1. Spectrum of Self-Directed Care Maryland, Medicaid Office of Health Services John S. Wilson April 5, 2012 Community First Choice

2. 2 How We Created the Spectrum Reviewed the Person Centered Planning for Consumer Directed Care resource guide produced by the National Resource Center for Participant- Directed Services (NRCPDS). Incorporated the key concepts of the guide into our analysis after having reviewed other states’ programs. Analyzed information on self-direction programs referred by community disability advocates. Resource Guide: http://www.bc.edu/content/bc/schools/gssw/nrcpds/tools/handbook.h tml http://www.bc.edu/content/bc/schools/gssw/nrcpds/tools/handbook.h tml

3. 3 How the Spectrum Works Analysis of self-direction programs in the following states: Kansas* (KS), Missouri (MO), Arizona† (AZ), New York (NY), Tennessee (TN), California (CA), Colorado (CO), Virginia* (VA), and Wisconsin (WI). Matrix consists of three models with varying degrees of state oversight and participant responsibility. * State allows participants to choose among a variety of models. † Self-direction model is non-Medicaid funded and run by Community Independent Living Centers.

4. 4 Plan of Service Professional ModelInterdisciplinary Team Model Self-Directed Participant Model Examples: KS*, VA*, MO Examples: NY, AZ†, New Mexico, KS*, WI, VA* Examples: CA, KS*, VA* Description: Professional creates plan of service for participants. Description: Participant works with professional to create plan of service. Description: Participants develop their own plan of service.

5. 5 Plan of Service (Supports Broker) Professional Model Interdisciplinary Team Model Self-Directed Participant Model Examples: MO, NY, KS*, VA* Examples: WI, VA*, KS*, AZ†, TN Examples: CA, KS* Supports Broker:Description: Mandatory case manager is only participant support person. Description: Case manager is supplemented by mandatory supports broker. Description: Consumer may choose someone to assist but isn't provided a broker or consultant Case ManagerAll models employ a case manager as primary participant support.

6. 6 Provider Rate Setting StateLimits w/ POCParticipant receives cash allotment Example: MO Examples: TN, WI, NY Examples: CA, KS, VA*, AZ† Description: State sets the rate. Participant has no control. Description: State approves a rate range (or a maximum) that the participant has option of paying providers. Description: Participants receive monthly allocation and spend according to their plan of service.

7. 7 Provider Qualifications StateWaive-ableParticipant Example: MO Examples: NY, KS*, VA* Example: AZ† Description: Providers must meet the minimum level of qualifications set by state. Description: Qualifications are set by state but can be waived. Description: Participants develop their own provider qualifications. No mandatory minimum requirement. All models allow participants to hire and fire staff

8. 8 Monitoring Case ManagerSupports LiasonNone Examples: TN, NY, VA*, KS*, MO Example: VA* Example: AZ† Description: Oversees plan of service. Description: Supports Broker is tasked with ongoing reviews, including collection of incident data, to ensure plan continuity. Description: Self-reported regularly.

9. 9 Discussion To recap, models vary in state oversight and consumer responsibility: Which model would be best for Maryland to adopt? What suggestions do you have regarding the models? What concerns do you have about the models?

10. 10 Service Delivery Options Provider ManagedSelf-Direction Examples: Description: Consumer can choose from range of Provider Managed options from traditional agency-based to “hybrid” agency based (described by MDF in other documents). For the purposes of Medicaid funding, a state must offer a traditional “provider-managed” service delivery option alongside self-direction and ensure there are no service breaks during transition periods. This feature recognizes that not all participants may want to assume the responsibilities that self-direction entails. Description: Managing Workers aka “employer authority”* Fiscal/Employer Agent (F/EA)* Co-employer / Agency with Choice* Consultant Broker Services Other (Fiscal Conduit, Public Authority/Workforce Council) Individual Budget aka “Budget Authority”* When a state offers self-direction of HCBS, it generally must allow participants to opt into or out of directing their services.

11. 11 Case Management Compared to Support Brokerage / Counseling Traditional Case Management RolesSupport Brokerage / Counseling Roles Description: While traditional case managers’ responsibilities vary, typical duties include: ■ explaining the program, process, and eligibility criteria ■ presenting setting (institutional, home, or community-based) and service options (traditional agency or self-direction) ■ conducting an assessment to determine eligibility (based on medical, functional, social, and behavioral factors)3 and to develop a service plan and match needs with resources ■ implementing the service plan Description: Counselors can provide individuals with detailed information to enable them to make informed decisions about whether self-direction is right for them, and if it is, about how to obtain and manage their services. Because self-direction is a relatively new service delivery option in most states, many individuals will need information about a wide range of topics, including: ■ the person-centered planning process ■ participants’ rights in the program ■ resources, choices, and options (Continued on next slide)

12. 12 Case Management Compared to Support Brokerage / Counseling (cont.) Traditional Case Management RolesSupport Brokerage / Counseling Roles Description: ■ monitoring the provision of services ■ assessing the quality of services ■ ensuring cost/budget neutrality, if required ■ revising the service plan when changes occur ■ performing periodic assessments and eligibility determinations Description: ■ risks and responsibilities associated with self- direction and decision making ■ program limitations or restrictions ■ reporting changes in condition and needs ■ recognizing and reporting critical events, abuse, or neglect ■ requesting a review of decisions, reporting grievances, and dispute resolution ■ the availability of criminal background checks and processes for conducting them (depending on the program design) In addition to providing information, counselors also encourage participants to seek information on their own. (Continued on next slide)

13. 13 Case Management Compared to Support Brokerage / Counseling (cont.) Traditional Case Management RolesSupport Brokerage / Counseling Roles Description: Counselors assist individuals with a wide range of self-directed activities. The extent and type of assistance provided to participants varies depending on their needs and preferences. Specific types of assistance include: ■ defining needs, preferences, and goals ■ developing the individual budget ■ managing the individual budget ■ developing a backup plan if a scheduled worker fails to show ■ developing a backup plan for emergency situations (Continued on next slide)

14. 14 Case Management Compared to Support Brokerage / Counseling (cont.) Traditional Case Management RolesSupport Brokerage / Counseling Roles Description: ■ identifying and obtaining services, supports, and resources ■ recruiting, hiring, and managing workers ■ obtaining training in practical skills related to personnel management or problem solving, including; (1) recruitment strategies; (2) how to interview, select workers, and check references; (3) how to negotiate rates and arrange schedules; (4) how to train workers; and (5) how to manage workers and dismiss/replace them if necessary ■ making decisions about the purchase of goods and services ■ assessing the quality of services received