1. Maryland’s Home and Community-Based Services Waivers Medicaid Advisory Committee June 2006

2. Overview • Review of Maryland’s Waivers • Waiver Services Registry • New Directions • Money Follows the Individual/Options Counseling • Waiver Tracking Systems • Waiver Quality Assurance • Reportable Event Policy • Participant Experience Survey (PES) 2

3. Review of Maryland’s Waivers • Maryland has seven home and community-based services (HCBS) waivers. • HCBS waivers provide support services in community settings to individuals traditionally served in long term care facilities. • In FY07, Maryland will serve more than 15,800 individuals in waivers. • Many waivers are out of “slots” and not accepting new community applicants. • There is a high demand for waiver services. 3

4. Review of Maryland’s Waivers:Funded Waiver Slots – FY07 Funded Waiver Slots - FY07 Waiver Older Adults Waiver 3,750 Living at Home Waiver 500 Waiver for Children with Autism Spectrum Disorder 900 Waiver for Individuals with Developmental Disabilities 10,288 New Directions Waiver (Developmental Disabilities) 200 Model Waiver for Medically Fragile Children 200 30 Waiver for Individuals with Traumatic Brain Injury 4

5. Review of Maryland’s Waivers:Funded Waiver Slots – FY07 Funded Waiver Slots - FY07 Waiver Older Adults Waiver 3,750 Living at Home Waiver 500 Waiver for Children with Autism Spectrum Disorder 900 Waiver for Individuals with Developmental Disabilities 10,288 New Directions Waiver (Developmental Disabilities) 200 Governor Ehrlich included $2 million for both Older Adults and Living at Home Waivers in FY2007 budget. Model Waiver for Medically Fragile Children 200 30 Waiver for Individuals with Traumatic Brain Injury 5

6. Review of Maryland’s Waivers:Funded Waiver Slots – FY07 Funded Waiver Slots - FY07 Waiver Older Adults Waiver 3,750 Living at Home Waiver 500 Maryland’s newest HCBS Waiver. Waiver for Children with Autism Spectrum Disorder 900 Waiver for Individuals with Developmental Disabilities 10,288 New Directions Waiver (Developmental Disabilities) 200 Model Waiver for Medically Fragile Children 200 30 Waiver for Individuals with Traumatic Brain Injury 6

7. Waiver Services Registry • The Older Adults, Living at Home and Autism Waiver are closed to community applicants. • DHMH developed a Waiver Services Registry for people who are interested in receiving waiver services. • Individuals may place themselves on the Registry by calling a toll-free number. • Individuals can find out their place (or number) on the Registry by calling the Registry’s toll-free number and providing their SSN. 7

8. Waiver Services Registry • As of May 2006, the Waiver Services Registry has: • 7,000 individuals interested in OAW • 1,400 individuals interested in LAH • 1,600 individuals interested in AUT • Nearly 6,000 individuals from the Registry have received the opportunity to apply for the Older Adults Waiver. • Department began mailing applications for new FY07 OAW and LAH in May 2006. 8

9. New Directions Waiver • Waiver Target Population: • For individuals with developmental disabilities of all ages who live in their own or family home • New Directions is an “Independence Plus” Waiver based on values of self-determination. • More control over their services and supports • Person Directed planning process produces individualized plan & budget • Participants use a Support Broker and Fiscal Management Service to obtain, manage and • Pay for services provided by individuals, agencies, businesses of their choice • No new money - opportunity to use the current $ in a new way. • Began enrolling individuals for services beginning April 2006.

10. Money Follows the Individual • In December 2002, DHMH developed a “Money Follows the Individual” Policy. • This means that individuals in nursing facilities whose service are paid by Medicaid may apply to the OAW or LAH waiver, regardless of the number of available “slots”. • Participants who have transitioned from a NF: • Older Adults Waiver: 1,220 total; 622 active • Living at Home Waiver: 182 total; 136 active 10

11. Options Counseling • SB620 (2004) required DHMH to use MDS information to identify and assist people who want to move to the community. • DHMH expanded Delmarva’s role during quarterly reviews. • Nurses discuss HCBS options with nursing home residents identified in MDS data. 11

12. Options Counseling • If a resident would like to apply to a waiver, the nurse will make a referral to the agency. Nurses will counsel any resident even if they did not indicate yes on MDS. • As of April 2006: • 624 individuals received options counseling. • LAH: 158 referrals; OAW: 189 referrals • Not interested in waiver services: 277

13. Options Counseling 13

14. Waiver Tracking Systems • DHMH and UMBC developed web-based application tracking system for the Older Adults Waiver. • Implemented in May 2004. • All users can follow an application as it flows through the eligibility process. • Living at Home Waiver tracking system in development. • System will improve overall customer service by reducing paperwork (faxing and mailing). • Will complete development late this summer • Pilot testing will begin by end of summer. • Plans of care are included in tracking system. 14

15. Waiver Quality Assurance • GAO Report published in June 2003 highlighted CMS’s lack of quality oversight in waiver programs. • In response, CMS has developed tools to assist states in developing better quality assurance programs. • DHMH has been working to strengthen the waiver quality assurance systems by developing a consolidated approach to quality assurance for all the waivers. 15

16. Waiver Quality Assurance:QA Initiatives • Establish Waiver Quality Council • Meets quarterly • State agency representatives from waiver programs • Continue to monitor participants through the Inspection of Care Team. • Increased and focused trainings for providers and case managers. • Survey participants on access to care, choice and control, respect and dignity, and community integration. • Monitor financial accountability using data reports. 16

17. Reportable Event Policy and Procedure • Policy and procedures for identifying, reporting and timely resolution of complaints and incidents for OAW, LAH and AUT participants and providers • Mechanism for DHMH and agencies to monitor and track • Effective August 1, 2005 • Focus groups over summer to discuss policy, forms and effectiveness with stakeholders 17

18. Participant Experience Survey (PES) • In 2005 DHMH surveyed OAW and LAH waiver participants using the CMS-developed PES in 16 jurisdictions. • 15 minute in-home survey measured overall experience in waiver programs in 4 areas: • Access to care, choice and control, respect and dignity and community integration. • First PES survey was in 2004 • Focus groups developed some improvement strategies • Waiver-improvement strategies were not fully implemented from 2004 when 2005 PES completed (due to grant time constraints) 18

19. Participant Experience Survey (PES) • Results comparison • Worked with UB to determine “statistical meaningfulness” (9% change in either direction) • Good baseline –2004 and 2005 results congruous • Improved results seen particularly in LAH (respect/dignity, awareness of consumer direction, ability to reach CM) • Fewer participants could name CM • Question changed in 2005, CM turnover, level of cognition • Ability to contact CM ultimately more important

20. Maryland’s Home and Community-Based Services Waivers Medicaid Advisory Committee June 2006