findings and implications june 21, 2011 prepared by with the assistance of minnesota department of...
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FINDINGS AND IMPLICATIONS
June 21 , 2011
P r e p a r e d b y W i t h t h e a s s i s t a n c e o f
M i n n e s o t a D e p a r t m e n t o f H u m a n S e r v i c e s
Waiver Review Initiative
Lead agency Comments
“The review process has been very organized from the State stakeholders with an attitude of working together with our County to improve services to our clientele…this process has resulted in improvements and process change that will definitely benefit our clientele.” – Clearwater County (Director of Human Services)
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Agenda
Describe the waiver review initiative
Share findings from the waiver review
Describe changes in waivers across county agencies over previous 5 years
Share how counties change in response to reviews
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About the waiver review initiative
A statewide project that began in 2006 to assure the Quality of Minnesota’s Home and Community Based Programs: • To identify promising practices • Assure compliance with program requirements• 75 lead agencies have been reviewed and as a result
o Surveyed over 1,300 staff o Conducted almost 90 focus groups o Reviewed over 5,000 case files
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Status: Waiver Review
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Some changes in the initiative
Providing more services on-site to counties • Detailed report of what we looked for• Answering questions about requirements, practices
Follow-up process started• 48 counties had been through the follow-up process
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Some changes in the initiative
Yahoo Group – save interesting tools collected from other counties
Instructions on how to find the Yahoo group with useful County tools. It can be found accessed at
http://www.theimprovegroup.com/waivers/countytools.pdf
DHS data portal – reports published on the DHS website Performance measures related to HCBS waiver
programs Updated quarterly New reports get added as they are developed
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Waiver review framework
The waiver review is designed & organized to examine the Center for Medicaid and Medicare seven quality areas;
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Waiver review framework, cont.
Quality area Definition
Participant Access
Individuals have access to home and community-based services in their communitiesKey benchmarks: Number of people on waiting lists; nursing facility residents under 65 who received screenings; community outreach
Person-centered service planning & delivery
Services and supports are planned and implemented in accordance with each persons unique needs and preferences
Key benchmarks: Use of CDCS; documentation of participant choice; service continuity
Provider capacity
There are sufficient providers who demonstrate capacity to serve participants
Key benchmarks: Days between entry into service agreement and paid claims; contract quality
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Waiver review framework, cont.
Quality Area
Definition
Participant safeguards
Participants are safe & secure in their communities, taking into account their choicesKey benchmarks: Frequency of face-to-face visits, back-up plans and emergency contact information in care plans
Participant rights
Participants receive support to exercise rights & accept personal responsibility Key benchmarks: Documentation of informed consent; participants are informed of their rights
Participant outcomes
Participants are satisfied with services & achieve outcomesKey benchmarks: Participant outcomes and goals in care plan; documentation of participant satisfaction
System performance
The system is efficient, effective & strives to improve qualityKey benchmarks: Percentage of participants served in community vs. institutions; waiver budget balances
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Findings and themes: participant access
Promising practices• Counties build strong relationships with agencies such as
schools, health clinics, hospitals & nursing homes • Increasingly, counties build strong regional collaboration to
better serve communities• Counties serve a higher-need population than in 2004
Limitations• Most counties (12 of 16) have fewer than 80% of screenings
completed on time in one or more programs• Some counties are facing challenges serving culturally
specific populations, notably Hispanic and Somali populations• Some counties are facing challenges in providing case
management to participants who live outside the county borders
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Findings and themes: participant access
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MMIS data CCT AC & EW DDAll HCBS
Programs
# of participants waiting for HCBS services
261 N/A 4,859 5,120
% of participants living in own home (first screening)
Under 22 = 75%Over 22 = 68%
69%Under 22 = 87%Over 22 = 12%
N/A
% of screenings done on time
61% 67% 89% N/A
Findings and themes: person-centered
Promising practices• DD ISPs nearly always exceed expected
documentation of needs, goals & outcomes• Counties provide increasing employment
opportunities for DD & CCT participants
Limitations• Not all CCT care plans are being developed within
ten days of the assessment, as required by MN statute
• Counties are not adequately addressing caregiver needs in care plans. Overall, only 41% of cases reviewed in the past year address caregiver needs
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Findings and themes: person-centered14
