QDDP Training for Service Providers providing Non-Innovations I/DD Services with the Merger and 1915 b/c Waiver Wake County Commons Building August 28th, 2012 A New Multi-County Area Authority Merging The Durham Center and Wake LME
Why are we changing? House Bill 916 is a mandate that supports the statewide expansion of the 1915 (b)/(c) Medicaid Waiver. LME s were encouraged to apply to operate the 1915 (b)/(c) Waiver or choose to merge with an LME that has been approved. Durham and Wake LME s merged on 7/1/12 to become Alliance Behavioral Healthcare. Johnston and Cumberland will join by inter-local agreement on 1/1/2013. The alliance of these four counties will encompass a population of almost 1.7 million residents, with about 186,000 Medicaid-eligible citizens making Alliance the largest of 11 MCOs statewide.
What will stay the same? Eligibility criteria and waiting lists for state funded services. State funded (IPRS) services, other than Targeted Case Management, remain in place. All current providers have the opportunity to enroll with Alliance to be in the provider network. ** All current Medicaid providers in Durham, Wake, Cumberland and Johnston counties must complete the Alliance application/credentialing/enrollment process by September 30, 2012 to become part of the Alliance Provider Network.
Timeline July 1, 2012 Wake and Durham LME s merged to become Alliance Behavioral Healthcare Services continue as they are for CAP, Medicaid, and state-funded (IPRS) For those individuals who it is appropriate to do so for, please begin looking at moving them off of TCM services. You do not have to wait until 12/31/12 to discharge from services or transition lead agency responsibilities. January 1, 2013 Alliance Behavioral Healthcare becomes an MCO and starts operating the 1915 (b)/(c) Waiver for Cumberland, Durham, Johnston, and Wake counties CAP I/DD recipients will start receiving NC Innovations services TCM is no longer a service available to individuals receiving publicly funded behavioral healthcare services.
TCM Transitions County Cumberland Wake Durham Johnston TOTAL PERCENTAGE Medicaid 203 581 214 46 1044 78% IPRS 29 106 131 7 273 20% Blank 6 9 0 1 16 1% Non-CAP TCM TOTAL 238 696 345 54 1333 100% 1. Discharge from TCM, fine with natural supports 54 169 48 24 295 22% 2. Direct Service Provider becomes Lead Agency 140 414 226 21 801 59% 3. High Risk when TCM ends 46 155 43 9 253 19% 1349 100% Group Home Expulsion 5 0 0 0 5 Released from Jail or Prison 0 0 1 0 1 Homelessness 0 1 3 1 5 CPS/APS Involvement 3 7 1 0 11 Health & Safety Risk to Self/Others in Current Environment 22 29 8 2 61 Sexually Inappropriate Behavior 0 2 0 0 2 Psych Hospital Admission/Discharge 0 1 2 1 4 Local Crisis Facility Admission/Discharge 0 0 0 0 0 Medical or Prescription Issues Requiring Immediate Attention 0 13 0 3 16 Other (see Sheet 2) 16 92 26 2 136 241
TCM Transitions 19% 59% 22% 1. Discharge from TCM, fine with natural supports 2. Direct Service Provider becomes Lead Agency 3. High Risk when TCM ends
IDD TCM (non-cap) Transition Plan August Task Alliance BHC Train direct service providers on Lead Agency responsibilities Begin withdrawing TCM from individuals in Category 1 who are managing successfully with natural supports and community resources. NOTE: TCM can only be terminated prior to 12/31/12 if the consumer/legal guardian choses that option. Begin planning with individuals/families who fall in Category 2 for the transition from TCM to Direct Service Providers Begin planning for those individuals in Category 3 * TCM Providers * * * * * * Direct Service Providers
IDD TCM (non-cap) Transition Plan (cont.) September Task Alliance BHC Direct Service Providers begin assuming lead agency responsibilities. TCM can remain in place with TCM still listed as a service in the plan to monitor transition and assist as needed. Continue planning for those in Category 3. Provider Networks determines whether or not Alliance has enough Community Guide providers to meet the need. October Task Alliance BHC Tier in and train Care Coordination staff coming from TCM providers to Alliance. TCM Providers * * * * * * * TCM Providers Direct Service Providers Direct Service Providers
