CMS Settings Rule Part B: Employment and Person Centered Planning Brackin & Associates Laura Brackin, PhD Nancy Robertson
Learning Objectives Participants will learn: the intent of the CMS rule major highlights of the rule The person centered planning requirements Assuring integration What do I do now 2
Person- Centered Planning
Person-Centered Planning Requirements The plans for 1915(c) and 1915(i) must be person-centered: Process - The process is driven by the individual People - Includes people chosen by the individual Directed by Individual - Provides necessary information and support to the individual to ensure that the individual directs the process to the maximum extent possible
Person-Centered Planning Requirements Times/Location - Is timely and occurs at times and locations of convenience to the individual Culture/Language - Reflects cultural considerations/uses plain language Disagreements - Includes strategies for solving disagreements Choice - Offers choices to the individual regarding services and supports the individual receives and from whom Updates - Provides method to request updates
Person-Centered Planning Personal Preferences - Conducted to reflect what is important to the individual to ensure delivery of services in a manner reflecting personal preferences and ensuring health and welfare Identifies Key Areas Strengths Preferences Clinical needs Support needs Desired goals and outcomes Requirements Self-Directed - May include whether and what services are selfdirected
Person-Centered Planning Risk - Includes risk factors and plans to minimize them Goals - Includes individually identified goals and preferences related to: Relationships Community participation Employment Income and savings Healthcare and wellness Education and other Requirements
Written Plans Must Reflect Setting - Setting is chosen by the individual and is integrated in, and supports full access to the greater community Employment - Opportunities to seek employment and work in competitive integrated settings Community Life - Opportunity to engage in community life, control personal resources and receive services in the community to the same degree of access as individuals not receiving HCBS
Written Plan Requirements Reflects Key Areas - Strengths Preferences Clinical needs Support needs Desired goals and outcomes Providers Providers of services/supports, including unpaid supports provided voluntarily in lieu of waiver or state plan HCBS
Written Plan Requirements Risk Risk factors and measures are in place to minimize risk Backup Plans Individualized backup plans and strategies Important Individuals Individuals important in supporting the individual Monitoring Individuals responsible for monitoring the plan
Written Plan Requirements Language Plan must be written in plain language and understandable to the individual Monitoring Plan must identify who is responsible for monitoring the plan Informed Consent Plan must confirm IN WRITING that the individual gave informed consent Signatures Plan must include signatures of all individuals and providers responsible
Written Plan Requirements Copy of Plan - A copy of the plan must be provided to the individual and his/her representative Distribution of Plan Plan must be distributed to the individual and others involved in the plan Self-Directed Services When applicable, plan must include information on purchase/control of self-directed services Unnecessary Services Plan must exclude unnecessary or inappropriate services and supports
Written Plan Requirements Setting Modifications - Plan must document any modifications to the settings requirements ALSO Final Rule includes requirements for reviews and revisions of plans. Plans must be reviewed and revised: Upon reassessment of functional need as required every 12 months When the individual s circumstances or needs change significantly At the request of the individual
Conflict of Interest Guidelines and Strategies The plan must include strategies for solving conflict or disagreement within the process, including clear conflict-of-interest guidelines for all planning participants Providers of HCBS for the individual, or those who have a interest in or are employed by a provider of HCBS for the individual must not provide case management or develop the person-centered service plan, except when the State demonstrates that the only willing and qualified entity to provide case management and/or develop person-centered service plans in a geographic area also provides HCBS.
Conflict of Interest Where there is conflict of interest. Protection - The State must devise conflict of interest protections including separation of entity and provider functions within provider entities which must be approved by CMS. Alternative Process - Individuals must be provided with a clear and accessible alternative dispute resolution process. CMS stated: We agree that complete independence of the person(s) facilitation the planning process is important to promote the statutory objectives.
Assuring Integration What will need to be evaluated?
