

Performance

Measures

Discovery Methods

Remediation

System Improvem

ent

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WAIVER BASICS - CONTINUED

Waiver Design: The population and geographic area to be served, the mix of services offered, the quality standards, including provider qualifications, policies and payment methods.

Performance Measures: The standards a state will use to evaluate how well the HCBS waiver is meeting each of the federal assurances and subassurances.


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WAIVER BASICS - CONTINUED

Discovery Methods: The data a state collects to measure how well it is meeting each performance measure; the method and frequency of data collection and analysis; and the person or entity responsible for using the data for decision-making.

Remediation: How a state will take action when individual problems are found.

System improvement: Method to prevent similar problems from happening to others or to make the HCBS waiver more effective and efficient.


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REMEDIATION Focus of remediation is to address and resolve all

individual problems uncovered in the course of discovery.

The rate of compliance is measured through the waiver’s performance measures.

CMS expects states to be in compliance with the statutory assurances.

If a performance measure indicates that the state achieved less than 100% compliance, the state must remediate all instances of non-compliance discovered.

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HCBS WAIVERS ARE:

Person centered;

Encourage people to play active roles in deciding the services they want to receive and when; and

Can make a big difference in the person’s and families quality of life.


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CHALLENGES IN ASSURING QUALITY IN HOME-BASED SETTINGS

Delivering services in home and community settings raises new challenges to assure the quality of these programs. There is no one on site to monitor care and services

at all times. Participants rely on many people for their care and

safety. Participants may be vulnerable and unable to seek

help. People may be afraid of losing their services if they

report problems.

So what are the assurances, and how do they relate to you?


QA?

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FEDERAL HCBS WAIVER ASSURANCES

Level of Care

Service Plan

Qualified Providers

Health &

Welfare

Financial Accountability

Administrative

Authority

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Level of Care: Participants enrolled in the HCBS waiver meet the level of care criteria consistent with those residing in institutions.

Service Plan: A person's needs and preferences are assessed and reflected in a person-centered service plan.

Qualified Providers: Agencies and workers providing services are qualified.


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Health and Welfare: Participants are protected from abuse, neglect and exploitation and get help when things go wrong or bad things happen.

Financial Accountability: A state Medicaid Agency pays only for services that are approved and provided, the cost of which does not exceed the cost of a nursing facility or institutional care on a per person or aggregate basis (as determined by the state).

Administrative Authority: A state Medicaid Agency is fully accountable for HCBS waiver design, operations and performances


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FEDERAL HCBS SUBASSURANCES EXAMPLES

Reference: Understanding Medicaid Home and Community Services: A Primer, 2010ase Managers on HCBS Waiver Assurances (PDF Version: http://aspe.hhs.gov/daltcp/reports/2010/primer10.pdf (253 PDF pages))

TABLE 2. Examples of Subassurances(Version 3.5 of the §1915(c) Waiver Application)

Level of Care The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver

Service Plan Service plans are updated/revised at least annually or when warranted by changes in the waiver participant’s needs

Service Plan Services are delivered in accordance with the service plan, including in the type, scope, amount, and frequency specified in the service plan.

Service Plan Participants are afforded choice: between waiver services and institutional care; and between/among waiver services and providers.

Provider Qualifications

The state verifies that providers initially and continually meet required licensure and/or certification standards and adhere to other state standards prior to their furnishing waiver services.

http://aspe.hhs.gov/daltcp/reports/2010/primer10.pdf

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ASSURANCES

SUBASSURANCES

PERFORMANCE MEASURES

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MARYLAND’S DD WAIVERSFEDERAL ASSURANCES


Performance Measures

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#1 - Number and percent of new waiver enrollees who had a level of care indicating the need for institutional level of care (ICF/ID) prior to receipt of services.

#2 - Number of completed annual LOC re-certifications over the number of active waiver participants.

*Performance Measures for both Community Pathways and New Directions Waivers

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#1- Number of IPs containing required information per COMAR 10.22.05.02

#2- Number of IPs surveyed that document supports necessary to achieve goals

#3- Number of IP reviewed within a year (365 days)


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#4- Number of people receiving services specified on their IP

#5- Number of people provided choice between community based services and institutional care

#6 - Number of people with choice between and among waiver services and providers


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#1- Number of providers licensed prior to the delivery of waiver services

#2- Number of licensed providers that offer all required direct care staff training

#3- Number of direct care staff that have completed all required training


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#4- Number of licensed service providers that have current approved QA plans

#5- Number of direct care staff that has undergone a criminal background check (New Directions Only)

#6- Number of Support Brokers that have completed all required training (New Directions Only)

*Performance Measures for both Community Pathways and New Directions Waivers unless otherwise indicated.

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PERFORMANCE MEASURES#1- Number of people who receive medical services as recommended by their physician(s)

#2- Number of people reporting they are free from mistreatment

#3- Number of incidents involving unauthorized or inappropriate use of restraints

#4-Percent of deaths based on population count vs. percent of deaths of Maryland population and US population


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PERFORMANCE MEASURES#5 - Number of budget modifications reviewed by resource coordinators (New Directions Only)

#6- Number of people with 2 level back up plans in their IP&B (New Directions Only)

#7- Number of critical incidents reported (New Directions Only)

#8 -Number of reportable incidents that are reported within required timeframes (New Directions Only)


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#1 - Number of DDA licensed waiver providers appropriately billing for services rendered

#2 - Number and percent of waiver service claims reviewed that were submitted for participants who were enrolled in the waiver on the date that the services was delivered

#3 - Number of rate based DDA licensed providers with completed annual independent audits


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Knowledge Check Question 1Which of the following statements is not true?A. HCBS stands for Home and Community Based

Services.B. The HCBS waiver is an alternative to institutional

care.C. Everyone who needs long term care is eligible for

an HCBS waiver.D. States must apply to CMS for permission to operate

an HCBS waiver.E. States have flexibility in how they design their HCBS

waiver.

F. All of these statements are true.


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Knowledge Check Question 1 - Answer

C. Everyone who needs long term care is eligible for an HCBS waiver.

Statement C is not true. HCBS is a Medicaid program serving low-income individuals. In addition to meeting programmatic eligibility, such as a need for institutional level of care, individuals must also be financially eligible for HCBS.


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Knowledge Check Question 2Which of the following is not a federal assurance?A. Level of Care B. Service PlanC. Qualified Providers D. Health and Welfare E. Standard Design F. Financial Accountability G. Administrative Accountability H. All are Assurances


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Knowledge Check Question 2 - AnswerWhich of the following is not a federal assurance?E. Standard Design

Correct. Standard Design is not an Assurance. CMS allows some flexibility in how states design their HCBS programs. For instance, states can decide the target population to be served, how many people to be served, the services to be provided, the geographic area to be served and the administrative structure for operating the waiver.


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Knowledge Check Question 3The federal assurances are:A. Assurances that states make to CMS in order to

operate an HCBS waiver.B. Designed to promote quality.C. Directly relate to the role of the resource

coordinator. D. All of the above.


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Knowledge Check Question 3 - AnswerThe federal assurances are:A. Assurances that states make to CMS in order to

operate an HCBS waiver.B. Designed to promote quality.C. Directly relate to the role of the resource

coordinator. D. All of the above.

All three of these statements are true.