IDD TCM (non-cap) Transition Plan (cont.) November Task Alliance BHC Assign Care Coordinators to non- CAP individuals in Category 3 who will have significant health/safety risks with loss of TCM. December Task Alliance BHC * TCM Providers TCM Providers TCM services end on 12/31/2012 * * * January Task Alliance BHC Community Guide and Respite available to Medicaid recipients who meet the requirements to receive the service(s). * * Direct Service Providers Direct Service Providers Direct Service Providers
Lead Agency Hierarchy Please use the following order to determine which agency will assume lead agency responsibilities when TCM services are no longer being provided: 1. Residential Provider 2. Vocational Provider (ADVP, LTVS) 3. Periodic Service Provider (Developmental Therapy, Personal Assistance) Residential Provider applies only to agencies that contract with Alliance BHC to receive a paid residential service (ex. group living). If an individual is living in a non-contracted home, lead agency responsibility moves to the next provider in the hierarchy. If an individual is receiving multiple services at the same time, lead agency hierarchy should also be followed.
Lead Agency Responsibilities 1. Annual plan development: Lead agencies will be responsible for making all reasonable attempts to coordinate the annual Support Planning Meeting with the individual and their team (other providers, legal guardian, family members, others who the individual may wish to be present, etc.). This coordination should be documented in the individual's medical record (ex. communication log, QP task log, etc.) Lead agencies will be responsible for developing the One Page Profile and non- Innovations crisis plan reflecting the input from the team and ensuring that all team members receive a copy of this information for their records. Lead agencies will be responsible for submitting the annual plan in it s entirety to the MCO for authorization purposes. Lead agencies will be responsible for submitting Service Authorization Requests in order to authorize the service(s) the lead agency is providing to the individual.
Lead Agency Responsibilities 2. NC SNAP completion: All individuals receiving IPRS funded services will continue to have the NC SNAP completed. Lead agencies are responsible for completing the NC SNAP annually. Lead agencies will be responsible for completing special updates as needed to reflect significant changes in an individual s support needs. Any special updates should be communicated and shared with other service providers also supporting the individual. Lead agencies will be responsible for providing a copy of the annual update NC SNAP as well as any special updates to all other providers also serving the individual. Lead agencies will be responsible for submitting the annual update NC SNAP to the MCO for authorization purposes as well as for entry into the state system.
Procedures for submitting the NC SNAP Durham/Wake Providers: o Currently providers need to submit SNAPs through Provider Connect as part of the service authorization process AND email as a PDF file to Melissa Shafer for state reporting purposes. *Please note, this should be sent through a secure email/zixmail. o Once Alpha MCS is in place (10/1/2012), SNAPS will no longer need to be sent as a separate email. Alliance QM will be able to retrieve SNAPs through the Alpha system as needed.
NC SNAP submission procedures (cont.) Cumberland County Providers: o Currently providers need to submit SNAPs through Carelink as part of the service authorization process AND fax a copy to Rose-Ann Bryda (910-323-9183) for state reporting purposes through 12/31/12. o Beginning January 1/2013, providers will utilize the Alpha system to submit SNAPs as part of the authorization process. Alliance QM will be able to retrieve SNAPs through that system as needed.
NC SNAP submission procedures (cont.) Johnston County Providers: o NC-SNAPs still need to be submitted in hard copy. As the MR-2 is submitted, providers should continue to submit the NC-SNAP at the same time to Anna O Neill. o Beginning January 1/2013, providers will utilize the Alpha system to submit SNAPs as part of the authorization process. Alliance QM will be able to retrieve SNAPs through that system as needed.
Lead Agency Responsibilities 3. Fee Application submissions: This is still being outlined by Alliance. Stay tuned for further information regarding this process.
