Self-Directed Support in a Changing Environment: Building Program - - PowerPoint PPT Presentation

Self-Directed Support in a Changing Environment: Building Program Integrity

Self Direction Conference May 8 , 201 7

Missouri Division of Developm ental Disabilities

Kyla Mundwiller Missouri Division of DD Director of Self-Determination kyla.m undw iller@dm h.m o.gov

SDS in a Changing Environment- OIG

Investigative Advisory

• n Medicaid Fraud and

Patient Harm Involving Personal Care Services

Issued by: Office of Inspector General (OIG), Department of Health and Hum an Services, Washington, DC To: Center for Medicaid and & CHIP, Center for Medicare & Medicaid Services

October 3, 2016

SDS in a Changing Environment- OIG

OIG Expects to Issue Report in 20 18

“

Data collected from the 50 State Medicaid Fraud Control Units (MFCUs) and OIG’s Office of Investigations which will include: indictments, convictions, and recoveries involving fraud and patient abuse or neglect. The data that w ill be presented in this brief “ are intended to illustrate the p rev a lence a nd m agnitud e of fra ud and p a tient abuse or neglect inv olv ing PCS.”

SDS in a Changing Environment- OIG

Oversight & Effectiveness of Medicaid Waivers

“

• versight of State waiver programs present challenges

to ensure that p ay m ents m ad e und er the w aiv ers are consistent w ith rega rd s to efficiency , econom y , and quality of care and d o not infla te Fed eral costs.” “ w ill determ ine the extent to w hich selected States made use of Medicaid waivers and if costs associa ted w ith the w aiv ers are efficient, econom ic, and d o not infla te Fed era l costs,”

SDS in a Changing Environment- OIG

20 12 “Personal Care Services: Trends, Vulnerabilities, and Recom m endations for Im provem ent”

• Services not provided in compliance with state

requirements

• Services not supported by documentation
• Services during Medicaid-reimbursed institutional

stays

• PCS attendants who did not meet state qualification

requirements

• Findings related to billing practices include billing for services not

rendered

• Services provided to furnished to ineligible beneficiaries, Services

provided by unauthorized caregivers.

• Abuse and neglect of beneficiaries by PCS attendants, resulting in

beneficiary harm

SDS in a Changing Environment- OIG

OIG Recom m endations:

Establish minimum Federal qualifications and screening standards for PCS workers, including background checks. Require States to enroll or register all PCS attendants and assign them unique numbers. Require that PCS claims identify the dates of service and the PCS attendant who provided the service. Consider whether additional controls are needed to ensure that PCS are allowed under program rules and are provided.

SDS in a Changing Environment- CMS

Strengthen Program Integrity in Medicaid Personal Care Services

Issued by: Center for Medicaid and & CHIP, Center for Medicare & Medicaid Services Dec 13, 2016

SDS in a Changing Environment- OIG-CMS

CMS in Response to OIG Recom m endations:

• Provider Qualifications and Basic Training
• In many consumer-directed personal care programs, much of the

training can also be provided directly by the beneficiary.

• Screening of PCS Providers
• FMS entity is considered the provider for purposes of screening

and enrollment. Verification of Need for Services

• Verification of Need for Services
• Documentation of Claims
• PCS providers, like providers of any other Medicaid services,

must be able to document the provision of services for which they have submitted a claim for payment.

• Prepayment Edits
• Post-Payment Reviews

SDS in a Changing Environment- OIG -CMS

CMS in Response to OIG findings:

• The program integrity safeguards that m ake policy and
• perational sense in the case of a PCS agency w ith

m any clients m ay not be suitable to an individual beneficiary directing his or her own PCS services.

• States are again encouraged to collaborate w ith their

stakeholders, including beneficiary advocates, to determ ine the m ethods of PCS delivery and the resulting program integrity protections that w ill prevent fraud and abuse while still m aintaining beneficiary autonomy in self-directed m odels.

• CMS strongly encourages use of self-directed m odels

w ith necessary supports using a person centered planning process.

SDS in a Changing Environment- GOP Health Policy Brief

Modernizing and Strengthening Medicaid to Protect the Most Vulnerable

The Medicaid program today is a critical lifeline for som e of our nation’s m ost vulnerable patients, as the program provides health care for children, pregnant m others, the elderly, the blind, and the disabled. Medicaid currently covers nearly 72 m illion Am ericans—m ore than Medicare — and up to 98 m illion m ay be covered at any one point in a given year. But today, the Medicaid safety net is under strain and not serving patients as w ell as it should. Ma ny sta te Med ica id p rogra m s suffer from significa nt w a ste, fra ud , a nd a buse, d ue to fa ilures in sta te a nd fed era l ov ersight.

