Participant Direction 201:

Support Brokerage in

Participant Direction

Services

Suzanne Crisp, Director of Program Design and

Implementation

Merle Edwards-Orr, Director of Veteran Initiatives

May 29, 2015

Goals for Today

Examine the functions to support individuals self-directing Except Financial Management Service (FMS)

Classify the functions

Identify specific tasks for each functional area

Introduce conflict of interest

Examine the various models

Quality oversight – what does this look like?

Hear from Kansas and New Jersey

Open Q&A

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Functions to Support

Participants

Why a Support System?

Required for all authorities: Information and Assistance (I&A)

Financial Management Services (FMS)

Studies have found this system is essential to a successful self-

directed program

When participants have questions, they must know where to

go

When supports are not available, how do you monitor and

measure the integrity of your program?

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Supporting the Individual

Level I – Case Management

Through the person-centered planning process: Assesses functional, social, and behavioral needs

Develops service/recovery plan

Determines individual budget allocation

Monitors the provision of services

Links participant with community resources

Safeguards health and welfare

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Supporting the Individual

Level 2

Distinct support system to self-direction

Provides information, assistance, and support through the

person-centered planning process

Tasks include: Providing orientation to self-direction

Explaining program permissibles

Making informed hiring and managing decisions

Identifying additional supports

Assisting with training staff

Developing a back-up plan for emergency situations

Assisting with FMS negotiations

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Information and Assistance:

Definition

The service/function that assists the participant (or the participant’s family or representative, as appropriate) in arranging for, directing and managing services

The service is available to assist in identifying immediate and long-term needs, developing options to meet those needs and accessing identified supports and services

Offers practical skills training to enable families and participants to independently direct and manage waiver services. Examples of skills training include providing information on recruiting and hiring personal care workers, managing workers, and providing information on effective communication and problem-solving

Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers,

Centers for Medicare & Medicaid Services

Information and Assistance:

Definition

The service/function includes providing information to ensure

that participants understand the responsibilities involved

with directing their services

The extent of the assistance furnished to the participant or

family is specified in the service plan

This service does not duplicate other waiver services,

including case management

Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers,

Centers for Medicare & Medicaid Services

Information and Assistance:

Purpose and Functions

These supports are made available to participants to help them

manage their waiver services For example, assistance might be provided to help the participant

locate workers who furnish direct supports or in crafting the

service plan.

The type and extent of the supports that must be available to

participants depends on the nature of the participant direction

opportunities provided under the waiver.

Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers,

Centers for Medicare & Medicaid Services

CMS Guidance to States

Information may be provided to participant about:

Person-centered planning and how it is applied;

Range and scope of individual choices and options;

Process for changing the plan of care and individual budget;

Grievance process;

Risks and responsibilities of self-direction;

Freedom of choice of providers;

Individual rights;

Reassessment and review schedules; and,

Such other subjects pertinent to the participant and/or family in managing and directing services.

Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers,

Centers for Medicare & Medicaid Services

CMS Guidance to States

Assistance may be provided to the participant with:

Defining goals, needs and preferences, identifying and accessing services, supports and resources;

Practical skills training (e.g., hiring, managing and terminating workers, problem solving, conflict resolution)

Development of risk management agreements;

Development of an emergency back up plan;

Recognizing and reporting critical events;

Independent advocacy, to assist in filing grievances and complaints when necessary; and,

Other areas related to managing services and supports.

Instructions and Technical Guidance for 1915(c) Home and Community Based Waivers,

Centers for Medicare & Medicaid Services

Support Brokerage

Models

Model A

CM conducts orientation.

Provides information and assistance – ongoing basis

Findings: Cost neutral Adds to CM workload CM selects who she/he

might work with Disincentive for CM to

take on labor intensive individuals

Due to time limitations, I and A may not be realized

Weak program = weak results

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I and A absorbed by the

existing case management

function

CM is trained on self-

direction

Offers the option during

assessments and

reassessments

If option selected by

individual, CM processes

enrollment

Model B

Findings: Frequently role confusion

Cost of the new function

may be an issue

What type of training is

involved?

Who monitors the new

function?

Quality oversight must be

embedded in the program

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I and A provided by a new

functional area

Added as a support service

either as a service (FMAP

Available) or administrative

function (50% match rate)

Provider qualifications

manage who provides.

Often times, family

members may provide

Works in concert with the

case manager

Model C

Findings: Cost may be an issue

Role clarification critical

Communication path to

CM essential

What type of training?

Who monitors

performance?

Quality oversight must be

embedded in the system

If one vendor supplies all I

and A – must ensure a

back-up plan is in place

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I and A contracted to a for-

profit or non-profit entity

Selected by a Request for

Proposal (RFP) method

Contract stipulates the day-

to-day operations of I and A

Model D

Findings: Communication between

the participant, financial

staff and I and A staff more

streamlined

Greater opportunity to

identify fraud, abuse, or

mis-use of funding

Monitoring may be more

challenging

Quality system must be

embedded in the program

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Emerging trend to contract

with the FMS entity

Along with processing

payroll and managing the

individual budget absorbed

duties of I and A

Has a greater opportunity to

offer a complete picture of

the activities and actions of

those self-directing

Conflict of Interest &

Managing the Moving

Parts

Conflict of Interest Policy

Providers of HCBS for the individual, or those who have an

interest in or are employed by a provider of HCBS for the

individual must not provide case management or develop the

person-centered service plan.