Non-lead Agency Responsibilities 1. Annual plan development: Non-lead agencies will be responsible for making all reasonable attempts to participate in the annual Support Planning Meeting with the individual and their team (other providers, legal guardian, family members, others who the individual may wish to be present, etc.). This participation should be documented in the individual's medical record (ex. communication log, QP task log, etc.) Non-lead agencies will be responsible for ensuring they have a copy of the One Page Profile and Non-Innovations crisis plan for their records. Non-lead agencies will be responsible for submitting the goal pages only for the service(s) they are providing to the MCO for authorization purposes. Non-lead agencies will be responsible for submitting Service Authorization Requests in order to authorize the service(s) the non-lead agency is providing to the individual.
Non-lead Agency Responsibilities 2. NC SNAP completion: Non-lead agencies will be responsible for communicating with the lead agency any changes they observe in an individual s support needs throughout the plan year. Non-lead agencies will be responsible for ensuring they have a copy of the annual update NC SNAP as well as any special updates in the individual s medical record.
Support Planning Support planning is. o A means - a road map- not an end. o A balance between what is important to and important for the individual. o A record of where the person wants their life to go PERSONAL OUTCOME - and what needs to happen in order to get there. o All resources formal, informal, family, and community should be included in the Support Plan.
Components of the Support Plan 1. Personal Dialogue / Narrative 2. Action Plan (Goals) 3. Crisis Prevention/Crisis Response 4. Signatures Let s discuss further-example Support Plan.
Goal writing tips Goals should be: Specific: Be precise. What behaviors do you want to see them exhibit to replace the symptom / targeted behavior? What skill do you want to see them learn/enhance/maintain? Measurable: How will you measure the progress? as evidenced by or rating scales. Goals that reflect a habilitative service as a responsible party should be measurable. Achievable: Set goals that can be reached by the target date. Think in small steps. Realistic: Set goals within reach. This is different from the dream or outcome. Timely: Set a deadline or expectation within the goal. within 3 months. Remember that when setting time expectations within a goal, you need to evaluate progress towards that goal when the appropriate time comes.
Goal writing tips Goals should be stated in the positive. The goal should state what the person wants, not what they don t want. The goal should state the behavior/skill that the team wants to see the person display, not what the team doesn t want them to do. Goals should always be responsive to the person s needs and accurately reflect their current skill level. Plan writing activity!
Questions to answer: Read the case studies and pick one to focus on: 1. What are the person s skills, positive attributes, etc? 2. What is important to? What is important for? 3. What is working? What is not working? 4. Pick one area to focus on and which service will be provided: develop a long range outcome and a short range goal for the person.
What is a Crisis? What factors may contribute to creating a Crisis Essential Components of Crisis Planning Overview of Crisis Plan format
Immediate danger to self or others Danger and opportunity A real or perceived stressor without the tools/means to alleviate it
People go into crisis because: There is an identified or unidentified problem (ex: depression, anxiety, medical condition, etc) Stressors individual has limited coping skills to adequately/appropriately deal with the problem/stressor There is a misunderstanding/misinterpretation of what the actual problem is
Precipitating events: Increase the likelihood of challenging behavior occurring when trigger event is present (i.e., makes individual vulnerable) Ex: Tiredness, medical condition, boredom, recent loss or trauma, isolation, change in routine, transition, etc Triggers: The straw that broke the camel s back Usually, on their own, aren t a problem but under specific conditions (vulnerabilities) can directly result in a problematic situation
Several factors, or precipitating events, can potentially trigger a crisis situation: Environmental factors Social factors Medical/Physical factors Cognitive/Affective factors
Environmental Factors: Noise levels Temperature either too hot or too cold Lighting Spaces which are too small or too large Unfamiliar settings Social Factors: Places that are too crowded Too many conversations occurring simultaneously Strangers Unfamiliar social situations
Medical/Physical Factors: Physical discomfort headaches, allergies, constipation, pain, etc. Medication side effects Hormonal changes Fatigue (physical or social) Hunger/thirst Sexual frustration Cognitive/Affective Factors: Mental health symptoms Frightened, worried, anxious Sad or depressed Cognitive processing deficits Skills deficits
Essential Elements include: A proactive component that identifies early known warning signals and triggers of an impending crisis An intervention component for steps when the individual is experiencing emotional, physical or situational difficulties that interferes with his/her ability to manage immediate needs without assistance Information about the process or procedure that will be followed when a crisis event or emergency situation occurs, such as who to call as First Responder, what actions to take with the individual in crisis, and what crisis services or hospitals should be used. DMH/DD/SAS Policy Guidance-Development of Community Based Crisis Stabilization Services, 2005
