State Innovations in Long-Term Services and Supports: Providing
State Innovations in Long-Term Services and Supports: Providing Person-Centered, Community-Based Care and Advancing Quality and Purchasing Strategies NASUAD HCBS Conference September 1, 2015 Supported by The SCAN Foundation Alexandra Kruse, Senior Program Officer, Center for Health Care Strategies www.chcs.org Welcome and Introductions Alexandra Kruse Senior Program Officer, Center for Health Care Strategies Chris Welch LTSS Program Specialist, Texas Health and Human Services Commission Jay Taylor
Deputy of Audit and Compliance for Long Term Services and Supports, Bureau of TennCare, Tennessee Division of Health Care Finance and Administration Aquila Jordan Director, Regulation and Policy, Office of the Secretary, Legal Division, Kansas Department for Aging and Disability Services 2 Agenda I. CHCS Introduction and Overview of National Long-Term Services and Support Scan II. Texas: State Innovations in Long-Term Services and Supports: Providing Person-Centered, Community-Based Care
III. Tennessee: TennCare Long Term Services & Supports Value Based Purchasing IV. Kansas: Integrating Long-Term Services and Supports in Managed Care V. Questions and Answers 3 About the Center for Health Care Strategies A non-profit health policy center dedicated to improving the health of lowincome Americans
4 ACA Vehicles to Rebalance Long-Term Care Settings Historically, Medicaid programs were not designed to support individual choice of settings: Facility-based care is an entitlement HCBS often has waiting lists Limited coordination for HCBS participants across all service areas The ACA provides states with opportunities to move individuals to or support them in the community through:
Money Follows the Person (MFP) Demonstration Balancing Incentive Payment Program Community First Choice (CFC) Options Program 5 State Migration to Managed Long-Term Supports and Services States moving from FFS to MMC; 16 states have comprehensive, state-wide MLTSS Populations and services included vary by state Source: Mathematica Policy Research. Unpublished Data. January 2015. 6
National LTSS Scan: Introduction CHCS project supported by The SCAN Foundation Analyze LTSS delivery system innovations in states using both MLTSS programs and ACA vehicles to transform care for vulnerable LTSS populations Seven states interviewed: - Arizona - California - Kansas - Minnesota - New Jersey - Tennessee - Texas Policy brief will highlight key takeaways 7
National LTSS Scan: Emerging Themes Continuous stakeholder engagement: NJ Reinvestment in HCBS: TX, TN Addressing housing and other social determinants of health: CA, TN Integrating all services for individuals using LTSS: KS Value-based purchasing in NF and HCBS settings: AZ, TN Workforce development to strengthen LTSS purchasing and delivery systems: TN, TX Medicaid/Medicare integration through both financial alignment demonstrations and D-SNPs 8 Agenda I.
CHCS Introduction and Overview of National Long-Term Services and Support Scan II. Texas: State Innovations in Long-Term Services and Supports: Providing Person-Centered, Community-Based Care III. Tennessee: TennCare Long Term Services & Supports Value Based Purchasing IV. Kansas: Integrating Long-Term Services and Supports in Managed Care V. Questions and Answers 9
State Innovations in Long-Term Services and Supports: Providing PersonCentered, Community-Based Care Chris Welch LTSS Program Specialist Texas Money Follows the Person Behavioral Health Pilot (MFP-BHP) Goals Builds off long-standing MFP efforts Transitions adults with severe mental illness and/or substance abuse disorders from nursing facilities to the community Helps people be successful in the community by integrating mental health and substance abuse services with Long-term Services and Supports (LTSS) Includes Cognitive Adaptation Training (CA) and substance abuse services provided up to six months before and after discharge
Results in positive, long-term changes to the Medicaid system 11 MFP-BHP Outcomes 381 individuals have transitioned into the community under the pilot since 2008 To date, 72% of individuals in the pilot have maintained independence in the community Examples of increased independence include getting a job at competitive wages, driving, volunteering, getting a GED, teaching art classes, leading substance use peer support groups and working toward a college degree 12 Community First Choice Senate Bill 7, 83rd Legislative Session, requires the
most cost-effective approach to basic attendant and habilitation service delivery Health and Human Services Commission (HHSC) met this requirement by implementing Community First Choice (CFC) services on June 1, 2015 CFC benefits are state plan benefits and available to all individuals enrolled in Medicaid who meet criteria Page 13 CFC Overview For CFC eligibility, an individual must: Be a child or an adult who is eligible for Medicaid; Require an institutional level of care for: a nursing facility; a hospital; an institution of mental disease (under age 21 or 65 or older); or