Providers may be allowed if the State demonstrates that the

only willing and qualified entity to provide case management

and/or develop person- centered service plans in a geographic

area also provides HCBS.

In these cases, the State must devise conflict of interest

protections …which must be approved by CMS. Individuals

must be provided with a clear and accessible alternative

dispute resolution process.”

42 CFR §441.301

Managing all the Moving Parts

Define roles and responsibilities

Develop policies and procedures

Conduct training

Create communication paths

Everyone needs to be part of the person-centered planning

process

Include the FMS staff

Identify how the functions will be monitored and by whom

Apply measurable performance standards

Require each function to submit data on activity

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Research Study & Findings

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Research Study “Multi-State Survey of Support Brokers”

Purpose: learn how supports brokers are prepared for and

carry out their duties. Survey n=140

Findings:

Inconsistent understanding of role

Inconsistent or lack of training

Low comfort level in helping participants with SD

Recommendations:

Training – periodic and on-going request Assisting with employer related duties

Managing hired workers

Update on program policies, procedures & options

Role definition Difference between case management and supports brokerage

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Findings from Managed Care

Studies

Frequently, I and A is subsumed by the case manager or

service coordinator.

Interviews with service coordinators reveal often times I and A

is lost and issues are referred to the FMS and often time never

resolved.

Service coordinators lack standardized training.

Confusion about their role with self-direction.

Service coordinators control level of time and enthusiasm

committed to self-direction.

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Quality Oversight

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Performance Indicator:

Person-Centered Practices

Desired State: 1) policy and procedures are in place that embed person-centered practices; 2) documentation reflects person-centeredness is practiced; and 3) training on person-centered practices is provided to all Support Brokers.

Performance Indicators Desk review of person-centeredness is in place in policy and procedures. Individual case review compares the number in the case review with the

number of case reviews where specific documentation lists the individual’s preferences, desires and personal outcomes.

During the reevaluation, individual case review compares the number in the case review with the number of cases where documentation lists if the individual’s preferences, desires and personal outcomes were achieved.

Reports are generated on the number of trainings conducted and staff attendance.

Participant Experience Surveys ask if support staff routinely discuss the individual’s preferences and personal goals.

Surveys ask if the planning process reflects individual preferences and desires.

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Performance Indicator:

Support Brokerage

Desired State:1) create sufficient provider qualifications to ensure

Support Brokers are competent and qualified to perform required duties;

and 2) conduct initial and ongoing Support Broker training.

Performance Indicators Individual case review reflects minimum qualification of the support

brokers are met.

The number of initial trainings and on-going trainings are captured

along with the number in attendance.

Training attendees complete a pre- and post-survey to measure level of

learning.

Training attendees complete an evaluation of the training and 95% state

training was excellent or very good.

Survey of support brokers state they receive sufficient training.

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Performance Indicators:

Duties of the Support Broker Desired State:1) policy and procedures specifically describe the roles

and responsibilities of the support broker; 2) prescribed contacts with participant are specified; 3) participant can contact the support broker; 4) support broker is helpful with questions or problems; and 5) support broker is helpful with acquiring additional resources/supports.

Performance Indicators Individual case review documentation by the support broker follows

accepted policy and procedures. Contacts with participant are documented and dates are within specified

timeframes. Participant experience survey reflects: a) participant knows how to

contact support brokers; b) participant is able to contact support broker successfully; c) support broker is helpful answering questions or managing programs; and d) support broker is helpful acquiring additional resources/supports.

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Performance Indicators –

Collection of Data from Support

Brokers Key Quality Strategies: 1) identify meaningful data that will measure

the quality of program activity; 2) ensure data is collected accurately and timely; and 3) dedicate sufficient staff to review and analyze data collected.

Performance Indicators Number of self-directed participants in caseload. Number of self-directed participant disenrolling with reason. Number of individuals desiring to self-direct but screened-out. Number of home visits within prescribed time period. Number of contacts or home visits made outside the prescribed time

period and reason for the delay. Number of critical incident reports filed. Number of referral to APS reported. Number of trainings attended and results of evaluation of trainings.

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Panel Discussion with

Kansas and New Jersey

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Panel Members

Aquila Jordan

Director, HCBS Waiver Services, Kansas Department for Aging

and Disability Services

Renee Davidson

Program Manager, New Jersey Division of Disability Services

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Panel Questions

1. Describe your model.

2. Why did you choose this model?

3. What are some of the challenges?

4. What recommendations would you make?

5. Is there anything you might want to do differently?

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Q&A

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