Money Follows the Person

Quarterly Stakeholder Meeting

October 23, 2013

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Agenda■ Welcome

■ MFP Data

■ Transition Coordination Entities

■ MFP Waiver Update

■ MFP Training Update

■ MFP Housing Update

■ Discussion

Demonstration Benchmark

Data

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MFP Demonstration Data

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MFP participants in the community by population

As of 9/30/2013

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MFP Demonstration Data

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Number of MFP participants in the community by qualified facility

As of 9/30/2013

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MFP Demonstration Data

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Number of transitions by type of community residence

As of 9/30/2013

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Transition Coordination Entities

Transition Coordination Entities

Transition Coordination functions:

EngagementEnrollmentTransition PlanningProvision of Necessary Goods and ServicesHousing SearchCoordination with Case ManagersConducting Baseline Quality of Life Survey

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Transition Coordination Entities

Engagement Provide outreach to individuals in MFP Qualified Facilities and

inform them about the availability of the MFP Demo Accept Referrals for Potential MFP Demo Enrollees

Enrollment Clarify the individual is eligible for MFP Have individual sign the Informed Consent Form Assist individuals, face to face, to enroll in the MFP Demonstration

and verify their MassHealth eligibility Include whether MFP Enrollee has an ABI in IS system

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Transition Coordination Entities■ Transition Planning

Provide assistance to individuals enrolled in the MFP Demo to understand the range of community-based services and options that may be available to them

Assist individuals in identifying and applying for Home and Community-Based Services (HCBS) Waivers for which they may be eligible

Refer those who do not enroll in one of the HCBS Waivers for MFP Demo case management

Based on individual choice, TE may refer to either:

To Massachusetts Rehabilitation Commission (MRC) or

To an ASAP

Develop person-centered transition plans to map out what the individual needs and how it will be arranged and provided 10

Transition Coordination Entities

Transition Coordination Coordinate transitions from facilities to community-based settings Arrange for and/or provide MFP Demonstration Transitional

Assistance Services

MFP Demonstration Transitional Assistance Services (i.e. necessary goods and services) Shopping for, purchasing or providing necessary goods and

services that are needed to make the move to the community including: One time costs like setting up utilities, security deposit,

furnishings Home Modifications Housing Search

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Transition Coordination Entities

MFP Demonstration Transitional Assistance Services (con’t)Housing Search

Linkage with Housing Search Entities who can assist in locating and applying for housing

Assisting with/providing transportation for viewing housing options

Coordination with Case Managers

Work with the Case Manager who is assigned through an HCSB waiver agency, or an MFP Demonstration Case Manager and any other case managers (for example DMH case managers)

Conduct baseline MFP Demonstration Quality of Life Survey

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Transition Coordination Entities

Case Manager – Transition Coordinator Collaboration

Once a waiver or Demo case manager is identified collaboration between the case manager and the transition coordinator begins

The transition coordinator is responsible for coordinating the MFP Demonstration Services, including Transitional Assistance Goods & Services when appropriate; this can include Demo services provided after facility discharge

The case manager is responsible for arranging and overseeing the delivery of waiver services and other community long-term care services

The transition coordinator and case manager will collaborate with other state agencies who may be involved with the MFP Demo participant

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Division of Duties– Pre-Discharge

Transition Coordinator■ Outreach to MFP qualified facilities &

individuals in them

■ Determine if individuals meet MFP Demo criteria

■ Obtain Signed Informed Consent

■ Facilitate MassHealth enrollment if necessary

■ Assist individuals to understand the range of available community-based services and options

■ Refer Demo participants for HCBS waiver eligibility or for Demo Case Management

■ Develop Person-Centered Transition Plan including Demo services needed

■ Link Demo participants with qualified HSEs when needed and assist with or provide transportation

■ Conduct baseline Quality of Life Survey

Case Manager

■ Collaborate as needed with Transition Coordinator to support the facilitation of the Enrollee/Participant’s discharge

■ Continue the person-centered planning process begun by the Transition Coordinator to ensure that all needed community-based long term services and supports (LTSS) are identified

■ Based on Person-Centered Transition Plan, begin development of detailed Individualized Service Plan and 24-Hour back-up plan to ensure that LTSS are appropriate, and will be in place at discharge

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Division of Duties – In the Community

Transition Coordinator

■ In collaboration with the Case Manager, arrange for the provision of Demo services as necessary throughout the participant’s first 365 days in the community

■ Collaborate with Case Managers to ensure ongoing successful residency in the community

■ Collaborate with Case Manager and other state agencies who may be involved with the MFP Demo participant

Case Manager■ Provide ongoing oversight and

monitoring of services ensuring waiver and/or state plan service delivery, appropriateness, and participant satisfaction

■ Make changes to the individual’s plan for community services as needed by the participant

■ Collaborate with the Transition Coordinator and other state agencies who may be involved with the MFP Demo participant

■ Conduct Quality of Life Survey at 11 Months and 24 Months

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Transition Coordination Entities■ Highland Valley Elder Services, Inc.

