OSSA/Brokerage Positions on K Plan Implementation; DHS Response to Concerns

On June 12th, 2013, several brokerage directors met with Erinn Kelley-Siel (Director of the Department of Human Services), Tricia Baxter (Chief Operating Officer for Aging and Disability Programs) and Patrice Botsford (Director of the Oregon Office of Developmental Disabilities Services) to discuss concerns related to planned changes to services for brokerage customers and individuals throughout the system. During the meeting, we shared a formal position document (see below*) outlining concerns, questions, and recommendations. Given the significant amount of systems change occurring in Oregon right now, the paper touched only on high level, immediate issues.Within a week of that meeting, Erinn, Tricia, and Patrice followed up in writing on each of our concerns and their responses are included below. Some questions have now been answered and others are still in process. We appreciate the Department's willingness to meet with us, their openness to feedback and input from the field and we look forward to regular, ongoing engagement on forthcoming changes and implementation strategies.________________________________

*Positions and Recommendations on the K Plan, Its Implementation, and Additional Department-mandated Changes (June 2013)

OSSA (Oregon Support Services Association) is a non-profit organization comprising the thirteen support services brokerages in Oregon. Collectively, the association represents over 7,000 adults with intellectual and/or developmental disabilities (I/DD) who live independently throughout Oregon's 36 counties. Brokerages have been in operation since 2001 and OSSA since 2010.We envision a world in which all people live the life they choose in communities where they are valued, respected, and honored. In this world, individual strengths are celebrated; high quality supports are ample and readily available; labels are absent; and self determination is universal. This vision is realized from neighbor to legislator.Present Situation: Community First Choice State Plan (K Plan) ImplementationIn June of 2013, responding to budgetary shortfalls and weak findings from a statewide CMS audit, the Oregon Office on Developmental Disabilities (ODDS) sent its Community First Choice State Plan Option K (K Plan) application to the federal government for approval. The K Plan, if approved, will bring a 6% increase in federal match funds to Oregon. ODDS has formed workgroups and brokerage representatives have participated over the last month and a half.This paper is an effort to capture the support services brokerage perspective in a publicly available set of thoughts, concerns, and issues surrounding the K Plan and its implementation in Oregon.OSSA supports many of the aims of implementing the K Plan including:

• Bringing additional federal funding into our state to preserve services for Oregonians with support needs
• Developing options for fluidity and portability across service elements
• Expanding of choice to the I/DD community

Additionally, OSSA has specific concerns about current implementation strategies including:

• Ensuring the principles of self-determination are at the foundation of implementation
• Offering true choice in Targeted Case Management across the system
• Lack of extensive testing of the Functional Needs Assessment prior to implementation and the potential repercussions on populations (e.g. people with autism) whose needs it may fail to capture
• Quality assurance review and customer/brokerage authorization of services prior to provider payment
• Significant loss of flexibility caused by changing from annual benefit levels to monthly fixed allotments
• Long term fiscal sustainability

Ensuring the Principles of Self-determination are at the Foundation of ImplementationIn developing a new service delivery model, it is important to validate the importance of self-determination as the cornerstone of Support Services, and not just a salvaged component of yesterday’s service delivery model. We support a model that honors the aspirations of the individuals while adhering to the funding criteria that brings needed federal matching funds to Oregon’s Medicaid funded programs.We believe that there is room for both. A person centered service delivery model based upon the principles of self-determination relying upon a Functional Needs Assessment to determine the disability related supports that are available in pursuit of life goals is a workable model.Recommendation: We recommend that ODDS continue to commit to retaining the principles of self-determination as defined in statute and rule to drive planning and implementation of the Community First Choice State Plan Option K. We recommend that the Functional Needs Assessment exist in a supportive role to determine those disability-related expenditures available in support of self-determined life goals.

DHS Response: The Department agrees. Person-centered planning and self-determination are foundations of the I/DD system. Although the functional needs assessment is required, plans will continue to be developed in support of an individual’s life goals with the functional needs assessment driving the ADL and IADL supports necessary to support the individual in achievement of their goals.

