The MFP/Pathways to Community

Living Program – A Snapshot

Updated 12/4/2014

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The Money Follows the

Person Demonstration

Program is one prominent

example of a rebalancing

initiative.

Created by the Deficit

Reduction Act of 2005,

Money Follows the Person

now operates in 43 states

and the District of

Columbia. Under the

Affordable Care Act, MFP

was extended through

December 31, 2016.

Money Follows the Person

GoalsRebalancing - Increase the use of Home and Community Based Services (HCBS) and reduce the use of Institutional

services

Individual Choice - Eliminate state barriers that prevent the use of Medicaid funds to enable individuals to receive

care in the settings of their choice

Continuity of Service - Strengthen the ability of Medicaid programs to assure continued provision of

HCBS

Quality Assurance - Ensure procedures are in place to provide quality assurance and continued

quality improvement

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Eligibility for Transition

Qualified institutional stay (nursing home or ICF/DD) of 90 days

or more, which does not include Medicare Skilled days:

Transition Coordinators may begin working with an individual prior to 3

months, but the participant must be a resident for 90 days or more at this

point in time.

Medicaid beneficiary/recipient one day prior to community

transition. They also need to maintain their Medicaid after

transition.

Nursing Home and ICF/DD level of care (DoN score > 30) for

IDoA & DRS participants and a qualifying ICAP score.

Transition to qualified community setting.

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Additional MFP Requirements

Federal CMS Requirements

CMS mandated that all MFP demonstration initiatives develop

forms & processes to capture the following:

Risk identification/inventory, mitigation planning & management

24 hour back-up plans

Reporting and management of critical incidents, tracking & analysis

Quality of Life surveys

A CMS form developed by the national research firm – Mathematica

Transition Coordinators administer survey prior to transition

Representatives of the UIC College of Nursing to administer follow-up

surveys

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Each participating

state agency/division

contracts with

community providers

that complete

identification,

assessment, and

transition

coordination.

How Does it Work?

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IDOA – Case Coordination Units, CCU

DHS DRS – Centers for Independent Living, CIL

DHS DMH – Community Mental Health Centers at targeted sites

DHS DDD – Bureau of Transition Services/PAS agencies

• CRA/ACCT involvement in SODC closures

CRM Web Application

The MFP web application was migrated to a Microsoft

Customer Relationship Management (CRM) cloud based

platform September 2014

Modern, cloud based system that allows flexibility to adapt and

coordinate with Federal and state policy changes

Coupled the statewide MFP referral process with the MFP web

based case management system - Referrals are fully automated

Enabled enhanced reporting capabilities and quality oversight

Enabled customizable dashboards, views, and reports

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Referrals 9/8/2014-12/4/2014

NOTE: Analysis does not include 4,600 referrals processed

manually prior to automated referral process

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Quality Assurances

Representatives of the University of Illinois at

Chicago College of Nursing are under contract

with the Illinois Department of Healthcare and

Family Services to provide quality assurance. This

includes:

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Review of care

management

processes and

forms;

Clinical consultations

and assistance in

identifying risks and

mitigation strategies;

Managing a

website for

additional

educational

resources;

Processing of on-

line forms;

Assisting with the

implementation of

plans to manage

Critical Incidents;

Managing of a web-based care management

system.

Illinois’ MFP: Benchmarks

Federal CMS requires states to set

annual benchmarks.

Two benchmarks are federally required

Transition goals

Annual increase in community service

expenditures

A minimum of 3 other benchmarks

must be selected by each state.

Illinois’ benchmarks were revised in

2012.10

Benchmark - Transitions

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Division 2008 2009 2010 2011 2012 2013 2014 to

date

Total

IDoA 0 12 55 81 61 66 35 310

DRS 0 18 29 68 100 81 38 334

DMH 0 27 100 95 54 37 37 350

DD 0 0 0 0 75 35 71 181

Colbert

Class0 0 0 0 0 113 337 450

Total 0 57 184 244 290 332 400 1507

Benchmark – Successful Transitions

Increase the

percentage of

participants

remaining in the

community for the

entire year.

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Year Goal Actual

2012 82% 72% (Jan-Jun 2012)

2013 83%

2014 84%

2015 85%

2016 86%

• In 2011, 80% of MFP participants who had

transitioned remained in the community for 365

days.

Benchmark – Disenrollment Rate

Decrease disenrollment rate due to readmission to a long

term institutional setting or hospital.

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Year Goal Actual

2012 14.75% 8% (Jan-Jun 2012)

2013 14.5%

2014 14.25%

2015 14%

2016 13.75%

Disenrollment rate was 15% through 2011.

Benchmarks - Housing

• Increase the availability of affordable, accessible, and supportive

housing by:

– Increasing coordination with public housing authorities and

associations,

– Increasing units on the housing locator website

(www.ilhousingsearch.org),

– Increase in transition coordinators utilizing the case worker portal

(on the housing locator website),

– Increase interagency communication regarding housing issues via bi-

monthly conference calls,

– Increase availability of rental subsidies for MFP participants.

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MFP Participant Characteristics –

“Typical” MFP Participant

57 year old male who lived in his current

nursing facility (NF) for approximately 2½

years

Almost half (42%) have 5 or more major

medical and mental co-morbidities

Major health conditions include diabetes,

heart disease, and COPD, and serious mental

illnesses (SMI)

Almost half (47%) experienced an Emergency

Department (ED) visit in the previous year

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MFP Websites

MFP HFS Website

http://www.mfp.illinois.gov/

MFP Web Referral Form

http://www2.illinois.gov/hfs/MFP/Pages/Referral.aspx

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