FINDINGS AND IMPLICATIONS

June 21 , 2011

P r e p a r e d b y W i t h t h e a s s i s t a n c e o f

M i n n e s o t a D e p a r t m e n t o f H u m a n S e r v i c e s

Waiver Review Initiative

Lead agency Comments

“The review process has been very organized from the State stakeholders with an attitude of working together with our County to improve services to our clientele…this process has resulted in improvements and process change that will definitely benefit our clientele.” – Clearwater County (Director of Human Services)

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Agenda

Describe the waiver review initiative

Share findings from the waiver review

Describe changes in waivers across county agencies over previous 5 years

Share how counties change in response to reviews

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About the waiver review initiative

A statewide project that began in 2006 to assure the Quality of Minnesota’s Home and Community Based Programs: • To identify promising practices • Assure compliance with program requirements• 75 lead agencies have been reviewed and as a result

o Surveyed over 1,300 staff o Conducted almost 90 focus groups o Reviewed over 5,000 case files

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Status: Waiver Review

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Some changes in the initiative

Providing more services on-site to counties • Detailed report of what we looked for• Answering questions about requirements, practices

Follow-up process started• 48 counties had been through the follow-up process

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Some changes in the initiative

Yahoo Group – save interesting tools collected from other counties

Instructions on how to find the Yahoo group with useful County tools. It can be found accessed at

http://www.theimprovegroup.com/waivers/countytools.pdf

DHS data portal – reports published on the DHS website Performance measures related to HCBS waiver

programs Updated quarterly New reports get added as they are developed

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Waiver review framework

The waiver review is designed & organized to examine the Center for Medicaid and Medicare seven quality areas;

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Waiver review framework, cont.

Quality area Definition

Participant Access

Individuals have access to home and community-based services in their communitiesKey benchmarks: Number of people on waiting lists; nursing facility residents under 65 who received screenings; community outreach

Person-centered service planning & delivery

Services and supports are planned and implemented in accordance with each persons unique needs and preferences

Key benchmarks: Use of CDCS; documentation of participant choice; service continuity

Provider capacity

There are sufficient providers who demonstrate capacity to serve participants

Key benchmarks: Days between entry into service agreement and paid claims; contract quality

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Waiver review framework, cont.

Quality Area

Definition

Participant safeguards

Participants are safe & secure in their communities, taking into account their choicesKey benchmarks: Frequency of face-to-face visits, back-up plans and emergency contact information in care plans

Participant rights

Participants receive support to exercise rights & accept personal responsibility Key benchmarks: Documentation of informed consent; participants are informed of their rights

Participant outcomes

Participants are satisfied with services & achieve outcomesKey benchmarks: Participant outcomes and goals in care plan; documentation of participant satisfaction

System performance

The system is efficient, effective & strives to improve qualityKey benchmarks: Percentage of participants served in community vs. institutions; waiver budget balances

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Findings and themes: participant access

Promising practices• Counties build strong relationships with agencies such as

schools, health clinics, hospitals & nursing homes • Increasingly, counties build strong regional collaboration to

better serve communities• Counties serve a higher-need population than in 2004

Limitations• Most counties (12 of 16) have fewer than 80% of screenings

completed on time in one or more programs• Some counties are facing challenges serving culturally

specific populations, notably Hispanic and Somali populations• Some counties are facing challenges in providing case

management to participants who live outside the county borders

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Findings and themes: participant access

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MMIS data CCT AC & EW DDAll HCBS

Programs

# of participants waiting for HCBS services

261 N/A 4,859 5,120

% of participants living in own home (first screening)

Under 22 = 75%Over 22 = 68%

69%Under 22 = 87%Over 22 = 12%

N/A

% of screenings done on time

61% 67% 89% N/A

Findings and themes: person-centered

Promising practices• DD ISPs nearly always exceed expected

documentation of needs, goals & outcomes• Counties provide increasing employment

opportunities for DD & CCT participants

Limitations• Not all CCT care plans are being developed within

ten days of the assessment, as required by MN statute

• Counties are not adequately addressing caregiver needs in care plans. Overall, only 41% of cases reviewed in the past year address caregiver needs