Standards to Assess Settings that Optimize Integration Physical environment allows unplanned interaction with non-disabled peers throughout the day Physical environment allows occasional unplanned interaction with non-disabled individuals Physical environment offers no opportunity for unplanned interaction with non-disabled individuals; requires planned interaction
What Does Integration Look Like? Activity Example Work/Volunteer work Learning Recreation Shopping Work on political campaign; volunteer at soup kitchen or kennel The same planned activities in the Books on tape; adult classes; self-help classes home community within all of life s togethers; movies; gambling; shows; activity domains: Having fun/a social life; getting together with friends; going out; peer get Grocery, clothes, other Health and Wellness Personal Care Maintaining Home Caring for Others Walking; gym membership; diet groups Hairstyling; having nails done Maintenance and improvement; cleaning; laundry Relatives, friends, others Spirituality Hobbies Worship; meditation; yoga classes; meeting groups; sodalities Pet care; walking the dog
What Does Integration Look Like? Integration means having the same unplanned interactions that others have: Run to the store to pick something up Borrow something from the neighbor Walk to the bus stop Shovel snow for the woman next door (or help pick up tree limbs after a hurricane) Walking the dog around the block and running into strangers and saying hello Hanging out at the pizza parlor Picking up the newspaper that was just delivered and saying hi to the delivery man Answering the door when the boy scouts are collecting for the food drive
Assuring Integration It means evaluating that the state must evaluate: Program Policies Payment and Billing Planning Processes Quality Management
Assuring Integration Program Policies Program Policies Regulations governing providers and practices Service definitions and standards Provider qualifications Training requirements
Payment and Billing Policies Rate methodology Assuring Integration Payment & Billing; Planning Incentives and disincentives for compliance - Adequacy of rates to achieve desired outcomes - Paying for specific activities and the delivery of outcomes Planning Processes Person centered planning, including assessment and planning requirements does it support compliance with the standard?
Assuring Integration Quality Management Quality Management Quality Oversight Individual plan monitoring requirements Provider monitoring Provider reporting requirements Performance outcome measurement
And Then Waiver and state plans - May need to be modified based on results of the review Information Systems - Modifications may be needed to implement changes to state policies and practices as well as reporting requirements Assess Current Services - To determine the extent to which the state s standards are being met and in order to develop a transition plan to change services but set the standards first
What Do I Do Now? Don t worry!
What Do I Do Now? Educate Educate yourself and others about: the new rule the requirements on individual choice The requirements on person-centered services plans Identify Identify any new applications or request for renewed or amended 1915 (c) waivers and 1915 (i) or (k) options expected by March 17, 2015
What Do I Do Now? Advise Advise the state on the process to use for assessing HCBS system Evaluate Evaluate your own programs, services, and processes to determine what changes might need to be made. Prepare Comments - Don t wait for the 30 day comment period on the plan. Make suggestions of changes needed to qualify for HCBS funding.
What Do I Do Now? Comment - Once transition plans are posted for comment, send in more comments, this time focus on whether the plan is accurate, comprehensive, and realistic Watch Watch for a second comment period. If a state makes substantive changes to a transition plan, they must allow for a second period of public comment.
