Community First Services and Supports (CFSS) June 14, 2013 Pam Erkel, Diane Benjamin, Jeanine Wilson

Current Environment For Reform Minnesota is building on a history of improvements to the system to address core values. Changing demographics and economic pressures put future of current system at risk of unsustainability. Opportunities have arisen at the federal level to support innovation and reform at the state level.

Values and Vision With Long Term Services and Supports (LTSS), people can live meaningful lives at all stages of life, according to their goals and priorities; people can contribute in a way that is meaningful to them. Minnesota’s long-term supports and services system is flexible, responsive and accessible to people who have an assessed need for LTSS. The LTSS system is well-managed to ensure future sustainability for those who will need it.

Goals of HCBS Redesign 1) Better Individual Outcomes Increased flexibility to better meet the needs of each individual; Increased stability in the community; Better-informed individual decision-making about LTSS options; Promotion of person-centered planning: life-long and crisis; Improved transitions between settings and programs, preventing avoidable health crises; Recognize and address the social determinants of health care need and cost.

Goals of HCBS Redesign 2) Right Service at the Right Time Low-cost, high-impact services reach people earlier. Decreased reliance on more costly services. HCBS, not institutional care, is the entitlement. 3) Ensuring the Future of LTSS Increased sustainability of the LTSS system; Increased efficiency in the use of public LTSS resources.

Reform Strategies Improve navigation and streamline access to services and supports; Redesign and improve services; Increase service coordination and service integration; Increase efficiency and sustainability of administrative systems.

Community First Services and Supports A redesign of the Personal Care Assistance Services benefit in order to: better meet the needs of each individual; increase and support each individual’s independence and recovery; support the stability of the individual; promote the ability of the individual to direct and his/her own services.

Community First Services and Supports A redesign of the Personal Care Assistance Services benefit in order to: reduce service barriers, gaps and duplication; serve people earlier with less intensive services, in some cases delaying or avoiding need for more intensive services; be more flexible and responsive and better able to adjust quickly to changing circumstances without high-intensity services; simplify administration of services; and create a more sustainable system.

Community First Services and Supports (CFSS) – replaces PCA Flexible service can include: Assistance Teaching Coaching Prompting Home modifications to replace human assistance Technology to replace human assistance Transition services Provider standards to promote access to agencies and staff with appropriate skills.

Community First Services and Supports Outcomes for CFSS Individuals will: Recover and/or gain skills to increase and maintain community stability Access the right service by the right provider at the right time Use technology or modifications to decrease need for human assistance when appropriate Delay or avoid the need to access other programs or more costly services Avoid use of inappropriate services Increasingly direct their own services

Summary of 1915(k) Regulations Scope: Make home and community-based attendant services and supports available to eligible individuals, as needed, to assist in accomplishing ADLs, IADLs, and health-related tasks through hands-on assistance, supervision, or cueing. Services and supports must be provided statewide and in the most integrated manner possible.

1915(k) Regulations Implementation Council: A Development and Implementation Council must be established with a majority of individuals with disabilities, elderly individuals and their representatives. States must consult and collaborate with the Council when developing and implementing a State plan amendment to provide 1915 (k) services and supports.

1915(K) Regulations Included Services: Assistance with ADLs, IADLs and health-related tasks; Acquisition of skills necessary for the individual to accomplish ADLs, IADLs, and health-related tasks Back-up systems to ensure continuity of services and supports Voluntary training on selecting, managing and dismissing attendants Optionally, expenditures for transition costs and expenditures related to increasing independence or substituting for human assistance, if assistance would otherwise be needed.

1915 (K) Regulations Assessment: Assessments must be conducted annually, and generally face-to-face, although telemedicine may be allowed, and must support the development of a person-centered service plan and, if applicable, service budget. Person-centered Service Plan: The planning process must be driven by the individual and include people selected by the individual. It must provide the information and support needed to ensure the individual directs the process to the greatest extent possible.

1915 (K) Regulations Service Models: States may choose one or more service-delivery models, including: Agency-provider models, which operate under contract or provider agreement with the State, Self-directed models with service budget, which may operate with several financial management options, including a financial management entity, a cash system, or a voucher system. Other models as developed by the State and approved by CMS.

1915 (K) Regulations Support System: must provide adequate information, counseling, training and assistance, as needed, to ensure that the individual is able to choose and manage their services, models and budgets. This support must include information on: person-centered planning the range and scope of individual choices the process for changing plans, services and budgets the grievance process individual rights identifying and assessing appropriate services risks and responsibilities and risk management.

1915 (K) Regulations Service Budget Requirements: The service budget for the self-directed model with a service budget must include the specific dollar amount the individual can use for services and supports as well as the procedures for: informing the individual about the budget before the person-centered service plan is finalized adjusting the budget determining circumstances that may lead to a change in the budget determining transition costs requesting a fair hearing if the individual’s request for a budget adjustment is denied or the budget is reduced.

1915 (K) Regulations Provider Qualifications: For all service delivery models, the individual retains the right to train their attendant care providers to meet their specific needs and in the manner that meets their personal, cultural and/or religious preferences establish additional staff qualifications based on their needs and preferences access other training provided by the State. For the agency-provider model, the State must define adequate qualifications for providers. For the self-directed model with service budget, an individual has the option to hire family members or others, provided they meet the qualifications established by the individual.

1915 (K) Regulations Quality Assurance System: The State must establish a comprehensive, continuous quality assurance system, which includes: A quality improvement strategy Methods to continuously monitor the health and wellness of each individual receiving services and supports Outcomes measures Standards for all service delivery models Methods for maximizing individual independence and control, and Methods for eliciting and incorporating feedback from individuals and their representatives, disability organizations, providers, families, community members and others to improve the quality of the services and supports benefit.

1915 (K) Regulations Data Collection: The State must collect and provide information annually on the number of individuals served and the types of services and supports provided. Increased Federal Participation: Federal Medical Assistance Percentages applicable to the State will be increased by 6% under an approved State plan amendment.

1915 (K) Regulations State Assurances: The State must must meet or exceed previous levels of State expenditures for home and community-based attendant services and supports provided to individuals with disabilities or elderly for the first year take necessary safeguards to protect the health and welfare of enrollees

Self-Direction & Risk Management The risk assessment and mitigation plan (or risk plan) is a written document for the participant that initially identifies risks for him/her living in the community with supports Outlines how these risks will be addressed/mitigated Is periodically reviewed and modified so that it is responsive to changing risks over time. The risk plan should be a component of the participant’s person-centered service plan

Risk Assessment & Mitigation Plan Customized and person-centered Identifies and documents all risks a participant might encounter when living in the community with supports Includes the participant and his/her designated representative, as appropriate, in the process Honors the participant’s preferences and appreciates his/her values

Risk Assessment & Mitigation Plan Allows participants the right to assume risk Conducted in the spirit of facilitating the participant to live successfully in the community, not as a way to prevent/discourage community living Provides an opportunity for the participant and his/her designated representative, as applicable, to review and provide feedback