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Findings and themes: person-centered14

CCT AC & EW DD

Percent of participants with current individual care plan (one year or less) 98% 98% 98%

Completeness of individual care plan- participant needs identified 90% 85% 100%

% of participants with a care plan that includes choice questions answered 94% 92% 100%

% of participants with an OBRA Level 1 or ICF/MR* LOC in case file 97% 98% 78%*

% of participants with a care plan that shows all services to be provided 98% 98% 100%

Findings and themes: provider capacity

Promising practices• Nearly all contracts include basic participant

outcomes and have a process to monitor if services are being provided

• County staff are well connected and communicate regularly with providers

Limitations• More than 34% of all contracts reviewed were

signed more than 60 days after the contract’s effective date

• Some counties have a very residential provider base

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Findings and themes: provider capacity

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*Statewide data** Fee-for-Service dataMMIS data

CADI EW** DD

% of authorized dollars actually paid for services in FY 2010*

85% 19% 92%

% of participants with a service agreement but no paid claims*

35% 23% 17%

Findings and themes: provider capacity

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Contract review data Yes

Are local contracts current for services being provided? 93%

Does the contract language include a process to examine if contracted services are actually provided?

99%

Does the contract include an established rate for services?

81%

Findings and themes: participant safeguards

Promising practices• In many counties participants are seen face-to-face

on a monthly or quarterly basis• During assessments county staff take a look at

kitchens, bathrooms, scatter rugs etc to ensure people are safe in their homes and to prevent falls

Limitations• Some counties had CCT participants that did not

have biannual face-to-face visits over the past year• Some Counties had more than 20% of DD

participants not visited in the previous six months

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Findings and themes: participant safeguards19

Case file results CCT AC & EW DD

Most recent case manager face-to-face visit within the last six months

86% 82% 86%

Health & safety issues outlined in care plan

98% 98% 100%

Back-up plan included in care plan

75% 56% 20%

Emergency contact included in care plan

92% 92% 90%

Findings and themes: rights/responsibilities

Promising practices• Most counties had 100% documentation of

participant rights for its DD cases

Limitations• Some counties had issues with public

guardianship and case management roles being performed by the same person

• Many counties do not regularly update participant rights forms

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Findings and themes: rights/responsibilities

Staff Survey data Mean

Providing participants with information about their rights and responsibilities 9.45

Assuring that participants are able to exercise their rights 9.38

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Findings and themes: rights/responsibilities

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Case file data CCT AC & EW DDAll HCBS Program

s

Documentation of informed consent 99% 96% 88% 97%

Documentation of participant informed of rights 98% 98% 98% 97%

Findings and themes: outcomes/satisfaction

Promising practices• Some counties are systematically collecting

participant satisfaction information • Counties are doing participant satisfaction surveys

Limitations• Goal setting continues to be a challenge in the LTC

programs, in many counties goals are not individualized.

• Participant satisfaction collected informally but not documented in case files

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Findings and themes: outcomes/satisfaction

Case file review dataAll HCBS Programs

Documentation of participant outcomes and goals in care plan

98%

Documentation of participant satisfaction in case file

57%

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Findings and themes: outcomes/satisfaction

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Staff survey results1-10 scale

Systematically collecting participant satisfaction data

8.55

Monitoring participant outcomes 8.70

Findings and themes: system performance

Promising practices• Case management practices are very strong in all

counties reviewed this year • Public Health and Social Services agencies and staff

have good working relationships and work together to serve participants

Limitations• Staff capacity has been stretched as a result of budget

cuts, and case managers report that keeping up with policy changes is a challenge

• Contracting for culturally-appropriate services continues to be a challenge in many counties

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Findings and themes: system performance

System data – 2010 CCTEW/AC

DD

Percent of LTC participants served in community vs. institutional settings 92% 65% 92%

Percent of LTC funding spent on participants in community vs. institutions

87% 33% 87%

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Findings and themes: system performance

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Staff survey results 1-10 scale

Communicating State and Federal policies to staff 8.26

Following State and Federal laws and regulations 8.98

Accessing quality interpreter services 9.53

Contracting for culturally – appropriate services 8.44

Changes in waivers during review period

Technology is being used increasingly to support case management and other services through electronic case files, mobile laptops, and delivering services electronically.