How do I evaluate my programs? 29
In a program. Person centered. Decisions driven by staff and professionals Decisions driven by the individual and his/her support network Programs vs Person Centered Planning occurs as a singular event, according to a prescribed format The person s goals are defined within the context of the program Planning is on-going and individualized The person s goals are defined within the context of a holistic plan Specialized supports are the first response to meeting individual needs Staff take the place of natural supports Generic supports are the first response Staff augment natural supports There is a pre-set schedule of activities that people take part in (or don t) Individuals develop their own personal schedule based on their 2014 goals National Convention 30
In a program. Person centered. Staffing is provided at pre-set times according to a fixed schedule Staffing is provided flexibly Focus on participation Focus on increased independence Focus on group needs Staff skills determine the selection of activities Focus on individual needs Preferred activities inform the selection of staff with appropriate skills Support is tied to the program the person can t take their support with them if they leave the program Services are portable the person can take their support and change service providers if they so choose. 31
Consider Rules That Get In The Way AWOL protocol Restroom rules Program start and end time Conflict resolution Attendance records for billing Behavior programs Fee structure 32
Strategic Change Organizational Culture & Leadership Shift to person centered approach Set culture of learning and leadership Evaluate policies and practices that limit choice, control, and flexibility Identify state and federal barriers and communicate those advocate for change Support Level (paid and unpaid) Communicate Provide training and resources (easily accessible) Individual Level strengthen capacity of individuals to develop relationships, networks and community partnerships 33
Sources & Resources
CMS Sources Date Informational Bulletin Final Rule CMS 2249-F 1915(i) State Plan HCBS Services, 5-Year Period for Waivers, Provider Payment Reassignment, and HCBS Setting Requirements for Community First Choice, and CMS 2296-F 1915(c) HCBS Waivers Press Release HHS Strengthens Community Living Options for Older Americans and People with Disabilities January 10, 2014 January 10, 2014 Fact Sheet HCBS Overview and Key Provisions January 10, 2014 Fact Sheet Summary of Key Provisions of the 1915(c) HCBS Waivers Final Rule January 10, 2014 Fact Sheet Summary of Key Provisions of Final Rule for 1915(i) HCBS State Plan Option January 10, 2014 Fact Sheet - Summary of Key Provisions of the HCBS Settings Final Rule January 10, 2014 Final Rule - 1915(i) State Plan HCBS, 5-year Period for Waivers, Provider Payment Reassignment, Setting Requirements for Community First Choice, and HCBS Waivers Webinar Final Rule Medicaid HCBS January 16, 2014 Unknown Document Questions and Answers 1915 (i) State Plan HCBS, 5-Year Period for Waivers, Provider Payment Reassignment, Setting Requirements for Community First Choice, and 1915(c) HCBS Waivers CMS 2249-F and 2296-F Unknown
CMS Toolkit Date Informational Bulletin HCBS 1915(c) Waiver and 1915(i) SPA Settings Requirements Compliance Toolkit March 20, 2014 Regulatory requirements for HCB Settings March 20, 2014 Incorporation of Heightened Scrutiny in the Standard Waiver Process March 20, 2014 Steps to Compliance for HCBS Settings Requirements in a 1915(c) Waiver and 1915(i) SPA March 20, 2014 Guidance on Settings that Have the Effect of Isolating Individuals Receiving HCBS From the Broader Community March 20, 2014 Exploratory Questions to Assist States in Assessment of Residential Settings March 20, 2014 Additional CMS Resources Date Letter to State Medicaid Director - Improving Access to HCBS: 1915(i) changes made by the Affordable Care Act (ACA) August 6, 2010 Informational Bulletin Updates to the 1915(c) Waiver Instructions and Technical Guide Regarding Employment and Employment Related Services September 16, 2011 Modifications to Quality Measures and Reporting in 1915(c) HCBS Waivers March 12, 2014
Title Source Implications of HCBS Final Rule on Non-Residential Settings Archived Webinar Just Like Home: An Advocate s Guide to Consumer Rights in Medicaid HCBS Overview of the New HCBS Rules U.S. Department of Labor, Office of Disability Employment Policy (ODEP), 2014 National Senior Citizens Law Center (NSCLC), May 2014 National Association of State Directors of Developmental Disability Services (NASDDDS), March 2014 Home and Community Based Settings: A Primer Q & A HCBS Final Rule Issue Brief: CMS Final Rule on HCBS Settings Advocacy Checklist & Resources for Impacting State Compliance with Medicaid HCBS Settings Rule, National Health Law Program (NHeLP), February 2014 National Health Law Program (NHeLP), February 2014 Association of University Centers on Disabilities (AUCD), January 13, 2014 DD Network, May 2014 HCBS Worksheet for Assessing Services and Settings DD Network, May 2014 The 2014 Federal Home and Community-Based Service Regulation: What You Need to Know The Arc United States, 2014
Questions?