1 iBudget Florida Stakeholders’ Meeting December 4, 2009
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iBudget FloridaStakeholders’ Meeting
December 4, 2009
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Overview of Proposed System
•Budgets determined through algorithm •Service array revised to increase flexibility•Waiver Support Coordination better match to family needs, shift to emphasis on service coordination from service approval processing•Service review more limited, focused, & streamlined, focusing on health & safety issues
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Overview of Proposed System
•Consumer and family training and tools for managing budgets•Policies for limiting risk of overspending and options for corrective action plans•Behind-the-scenes reviews for health & safety, provider manipulation, and fraud•Process for determining budgets for consumers with exceptional needs
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Overview of Proposed System
• Electronic/automated as much as possible—virtually paperless• Phase-in over a reasonable time period—e.g., number of consumers (say by geography) and budget amounts
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Consumer and Family Control
Main question:
What would be reasonable limits on individual control?
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Consumer and Family Control
APD Recommendations:
• Training be provided to consumers and families on choice-making
• Consumers and families have greater control over the amounts and types of services they get
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Consumer and Family ControlFeedback so far:• System now does provide for adequate
consumer control• System now does not provide for
adequate consumer control• Some individuals don’t have natural
supports to help exercise self-direction
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Consumer and Family ControlFeedback so far:• Some families will be unable to manage
a budget• Concern that individuals’ natural
supports might not let them make desired choices
• Concern that some providers may not cooperate or may be manipulative
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Consumer and Family ControlFeedback so far:• Consumers may make poor choices
that put them at risk• Consumers need opportunities to make
choices and learn from the poor ones
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Consumer and Family Control
Decisions needed:• Limits on spending to ensure that funds
last through the year – Option A: Monthly allocation– Option B: 10% up front; 85%, spread over
12 months; 5% emergency reserve– Option C: 20% up front; 80% spread over 4
quarters
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Consumer and Family Control
Decisions needed:• Other methods to discourage
overspending – Monthly statements– Waiver support coordinator issues
service authorizations (consumer and family may do so in Option C)
– Swipe card system
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Consumer and Family ControlDecisions needed:• What to do if a person overspends but
still needs services– Require to adjust services to fit budget– Limit flexibility to make future changes– Require a representative to help– Temporary increase in funding to meet
critical health and safety needs– Require training or a mentor paid from
budget
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Consumer and Family Control
Decisions needed:• How to provide training on making
good choices– Web– Through Waiver Support Coordinator– In-person group trainings hosted by FCC
or Area Office– Paid service through person’s budget
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Consumer and Family Control
Decisions needed :• Caps on service amounts:
– Option A: Similar to current handbook– Option B: Only on limited services which
are related to health & safety– Option C: No
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Consumer and Family Control
Decisions needed :• Whether funds for certain critical health and
safety-related services must be reserved and may not be spent on other services:– Option A: Residential habilitation,
nursing, therapies– Option B: Residential habilitation only– Option C: None
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Consumer and Family Control
Decisions needed :• Who may issue service authorizations to
begin or end services:– Option A: Waiver support coordinator,
along with area staff for certain services– Option B: Waiver support coordinator– Option C: Consumer, family, and waiver
support coordinator
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Consumer and Family Control
Decisions needed :
• What information consumers need to make good decisions – Their own goals and needs– Traditional and innovative strategies for
achieving goals/meeting needs– Outcomes/performance data
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Consumer and Family Control
Decisions needed :
• How to help consumers track spending– Waiver support coordinator – Web-based budget tool– Service logs– Monthly statement
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Consumer and Family Control
Decisions needed :
• How to find out if any providers are uncooperative or manipulative– Analysis of service usage/spending
patterns– Reports from consumers/families– Quality assurance contractor reporting
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Consumer and Family Control
Decisions needed :• What support to give to consumers who
don’t have unpaid help in decision-making– Waiver support coordinators continue in that
role– Waiver support coordinators help find supports
to help– Quality assurance review– Behind-the-scenes audits
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Consumer and Family Control
Decisions needed :• If funds can be carried over to a
future year like in CDC+– Option A: No– Option B: 50% carry over for up to 1
year– Option C: 100% carry over, no time
limit
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Service Review
Main question:
How do we best ensure that individuals receive the services that they need within allowable waiver coverage?