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Why is it important for you to know about the six assurances and performance measures?

Because the assurances and performance measures have an impact on your work each and every day.


Much of what you are asked to do, and particularly how you are asked to document what you do, tie back to the assurances and performance measures.

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RC QUALITY ROLES AND RESPONSIBILITIES

RC is critical for connecting people and their families to services and supports within DDA and various other systems or community resources including medical services, educational services, housing assistance, food stamps, public transportation, social activities, etc.

As a resource coordinator, you play a key role in assuring that the services and the waivers work to meet participant needs and improve outcomes.

Resource coordinators understand how quality services and supports protect vulnerable people and keep families together.

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QUALITY ROLES AND RESPONSIBILITIES

RC covers a wide range of assessment, planning and coordination, referral, and monitoring activities to assist a person to obtain and retain services needed, including comprehensive assistance in gaining access to needed supports and services regardless of how the services are financed.

But others are involved in this process as well. In fact, the HCBS waiver quality cycle has multiple partners with multiple roles.

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WAIVER QUALITY REQUIREMENTS

RCRC

RC

- Resource Coordinator


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CMS WAIVER QUALITY REQUIREMENTS

RCRC

RC



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WAIVER QUALITY REQUIREMENTSThe quality cycle begins with the federal

role and the responsibilities of CMS.

CMS RoleCMS defines HCBS waiver requirements and is

responsible for determining that each HCBS waiver meets the six federal assurances. CMS oversight of HCBS waivers also includes:

Sets policy and requirements for HCBS waivers based on the assurances.

Approves HCBS waiver applications submitted by a state.

Reviews the state’s evidence to determine if the HCBS waiver meets federal assurances. Some of this evidence may come from your records.

Reports to Congress on the performance of HCBS waiver programs.Reference: CMS Training for Case Managers on HCBS Waiver Assurances

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If a state meets the six assurances, as determined by a review of evidence, CMS will approve the state’s renewal application and the state will be able to continue providing HCBS waiver services.


Level of Care

Service Plan

Qualified Providers

Health & Welfare

Financial Accounta

bility

Administrative

Authority

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Where does that state evidence come from?

In part, it comes from you such as IPs and other data from records to assess federal assurances.

States combines these data with reviews from other agencies (i.e. OHCQ, Medicaid) to produce reports, known as evidence.

As part of the waiver renewal process, a state must provide evidence demonstrating a continuous quality improvement process and compliance with the HCBS waiver assurances.

If a state meets the six assurances, as determined by a review of evidence, CMS will approve the state’s renewal application and the state will be able to continue providing HCBS waiver services.


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If the evidence is found to be insufficient, states are required to develop an improvement plan for collecting the evidence and/or improving areas known to be weak.

If states persistently fail to provide evidence or fail to meet HCBS waiver assurances, CMS has the authority to terminate the HCBS waiver program.


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DDA is committed to improving quality is all waiver assurances and conducting ongoing system-wide reviews of ways to improve.

Coordination

Service Delivery

Accountability of

Funding

Federal Assurance

s

CQI

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MEDICAID’S WAIVER QUALITY REQUIREMENTS

RCRC

RC



DDA

&DDA’s

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State Medicaid Agency RoleThe state Medicaid Agency is accountable to

CMS for the design and operation of its HCBS waivers.

The DD waivers are managed by Sandra Brownell from the Office of Health Services (OHS).

DDA manages or operates the DD waiver programs, but the state Medicaid Agency has final authority.


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WAIVER QUALITY REQUIREMENTSWhat does our state Medicaid agency do? Determines the rules and policies under which

the HCBS waiver operates in your state. These rules must be consistent with Federal assurances.

Monitors that rules and policies are being met. Your state looks at participant records, provider agency records, program data and results of participant surveys to assess performance.

Works with other state agencies with responsibilities for quality (e.g., state licensure, protective services).

Arranges special investigations and hearings on serious issues.


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WAIVER QUALITY REQUIREMENTSWhat does your state Medicaid agency

do?

Identifies and supports quality improvement initiatives.

Enforces rules and policies through sanctions, fines and termination.

Reports to CMS, including evidence reports showing that it meets the terms of the HCBS waiver and the assurances.


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WAIVER QUALITY REQUIREMENTSWhat does your state Medicaid agency

do?

Identifies and supports quality improvement initiatives.

Enforces rules and policies through sanctions, fines and termination.

Reports to CMS, including evidence reports showing that it meets the terms of the HCBS waiver and the assurances.


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WAIVER QUALITY REQUIREMENTSWhat is DDA responsible for? Determines the rules and policies under

which the providers (including resource coordination, support brokers, fiscal management services, and service providers) perform.

Monitoring providers including reviewing participant records, provider agency records, program data and results of participant surveys to assess performance.

Quality – discovery, remediation, and system improvements.

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ONE DDA QUALITY SYSTEM

DDA

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One DDA Quality System with Multiple Strategies and Activities

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RC’S WAIVER QUALITY REQUIREMENTS

RC

RC



DDA

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QUALITY PERSON-CENTERED SERVICES AND SUPPORTS

At the center of the system are the people we serve: the entire system is created to assure that participants get the individualized services and supports they need.

But who is responsible for assuring the quality of those services?

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Resource Coordinator’s Quality Role Ultimately, quality services and supports

begin with the interaction between a participant and a resource coordinator; quality depends on your ability to implement the safeguards contained in the federal assurances.


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WAIVER QUALITY REQUIREMENTSResource Coordinator’s perform the following

core functions in assuring the quality of an HCBS waiver:


Assessment

Plan Developm

ent

Information &

Referral

Monitoring

Remediation

Quality

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RC CORE FUNCTIONS

Assessment: The foundation of your work is an accurate evaluation of a participant’s strengths, needs, preferences, supports and desired outcomes.

Service plan development: You work with participants to design a service plan that enables them to meet their goals.

Information and Referral: You provide information to help participants choose qualified providers and make arrangements to assure providers follow the service plan.


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RC CORE FUNCTIONS

Monitoring: You make sure participants get authorized services and that services meet individual needs and goals.

Remediation: You resolve problems when something goes wrong as well as anticipate the potential for problems including health and safety issues (i.e. provider failure to take person for medical follow up, late annual plans, etc.)


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RC CORE FUNCTIONS

In addition to the important work you do to promote quality directly with participants, as resource coordinator you have an equally important role in documenting what you do.

Good documentation: Allows you to review your work and track

changes.

Provides continuity for others who work with the person.

Helps you, service providers, DDA, and Medicaid identify opportunities for quality improvement.

Provides the evidence required by Medicaid and DDA to meet the federal assurances.


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RC QA CORE FUNCTIONS

The information you provide through your documentation not only provides evidence that you are meeting the assurances, it also impacts future services.

This is the quality improvement aspect of this cycle.


Documentation &

Information

Lesson’s Learned

Knowledge and

Experiences

New HCBS Services

Better Outcomes for People

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RESOURCE COORDINATION

SERVICE FRAMEWORK FISCAL YEAR 2013

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RC SERVICES WILL SUPPORT:

1. People in community services -regardless of Waiver or Stated funded

2. People on the Waiting List – all people in crisis resolution,

crisis preventions, and current request based on available resources and methodology

3. People transitioning from a facility to the community

Note: DDA primary services are “habilitative” compared to rehabilitative, medical, and behavioral health services.

