DD Services and Utilization Management

1. DD Services and Utilization Management March 2009

2. Today’sObjectives • To review the vision and outcomes of the PBH DD System • To review the Service definitions for several core services within the system • To learn about new Utilization Management Criteria • To learn more about how to clinically support service requests • To learn about changes to the ISP planning process

3. Vision of the PBH DD Service System • To value and support individuals with intellectual and developmental disabilities to be fully functioning members of their community; • To promote Promising Practices that result in real life outcomes and community membership for individuals; • To offer service options that will facilitate each individual’s ability to live in homes of their choice, have employment or engage in a purposeful day of their choice and achieve their life goals; • To provide opportunity for individuals to direct their service to the extent they choose; • To provide educational opportunities and support to foster the development of stronger natural support networks and enable individuals to be less reliant on formal support systems.

4. OneWaiver System State Medicaid Plan Piedmont Cardinal Health Plan 1915(b)(c) concurrent waiver 1915b Cardinal Plan Behavioral Health 1915c Innovations Waiver New Medicaid B-3

5. Managed Care and Innovations • PBH through the waiver system is allowed to develop UM/UR criteria that is unique to our waiver system as long as it is no more restrictive than the state plan. • Provides greater flexibility with funding • Allows us to limit our provider network to enhance quality, ensure specialty areas and ensure adequate choice.

6. Partners to Guide the System • Network-a sufficient choice of highly qualified providers who are trained to follow best practice in their delivery of services • Care Coordinators-Global oversight to ensure that individuals receive coordinated, appropriate care. • Support Coordinators-Work with the team to develop the ISP, monitor services and coordinate/link the person to services that help them achieve their personal outcomes .

7. Utilization Management - a tool to ensure individuals receive: • Right service • Right time • Right provider • Right intensity • Right duration • Right rate • Right outcome

8. Utilization Review A new concept for community based developmental disabilities…….. • Retrospective evaluation by an outside party (PBH) to assure that services provided to an eligible participant are necessary, appropriate, and cost effective.

9. Practice Guidelines • Systematically developed statements to assist the practitioner and individual in decisions about appropriate care for specific circumstances • Based on Evidenced Based Practice and Community Practice in the field of Intellectual and Developmental Disabilities

10. Outcome Measures • Continually working on new and better ways to make sure that services support people’s life goals resulting in positive outcomes. • Council on Quality and Leadership • Utilization Review

11. Meaningful Day • Definition • Resources • New Mexico • Others • Moving the System from: • Institution setting  segregated community • Institution setting  inclusive community

12. Why changes for Innovations now? • Innovations has experienced increased spending. However, spending is within overall Medicaid systems limits. • PBH has flexibility within the Piedmont Cardinal Health Plan on how our capitation payments are spent (on 1915b waiver expenses or 1915c waiver expenses) • We do not expect to exceed our Medicaid budget for 08/09 • In typical Managed Care systems, you expect to have savings during the first two years of the waiver, and then to experience much tighter budgets in the later years. We are in a cycle where our capitation payments are being more closely correlated to our costs, and this means that our management of the waiver services must be more exact.

13. HSRI is evaluating • There has been a limited evaluation of how PBH has managed medical necessity and utilization of services within the Innovations waiver. • PBH contracted with HSRI to conduct a study of the Innovations waiver with a focus on medical necessity, consumer need, and type and amount of service received. • HSRI was selected because of their experience working with 1915 (c) waivers across the country and because of the research they are doing with the Supports Intensity Scale. • The goal of the study is to help us improve and refine our utilization management and utilization review strategies.

14. Study Findings • Preliminary findings suggest that in our current system, people’s assessed needs do not consistently match the services or budgets they receive. • People with high support needs may get lower levels of service and have a lower budgets. • People with low support needs may receive a higher intensity of services and many more hours of service.

15. Strategy for Improvements • Structured Utilization Management and Utilization Review Criteria for each Innovations wavier service • Implementation schedule to review all plans against this criteria • Educate providers/participants and stakeholders on the review criteria • Refine the planning process so that the needs of the individual are used to inform the type and amount of service.

16. Why waivers are not allowed to do the following: • Replace services that are funded through IDEA for school age children. • Replace services that are funded through Vocational Rehabilitation. • Supplant natural/community supports that exist for individuals. • Other sources of funding to meet the need. • Serve anyone other than the Medicaid recipient with Medicaid funds. Medicaid is the payer of last resort……..

17. Tools to Move the DD System to Outcomes

18. Supports Intensity Scale • Supports Intensity Scale • Person Centered Supports Assessment • Planning Tool • Family Chooses the respondents

19. Individual Budget • Each person is assigned a budget based on age and life circumstances • Modifications can be requested (See Innovations Technical Manual Chapter 8) • Base Budgets have been adjusted to the actual utilization.