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Service ReviewAPD Recommendations:The process as we know it go away—be
minimized or eliminated as much as possible while meeting federal requirements
• Streamlined paperwork• More flexibility• Personalized approach
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Service Review
Feedback so far:Scaling back is great but we need something to meet federal requirements for assessing medical necessity of services
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Service Review
Decisions needed:
• What are situations requiring a review?
• Who will conduct reviews?
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Service Review
Decisions needed:
• Situations requiring review– Under all options:
• Newly-enrolled in waiver• If overspent budget within last 12
months• First time in a licensed home
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Service Review
Decisions needed:
• Situations requiring a review– Under all options:
• Temporary significant change in needs requiring additional funds
• Permanent significant change in needs requiring additional funds
• Extraordinary need request
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Service Review
Decisions needed:
• Situations requiring a review– The first iBudget Florida plan:
• Option A: Yes• Option B: Yes• Option C: Only if using different
services than previous plan
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Service Review
Decisions needed:
• Situations requiring a review– Every 3 years:
• Option A: Yes• Option B: No• Option C: No
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Service Review
Decisions needed:
• Situations requiring a review– If adding new service family:
• Option A: Yes• Option B: Yes• Option C: No
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Service Review
Decisions needed:• Situations requiring a review
– If increasing amounts of certain services within budget amount:
• Option A: Yes--behavioral services, nursing services, therapies
• Option B: Yes—intensive behavioral services, nursing services, therapies
• Option C: No
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Service Review
Decisions needed:• Situations requiring a review
– If decreasing amounts of certain services within budget amount:• Option A: Yes--behavioral services,
nursing services, therapies• Option B: No• Option C: No
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Service ReviewDecisions needed:• Situations requiring more frequent
review:– If meets certain criteria:
• Current or previous forensic involvement• Extraordinary medical needs• Extraordinary behavioral needs• Community based care child• Only paid supports in person’s life
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Service ReviewDecisions needed:• The process for requesting reviews
– Computer-based
• Who will perform reviews– Option A: Contracted provider, Central
Office, and Area Offices– Option B: Central Office and Area
Offices– Option C: Area Offices
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Quality Assurance and Quality Improvement
Main question:
How do we ensure health, safety, and good outcomes?
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Quality Assurance and Quality Improvement
APD Plans:• New quality assurance contract uses different
measures– Increasing percentage of support coordination records
reviewed to 50%– Will review about 25% of consumers individually
• Florida is joining National Core Indicators initiative
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Quality Assurance and Quality Improvement
Feedback so far:• Support revision of the quality assurance system
to be more understandable, less bureaucratic, and more person-centered
• Concern that individuals may make poor choices that put their health and safety at risk
• Concern that individuals may be at risk of exploitation by providers and natural supports
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Quality Assurance and Quality Improvement
Key Areas:• Health & safety• Budget management• Outcomes• Compliance
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Quality Assurance and Quality Improvement
Participants in QA/QI System:• Consumers & families• Waiver Support Coordinators• Providers• Family Care Councils• Advocacy & provider organizations• APD Central Office staff
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Quality Assurance and Quality Improvement
Participants in QA/QI System:• APD Area staff
– Certified Behavior Analysts– Nursing staff– Questionnaire for Situational Information Administrators– Licensing– Group home monthly monitoring– Provider enrollment– Supported living coordinator
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Quality Assurance and Quality Improvement
Examples of key activities:• Assessment• Planning• Training• Standard setting/process determination• Monitoring/data analysis• Information sharing• Problem identification• Corrective action
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Quality Assurance and Quality Improvement
Decisions needed:• Options:
– Health & safety:• Requirement for use of full or enhanced waiver
support coordination by certain individuals (e.g., those with forensic involvement)
• Competency-based training• Utilization reviews to identify service patterns
of concern
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Quality Assurance and Quality Improvement
Decisions needed:
• Options:– Health & safety:
• Review by area certified behavior analysts and nursing staff based on QSI scores
• Limits on certain flexibility in selecting and changing services
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Quality Assurance and Quality Improvement