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DDA RC SERVICES OVERVIEW

Eligibility Assistance Services

Waiting List

Coordination

Services

Community

Coordination

Services

Transition Coordinat

ion Services

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DDA RC SERVICE CORE FUNCTIONS

Resource Coordinator’s perform the following core functions in assuring the quality of an HCBS waiver:


Assessment

Referral & Related

Activities

Plan Developm

entMonitorin

g

Remediation

Quality

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ELIGIBILITY ASSISTANCE SERVICES - ASSESSMENT

Comprehensive Assessment of the person’s needs and supports to determine eligibility within 45 days of referral by DDA including analysis of the following:

General medical, developmental, and mental condition;

Desires, expectations, dreams, aspirations, and goals;

Environmental, social, and functional status; Full range of service needs and preferences;

and Completion of the DDA Critical Needs

Recommendation form. LOC

Performance Measure

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ELIGIBILITY ASSISTANCE SERVICES - ASSESSMENT

Assistance with information gathering such as obtaining professional evaluations and assessments necessary to document and confirm eligibility and priority for services;

DD Eligible SO Eligible

Crisis Resolution

Crisis Prevention

Current Request

Future Need

or

or or

or

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ELIGIBILITY ASSISTANCE SERVICES - STRATEGIES

Become expert on the DDA Eligibility Criteria – DD, SO, and priority

Recommendations based on facts and supporting evidence as it relates to the established criteria in Health General and COMAR

Eligibility process should be transparent to people and families

New Eligibility Guide (Under development)

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ELIGIBILITY ASSISTANCE SERVICES - STRATEGIES

Eligibility AppealsDuring appeals, 90% or more are settled

before they ever go to hearing.

After the family receives clarification about the matter through dialogue with staff, many appeals are withdrawn.

If we communicate the process better from the beginning we can minimize confusion, frustration, and time

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REFERRAL AND RELATED ACTIVITIES

Referral and related activities occur: At time of initial meeting and

Any follow up contacts, such as sharing information, making referrals, monitoring, and assisting the person with applications to: Community connections, generic, and

natural supports; and State and federal programs.

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MONITORING AND FOLLOW-UP ACTIVITIES

Monitoring of progress and services are essential for people to achieve their outcomes and goals.

Person specific plans and services that:Demonstrate no or negative results, Maintain people in restrictive settings, or Impede employment opportunities

shall be re-evaluated and redesigned to more effectively meet the needs of the person

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Monitoring of progress and services are essential for people to achieve their outcomes and goals.

Person specific plans and services that demonstrate:No or negative results, Maintain people in restrictive settings, or Impede employment opportunities

shall be re-evaluated and redesigned to more effectively meet the needs of the person

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Monitoring and follow-up activities, in format approved by the DDA, which includes:

Within thirty (30) days of service initiation, review the IP and update or modify as needed.

Minimum quarterly face-to-face contact with the person to assess current needs and satisfaction

Meetings shall be conducted in the different settings where DDA services are being rendered (i.e. own home, day program, group home/alternative living unit);

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Monitoring, follow-up, and documentation (in format approved by the DDA) on the implementation of the plan to include assessment of:

Service PlanPerformance

Measures

Services being rendered as specified in the plan,

Progress toward goals, Routine medical care, needed health

services, and follow up, Request for service change and

modifications to meet health and safety needs and goals,

Back up plans for direct care staff and natural disasters;

H & WPerformance Measures

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Assist with on-going referrals as needed;

Assistance with transitioning to new services, providers, and/or unpaid supports;

Monitoring, follow-up, and documentation on all reportable incidents as defined in DDA’s Policy on Reportable Events ( http://dda.dhmh.maryland.gov/SitePages/policies.aspx).

Submitting person specific updates to DDA as needed or requested.

http://dda.dhmh.maryland.gov/SitePages/policies.aspx

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Maintaining Waiver Eligibility which includes:

Assessment of and completion of certificate of need form (LOC) annually within 365 days of the previous assessment forms;

Assessment of Medicaid financial eligibility annually or more frequently as needed; and

Re-application if gap in eligibility occurs.

LOC Performance Measure

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MONITORING AND FOLLOW-UP ACTIVITIES HELPFUL STRATEGIES

Questions to Ask:1. How are services going?

2. How are you progressing toward your goals?

3. Updates on medical recommendations, demographics, etc

4. Are services meeting your needs/goal?

5. Do you need any new services (I&R)?

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Service Delivery Questions to Ask:

1. Initial service implementation meeting needs and goals?

2. Have all services been established? (Residential identified but no Day/Employment?)

3. Most integrated setting?

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New Information or referral needs?

Share community services and resource list and updates on new ones (LISS, SC Impact Fund, Respite, disability specific programs, self advocacy groups, education, employment, etc.)

At least one generic resource should be provided each time.

101


Follow up on: Emergency situations Short term solution such as funding during the

day to allow for person to locate day placement Temporary respite to protect health and safety

while options explored, and services identified Medical Care

102

PROCESS, POLICY, & FORMSUPDATESHELPFUL STRATEGIESREMINDERSPERFORMANCE MEASURES

LINKS

103

DDA APPLICATION

DDA application being updated New Consumer friendly instruction

guide to be included To be shared at next training Target implementation July 1, 2012

104

DDA INITIATION OF SERVICES

Initiation of service delivery to an eligible individual seeking DDA-funded services shall be dependent upon:

(1) Assigned service priority, except for family support services and low intensity support services which are provided on a first-come, first-served basis;

(2) Availability and allocation of funds(3) Availability of an appropriate community

services; and (4) The individual's completing an application for

Medical Assistance or other alternative funding.

Note: If an emergency situation arises and immediate services are needed to resolve a crisis, DDA may authorize the initiation of servicesReference: COMAR 10.22.12.11

105

DDA INITIATION OF SERVICES

Except in an emergency situation or a case approved by the Director because of extenuating circumstances, DDA may not fund services for individuals with State-only dollars unless the individual has been denied:

(1) Medical Assistance including waiver services; and

(2) Related alternative funding.

106

DDA WAIVER & MEDICAID ENROLLMENT

INITIATIVE

100 % State

General $

vs.

50% State General $

and 50% Federal

$

Note: Process, tracking, and procedure to be shared soon

Maximize all DDA State General Funds

INTEGRATION IT SYSTEM(S)

107

IT System

Plans

RCRFSCFiscal

PORII

HRST

Notes: Multiple efforts underway currently which includes stakeholder input, coordination with Medicaid and Dept IT office and other partners.Additional information shared in each subject area

108

INTEGRATED IT SYSTEMSeveral efforts are under way to develop an

integrated information technology system

An integrated system will provide information, data, and evidence in a more efficient and effective manner

An integrated system will support quality efforts

Discovery

Remediation

Reporting

System

Improvement

109

INTEGRATED IT SYSTEMAn integrated system will support system

accountabilitySystem

Accountability

* •Eligibility and Service Access

* •Federal and State Assurances

* •Contract Monitoring

* •Fiscal Accountability

110

INTEGRATED IT SYSTEM

Input on Resource Coordination related components and formats to be obtained via the Resource Coordination Coalition

ELIGIBILITY & ACCESS

CRITICAL NEEDS RECOMMENDATION FORM (CNR)

ON-GOING ASSESSMENT & UPDATES111

112

ELIGIBILITY AND ON-GOING ASSESSMENT

People in Crisis (crisis resolution) Advise DDA Regional Office (RO)

immediately Address immediate health and safety Contact the police, APS, CPS, EMS (911) Complete Critical Needs Recommendation

form and send to RO ASAP Brain storm temporary strategies with your

supervisor

113


People at risk of crisis (crisis prevention)√ Assist people and families is both short term and long

term planning to address risks and achieve outcomes

√ Assist in obtaining the best quality and most appropriate services and supports within available theirs and generic community resources

√ Assist people and families with applying for various services (including LISS and non DDA services such as Medicaid, food stamps, mortgage and utility assistance)

114


People with no crisis risk (current request/future need)

√ Explore/advise of informal and formal supports, generic and community services including LISS, respite, park and planning, Self Advocacy Networks, etc .

