John Agosta, PhD
JAgosta@hsri.org
Katie Howard, MPH
KHoward@hsri.org
Self Direction and Resource Allocation
September 9, 2014 at 12:00 pm ET
Presentation Outline
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Objectives
Goals of Resource Allocation
Steps in the Process
Evaluation
Managed Care and other State Plan
options
• Questions
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Objectives
• Identify issues that Resource Allocation
addresses
• Familiarize participants with methods of
Resource Allocation
• Identify steps to implementing Resource
Allocation
• Understand how assessment instruments
can be used to set budgets
Challenges in the Field
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Accelerating service demand
Budget stress
Reliance on legacy and inefficient systems
Workforce shortages
Need for continued community integration
and self direction
Goals of Resource Allocation
• Enable policy makers to make disciplined
fiscal choices
• Allocate resources based on assessed
support level
• Accommodate people with extraordinary
needs in HCBS waiver programs
• Can create flexibility in individual service
planning
A Lot
We want to move from a low
correlation like THIS…
$
Little
Little
A Lot
Support Needed
…to a high correlation like
THIS
A Lot
$
Little
Little
A Lot
Support Needed
Blending Together Principles Related to Service
Delivery and System Management
Services and
Disciplined
fiscal
and
management
practices
supports preferred
by people with
developmental
disabilities
A Person-Centered and
Sustainable System
Exemplar States that Use Assessment Informed
Resource Allocation for People with IDD
• Colorado - Supports
Intensity Scale (SIS)
• Connecticut – Level of
Need (CT-LON)
• Indiana - Inventory for
Client and Agency
Planning (ICAP)
• Louisiana – SIS
• New Mexico - SIS
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Oregon – SIS
Rhode Island – SIS
South Dakota – ICAP
Washington – SIS
Wyoming – ICAP
States in process:
• North Carolina - SIS
• Virginia -- SIS
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Steps in the Process
1.
2.
Establish guiding policy goals and a communication plan
Identify and implement an assessment tool to measure support needs
accurately and reliably.
3. Determine what services will be included in the model
4. If possible, review historical utilization for services that will be included
in the model
5. Establish a supports level framework and assign individuals to their
appropriate level
6. Identify “service packages” for each level (service and expected use)
7. Consider rates paid for services and calculate impacts
8. Validate the model with a review of individual records
9. Revise model as warranted then implement the model
10. Evaluate based on policy goals once full implementation has occurred
Policy Goals
• Establish guiding principles for the plan
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Integration
Self direction
Equity and efficiency
Sustainability
• Assess the current system:
– Service array
– Rate structure
– Policies
• Determine future goals for the system
– Stakeholder input
Assessment
Tool
• Identify an assessment tool
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Valid
Reliable
Time and intensity of supports
Align closely with ADLs/IADLs
Identify other data need to be collected
• Identify random stratified sample of service
population
• Create an assessment plan
Included
Services
• Examine current waiver services
• Determine if any need to be added to aid
inclusion in the community
• Establish which services will be a part of
the resource allocation model
• Examine historical utilization patterns in
relationship to support assessment data
and other factors
Tying Supports to Budgets
Framework
• Groups individuals with similar needs
• Reflects current support needs
• Based on supports needed for every day
activities as well as supports for behavioral
or medical conditions
• Includes exceptions process
Establishing Supports Available
Those above the authorization levels are reduced (and may be stepped down over time);
those below may or may not increase based on their decisions. The system must take
exceptional support needs into account.
Factors to Consider
• Assessment level framework
• Using the instrument to inform design of a
person centered plan.
• Exceptions process
• Per person costs in relation to the cost of
implementing a resource allocation system
• Child versus Adult differences
• Living setting and impacts on anticipated costs
• Specific state or jurisdiction factors
Rates
• Level of Support Framework can inform how
much providers are reimbursed for certain
individuals
• Reimbursement rates for services should be
fair and sufficient
• Consider whether to incentivize services that
increase community involvement and
independence (i.e., employment)
Service
Packages
• Identify factors that effect service packages
• Group services together when establishing
budgets
• Create budgets for each combination of factors
based on desired outcomes for support level
with that combination of factors
– For example, service packages are developed for
adults that include an expectation of use of Supported
Employment.
• Consider base budgets versus add-on budgets
Provider
Networks
• Identify gaps in service
• Create policy for attracting providers
• Establish service packages that allow
providers to support individual at the
person’s support level
• Use rates to strengthen provider network
in a way that aligns with system goals
Validate
Model
• Pull a sample of records
• Gather case files and other information
• Verify that the person meets the criteria of
the Level of Support
• Confirm that the Service Package is
adequate
• Make adjustments to model based on
issues identified during validation process
Implementation
• Communicate with Stakeholders
throughout the process
• Appeals process
• Planning process
– Protection against conflict of interest in case
management
– Person centered planning
– Services used
Evaluation
Once system implemented:
• Check reliability of assessors
• Look at new service utilization patterns
• Gather feedback from service recipients
• Establish whether change has occurred
related to original policy goals
• In time, modify the model to address
identified issues
Resource Allocation within Managed Care
and Other CMS Authorities
• Commonly used with 1915(c) waivers
• MLTSS for people with I/DD
– 1915(b)/(c)
– 1115
• Other State Plan options 1915(i)(j)(k)
– Functional assessment
– Flexible
– Self-directed
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Where to Find Help
• To request TA:
http://www.hcbs-ta.org/request.aspx
• For additional information:
http://www.hcbs-ta.org
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