■ Independence Associates, Inc.

■ MetroWest Center for Independent Living, Inc.

■ Minuteman Senior Services

■ Montachusett Home Care Corporation

■ Mystic Valley Elder Services, Inc.

■ Northeast Independent Living Program, Inc.

■ Old Colony Elder Services, Inc.

■ Southeast Center for Independent Living, Inc.

■ Somerville-Cambridge Elder Services

■ South Shore Elder Services, Inc.

■ Springwell

■ Stavros Center for Independent Living, Inc.

■ Tri-Valley, Inc.

■ WestMass ElderCare, Inc.

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■ Aging and Disability Resource Consortium of the Greater North Shore, Inc.

■ BayPath Elder Services, Inc.

■ Boston Center for Independent Living

■ Boston Senior Home Care

■ Bristol Elder Services

■ Center for Living & Working, Inc.

■ Central Boston Elder Services

■ Chelsea Revere Winthrop Home Care Center Inc.

■ Coastline Elderly Services, Inc.

■ Cape Organization for Rights of the Disabled (CORD)

■ Elder Services of Berkshire County, Inc.

■ Elder Services of Cape Cod and the Islands, Inc.

■ Elder Services of the Merrimack Valley, Inc.

■ Elder Services of Worcester Area, Inc.

■ Southwest Boston Senior Services, Inc. d/b/a Ethos

■ Franklin County Home Care Corporation

■ Greater Springfield Senior Services, Inc.

■ Health and Social Service Consortium, Inc. HESSCO Elder Services

Transition Coordination Entities: Transition Projections

Organization CY14 Projection

Aging and Disability Resource Consortium of the Greater North Shore, Inc. 55BayPath Elder Services, Inc. 15Boston Center for Independent Living -Boston Senior Home Care 54Bristol Elder Services 25Center for Living & Working, Inc.  -Central Boston Elder Services 5Chelsea Revere Winthrop Home Care Center Inc. 5Coastline Elderly Services, Inc. 10Cape Organization for Rights of the Disabled (CORD) 8Elder Services of Berkshire County, Inc. 10Elder Services of Cape Cod and the Islands, Inc. 1Elder Services of the Merrimack Valley, Inc. 13Elder Services of Worcester Area, Inc. 20Southwest Boston Senior Services, Inc. d/b/a Ethos 6Franklin County Home Care Corporation 4Greater Springfield Senior Services, Inc. 18Health and Social Service Consortium, Inc. HESSCO Elder Services 9Highland Valley Elder Services, Inc. 2

Organization CY14 Projection

Independence Associates, Inc. 18MetroWest Center for Independent Living, Inc. 12Minuteman Senior Services 9Montachusett Home Care Corporation 9Mystic Valley Elder Services, Inc. -Northeast Independent Living Program, Inc. 10Old Colony Elder Services, Inc. 48Southeast Center for Independent Living, Inc. -Somerville-Cambridge Elder Services 12South Shore Elder Services, Inc. 75Springwell 20Stavros Center for Independent Living, Inc. 15Tri-Valley, Inc. 6WestMass ElderCare, Inc. 10

Total 504

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MFP Waiver Update

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MFP Waiver Update

MFP Demonstration Participants may access services through:

The MassHealth State Plan including:

State Plan LTSS – PCA, AFC, ADH, etc.

SCO or PACE

One Care or other State Plan services

HCBS waivers including:

Frail Elder Waiver

MFP Community Living Waiver

MFP Residential Supports Waiver

ABI Residential Habilitation Waiver

ABI Non-Residential Habilitation Waiver

DDS Intensive Supports Waiver

DDS Community Living Waiver

DDS Adult Supports Waiver

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MFP Waiver Update

Common Requirements of all HCBS Waivers

Participants must be at a facility level of care (LOC), the specific LOC varies by waiver

Participants must have an ongoing need for waiver services and must receive waiver services at least once a month

Participants must be able to be safely served in the community with available waiver and state plan services

MassHealth is responsible for all HCBS waivers, with one of the sister EOHHS agencies having day-to-day responsibility for oversight and operations

MFP Waiver Update

HCBS Waiver Capacity Status

Frail Elder: available MFP Community Living: available MFP Residential Supports: at capacity for this waiver yearABI Residential Habilitation Waiver: available ABI-Non Residential Habilitation Waiver: at capacity for this waiver year DDS Intensive Supports Waiver: available DDS Community Living Waiver: available DDS Adult Supports Waiver: available

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MFP Training Update

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MFP Transition Entity Training

Transition Entity Training has been on-going since Mid-October, encompassing:

MFP Information System (IS)MFP Demonstration, Transition Coordination and Waiver OverviewMFP Demonstration Transition Entity Payment and Claims OverviewMFP On-Line Training Modules

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MFP Information System (IS)

Comprehensive instruction on how to use the MFP-IS application on the EOHHS Virtual Gateway to add, manage, and track Enrollees and Participants from enrollment through completion or disenrollment.

