ALASKA DEPARTMENT OF HEALTH AND SOCIAL SERVICES

HCBS Technical Assistance for Alaska’s Division of Senior and Disabilities Services

From November 2015 to June 2016, HCBS Strategies provided technical assistance to the Division of Senior and Disabilities Services (SDS) and the Alaska Mental Health Trust Authority around a variety of HCBS topics. HCBS Strategies provided guidance to SDS about national trends in Federal Financial Participation (FFP) claiming and how FFP may be implemented in Alaska. More recently, we coordinated with the current 1915(i) and (k) contractor and SDS to review deliverables, provide guidance on relevant national trends, and establish the next steps for implementing and sustaining the effort.

HCBS Strategies was awarded a second Technical Assistance contract in June 2016 to support the Division of Senior and Disability Services with the ongoing planning and implementation of the 1915(i) and (k) efforts.

Conflict Free Case Management in Alaska

HCBS Strategies partnered with Agnew Beck Consulting to develop a draft plan for Alaska to come into compliance with CMS conflict free requirements contained in CMS HCBS rules.

As part of this project, HCBS Strategies and Agnew Beck facilitated interviews with a number of State agencies to gain a better understanding of the implications of the conflict free requirements on the processes of the State and local agencies. HCBS Strategies interviewed State staff in Colorado, Wyoming, Minnesota, and Hawaii about their efforts to comply with conflict free requirements.

HCBS Strategies and Agnew Beck then developed a report documenting the following:

  • Rationale for CMS Rules and interpretation of the conflict free requirements
  • Summary of the delivery of case management in Alaska and lessons from other states
  • Draft plan to comply with the conflict free requirements in Alaska
  • The vision for the case management system in Alaska

HCBS Strategies is now working with the State to pre-certify HCBS case management agencies as conflict free. HCBS Strategies has developed a solicitation that will be used by agencies in Alaska who wish to perform case management functions to provide assurances that they meet the conflict free requirements.

Development of Standard Tools

HCBS Strategies worked with Alaska to develop a standardized intake and screening tool. This tool will help clarify which programs individuals may be eligible for and who should be referred for an assessment. The tool should help reduce the number of people who are referred to programs that may not be the best fit and minimize the number of unnecessary assessments.

Development of Community First Choice Option

HCBS Strategies assisted the State of Alaska in exploring the development of the Community First Choice (CFC) option for attendant care services under the provisions of the Affordable Care Act. We reviewed Alaska’s current attendant care programs and facilitated discussions with the State on key design decisions that would be required in the implementation CFC. The design considerations included providing consultation of the program framework and participant access, quality assurances, support infrastructure, fiscal impact analysis, and proposed an implementation timeline.

As part of this scope of work and as a requirement under CFC we facilitated a participant advisory group designed to provide feedback and guidance to the State on the development of CFC. We also facilitated community forums to obtain additional feedback to the State on the proposed design of CFC. These design decisions and stakeholder feedback were integrated into our final report deliverable that advised the State on the implementation of CFC.

Developing a Long Term Care Plan for the State of Alaska

HCBS Strategies assisted the Alaska Department of Health and Social Services develop a plan for improving their long term care system. The purpose of this website is to facilitate the sharing of information among stakeholders and provide greater visibility to the project.

This report presents the following:

  • A summary of the input received from stakeholders via focus groups, interviews and surveys.
  • Our analyses of strengths and vulnerabilities of the operational infrastructure the State uses to deliver and monitor long term care services.
  • Our analyses of expenditure trends.
  • Recommended actions to be included in the LTCP.
  • A summary of stakeholder reactions to these recommendations and modifications we made based upon this input.
  • A three year action plan (3YAP) that translates the recommendations to be implemented within the first three years into discrete and interrelated tasks.
  • The framework for an Ongoing Planning Process to oversee the implementation of these changes.

COLORADO DEPARTMENT OF HEALTH CARE POLICY AND FINANCING

LTSS Assessment Redesign

The Colorado Department of Health Care Policy and Financing (HCPF) has contracted with HCBS Strategies to develop a new process for assessing the need for long term supports and services (LTSS).

