Ligas Rates Oversight Committee - November 13, 2023

Guidehouse Developmental Disability Services Rate Study

  • Study resulted from a non-compliance finding by the Court in the Ligas Consent Decree, largely due to concerns surrounding rates and capacity.
  • State created a stakeholder workgroup - Ligas Rates Oversight Committee - to make recommendations around rates and rate methodologies within the I/DD system. ?
  • Oversight Committee worked with 7 subcommittees to make recommendations around the adult residential (CILA, ICF) and day program (CDS, SEP) systems.?
  • DDD contracted with Guidehouse to take the Committee's recommendations and create new and updated rates and rate methodologies.
  • Development Disability Services Rate Study was released December 2020.?
  • Study recommends implementation over 5 years; State implementation is over 7 years.
  • Estimated cost to implement all recommendations: $745 million+? (Note: This assumes full funding of CILA Rate Calculator with DSP hour system changes.)
  • State's investment in Guidehouse by Fiscal Year:
    • FY 2022 - $142M
    • FY 2023 - $138.9M
    • FY 2024 - $196.7M
    • TOTAL INVESTMENT (to date): $477.6M
    • Total left to invest: $267.4M
  • Recommendations left to implement:
    • $3.00/hour DSP wage increase
    • Implement Zero-Hour Model (funds staff 24 hours/day, 7 days/week)
    • Expand day program service array (medical/behavior add-on)

Community Integrated Living Arrangement (CILA) RATE CALCULATOR

  • Program Costs
    • Staffing Costs
    • Other Supply Costs
    • Miscellaneous Consultant Service Costs
  • Nursing Costs
  • Room and Board Costs
  • Non-Housing Room and Board Costs
  • Transportation Costs
  • Administration Costs

CILA Rate Calculator - Program Component

  • Program - Staffing Costs
    • Direct Support Professional (DSP) staff
      • Prime Time
      • Non-Prime Time
      • Night Shift
      • Saturday and Sunday
      • Substitute Staff
    • Qualified Intellectual Disability Professional (QIDP)
    • Supervisor
  • Current Staffing Model deducts five (5) hours per day Monday - Friday for day programming.
  • NOTE: Guidehouse has recommended adopting a Zero-Hour Staffing Model which funds staff 24/7. (minimum round-the-clock staffing)

CILA Rate Calculator - Guidehouse Staffing Tables

  • Inventory for Client and Agency Planning (ICAP) Assessment
    • Scores range from 1 to 100
      • Lower scores equate to greater needs/more supports needed
      • Higher scores equate to lower needs/fewer supports needed
  • Health Risk Screening Tool (HRST) Assessment
    • Scores range across 6 Health Care Levels
      • Higher HCL (5-6) equate to greater needs/more supports needed
      • Lower HCL (1-2) equate to lower needs/fewer supports needed
  • Inventory for Client and Agency Planning (ICAP) Assessment
    • Scores range from 1 to 100
      • Lower scores equate to greater needs/more supports needed
      • Higher scores equate to lower needs/fewer supports needed
  • Health Risk Screening Tool (HRST) Assessment
    • Scores range across 6 Health Care Levels
      • Higher HCL (5-6) equate to greater needs/more supports needed
      • Lower HCL (1-2) equate to lower needs/fewer supports needed
  • An individual's ICAP score plus Health Care Level (from the HRST) determines the individual's Assessment Level.
  • Assessment Levels range from 1 to 6
    • 1 - lowest need
    • 6 - greatest need
  • Different Assessment Levels assign a "weight" to determine the Staffing Table Look-Up score for the GH Staffing Tables
  • Staffing Table Look-Up score is the number used to determine the DSP staff hours via the Guidehouse Staffing Tables.
  • There is a weight added to the Assessment Levels 1-4.
  • There is no weight added to Assessment Levels 5 and 6.
  • ICAP plus HRST Level equates to an Assessment Level which translates to a Resource Use Level (RUL) which is also the reimbursement level
    • Range from RUL 1 - 4
      • Very low ICAP Scores - RUL 4 (1-131) - Highest DSP Hours
      • Lower Middle ICAP Scores - RUL 3 (132-250)
      • Higher Middle ICAP Scores - RUL 2 (198-210)
      • Very High ICAP Scores - RUL 1 (211-250) - Lowest DSP Hours
  • Range of staff hours at highest and lowest ends of both the current and GH Staffing Tables are similar.

