Team 1 - Support Coordination Enhancement (4-15-14)

Location of Meeting: Central Illinois Service Access, Lincoln IL

Team 1 Handout:  CMS Final Rule on Medicaid HBS Services

Members Present

Members Absent

• John Knight, DDD
• Vickie Stillman-Toomey, NASDDDS

Reading and Approval of Minutes

Reviewed the minutes from 3-13-14 with 2 minor corrections (minutes on DHS web site are correct)

1. Agenda Item #1 What Did We Accomplish since our first meeting?

   Providers are having questions around what the role of their QIDP is going to be with the changes. How is that going to affect service faciliators? How will funding decisions be made regarding choices? Providers are worried about how decisions will be made with the new service coordination role.

   Discussion regarding Service Faciliatation for Home Based Services:

   Currently service faciliatation is done through provider agencies since it has become a medicaid program. Previously the "service facilitation" was completed through the service coordination agency until home based services became a waiver program. It is difficult to find agencies to provide service faciliatation because the payment is so low (they are only able to bill 3-5 hours per month for service facilitation). Some agencies will also only provide the service if the individual attends their day program. The role also is confusing for families as to who does what role (is it a service faciliatation role or a service coordinator role?) Would it make sense for service facilitation to be clarified and/or possibly handled by Service Coordination agencies as we look to streamline this process? What would be the benefits and drawbacks?

   Discussion regarding innovation/creativity/change: We've got to be able to question without people feeling defensive.

2. Agenda Item #2: CMS Rule Discussion

   CMS Final Rule on Medicaid Home and Community Based Services was passed January 10, 2014 and is effective as of March 17, 2014. The rule itself is 87 pages long.

   See attached 3 page handout titled "CMS Final Rule on Medicaid Home and Community Based Services".

   1915c is the waiver that Illinois is under for DD services. It allows that for the first time that a medicaid office can combine multiple populations under one waiver (aging, mental health, DD). At the state level it is difficult to administer multiple waivers so this will make the process easier for states but the rule will be a big change for providers. Just because they can combine does not mean they will combine these groups into one waiver.  Questions and Comments in Regard to the new CMS rule:

   • Discussion regarding Risk (in regards to making choices):
     • There needs to be tools in place around risk. How do we negogiate risk? Right now it's either all or none. The all encompassing policies of providers make decisions and are in control. That needs to change so that the individual has the right to make decisions (as they are capable) and informed choice. How can we as a system help to make that happen for providers? The same approach doesn't work for everyone. The role of the team in the decision making needs to be clearly spelled out. Who is the leader of the team and how does the team make decisions to support the individual? (Look at the Irwin Siegel agency-underwriters for an insurance agency specifically in liability in the developmental disability field. They have specialized in providing support for providers for years. They are very effective at training providers on managing risk while supporting choices.)
     • The individual service plan (written by ISSA) will include the person's whole life-the bigger picture. It will address questions such as "What is the plan is going to be for this year? How do I want my life to be?" It will include preferences similar to the Ligas transition plan currently in use.
     • The provider service plan (written by the provider) will say "How the plan is going to be implemented? How do we make that happen for you?"
     • Some further questions to be answered will be: Who approves the plan? Which plan? Will rates reflect the new changes in place for choices/decisions in the ISP? How will funding pay for the new choices? Choices are not limitless. In the medicaid system there are limits as to what is available and we have to stay within those choices.
     • Individual Service Coordination needs to monitor the plan and assure services are delivered as described in the plan. What is the role of enhanced ISC around the monitoring part?

3. Agenda Item #3: Role of PAS/ISC Agencies

   1. What are we and what should we be called?  How is the PAS/ISC/ISSA Agency currently referred to?
      • PAS Agency (often by providers)
      • Service Coordination Agency
      • Individual Service Coordination
      • Independent Service Coordination
      • ISSA agency
   2. Programs (and funding streams) in our agencies
      • 1. Pre-Admission Screening

        Assessments: ICAP/SIB, Psychological, Psychosocial, Physical/Medical History. Review assessments to determine if: 1. Person has a developmental disability, 2. Does the Person require skilled nursing care? 3. Does the person require active treatment?