The project has the following stages:

  1. Understanding how Colorado’s current LTSS assessment processes work, including a review of the tools used across the State and local departments and meetings with these entities.
  2. Develop a document that identifies how the new assessment process can support Colorado’s home and community-based services (HCBS) systems change efforts (formerly the white paper).
  3. Selecting the tool or tools that will serve as the basis of the new assessment process.
  4. Customizing the tool or tools to meet Colorado’s unique needs.
  5. Piloting the tool to understand the impact on eligibility determinations.
  6. Developing a plan for implementing the new tool and related processes.

The operational review mentioned in Step 1 has been complete, and during this process it was found that there are far more initiatives working towards systems change across the State than originally anticipated. As a result, the timing of the white paper (Step 2) was moved forward and refocused to discuss how the new assessment process might support proposed systems change efforts. As a result, the Department has decided on the tools that they will be using as models to develop their own tool (Step 3), and the draft assessment tool has been developed (Step 4). This modular assessment tool has been customized to meet the specific needs of Colorado and requirements from the HCBS Final Rule, and includes elements from the federal FASI (formerly CARE) tool and Minnesota’s MnCHOICES, which HCBS Strategies helped develop. The tool has gone through rigorous review with the State and stakeholders over the course of dozens of meetings. The pilot (Step 5) will occur when a final iteration of the FASI tool is available (anticipated date of late 2016).

For more information, please visit the blog at:  http://coassessment.blogspot.com/

Developing an Integrated Implementation Plan for Statewide Long Term Services and Supports

HCBS Strategies is currently working with the Department of Health Care Policy and Financing (HCPF) on the development and execution of an integrated plan for statewide LTSS. Currently, Colorado has over 15 LTSS enhancement and expansion projects that are co-occurring, many of which overlap. There has been little coordination across these projects, and Colorado has contracted with HCBS Strategies to develop an integrated implementation plan. This plan has been proposed to include descriptions of each of the efforts, a detailed implementation timeline, steps for coordinating the implementation of these efforts to minimize duplication, and the establishment of several workgroups to coordinate ongoing efforts.

HAWAII DEPARTMENT OF HEALTH, EXECUTIVE OFFICE ON AGING

Hawaii Executive Office on Aging’s No Wrong Door (NWD) Initiative

In 2014, HCBS Strategies worked with Hawaii on its proposal and fulfillment of the objectives under a one-year planning grant from the Administration for Community Living (ACL) to develop a plan and vision for how the No Wrong Door effort, referred to as the ADRC Network in Hawaii, would be implemented. As a result of this planning effort, HCBS Strategies worked with the Executive Office on Aging (EOA) and the Office of the Governor to develop a successful application for a highly competitive ACL grant that funds the implementation of the ADRC Network. HCBS Strategies is now working with EOA and the other State partners on the three-year plan to implement the ADRC Network.

Under the ADRC Network effort, HCBS Strategies has led the development and implementation of a comprehensive implementation plan that includes six State agencies, four local agencies, and two contracting partners. Agencies involved in this effort include:

  • Adult Mental Health Division (AMHD)
  • Adult Protective Services (APS)
  • Assistive Technology Resource Center (ATRC)
  • Center for Independent Living (CIL)- Access to Independence
  • Center for Independent Living (CIL)- Aloha Independent Living Hawaii
  • Children with Special Health Needs Branch (CSHNB)
  • Developmental Disabilities Division (DDD)
  • Division of Vocational Rehabilitation (DVR)
  • Med-QUEST Division (MQD) with links to all Health Plans
  • Office of Veterans Services (OVS)
  • Veterans Health Administration (VHA)
  • The four county Area Agencies on Aging (AAA) which operate the Aging and Disability Resource Centers (ADRCs).

Thus far in implementation, HCBS Strategies has worked with EOA and the other agencies to develop:

  • An automated referral tool that allows the agencies (Doors) to send common referral information across Doors to reduce 1) the need for the participant to tell their story multiple times and 2) the number of individuals who are not contacted after being referred to another agency. The referral tool includes the ability to “close the feedback loop”, which requires the agency receiving the referral to mark that they are acting on the referral, after which the system sends a notification to the agency who generated the referral to let them know the referral has been acted upon. HCBS Strategies is currently leading the pilot effort of this tool within the City and County of Honolulu.
  • An advisory group that consists of individuals with disabilities, providers, family members, and advocates;
  • A framework and plan for the initiatives that will continue or begin after the initial three year grant period;
  • Draft person-centered standards to meet the CMS rules;
  • FFP claiming methodology, including the completion of two time studies;
  • Interviews with five states on potential methods for implementing managed LTSS in Hawaii; and
  • Interviews with each of the State agencies and other partners to collect information on organization structure, service offerings, intake and assessment procedures, and training efforts. This information will be translated into living documents to improve the understanding of the functions of each agency across partners.