an intermediate care facility for individuals with an intellectual disability or related condition; and Receive an annual redetermination. Page 14 CFC Services Personal assistance services Habilitation Emergency response services Support management
Page 15 Community First Choice Goals Provides an expanded array of state plan Longterm Services and Supports (LTSS) for eligible individuals Provides access to services for individuals with intellectual or developmental disabilities (IDD) currently on waiver interest lists Allows Texas to claim an enhanced state match for CFC services Page 16 CFC Implementation Challenges Timeframe for implementation Competing staffing resources: Nursing facility carved into managed care Dual Demonstration
Residual work from managed care expansion statewide Obtaining an approved State Plan Amendment Creating additional LTSS for a state with a robust array of existing LTSS Page 17 CFC Implementation Challenges Collaboration between multiple state agencies, managed care organizations, provider agencies, stakeholder groups, etc. Ability to assess and begin delivery of services timely Stakeholders with competing priorities Page 18
CFC Implementation Successes Able to offer benefits to individuals who would otherwise continue to wait for services Used existing provider base Used existing Level of Care assessments Modified existing functional assessments Stakeholder support for implementing CFC Fostering closer collaboration between multiple entities Page 19 Lessons Learned Start early Stakeholder input and buy-in early in development process Adequate stakeholder education Develop program independent of existing
infrastructures Page 20 Future Goals for LTSS in Texas Legislative direction to offer additional services for STAR+PLUS members with intellectual or developmental disabilities was provided in 84th Legislative session Non-medical transportation Respite care Implement the successful interventions and practices from the Behavioral Health Pilot in Medicaid managed care system Page 21 Contact Information for CFC
Community First Choice http://www.hhsc.state.tx.us/medicaid/managedcare/community-first-choice/ Email questions to: [email protected] MFP-BHP http://www.dshs.state.tx.us/mhsa/MFP/ Jessie Aric, MHP-BHP Program Manager [email protected] Page 22 Agenda I. CHCS Introduction and Overview of National Long-Term Services and Support Scan II.
Texas: State Innovations in Long-Term Services and Supports: Providing Person-Centered, Community-Based Care III. Tennessee: TennCare Long Term Services & Supports Value Based Purchasing IV. Kansas: Integrating Long-Term Services and Supports in Managed Care V. Questions and Answers 23 TENNCARE LONG TERM SERVICES & SUPPORTS (LTSS) Value Based Purchasing Presentation Goals
Provide an overview of TennCare LTSS Value Based Purchasing (VBP) initiatives Discuss the Quality Improvement in LTSS (QuILTSS) development process, including stakeholder engagement Discuss the lessons learned from QuILTSS for Nursing Facilities (NFs) Preview next steps for LTSS VBP, applying lessons learned to HCBS 25 TennCares LTSS VBP QuILTSS focused on the members experience in NFs and HCBS for seniors and adults with physical disabilities Enhanced Respiratory Care initiative for ventilatordependent individuals or others with significant respiratory care needs receiving services in a NF Services provided to individuals with I/DD:
New Behavioral Health Crisis Prevention, Intervention and Stabilization services and Model of Support Section 1915(c) waivers New MLTSS program Employment and Community First CHOICES May include ICF/IID services in the future 26 QuILTSS Stakeholder Engagement RWJF grant for technical assistance provided by Lipscomb University School of TransformAging 18 community forums in 9 cities and online survey of consumers, families, and providers Findings: http://www.lipscomb.edu/transformaging/tare port used to develop a Quality Framework
Stakeholders provided input into the design of the bridge payment approach and a division of reconsideration process 27 QuILTSS Timeline October and November 2013: Community forums December 2013: Technical Assistance Report Spring 2014: Stakeholder meetings to establish QuILTSS framework and specific measures August 2014: Implement Bridge payment process for NFs, including on-line submission, multiple reviews, feedback, and reconsideration process with external stakeholder committee Fall 2014: Stakeholder meetings to establish HCBS
measures 2015: MCO contract changes, HCBS settings rule assessments (system, MCOs, and provider), NCI-AD, 28 new technologies to collect point-of-service quality QuILTSS Quality Framework This framework was developed with the stakeholder group based on the input received during the community forums, with the intent of applying across LTSS and settings, where appropriate (some measures will be different for HCBS) Threshold Measures Minimum standards to participate in QuILTSS Quality Measures Satisfaction of Member/Resident, Family and Staff (35 points) Conducting surveys and taking action based on results
