1. Updates for Self-Direction

2. Agenda: Self Direction Growth and Updates
Understanding the People Who Choose Self-Direction
Applied Self-Direction Technical Assistance Recommendations

3. Self Direction Growth and Updates

4. 7/6/2018

5. 7/6/2018 * *

6. Self Direction Updates
FI fee change
New Fiscal Intermediary (FI) agency in downstate region
Webinars from ASD technical assistance completed in early summer
Updated Guidance for Providers

7. Self-Direction Guidance for Providers
Updated version issued June 8, 2017

8. Self-Direction Guidance for Providers: Key Updates
Added language regarding Annual Effective Dates
Added language regarding retroactive amendments
Added a section regarding Self-Direction Budgets for children
Explanation that Annual Effective dates are fixed and represent PRA period, which will be reviewed against Utilization. Only change to Annual Effective date results from change to Budget Type.
Only CNBAs can be done retroactively, back to first of prior month
Children, like everyone else, must be Waiver enrolled first. Need to demonstrate ongoing service need (not support service). Very young children have Early Intervention services available. OPWDD services cannot replace or replicated SED services.

9. Self-Direction Guidance for Providers: Key Updates
Removal of graduated broker rates
Two of Three Rule
Clarification regarding unpaid brokers
Attachment B removed and language added to Chapter 4 to eliminate graduated Broker rates and establish rate as an hourly fee negotiated between the participant and the Broker, which should be commensurate with the level of training and experience of the Broker. The maximum fee that can be considered for delivering Support Broker services remains $40 per hour.
“To promote independent choice and limit potential for conflicts of interest, a participant’s Support Broker should not be directly employed by the same provider agency that provides their FI service and employs their service coordinator. This is referred to as the “2 of 3 rule” and can be waived by the DDRO if it is established that the arrangement is in the best interest of the participant.“
- Unpaid Brokers need to have initial training requirements and a Broker agreement to qualify for Budget Approval but billing requirements per ADM do not apply

10. Self-Direction Guidance for Providers: Key Updates
Added language about private lessons
Added language regarding camps that are waiver respite
Added section on Staffing Support to clarify allowable activates in context of Support Broker and FI and to clarify who is excluded as employed by non-profit
“Private classes and lessons are allowable as long as they relate to an integration goal and the lessons are not taking place privately for the purpose of segregating the participant.”
“IDGS Camp Reimbursement is available for Camps that are not funded as Medicaid Waiver Respite Camps. Self-Direction participants can choose to attend Waiver Respite funded Camps. However, those camps must be included in their Self-Direction Budget as Direct Provider Purchased Respite.”
The staffing support role can only include tasks in the spectrum of, “Assistance with scheduling self-hired staff and with assisting the person to complete staffing related paperwork.” The person who provides Self-Directed Staffing Support through IDGS may be someone who provides self-hired CH, Respite or SEMP services to that participant or other participants, however, they cannot be otherwise employed by a not for profit agency.

11. Self-Direction Guidance for Providers: Key Updates
Added section on Health Club/Organizational Memberships to clarify distinction between this service and a person’s activity fees/expenses
Added “4 tests” language for OTPS
Organizational Memberships
(Reimbursable as Memberships)
Ski club membership dues
Museum or zoo membership
Softball league fees
Pony Club membership
Girl Scout/Boy Scout dues
Membership dues for a Bowling League
Community group membership fees (e.g., 4-H, Kiwanis, Elks)
Activity Fees
(Not Reimbursable as Memberships)
Ski resort lift tickets and equipment rental
Tickets or season passes to a water park
Tickets to a baseball game
Horseback riding helmet
Scout uniform and trip expenses
Bowling shoe rental fee
Group shopping discounts (Wholesale “club” memberships, Community Supported Agriculture)
Online dating websites
1.Be related to a valued outcome in the person’s plan
2.Increase the person’s independence and/or health and safety
3. Not be an OTPS excluded item (see page 29 of the SD Guidance)
4. Not be funded through any other source

12. Self-Direction Guidance for Providers: Key Updates
Short Chapter added to address inclusion of Family Support Services in SD Budgets
Added language to clarify use of CTS and ISS Transition Stipend in scenarios where a person qualifies for both
Added section to address services outside of the U.S.
FSS needs to be included in the Budget as a DPP, under contracted. Requires prior approval
“If an individual qualifies for both Community Transition Services (CTS), and an ISS Transition Stipend, it is the expectation that the CTS funding be maximized before requesting funding through an ISS transition stipend.  If an individual receives the maximum payment through CTS, they can only request the difference between the maximum ISS transition stipend and the amount reimbursed through CTS.  - Per WebEx in Fall of 2016
Services outside of the United States are allowed only in the following four locations:
the Commonwealth of Puerto Rico
The Virgin Islands
Guam
Canada
The participant and Plan/Budget must meet all the requirements outlined in “Out-of-State Criteria” listed above.
Prior to approval of the plan containing funding to pay for services provided in allowable areas outside of the U.S., (1) a definite return date for the participant, and (2) a statement confirming that the individual is intending to remain a NYS resident upon return must be provided.

