Building a Person-Centered System of Care 2012...For proposed LME-MCOs that have not yet merged, the lead LME name is shown first. Dates shown after Jul 2012 are the planned Waiver

MERCER 0 September 20, 2012

BUILDING A PERSON-CENTERED SYSTEM OF CARE USING THE TOOLS OF MANAGED CARE, INDIVIDUALIZED ASSESSMENT AND ACUITY BASED BUDGETING

SEPTEMBER 14, 2012

Kelly Crosbie, North Carolina

Brenda Jackson and Mary Sowers, Mercer

September 13, 2012

North Carolina Department of Health and Human Services

Division of Medical Assistance


Session Overview

• Identifying needs and allocating resources based on needs in a managed

care environment and role of Person-Centered Planning

• Medicaid Authorities – Options and considerations

• The North Carolina Experience – Origins and experiences from a State

perspective


Multi-faceted Approach to Program Design

• Successful program design includes multiple dimensions:

– Programmatic – Determination and clear articulation of program goals

and objectives (short and long term), meaningful stakeholder (initial and

ongoing) engagement, desired operational features and Medicaid

authorities that can support them, key partners for implementation and

operation, identification of needed tools for success

– Financial – Analysis of available resources, initial and ongoing payment

design, identification of operational cost components, system-wide

analysis (i.e., do the interventions in this program impact other aspects

of the service system)

– Functional and Clinical Supports – How to improve care, reduce costs,

enhance person-centered planning and establish a modern service

system that will enable supports for community living, but also foster

better health and wellness

• And, quality, measurement and state oversight strategies considered

through every step…


Building the frame – Authority Development

• There are more options in Medicaid today than ever before

• Careful analysis of each authority is necessary to determine which authority

is most advantageous and is most aligned with the State’s short- and

long-term goals

• For North Carolina’s program design, 1915(b)/(c) Concurrent Waiver

authority provided the necessary structure to meet their goal of designing a

system that is capable of managing public resources available for mental

health, intellectual and other developmental disabilities and substance

abuse services


The 1915(b) Side of the Frame

• Section 1915(b) waivers allow states to:

– 1915(b)(1) – mandate managed care enrollment

– 1915(b)(3)– use cost savings to provide additional services

– 1915(b)(4) – limit number of providers for services

– Waive comparability (offer services to a subset of Medicaid eligible individuals)

– Waive statewideness (offer services to individuals on a less than statewide basis)

– Have multiple programs within a single 1915(b) authority

– This gives states the opportunity to utilize a managed care service delivery system (which

can take many forms!)

• States can:

– Elect to use managed care entities to coordinate services, even in a fee-for-service (FFS)

environment

– Elect to prepay and capitate for services, and share risk with managed care plans for the

delivery of services

– Include a differing array of services in managed care – full panoply of services or a smaller

array

– Mandate enrollment in managed care or allow individuals to voluntarily enroll


The 1915(c) Side of the Frame

• Section 1915(c) waivers allow states to:

– Apply institutional income and resource eligibility rules to medically

needy individuals

– Offer additional supports and services to individuals to live in their

homes and communities

– Waive comparability (offer services to a subset of Medicaid eligible

individuals

– Waive statewideness (offer services to individuals on a less than

statewide basis)


Together, the 1915(b)/(c) Concurrent Waiver

• Enables the provision of person-centered HCBS in a managed care

environment, enables the use of additional creative services through the

use of 1915(b)(3) authority or services provided by managed care plans as

cost effective alternatives

• The waiver authorities (and related State agreements with partners) can

enable person-centered planning and assessment, individualized resource

allocation based on acuity and maximum individual choice and control over

services


1915(b)/(c) Concurrent Authority – Additional Considerations

• Each Medicaid authority has its benefits and challenges – and the

1915(b)/(c) concurrent waiver is no exception

– Both 1915(b) and 1915(c) requirements continue to apply – so States

must consider strategies to align practices to meet both requirements –

around issues such as quality, cost effectiveness/cost neutrality and

others

– However to the extent that dual eligible individuals are in the two

waivers, states may apply for concurrent 5 year waivers


Managed Community Based Services and Supports

Carefully constructed managed care and HCBS authorities can serve as a foundation for a strong service

delivery system when coupled with strong state expectations (through contracts and oversight) and strong

quality measurement strategies

Person Centered Integration Individual Control Quality

Managed HCBS

in NC

1915(b) authority waives freedom of choice and

permits HCBS services for individuals from savings

1915(c) authority authorizes HCBS services and institutional

eligibility for the DD population


Acuity-Based Budgeting

• HCBS service approval not driven by traditional concept of medical

necessity (e.g., respite and community attendant based care)