CCT AC & EW DD
Percent of participants with current individual care plan (one year or less) 98% 98% 98%
Completeness of individual care plan- participant needs identified 90% 85% 100%
% of participants with a care plan that includes choice questions answered 94% 92% 100%
% of participants with an OBRA Level 1 or ICF/MR* LOC in case file 97% 98% 78%*
% of participants with a care plan that shows all services to be provided 98% 98% 100%
Findings and themes: provider capacity
Promising practices• Nearly all contracts include basic participant
outcomes and have a process to monitor if services are being provided
• County staff are well connected and communicate regularly with providers
Limitations• More than 34% of all contracts reviewed were
signed more than 60 days after the contract’s effective date
• Some counties have a very residential provider base
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Findings and themes: provider capacity
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*Statewide data** Fee-for-Service dataMMIS data
CADI EW** DD
% of authorized dollars actually paid for services in FY 2010*
85% 19% 92%
% of participants with a service agreement but no paid claims*
35% 23% 17%
Findings and themes: provider capacity
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Contract review data Yes
Are local contracts current for services being provided? 93%
Does the contract language include a process to examine if contracted services are actually provided?
99%
Does the contract include an established rate for services?
81%
Findings and themes: participant safeguards
Promising practices• In many counties participants are seen face-to-face
on a monthly or quarterly basis• During assessments county staff take a look at
kitchens, bathrooms, scatter rugs etc to ensure people are safe in their homes and to prevent falls
Limitations• Some counties had CCT participants that did not
have biannual face-to-face visits over the past year• Some Counties had more than 20% of DD
participants not visited in the previous six months
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Findings and themes: participant safeguards19
Case file results CCT AC & EW DD
Most recent case manager face-to-face visit within the last six months
86% 82% 86%
Health & safety issues outlined in care plan
98% 98% 100%
Back-up plan included in care plan
75% 56% 20%
Emergency contact included in care plan
92% 92% 90%
Findings and themes: rights/responsibilities
Promising practices• Most counties had 100% documentation of
participant rights for its DD cases
Limitations• Some counties had issues with public
guardianship and case management roles being performed by the same person
• Many counties do not regularly update participant rights forms
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Findings and themes: rights/responsibilities
Staff Survey data Mean
Providing participants with information about their rights and responsibilities 9.45
Assuring that participants are able to exercise their rights 9.38
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Findings and themes: rights/responsibilities
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Case file data CCT AC & EW DDAll HCBS Program
s
Documentation of informed consent 99% 96% 88% 97%
Documentation of participant informed of rights 98% 98% 98% 97%
Findings and themes: outcomes/satisfaction
Promising practices• Some counties are systematically collecting
participant satisfaction information • Counties are doing participant satisfaction surveys
Limitations• Goal setting continues to be a challenge in the LTC
programs, in many counties goals are not individualized.
• Participant satisfaction collected informally but not documented in case files
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Findings and themes: outcomes/satisfaction
Case file review dataAll HCBS Programs
Documentation of participant outcomes and goals in care plan
98%
Documentation of participant satisfaction in case file
57%
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Findings and themes: outcomes/satisfaction
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Staff survey results1-10 scale
Systematically collecting participant satisfaction data
8.55
Monitoring participant outcomes 8.70
Findings and themes: system performance
Promising practices• Case management practices are very strong in all
counties reviewed this year • Public Health and Social Services agencies and staff
have good working relationships and work together to serve participants
Limitations• Staff capacity has been stretched as a result of budget
cuts, and case managers report that keeping up with policy changes is a challenge
• Contracting for culturally-appropriate services continues to be a challenge in many counties
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Findings and themes: system performance
System data – 2010 CCTEW/AC
DD
Percent of LTC participants served in community vs. institutional settings 92% 65% 92%
Percent of LTC funding spent on participants in community vs. institutions
87% 33% 87%
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Findings and themes: system performance
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Staff survey results 1-10 scale
Communicating State and Federal policies to staff 8.26
Following State and Federal laws and regulations 8.98
Accessing quality interpreter services 9.53
Contracting for culturally – appropriate services 8.44
Changes in waivers during review period
Technology is being used increasingly to support case management and other services through electronic case files, mobile laptops, and delivering services electronically.