√ Encourage both short term and long term planning for the future

115

WAITING LIST ON-GOING ASSESSMENT

Inquire about current situation and needs with every contact

Complete CNR updates and forward to RO as situations and needs change

Immediately contact the RO for people in crisis

All people determined to no longer meet their current priority category will be notified of change in determination and advised of their appeal rights as per regulations and standard operational procedures

116

CNR FORM UPDATES

Statewide Critical Needs Recommendation Form to be shared at next training.

Effective implementation date is July 1, 2012

117

PCIS UPDATES

Demographic changes such as phone numbers, addresses, corrections to PCIS, etc.

Changes to designated “Contacts”

Changes to primary caregiver and caregiver age

Share changes with designated resource coordinator(s) in your agency with PCIS change permission or the DDA Regional Office

Statewide PCIS “updates/changes” protocol under development

118

SYSTEM RESPONSIVENESS

Collectively our system must be responsive to people

Timely action is essential: To protect health and safety for people in crisis and

at risk of crisis

Component of customer services

Quality indicator

119

SYSTEM RESPONSIVENESS

For people in crisis – The application and eligibility recommendations,

waiver packet, and plan (provisional, initial, or IP) should be developed during the first encounter and must be submitted as soon as possible

Further in-depth planning, additional service, and options can be explored as the situation is stabilized

SERVICE PLAN DEVELOPMENT

120

Updates Helpful StrategiesReminders

121

PLAN DEVELOPMENT – IDENTIFYING SERVICES There are several things to consider when identifying

services and support to meet people’s needs including:

1. Services, items, and supports 2. Urgency for establishing services and supports3. Impact of the services and supports to meet goals4. Cost of services and supports5. Identifying service providers

What questions do you use to guide identifying services and service planning?

122

SERVICES, ITEMS, AND SUPPORTS

Does the plan reflect all services – natural, informal, generic, State and federal programs, and DDA funded services?

Does the service/item align with the need identified to support the goal?

Is the person self directing? Is a support broker and fiscal management service provider needed?

Are there special or unique services (e.g. assistive technology, home modification, customized wheelchair) needed?

Is the services needed Habilitative? Rehabilitative? Medical? Dental? Other?

What services/resources were explored? Is this service available from another source?

(Duplicative?) Is the service/item recommended by a professional? For

what purpose? For how long? For what outcome? Is the service/items a DDA waiver service? Is the person eligible for DDA funding today?

123

URGENCY

Is the person’s health and safety currently at risk?

Are there any allegations or indicators of possible abuse, exploitation, or neglect?

If at risk, what informal or formal services or supports can be established immediately to support health and safety?

Will the person be transitioning from foster care, an institution, or court order? When?

Is the funding source time limited?

124

IMPACT

Does the services support the person in the most integrated environment?

Does the services support or lead to employment? Retirement?

Does the services and support address or seek to resolve or prevent reoccurrence of the crisis trigger?

Does the services support the person’s health and safety?

125

COST

Is the cost for services a reasonable and customary cost?

Is there any lower cost service or item available that will meet the identified need?

Is the service/items covered under the DDA waiver or State funds?

Fair Cost

126

PROVIDERS OF SERVICES

It is important to identify the appropriate service provider to provide the services to meet the person’s needs.

Can they provide the services, supports, and/or items needed to support the person’s goals?

How soon can they start? How will the services be monitored? How will progress be reported to the person and

their team? If a DDA licensed provider, does the service

funding plan match the IP?

127

INTERVENTION SERVICESIntervention services can help people and families

find ways of creating strategies and/or alternative supports that can eliminate or minimize the potential for future crisis.

The service(s) can vary from person to person and may be of a short duration, or may be very intense and time consuming upfront, that diminishes over time.

PLANS

128

•People on Waiting List

Waiting List Plan

•People In ServicesIP•People transitioning from a facility

Transition Plan

129

WAITING LIST PLAN

• People on DDA Waiting List

Waiting List Plan

130

WAITING LIST PLAN Focuses on the provision of non-DDA services in the

most integrated setting

Is developed in collaboration with the person and their identified representatives

Is completed within the first thirty (30) days of initial meeting, in a format as approved and required by the DDA

Update and revise the plan as circumstances change

Annual Plan Update to be conducted within 365 days of the previous initial plan

131

WAITING LIST PLAN Provides an action plan for the person and

and/or their family to follow in several key areas such as:

Provides a snapshot of resources recommended, contact information, and follow up actions

Home School/Work/Day Medical

Transportation

Social/ Recreational

Financial Assistance

Other

132

WAITING LIST PLAN

Resource Coordinator Name and Phone Number: Jani Smith, 410-827-4538

HOME

Resource TypeResource Name and Contact

Information Person to Follow-Up &

When

Front porch ramp LISS, 1-877- 230-4951 or 1- 877-282-8202

Tammy Jones, by 7/1/12

Stair glide DORS, 410-554-9442 Ms. Jones, mother, by 6/25/12

SCHOOL/WORK/DAY

Resource TypeResource Name and Contact

InformationPerson to Follow-Up &

When

Behavioral Supports Anne Arundel County Public Schools, 410-222-5312

Ms. Jones, mother, 6/20/12

Behavioral Supports TAS through Humanim, 410-381-7171

Jani Smith, Resource Coordinator by 6/20/12

Draft Example

133

WAITING LIST PLAN

Draft Example

MEDICAL

Resource TypeResource Name and Contact Information

Person to Follow-Up & When

Dental Services Donated Dental Services, 410-964-1944

Tammy Jones, by July 1, 2012

TRANSPORTATION



Transportation to churchContact Ms. Ella (Youth Ministry), 410-284-7134


New electric scooter

Contact MA Health Choice Special Needs Coordinator re: coverage by 410- 853-3000

Ms. Jones, mother, by 8/1/12

134

WAITING LIST PLAN

Draft Example

SOCIAL/RECREATIONAL



YMCA membership

Request discount from YMCA, 443-322-8000 and pay monthly fee from paycheck


FINANCIAL ASSISTANCE (for items such as utility bills, camp, etc.)



BGE bill paymentBGE Energy Assistance,

410-685-0123 Ms. Jones, mother, by 6/15/12

Dental services LISS, 1-877- 230-4951 or 1- 877-282-8202


135

WAITING LIST PLAN

Draft Example

OTHER



Legal Advocacy MDLC, 410-727-6352Tammy Jones, by

6/10/12

136

WAITING LIST PLAN People in crisis or at risk of crisis may only

emphasize need in that specific area.