To monitor progress of the initiative and allow stakeholders to review documents and provide additional feedback, we have developed a website. It can be found at http://hinwd.blogspot.com/

Supporting Systems Change in Hawaii

HCBS Strategies is currently working with EOA and its partners in order to realize the goals and objectives laid forth in the 5-year plan for implementing ADRCs. HCBS Strategies is working with EOA to implement core pieces of the ADRC operational infrastructure that includes:

  • Automating protocols for referrals, intake, assessment, and support planning
  • Developing Options Counseling competencies and protocols
  • Creating procedure, approval, and documentation requirements for drawing down Medicaid administrative federal financial participation (FFP) to support core ADRC functions
  • Establishing memorandum of understandings (MoUs) with other partner agencies
  • Determining policies and procedures that incorporate evidence-based approaches for targeting services, determining whether case management is needed, and establishing support plans (utilizing the interRAI framework)
  • Developing provider agreements between Veterans Health Administration Medical Center and the ADRCs

Systems Change Developer

HCBS Strategies was contracted to fulfill the role of the Systems Change Developer (SCD). The objective was to create a five year strategic plan that guided the development of a streamlined operations infrastructure for Hawaii’s ADRC, Community Living Program, and Person-Centered Hospital Discharge Planning efforts. The SCD effort built an infrastructure that streamlined access to HCBS, helped target scarce resources to individuals at greatest risk of institutionalization and Medicaid spend down, and provided a participant-directed option under the state-funded Kupuna Care program.

While the main thrust of the effort was to develop the five year plan, we also engaged in building infrastructure to develop and sustain collaboration among the stakeholders. As part of this effort, we facilitated the two ADRC recharge conferences.

Hawaii Strategic Five-Year Plan

Download the strategic plan:

ADRC Recharge Conference

Download the strategic plan:

NEBRASKA STATE UNIT ON AGING

ADRC Pilot Evaluation

HCBS Strategies worked with the Nebraska State Unit on Aging (SUA) as the evaluator for the State’s ADRC pilot. The State contracted with three Area Agencies on Aging (AAAs) teams, seven AAAs in total, to develop and pilot ADRCs in Nebraska. HCBS Strategies worked with these sites to determine the qualities of the program activities implemented and the effectiveness in meeting or addressing the program goals and objectives. As a result of the pilot efforts, the Nebraska State Legislature has agreed to fund the statewide ADRC effort on an ongoing basis.  HCBS Strategies produced three evaluation reports that can be found below:

November 29, 2016
November 30, 2017
November 30, 2018
Year 1
Year 2
Year 3

ADRC and AAA Medicaid Administrative Claiming

The Nebraska SUA has contracted with HCBS Strategies to develop and implement infrastructure to support drawing down federal financial participation (FFP) through Medicaid administrative claiming.  In addition to developing the infrastructure, HCBS Strategies will conducting training and overseeing all aspects of the ongoing administrative claiming.

OREGON OFFICE OF DEVELOPMENTAL DISABILITY SERVICES

Establishing a Valid and Reliable Assessment Tool

The Oregon Office of Developmental Disability Services (ODDS) contracted with HCBS Strategies, Mission Analytics Group, and Barbara Gage of the Post-Acute Care Center for Research (PACCR) to redesign their assessment tool for individuals accessing services for intellectual and developmental disabilities. The primary goal under this effort was to update the current assessment tool to utilize nationally recognized valid and reliable items from tools including CMS’ FASI tool, MnCHOICES, and the Colorado Assessment Tool.

Under this effort, HCBS Strategies performed a comprehensive review of the five current tools used by the State for assessing individuals with intellectual and developmental disabilities. The items within these tools were evaluated for face validity and reliability, and then cross-walked with the FASI, MnCHOICES, and the Colorado Assessment Tool to identify areas were updates were needed. Throughout the effort, FASI item experts were consulted to ensure optimal reliability and validity. Realizing that an overhaul would be required to develop a valid and reliable tool, HCBS Strategies led the effort to design a paper version of the tool that incorporated items from the five current State tools, and coordinated with the State during the automation phase. The Tool was piloted throughout the state in late 2016, and has been implemented statewide.

