DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
My Life, My Community!
Waiver Redesign Update
with HSRI Recommendations
Connie Cochran
Assistant Commissioner
&
Dawn Traver
Waiver Operations Manager
Virginia Department of Behavioral
Health and Developmental Services
Virginia is Shifting
the Array of Services
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
More Integration and Options for Independence
Nursing
Facilities, ICF,
Day Support
Group Homes
Prevocational
Current Array of Services
Sponsored
Residential
Family Home
Group
Supported
Employment
Individual’s
Own Home or
Apartment,
Individual
Supported
Employment
Future Array of Services
Page 2
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Four Main Areas of
Settlement Agreement
Serving individuals with DD
in the most integrated
setting and building quality
community-based
alternatives for individuals,
particularly individuals with
complex needs
Quality and risk management
system, including monitoring
and evaluating services, and
implementing quality
improvement processes at
an individual, provider, and
state-wide level
Transitions from training
centers
Supporting independent
housing and employment
options for individuals with
DD
Page 3
Individuals Served By Virginia’s
Developmental Disability System
February 5, 2014
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
On waitlist for ID
or DD waiver
41%
8,115
Training Center
4%
674
10,797
Served in
community on
ID/DD Waivers
55%
Page 4
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Waiver Transformation Activities
• On July 1, 2013, DBHDS & DMAS
awarded a contract to the Human Services
Research Institute (HSRI) to study
Virginia’s HCBS Medicaid Waivers for
persons with ID and DD.
• The study was named “My Life, My
Community!”
Page 5
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Goals of
My Life, My Community!
1. Evaluate the efficiency, effectiveness and flexibility of the
current waivers.
2. Recommend approaches for system changes including
waver enhancement, and the potential efficacy of one
comprehensive waiver and one supports waiver.
3. Conduct a study of current Medicaid rates.
4. Recommend new rate structure based on the study and
exploring an individual resource allocation system for
efficient distribution of waiver funds.
5. Aid in implementing the new system.
Page 6
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
My Life, My Community:
Two Phases
Phase I
• Evaluate the waivers
• Hold public stakeholder forums and report on
results
• Evaluate SIS administration and create process
for data use
• Develop a plan to reduce the number of waivers
• Review policy changes
• Report on findings
Page 7
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
My Life, My Community:
Two Phases (cont’d)
Phase II
• Conduct a cost study and propose a more appropriate
rate structure
• Explore a resource allocation framework
• Create a rate structure
• Evaluate SIS data
• Analyze the potential impact of the proposed waiver
system
• Align with the Quality Management System
• Develop a communication plan
Page 8
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Public Forums
• HSRI held 8 stakeholder meetings across
the state between 9/23 and 10/10/13
• All were welcome: self advocates, family
members, providers, CSBs, advocacy reps
• The resulting report is available at:
http://www.dbhds.virginia.gov/MLMC.htm
• The information gathered helped inform
the Phase I report
Page 9
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
My Life, My Community Public
Forums Conclusions
Primary Principle: One Unified, NeedsBased Waiver
• The waiver needs to address the
increasing demand for services in the
state
• The waiver should offer a flexible array of
services that allow for choice, control &
creativity to meet individual needs &
preferences
Page 10
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
My Life, My Community Public
Forums Conclusions (cont’d)
• Waiver rates need to be commensurate
with the costs of providing services
• The waiver needs a uniformly implement,
sound infrastructure for screening,
providing case management/service
coordination services that enable users to
access services free of conflict of interest
Page 11
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
December 20, 2013: HSRI Phase I
Recommendations
• Phase I report included a series of short and
long term recommendations
• Available at http://www.dbhds.virginia.gov/MLMC.htm
• DBHDS will evaluate each of these
recommendations, in conjunction with
stakeholder input, before making policy
decisions or final recommendations
• Final recommendations to Governor for General
Assembly consideration at 2015 session
Page 12
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Major HSRI Recommendation
VA should initiate the development of two new
1915(c) Waivers that include eligibility for people
with ID, DD and related conditions
– Comprehensive waiver with wide service
array, including residential
– Support waiver with similar supports array
but no 24-hour residential option
Page 13
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Waiting List Recommendations
Long Term Recommendation
• A single set of waiting list criteria should be created
Short Term Recommendations
• DD Waiver emergency slots should be available on a
continual basis
• DBHDS/CSBs should perform continual outreach to
ensure people know how to apply for services/WL
• Review WL data to determine which individuals are
receiving services through other sources/not receiving
any services
• Stakeholders should contribute to revised policies that
integrate WLs
Page 14
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
CSB Recommendations
Long Term Recommendations
• Clarify & strengthen the oversight role of the
state in contract with CSBs & practice related
to Medicaid funded activities
• CSBs as single point of entry for individuals
with DD added to statute
• Expand role of CSBs as case management
entities for those with DD & related conditions
• Develop long-term plan for transitioning
CSBs into case management providers vs.