13. Self-Direction Guidance for Providers: Key Updates
Budget Review Process and Support Broker Training Policy added as Attachments

14. Understanding the People Who Choose Self-Direction

15. What Services Are People Self-Directing?
7/6/2018
What Services Are People Self-Directing?
This represents % of $ for services contained in the budgets** for people who self-direct with budget authority.
Out of $372 million, $201 million, or 54% of total budgeted $ were allocated towards self-hired CH.
In contrast. $53 million, or 14% was allocated towards all categories of IDGS (full details are below)
** The data comes from 6014 self-direction budgets, representing budgets submitted between 10/28/2015 and 5/19/2017, as budgets still on the 2014 template are not compatible with the dataset.
Self-Hired Community Habilitation $201,562, %
Self-Hired Respite $20,340, %
Self-Hired SEMP $ 6,428, %
Support Broker $10,247, %
IDGS $53,649, %
Housing Subsidy $10,674, %
Live-In Caregiver $1,050, %
Agency Supported Services $11,779, %
DPP and Contract Services $31,361, %
FRR $11,309, %
Other Than Personal Services $13,665, %

16. People Self-Directing Compared to Others in Traditional Services
7/6/2018
People Self-Directing Compared to Others in Traditional Services
Compared those who self direct (SD) their services to those who do not self direct their services
Approximately 5,000 people in SD group and 91,000 people in non-SD group
Analyzed:
DDP2 Health, Behavior, and Adaptive Scores
Level of Functioning
Age Groups

17. Health, Behavior, and Adaptive Score Comparisons
7/6/2018
Health, Behavior, and Adaptive Score Comparisons
Overall, adaptive and health scores were similar between the SD and non-SD groups.
Behavior scores were higher in the SD than in the non-SD group.
Average score of 51.5 versus 39.0, respectively.
Higher adaptive, health, and behavior score indicate more need

18. Adaptive, Behavior and Health Scores SD vs. Non-SD groups
7/6/2018
Adaptive, Behavior and Health Scores SD vs. Non-SD groups
SD Group
Average
Non-SD Group
Adaptive Score
186.8
189.6
Behavior Score
51.5
39.0
Health Score
5.3
5.4

19. 7/6/2018
Level of Functioning
The SD and non-SD groups had similar proportions of people with mild and moderate impairment functional levels.
Over twice the proportion of individuals in the SD group have normal or above functional levels compared with the non-SD group.
Higher proportions of individuals in the non-SD group have severe or profound impairment functional levels compared with the SD group.

20. 7/6/2018

21. 7/6/2018
SD vs. Non-SD – Age
Overall, the SD group is younger than the non-SD group.
The average age of the SD group is 25 years old compared to 37 years old for the non-SD group.

22. 7/6/2018

23. Comparison of SD and non-SD by Age group
7/6/2018
Comparison of SD and non-SD by Age group
Sought to establish if differences in adaptive, behavior, and health scores, as well as level of functioning exist by age group.
Compared those aged 0 to 21 and those aged 22+.

24. Adaptive, Behavior and Health Scores SD vs. Non-SD by Age Group
7/6/2018
Adaptive, Behavior and Health Scores SD vs. Non-SD by Age Group
Age 0-21
Age 22+
Self-Directing Average
Not Self-Directing Average
Adaptive Score
233.3
238.8
153.8
174.6
Behavior Score
70.7
49.4
38.2
35.8
Health
Score
5.0
3.8
5.5
5.8

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26. 7/6/2018

27. What might this data be telling us?
People who self-direct their services look comparable to those served in our larger system.
Self-direction may offer better options for people who present behavioral challenges.
Families and people who are transitioning into adult services are taking advantage of the option to self-direct their services at a higher rate.

28. Applied Self-Direction Technical Assistance Recommendations

29. Recommendations from Applied Self-Direction
In Fall of 2016, OPWDD requested technical assistance for its Self-Direction service from the Centers for Medicaid and Medicare Services (CMS).
CMS asked an experienced firm, Applied Self-Direction (ASD), to assess OPWDD’s Self-Direction program and provide recommendations for improvement.
ASD reviewed extensive material, conducted multiple interviews and reflected on feedback from focus groups involving Self-Direction participants, parents, Support Brokers, Fiscal Intermediaries (FIs) and OPWDD Regional staff.
ASD shared their findings and recommendations in Webinars that are available for viewing. The following information is a summary of those recommendations

30. Recommendations from Applied Self-Direction
ASD Recommendation #1: Improvements in Support Broker Training to increase availability of support broker training and move portions of required trainings online.
ASD Recommendation #2: Carefully transition away from Independent Support Brokers

31. Recommendations from Applied Self-Direction
ASD Recommendation #3: Replace Individualized Goods and Services (IDGS) categories with a statement that Goods and Services must be directly related to the meeting the individual’s goals in the context of their disability and define what is not allowable.
ASD Recommendation #4: Develop an all-encompassing service for self-hired staff, instead of using Community Habilitation, Supported Employment and Respite

32. Recommendations from Applied Self-Direction
ASD Recommendation #5: Modify requirement for the number of Support Broker Circle of Support Meetings to be based on need, instead of four per year
ASD Recommendation #6: Move final approval of Self-Direction (SD) Budgets from OPWDD Central Office to OPWDD Regional Offices

33. Recommendations from Applied Self-Direction
ASD Recommendation #7: Move away from a 100% review of all SD plans at the Central Office level. For example, Central Office could do 10 to 25% of the reviews of Self-Direction (SD) Budgets.
ASD Recommendation #8: Carefully move forward towards implementing a software solution

34. Activities Underway to Address Recommendations:
Improved Broker training with more online training under development
Streamlined approval processes
Planning to implement changes that will increase Broker accountability
Subcommittee proposed workgroup to look at FI consistency
Implementing desk audits to review compliance/quality issues