CILA Rate Calculator Timeline

  • January 1, 2023 - CILA Rate Calculator approved for implementation via Waiver Amendment
  • February 2023 - IDHS paused implementation of CILA Rate Calculator
  • September 1, 2023 - DDD back on contract with Guidehouse
  • September 21, 2023 - First meeting of Ligas Rates Oversight Committee
  • December 31, 2023 - Pause expires

CILA Rate Calculator Comparison

  • February Rate Calculator
    • 3.7 million hours loss (12% decrease)
    • 66% of CILA residents would see hours reduced
    • 34% of CILA residents would see hours increased
  • October Rate Calculator
    • 2.5 million hours loss (8.7% decrease)
    • 90% of CILA residents would see hours reduced
    • 10% of CILA residents would see hours increased

CILA RATE CALCULATOR IMPLEMENTATION OPTIONS

  • Scenario 1 - Full CILA Rate Calculator Implementation January 1, 2024
  • Scenario 2 - Full CILA Rate Calculator Implementation plus Zero-Hour Model Implementation July 1, 2024
  • Scenario 3 - Partial CILA Rate Calculator Implementation January 1, 2024 with full implementation July 1, 2024

Scenario 1 - Full CILA Rate Calculator 1/1/24

  • Reduces statewide funded DSP by 2.5M hours
  • Reduces annual cost by $86.6M (based on DSP wages 1/1/24)
  • 1,006 clients with increase in DSP funded hours
  • 8,757 clients with decreases in DSP funded hours
  • 7 CILA providers with increase in DSP funded hours
  • 208 CILA providers with decreases in DSP funded hours
  • Impact less on smaller homes

Scenario 1 Impact by CILA Size

Size Current GH Change Change %
1 366,446.0 364,554.0 -1,892.0 -0.5%
2 293,523.5 285,262.0 -8,261.5 -2.8%
3 2,073,160.7 1,946,163.0 -126,997.7 -6.1%
4 6,085,146.0 5,680,211.0 -404,935.0 -6.7%
5 2,782,671.2 2,573,899.0 -208,772.2 -7.5%
6 5,119,850.3 4,661,422.0 -458,428.3 -9.0%
7 2,118,273.8 1,912,112.0 -206,161.8 -9.7%
8 9,779,651.7 8,697,862.0 -1,081,789.7 -11.1%
Grand Total 28,618,723.3 26,121,485.0 -2,497,238.3 -8.7%

 Scenario 2 - Full CILA Rate Calculator plus Zero-Hour Model Implementation 7/1/24

  •  Maintains statewide funded DSP, net decrease of 105K hours (1.0M increase and -1.1M decrease)
  • Reduces annual cost by $4.1M (based on DSP wages 1/1/24)
  • 3,970 clients with increases in DSP funded hours
  • 5,793 clients with decreases in DSP funded hours
  • 97 CILA providers with increases in DSP funded hours
  • 118 CILA providers with decreases in DSP funded hours
  • Positive impact on DSP hours for smaller homes
  • Implementation will require Waiver Amendment approval

Scenario 2 Impact by CILA Size

CILA Size Current Hours GH w/Zero Hour Hours Hours Change Change %
1 366,446.0 420,884.0 54,438.0 14.9%
2 293,523.5 322,581.0 29,057.5 9.9%
3 2,073,160.7 2,195,858.0 122,697.3 5.9%
4 6,085,146.0 6,324,107.0 238,961.0 3.9%
5 2,782,671.2 2,849,852.0 67,180.8 2.4%
6 5,119,850.3 5,069,807.0 -50,043.3 -1.0%
7 2,118,273.8 2,056,004.0 -62,269.8 -2.9%
8 9,779,651.7 9,274,237.0 -505,414.7 -5.2%
Grand Total 28,618,723.3 28,513,330.0 -105,393.3 -0.4%