CDCS services have been used in greater numbers in rural, suburban and urban communities alike; each community seems to have different reasons for its use of CDCS.

The majority of participants are being served in the community as opposed to institutions, and the percentage is increasing.

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Changes in waivers during review period

Care plan documentation of participant health and safety and participant goals is improving.

Compliance with technical requirements is improving.

• In 2006, 9% of CCT cases had a complete documentation of a backup plan, while 74% of the CCT cases we reviewed in the past year had this documentation

• In 2006, 67% of LTC cases had a completed OBRA level one, while 98% of LTC cases we reviewed in the past year had this documentation

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Changes in waivers during review period

2006 2010 2006 2010 2006 2010Identifies participant

needsAddresses health &

safety issuesIncludes participant outcomes & goals

0%

20%

40%

60%

80%

100%

None Below Meets Exceeds

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Changes in waivers during review period

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06

20

10

20

06

20

10

20

06

20

10

20

06

20

10

Plan for services to be provided (formally or in-

formally)

Choice questions are answered

Care plan is signed and dated

Caregiver needs are included

0%

20%

40%

60%

80%

100%

None Partial Complete

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Changes in waivers during review period

Contracting practices are improving; most counties moved to the DHS model contract over the last 30 months, and now contracts meet all requirements and in general are in place for all services, with a few incidental exceptions.

The proportion of participants earning income is increasing. In the DD program, 49% of participants earned income in 2005, and 56% earned income in 2009. In CCT, 20% of participants earned income in 2005, while 21% earned income in 2009.

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Continuing challenges

Some issues continue to challenge counties; these could be considered when working with counties and/or supporting their work: • Counties are facing increasingly limited budgets,

particularly for travel, staff reductions and training. They are addressing these limits by using internal cross-training whenever possible.

• Some counties struggle when switching between

different waivers and/or health plans to meet the various care plan and documentation requirements. They have frequently requested tools resources such as requirement checklists to support their work

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Continuing challenges

Keeping up with the pace of program changes remains difficult for counties; some have assigned staff to be internal “experts” on specific issues, but others do not have a system for adapting to change.

While DHS offers a number of resources, the resources are not available to all programs; county staff continue to ask that Regional Resource Specialists or similar support be available for AC and EW programs.

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Lead agency Comments

“The review confirmed many areas SLC [St. Louis County] has known are challenging areas with room for improvement. The difficulty has been with limited resources and the need for greater direction and consistency locally and from DHS. On a positive note, in the intervening 3 years, both DHS and SLC are moving forward step by step to improve the overall waiver administration and service delivery.” (Deputy Director, St. Louis County)

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Follow – up

The follow up summarizes the results of the waiver review follow up activity from 2008 through 2010.

Results are organized into the following sections: Individual Case Compliance Cohort Compliance Lead Agency Service Improvements

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Follow-up results

Purpose

The follow-up review:

• Confirms lead agency compliance with corrective action plans;

• Tracks local improvement efforts;• Obtains feedback on the helpfulness of the

review.

Follow-up results

ProcessThe lead agency submits documentation to verify

planned changes to their programs were implemented as stated in their corrective action plan

A list of cases and required documentation is sent to the lead agency that includes cases previously found non-compliant, along with additional cases to ensure that the practice has been consistently implemented and not only applied incidentally.

Lead agencies are also asked about recommendations that were included in the waiver review report.