Should be able to function on it s own Portability the plan must have the ability to move with the individual in the various settings in which they will interact Staff and family in all locations must be trained on prevention and response strategies Language should be understandable to all the people utilizing the plan Develop the plan with the individual, paid supports and natural supports
Crisis Planning is the development of supports which are flexible and which lessen the possibility of a situation or circumstance occurring in which the individual feels vulnerable Crisis Planning is proactive and includes preventative strategies Crisis Planning is not A plan for the physical management of an individual A strategy to control the behavior of a person
Environmental Modifications: Noise levels, temperature, etc. Social Modifications: Setting or type of activity, number of individuals included in a grouping, etc. Routine Modifications: Change of work hours, bedtime, staffing patterns, etc. The strategies which the person being supported identifies as being successful Respectful strategies for how to proceed when a situation is no longer safe
People with ID/DD are more likely than their typically developing peers to experience mental illness People with ID/DD are more likely than their typically developing peers to experience problems with physical health. Some mental illnesses manifest themselves differently in people with ID/DD Most people with ID/DD have different reactions to medications than those of their typically developing peers.
Crisis planning is ever changing and evolving What works one day, may not the next Continue to be observant and open minded It is ok to be wrong and have to adjust your plan Change plan as often as needed Don t under estimate the importance of documentation Document what happened prior to, during and directly after crisis.
Identify the Precipitating Event (Problem) and Behaviors Develop Preventative Strategies Develop Interventions Define the Emergency Protocol Debrief
Problems manifest differently in those with ID/DD than their typically developing peers. -Ex: depression, anxiety, OCD type symptoms, impulse control issues, seizures, trauma, etc. Identifying behavior Identify the early warning signs - behaviors that may not affect anyone other than the individual. Changes in affect, facial expression, body language, etc.
Behavior is communication. What is this person trying to tell you? Important to have a good understanding of the individual s cues. Different for everyone Sometimes difficult to identify
Regulating the environment and using preventative techniques are the key Strong emphasis on teaching replacement behaviors, tolerance and coping Increase the level of structure and organization in the individual s day Build breaks into the schedule Teach relaxation techniques as a regularly scheduled activity rather than when someone is visibly upset Develop activities that assist the individual with distinguishing behavior and emotion Be observant and creative in developing preventative strategies
Interventions should neutralize the trigger and address vulnerabilities Interventions should use individual s known strengths and interests whenever possible Should incorporate preventative and intervention strategies from Behavior Support Plan
Interventions include: o Manipulating setting/ environment, i.e, remove from chaotic/crowded room o Using objects, pictures or other non-verbal cues to ask for help, communicate problem o Talking/processing with individual o Allow for choices (do not give more than 2-3 at a time) o Ask individual to assist with a non-traditional task o Planned ignoring of negative behavior
Joe enjoys work and usually leaves the house without a problem. Today Joe starts to scream and slap his head when staff tell him it s time to leave for work. Historically Joe refuses activities and slaps his head when he has a headache. He has limited verbal communication skills and can t tell someone when he doesn t feel good. What is the precipitating event(s) and what is the trigger? Possible Interventions: 1. Assist Joe in communicating about headache 2. Modify request (can take day off) 3. Tylenol (treat headache) 4. Let Joe go to a quiet place room to lay down, listen to soothing music he enjoys
Know who to contact within your agency when you have questions/concerns during a crisis Contact mobile crisis management team in your area Contact NC START for further consultation and assistance Contact police as an absolute last resort
Debriefing should occur every time the plan is used Allows for the plan to evolve by reviewing what works or not and updating new information Provides the team the opportunity to discuss and learn from experience Keeps the team on the same page and invested Helps keep consistency in plan implementation Don t forget documentation!! *Other updates should occur as needed any time there is a change in the individual s condition or circumstance
Questions? NC START Central Team contact information: James Vann, Director 919-606-3872 Anne La Force, Clinical Director 919-418-3179 NC START Crisis Line: 1-800-662-7119 ext. 8730
NC SNAP registration procedures Provider staff notifies the local IDD Network Specialist (preferably by email) their request for training. The provider will be sent the Eligibility Determination for NC SNAP Training, the Registration for NC SNAP Training and the Training Schedule as provided by the Murdoch Center Training Coordinator. The Eligibility Determination for NC SNAP Training Form and the Registration Form are completed in full by the provider and returned to the IDD Network Specialist. The Eligibility Determination form is returned to the IDD Network Specialist who reviews the information and determines if the requesting person meets the requirements of a QDDP. The IDD Network Specialist emails the requestor with the results.
