ADVANCED ISSUES IN THE HABILITATION SUPPORTS WAIVER

1. ADVANCED ISSUES IN THE HABILITATION SUPPORTS WAIVER

2. TODAY’S AGENDA • Welcome & Introductions • Quality Improvement Strategy (QIS) and Performance Measures (PMs) • Service-related Issues • Assessment-Related Issues • MI Choice referrals & NFTI Activities • Year-End Activities • HSW Database Rewrite

3. QIS & PMs

4. QUALITY IMPROVEMENT STRATEGY • The cycle of QIS - DDRI • Design • Discovery • Remediation • Improvement • Six Assurances have PMs to demonstrate QIS cycle • Administrative Authority • Level of Care (LOC) • Qualified Providers • Plan of Services (IPOS) • Health & Welfare • Financial Accountability

5. DESIGN PHASE • Managed care system delegates most of the authority for provision of waiver to the PIHPs. • State must assure that the assurances are met through monitoring activities, such as site reviews, desk audits, etc.

6. DISCOVERY PHASE • Data is gathered from many sources (see handout) • Aggregated and analyzed quarterly by MDCH • Issues that are identified for individuals must be remediated within timeframes specified in the waiver renewal.

7. DISCOVERY PHASE • Example of how data is tracked and analyzed from the site review dimensions: Note: Site Review Dimensions have changed since the initial tracking spreadsheet was developed

8. DISCOVERY PHASE • Evidence needed for PMs • LOC – must meet the requirements for ICF/MR LOC • For recertification desk audits, please send packets via snail mail • IPOS should document explanation of • Freedom of choice of providers • Freedom of choice of waiver services • Qualified Providers – PIHP records must demonstrate credentialing, training, and each provider of waiver services meets the MPM provider qualifications.

9. DISCOVERY PHASE • Evidence needed for Other QIS Activities • BTP Review Committee Minutes – can we tell from the documentation • Reviewed because of use of Intrusive • Medications • Other methods • Reviewed because of use of Restrictive • Reviewed because of both Intrusive and Restrictive • Is QI data re: HSW enrollees with behavior plans that include intrusive and/or restrictive interventions aligning with the reviews? • Is Health Conditions data on number of psychotropic medications aligning with the reviews?

10. REMEDIATION PHASE • Most of the PMs require individual-level remediation, including LOC, IPOS, Qualified Providers, and Health & Welfare. • Timeframes for remediation must be followed • New template for remediation of Critical Incidents will be sent out later this week • Some of the Administrative Authority PMs & Financial Accountability PMs are not remediated at the individual level.

11. IMPROVEMENT PHASE • Continuous improvement as issues are identified – may be improvement at the individual, local, regional, and/or state level. • Example: Supports coordinators were providing customer handbook with information about freedom of choice of waiver services & providers, but now are also explaining those to the enrollee.

12. SERVICE-RELATED ISSUES

13. GOODS & SERVICES • Not seeing any utilization • Feedback from PIHPs, providers and enrollees & families • Other services already provide ways to purchase goods & services • Fear of requirement of replacing paid caregivers • What if it doesn’t work out? • Once we give it up, we can’t get it back • Concern about the timeframe for phase-out of paid caregivers • What other issues are limiting use?

14. RESPITE • HSW service is an entitlement • Is provided during the times that family is not being paid to provide care • See MPM for definition of what “unpaid caregiver” means • If determined to be medically necessary, cannot simply shift burden to family to find a family friend respite provider and use GF • If family CHOOSES this to be able to employ someone they have in mind, that’s fine • However, if family can’t locate a respite provider, PIHP has obligation to assist with securing qualified providers.

15. PRIVATE DUTY NURSING • Changes to the PDN policy have been in place for a year • Has the ability to do transition from nursing to trained aides been useful? • What has impact been? • MDCH considering eliminating requirement for desk audits of PDN determinations for people age 21+ receiving HSW PDN. • What are your thoughts?

16. ASSESSMENT-RELATED ISSUES

17. ICF/MR • W197 of the CMS Surveyor's Guide for ICF/MRhttps://www.cms.gov/manuals/Downloads/som107ap_j_intermcare.pdf • §483.440(a)(2) Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program. • Guideline:The regulations define the target population eligible for the ICF/MR benefit, by defining the services that are required for a facility to provide in order for it to qualify as an ICF/MR and receive Federal Financial Participation (FFP). At the front end, one of the “required services” is training in basic fundamental skills. The type of skills described in W242, by their very nature, target a population who have significant deficits in growth and development.

18. ICF/MR • W242 of the CMS Surveyor's Guide for ICF/MR https://www.cms.gov/manuals/Downloads/som107ap_j_intermcare.pdf • §483.440(c)(6)(iii) Include, for those clients who lack them, training in personal skills essential for privacy and independence (including, but not limited to, toilet training, personal hygiene, dental hygiene, self-feeding, bathing, dressing, grooming, and communication of basic needs), until it has been demonstrated that the client is developmentally incapable of acquiring them. • Guidelines: The receipt of training targeted toward amelioration of these most basic skill deficit areas is a critical component of the active treatment program needed by individuals who are eligible for the ICF/MR benefit, and therefore, is a required ICF/MR service.

19. LOC DETERMINATIONS • Data shows high level of accuracy with PIHPs making LOC determinations. • Form for Major Life Activities being reviewed for revisions to make it easier for QMRPs to score and determine ICF/MR level of care based on W197 and W242. • This should further improve accuracy and reduce pend rate for new applications even further • Will assist managers in training younger workforce of QMRPs who have not had experience in ICF/MRs • For school-aged applicants, if we don’t see habilitative objectives, we may request the IEP - skill development should be coordinated between home and school.

20. HOUSEKEEPING ISSUES • Please do not send emails with Protected Health Information like name, Medicaid ID, etc. unless it is encrypted. • If a packet is larger than 20 pages, please send via snail mail unless it is a highest-priority situation.

21. MI CHOICE & NFTI

22. Referrals to MI Choice • Need to work with people to figure out which program is most appropriate to meet the needs • Not for cost-shifting • Waiver managers available to do phone consultation

23. NFTI ACTIVITIES • Nursing facility transition initiative • More people being transitioned from nursing homes have diagnoses on Axis I & Axis II. • Not always clear whether the person meets eligibility for managed specialty services plan (b-waiver). • Need to encourage nursing home residents to request intakes through Access Center to make determination of eligibility. • Important to do outreach & education with NFTI coordinators and MI Choice Waiver agents

24. YEAR-END ACTIVITIES

25. RECOUPMENTS FOR NON-SERVICE MONTHS • FY10 Manual Processing • MDCH greatly appreciated the hard work by the PIHP staff !!  • FY11 Manual Processing • Target is to do quarterly rather than year-end • FY12 CHAMPS Processing (projected) • Target is to get programming completed mid-FY12 • PIHPs would get advance notice before recoupments would “go live”.

26. RESIDENTIAL CODES • Validation process went very smoothly this year • Please check to make sure the codes we entered are correct and let us know if we need to fix any.

27. DATABASE

28. HSW DATABASE • HSW database reports related to payments and recoupments are available and appear to be working • Database needs to be rewritten into a different software platform as the current system is no longer supported. • Three HSW coordinators are assisting with the design • Will incorporate the suggestions provided earlier this year by HSW coordinators & users. • Will include ability to track individual-level performance measures & remediation • Will have ability to copy data into excel – WITH DISCLAIMER • Won’t be able to accept electronic documents