1. Staten Island MSC Forum
Kate Bishop and Amanda Harper
NYS Office for People With Developmental Disabilities
7/20/17

2. Agenda
Care Coordination Updates
Overview of Person-Centered Planning

3. System Change Care Coordination Organizations
11/14/2018
System Change Care Coordination Organizations
Builds from the experience and expertise in the field of developmental disabilities today
Stronger coordination structures to support community based supports
Strong person-centered practices with holistic view of person

4. 5/19/17
What is a CCO?
Care Coordination Organizations (CCO), a new organization to be approved by OPWDD
To provide enhanced care coordination services
Level of service tailored to individuals’ needs
Regionally based / community resources expertise
Personal choice
Build on traditional MSC role
IT enabled
Conflict free
Foster HCBS Rule attainment

5. Care Coordination Organizations (CCOs)
5/19/17
Care Coordination Organizations (CCOs)
CCOs will be designed as specialized Health Homes, with their focus on coordinating care for people with developmental disabilities.
CCOs will operate under the 1115 waiver.
CCOs may subcontract with existing IDD MSC provider agencies for a period of time

6. Why Focus on Care Coordination?
Provide services with a holistic view of the person– health, wellness, behavioral health and LTSS
Community living has many moving parts
Increased attention to a person’s life goals
Offer improved career path for current service coordinators
Build on strengths of current structure
A path to managed care and Value Based Payments (VBP)
Community- as we have more and more people exploring self directions and non certified living situations coordination needs increase
Career path- with focus on health, wellness behavioral health there are more areas of specialty that can allow for advancement that isn’t currently available with in our typical MSC administrative structure.
VBP- focused on outcomes vs dotting of I’s crossing of T’s. Our system has focused a lot on compliance vs quality and the outcomes of the people we support. Recognize that the system needs to move forward and to pay greater attend to goals and personal outcomes of the person served and the value in this. Rewarding providers for their hard work and doing well.

7. Benefits of Care Coordination
Increased individual satisfaction and choice through person-centered planning
Service authorization, activation and monitoring improved (more seamless, reduced paperwork)
Improved access to services and providers and reduction of unnecessary delays
Enhanced integrated opportunities for independence to the extent possible
Support of meaningful outcomes and value-based performance metrics
IT enabled communication & data sharing
Increased accountability
- Intention of care coronation to better streamline our system and get out of the way of the PCP process and increasing the independence of the people we support.
Show of hands-providing services to someone who isn’t happy where they are, is getting more of less supports than they require. Still using paper to share plans and make changes?
-through enhanced IT systems we can improve communication and efficiency while decrease deficiencies and compliance issues due to preventable systems issues that can be addressed using technology.

8. Health Care Transitions for People With Developmental Disabilities
Disability is a lifelong condition
Differences in individual abilities
Co-morbidities and co-occurring conditions
Over time, people’s health status & support needs change
Someone with I/DD is more than twice as likely to be admitted when they present in hospital emergency departments
People with I/DD in inpatient settings can be stable but not have appropriate long term supports and services identified

9. Underutilized Preventative Health Care Services
11/14/2018
Underutilized Preventative Health Care Services
Preventive screenings
Health promotion
Dental
Chronic care management
Health optimization
Maximize use of preventative services to maximize good health for optimum community life and independence

10. Care Coordination is a Comprehensive Model
Care Coordination Functions
Linkage and Referral
Advocacy
Care Planning
Assess-ment
Monitoring
Record Keeping
Coordina-tion with providers
Cost Mgmt.
Eligibility & Benefits Maint.
Central Point of Contract

11. Comprehensive Care Management Includes
Use of care teams comprised of individuals receiving support and services and their representative/circle of support, developmental disability service providers, and medical, behavioral health providers, social workers, nurses and other care providers, as appropriate
Conflict-free care management services must be person-centered and person-driven
Comprehensive care coordination that addresses the individual’s needs holistically, including better access to physical, behavioral health services, and wellness
Support and care is detailed and monitored through the use of the OPWDD defined Life Plan that is integrated and electronic