October 1 – 16, 20139 Training Sessions91 Individuals TrainedExcellent Participant Questions and Feedback

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MFP Training Update

The MFP Information System:

The MFP-IS is a web-based application used to record, maintain and track information about MFP Enrollees and MFP Participants in the communityThe MFP-IS is NOT a case management or client information system It allows users to keep track of Enrollees, data about them, changes in their status, dates of enrollment and transitions, quality of life surveys and other information required to report MFP data appropriately to CMS

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MFP Demonstration, Transition Coordination and Waiver Overview

Complete overview of the MFP Demonstration for transition entity staff including transition services and supports available to Enrollees and Participants.

October 22 – November 1, 20136 Training Sessions (AM) and Locations

October 22 - Central Boston Elder Services, Boston October 25 – Independence Associates, Brockton October 28 – North Shore Elder Services, Danvers October 30 – Bristol Elder Services, Fall River October 31 – Greater Springfield Senior Services, Springfield November 1 – UMass Medical School, Shrewsbury

95 individuals are registered to attend 26

MFP Demonstration, Transition Coordination and Waiver Overview

TopicsMFP Demonstration Overview

Transition Coordination Overview

Quality of Life Survey

MFP Demonstration Services, including Housing Search Assistance

HCBS Waivers and MassHealth State Plan service options

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MFP Payment and Claims Training

Overview of the MFP Demonstration provider payment and claiming process for staff responsible for agency billing activity. October 22 – November 1, 20136 Training Sessions (PM) and Locations

October 22 - Central Boston Elder Services, Boston October 25 – Independence Associates, Brockton October 28 – North Shore Elder Services, Danvers October 30 – Bristol Elder Services, Fall River October 31 – Greater Springfield Senior Services, Springfield November 1 – UMass Medical School, Shrewsbury

70 individuals are registered to attend

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MFP On-Line Training ModulesModule series created to provide transition coordinators with a general overview of the MFP Demonstration including goals, benefits, participant eligibility requirements, and how individuals will receive long term supports and services through existing and new HCBS programs.

Current on-line training modules include:MFP Demonstration GrantAdministering the Quality of Life SurveyMA State Plan ServicesMA HCBS WaiversExecutive Office of Health and Human Services Overview

Note: Additional training modules are in development.

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MFP Housing Update

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MFP Housing Update

Housing Search Entities (HSEs)■To be qualified by MRC, an HSE must:

Have successful experience assisting elders and/or individuals with disabilities to secure affordable & accessible housing

Demonstrate knowledge of:

Local public and private housing resources

State & federal housing programs

■HSE responsibilities include:

Working closely with MFP participants, transition coordinators and case managers to ensure complete and timely housing applications

Coordinating with regional/statewide housing specialists on housing options for MFP participants

Identifying housing options for and presenting them to MFP Participants

MFP Housing Update

Referrals for Housing SearchWhen an MFP Demo participant is interested in housing in the community, the participant should be referred to the Qualified Housing Search Entity (HSE) of their choice

When referring an MFP Demo participant for housing, the Transition Entity (TE) will utilize the Referral for Housing Search and Services Form

The HSE must accept or deny a referral within 3 business days

When the HSE and TE are the same organization: The participant must be given a choice of HSE – the participant should not be automatically referred to the HSE in the organization that is providing transition coordination.

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MFP Housing Update

Transition Entity Housing Search Entity

Creates transition plan for enrollee including identifying general housing needs & preferences

Refers to housing search entity Collects supporting documents for

and assists in completion of housing applications

May assist with visiting housing options & arranging/providing transportation to see a unit

Secures necessary routine items, goods and services when housing is identified

Determines specific housing preferences, conducts individualized search, and recommends options

Submits and tracks housing applications

Attend EOHHS housing trainings

Coordinates with appropriate parties per such training on available housing options

Division of Duties

MFP Housing Update

MRC Qualified HSEs Aging & Disability Resource Consortium of the Greater No. Shore – Northern RegionAdvocates – Greater Boston, Central, Southeast RegionsAIDS Action Committee – Greater Boston RegionHearth, Inc. – Greater Boston RegionHousing Assistance Corporation – Greater Boston RegionIndependence Associates – Southern RegionMetropolitan Boston Housing Partnership - Greater Boston RegionMetrowest Center for Independent Living – Central Region Northeast Independent Living Program – Northern RegionSouth Middlesex Opportunity Council – Central RegionStavros Center for Independent Living – Western Region

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More Information on MFP ■ MFP Website:

http://www.mass.gov/eohhs/consumer/disability-services/living-supports/community-first/money-follows-the-person-rebalancing-grant.html

■ Information you will find:

MFP Planning Grant documents

MFP Project Summary and Operational Protocol

Past MFP Presentations (PPT and RTF)

Upcoming meeting announcements

■ Please contact MFP@state.ma.us if you have further questions or would like to be added to our mailing list for announcements of future MFP meetings

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Discussion