1. 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

2. Virginia is Shifting the Array of Services
More Integration and Options for Independence
Nursing Facilities, ICF,
Day Support
Group Homes
Prevocational
Sponsored Residential
Family Home
Group Supported Employment
Individual’s Own Home or Apartment, Individual Supported Employment
Current Array of Services
Future Array of Services

3. 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

4. Individuals Served By Virginia’s Developmental Disability System February 5, 2014
674
8,115
10,797

5. 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!”

6. Goals of My Life, My Community!
Evaluate the efficiency, effectiveness and flexibility of the current waivers.
Recommend approaches for system changes including waver enhancement, and the potential efficacy of one comprehensive waiver and one supports waiver.
Conduct a study of current Medicaid rates.
Recommend new rate structure based on the study and exploring an individual resource allocation system for efficient distribution of waiver funds.
Aid in implementing the new system.

7. 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

8. 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

9. 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:
The information gathered helped inform the Phase I report

10. My Life, My Community Public Forums Conclusions
Primary Principle: One Unified, Needs-Based 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

11. 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

12. December 20, 2013: HSRI Phase I Recommendations
Phase I report included a series of short and long term recommendations
Available at
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

13. 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

14. 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

15. 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

16. 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
Case management for those on I/DD waivers
Case management for those not receiving waiver services

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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”

26. 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

27. 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.

28. Timeline for Implementation of My 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

29. Questions?