Decisions needed:• Options:
– Budget management:• Training for all levels of skill• Timely information through web-based tools
– Consumer & family – Support coordinator – Area office– Contracted Quality Assurance reviewers
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Quality Assurance and Quality Improvement
Decisions needed:
• Options:– Budget management:
• Policies to deter overspending• Corrective action plans to address
overspending• Data analysis of spending patterns
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Quality Assurance and Quality Improvement
Decisions needed:• Options:
– Outcomes:• Training on outcomes under a more self-
directed system• Training for support coordinators on handling
issues of poor choice-making• Central Office review of support plans to
assess consumer goals under new system
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Quality Assurance and Quality Improvement
Decisions needed:
• Options:– Outcomes:
• Procedures for waiver support coordinators to access area office support and direction in addressing problematic consumer choice-making
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Quality Assurance and Quality Improvement
Decisions needed:
• Options:– Compliance:
• Training for consumers/families on provider responsibilities
• Revise relevant assurances and the handbook to clarify expectations and responsibilities under self-directed system
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Quality Assurance and Quality Improvement
Decisions needed:• Options:
– Compliance:• Review service patterns to identify provider
non-compliance• Review service delivery against budget/support
plan• Publicly share information about non-compliant
providers
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Services
Main question:
What services and flexibility should be available to consumers?
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Services
APD Recommendations:• Must use Medicaid enrolled providers• Services allow more flexibility• Rates be neutral• Same set of services available to all
individuals
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Services
Feedback so far:• Make additional services available in
Tier 4• Want flexibility to use greater amounts
of services• Use algorithm to determine level and
intensity of services (e.g. Res Hab)
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Services
Feedback so far:• Start from scratch with new handbook• Like the very broad services, but if
they’re in service families, make sure they are logically grouped
• Very broad services might be more challenging for consumers to navigate—hard to know how to meet needs
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Services
Decisions needed:• Design of service array
– Broader services—allow to meet changing needs day-to-day (current worker can switch between similar tasks)
– Service families—allow to meet changing needs over time (can get a new worker to do new tasks)
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Services
Option 1: Modified Status Quo
Option 2: Modified Mercer Option 3: Minimalist
No Service Families
Residential Services Places to Live
WellnessWellness
Therapeutic Supports
Personal Supports
Personal SupportsLife Skills Development
Transportation
Support Coordination
Environmental and Adaptive Equipment
Equipment
Comparison of Service Families in Options
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ServicesComparison of Services in Options
Option 1: Modified Status Quo Option 2: Modified Mercer Option 3: Minimalist
Residential Habilitation Services
Residential Habilitation (Standard) Basic Residential
Residential Habilitation (Behavior Focused)
Enhanced Residential
Residential Habilitation (Intensive Behavior)
Specialized Medical Home Care Specialized Medical Home Care
Nursing Residential Nursing
Meaningful Day
Adult Day Training
Flex Benefit
Companion Services
In-Home Support Services In-Home Support Services
Personal Care Assistance Personal Care Assistance
Respite Care Respite Care
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ServicesComparison of Services in Options
Option 1: Modified Status Quo Option 2: Modified Mercer Option 3: Minimalist
Support Coordination Support Coordination (Limited)Basic Supports
Transportation Transportation
Behavior Analysis
Behavior Analysis Services
Enhanced Supports
Behavior Assistant Services
Community Training and Supports
Family & Guardian Training
Mentoring
Person Centered Planning
Support CoordinationSupport Coordination (Transitional)
Support Coordination (Full)
Meaningful DaySupported Employment
In-Home Support Services Supported Living Coaching
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ServicesComparison of Services in Options
Option 1: Modified Status Quo Option 2: Modified Mercer Option 3: Minimalist
Adult Dental Services Adult Dental Services Basic Wellness
Dietician Services Dietician Services
Enhanced Wellness
Occupational Therapy Occupational Therapy
Physical Therapy Physical Therapy
Respiratory Therapy Respiratory Therapy
NursingPrivate Duty Nursing
Skilled Nursing
Specialized Mental Health Services
Specialized Mental Health Services
Speech Therapy Speech Therapy
Durable Medical Equipment and Supplies
Durable Medical Equipment and Supplies
Equipment
Environmental Accessibility Adaptations
Environmental Accessibility Adaptations
Consumable Medical Supplies/PERS
Personal Emergency Response Systems (Unit and Services)
Consumable Medical Equipment
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Waiver Support Coordination
Main question:What should the waiver support coordinator’s role be?
