Person Centered Care in Managed
Care – Myth or Reality?
• YAI Conference
• Monday May 6th, 2013
• Presentation by
• Jerry Huber
• Deputy Commissioner OPWDD
The Amazing Race
Care Coordination
Case Studies
RFA
Front Door
DISCO
ICS
Coordinated Assessment System (CAS)
RFI
People
First
Waiver
InterRAI Pilots
CQL
Managed Care
Personal Outcome Measures
Equity
Balance
Person Centered
T H E M E S
Needs Based
Outcomes Driven
Incentivized
OFF TO THE RACES
 Improving how we meet needs - expanding self
direction and employment to provide
opportunities for everyone, launching CAS
 Improving quality of our care through workforce
support and measuring individual outcomes
 Participating in NYS Olmstead Plan – creating
more housing opportunities & moving people out
of institutions
 Launching managed care through pilot DISCOs –
moving toward integrated, holistic care
 Continuing health and safety reforms –
AGENDA FOR TODAY
• 1. Discuss 4 Essential aspects of PersonCentered Practice as a Foundation for
Managed Care
• 2. Discuss similarities and differences within
managed care for people with ID/DD as
compared with mainstream managed care
• 3. Outline milestones and time tables for the
transition in managed care here in NY
• Person Centered
• Assessment
Based
• Measurable
Outcomes
• Standardized
• Comprehensive
• Outcomes Based
Assessment
Planning
Evaluation
Access
• Access to
Services “Front
Door”
• Consistency
Assessment
Evaluation
Planning
Access
8
Goals of Needs Assessment
Standardized needs
assessment that identifies
individual needs and
strengths to inform
Person-centered care
planning
Ability to draw on
individual or aggregate
level data for
quality monitoring
purposes.
An assessment tool that
can inform acuity
levels for resource
allocation.
9
New York State-specific
InterRAI DD
interRAI
Intellectual
Disability (ID)
Items from
Child and
Youth ID
and Mental
Health tools
Items from
Community
Mental
Health
(CMH) tool
Items from
the
Correctional
Facilities
tool
New York
State OPWDD
Coordinated
Assessment
System (CAS)
10
Coordinated Assessment System
Child and
Adolescent
Supplement
Substance
Use
Supplement
CAS Core
Medical
Management
Supplement
Mental
Health
Supplement
Forensic
Supplement
11
CAS and the Case Study
• 18 Assessment Specialists hired to complete CAS for
the case study
• Assessment Specialists received extensive training
specific to the CAS
• CAS summary and CAPs will be used by agencies to
inform care planning
• Ongoing review of the CAS, protocols and manual
will continue throughout the case study
• Reliability and validity testing will be conducted
12
Long-Term Vision
• New Coordinated Assessment System will be phased in
thoughtfully over the next several years:
• Beginning with year long case studies,
• Moving next to DISCO pilot projects,
• Next into use with all newcomers to the service system,
• Eventually, over time, will be used with those currently
receiving services.
• We will be careful not to disrupt lives, but instead identify
opportunities for greater integration and independence
based on needs, strengths and desires.
13
For More Information…
InterRAI Integrated Assessment Suite:
www.interRAI.org
CAS specific questions:
coordinated.assessment@opwdd.ny.gov
14
Assessment
Evaluation
Planning
Access
15
Essential Elements of Person Centered
Care
1.
2.
3.
4.
5.
6.
7.
Person-Directed
Person-Centered
Outcome-Based
Information, Support and Accommodations
Wellness and Dignity of Risk
Participation of those that individual selects
Community Integrated
16
FUTURE
• The DISCO will be responsible for ensuring that they
have organizational characteristics that support
person centered planning
• Person centered planning is expected to be part of
and integrated into the entire culture of an agency
and managed care entity
17
Assessment
Evaluation
Planning
Access
18
What Is the Front Door Initiative?
• The Front Door Initiative is:
 A person centered approach to developing plans of
support for people - not a program or a service
 Part of the fundamental process by which people
access supports and services through OPWDD providing a broader array of individualized service
options to give individuals and families more
flexibility and choice of supports and services that
meet their needs
19
Why Now? – 3 Factors
1. The sustainability factor - how do we sustain
appropriate service provision within fiscal realities?
2. The relevancy factor - are the services we currently
offer those that families and individuals coming
into our service system are seeking?
3. The compliance factor - in light of Olmstead and
recent federal decisions on ADA, will the menu of
service options we provide allow us to meet the
goals of Olmstead and federal requirements?
20
OPWDD’s Front Door
Initial
Contact
Eligibility
Determination
Assessment
of Skills
Support
Needs
Identified
Informed
Decision
Making and
Individualized
Plan
Development
Service
Authorization
and
Implementation
21
Front Door Goals
Facilitate OPWDD’s approach to the delivery of
services based on:
 A focus on the values of self determination and
self-direction
 Resources to individuals based on needs, rather
than the programs currently available
 More informed choice of supports and services
 Holistic use of paid and community supports
 Statewide consistency and availability of
individualized and self-directed service options
22
3 Approaches to Achieve Goals
Simplify
Access to
SelfDirection
Streamline
Internal
Processes
OPWDD &
Provider
Partnership
Through
Change
23
OPWDD & PROVIDER
PARTNERSHIP THROUGH
CHANGE
24
Areas for Increased Partnership
Reinvestment Planning and
Implementation
Communication in Service
Planning
25
Reinvestment
Reinvestment is one or more
methods for individuals to
maintain service dollars but
change service type to be able to
purchase services in a more
integrated setting.