It is important that we explore all areas of an person’s life (holistic) to ensure the needs of the whole person are being addressed and start application processes

Always take appropriate action and seek immediate assistance for life threatening situations

Responsible person for follow up actions should be decided at meeting

137

WAITING LIST PLAN Monitoring and follow-up, based on the

minimum frequency in UFA/MOU/Contract, or more frequently as needed, to include:

Follow up on current circumstances, progress toward goals, and referral status;

Identification of new support and resource options for intake and referral; and

Submit updates to DDA Regional Office on circumstances related to health and safety or changes to priority status.

138

WAITING LIST PLAN

Input on the final Waiting List Plan components and format to be obtained via the Resource Coordination Coalition

Format and user guide will be shared statewide

139

INDIVIDUAL PLAN

• People In ServicesIP

140

INDIVIDUAL PLAN

My Hopes

My Dreams

My Strengths

My Values

My Support

My Goals

My Team

My Hobbies

PERSON

Holistic

141

IP UPDATES AND REMINDERS

Development of plan: Focuses on services in the most integrated setting;

Is developed in collaboration with the person and their identified representatives;

Includes supports necessary to achieve goals

Offering people choice of services and services providers;

Contains all elements noted in COMAR 10.22.05;

Is completed within the first thirty (30) days of initial meeting; and

Includes back up plans for direct care staff and natural disasters.

Service Plan

Performance Measures

142


Resource Coordinators shall: Facilitate and coordinate interim meetings as

needed with the person

Update and revise the IP as circumstances change; and

Facilitate and coordinate the annual IP update to be conducted within 365 days of the previous plan.

Service PlanPerformance

Measures

143


Ensure the IP is a working document, accurately reflecting a person’s goals, strengths and needs in a manner that someone unfamiliar with the person can read it and understand specifically how to support that person

144

IP UPDATES Automation efforts to include ability to upload

data from existing IP software used by some agencies

Incorporation of federal assurance data elements

Additional stakeholder input is underway

IP Requirement - Refer to IP memo dated February 6,

2012 at http://dda.dhmh.maryland.gov/SitePages/Developments/Feb2012/IP-Feb-2012.pdf

Target system training December 2012

Target implementation March 2013

http://dda.dhmh.maryland.gov/SitePages/Developments/Feb2012/IP-Feb-2012.pdf

145

TRANSITION PLAN

• People transitioning from a facility

Transition Plan

146

TRANSITION PLAN

Development of plan : Focuses on transition from the

institutional setting to the community;

Is developed in collaboration with the person and their identified representatives;

Offers people choice of services and services providers;

Addresses challenges to transitioning;

Is completed within the first thirty (30) days of initial meeting;

Community

147

WRITTEN PLAN OF HABILITATION

Assessment and completion annually of the automated Written Plan of Habilitation form within the DDA’s information system (PCIS2) for people residing in an State Residential Center only which includes: Identification of various service and support

needs of the person to transition to the community;

Recommendation of a range of the most integrated setting service options both licensed through and outside the DDA; and

Identification of community-based Medicaid waiver services and any other services and supports that may be available.

148

TRANSITION PLANResource Coordinators: Facilitate and coordinate interim meetings as

needed with the person;

Update and revise the plan as circumstances change; and

Facilitate and coordinate the annual plan update to be conducted within 365 days of the previous plan.

149

TRANSITION PLANMonitoring and follow-up activities to include:

Follow-up on current circumstances, progress toward goals, and referral status;

Identification of new support and resource options for intake and referral;

Submitting updates to DDA Regional Office regarding changes in circumstances and as requested; and

Increased contact frequency as needed based on active transition process.

150

WAIVER

UPDATES HELPFUL STRATEGIESREMINDERS

151

WAIVER ENROLLMENT FORMS

1. Community Pathways or New Directions Waiver Enrollment Checklist s

2. Initial Certificate of Need3. Waiver Applicant Verification Form (WC-2C)4. Freedom of Choice5. Medicaid Application6. Plan

Note: Form revised effective 7-1-12 is available on DDA website

152

COMMUNITY PATHWAYS WAIVER ENROLLMENT

FORMS1. Community Pathways Waiver Enrollment

Checklist

Complete all information that appliesNote person’s current address at the time of

enrollment; not the address of a facilityCheck all waiver services that applyInclude the date of the Medicaid application – it

must be dated within six months of the waiver effective date

Include fax number and email address of the resource coordinator


153

NEW DIRECTIONS WAIVER

ENROLLMENT FORMS1. New Directions Waiver Enrollment Checklist

Complete all information that applies

Note person’s current address at the time of enrollment; not the address of a facility

154


2. Initial Certificate of Need*

Indicate Community Pathways or New Directions (there are no longer 2 separate forms)

Level of Care effective date is the date of the waiver meeting. (Not a future or past date.)

Include the CNR date Sign and Date


LOC Performance

Measure

Note: Same form used for both Community Pathway and New Directions.

155


FORMS3. Waiver Applicant Verification Form (WC-2C)

Complete all information that applies If the person is discharged from a facility,

include the actual discharge date Indicate the appropriate funding source, i.e., TY,

WLEF, CR, etc. Include the person’s site address, not the

agency address


156

NEW DIRECTIONS WAIVER ENROLLMENT

FORMS3. Waiver Applicant Verification From (WC-2C)

Complete all information that applies

Include the person’s address

157


4. Freedom of Choice* Indicate Community Pathways or New Directions

(there are no longer 2 separate forms) Person, Authorized Representative or Guardian

must indicate they have been given a choice between waiver services and institutional services.

Individual, Authorized Representative or Guardian/Parent must indicate they have been given a choice between waiver service options and providers.

Note: Form revised and includes fact sheet. Revision effective 7-1-12 and available on DDA website

*Note: DDA LOC Performance Measure : #5- Number of people provided choice between community based services and institutional care

Note: Same form used for both Community Pathway and New Directions.

158


5. Medicaid Application (MA) (Short or long form?) Based upon Medicaid coverage group

Note: Use current Medicaid Application dated 7/1/11. DREP Instruction & DREP Form revised effective 7-1-12 is available on DDA website

1st

•Complete the Community Check Fax Request/Response Combination Form

2nd

•Fax to the DHMH - Division of Recipient Eligibility Programs (DREP) Fax Number (410) 333-5087

3rd• Complete the “long” or

“short” form based on response from DREP

Steps

159


FORMS6. Plan Waiver Service Plan Initial, Provisional, or Full Plan (IP) with enrollment

Various Person Centered Planning methodologies (i.e. ELP, MAPS, PATHS, ETC.) can be used

All services shall be listed such as: Resource Coordination Supported Employment

Providers of services can be “tbd” if unknown or undecided

160

NEW DIRECTIONS WAIVER ENROLLMENT

FORMS6. Plan Waiver Service Plan

*All About Me *Demographics *Rate

*Important *Goals of Pay

People *Preferences *Unit of Service

*Supports *Frequency

*Transportation

*Health Related

Person Centered

PlanPlan Budget IP & B

(Example)

Note: ND participants may use any PCP or Plan (IP) but should use the “budget” form. IP & B is available on the DDA website

161

WAIVER“REPORTING” FORMS

1. WC12 - A Reporting Form

2. WC12 - B Discharge Reporting Form

3. WC12 – C Change in Service

4. WC12 – D Financial Reporting

162


1. WC12 - A Reporting Form Address

Change in placement (transfer of services)* Transfer to CSLA or F/ISS require copy of SFP

Transfer of provider agencies

Transfer of Resource Coordination Agency

Admission to Nursing Home or Chronic Rehabilitation Facility

163


2. WC12 - B Discharge Reporting Form

Discharge from Waiver

Actual date of discharge (last date of waiver service)

Note: Some people may be discharged from the waiver but still receive DDA services via State funds.