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Waiver Support Coordination
APD Recommendations:
• Waiver support coordinator’s role will shift to more of a facilitator and guide
• Will be seeking to reduce paperwork• Allow more customized level of
service
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Waiver Support Coordination
Feedback so far:• Desire for greater flexibility in choosing
level of support coordination• Waiver support coordinators play an
important and multifaceted role in the APD system. Need to ensure they are still available to help consumers and families.
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Waiver Support Coordination
Decisions needed:• What waiver support coordinator
service options will be available:– Limited– Full– Enhanced (currently transitional)
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Waiver Support Coordination
Decisions needed:• Situations which may indicate need for
full (or enhanced) waiver support coordination:– Newly-enrolled in waiver– Forensic involvement– Complex medical needs– Complex behavioral needs
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Waiver Support Coordination
Decisions needed:• Situations which may indicate need for full (or
enhanced) waiver support coordination:– Transition from school– Change in residential setting to group home or
supported living– Verified abuse or neglect – Dual diagnosis– Alcohol or drug abuse history
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Waiver Support CoordinationDecisions needed:• Waiver support coordinators’ general tasks
– Annual plan, level of care determination, and maintenance of Medicaid eligibility (required by CMS)
– Handle exceptional/changed needs requests
– Providing information about, access to, and coordination of services
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Waiver Support CoordinationDecisions needed:• Waiver support coordinators’ general
tasks– Help create social connections– Increase access to community
resources– Training consumers and families in
self-direction and budget management
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Waiver Support CoordinationDecisions needed:• Waiver support coordinators’ general
tasks– Budget management in consultation
with consumer and family– Monitoring of health and safety– On call 24/7
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Service Providers
Main question:
Who may provide services?
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Service Providers
APD Recommendation:• CDC+ option continue, although participants
will get iBudgets• Everyone else use Medicaid-enrolled
providers• Rates be neutral
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Service Providers
Feedback so far:• Ensure consumers have support and training• Need timely notice and payment• Self-directed system could pose management
challenges – Staffing, regulation compliance, revenue projections
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Service Providers
Decisions needed:• What competencies and standards that
providers would need to meet• What information or notice is given to
providers to begin or end services
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Service Providers
Your thoughts:• What opportunities does a more self-
directed system pose for providers that are creative and innovative?
• How can providers, consumers, and families work more cooperatively in a self-directed system?
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Implementation
Feedback so far:• How to ensure that calculation of iBudgets is
understandable to consumers and their families
• Need to carefully communicate with any consumers and families from the wait list when they do join
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Implementation
Your thoughts:• How can we communicate with
stakeholders:– Individually– Through providers– Through organizations
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Implementation
Your thoughts:• What should we tell them?
– Consumers– Families– Waiver Support Coordinators– Providers– Advocates
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Conclusion
Questions?
Comments?
Suggestions?
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Conclusion
Public CommentPlan Next MeetingAdjourn
Thank you for your time and input!