Issued by: GOP Health Policy Brief February 2017

Building Program Integrity

If you have seen one self-directed support program you have seen

• ne self-directed program .

If you have seen one state structure for hom e and com m unity based supports you have seen one state's structure.

What is Self-Directed Supports?

Self-directed supports (SDS) is an option for service delivery for individuals, who live in their own private residence or that of their family member & who wish to exercise more choice, control and authority over their waiver supports. SDS is firmly grounded in the principles of self- determination.

Where did this all begin?

1993 Original Proposal to the Robert Wood Johnson Foundation. “If ind iv id ua ls a nd fa m ilies ha v e control of the resources, q ua lity w ill go up a nd cost w ill go d ow n.”

Self-Determination Principles

Freedom : Individuals will live a meaningful life in the community and make choices about their lives. Authority: Individuals will have meaningful control over a set amount of dollars that can be used to build the supports that they need by purchasing only what is needed and paying for what is received. Support: Individuals will have support to organize resources in ways that are life enhancing and assist them in reaching their dreams and

• goals. Individuals have a circle of supports made up of family, friends

and both paid and unpaid supports. Responsibility: Individuals assume responsibility for giving back to their community, for seeking employment, and for developing unique gifts and talents Confirm ation: Individuals are recognized for who they are and what they can contribute, having a leadership role in developing policies that affect their lives and helping others reach success.

SDS is based on the prem ise that the individual and their representative know best about their needs and how to address those needs. The individual m ust be em powered to m ake decisions about the services they receive, including having choice and control over the type of supports they receive, who provides the supports and when and where the supports are delivered.

Self-Directed Supports

Shifting Pow er

From

Professionals planning for individuals Reliance on paid professions who are only temporarily part of an individuals life A view that only professional can be responsible Support Coordination as a means to let people into existing services

To

Individuals and families planning for themselves Reliance on the lifelong commitment of individuals and families to manage their own lives Respect for the fact that individuals and families have a vested interest in acting responsible on their own behalf Support Coordination & Support Brokerage as a means for individuals and families to create services in response to their needs and dreams

A Brief National History

1993 Original Proposal to the Robert Wood Johnson Foundation (RWJF) 1995 Statewide in New Hampshire 1996 RWJF go National 19 states 1998 10 more states 2002 CMS announces Independence Plus imitative 2004-07 CMS revised waiver application to allow SDS

2013

A Brief Missouri History

1998 Missouri’s State Planning Council(MPC) “Show Me Change: Building A Participant-Driven System For Missourians With Developmental Disabilities.” The report concluded:

“ Resources for supports in Missouri m ust be allocated and expended from a person-centered rather than a provider centered perspective.” “ Individuals m ust be in control of their allocated resources for services and supports and how they are delivered.”

2003 “ DMH Practice Guidelines for Consum er Directed Supports and Services” 2003 Independence Plus Grant

A Brief Missouri History

Fiscal Intermediary Program

Demographics for FY2003

81 Families participated in the FI program

Only 15 Individuals were their own employer.

Marvin Wilson contract for payroll. 1999-2007 2001 Columbia EDP did payroll. Timesheets were entered into CIMOR by Regional Office (RO) staff. Service Coordinators and sometimes RO staff were responsible for employer & employee enrollment packets.

A Brief Missouri History

2007 RFP for single Fiscal Management Service 2008 ASI Fiscal Management Service

State was no longer collecting time sheets but continued to assist with employer and employee. SDS was the program of last resort Was not being utilized statewide primarily in regions where were part of Independent Plus Grant. SDS was not implemented consistently across the state FMS completed background screenings

A Brief Missouri History

2009 Self-directed Support Coordinators in 12 Regions 2009 SDSC Monthly Reports & Goals 2009 Consultation from National Experts Sue Flannigan and Robin Cooper 2009 Created structure to ensure em ployee training exem ptions are tracked consistently. 2010 “ Got Choice?” Handbook finalized

A Brief Missouri History

2010 Service Coordinator training.

Service Monitoring Guidelines Created tools for SC

ISP Checklist PA Assessment

A tool for ensuring that the ISP is meeting waiver requirements and helps to determine goals and

• utcomes.

Medicaid Waiver, Provider and Services Choice Statement

A Brief Missouri History

2011 SDS Improvement Plans 2011 Began to track Initial Review done SDSC 2011 Consultation from National Experts Sue Flanagan for FMS –RFP 2012 Consumer Direct FMS

Added maintenance of employee training qualifications Added Prepayment edits and monthly reports to identify potential payment issues. (only works if you have a single FMS) Lessons learned about state unemployment and tax agencies.