Culture Change/Quality of Life (30 Points) Respectful treatment, member choice, member/family input, meaningful activities Staffing/Staff Competency (25 Points) Volume of staff, choice of staff, consistency of staff, initial and ongoing staff training Clinical Performance (10 Points) Health related measures, prevention and early detection, ongoing functional assessment a division of 29 Current Status As of August 1, 2015:
QuILTSS for NFs has been active for one year 291 NFs have made submissions (296 Medicaid) NFs have completed 5 quarterly submissions MCOs have distributed over $16 million in payments for quality-based rate adjustments for the first 4 submissions QuILTSS for HCBS is in development Hosted a series of HCBS-specific stakeholder meetings Program changes / capacity development to support QuILTSS in process a division of 30 Available
NF Performance Total QuILTSS Scores 160 140 Score # of Facilities 120 100 0-25 26-50 51-75 76-110
80 60 40 20 0 #1 #2 #3 #4 #5 QuILTSS
Submission 32 NF Performance Facilities receiving QuILTSS points Resident Satisfaction Survey Took Action based on Resident Survey % of Facilities 100% 90% 80% 70%
60% 50% 40% 30% 20% 10% 0% #1 Family Satisfaction Survey Took Action based on Family Survey Staff Satisfaction Survey #2
#3 Took Action based on Staff Survey #4 #5 QuILTSS Submission 33 NF Performance Facilities receiving QuILTSS points 100% 90% 80%
% of Facilities 70% 60% CC/PCP Assessment Took action based on CC/PCP Assessment 50% 40% 30% 20% 10% 0% #1
#2 #3 #4 #5 QuILTSS Submission 34 TN 5 Star rating is improving October 2013, February 2015, average=2.9
2.00% average=3.2 1.98% 13.86% 20.00% 17.00% 1 Star 2 Star 3 Star 4 Star 5 Star 19.00% Too
New 22.00% 23.76% 18.81% 23.76% 17.82% 20.00% 35 Comparison of QuILTSS for NF vs. HCBS HCBS NFs
500+ providers 296 facilities Heterogeneous Homogeneous providersproviders Diversity of History of data collection Data collection history History of QI processes QI process history 24/7 interaction with members Organizational structure Well-organized industry groups Periodic interaction with New money to support quality members Industry group is not as component of rate well-organized
No new money, rates adjust higher and lower 36 Lessons Learned Stakeholder involvement (formal and informal) Transparency is key (nobody likes surprises) This is an iterative process (you cannot get there all at once) You will need to develop the capacity of the system to measure and improve quality Be at least two steps ahead of the system (you need a lot of lead time for the planning) Communication, communication, communication (and then communicate some more) Frequent Consistent
Questions Program must support member-focused quality Clear expectations and clear feedback to providers 37 QuILTSS for HCBS Focus on Personal Assistance and Residential Services Utilize the QuILTSS framework, with adjustments as appropriate Person-Centered Plan is key to driving the member experience Goals and preferences Employment and community integration Leverage technology Point-of-service satisfaction survey in Electronic Visit Verification
38 VBP for I/DD services New Behavioral Health Crisis Prevention, Intervention and Stabilization services and Model of Support to be implemented later this year Delivered under managed care program, in collaboration with I/DD agency Focus on crisis prevention and in-home stabilization, sustained community living, reduced inpatient utilization Performance measures (e.g., decrease in PRN use of anti-psychotics, decrease in crisis events, increase in in-place stabilization when crises occur, and decrease in inpatient psychiatric admissions and inpatient days) will be tracked and utilized to establish a VBP component (incentive or shared savings) for the reimbursement structure Section 1915(c) waivers Under SIM grant, developing acuity-based reimbursement approach for
residential and day services, using the Supports Intensity Scale Plan to develop a QuILTSS-like quality component or reimbursement as well 39 VBP for I/DD services Employment and Community First CHOICES MLTSS program to be implemented in 2016 Promotes integrated employment and community living as the first and preferred outcome for individuals with I/DD Outcome-based reimbursement for certain employment services Reimbursement approach for other services will take into account providers performance on key outcomes, including number of persons employed in integrated settings and # of hours of employment (after a reasonable period for data collection and benchmarking)
May modify ICF/IID reimbursement structure in the future, using approach similar to NF services (with modifications, as appropriate) 40 Enhanced Respiratory Care (ERC) Chronic Ventilator Care, Ventilator Weaning, Tracheal Suctioning Clinical Components Liberation rates Time to liberation Infection rates Hospitalization rates Technology Components Availability and use of state of the art technology that supports liberation and maximizes independence
41 The Bottom Line At the end of the day, LTSS VBP is not about the money. It is not about the system. It is not about the provider. VBP is about the members and the quality of their experience. We want to pay for the right service, in the right place, at the right time delivered in a manner that is consistent with members needs, goals and 42 Agenda I.