164


3. WC12 – C Change in Service

New service (Copy of SFP required) for Community Pathways

Discontinuing a service

Relates to contribution of care for Community Pathways

165


4. WC12 – D Financial Reporting

Changes in person’s income

Changes in insurance

Changes in resources

Note: This form is to be sent to DEWS only

166

MEDICAID HELPFUL STRATEGIES & REMINDERS

Ask to be one of the person’s MA application contacts

Advise people of supporting documents needed when you set up appointment so they can gather

Financial information is based on the “person’s” not the parents or family income/resources

Once the MA application is signed it is live – it must be processed so do not hold

167


MA (including waivers) requires annual financial redetermination unless person has SSI or unscheduled review

Prevent loss of waiver eligibility - Redetermination date is based on waiver enrollment date so flag 3 months prior to start discussion and monitor to prevent loss of waiver eligibility

Report income/insurance/resource changes via WC12-D as they arise

168


DEWS will send letter to person (and their contacts listed on MA app) regarding redetermination, need for information, and loss of eligibility

People and families may not respond to DEWS letter so follow up

Alert DDA RO of any resistance to applying for waiver or providing requested documentation

169

LOC HELPFUL STRATEGIES & REMINDERS

LOC Recertification is required annually

Must be completed prior to anniversary date and mailed to HQ Waiver Unit

LOC Recertification Report is shared with each RC Agency – so track, monitor, and complete on time

You are certifying the person still meets ICF/ID LOC

Do not complete for people discharged from waiver or inactive people

*Note: DDA LOC Performance Measure #2 - Number of completed annual LOC re-certifications over the number of active waiver participants.

170

PLANS HELPFUL STRATEGIES &

REMINDERS Develop Professional IPs (do your best!)

No drafts

Be informed, educated on services, processes, procedures, and rules

Seek additional training and help as needed

High Quality Customer Services Schedule PCP within reasonable time frame Answer questions and seek answers What is you or your family member needed a plan

before you could be considered for services?

171

PLANS HELPFUL STRATEGIES &

REMINDERS Develop Professional IPs (do your best!) Be informed, educated on processes, procedures, and rules Seek additional training and help as needed IP must contain all elements noted in COMAR 10.22.05

Annual plans (IP) must be completed within 365 of previous plan – so track, monitor, and plan ahead

All outstanding plans must be remediated immediately*

*Note: DDA Plan Performance Measure #1 -Number of IPs containing required information per COMAR 10.22.05.02

*Note: DDA Plan Performance Measure #3- Number of IP reviewed within a year (365 days)

*Reference: IP Memo dated February 6, 2012Note: Some RC agencies have developed IP Component checklist. Check with your agency

172

PLAN HELPFUL STRATEGIES & REMINDERS

Become an expert in the waiver services See waiver applications scope of service & type

of providers Know which services require DDA pre-authorization New Waiver Regulations in process

Advise people they have choice among services and service providers

All annual IP must be submitted to the RO*

Report suspected cases of fraud to DDA

*Note: DDA Plan Performance Measure #6 - Number of people with choice between and among waiver services and providers

*Reference: IP Memo dated February 6, 2012

173

FACILITIES TRANSITIONS HELPFUL STRATEGIES & REMINDERS

For People transitioning from facilities (including NF, incarceration, MHA facility, SRC, SETT)

MA eligibility can be determined up to 6 months prior to discharge

Waiver Advisory Opinion Determination Advisory as to eligibility post transition can be

made

174


Complete MA application, Cover Sheet, and send with supporting documentation to RO Waiver Coordinator

No additional waiver paperwork is needed at this time

If Medicaid eligible (financial eligibility) then DEWS will send “Waiver Advisory Opinion Letter”

Person has to find community residence (typically six months from date of application)

If community residence is not established by due date, a new MA application is required

*People transitioning from Facilities (including NF, incarceration, MHA facility, SRC, SETT)

175


Once community residence is finalized complete remaining waiver paperwork including: Waiver Enrollment Checklist Initial Certificate of Need Freedom of Choice Waiver Application Verification Form Provisional or IP

Send all items to RO Waiver Coordinator

*People transitioning from Facilities (including NF, incarceration, MHA facility, SRC, SETT)

176

Waiver Re-enrollmentHelpful Strategies &

Reminders People can re-enroll/re-enter their waiver slot

during the same fiscal year (i.e. July 2012 to June 2013)

People can re-enroll/re-enter from a long-term care stay (nursing home, SRC)

If the person will tentatively be discharged within six months, then submit the MA cover sheet, supporting documentation, and application to DDA

Advise DDA of discharge date so DDA can authorize effective waiver enrollment date

177

NEW DIRECTIONS WAIVER

UPDATESHELPFUL STRATEGIES

& REMINDERS

178

ROLES AND RESPONSIBILITIES

Resource Coordinators, Support Brokers, and Fiscal Management Services all have unique roles

Roles and responsibilities can be supported but shall not be duplicated as per federal assurances

• Referral and Related Activities• Plan Development• Monitoring and Follow Up

Resource Coordinator

• Human Resource Department• Recruitment, Interviews, and

Supervision• Timesheet review and approval• Budget monitoring

Support Broker

• Accounting & Payroll Department• Management Approved Budget • IRS Fiscal Agent• Pay service providers

Fiscal Management

Services

179

NEW DIRECTIONS & SUPPORT BROKERS

TRAININGOrientation

*Stories*Group Exercises

*VideosAudio Clips

• People, Families, Independent Contractors, and Agencies

• Resource Coordinators

Initial Support Broker Training



Individualized Budgets



Recertification

• Update on policies & procedures

• Refresher course

*New Directions participants and self advocates will share personal stories and advice.

New in

FY 13

180

SUPPORT BROKERSSeveral Support Broker Options (certified independent contractor, agency, or family member)Support Brokers can not provider other services to the same waiver participant Family members as Support Brokers

*You must continually evaluate whether the decisions made are the person’s choice or the family member’s choice

Person’s Wants

Family Wants

*New Person to spend time with

*Community Integration

*Family Member as paid staff

*Respite

181

NEW DIRECTIONS HELPFUL

STRATEGIES & REMINDERSResource coordinators must review and certify IP & B Helpful questions to review: Is the plan holistic (all needs and all resources)? Are the goals clear or vague? What is the plan of action to meet the goals? Do the services identified support the person’s

goals? Does it support health and safety? Are the services covered under the waiver? Does the plan and budget match? Does the budget add up?

182


STRATEGIES & REMINDERSResource coordinators Plan and Budget Responsibilities Plan, Assess, and Monitor throughout the year Recommend service (holistic, various resources) and

budget change (+) and (-) to meet needs, goals, etc. Evaluate budget modification against person’s

choice and health and safety Avoid end of the year mass spending of unused

budget Note: Annual budget is not based on previous year’s actual expenditures.