Follow-up results

Process.

The submitted documentation is reviewed for compliance with state and federal requirements.

A draft report is sent to the lead agency for review

Report is finalizedAdditional corrective actions re-issued if

necessary

Follow-up results41

Follow-up results

250

750

1250

1750

2250

2750

Corrective Action Effectiveness 92%

Follow-up results

Total Corrective Full %Correction

s

Cohort Actions IssuedComplianc

eCorrecte

d Re-issuedAitkin 2 5 3 60% 2Clearwater 1 14 13 93% 1Douglas 2 5 4 80% 1Freeborn 2 7 5 71% 2Goodhue 3 9 7 78% 2Lincoln Lyon Murray 3 8 7 88% 1McLeod 2 3 1 33% 2Mower 3 13 11 85% 2Nobles 2 8 5 63% 3Pipestone 1 4 2 50% 2Polk 3 8 5 63% 3Pope 2 4 3 75% 1Rock 1 4 4 100% 0St. Louis 5 13 8 62% 5Wabasha 2 12 11 92% 1Wadena 2 3 2 67% 1Washington 4 8 5 63% 3Yellow Medicine 1 4 3 75% 1Overall 132 99 75% 33

Follow-up results

Tim

ely

Care

Plan D

evel

opm

ent

Long T

erm

Scr

eenin

gs On T

ime

Freq

uency

of F

ace-

to-F

ace

Visits

0%30%60%90%

% Corrective Actions Re-issued 2010

% Corrective Actions Re-issued 2010

Follow-up results

Total Corrective Actions Issued

Full Compliance Corrections Re-issued

2009 91 71 20

2010 132 99 33

1030507090

110130

Lead Agency Overall Compliance Im-provement

Follow-up results

5

15

25

35

45

55

65

75

85

95

Percentage of Corrective Actions Remediated

Follow-up results

  Total Corrective Actions Issued

Full Compliance

% Corrected

Corrections Re-issued

Total Lead Agencies

        Count

%  

Cohort 1

61 54 89% 7 12% 9

Cohort 2

66 51 77% 15 23% 12

Cohort 3

54 41 76% 13 24% 11

Cohort 4

19 12 63% 7 37% 3

Cohort 5

23 12 52% 11 48% 2

Overall 223 170 76% 53 24% 37

Follow-up results

1030507090

110130150

Lead Agency Response to Recommen-dations

Follow-up results

Conclusions The follow-up process continues to be an effective

mechanism to assure compliance and secure feedback on recommendations.

Most lead agencies have made significant progress in achieving compliance.

Frequency of face-to-face case manager visitation, timing of screenings and care plans continue to be major challenges for lead agencies.

Lead Agencies implemented over three-quarters of all recommendations made by the Department relating to service improvements.

Follow-up results

Adjustments Made to the Process Include:

Reduce the time interval between the Initial Waiver Review visit and the Follow-Up Process to between 15 and 18 month intervals.

Planning to implement phase II of the follow-up process after the initial follow-up reviews are completed.

Follow-up results

The ChallengeCMS will want to know the remediation steps taken

by the department on outstanding compliance issues identified in the follow-up review. This will necessitate another follow-up

CMS will require 100% remediation of identified deficiencies.

DHS must provide evidence of on-going remediation efforts to CMS as we renew our waivers. The Initial review of all counties will be completed next year and it will take some time to develop and operationalize new protocols.

Lead agency Comments

“On behalf of Washington County I would like to thank you and your staff for the respectful manner by which this review was conducted…and was pleased by the cooperation that was evident between our respective agencies.”(Director of Washington County

Community services)

Resources

To contact us: Jean MartinDepartment of Human

Servicesjean.m.martin@state.mn.us651-431-2578

Tom SkarohlidDepartment of Human

Services

Thomas.a.Skarohlid@state.mn.us651-431-2431

*Please feel free to call with questions about this presentation or how to interpret any of

the included data

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