      • Bogard
        • Create annual service plan
        • Broker for services
        • Monitor the services on a monthly basis
        • Authorize expenditures
      • 3. Program 500/PUNS
        • Community outreach/education
        • Provide linkage to community resources
        • Complete the PUNS, enter information into ROCS
   3. ISSA/Waiver-funded program
      • Advocate for individuals who are in a waiver program (DT, AHBS, CILA)
      • 4 visits a year to monitor services on a quarterly basis and as needed
      • Attend ISP and complete ISP note
      • Approve ISP
      • Annual waiver redetermination
      • involved if there is a crisis/life change
      • One visit is residential, one visit in at day training, and the third visit can be done at either DT or residential (An ISSA visiting note is completed for the 3 visits).
      • Liason with family and provider

        What do we do that is meaningful? We don't want to necessarily be defined only by the programs that we offer? Agency names in other states: Resource Coordination, Service and Support Administrators, Supports Coordinator, Service Coordinator. Discussion was held around how the agencies should be identified in an easy to remember fashion that encompasses all of the programs.

        This team's recommendation is that we be called Independent Service Coordination Agencies. We will discontinue the reference to PAS/ISC/ISSA and strictly be referred to as Independent Service Coordination (ISC).

4. Agenda Item 4: What currently makes sense/works well/upside right now with the Role of the PAS/ISC agencies?

   1. Consistent (Activities/Services):

      • number of required visits
      • ISC functions are separate
      • annual waiver redeterminations
      • community presence
      • consistent staff at ISC agencies/longevity with staff (3 people mentioned)
      • statewide forms are consistent for completing PUNS, Visiting Notes, Waiver Redeterminations (3 people mentioned)

   2. Relationship with Bureau of Regional Services (BRS), Bureau of Transitional Services (BTS), and Bureau of Quality Management (BQM)

      • BTS: fast turnaround with applications
      • quick approval for ligas funding
      • familiar with standards
      • having one contact person within DDD
      • how familiar/knowledgeable they are with standards
      • staff are accessible to people
      • DHS staff participate in state meetings
      • communication has improved (webinars/web/email) (2 people mentioned)
      • BQM/BTS staff are responsive to questions
      • consistency of regional staff: same network faciliatators for a long time/good relationship (2 people mentioned)

   3. Documentation/Paperwork

      • consistent reporting
      • the state provides the forms for us to complete tasks
      • access to forms on the web

   4. Payment

      • fee for service
      • expedited payments/ability to receive expedited payments (3 people mentioned)

   5. Relationships with families and self advocates

      • face to face meetings to explain choices
      • strong relationships due to longevity (4 people mentioned)
      • knowledge: family trusts us because of knowledge (2 people mentioned)
      • outreach

   6. Authority/Oversight

      • constructive feedback during the BQM survey has improved
      • ensuring consistent services for all waiver persons
      • perceived by provider as having authority by BQM when asked to monitor

   7. Reporting

      • Quarterly reporting is minimal
      • BQM survey results are done in a timely manner

   8. Outcomes/Achieving results for our customers

      • Liason
      • Linking the person with needed services/hearing the stories about how a person's life has changed for the better
   9. Training
      • webinars and web based training on different topics
      • more opportunities and options thru webinars
      • internal training with ISC agencies is effective and consistent

5. Agenda Item 5: What doesn't make sense/not working well/downside right now within the role of the PAS/ISC agencies?

   Our name: we are called to many different names. This team's recommendation is that we be called Independent Service Coordination Agencies.

