May 8, 2013
Developmental Disabilities Individual Support
and Care Coordination Organizations and
Accountable Care Organizations: A New
Service Delivery Model for the Intellectually
and Developmentally Disabled
YAI International Conference
May 6-9, 2013
Presented by
David A. Gregory, FACHE
Partner, Presscott Associates
A Division of ParenteBeard LLC
Presentation Overview
• ACOs
– Healthcare reform
– Commercial
• Developmental Disabilities Individual Support and Care
Coordination Organizations (DISCOs) – definition
• Synergy: ACO and DISCO service delivery models
• DISCO implementation/requirements
• DISCO – Core Elements of new service delivery models
• Guiding principles for service improvements
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A Division of ParenteBeard LLC
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Accountable Care Organizations (ACOs)/
Healthcare Reform
• Introduced through the federal Patient Protection and Affordable Care
Act (PPACA) of 2010
• Definition: Physicians, hospitals and other health care professionals
working together to coordinate care and share in savings or losses for
traditional Medicare beneficiaries assigned to the ACO
• Part of Medicare through the Medicare Shared Savings program in
2012
• Payment tied to achieving healthcare quality goals and outcomes that
result in cost savings
• Create incentives for healthcare providers to work together to treat
individuals across various healthcare settings
• Providers receive a share of the savings beyond a predetermined
threshold amount
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ACOs and Commercial Health Plans
• Commercial health plans have emulated healthcare reform
• Commercial health plans have implemented various value-based
contracting models
• Health plans goals
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Collaboration among providers in delivery system/integrated delivery systems
Coordination of patient care among the continuum of care
Accountability and shared risk among providers
Increased quality and improved patient outcomes
Cost savings
New payment models
Patient satisfaction
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A Division of ParenteBeard LLC
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Developmental Disabilities Individual
Support and Care Coordination
Organizations
(DISCOs)
• Created by the New York
Office for People With Developmental
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Disabilities (OPWDD) People First Waiver of the Social Security Act
Non-profit organizations that provide individualized supports/services,
care coordination to individuals with developmental disabilities and/or to
their families
Function as fiscal intermediaries (manage care/reimbursed on an
individual budgeting, global budgeting or capitation basis)
Serve individuals with all levels of need by providing supports/services
directly or indirectly through sub-contracts with provider agencies.
Initially, monthly capitation payments based on the disabled individual’s
assessed needs, with the state sharing some financial risk
DISCOs will evolve to full financial risk for meeting service needs within
the capitation revenue
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People First Waiver
• Develop/implement creative service delivery and payment
models that integrate acute and long-term care to achieve
improved health outcomes and quality of care while lowering
health care costs for the developmentally disabled population
• Target population: 100,000 New Yorkers enrolled in
Medicaid who have substantial developmental disabilities as
defined in New York State Mental Hygiene Law
– 80% of these assessed to need an institutional level of care through
either an ICF/MR or nursing home
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A Division of ParenteBeard LLC
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People First Waiver will Demonstrate
• Better care coordination for developmentally disabled individuals with
extremely complex medical/behavioral health needs can be achieved
through specialized systems of care management/coordination
• A transformed long-term care delivery system that places personcentered planning, individual responsibility and self-determination at the
forefront can enhance care and individual satisfaction and lower Medicaid
costs
• New reimbursement models for institutional and community-based care
systems can encourage efficiency, improve accountability and reduce
costs
• The continued provision of essential mental hygiene services through the
establishment of a safety net care pool will provide lower-cost services
that meet individuals’ needs and defer entry into higher costs Medicaid
services
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Synergy: ACOs and DISCOs
• ACOs: Timely model of healthcare delivery for disabled
people with complex care needs
• DISCOs
– New person-centered goals/comprehensive plan of care for
individuals with intellectual and developmental disabilities
– Care coordination/case management designed for individual’s unique
needs/circumstances
• Community/home-based alternatives replacing old systems
of institutionally-based care
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A Division of ParenteBeard LLC
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ACO Development: First Steps
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Form an organization/infrastructure
Define organizational Mission, Goals and Objectives
Establish leadership/governance
Identify population to be served
Define services and service area
Develop/contract with a provider network
Address legal/compliance issues
Identify financial resources
Develop an operating budget
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A Division of ParenteBeard LLC
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ACO Development: First Steps (cont.)