CDCS services have been used in greater numbers in rural, suburban and urban communities alike; each community seems to have different reasons for its use of CDCS.
The majority of participants are being served in the community as opposed to institutions, and the percentage is increasing.
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Changes in waivers during review period
Care plan documentation of participant health and safety and participant goals is improving.
Compliance with technical requirements is improving.
• In 2006, 9% of CCT cases had a complete documentation of a backup plan, while 74% of the CCT cases we reviewed in the past year had this documentation
• In 2006, 67% of LTC cases had a completed OBRA level one, while 98% of LTC cases we reviewed in the past year had this documentation
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Changes in waivers during review period
2006 2010 2006 2010 2006 2010Identifies participant
needsAddresses health &
safety issuesIncludes participant outcomes & goals
0%
20%
40%
60%
80%
100%
None Below Meets Exceeds
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Changes in waivers during review period
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06
20
10
20
06
20
10
20
06
20
10
20
06
20
10
Plan for services to be provided (formally or in-
formally)
Choice questions are answered
Care plan is signed and dated
Caregiver needs are included
0%
20%
40%
60%
80%
100%
None Partial Complete
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Changes in waivers during review period
Contracting practices are improving; most counties moved to the DHS model contract over the last 30 months, and now contracts meet all requirements and in general are in place for all services, with a few incidental exceptions.
The proportion of participants earning income is increasing. In the DD program, 49% of participants earned income in 2005, and 56% earned income in 2009. In CCT, 20% of participants earned income in 2005, while 21% earned income in 2009.
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Continuing challenges
Some issues continue to challenge counties; these could be considered when working with counties and/or supporting their work: • Counties are facing increasingly limited budgets,
particularly for travel, staff reductions and training. They are addressing these limits by using internal cross-training whenever possible.
• Some counties struggle when switching between
different waivers and/or health plans to meet the various care plan and documentation requirements. They have frequently requested tools resources such as requirement checklists to support their work
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Continuing challenges
Keeping up with the pace of program changes remains difficult for counties; some have assigned staff to be internal “experts” on specific issues, but others do not have a system for adapting to change.
While DHS offers a number of resources, the resources are not available to all programs; county staff continue to ask that Regional Resource Specialists or similar support be available for AC and EW programs.
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Lead agency Comments
“The review confirmed many areas SLC [St. Louis County] has known are challenging areas with room for improvement. The difficulty has been with limited resources and the need for greater direction and consistency locally and from DHS. On a positive note, in the intervening 3 years, both DHS and SLC are moving forward step by step to improve the overall waiver administration and service delivery.” (Deputy Director, St. Louis County)
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Follow – up
The follow up summarizes the results of the waiver review follow up activity from 2008 through 2010.
Results are organized into the following sections: Individual Case Compliance Cohort Compliance Lead Agency Service Improvements
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Follow-up results
Purpose
The follow-up review:
• Confirms lead agency compliance with corrective action plans;
• Tracks local improvement efforts;• Obtains feedback on the helpfulness of the
review.
Follow-up results
ProcessThe lead agency submits documentation to verify
planned changes to their programs were implemented as stated in their corrective action plan
A list of cases and required documentation is sent to the lead agency that includes cases previously found non-compliant, along with additional cases to ensure that the practice has been consistently implemented and not only applied incidentally.