12. Person-Centered Life Plan
11/14/2018
Person-Centered Life Plan
Supports and services are detailed and monitored through the use of OPWDD’s Life Plan, an integrated and person-centered electronic service plan
Care Coordination Organizations (CCO/HHs) will be responsible for the development of the Life Plan
The Life Plan must include specific domain areas and be accessible electronically to all authorized members of the care team

13. 11/14/2018
Timeline & Next Steps
Now until August 4: Comments on the draft Application will be accepted—applications are not being accepted at this time.
September 30, 2017: The final Application will be released and applications begin to be accepted.
November 30, 2017: Last day for CCOs to apply.
December 2017 – February 2018: Review and approval of Applications, Start-up Grant Awards.
March-June 2018: Readiness activities.
July 2018: Transition to CCO/HH.

14. What Can We Do Right Now?
The service relationships and expertise of the current MSC workforce will have an integral role in the transition to CCOs
Continue providing quality MSC services
Maintain current enrollment and caseload practices
Ensure that service coordinators understand and are following the Person-Centered Planning (PCP) regulation
Take opportunities to learn more about health and behavioral health systems and integration of care

15. 11/14/2018
What Do I Need To Do?
Attend upcoming Webinars offering additional details.
Read the draft application to learn more about CCOs.
Connect with potential CCOs in your geographic region.
Reach out to OPWDD with questions.
Check OPWDD’s website frequently for updates and new materials.

16. Questions/Discussion

17. 11/14/2018
Kate Bishop Division of Person Centered Supports OPWDD Care.

18. Person-Centered Planning
What is different for Service Coordinators?
For todays presentation were going to focus on the aspects of the PCP regulations that specifically relate to MSC documentation. I’m operating on the assumption that everyone is very familiar with Person-Centered Planning and has reviewed the March 2014 federal regulations and November 2015 NY State Final Regulations. Links to both of these documents are available in this power point.

19. NYS Person-Centered Planning (PCP) Regulations: Documentation Elements
Person Centered Service Plan (PCSP) is the Individualized Service Plan(ISP) and it’s attachments.
Must be developed using a person-centered planning process.
An Frequently Asked Questions FAQ that was sent to provider agencies on May 1st. The FAQ was created to provide guidance regarding program standards and documentation requirement concerning OPWDD PCP regulations. Throughout the PCP regulations and the FAQ the person-centered service plan or PCSP is referred to. The PCSP must be developed using a person-centered planning process (ie. the person directs the planning process to the best to their ability. Planning is considerate of culture, communication needs, done where and when planning happens, methods to address conflicts of interest and need to change a plan etc)
The ISP and it’s attachments are the Person-Centered Service Plan and must be developed using this process.

20. NYS PCP Regulations: Documentation Elements cont’d
Notice of Person-Centered Rights
Functional Assessment
Identification of self-direction
Risk Factors & Safety
Alternative Residences
Rights Modification
Agreement & Signatures
The following items are required of the PCP process and service plan. As mentioned in the March 8th supervisors conference, and I will touch on briefly, these items will also be surveyed against with DQI. The regulations did not change any of the billing standards outlined in , these are program standards. These are not at this time incorporated into fiscal audits just to be clear.
Notice: Everyone should have in their record. Is everyone familiar with this
One time letter provided at initiation of PCP process. Link of OPWDD website to letter than can be used. Informs person of their right to a PCP and process
Functional Assessment- SC must use to ensure that supports are appropriate and necessary. Show of has who is familiar with the CAS? The implementation of the CAS is underway, we will touch on the Cas in the next slide. It will replace the DDP2 right now the DDP2 and the CAS are the state sanctioned functional assessments that must be used. If someone has a CAS assessment this is used in place of the DDP2.
Identification of Self-direction: any service that the individual elects to self-direct must be documented in the plan. The MSC should have the MOU from the FI and the budget from the broker but there are not required attachments to the ISP. The attachments remain the same as indicated by the ISP instructions the individual can choose to attach to the ISP.
Risk Factors & Safety- PCP must develop strategies to address Health and Safety risks. The intention isn’t to eliminate risk but to work with the individual and their circle of support to identify risks and develop safeguards to help the person achieve their outcomes. There is a tool on the OPWDD website to assist with this process, link in following slide.
Alternative Residence: when someone moves into a certified residence it must be documented alternative housing options that were considered. The MSC must ensure that the PCSP documentation includes that the individual is satisfied with their current living situation and if they are not the active planning taking lac eto assist the person to make a change.
Rights Modification- review the Regs and FAQ to become familiar with the requirements of rights modification and special considerations to tenants rights. The MSC is responsible for ensuring that there is proper documentation of rights restriction. If there is not it is the SC responsibility to have the rights restored or for the proper documentation to be put in place.
Agreement and signatures- plan must be finalized
Singed by service coordinator and informed written consent of the person. Best practice is for all service providers to review and sign the plan.