Waiver services providers
Page 15
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Case Management
Recommendations
Long Term Recommendations
• Address conflicts of interest within the
current case management system
• Shift all case management to the public
CSB system
• Develop 2 new State Plan Amendments
o Case management for those on I/DD waivers
o Case management for those not receiving
waiver services
Page 16
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Case Management
Recommendations (cont’d)
Short Term Recommendations
• Enable ID & DD Waiver case managers to
bill for activities up to 6 months prior to
transition to the community
• Administration of the SIS should be done
by an independent entity
Page 17
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Service Array
Recommendations
Long Term Recommendations
• Enhance and encourage Positive
Behavioral Support services
• Remove restrictions on “general
supervision” in Congregate and In-home
Residential Support services
• Consider stakeholder forum feedback on
transportation services
Page 18
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Service Array
Recommendations (cont’d)
Long Term Recommendations
• Consider adding Caregiver Retention
payments or vacancy factor to rates
• Consider adding a “Community Guide”
service to promote community integration
• Add dental services to the waivers
Page 19
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Service Array
Recommendations (cont’d)
Short Term Recommendations
• Streamline the process for preventing and
addressing crises for those served in the
community
• Ensure access to Skilled Nursing services for
those with significant medical issues
• Continue to support self-directed service
options
Page 20
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Employment
Recommendations
Long Term Recommendations
• Revise employment service definitions to
align with CMS 2011 employment
informational bulletin
• Make discussions about individuals’ career
interests a priority before determining
day/employment services
Page 21
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Quality Improvement
Strategies Recommendations
Long Term Recommendation
• DMAS & DBHDS should create a unified
Quality Improvement System for the two
new waivers to safeguard individuals and
improve their quality of life
Short Term Recommendation
• VA should proceed with revisions to the ID
Waiver QIS for the 2014 renewal per draft
guidance issued by CMS in August 2013
Page 22
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Incident/Risk Management
Recommendations
Long Term Recommendations
• Develop a critical incident manual that
clarifies the roles and responsibilities of
everyone in the system
• Automatically notify SCs/CMs of critical
incidents reported in CHRIS
• Clarify DBHDS role & responsibility for
conducting certain types of investigations
Page 23
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Incident/Risk Management
Recommendations (cont’d)
Long Term Recommendations
• Expand Death Reporting and Mortality
Reviews to all I/DD waiver recipients whose
death is unanticipated or unexplained
Page 24
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Next Steps
Response to Phase I recommendations
• Stakeholder meetings to further discuss
DBHDS’/DMAS’ response to major issues
Phase II began in January
• Burns & Associates to met with a committee of
provider stakeholders for input into the
development of a survey for all providers
regarding ID/DD Waiver rates
– “Provider Advisory Committee”
Page 25
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Stakeholder Groups Being Formed
Waiver Development Advisory Committee
•Overarching committee to provide input to the process of
new waiver development
Subcommittees:
–
–
–
–
Provider Advisory Committee
Eligibility Requirements
Waiting Lists
Case Management
Page 26
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
SIS Related Next Steps
• ID support coordinators no longer administering
the SIS to individuals receiving ID and DS
Waiver services
• DBHDS contracted with an external vendor
(AAIDD) to complete the SIS on individuals
receiving ID, DD & DS waiver
• Approximately 1,450 SIS interviews to be
completed through June, 2014
• The information will be used to inform the rate
study.
Page 27
DBHDS
Virginia Department of
Timeline for Implementation of My
Behavioral Health and
Developmental Services
Life, My Community
• Renew Intellectual Disability (ID) Waiver (January
2014 – July 2014)
– only make small modifications to the current
program
• Design New Developmental Disability Waiver(s)
(January 2014 – January 2016)
– The WDAC and subcommittees will provide
consultation and guidance in development of
these solutions
Page 28
DBHDS
Virginia Department of
Behavioral Health and
Developmental Services
Questions?
Page 29