26
Steps to Achieve Reinvestment
Models
• Review and modify existing processes, procedures and
templates or develop new ones that enable providers to
reinvest dollars associated with existing services that support
more choice and better outcomes for people while also serving
more people
• Develop consistent policies, procedures and reports that
OPWDD Regional Offices can utilize to better manage base
resources
• Create policies that can be put in place that shift management
of current resources away from vacancy management and
toward capacity management and more integrated settings
27
Communication in Service Planning
OPWDD and partners must communicate about
individual level of need and how that need
impacts service planning. Services in traditional
supervised IRA and day habilitation settings will
not be authorized by OPWDD simply because a
program opportunity is available. An individual
must have a level of need significant to require the
level of support offered in these services and must
choose these options as opposed to an option in a
more integrated setting
28
Assessment
Evaluation
Planning
Access
29
HCBS Quality Framework
30
CMS Increasing
Expectations
Using Data to drive systems improvements
Evidence Based Performance Measures for
Federal Waiver Assurances
Regulatory Compliance
How do we make this Shift?
“The measure of Quality is
not the delivery of a
support or service, but the
results that services or
supports provide for each
person”
Source: Designing
Quality—Responsiveness to
the Individual. CQL 1999
• Evolving system
• Historically –
Compliance/QA focus
• Shifting from sitebased “bricks &
mortar” inspections to
reviews focused on
individuals and
achievement of
outcomes
32
What are CQL Personal Outcome
Measures?
• Valid and reliable personal outcome measures
that focus on what is meaningful to the person
served.
• Provides a methodology to assess how well the
organization’s provision of supports and services
facilitate outcomes that are meaningful to each
individual.
• Different than National Core Indicators (NCI)
which are system outcome measures.
33
CQL The Council on Quality and
Leadership
My
Self
My
World
My
Focus
My
Dreams
My Focus: What is most important to me
now.
34
CQL The Council on Quality and Leadership
My Self
1.
2.
3.
4.
5.
6.
7.
8.
9.
People are connected to natural supports.
People have intimate relationships.
People are safe.
People have the best possible health.
People exercise rights.
People are treated fairly.
People are free from abuse and neglect.
People experience continuity and security.
People decide when to share personal information.
35
CQL The Council on Quality and Leadership
My World
1. People choose where and with whom they live.
2. People choose where they work.
3. People use their environments.
4. People live in integrated environments.
5. People interact with other members of the
community.
6. People perform different social roles.
7. People choose services.
36
CQL The Council on Quality and Leadership
My Dreams
1. People choose personal goals.
2. People realize goals.
3. People participate in the life of
the community.
4. People have friends.
5. People are respected.
37
Proposal for Operationalizing POMs in
DISCO Pilots – Components
Care Coordination
Framework
Practice Guidelines
QI Plan—Use of
CQL Data in
Quality
Improvement
Communication
and Learning
throughout the
OPWDD
system
38
CARE COORDINATION
• WHAT TIES IT ALL TOGETHER:
–ASSESSMENT BASED ON NEEDS
–PERSON CENTERED IN THEORY AND IN
PRACTICE
–ACCESS – RIGHT SERVICES AND THE
RIGHT TIME
–EVALUATION – FOCUS ON REAL
OUTCOMES FOR THOSE SERVED
CARE MANAGEMENT AND MANAGED
CARE
• Concepts of care management are rooted in
the development of managed care principles
• Care Management has a focus on the best
outcomes for individuals served
• Managed Care’s history has had a focus on
cost containment
• Each rely on concepts of health promotion
and disease prevention
CMS’s “Triple Aim”
Better Health for
the Population
Better Care
for Individuals
Lower Cost
Through
Improvement
41
Where does Person Centered Planning
Fit In?
• Since much of the Medicaid cost for those
with long term care needs is outside of
traditional health care, the emphasis needs to
be on planning for all aspects of the individual
needs for each person enrolled in a managed
care plan
Variations in Managed Care Strategies
for those with LTC Needs
• 1. Population already has complex medical
and social needs
• 2. Due to these needs utilization of resources
including specialty care is often quite
extensive
• 3. Cost for services most often tied into daily
living needs, including housing and day
activities in addition to medical needs
Integrated Care is a Must
• To really provide comprehensive Person
Centered planning and care to the DD
population, there is a need to integrate good
care coordination that includes all aspects of
medical, behavioral and social needs of the
individual
Where Does Self Directed Care Fit In?
• Different models of Self-Direction under
Managed Care:
– Carved Out Models (ex. WI)
– Carved In Models (ex. Michigan)
– With either model, MC organizations in NY will
need to provide Self-Directed Options for those
enrolled
Person Centered Care in Managed
Care – Myth or Reality?
• It will be what we make it
• Concepts of good care coordination, Person
Centered Planning and quality Managed Care
are not mutually exclusive concepts
• Managing one’s complete care is the
requirement of the individual, his or her circle
of support and the provider network
• It Takes a Village but we need to create that
Village
Enhancing Individualized Services in
New York – A RECAP
• The Need for Reforms of Financial
and Service Platforms prior to
going into Managed Care:
–1. The Sustainability Factor
–2. The Relevancy Factor
–3. The Compliance Factor
OPWDD Transformation
As OPWDD pursued development of the People First
Waiver, we worked with CMS to define priority
elements of system transformation:
 Expanding opportunities and supports for
EMPLOYMENT
 Expanding COMMUNITY SERVICE OPTIONS –
supportive housing, community-based services
 Expanding SELF DIRECTION options
 OLMSTEAD PLAN- Creating opportunities for people
to move from institutions to integrated settings