DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
The New Exceptional Rate
for the ID Waiver
Lee Price, Sr. Policy Advisor for the
Office of the Settlement Agreement
Executive Advisor
& Dawn Traver, Community Resource
Manager, Division of Developmental
Services
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
The Underlying Issue
• DBHDS recognizes that there are individuals in
the training centers and the community who
have greater needs than can be adequately met
through the existing rate of reimbursement.
– High medical support needs
– High behavioral support needs
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Intent of an Exceptional Rate
• The “exceptional rate” was conceived to be a
stopgap measure to address this problem – not
a final solution
– DBHDS is hopeful that the waiver study currently
underway will assist in crafting long-term
improvements to the service system
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
General Assembly Action
• The 2013 General Assembly included a budget
bill item to provide funding for an exceptional
rate for ID Waiver Congregate Residential
Support services:
– Provided $3,682,880 in state general funds to
support the exceptional rate
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Budget Bill Language
• The exceptional rate is designed for those
– “currently residing in an institution and unable to
transition to integrated settings in the community
due to the need for services that cannot be
provided within the maximum allowable rate
AND
– whose needs present imminent risk of
institutionalization and enhanced waiver services
are needed beyond those available within the
maximum allowable rate.”*
*Budget Bill Item 307 #3c
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
General Assembly Intention
• Budget bill intent:
– Provide a temporary (i.e., until waiver redesign)
exceptional rate for those with complex medical
or behavioral needs
– Enable those individuals to receive enhanced
waiver services beyond those provided through
the existing maximum rates
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Extent of Impact
• The approved funding is estimated to provide
additional supports to approximately 250 people.
• It is anticipated that the exceptional rate will be
25% more than the current Congregate
Residential Support rates
– NoVa: $21.70/hour
– ROS: $18.88/hour
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Current Status
• DBHDS & DMAS staff have drafted criteria for
the new rate and sent to CMS for approval:
– Individual eligibility – will involve, among other
factors, SIS® scores
– Special review process before service
authorization
– Provider requirements
• Will release the details once CMS approves the
Waiver amendment
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Current Status (cont’d)
• Waiting to hear back from CMS
• State regulations are being drafted, but their
approval process begins after CMS Waiver
amendment approval
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Hopeful Timeline
• CMS Waiver amendment approval by early
October 2013
• ID Waiver regulations about the exceptional rate
in place by early January 2014
• The first individuals approved for exceptional
rate funding by mid-February 2014
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Some Possible Examples of Individuals
Who May Need the Exceptional Rate
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
MT
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Things That Are Important
To/For MT
TO:
FOR:
• Playing my
keyboard/listening to music
• Being outside; going on
vacations
• Being lifted up and down on
the ARJO lift
• Watching the hands of a
clock move
• Water
• Visiting with family/friends
• Maintaining optimal
positioning for respiratory
health
• Adequate nourishment and
hydration
• Visual, auditory and tactile
stimulation
• Total assistance with ADLs
• Engaging in many social,
recreation and leisure
activities
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
MT’s Recent Hospitalizations
• Hospitalized seven times in between January
2012 - April 2013 for
– Pneumonia
– Respiratory difficulties
• Each hospitalization lasted 5 to 15 days for a
total of 70 days
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Knowledge/Expertise MT’s
Provider Must Have
• Pneumonia prevention plan of care
• NPO – Nutrition/hydration/medications via Gtube
• DNR (parents wish no CPR/chest compressions)
• Knowledge of dysphagia
• Bowel movement protocol
• Repositioning protocol
• Weight and fluid intake protocol
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
MT’s Staffing Needs
• Two hours of nursing services per shift
• Monitoring vital signs and assessing for signs of illness.
• Assessing respiratory status; administering Albuterol
nebulizer for severe wheezing
• Checking G-tube integrity/patency and stoma site
condition every shift
• Monitoring positioning during enteral feeding and
optimizing positioning at all times
• Oropharangeal suctioning as needed
• Monitoring oxygen support via nasal cannula
continuously from bedtime to 7AM
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
RH
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Things That Are Important
To/For RH
To:
For:
• Making his own choices
about mealtimes, snacks
and TV
• Personal space/private time
• Sporting activities
• Socializing with family and
friends
• Warm water activities
• Playing games, listening to
music and looking at books
• Structure
• Something constructive to
do during the day
• Being encouraged to
participate in ADLs
• Maintaining good health
through regular medical and
nutrition management
• Managing his challenging
behaviors and
communication
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DBHDS
Virginia Department of
Other Important Things Per RH & His
Authorized Representative
Behavioral Health and
Developmental Services
• Home designed for individuals on the autism
spectrum; quiet with sensory items available
• Home where the others can tolerate RH when he
chooses to be loud
• Space to roam while still being supervised
• Own room
• Home with no more than 4 other individuals
• Fenced in back yard
• Structured environment
• Being close to his family
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
RH’s Behavioral Data: 2012 –
2013
• 60 episodes of aggression
– 7 episodes were documented
– 53 episodes were managed with proactive intervention
 Attacked parents in vehicle
 Bit, hit and kicked staff
 Bit peers
• He had 40 events of property destruction
 1 event was documented
 39 events were managed with proactive intervention
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
RH’s Behavioral Data: 2012 –
2013 (cont’d)
• 214 episodes of self injurious behavior
– 18 episodes were documented
– 196 episodes staff were managed with proactive
intervention
 Biting self to the extent of drawing blood
 Hand banging on windows and doors
 Slapping self in face to the extent of drawing blood
 Hitting his face on his knees, blacking his eyes and
bruising his face
• TOVA interventions were implemented 4 times
• Chemical restraint was utilized 1 time during an episode of
especially challenging behavior
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
RH’s Staffing Needs
• Staff trained and practiced on his positive
behavioral support plan
• 24 hour awake supervision with two staff awake
at night
• Follow communication plan
• Two staff for medical appointments to assist with
his aggression toward medical professionals
• Supervision in bathrooms if others are nearby to
reduce the risk of aggressive episodes
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
PJ
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Things That Are Important
To/For PJ
To:
• Listening to country
music
• Taking trips
• Talking to people about
trips I’ve taken
• Looking at pictures in
magazines
• Watching a movie or
television with others
from time to time
For:
• Being reminded to take
small bits so I don’t choke
• Intense supervision to
make sure I don’t hurt
myself
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Current Challenges for PJ
• I will sometimes leave where I am supposed to be and will
“wait” for someone to come find me. I enjoy this game and I
laugh when I am found.
• When I become upset I may remove my clothes and throw
feces.
• I often pull clothes, hair, and jewelry and scratch or kick
support partners.
• I struggle with transportation and often grab the steering
wheel, open doors, jump out or squeeze through windows,
while riding in a vehicle.
• I will often destroy things in my home and other environments
such as the community or at my day program.
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
PJ’s Staffing Needs
• Having 1:1 support for transportation to prevent
elopement, SIB or other challenging behaviors
• Having 1:1 support when walking around in the
community, as he will drop to the ground, roll
around in parking lots and disrobe in public
• Having an effective Behavior Support Plan,
Nutritional Management Plan,
• Having supports for oral and personal hygiene
and with taking needed medications
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DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
PJ’s Staffing Needs (cont’d)
• Having a Positive Behavior Support Facilitator to develop
and monitor Behavior Support Plan
• Instances of serious physical aggression should be
addressed by following his BSP and involving START
services to support acute and on-going concerns
• A structured and active employment or day support
setting where line of sight supervision is provided
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