• There is still a need to have an equitable distribution of resources

• Through strong assessment processes an individual can be given a budget

based on their acuity and individual resource accessibility

• Through person-centered planning, the participant then has a major role in

self-determination of their plan of care services within that budget

• Individuals continue to be afforded appeal rights to appeal service

authorization denials for services requested

• Appendix C-4 can be used to outline the State’s structure for structuring

individual budgets

• Now – how it works on the ground…


medicaidnorth carolina

medicaidnorth carolinaNC Department of Health and Human Services

North Carolina Innovations (c) Waiver &

Innovations Plus

Kelly Crosbie, LCSW Chief, Behavioral Health Policy Section




DMA

HCBS Waivers in North Carolina

• CAP-Children (1992)

• CAP-Disabled Adults (1982)

• CAP MR/DD (now CAP-IDD)—current since 2008

• Innovations (IDD) Waiver (2005 pilot)

• Lots of interest around TBI Waiver




DMA

Person-Center Planning in North Carolina

• Person Centered Plan: Required for any individual receiving

community-based mental health, substance abuse, or

intellectual/developmental disability services (MH/SA/IDD)

• Providers are required to have training in PC Thinking & Planning

• “Bumps”—paperwork hurdle or treatment/support philosophy?

• Test-run of the SIS—mixed results

• Targeted Case Management—what is the goal of the service?

– 4 CMS functions?

– Advocacy?




DMA

NC Waivers & Legislative Actions

• 2005 –Pilot 1915 b/c waiver through PBH LME (Local Management

Entity)

– 5 counties

– In 2009 began to explore resource allocation for (c) waiver

- Cost overruns

- Concerns of “medical necessity” model for determining services

- Only part of the state to have MCO care coordination INSTEAD of targeted case

management

• 2009 SB 897

• RFA Process, the State can select two new demonstration sites;

• Complete a Legislative Report to evaluate the impact on I/DD consumers

ICFs-MR




DMA

NC Waivers & Legislative Actions

• 2011 House Bill 916

• PBH allowed to expand

• Detailed instructions for statewide b/c expansion by July 2013

• Replicate the “PBH Model”

• Protect rates for ICFs-MR & state developmental centers

• Eliminate ‘targeted case management’ and implement ‘care coordination’

by MCO

• Develop a “resource allocation methodology” for recipients on the (c)

waiver—”based on need”

• Institute Community Guide (service)

• Explore (i) option for IDD services

• Reinvest savings into new HCBS waiver slots

End Result: 11 Prepaid Inpatient Health Plans (PIHPs)

or LME-MCOs


Local Management Entity - Managed Care Organizations (LME-MCOs)

and their Member Counties (Current and Proposed on January 1, 2013)

Anson

Ashe

Avery

Beaufort

Bertie

Bladen

Brunswick

Burke

Cabarrus

Caldwell

Carteret

CatawbaChatham

Cherokee

Clay

Cleveland

Columbus

Craven

Currituck

Forsyth

Gates

Graham

Granville Halifax

HarnettHenderson

Hertford

Jackson

Jones

LeeLincoln

Macon

Madison

Montgomery

Moore

Nash

Northampton

Onslow

Pamlico

Pender

Pitt

Polk

Robeson

Rockingham

Rowan

Rutherford

StokesSurry

Swain

Union

Vance

Wake

Warren

Watauga Wilkes

Wilson

Yancey

For proposed LME-MCOs that have not yet merged, the lead LME name is shown first.

Dates shown after Jul 2012 are the planned Waiver start dates.

Reflects plans and accomplishments as of July 13, 2012.

Orange

Transylvania

Person

Western Region Central Region Eastern Region

Cumberland

Scotland

Haywood

New

Hanover

Durham

Alleghany

Alamance

Iredell

Johnston

Duplin

Sampson

Wayne Lenoir

Dare

Hyde

MartinTyrrell

Washington

Camden

Perquimans

Pasquotank

Greene

Smoky Mountain Center

Jul 2012

Alexander

Mitchell

Gaston

Buncombe

CenterPoint Human Services

Jan 2013

Caswell

Chowan

Edgecombe

Western Highlands Network

Jan 2012

McDowell

Alliance Behavioral Healthcare/

Johnston/ Cumberland

Jan 2013

CoastalCare

Jan 2013

Guilford

Randolph

Sandhills

Center/

Guilford

Oct 2012

East Carolina Behavioral Health

Apr 2012

Eastpointe

Jan 2013

MeckLINK Behavioral Healthcare

Jan 2013

Cardinal Innovations Healthcare Solutions

(All counties as of Apr 2012)

Partners Behavioral Health Management

Jan 2013

Stanly

Davie

Franklin

HokeRichmond

Mecklenburg

Yadkin

Davidson



DMA




DMA

Policy Philosophy (Lawmakers & Policy-Makers)

• Care Coordination

– MCOs need the full toolbox to manage care

– What happens to ‘advocacy?’