Note: ND Participants will receive notice of 2% COLA for FY 2013

183


STRATEGIES & REMINDERSMedications section should include: Over the counter medications Drug name, dosage, and prescribing physician What the medication is being taken for Who is administering the medication

For participants who cannot self medicate:

All paid staff dispensing medication need to have Medication Technician training

IP & B must include nursing delegation services

Support brokers who are nurses cannot perform nurse delegating services.

184


STRATEGIES & REMINDERS

The IP & B must contain a two level back-up system including:

Name Addresses Phone numbers Responsibilities

Note: Support broker and primary staff cannot be listed as back-up staff.

Primary Staff

Back-Up #1 Back-Up #2

185

SELF DIRECTION MYTHS

RUMORS, AND MISUNDERSTANDING

You must have family involvement for ND? Community of Practice is the only way someone

can self direct? PATH are person centered planning tool only

allowed with Community of Practice? DDA is moving away from New Directions – it is

not their focus – it’s a flash in the pan? People will loose RC as a service if they use ND? You must go into the CP waiver prior to using the

ND Waiver? Waivers are open? Closed? People are not ready to self-direct?

REQUEST FOR SERVICE CHANGE AND SERVICE FUNDING PLAN PROCESS

186

187

REQUEST FOR SERVICES CHANGE

Any time after the receipt of services, an eligible person may:

(1) Apply for or request a change in intensity of services or support, or apply for additional services;

(2) Request a less intensive form of that service, and may receive the less intensive service if it is available.

Reference: COMAR 10.22.12.11

188


Complete and accurate information assist with

review and determining approval status as well

as eliminates the need for follow up questions from the regional office.

Background and summary information should include information relevant to the person and requested need

The IP Services Summary Addendum form can assist reviewers with a clear and concise picture of the services currently provided (DDA and/or other services) and services that are being requested

Full disclosure of resource exploration provides an overall understanding of what has been tried

A comprehensive description of any potential health and safety risks allows for an accurate assessment of need

189


Including all relevant information in a legible format provides ease of review.

Site to Site Transfers

• Cost Neutral-One person or Complete site• Verify staffing ratios• Accessibility• Health and safety• Team agreement

• Cost Increase or Decrease• Rationale for increase or decrease in funding

Legibility and Print Size

190

WHAT’S THE IMPACT?

Emergency Request Provides ability for

immediate approval/denial

Allows for a service start date from the date of the initial verbal emergency request and prior to the submission of the RFSC from

Is flagged by the regional office for expedited review and approval

Standard Request Is reviewed

chronologically as received by the regional office

Service start date can only be authorized back to the date that the RFSC form is submitted

The type of request affects the potential start date for service authorization and may affect the time to

process the request.

191

WHAT’S THE IMPACT?

DD Eligible• May be eligible for

full residential and/or vocational services

Supports Only Eligible• Not eligible for full

residential and vocational services

• Only eligible for services described in regulations as support services

Waiver Eligible Waiver covered

services with a demonstrated need are approved

State Only Funded Additional services

are only considered when health and safety are the emergent needs

Eligibility status and the type funding the person receives plays a role in the final approval decision.

192

ONE TO ONE STAFFING

This type of support can be supportive or restrictive. DDA wants to be sure that people get what they need in the least intrusive manner.

Be sure that the Request for Service Change packet includes the following:

1. The role of the one to one staff person2. Length of time the 1:1 supports are requested3. Data and information to support the need for the

request (e.g. data summaries, incident reports, professional recommendations, etc.)

4. The work that will be completed during the time that one to one supports are in place

193

1:1 STAFFING FOR BEHAVIOR SUPPORTS

Guidelines for Approval Periods Up to One Year

• New patterns of behavior that indicate a need for a plan (no current plan)

• Person changes service provider• Time for acclimation to new surroundings, assessment of

behavior, plan development and approval, and staff training

• Person currently exhibits life threatening behavior (i.e. PICA, Lesch Nyhan, Prader Willi), that may require on-going support-• Annual review of training, environmental changes and

other supports to minimize intrusive intervention

Up to Six Month Approvals• Person has need for plan modification

Up to Three Months• To train staff in the implementation of the plan• To stabilize medications that are a part of the overall

194

1:1 STAFFING FOR MEDICAL NEEDSApprovals for this type of request are based on:

1. The type of need2. Prognosis for health status

improvement3. Specific time frames indicated in

supporting documentation (medical reports, physicians orders, etc.)

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AWAKE OVERNIGHT (AON) STAFFING

Be sure that the Request for Service Change packet includes the following:

1. The role of the one to one staff person2. Length of time the AON supports are requested3. Data and information to support the need for the

request (e.g. sleep or behavioral data summaries, incident reports, professional recommendations, etc.)

4. Other measures that have been attempted (technology, behavior support services, etc.) and been unsuccessful

POLICY ON REPORTABLE INCIDENTS AND INVESTIGATIONS(PORII)

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EVIDENCE AND DOCUMENTATION

PORIIIPRC

Monitoring

Health

Welfare

&

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PORII FEDERAL ASSURANCE

Federal Requirements include: Participants’ health and welfare are

safeguarded and monitored

Adequate system for identification and documentation of Reportable Events to ensure people are adequately protected from abuse, neglect, financial exploitation, rights violation, and to ensure that waiver services appropriately meet their needs.

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PARTICIPANTS’ HEALTH AND WELFARE ARE SAFEGUARDED AND MONITORED

People receive medical services needed

People are free from mistreatment Abuse, neglect, and exploitation Unauthorized or inappropriate use of restraints

Plan and plan modifications continually support the person’s health and safety

Critical Event or Incident Reporting and Management Process

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PERFORMANCE MEASURES#1- Number of people who receive medical services as recommended by their physician(s)

#2- Number of people reporting they are free from mistreatment

#3- Number of incidents involving unauthorized or inappropriate use of restraints

#4-Percent of deaths based on population count vs. percent of deaths of Maryland population and US population


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PERFORMANCE MEASURES#5 - Number of budget modifications reviewed by resource coordinators (New Directions Only)

#6- Number of people with 2 level back up plans in their IP&B (New Directions Only)

#7- Number of critical incidents reported (New Directions Only)

#8 -Number of reportable incidents that are reported within required timeframes (New Directions Only)


PORII

UPDATES HELPFUL STRATEGIESREMINDERS

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PORII – HELPFUL STRATEGIES

AND REMINDERSThe police do not always understand that

people with developmental disabilities have the same rights other citizens.

If the person in services alleges abuse and the police are not investigating then: The RC should follow up with the person who was

the victim and help him/her file charges against the aggressor.

Often the agency is focusing on linking the person in services to supportive services (e.g.: counseling) or conducting "damage control."

The RC can empower the person by helping him/her seek justice.

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AND REMINDERSPeople in services also should have the

opportunity to file charges in instances where theft has occurred.

There have been many cases where agencies learn an employee has stolen funds from a person in services.

The agency reimburses the person, but does not offer the person the opportunity to file charges against the person who stole from them.

The person who was the victim of theft should have the opportunity to press charges.

In doing so, action may be taken against the staff...preventing future employment at other DDA licensed providers.