Zero-Hour Model Recommendation

  • Funds CILAs with minimum, round-the-clock staffing (24 hours/day, 7 days/week)
    • DDD is currently funding at Five Hour Model whereby CILAs are reimbursed for 19 hours/day Monday-Friday, 24 hours/day Saturday and Sunday
  • Provides opportunities and flexibility to CILA residents to have more options throughout the day, evening, or weekend including competitive, integrated employment, community-based day programming, and personal choice.
  • Provides more opportunities for an aging CILA population to allow "retirement" from traditional day programming.
  • Addresses potential gaps in funding between CILA and day program

Scenario 3 - Partial CILA Rate Calculator Implementation 1/1/24 with Full CILA Rate Calculator Implementation 7/1/24

Implementation of 1/1/24 Partial CILA Rate Calculator

  • Initial decrease of 370K hours (1/1/24), final decrease of 2.5M hours (7/1/24)
  • Reduces FY24 cost by $6.6M (based on DSP wages 1/1/24)
  • 4,038 clients with increase in DSP funded hours
  • 5,725 clients with decreases in DSP funded hours
  • 142 CILA providers with increase in DSP funded hours
  • 73 CILA providers with decreases in DSP funded hours
  • Does not result in prioritization of impact on smaller homes
  • Effective 7/1/24 implement Option 1 with full GH rate calculator

Scenario 3 Impact by CILA Size

Size Current GH w/phased-in tables Change Change %
1 366,446.0 364,554.0 -1,892.0 -0.5%
2 293,523.5 289,658.0 -3,865.5 -1.3%
3 2,073,160.7 2,025,988.0 -47,172.7 -2.3%
4 6,085,146.0 6,187,665.0 102,519.0 1.7%
5 2,782,671.2 2,722,179.0 -60,492.2 -2.2%
6 5,119,850.3 5,159,533.0 39,682.7 0.8%
7 2,118,273.8 2,058,543.0 -59,730.8 -2.8%
8 9,779,651.7 9,440,351.0 -339,300.7 -3.5%
Grand Total 28,618,723.3 28,248,471.0 -370,252.3 -1.3%

Scenario breakdown by DSP Funded Hours and Cost - full year

- DSP Funded Hours (millions) Cost of DSP Hours (millions)
Current DSP Hours Funded 28.6 $987.1
GH CILA Rate Calculator 26.1 $987.1
GH CILA Rate Calculator w/Zero Hour 28.5 $987.1
GH Rate Calculator w/Partial Implementation 28.2 $973.9

Review of Consolidated Financial Reports (CFRs)

  • 215 CILA Providers (24-Hour) - based on the most recent CFRs
  • 87 or 40% reported hours less than the CILA Rate Calculator
    • 25 or 11% reported more hours than the CILA Rate Calculator
  • This was reduced to 12 with implementation of Zero-Hour Scenario 
  • 67 or 31% of providers had incomplete CFRs
  • 36 or 17% of providers did not have CFRs submitted

Note- this analysis is not perfect.  Going forward DD is requesting CFRs contain complete DSP hours provided.

IDHS Implementation Recommendation

  • Scenario 2 - Full CILA Rate Calculator Implementation plus Zero-Hour Model 7/1/24
  • Maintains integrity of the full Guidehouse CILA Rate Calculator implementation
  • Accelerates the Zero-Hour model from FY27 to FY25 
  • Adds hours to smaller homes and to clients with high behavioral needs

Implementation Communications Needed

Will need GOMB and GO approval prior to announcement.

  • Ligas Rate Oversight Committee Meeting - November XX
  • Legislator Briefing Covering Guidehouse Rate Implementation - November 16
  • Written communication for release to all providers immediately following Rate Oversight Committee meeting.
  • Targeted phone calls prior to key stakeholders.

Arguments:

  • Implementing to maintain integrity of Rate Study.
  • Demonstration of all other investments that have been made to the system.
  • Rightsizing hours
  • Incentivize smaller CILA settings