Department of Human Services “Going Home Plus”

1. Department of Human Services“Going Home Plus” Money Follows the Person Demonstration Grant Stakeholders Meeting Monday October 22, 2007 Section 6071 of the Deficit Reduction Act 2005

2. Stakeholder Meeting Objectives • Provide an overview of the grant and national trends • Provide an overview of the benchmarks • Provide an overview of the Guidelines for drafting the Operational Protocol • Discuss timelines • Form workgroups to draft areas of the Operational Protocol

3. Stakeholder Objectives The Objectives of the Stakeholder Committee are to: • Provide input as draft processes, guidelines, and criteria are developed for structuring the project • Provide input on policy and technical matters to the Department of Human Services The Stakeholder Group is comprised of “community” subject matter experts and “State” subject matter experts.

4. NursingFacility Characteristics- 2005

5. Trends in Home and Community-Based Services (HCBS)

6. Medicaid Spending on Long-Term Care Services, by Type of Service, 2005 Hawaii Nation Source: AARP (2006) Across the States: Profiles of Long-Term Care and Independent Living

7. CMS Awards Money Follows The Person • 31 States have been awarded $1,435,709,479 • Tier I: 17 states • Tier 2 13 states and D.C. • Since the beginning of Medicaid, this is the Single Largest Investment in Medicaid LTC (Ever) • Long Term Care target populations: Elders, individuals with Developmental Disabilities, Physical Disabilities, Traumatic Brain Injury and Mental Illness • Higherpercentage of federal matching dollars x 12 months after an individual moves out of an institution and into the community to help cover the costs of moving people out of nursing homes and into community settings • State Maintenance of Effort required. States must continue to provide community services after that period as long as the person needs community services and is Medicaid eligible

8. Going Home Plus (GHP) • Hawaii’s Award: $10,263,736 federal funding over 5 years • Dates: May 3, 2007 through September 30, 2011. • The Hawaii “Going Home Plus” demonstration will bring together the State’s resources to support persons who have resided in a health care institution for at least 6 months but no longer than 2 years as they transition back to community living.

9. Objectives Rebalancing 1) Increase use of home and community based, rather than institutional services Flexible Funding 2) Eliminate barriers or mechanisms (state law/budget/state plan) that prevent or restrict the flexible use of Medicaid funds Sustainability 3) Increase the ability of the state Medicaid program to assure continued provision of community-based services Quality 4) Ensure quality assurance strategies and procedures are in place

10. Medicaid Funding • Federal – State partnership • Hawaii matching rates: – Federal 56.5% – State 43.5% • HCBS enhanced match for 12 months – 84.75% Federal (15.25% State)

11. GHP Funding Method • Performance Based Funding- The State will only being reimbursed for persons who have successfully moved into the community • The State is reimbursed on a per person basis Enhanced Match for 12 months after transition Regular Match until person no longer requires HCBS services

12. 6 months 365 days day 366 - ? Timeline for Participants Day of Discharge After 365 days in demonstration, the qualified HCBS package must continue through a waiver, managed care plan or State Plan Amendment

13. Pre Implementation Phase • 3 – 12 months planning period, must include formal stakeholder process [Hawaii- 5months] • Development of operational protocol • Identify target populations, participant selection mechanism, detailed delivery service plan, quality management system • Must be approved by CMS before implementation • Pre-implementation phase: costs for project manager, staff & transition coordinators paid at regularadministrative match

14. Implementation Phase • Qualified HCB Program Services • Enhanced Match • Must be continued at the conclusion of the demonstration via waivers or State Plan. • HCB Demonstration Services • Enhanced Match • No requirement to continue beyond the demonstration; waiver or state plan amendment would be needed. • Supplemental Demonstration Services • Regular FMAP • Cannot receive Federal reimbursement beyond the demonstration; short term non-waiver services; fill gaps.

15. Restrictions • Cannot use money for housing or bridge funds • Residents of Psychiatric Residential Treatment Facilities (RTFs) not eligible • Group housing only where no more than 4 unrelated individuals reside • Cost effectiveness for waivers is required

16. Qualified Participants • Reside in an inpatient facility (nursing home, ICF-MR or hospital) for a minimum of 6 months to a maximum of 2 years • Facility costs must have been paid by Medicaid for at least one month prior to transitioning • Must meet nursing facility level of care • Require HCBS services in order to successfully reside in a community based setting.