• Develop a marketing plan
• Establish clinical integration/care coordination/
management
• Develop information systems for data collection/
management/sharing
• Address patient engagement
• Draft implementation agenda and timing
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DISCO Goals 1
• Provide individualized planning for all enrollees that focuses on individual
outcomes
• Promote OPWDD’s four valued outcomes for individuals:
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Live and receive services in the most integrated settings
Meaningful and productive community participation, including paid employment;
Develop meaningful relationships with friends, family, and others in their lives
Experience personal health, safety and growth
• Ensure that each individual who chooses to do so can self-direct his or
her services including the option for budget and employer authority
• Maintain a well trained workforce that minimally meets all OPWDD
requirements and is culturally competent to meet the needs of the
individuals seeking or receiving supports and services in the communities
in which they live.
1
OPWDD Application
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DISCO Organization and Management/
Governing Board
• Governing Board to establish/oversee DISCO
policies
• Participate in OPWDD-required abuse and training
• Meet 4 times per year
• Within 1 year of becoming operational, have 20%+
individual/advocate board membership, or advisory
council with board input
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A Division of ParenteBeard LLC
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DISCO Organization and Management/
Service Delivery Network
• Contracted provider network
• Providers with specialized expertise for individuals
with developmental disabilities/special populations
• Choices of at least 2 providers for each provider
type
• Responsive to community cultural considerations,
including language
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A Division of ParenteBeard LLC
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DISCO Organization and Management/
Contract Management
• Established service contracts with network providers
• Policies and Procedures for contract monitoring
• Contracts must include:
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Service standards
Staff/agency qualifications
Provider compliance monitoring and remedies
Reportable events (“Unusual Incidents”) and processes
Billing processes and rates for service units
Appeals/grievance processes for resolution of payment issues
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A Division of ParenteBeard LLC
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DISCO Organization and Management/Enrollment
Monitoring and Disenrollment Reporting
• Qualified individual, all ages, will be eligible to enroll in
DISCO pilot with authorization of OPWDD Regional Office
• Qualifications
– Qualifying developmental disability
– Meets ICF/DD level of care
– Medicaid enrolled (included dually eligible)
• Not included during pilot phase
– OPWDD state operated residential and day services
– SNF, OASAS/OMH or private psychiatric hospital residents
• Enrollment, disenrollment, service utilization, encounter data,
enrollee satisfaction, marketing, grievance/appeals, fiscal
data
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A Division of ParenteBeard LLC
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DISCO Organization and Management/
Assessment of Prospective Members
• OPWDD developing an assessment tool (CAS)
• State will complete initial assessments
• DISCOs will use assessment tool to support care
plan development and monitoring
• Current instrument (DDP2) must also be completed
for enrollees
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A Division of ParenteBeard LLC
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DISCO Organization and Management/
Care Management
• Establishment/implementation of written care plan
• Assistance to enrollees to access services reflecting
person’s communicated choices/needs
• Application process assesses DISCO’s readiness to provide
care management, health/safety monitoring, OON referrals
(as needed)
• Primary care manager and care management team
• Quality assessed by qualifications of care coordinators,
quality outcome measures
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A Division of ParenteBeard LLC
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DISCO Organization and Management/
Financial Requirements
• Initial capital to comply with DOH Regulation Part
98-1.11 escrow and contingent reserve
requirements
• Must identify sources of initial capital
• Reserve and escrow requirements (exception for
“start-up” period)
• Minimum net worth equal to greater of escrow
requirement or contingent reserve
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A Division of ParenteBeard LLC
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DISCO Organization and Management/
Accounts Receivable-Payable
• Receivable: Management of capitation
revenues (based on member months)
• Payable: Payment of claims received from
the subcontract network providers
• OPWDD examining methodologies for
establishing standardized fees for cap rate
and provider payments
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A Division of ParenteBeard LLC
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DISCO Organization and Management/
Budget-Finance-Accounting
• Monitoring and reporting of all financial aspects of
the DISCO operation
• Budgets
– Number of enrollees
– Service delivery costs
– Administrative operating costs
• Required reports
– Annual Financial Statements: Medicaid Managed Care
Operating Report
– Quarterly Financial Statements
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A Division of ParenteBeard LLC
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DISCO Organization and Management/
Utilization Management and Review Systems
• Assure maximum system use of available
community-based and integrated services
• Direction/link to care coordinators,
enrollee/advocates, caregivers regarding services
promoting objectives of People First Waiver
• Aggregate reporting of uses and costs of services
and trends
• Recommendations based on utilization data/reports
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A Division of ParenteBeard LLC
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DISCO Organization and Management/
