The New Exceptional Rate for the ID Waiver

D B H D SVirginia Department of Behavioral Health and

Developmental Services

The New Exceptional Ratefor the ID Waiver

Lee Price, Sr. Policy Advisor for the Office of the Settlement Agreement

Executive Advisor

& Dawn Traver, Community Resource Manager, Division of Developmental

Services

DBHDSVirginia Department of

Behavioral Health andDevelopmental Services

The Underlying Issue

• DBHDS recognizes that there are individuals in the training centers and the community who have greater needs than can be adequately met through the existing rate of reimbursement.– High medical support needs– High behavioral support needs



Intent of an Exceptional Rate

• The “exceptional rate” was conceived to be a stopgap measure to address this problem – not a final solution– DBHDS is hopeful that the waiver study currently

underway will assist in crafting long-term improvements to the service system



General Assembly Action

• The 2013 General Assembly included a budget bill item to provide funding for an exceptional rate for ID Waiver Congregate Residential Support services:– Provided $3,682,880 in state general funds to

support the exceptional rate



Budget Bill Language

• The exceptional rate is designed for those– “currently residing in an institution and unable to

transition to integrated settings in the community due to the need for services that cannot be provided within the maximum allowable rate

AND– whose needs present imminent risk of

institutionalization and enhanced waiver services are needed beyond those available within the maximum allowable rate.”*

*Budget Bill Item 307 #3c



General Assembly Intention

• Budget bill intent:– Provide a temporary (i.e., until waiver redesign)

exceptional rate for those with complex medical or behavioral needs

– Enable those individuals to receive enhanced waiver services beyond those provided through the existing maximum rates



Extent of Impact

• The approved funding is estimated to provide additional supports to approximately 250 people.

• It is anticipated that the exceptional rate will be 25% more than the current Congregate Residential Support rates– NoVa:$21.70/hour– ROS: $18.88/hour



Current Status

• DBHDS & DMAS staff have drafted criteria for the new rate and sent to CMS for approval:– Individual eligibility – will involve, among other

factors, SIS® scores– Special review process before service

authorization– Provider requirements

• Will release the details once CMS approves the Waiver amendment



Current Status (cont’d)

• Waiting to hear back from CMS

• State regulations are being drafted, but their approval process begins after CMS Waiver amendment approval



Hopeful Timeline

• CMS Waiver amendment approval by early October 2013

• ID Waiver regulations about the exceptional rate in place by early January 2014

• The first individuals approved for exceptional rate funding by mid-February 2014



Some Possible Examples of Individuals Who May Need the Exceptional Rate



MT



Things That Are Important To/For MT

TO:• Playing my

keyboard/listening to music• Being outside; going on

vacations • Being lifted up and down on

the ARJO lift• Watching the hands of a

clock move• Water• Visiting with family/friends

FOR:• Maintaining optimal

positioning for respiratory health

• Adequate nourishment and hydration

• Visual, auditory and tactile stimulation

• Total assistance with ADLs• Engaging in many social,

recreation and leisure activities



MT’s Recent Hospitalizations

• Hospitalized seven times in between January 2012 - April 2013 for

– Pneumonia

– Respiratory difficulties

• Each hospitalization lasted 5 to 15 days for a total of 70 days



Knowledge/Expertise MT’s Provider Must Have

• Pneumonia prevention plan of care• NPO – Nutrition/hydration/medications via G-

tube• DNR (parents wish no CPR/chest compressions)• Knowledge of dysphagia• Bowel movement protocol• Repositioning protocol • Weight and fluid intake protocol



MT’s Staffing Needs

• Two hours of nursing services per shift• Monitoring vital signs and assessing for signs of illness.• Assessing respiratory status; administering Albuterol

nebulizer for severe wheezing • Checking G-tube integrity/patency and stoma site

condition every shift• Monitoring positioning during enteral feeding and

optimizing positioning at all times• Oropharangeal suctioning as needed • Monitoring oxygen support via nasal cannula

continuously from bedtime to 7AM



RH



Things That Are Important To/For RH

To:• Making his own choices

about mealtimes, snacks and TV

• Personal space/private time • Sporting activities• Socializing with family and

friends• Warm water activities• Playing games, listening to

music and looking at books

For:• Structure • Something constructive to

do during the day• Being encouraged to

participate in ADLs• Maintaining good health

through regular medical and nutrition management

• Managing his challenging behaviors and communication



Other Important Things Per RH & His Authorized Representative

• Home designed for individuals on the autism spectrum; quiet with sensory items available

• Home where the others can tolerate RH when he chooses to be loud

• Space to roam while still being supervised• Own room• Home with no more than 4 other individuals• Fenced in back yard• Structured environment• Being close to his family



RH’s Behavioral Data: 2012 – 2013

• 60 episodes of aggression– 7 episodes were documented – 53 episodes were managed with proactive intervention

Attacked parents in vehicle Bit, hit and kicked staff Bit peers

• He had 40 events of property destruction 1 event was documented 39 events were managed with proactive intervention



RH’s Behavioral Data: 2012 – 2013 (cont’d)

• 214 episodes of self injurious behavior– 18 episodes were documented – 196 episodes staff were managed with proactive

intervention Biting self to the extent of drawing blood Hand banging on windows and doors Slapping self in face to the extent of drawing blood Hitting his face on his knees, blacking his eyes and

bruising his face• TOVA interventions were implemented 4 times• Chemical restraint was utilized 1 time during an episode of

especially challenging behavior



RH’s Staffing Needs

• Staff trained and practiced on his positive behavioral support plan

• 24 hour awake supervision with two staff awake at night

• Follow communication plan• Two staff for medical appointments to assist with

his aggression toward medical professionals• Supervision in bathrooms if others are nearby to

reduce the risk of aggressive episodes



PJ



Things That Are Important To/For PJ

To:• Listening to country

music• Taking trips• Talking to people about

trips I’ve taken• Looking at pictures in

magazines• Watching a movie or

television with others from time to time

For:• Being reminded to take

small bits so I don’t choke• Intense supervision to

make sure I don’t hurt myself



Current Challenges for PJ

• I will sometimes leave where I am supposed to be and will “wait” for someone to come find me. I enjoy this game and I laugh when I am found.

• When I become upset I may remove my clothes and throw feces.

• I often pull clothes, hair, and jewelry and scratch or kick support partners.

• I struggle with transportation and often grab the steering wheel, open doors, jump out or squeeze through windows, while riding in a vehicle.

• I will often destroy things in my home and other environments such as the community or at my day program.



PJ’s Staffing Needs

• Having 1:1 support for transportation to prevent elopement, SIB or other challenging behaviors

• Having 1:1 support when walking around in the community, as he will drop to the ground, roll around in parking lots and disrobe in public

• Having an effective Behavior Support Plan, Nutritional Management Plan,

• Having supports for oral and personal hygiene and with taking needed medications



PJ’s Staffing Needs (cont’d)

• Having a Positive Behavior Support Facilitator to develop and monitor Behavior Support Plan

• Instances of serious physical aggression should be addressed by following his BSP and involving START services to support acute and on-going concerns

• A structured and active employment or day support

setting where line of sight supervision is provided

The New Exceptional Rate for the ID Waiver

Documents

Transcript of The New Exceptional Rate for the ID Waiver