CHCS Introduction and Overview of National Long-Term Services and Support Scan II. Texas: State Innovations in Long-Term Services and Supports: Providing Person-Centered, Community-Based Care III. Tennessee: TennCare Long Term Services & Supports Value Based Purchasing IV. Kansas: Integrating Long-Term Services and Supports in Managed Care V. Questions and Answers 43
Integrating LTSS in Managed Care Aquila Q Jordan, JD/MPA September 1, 2015 Director, Policy and Regulations [email protected] Better Lives for Aging and Disabled Persons in Kansas Self-Determination Greater Independence Competitive Employment 45 Improved Access to Services Better Overall Care Top Service Challenges for
States Highest Cost Individuals People with challenging behavior Criminal offenses adjudicated and non-adjudicated Sexual offenders Mental health disorders People with significant medical care needs Waiting Lists Decreasing or minimizing use Serving based on priority need or place in line Managing Cost Equity & Fairness Reasonableness Implementing Promising Practices Person-Centered Practices
Positive Behavioral Approaches Competitive Employment 46 KanCare History January 1, 2013 Coordination of care under 1115 Demonstration Physical health/Medical services Behavioral health services Non-emergency medical transportation Nursing facility and other long-term care facilities
Value-added benefits and in lieu of services Long-term services and supports (Waiver HCBS) Mandatory enrollment in managed care BUT the HCBS programs continue to operate under the 1915(c) waiver authority concurrently with the 1115 waiver Excluded I/DD long-term services and supports 47 1115 WAIVER SERVICES Medical services Behavioral health services EPSDT & state plan benefits Transportation Nursing facilities Other long-term care Value-added benefits
In lieu of services 48 1 1915(c) HCBS WAIVERS Autism Frail elderly (FE) Intellectual/Developmental disability (I/DD) Physical disability (PD) Serious emotional disturbance (SED) Technology assistance (TA) Traumatic brain injury (TBI) HCBS Programs under 1915(c)
WAIVER POPULATION SERVED Under the 1915(c) waivers, more than 25,000 individuals individuals with Autism Spectrum Disorder (ASD) ages Autism receive long-term services 0-5and yearssupports in one of seven waivers: frail individuals over age 64 Frail Elderly Intellectual and Developmental Disability individuals with intellectual disabilities and
developmental disabilities (I/DD) ages 5 and older Physical Disability individuals ages 16-64 with physical disabilities Serious Emotional Disturbance individuals with serious emotional disturbance (SED) ages 4-21 Technology Assisted medically fragile and technology dependent (MFTD) individuals ages 0-21 Traumatic Brain Injury
individuals with traumatic brain injury (TBI) ages 16-64 49 The goals of managed care are to provide better results through service and support coordination across multiple services and providers to meet individuals needs. Managed Care & I/DD 502/7/20 Isaiah at our Family
Reunion August 2013 KanCare I/DD Implementation I/DD Pilot Project in 2013 Stakeholder, provider, MCO and state workgroup ~ 500 I/DD consumers and 25 providers participated Tested billing and claims system, updated workflows and process, evaluated coordination outcomes MCO Readiness Reviews in November 2013 Full day onsite reviews to cover five core areas Reviewed policies, staffing, training, procedures, and billing/claims 51
KanCare I/DD Implementation Implemented February 1, 2014 Eliminated secondary waiting list Trained care coordinators and targeted case managers on person-centered planning process Regular engagement calls with MCO and state Weekly consumer calls at noon on Wednesdays 2x weekly provider calls on Mondays and Fridays Reports and Updates Bulletins: I/DD (weekly), HCBS (monthly) MCO billing, claims & credentialing report 52 KanCare Health Homes Implementation Implemented July, 1, 2015 for SMI (including I/DD) populations
Stakeholder Engagement (July 2014 to July 2015) Conducted two public forums Robust website Over 100 presentations. Consumer and provider tours Federal rules: Members enrolled in a health home cannot have a targeted case manager who is not part of their health home Kansas Model: Blended health home model for I/DD to all TCMs to bill for 2 of the 6 core services and be paid monthly by Health Home Partner (HHP) Limitation: If a TCM is not contracted with a (HHP), the member can choose another HHP or opt out of health homes entirely 53 KanCare Lessons Learned 54
KanCare Lessons Learned Engagement is Critical Provider Education increased sophistication in contracting, billing, and claims Consumer Education early and frequent engagement across disability populations Pay for Quality Pay for Performance is about results and outcomes Pay for Quality is about quality of life, quality controls, and quality assurance Communication is Constant Develop consistent avenues for communication from stakeholders early on Develop a system for sharing, gathering, and updating information frequently Measure Progress AND Outcomes Improvements in coordination of care may occur in unexpected areas Ongoing technical assistances allows for constant improvement and innovation 55