Quality Assurance System
• QA/PI program and approved written quality plan addressing
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Ongoing assessment
Implementation
Evaluation of overall quality of care and services
Specific measurable activities
Meet requirements of Article 44 of PHL and regulations of 42 CFR
438.240 (QA/PI)
– Approved by Commissioner of OPWDD
– Board-level accountability
– Objective, measurable and relevant quality indicators
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A Division of ParenteBeard LLC
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DISCO Organization and Management/
Management Information System
• Compliant with Statewide Policy Guidance –
common information policies, standards and
technical approaches governing health
information exchange
• Maintenance of health information system that
collects, analyzes, integrates and reports data
• Data available to State and upon request to CMS
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A Division of ParenteBeard LLC
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DISCO Organization and Management/
ADA Compliance Plan
• Compliance with Americans with Disabilities Act
• Compliance plan to be submitted with
Application
• State guidelines addressed
• SDOH guidelines found in the Model Contract
• Must be approved by OPWDD
• ADA checklist must be completed
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A Division of ParenteBeard LLC
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DISCO Service Area
• Geographic area for certificate of authority to
operate a DISCO
• Sufficient provider network
– Services availability to enrolled population
– Services accessibility to enrolled population
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A Division of ParenteBeard LLC
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DISCO Marketing Strategy
• Marketing plan must be submitted
– Goals
– Strategy
– Address information needs of eligible persons
• Limitations on marketing activities defined
• Monitoring to ensure compliance with state/
federal requirements
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A Division of ParenteBeard LLC
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DISCO Self-Direction Services
• Self-directed services must be available
• DISCO must provide description of how it will
offer self-direction
• Education and supports for self-direction
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DISCO Person-Centered Planning
• Individualized Service Plan (ISP) developed by the
care coordinator, person and person’s circle of
support
• DISCO must describe process and principles for
ISP
• Training for care management staff, individuals and
families
• Measurement of outcomes
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A Division of ParenteBeard LLC
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Productive Community Participation and
Competitive Employment
• Support individual with I/DD to fully participate in
their communities, including employment
• DICSO must describe process/methods for
increasing volunteerism and employment for
enrollees
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Core Elements of New Service Delivery
Models
• Integrated primary/acute care, behavioral health,
long-term services
• Stakeholder input in design/management of care
models
• Addressing individuals’ support/caregivers’ networks
• Maintenance of provider relationships
• Integrated funding (Medicare, Medicaid, State)
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A Division of ParenteBeard LLC
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Core Elements of New Service Delivery
Models (cont.)
• Risk assessment for individual-centered goals for
resource allocation
• Performance measurement
• Information technology for data collection and
measurement
• Reimbursement design (EOC, risk, P4P)
• Life-long planning for persons with I/DD
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A Division of ParenteBeard LLC
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Guiding Principles for I/DD Service
Improvements
• Consistent with Developmental Disabilities and Civil Rights
Act and ADA of 1990
• Access to services and supports
• Ability to have choices/make decisions
• Achieve outcomes (e.g., independence, meaningful work,
dignity, well-being)
• Service delivery that integrates/coordinates programs and
funding
• Systems demonstrate value to consumers and purchasers
(need data and measurements)
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A Division of ParenteBeard LLC
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Essential Elements for Success
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Strong leadership
Provider input
Clear Mission Statement (addresses integration)
Realistic Goals
Objectives that are tangible, measurable, can be
validated
• Provider commitment/engagement
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A Division of ParenteBeard LLC
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Essential Elements for Success (cont.)
• Care management
– Evidence-based clinical guidelines
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Clear, concise processes
Provider accountability
Preventive care and wellness orientation
Performance goals/measurements
• IT: EHR, data sharing for informed decision-making
• Communication, feedback (internal, external)
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A Division of ParenteBeard LLC
34
Essential Elements for Success (cont.)
• Organizational culture
• Strategy: Formal Business Plan, Implementation
Agenda and timeframes
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Summary
• Essential elements in provider integration are part of
a Business Plan
• Integration is relationship-building
• Relationship building required concerted effort
• Successful relationships beyond affiliation are
crafted by having a Plan of Action
Result: Achievable accountability and competitive
positioning for the DISCO
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A Division of ParenteBeard LLC
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Contact Information
David A. Gregory, Partner
Presscott Associates – A Division of ParenteBeard LLC
dgregory@presscott.com
office 201.612.0561
The Empire State Building
350 Fifth Avenue, 68th Floor
New York, NY 10118
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A Division of ParenteBeard LLC
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