21. Functional Assessment: The Coordinated Assessment System (CAS)
The CAS is being implemented as a tool to inform the person-centered planning.
MSC Role in the CAS
Provide contact information to CAS assessor
Relay meeting date and time to involved participants
Provide documents requested from the assessor
Review the CAS summery with the person and his/her involved family member and team within 30 days
Incorporate aspects of the CAS into the PCSP/ISP
Touching briefly on the CAS. As mentioned it is a state sanctioned functional assessment that is state wide. At this time the function of the CAS is to inform that person-centered service plan. We’re going to focus on the what the role of the MSC is in the CAS assessment process. There are 3 handouts to review. These documents are provided to an MSC when they are contacted by a CAS assessor regarding someone on their caseload. It informs them of what their role is in the process, what documents they will need to provide the assessor, and understanding the CAS Summaries. The following bulleted points are the areas of responsibility for the MSC-
Contact info- the individual and their guardian or involved family member. This is very important and can early on create significant challenges if there is an oversite, such as not including a guardian. When giving out contact information its also good to reach out to the person and family to let know to expect the CAS assessor.
Relay meeting date- the CAS assessor will give the MSC the date of the meeting and who the person will like to attend. The MSC coordinates with the person/family member and lets the assessor know if there is an issue preventing the assessment from a conflict to an emergency. Reminder, the MSC in many cases will not need to be present for the assessment.
Provide documents in a timely manner that suits the person- work with the assessor for the best way to obtain documents. It may not be the same for every person.
When the assessment is done it is the MSCs responsibility within 30 days to distribute and review the assessment with the person and their family. This needs to be a review with the person it is not sufficient to distribute the CAS without reviewing it’s findings with the person and their family. This should be documented in an MSC monthly note. If there are safeguards or other pertinent issues identified then an addendum needs to be completed with in 30 days as well
Please be sure to sign up for the June 7th supervisors conference. The CAS and the MSC roll will be discussed in further detail.

22. Assuring PCP Follow-Through in DQI Survey
Agency Review
used annually to review all agency systems and/or mechanisms, including MSC.
Person Centered Protocol
Used by DQI surveyors for routine reviews of MSC services provided to individuals
Assesses against the PCP Regulations
The Agency MSC Review will continue to look at an agency annually to ensure that agencies have systems and performance standards to provide MSC services with qualified MSCs. Also DQI wants to see at an agency review that the agency has a system to obtain information from individuals and advocates regarding their satisfaction with services and has a procedure to address areas of dissatisfaction both individually and systematically. Agency process that guards against conflicts of interest in service coordination.
The person centered protocol will look at the quality and effectiveness of MSC services for the agency and towards data to determine the effectiveness of MSC statewide. Section 1 of the Person Centered Protocol surveys against the PCP Regs and will look for documentation regarding the CAS, Notice of PC rights, Rights modifications etc.
For further information on DQI new procol please see the materials from the March 8th conference in E-Visory #3-17

23. Tools to assist Person-Centered Planning Final Regulations
Federal Regulation 42 CFR § (c)
Person-Centered Planning Rights Notice
For questions related to the CAS or to request further training:
Strengths and Risk Inventory
For questions related to the DQI Survey
When you receive the power point right click the hyper link to access the resources
Coming soon- DQI protocol is an online tool that is being tested and will be available when complete.
A Q & A offering guidance for specific Person-centered planning and process questions.
As mentioned the FAQ will be available online shortly. The link will be shared through E-Visory.

24. Questions & Discussion
11/14/2018
Questions & Discussion
Amanda Harper, Assistant MSC Statewide Coordinator