NC SNAP registration procedures (cont.) If the requestor is approved for the training, the IDD Network Specialist then sends the Registration request to the Murdoch Center Training Center Coordinator The Murdoch Center Training Coordinator sends a confirmation letter to the IDD Network Specialist who in turn sends this confirmation to the Provider Agency staff who requested the training.
B3 Services These services are available to those who have Medicaid The two services available for individuals with I/DD starting January 1, 2013 are: Community Guide Respite B3 services will be submitted to the I/DD Utilization Management Department for Prior Approval
Community Guide Each MCO is given Medicaid funding for B3 services An Individual on NC Innovations will not use B3 Community Guide funding NC Innovations Community Guide is part of the annual individual budget
Community Guide The Community Guide assists individuals in locating and coordinating community resources and activities. They assist and support, rather than direct and manage There are specific functions of the community guide such as: assistance in accessing and locating non-medicaid supports supporting the individual in preparing for their IEP assistance with finding a place to rent or purchase
Community Guide Community Guide services are intermittent and fade as community connections are made This service does not duplicate administrative functions of Care Coordination such as: Referral to services Plan development Requesting medical supplies Community Guide will inform the MCO of health and safety issues that are not being addressed
Respite Just like Community Guide, an individual on NC Innovations will not use B3 Respite funding NC Innovations Respite is part of the annual individual budget Respite services provide periodic support and relief to the primary caregiver(s) from the responsibility and stress of caring for the individual It has not been determined yet on how this service will be authorized except that prior authorization is needed
IDD Access and Care Coordination IDD Provider Training August 28, 2012 A New Multi-County Area Authority Merging The Durham Center and Wake LME
IDD Access Coordination Alliance will have 6 IDD Access Coordinators: Part of Customer Services Call Center Complete screenings and gather documentation for individuals seeking IDD Services Present information to IDD Eligibility Review Committee Maintain wait lists and Registry of Unmet Needs Make referrals when resources are available and/or as openings occur Provide information to consumers and family members about available community resources and supports A New Multi-County Area Authority Merging The Durham Center and Wake LME
IDD Care Coordination Alliance will have 48 IDD Care Coordinators: Work out of local offices and in each community Durham 11 Wake 20 Cumberland 12 Johnston 5 Each participant of NC Innovations will have an IDD Care Coordinator who assesses need, develops plan, arranges services, monitors for health, safety, quality, satisfaction, and assures that waiver requirements are met. A New Multi-County Area Authority Merging The Durham Center and Wake LME
IDD Care Coordination (cont d) Provide shorter term crisis response and intervention to non-innovations recipients Caseload size is expected to be 35 40 Firewall at time of authorization requests between Care Coordination and UM Care Management Vacancies for Access and Care Coordinators are currently posted Goal is to be fully staffed by November 1 A New Multi-County Area Authority Merging The Durham Center and Wake LME
Conclusion Questions? Comments?