Lead agencies are also asked about recommendations that were included in the waiver review report.
Follow-up results
Process.
The submitted documentation is reviewed for compliance with state and federal requirements.
A draft report is sent to the lead agency for review
Report is finalizedAdditional corrective actions re-issued if
necessary
Follow-up results41
Follow-up results
250
750
1250
1750
2250
2750
Corrective Action Effectiveness 92%
Follow-up results
Total Corrective Full %Correction
s
Cohort Actions IssuedComplianc
eCorrecte
d Re-issuedAitkin 2 5 3 60% 2Clearwater 1 14 13 93% 1Douglas 2 5 4 80% 1Freeborn 2 7 5 71% 2Goodhue 3 9 7 78% 2Lincoln Lyon Murray 3 8 7 88% 1McLeod 2 3 1 33% 2Mower 3 13 11 85% 2Nobles 2 8 5 63% 3Pipestone 1 4 2 50% 2Polk 3 8 5 63% 3Pope 2 4 3 75% 1Rock 1 4 4 100% 0St. Louis 5 13 8 62% 5Wabasha 2 12 11 92% 1Wadena 2 3 2 67% 1Washington 4 8 5 63% 3Yellow Medicine 1 4 3 75% 1Overall 132 99 75% 33
Follow-up results
Tim
ely
Care
Plan D
evel
opm
ent
Long T
erm
Scr
eenin
gs On T
ime
Freq
uency
of F
ace-
to-F
ace
Visits
0%30%60%90%
% Corrective Actions Re-issued 2010
% Corrective Actions Re-issued 2010
Follow-up results
Total Corrective Actions Issued
Full Compliance Corrections Re-issued
2009 91 71 20
2010 132 99 33
1030507090
110130
Lead Agency Overall Compliance Im-provement
Follow-up results
5
15
25
35
45
55
65
75
85
95
Percentage of Corrective Actions Remediated
Follow-up results
Total Corrective Actions Issued
Full Compliance
% Corrected
Corrections Re-issued
Total Lead Agencies
Count
%
Cohort 1
61 54 89% 7 12% 9
Cohort 2
66 51 77% 15 23% 12
Cohort 3
54 41 76% 13 24% 11
Cohort 4
19 12 63% 7 37% 3
Cohort 5
23 12 52% 11 48% 2
Overall 223 170 76% 53 24% 37
Follow-up results
1030507090
110130150
Lead Agency Response to Recommen-dations
Follow-up results
Conclusions The follow-up process continues to be an effective
mechanism to assure compliance and secure feedback on recommendations.
Most lead agencies have made significant progress in achieving compliance.
Frequency of face-to-face case manager visitation, timing of screenings and care plans continue to be major challenges for lead agencies.
Lead Agencies implemented over three-quarters of all recommendations made by the Department relating to service improvements.
Follow-up results
Adjustments Made to the Process Include:
Reduce the time interval between the Initial Waiver Review visit and the Follow-Up Process to between 15 and 18 month intervals.
Planning to implement phase II of the follow-up process after the initial follow-up reviews are completed.
Follow-up results
The ChallengeCMS will want to know the remediation steps taken
by the department on outstanding compliance issues identified in the follow-up review. This will necessitate another follow-up
CMS will require 100% remediation of identified deficiencies.
DHS must provide evidence of on-going remediation efforts to CMS as we renew our waivers. The Initial review of all counties will be completed next year and it will take some time to develop and operationalize new protocols.
Lead agency Comments
“On behalf of Washington County I would like to thank you and your staff for the respectful manner by which this review was conducted…and was pleased by the cooperation that was evident between our respective agencies.”(Director of Washington County
Community services)
Resources
To contact us: Jean MartinDepartment of Human
Tom SkarohlidDepartment of Human
Services
*Please feel free to call with questions about this presentation or how to interpret any of
the included data
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