20. Utilization Management • DD System Utilization Management Criteria

21. Benchmark vs. Limit • Limit- is the maximum amount of service available under the waiver. Can not be exceeded under any circumstance and can not be appealed. • Benchmark- the amount of service that would typically be expected to be received by most individuals with low to moderate need. Can be exceeded with additional documentation and can be appealed.

22. Limits on Sets of Services • Limits on Sets of Services/Communication • Hard Limits that cannot be appealed • Limits are intended to be for exceptional needs • Revised School Age coverage 3-21

23. Exceptional Care • A specialized Utilization Management review to authorize services of higher frequency and intensity. • Requires additional documentation • Expectation that this level would be faded over time.

24. Utilization Review • Utilization Review Criteria and Process • Retrospective evaluation by an outside party (PBH) to assure that services provided to an eligible participant are necessary, appropriate, and at the lowest cost

25. Yes Means Within the Service Definition Covered activity only provided if the person has a need in this area No means Not within the service Definition Use other funding ,natural or community based if the person has a need in this area. Yes and No Documents

26. Home Supports • Intent • Definition • Communication • Yes/No Document • Utilization Criteria Benchmark • Documentation

27. Home Supports Tips • The service must originate from or end at the home of the individual. • AFL clarified to be spending one night or more regularly in the home of the provider staff person/correct service is Residential Supports. • Unscheduled services should be Respite • Can not substitute home supports for Crisis Services • Other clarifications

28. Home Supports II Benchmark Under Benchmark Exceptional Care • Must be medically necessary • Must be appropriate need • Within service definition & limits Children: Over 21hrs/wk school weeks (43 wks/yr) Over 42hrs/wk non-school weeks (9 wks/yr) Adults: Over 30hrs/wk if receiving all services in private home Over 54hrs/wk in combination with CN, SE & DS Documentation: • Short Range goals/Task Analysis • OP notes, data for each goal for 3 mths • Level 1 Incident Reports for 3 mths • Medical/Professional documentation • Fading Plan • Consumer Schedule (Incl. all daily/weekly activities) • Behavior Support Plan (if applicable) • Data (behavior/sleep/other) Children: 21hrs or under/wk school weeks (43 weeks/yr) 43hrs or under/wk non-school weeks (9 weeks/yr) Adults: 30hrs or under/wk if receiving all services in private home 54hrs or under/wk in combination with CN, SE & DS CN-Community Networking/SE-Supported Employment/DS-Day Supports

29. Day Supports • Intent • Definition • Communication • Yes/No Document • Utilization Criteria Benchmark • Documentation

30. Day Supports Tips • Is a group service • Individual is exceptional care • Individual services must have a fading plan • Must submit a TAR every 90 days to continue services. • No individual Day Supports just to go on outings.

31. Community Networking • Intent • Definition • Communication • Yes/No Document • Utilization Criteria Benchmark • Documentation • Differences with Requests under Individual Goods and Services

32. Community Networking Tips • Planned, purposeful experiences • Experiences not just outings, time fillers or participant outcomes • Opportunity to engage in activities where people without disabilities are involved • Outcomes/goals/strategies support less reliance on services/more reliance on community supports • Assist in making community connections

33. Supported Employment • Intent • Definition • Communication • Yes/No Document • Utilization Criteria Benchmark • Documentation

34. Supported Employment Tips • Typically employment is 10 or more per week • Typically earns minimum wage • Reasonable expectation that the position will last up to 90 and beyond • Integrated setting with non-disabled people • Encouraging Co-Worker Supports

35. Implementation Schedule • Day Supports effective April 1, 2009 • All UM criteria effective for Newparticipants April 1, 2009 • All UM criteria implemented for existing participants at the time of Annual ISP review, beginning with plans effective July 1, 2009 • All participants must be in compliance with new UM criteria no later than October 1, 2009

36. Planning Process • Things to consider throughout the planning process • ISP Pre-meeting checklist • Facilitating the meeting • Planning checklist for Service Providers • Decision making Process • Revised Individual Support Plan

37. New Tool to Assess Needs • Needs assessment – Community Guide

38. New Tools to Assist Teams • Behavior Support Plan • Sample Behavior Data Sheet • Fading Plan

39. Services that Can Help with Fading • Specialized Consultative Services • Natural Supports Education • Assistive Technology Equipment and Supplies • Home Modifications • Vehicle Adaptations • More information on technology later

40. Case Studies • How to Apply the Criteria

41. Questions and Answers

42. Next Steps • Communications posted with Criteria • Communications developed for families • Meeting with Advocates • Manual changes to reflect new criteria • Provider Training in May • Provider Training in September • Family Forums to discuss changes

43. Contact List • Utilization Management/Utilization Review Criteria- Contact Beth Monaco 704-743-2138 • Planning Process Questions- Tammy Gilmore, Anna Yon 704-721-2747, 704-721-2759