MARYLAND DEPARTMENT ON AGING

HCBS Strategies worked with MDoA in implementing its Enhanced Aging and Disability Resource Center (ADRC) grant. HCBS Strategies collaborated with MDoA on the successful application in a highly competitive procurement process. The grant allowed MDoA to make substantial enhancements to the Maryland Access Point (MAP) program (Maryland’s version of the ADRC). We provided assistance with tasks including:

  • Administrative start-up and project management
  • Development of an ADRC CQI plan
  • Development of a sustainability plan
  • Expansion of MAP to provide statewide coverage serving all required disability populations.

Administrative FFP

In addition to the above tasks, another core component of these efforts was to develop infrastructure for drawing down Medicaid administrative federal financial participation (FFP) funding for Medicaid LTSS for the MAP program. We helped the MDoA team establish what method they would like to use for time studies for this program, either random moment time study or continuous daily log. We developed online surveys for both of these methods and piloted each with participants at entities throughout Maryland and analyzed the results to determine which method provided the best results for MDoA. This was then translated into a white paper.

Options Counseling Grant Support

In previous efforts, HCBS Strategies assisted MDoA with the development and implementation of a grant from ACL to build Options Counseling Infrastructure in Maryland’s ADRC program.

Key tasks in this effort included:

  • The establishment of infrastructure to facilitate collaboration among the state and local ADRC sites.
  • Background research and presentation of proposed models for options counseling
  • The development of options counseling protocols for the initial intake, support planning, and ongoing case management business operations.
  • The development of staff qualifications, training requirements, and performance indicators.

NH Diversion Modernization Grant

HCBS Strategies assisted MDoA with implementing a NH Diversion grant it received from AoA. HCBS Strategies assisted in a variety of efforts, including the development of targeting criteria in order to identify individuals at high risk of institutional placement and developing reimbursement approaches.

MINNESOTA DEPARTMENT OF HUMAN SERVICES

The State of Minnesota worked with HCBS Strategies to refine its assessment processes to ensure greater consistency across the counties and across all populations with disabilities under age 65. This project developed standards and protocols, a common data collection tool, and recommendations to best utilize these tools to improve the reliability and equity of service provision, with careful regard given to the possible impact on service funding structures. The State’s vision was to have a comprehensive assessment process that supports improvements to the quality and efficiency of supports.

 

This effort resulted in the MnCHOICES Comprehensive Assessment (formerly known as the Universal Assessment, and COMPASS). Development of the tool was completed in August 2007, and the tool has now been implemented.

The purpose of this project page was to facilitate the sharing of information across the stakeholders involved in the development of this effort. This work was overseen by the Comprehensive Assessment Steering Committee. Thus, this site contains documents that were developed as a part of the effort to make sure that all the stakeholders were full and active participants.

To receive home and community-based service programs an initial screen is required to establish eligibility and determine a person’s need for services. An annual screen is required thereafter to determine continued functional eligibility. The screening and assessment process prior to MnCHOICES was at times challenging and time consuming. First, there were multiple forms to complete, sign, and process. This made the intake process confusing and cumbersome for families and for some county staff. In addition, individuals and their families or caregivers did not feel that the present data collection instruments captured what their true needs were, yielding a service plan that was often not responsive to the actual needs of the individual and their situation.

Based upon input of numerous stakeholder groups, we heard the following as reasons for the need to change the current approach:

  • Assessments are performed at a period of time and reflect a “snapshot” versus the overall needs of the person. Parents tend to want to base the assessment of their children on their worst days. The new tool will allow for some clarity in how to address this.
  • People may switch from waiver to waiver, which is hard for staff at the local level. Having a single assessment process will help to determine what services fit a persons’ needs best.
  • One of the greatest concerns of county-level providers is the inability to meet the timeframes, e.g., 10 days for assessment. Factors contributing to this are:
    • Obtaining medical necessity approval for primary care provider/medical provider.
    • Numerous forms to sign.
    • The time it takes to perform the assessments for mental health, especially for the CADI waiver.
    • Obtaining all of the necessary eligibility requirements for DD in particular, such as psychological evaluations, and disability certifications.
  • Services cannot start without a service agreement, which is driven by assessment and service eligibility determination.
  • Multiple forms are confusing and cumbersome for families and for some county staff.
  • Staff at the county level do not want to be forced by the design, to complete all form fields if they are not relevant.
  • Current tools are not specific enough to capture the Active Treatment requirement of the DD waiver.
  • Currently the LTCC is too focused on the aged and not on youth or children.
  • DD does not satisfactorily screen for level of complexity and intensity of the needs of the DD population.
  • The issue of having two screening tools, one for DD and one for LTC, not only limits the ability to screen true levels of intensity for the DD populations, it also creates a separation at the county level of separate service provision units.
  • Tools do not adequately screen for mental health needs to help plan for services.
  • Consumers do not feel that the present design captures what their true needs and therefore staff are not responsive to actual needs.
  • Assure assessment for services and supports to individuals with disabilities are driven less by the funding stream (i.e., waiver or state plan) and more by the needs and preferences of the individual. A key starting point for this reform will be the ability to accurately assess what individuals need and prefer.
  • Allow intake and assessment staff at the county level to gather additional information on specific populations, such as individuals with greater medical needs or mental health concerns.
  • Streamline the process to reduce use of duplicative forms across waiver populations.
  • More accurately reflect the true needs of the individual and family/support system.
  • Capture more relevant information to address vocation, habilitation, skills adaptation and other needs for which the State currently does not offer tools.
  • Enhance the ability to conduct initial behavioral health screens for CADI and MR/RC by providing more definitions for screening.
  • Move toward an automated intake and screening process that is less cumbersome for the consumer and will capture more accurate data about the individual for service planning.

The MnCHOICES Comprehensive Assessment, formerly known as the Universal Assessment and COMPASS, is designed as an automated, modular tool that only prompts for information that is relevant to a particular individual. Thus, it includes higher level trigger questions that determine whether a particular section, or subset of questions within a section, is addressed.

These sections can be classified into the following three phases: (1) the “initial contact” screening call that captures the reason for referral, the urgency of the person’s needs, and whether a full assessment is needed; (2) the assessment of preferences, strengths, and needs; and (3) the development of the support plan.

We have described the structure of this process as resembling a “tree.” At the base of the tree, there is a trunk, consisting of information we discover through a person-centered interview about the person’s life goals and strengths. This information is used to direct the assessment into those areas of most importance to the person.

The state intends that the MnCHOICES Comprehensive Assessment will ultimately be automated and linked directly to the Medicaid Management Information System (MMIS). Below we provide links to mock-up versions designed to reflect what the automated version should look like.

A. First Contact Triage Intake– Updated November 5, 2010

B1. Person-Centered Interview – Ages 14-64  – Updated November 4, 2010

B2. Person-Centered Interview-Over 65- Updated November 4, 2010

B3. Person-Centered Interview for Birth to 13- Updated November 5, 2010

C. Capacity for Self Direction- Updated June 8, 2010

D. Initial Trigger Questions- Updated February 20, 2010

E. Adult Health Assessment- Updated February 24, 2010

F. Substitute Decision-Making – Updated June 1, 2010

G. Functional Memory and Cognition- Updated October 30, 2010

H. Children’s Health and Functioning- Updated October 20, 2010

I. Sensory Channels and Communication Skills- Updated June 7, 2010

J. Social Communication and Friendships- Updated July 7, 2010

K. Living Arrangements Environmental Screening- Updated May 28, 2010

L. Caregiver Assessment- Updated November 3, 2010

M. Activities of Daily Living- Updated September 20, 2010

N. Instrumental Activities of Daily Living- Updated July 6, 2010

O. Employment Module- Updated May 27, 2010

P. Support Planning Module- Updated March 4, 2010

Q. Demographic-Administrative- Updated July 15, 2010

S. Assessment Conclusions Iteration- Updated July 2, 2010

ILLINOIS GOVERNORS’ OFFICE ON HEALTH INNOVATION AND TRANSFORMATION (GOHIT)

1115 Demonstration Waiver Support

In 2014, HCBS Strategies assisted GOHIT with designing policy and operations for its ambitious 1115 Demonstration Waiver that combined nine waivers into a single program. Dr. Lutzky acted as the Subject Matter Expert for the LTSS Workgroup. Under this scope, he reviewed current program operations, proposed approaches for integrating these operations, and worked with a workgroup of State agency representatives and workgroups of stakeholders to review these changes.

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