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AND REMINDERS

Regulations require a team meeting within 5 days of an unauthorized restraint.

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AND REMINDERSOften there is question re: whether or not the

Incident Report must be disclosed to the resource coordinator.....

Under Maryland Code Health General Title 7- Developmental Disabilities Law, Subtitle 10 - Rights of Individuals, Section 7-1010 - Records - Consent to disclosure; Disclosure of the Appendix 4 (initial report) to the Resource Coordinator is required.

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AND REMINDERSMedical Review Committee (“MRC”) The Appendix 7 includes information pertaining

to the agency's internal investigation and may be protected under the protection given to a Medical Review Committee (“MRC”).

Some agencies have concerns about confidentiality or sharing information from Appendix 7’s, the agency investigation, or Standing Committee discussions.

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AND REMINDERSMedical Review Committee (“MRC”) This information may remain confidential if the

agency operates its Standing Committee within the context of a Medical Review Committee (“MRC”).

The bylaws or policies governing the actions of one’s Standing Committee need to be consistent with those governing a MRC, in order to have the expected protections.

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AND REMINDERSMedical Review Committee (“MRC”)

Md. Code Health Occ. (“HO”) §1-401 establishes the rules governing Medical Review Committees (“MRC”) also known as Peer Review Committees (“PRCs”).

It is a somewhat confusing statute; however, for the following reasons, it permits alternative health care systems to establish MRCs.

Licensed providers probably have MRCs, even if they are not called that.

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AND REMINDERSWhat Does A Medical Review Committee

(“MRC”) Do?

The short answer is that it “EVALUATES.”

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AND REMINDERSA MRC does one (or all) of the functions listed in HO

§1-401(c):

Evaluates and seeks to improve the quality of health care provided by the providers of health care;

Evaluates the need for and the level of performance of health care provided by providers of health care;

Evaluates the qualifications, competence, and performance of providers of health care; or

Evaluates and acts on matters that relate to the discipline of any provider of health care.

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AND REMINDERS

As you will note that a MRC may perform far more duties for the agency than risk management, utilization review and credentialing.

A committee could be established to evaluate the quality of care generally provided in the facility and be a MRC.

Some agencies have several such committees, i.e.: the Standing Committee.

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AND REMINDERSThe thought to remember is that confidentiality is

given because the balance of improving healthcare delivery systems through evaluation and subsequent reforms, outweighs the normal ability of parties to obtain information and documents for civil cases and for the public to obtain documents through the Public Information Act.

Thus, a committee set up with procedures to evaluate which does that and acts in accordance with the recommendation, is probably a MRC, even if it has not been named as such.

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PORII – FY 2013 POLICY REVISIONS

In addition to meeting CMS requirements, the policy is being revised with the goals of: Making the policy less cumbersome for the

providers Define the roles and responsibilities of key

staff at DDA, OHCQ and Medicaid

DDA

OHCQMedicaid

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PORII –PROPOSED POLICY REVISIONS

1. Integrated IT System

By 07/2012 DDA, Medicaid and OHCQ will have a draft plan for implementation of the PCIS2 web-based incident reporting module.

The PCIS2 module allows:

OHCQ, DDA and Medicaid real-time access to reports,

The state and the providers using the system to analyze data trends

PCIS2 has safeguards in place that assisted providers in submitting complete & acceptable incident reports and investigations.

OHCQ

DDA

RC

Provider

Medicaid

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2. Neglect & Police Notification

The current PORII requires police notification every time an allegation of neglect is made.

There is concern that these notifications are watering down the system and resulting in desensitization of the police department.

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2. Neglect & Police NotificationCurrent ExamplesPolice do not take serious allegations seriously

because they come out to the sites all the time for instances where there was a report of neglect:

1:3 staffing vs. 2:3 staffing (lack of supervision), or

Person shows up for the day program without his coat

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2. Neglect & Police Notification Proposed Revision:

All allegations of neglect will continue to be reportable, but the requirement of police notification will apply to only incidents involving substantial risk of life-threatening harm.

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3. Resource Coordination Notification

The revised policy will require agencies to send the Appendix 4 (not the Appendix 7) to the Resource Coordinator.

Q: Under what authority are agencies required to disclose Appendix 4s to Resource Coordinators

A: Disclosure of the Appendix 4 is required under Maryland Code Health General Title 7- Developmental Disabilities Law, Subtitle 10 - Rights of Individuals, Section 7-1010 - Records - Consent to disclosure.

A4

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3. Resource Coordination Notification

Q: Does the policy require agencies send the Appendix 7 to the Resource Coordinator who works with the individual identified in the incident report?

A: No. agencies are not required to provide the Resource Coordinator with the Appendix 7, Agency Investigation Report. Agencies are required to collaborate with Resource Coordinators to make sure that appropriate action is taken to protect the participant from harm. The agency is required to advise the Resource Coordinator of the interventions taken and follow-up plan that will prevent future recurrence.

A 7

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4. More User-Friendly

A Frequently Asked Questions (FAQ)/Technical Assistance section was added to the policy.

Prompts to ensure the provider documents the immediate response to the incident for health and safety assurances are included in the PCIS-2 module.

PCIS

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5. Agency Investigation Timeframe

CMS has stated that the current timeframe for investigation of reportable incidents (21 days) needs to be revised

The proposed change to PORII shortens this timeframe to 10 days.

2013

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6. Incidents Have Been Broken Down Into "Tier I" And "Tier II."

All “Tier I“ incidents will be sent to OHCQ Some incidents ("Tier II") will be sent only to

DDA and Resource Coordination (not to OHCQ). DDA will conduct the initial follow up. The DDA regional office can make a referral to

OHCQ & request follow up on any of the Tier II incidents where DDA has concerns.

OHCQ

DDA

Tier II

Tier IConcer

n

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7. The New Category "Choking" has been added to PORII

8. Roles Defined

The PORII describes the roles in incident reporting for

Resource Coordinators Support Brokers

PORII

SB

RC

LOW INTENSITY SUPPORT SERVICES

UPDATES

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FY 12 - LISS $1.25 MILLION FUNDING EXPANSION

Effective May 29, 2012 until June 30, 2012 or until all funds are allocated.

First-come, first-serve basis for eligible people

People eligible for the DDA’s Service of Short Duration (SSD) funding shall have their needs addressed under the Waiting List Initiative and not through LISS.

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LISS FY 2013

Funding allocation for Fiscal Year 2013

Includes 2% COLA

LISS regulations to be published soon

LISS form and FAQ printed in Spanish

User Guide to be developed based on regulations and program experience

Request not processed by June 30, 2012 will be processed under FY 13 funds

FISCAL UPDATES

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FISCAL UPDATES2 % Fiscal Year 2013 Cost of Living

Allowances (COLA)

Providers Resource Coordination Agencies Low Intensity Support Services Specialized Services New Directions Participants

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FISCAL UPDATESFiscal Year 2013 Expansion

Transitioning Youth Emergency Forensic Waiting List Equity Fund

Budget Reconciliation and Financing Act Bill (BRFA) (SB1301) -includes a provision allowing DDA to carry-over up to $5 million from this fiscal year (FY2012) to next fiscal year (FY2013).

D EVELOPMENTAL D ISABILITIES A DMINISTRATION R ESOURCE C OORDINATION S ERVICES Training #1 June 5,...

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