• SIS

– What tool will get us planning built on ‘need’

– What is the best way to enhanced ‘person centered’ planning?

• Resource Allocation

– Predictable Costs

– Creation of savings for reinvestment

– What is needed: no more, no less




DMA

Policy Philosophy (Lawmakers & Policy-Makers)

• ICFs and State Developmental Centers

– Safety net—should be protected

• (i) option

– Long wait-list? (theme of fairness & equity)

• Should individuals with HCBS waiver services be included under

‘managed care?’

– Do any managed care tools benefit this group?

– How many systems should we have?

– Challenges already with BH/Physical Health integration




DMA

What Else Is Happening in NC?

• Enforcement of HCBS community living standards

• DOJ settlement—SPMI population

• IMD determinations of adult care homes

• Increased role of Money Follows the Person (MFP)




DMA

Innovations Plus

Standardized Assessment + Resource Allocation




DMA

Values of Innovations Plus

• Value and support waiver participants to be fully functioning members of

their community

• Offer service options that will help people live in the homes of their choice

and engage in purposeful activities of their choice

• Provide opportunity for participants to direct their own services

• Foster the development of stronger natural supports networks

• Enable participants to be less reliant on formal support systems




DMA

Innovations Plus—Step #1

• Statewide implementation of the Supports Intensity Scale (SIS) for

individuals on the Innovations waiver

– Reliable & valid instrument

– Currently being used in 17 other states

– Quantifiable: yields solid information about support needs

– Results from the SIS are used for person-centered planning

– NC will be norming site for Child SIS




DMA

SIS Implementation—Getting Started

• Community Forums

– DDTI in partnership with DMA and LME-MCOs will conduct

Community Forums across the state over the next several months

• Build examiner capacity

– LME MCO SIS staff training has begun and will continue in phases

throughout the Summer and early Fall (AAIDD)

• Supports Intensity Scale (SIS) assessments performed (sample

by July 2013!): MCOs & AAIDD




DMA

Innovations Plus—Step #2

• The information from the SIS assessments will be used to help develop

person-centered plans (at the individual level)

• SIS results from a representative sample (5200+) will be used to develop

a resource allocation model (a funding model) for NC

– Developed by Human Services Research Institute (HSRI)

• Each person will then be given an Individualized Budget Amount that is

based on their level of need*

*Due process/appeal rights will always apply




DMA

Innovations Plus: Building Success

• Local Stakeholder Engagement

– UNC Developmental Disabilities Training Institute (DDTI) and LME-MCOs

• Statewide Marketing Strategy

– Human Services Research Institute (HSRI)

• Building on current success

– PBH Supports Needs Matrix

• On-going quality monitoring of SIS

– American Association of Intellectual and Developmental Disabilities (AAIDD)

• Communication between policy-makers and law-makers




DMA

The Goal of Innovations Plus?

Innovations Plus system changes will:

– create a fairer system for all

– help people use the money they have more wisely

– help assure that people get the right amount of supports for their needs

• Predictable costs = more slots

– More individuals served

– Reduced waiting lists

A system based on “person centered” assessments and planning




DMA

Contact Information

Kelly Crosbie, LCSW

Chief, Behavioral Health Policy Section

NC Division of Medical Assistance

919-855-4293

[email protected]

http://www.ncdhhs.gov/dma/lme/MHWaiver.htm

mailto:[email protected]

http://www.ncdhhs.gov/dma/lme/MHWaiver.htm


Considerations for Selecting Medicaid Authorities

• Strong strategies for success:

– Early and ongoing engagement with stakeholders (including CMS)

– Detailed waiver construction, including keen focus on the necessary

infrastructure to support, oversee and calibrate the programs

– Understanding the ramifications of implementation strategies

– Make sound early investment decisions – consider long-range goals and

growth/evolution objectives when selecting tools – not just the short-term

considerations


Financing and Quality

• Observations on using tools and finances to drive to desired outcomes and

equity in the service system

– Whether in FFS or in capitated arrangements, articulating what you want

to buy is key, including the outcomes you desire and expect

– And, measuring to make sure what you want to buy is what has been

provided – including a system of care that equitably allocates resources,

and provides person-centered service delivery in the most integrated

setting


For More Information:

Brenda Jackson

[email protected]

Mary Sowers

[email protected]



Documents

Building a Person-Centered System of Care 2012...For proposed LME-MCOs that have not yet merged, the lead LME name is shown first. Dates shown after Jul 2012 are the planned Waiver