A Brief Missouri History

2012 MMAC Audits 2013 “ Guide to Docum entation for Individuals Self-Directing Supports” 2013 SDS Provider Relations Reviews 2013 Began work on the SDS Rule 2013 “ Guide to Creating your ow n ISP when Self-Directing Supports”

A Brief Missouri History

2014 Growing provider capacity for Support Brokerage 2014 Department of Labor’s Application of the Fair Labor Standards Act (FLSA) to Domestic Service

Economic Realities Test

Power to Hire & Fire Control of Wages Control over Hours and Scheduling Supervision, Direction and Control of Work Provide Equipment and Mandatory Training

2015 Statewide Individual Budget allocation process. 2015 Began to incorporate LifeCourse tools into training

LifeCourse tools for individuals, families, and

• professionals. Are helpful in having conversations with

individuals and families about a vision for a good life and how to achieve it. “ Personal Supports Budgets as a Means for Prom oting Self Direction: Balancing Ideology with Fiscal Discipline Within a LifeCourse Fram ework “ Tom orrow at 1:00!

www.lifecoursetools.com

A Brief Missouri History

A Brief Missouri History

2016 Public Partnerships (PPL) FMS Contract

Added Maintenance of Service Documentation Additional prepayment edits Additional post payment reports

A Brief Missouri History

2016 “Guide to Preventing Common Mistakes and Fraud”

Strengthen Program Integrity in Medicaid Personal Care Services

Issued by: Center for Medicaid and & CHIP, Center for Medicare & Medicaid Services: Dec 13, 2016

“Preventing Medicaid Improper Payments for Personal Care Services” (July 2016) CMCS, Increasing Fiscal Protections for Personal Care Services. April 2016.

A Brief Missouri History

2017 SDS and FMS Advisory Group

Includes: Individuals, Designated Representatives, family members, Support Brokers, FMS, Support Coordination, and State agency. What is working/ what is not working in order to create a work plan. Creating informed stakeholders.

A Brief Missouri History

2017 Regional Training Events Informational Events: Self-Directed

Supports & Integrated Supports and Services

A Brief Missouri History

2017 SDS Rule (2013)

Missouri Growth in Self Directed Supports by Year

• 200

400 600

403

800 1,000

791

1,200 1,400 1,600

81 168 272 631 1,018 1,140 1,332 1,516 1,575

Growth in Self-Directed Supports Num ber of Participants by Fiscal Year

Missouri SDS # by Region

50 100 150 200 250 300

57 96 55 158 267 52 87 140 106 200 137 220

Total # of Individuals Enrolled in SDS By Region

(Statewide 1575 individuals )

Missouri SDS % by Region

6.00% 4.00% 2.00% 0.00% 8.00% 10.00% 12.00% 14.00% 16.00% 18.00% 20.00%

9.08% 5.62% 8.84% 19.17% 9.83% 15.34% 13.43% 12.44% 16.69% 16.06% 10.25% 14.14%

Total % of Individuals Enrolled in SDS by Region

(Statewide 11.77%)

Support Brokers % by Region

20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0%

11% 19% 9% 13% 10% 17% 11% 1% 15% 2% 14% 6%

Percent of Individuals with SB

(Statewide 10%)

Working Together for Success

SDS in a Changing Environment

New ISP Guide & Implementation Strategies

Personal Outcom es are what drive a person’s ISP. These are things that the individual is interested in trying, learning, doing, or achieving in the next year. Personal Outcom es must relate to what is important to the individual Goa ls describe the actions to be taken towards achieving the Personal Outcome, and are developed as a part of the person-centered planning process. Each Goal has Im plem entation Strategies in place to provide step-by-step actions and instruction for the people responsible for implementing the Goal. Im p lem enta tion Stra tegies: The provider responsible for providing the service(s) used to help the individual achieve his/ her personal

• utcome(s) and related goals develops the

Im plem entation Strategies.

SDS in a Changing Environment

• Mortality Reviews

3.070 - Death Notification and Mortality Review Reviewed 4/ 2011

Mortality Review Form Mortality Review Flowchart Death Notification Form

SDS in a Changing Environment- EVV (?)

Electronic Visit Verification (EVV) system

Section 12006 of the Cures Act mandates that effective January 1, 2019, states must use an electronic visit verification (EVV) system for Medicaid-funded personal care services or face reductions in their federal match. Effective January 1, 2023, states will also be required to use an EVV system for Medicaid- funded home health services or face a reduced federal match.

dm h.m o.gov/ dd/ progs/ selfdirect.htm l

Guides and Publications

Guides and Publications

The Division of Developmental Disabilities Mission

For more information on Self-Determination and Self-advocacy in Missouri visit: Missouri Division of Developm ental Disabilities

http:/ / dmh.mo.gov/ dd/