Monday, February 07, 2005

A newish Day: Second Plenary

Speakers: Bob Gettings and Valerie Bradley
Topic: Restructuring Long-Term Supports for Individuals with Developmental Disabilities: A National Policy Perspective

11:06 Bob Gettings (BG,) a discussion of factors motivating the reassessment of Medicaid policy, assess the prospects of alternative proporals and place them in CA-DD context.

BG urging DD stakeholders to craft their messages within the context of broader reform strategies.

"Medicaid reform could not and, in my mind should not, be the be-all and end-all of [system] reform."

"Simply being oppositional, in the current context, may not be enough."

Five Alternative Medicaid Reform Strategies
1. Capped Entitlement (Block Grant)
2. Federalize Services to Dual Eligibles
3. Strengthen State Cost Containment Powers
4. Emphasize Cost-Efficient Service Delivery
5. Continued Gridlock over Medicaid Policy

Block Grant:
>>Shift burden to States
>>Most States would be unable to maintain current eligibility and benefits (cost-cutting by proxy)
>> Impact on DD services uncertain [And, in all likelihood, protection of DDS services might suggest losses in other programs serving people with disabilities]

>>In theory, states would achieve substantial savings; many savings likely returned to fed. treasury.
>>Exacerbate Federal Deficit
>> Two-tiered system of DD benefits, more complication

Strengthening State Cost Containment Powers
>> Differences among state Medicaid programs further accentuated

Implications of Emphasizing cost-effective service delivery methods
>> More tightly managed set of benefits [?] and stronger emphasis on outcomes [!]
>> Properly structured, this approach could make it easier to promote individualization and consumer direction [slef-determination]
>> Challenge many traditional operating assumptions and, thus, be opposed by a variety of existing stakeholders
>> A variety of tough system design choices would be required

Implications of continued legislative gridlock
>> DD systens are likely to be buffeted by intrastate initiatives to contain the growth in Medicaid Outlays.
>>> Potential threat of centralization and less DD system management autonomy
>>> Possibility of reallocating dollars among programs, purportedly to achieve greater equity.

11:35 Valerie Bradley

There will be a national conference in DC in September co-hosted by several national agencies. Urges advocates to attend. No data yet on how to enroll.

1. Historical Overview of CMS changes
2. Antecedents for changes in CMS expectations
3. Changes in management and oversight of the waiver
4. Implications for States.

Standards are changing:
"Better than the institution" no longer adequate
Are we supporting positive outcomes
Is there Quality Improvement
Changing state role
Changes in experiences and expectations of families and people with developmental disabilities.
Moving away from prescriptive standards to individualized risk management
Consumer and family participation in oversight [I wish this were a better description of CA's system evolution]

GAO found problems in HCBS (medicaid waiver, see previous posts) services around QA systems

Quality Focus Area
>Access to Services
>Providers are available and capable
>Safeguards protect people
>Support for people exercising rights
>Personal outcomes and satisfaction
>system monitors itself, uses data to improve outcomes

New Approach to HCBS waiver-writing- New requirements as of this year
>>>States must build quality and self-direction into the design of their waiver application
>>>States monitor individuals/solves problems
>>>States collect and analyze data for trends and patterns
>>>States change policies, practices and resources based on analysis
>>>States report Quality Management (QM) activity and results to CMS and the public
>>>CMS maintains an ongoing dialogue with states and looks for evidence of state oversight

> Individuals and families can obtain information
> Intake and eligibility determination processes are understandable, user-friendly and assistance is available
> Referrals for people who need services but aren't HCBS-eligible
> Individuals given infornatuin to exercise choice, services initiated promptly

Person-Centered practices:
>> Services planned and implemented in an individualized manner
>> Plans address the needs for HCBS, healthcare and other services
>> Information and support is available to help participants make selections among service options and providers
>> Participants have the authority and are supported to direct and manage their own services to the extent they wish.
>> Participants have acces to and assitance with obtaining and coordinating services
>> Services are furnished in accordance with plan
>> Regular, systematic and objective methods are used to monitor the individuals well being, health status and the effectiveness of services
>> Significant changes in the person's needs promptly trigger modifications to the plan

Enough qualified providers
>>> Sufficient providers that demonstrate capacity to serve

>> Health risks and safety assessed and interventions identified
>> The safety of the paricipant's living arrangement is assessed, risk-factors are identified and modifications are offered to promote independence and safety
>> Safeguards are in place to protect participants from critical incidents and life-endangering situations
>> Behavioral interventions are subject to rigorous oversight
>> Medications managed effectively and appropriately
>> Safeguards in place in the event of natural disasters/ public emergencies

Respecting and supporting rights
Participants are informed, supported and receive training to
-exercise their rights
-exercise their decision-making authority
-exercise their medicaid due process rights
-register grievances and complaints

Self-direction supports
-Conduct criminal background
-Assist participant to identify/recruit staff, verify qualifications
-Provide training to participant in staff supervision, doocumentation
-Receive and verify staff time record
-Verify that services are within approved limits
-Operate a payroll system for staff compensation
-Submit medicaid claims for services furnished by participant-employed staff
-Arrange for emergency back-up services as necessary
-Notify appropriate entity concerning service provision problems or issues that require attention
-Assist participant in addressing staff issues or problems that require attention
Assist participant in addressing staff issues or problams including termination

Good Outcomes and Satisfaction
>> Participants and family members are asked about their satisfaction with services and supports
>> Services and supports lead to positive outcomes for each participant

Quality Management System:
>>> Systen engages in systemic data collection and analysis of program performance and impact
>>> The system supports participants of diverse cultural and ethnic backgrounds
>>> Participants have an active role in program design, performance appraisal and quality improvement activities Financial accountability is assured; payments are made promptly in accordance with requirements

Quality is your friend:

12:00 Questions
(skipping some)

Q. Does CMS consider generalizing outcome measurements from community-based services under the HCBS waiver to more institutional settings?
VA: I don't think so
BG: There are limitations in federal law from doing that [for now]

Q. One of the things we're seeing a lot of is turnover rate among front-line staff at providers [Yo! you didn't find turnover at ¡Arriba!. Worker's comp seems to be part of the problem- what can be done?
VB: States, not Feds responsible for Worker's Comp. Frontline staff are critical to quality.

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