   1. Consistent (Activities/Services)

      • Definitions are open to interpetation and lack consistency
      • Blurred role with service faciliatation
      • All ISC's are not consistent
      • DHS staff are not consistent
      • Paperwork not consistent between ISC agencies
      • Caseloads/expectations are different

   2. Relationship with Bureau of Regional Services, Bureau of Transitional Services, and Bureau of Quality Management

      • Need strong support in enforcing rules
      • Inconsistent guidance on the rules
      • Most new information comes through Don Moss instead of directly to ISC agencies
      • Not always clear on who in DHS agency we need to report to
      • Lots of turnover in BQM staff
      • Turnover in region staff
      • Unrealistic expectations: impact of increased monitoring of providers, staffing, crisis, provider crisis

   3. Documentation/Paperwork

      • regular updating of forms, outdated forms on website (4 people mentioned)
      • not being notified when forms are updated
      • redundant financial reports
      • ROCS is not functional
      • ISSA visiting note report needs refinement
      • cost over requests for additional hours
      • Conflicting guidance on additional information needed (what is that information)
      • many forms/manuals still in draft status years later

   4. Payment

      • ROCS Is outdated
      • Payments are inadequate (4 people mentioned)
      • Delays in payments (2 people mentioned)
      • Cap on payments
      • Training on reporting or monitoring: no consistent process to pay ISC agency for additional ISSA monitoring

   5. Relationships with families and self advocates

      • Confused about ISC roles (2 people mentioned)
      • Inadequate resources to fully engage with families
      • Families are unsure who case managers actually are: is it provider or ISSA?
      • Families are secretive with issues-bring things to ISSA that they are scared to bring to provider; then provider interprets ISSA as being retalitory (when just voicing family concerns)

   6. Authority/Oversight

      • no perceived authority (mentioned by 2 people)
      • unclear and inconsistent rules
      • no consistent support with issues
      • we report to many different entities within DHS
      • our decisions are questioned by providers

   7. Reporting

      • ROCS antiquated
      • ISC is confused as to who they report to within DHS

   8. Outcomes/Achieving results for our customers 

      • Not really defined yet
      • no way to measure and no consequences
      • people have to wait a long time for services

   9. Training

      • specific DHS training for ISC's or new initiatives
      • no written responses to questions
      • no regular ongoing training opportunities
      • not enough consistent training
      • not learning about new state initiatives in a timely manner

6. Agenda Item #6: What should remain the same and what do we believe should change?

   What are your top 2-3 issues?

   • increase consistency at all levels: communciation among ISC and DHS, families, ISC's,
   • have a clear role of ISC to families, DHS, providers (8 people mentioned)
   • adequate and prompt payments (2 people mentioned)
   • clear mechanism set up for communicating changes and timely accountability methods
   • increase ISSA hours available to advocate (4 people mentioned)
   • regular training for ISC staff (3 people mentioned)
   • development and scheduling of statewide training (certain trainings they would need to attend before becoming an ISSA and then ongoing training-almost like a certification process)
   • change monitoring forms to reflect outcomes
   • statewide outreach to individuals, families and providers on the new ISC role (2 people mentioned)
   • a modern IT system for data management
   • clear set of expectations for routine ISSA visits
   • consistent paperwork requirements (2 people mentioned)
   • person centered planning-person driven system
   • enhance or define role of ISC agencies within DHS, BQM, BTS
   • clear expectation of routine visits and emergency events
   • streamlining of reporting
   • working on focus of being person driven
   • DHS will remain steadfast with commitment to changes

ACTION ITEMS (to be completed before our next meeting):

1. Each member of the team will talk with a parent(s) in your area regarding what is happening with the team and get their input. Feel free to present information at any parent advocacy meetings and get feedback. Lisa will talk with a parent group in her area and bring back feedback (Advocates Network). We will also ask Laurie (a parent in Service Inc's area) if she is interested in serving on the committee and if so, her information will be forwarded to Rose Ann.
2. Look at the ISSA Guidelines and Attachment A to prepare for discussion at our next meeting. DDD will scan and email to Denise so she can email out to everyone.

Minutes Prepared By: Denise Oligney-Estill