17. Qualified Residence • A home owned or leased by the individual or family member • An apartment with an individual lease, with lockable access & egress, and includes living, sleeping, bathing and cooking areas over which the individual or family member has domain and control • A residence in a community based residential setting where a maximum of 4 unrelated individuals reside.

18. Benchmarks 2 Statutory Benchmarks • Projected #s transitioned in each target group for each demonstration year • Qualified Expenditures for HCBS during each of the 5 years of the program • Limited to state spending on HCBS (not versus institutional spending) • Include all Medicaid HCBS spending not just “Going Home Plus” expenditures

19. Hawaii’sProposed Transitions Projection: 90% of discharges will remain in community for one year or more

20. More about Benchmarks • At least 3 additional Benchmarks[stated as measurable annual outcomes] • Represent the reinvestment commitment of the state • Are measures of progress on rebalancing the state’s system • Should not be related to individuals in the demo per say • Examples: • Progress toward flexible financing strategies • Increase in available supportive services • Increases in the workforce • Increase in self-directed services • Increased use of transition coordinators • Improvement in QA system

21. Additional Benchmarks • Benchmark #3: • Combine Medicaid State Plan and HCBS Budgets • Benchmark:* • Processes for screening, identifying and assessing transition candidates • Benchmark:* • Use of Transition Coordinators • Benchmark: • Technology to support a virtual care team • Benchmark:* • Improve quality management system for HCBS

22. Going Home Plus Key Points • Oahu: Year 2 (2008) and Year 3 (2009) • Statewide expansion during Years 3 (2010) & 4 (2011) or earlier • Use of Transition Coordinators • One-time Transitional Costs: • Training Institute • Virtual Care Team

23. Timeline for Operational Protocol • Hawaii must submit its Operational Protocol to CMS no later than May, 2008. • CMS has 45 days from receipt of our Operational Protocol to respond. • The implementation phase can begin when Hawaii receives approval form CMS.

24. Operational Protocol The objectives of the Operational Protocol are: • Provide CMS with an understanding of the operation of the demonstration project • Serve as a resource for CMS to prepare for site visits • Serve as a manual to State staff for demonstration project implementation • Provide stakeholders with an understanding of the operation of the demonstration project

25. Operational Protocol (cont) • State must submit detailed financial status reports and semi annual progress reports • State must participate in a national evaluation • State must submit Maintenance of Effort statements annually

26. Required Contents of the Operational Protocol A. Project Introduction • 1. Case Study • 2. Benchmarks • B. Demonstration Policies and Procedures • 1. Participant Recruitment and Enrollment • 2. Informed Consent and Guardianship • 3. Outreach/Marketing/Education • 4. Stakeholder Involvement • 5. Benefits and Services • 6. Consumer Supports • 7. Self-Direction • 8. Quality • 9. Housing • 10. Continuity of Care Post Demonstration • C. Organization and Administration • D. Evaluation • E. Final Budget

27. Work groups • Workgroup #1: Participant Recruitment and Enrollment • Workgroup #2: Informed Consent and Guardianship • Workgroup #3: Outreach/Marketing/Education • Workgroup #4: Benefits & Services/Consumer Supports • Workgroup #5: Housing

28. Workgroup cont. Workgroup Composition: • Consumers • Providers, and • State Staff Workgroup members shall have subject matter expertise

29. Workgroup #1 Recruitment and Enrollment Workgroup • Participant selection criteria and policies • Development of recruitment and enrollment materials • Training for participants • Transition Coordinators

30. Workgroup #2 Consent and Guardianship • Informed Consent for enrollment • Forms • Procedures for involving guardians • Guardianship issues and policies

31. Workgroup #3 Outreach/Marketing/Education • Information for enrollees, providers and case workers • Distribution of materials • Staff Training/public training • Media • Translation of materials

32. Workgroup #4 Benefits & Services/Consumer Supports • Identification of services for each population • Service delivery system for each population • HCBS demonstration Services • Supplemental Services • 24hr back up system • Complaint/resolution process for backup & support services

33. Workgroup #5 Housing • Identify types of qualified of residences available in state • Existing or planned inventories and shortages • How Medicaid will work with Housing Finance, Public Housing Authorities • Strategies to promote availability, affordability accessibility

34. Upcoming Meetings Meeting dates: • Stakeholder group: 2 meetings • Monday, January 7, 2008 • Monday, March 3, 2008 • Workgroups: 4 meetings per workgroup • To be scheduled