Measure Progress MANAGED CARE IS more than a financing mechanism. Defining quality outcomes for people with disabilities Seeking opportunities for integrating care with services Improving independence and self-determination Working and living in the community with strong relationships Focusing on the person: their dreams, hope and desires Collaborating together to find innovative solutions PROGRESS supporting more people and their families in the community 56 Why Integrate the Waivers? To create fairness for groups that get HCBS
To offer a larger set of services To improve transitions between HCBS programs and from childrens to adults services To support development and expansion of community-based services To make things simpler for KanCare members, their families, providers and the state 57 How Will Waiver Integration Work? Full integration of seven 1915(c) waivers into the 1115 waiver HCBS eligibility requirements by waiver population will remain the same, but there will be two sets of services instead of seven: Childrens benefit Adults benefit Core Features - No Changes
Eligibility rules, processes and assessing entities stay Early Periodic Screening Diagnosis and Treatment (EPSDT) Access to state plan services Person-centered integrated service plans of care Core quality measurements of the 1915(c) waivers HCBS Transition Plan and HCBS Final Rule 58 There is a wide variation in mental abilities, behavior and physical development in individuals with Down syndrome [ or any disability]. Each individual has his/her own unique personality, capabilities and talents. In other words, people with Down syndrome [or any disability] are not all the same; just like individuals in the typical population are NOT all the same. Noahs Dad (blog 592/7/20
60 1115 WAIVER SERVICES KanCare CommunityCare Medical services Behavioral health services Childrens HCBS benefit EPSDT & state plan benefits Short-term Transportation Long-term
Nursing facilities Adults HCBS benefit Other long-term care Short-term Value-added benefits Long-term In lieu of services 1 Cross-Walk of HCBS Waivers Childrens HCBS Adults HCBS Autism (0-5) Intellectual/Developmental
Note: The ages are proposed population groups and subject to change based on public comment and feedback How Will Integration Improve Services? Increase Access to Services People will get needed services and supports no matter which disability group they are in Reduce or get rid of waiting list for services by improving traditional service models Provide supports for natural caregivers Improve Community Integration Help more people get real jobs in the community Offer better supports for person-centered independent living no matter what disability a person has
62 Nothing about me without me. Cathy, 45, has a killer freestyle and is a jazz connoisseur 63 Timeline DATE 64 ACTIVITY Aug-Sept 2015 Public meetings & conference calls
September 30, 2015 Publicly post draft 1115 amendment Sept-Nov 2015 Stakeholder engagement technical November 9-13, 2015 Public meetings on draft amendment November 20, 2015 Post public comments January 4, 2016
Submit 1115 amendment to CMS Jan-May, 2016 Stakeholder engagement operations July 1, 2016 KanCare CommunityCare begins State Considerations Technical Elements of the Amendment
Stakeholder workgroups and engagement Statutory and regulatory compliance Service definitions, limitations, and rates Quality assurance and performance measures Operational Elements of Implementation Education of state staff, consumers, providers, legislators, and other stakeholders MCO and provider readiness reviews Assessments, eligibility & workflows Updated policies, tools, and protocols Transitions, terminations & appeals 65 Most People with Disabilities in
Services Live with Family Sustainability depends on how well the system supports: Person-centered independent living Families People with employment 66 For more information about KanCare: www.kancare.ks.gov For more information about waiver integration: http://www.kancare.ks.gov/section_1115_waiver.htm OR www.kdads.ks.gov
67 Agenda I. CHCS Introduction and Overview of National Long-Term Services and Support Scan II. Texas: State Innovations in Long-Term Services and Supports: Providing Person-Centered, Community-Based Care III. Tennessee: TennCare Long Term Services & Supports Value Based Purchasing IV. Kansas: Integrating Long-Term Services and Supports in Managed Care V.
cost-effectiveness of Medicaid services Subscribe to CHCS e-mail updates to learn about new programs and resources Learn about cutting-edge efforts to improve care for Medicaids highest-need, highest-cost beneficiaries www.chcs.org 70
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