True Choice in Targeted Case Management Across the SystemIn the current system, CDDPs provide Targeted Case Management (TCM) to children and adults receiving comprehensive care. In addition, they serve a small number of people receiving In-Home Comprehensive Services. Brokerages currently provide TCM exclusively to adults with I/DD who live independently in the community (support services).Over the past couple of months, ODDS representatives have stated that CMS is "mandating choice in who provides TCM" under the K Plan. We are told that, per CMS mandate, customers must now be offered the choice of a CDDP case manager OR brokerage Personal Agent for support services.When reviewing the system as described we find the decision to offer choice only in one area (support services) puzzling and inconsistent. As you see below, choice is decidedly limited to just one subset of the recipient base - the program recipients brokerages currently serve. Recipients in all other service elements continue to have no choice in who provides TCM.

	Brokerage Provides TCM	CDDP Provides TCM
Support Services	●	●
In Home Comprehensive		●
Residential		●
Supported Living		●
"Not in Service" Case Management		●
Child Case Management		●
Family Support		●

The vast majority of brokerage customers currently have at least two different entities providing Targeted Case Management to choose from. Many have four or five choices. Customers in every other service delivery program in the state currently have no choice. The proposed change marginally increases choice for a small percentage of brokerage customers while continuing to leave half or more of Oregon’s I/DD population with no choice whatsoever.Further, we are concerned about conflict of interest free choice counseling under the new proposal. We understand that there have been conversations about third party choice counsel for people entering adult services. While we welcome any attempted neutral approach to assuring appropriate counsel, we are concerned about the viability of neutrality in a system that offers choice only to a select group.An example: We think this model's flaws are particularly evident during the period when recipients transition from child to adult services. Turning 18 is a time of enormous stress and change for an individual and his/her family. They are dealing with becoming their own decision-maker, an independent signer and they no longer have a de facto guardian. Further, they are applying for Social Security, updating their Medicaid status and possibly undergoing additional eligibility testing related to their I/DD diagnosis. Additional changes, particularly changing case managers, during such a period of upheaval seems an unlikely preference for most families. Real choice should be offered from the beginning so that people have time to form and maintain their relationship with their case manager, be they from the CDDP or the brokerage.Recommendation: We recommend that ODDS provide universal choice by permitting brokerages to provide targeted case management in all service elements serving people with I/DD (including children). In the absence of full choice, we believe ODDS should create a distinction between CDDP and brokerage case management by assigning facility-based services to CDDPs and community-based adult services to brokerages. Our recommendation is consistent with the Oregon IDD Coalition's recommendation on this topic.

 DHS Response: There is a statutory change that would be required in order to allow brokerages to serve children under the age of 18. However, as noted in the revisions to the chart (below), brokerages will be allowed to serve In-Home Comprehensive and “Not in Service” Case Management individuals. Residential and Supported Living services are to be phased in at a later date. It is the intent of ODDS that brokerages will be allowed to serve these populations within the next 12 months. Full choice of service providers (CDDP or Brokerage) will be given to individuals in all areas, with the exception of services related to children. This is a statutory change that can be explored during a future legislative session if so desired.

ODDS has added updates to the chart. Please see below:

	Brokerage Provides TCM	CDDP Provides TCM
Support Services	●	●
In Home Comprehensive	7/1/13	●
Residential	7/1/14	●
Supported Living	7/1/14	●
"Not in Service" Case Management	7/1/13	●
Child Case Management	Planned, pending statute change	●
Family Support	Planned, pending statute change	●

Functional Needs Assessment Development and TestingODDS representatives have been developing a new Functional Needs Assessment tool (FNA). Under the K Plan, services and supports are based upon a tool designed to determine a number of hours of service. Because this is a Medicaid requirement, it has been placed front and center as the driver of services. While we respect the necessity of the FNA, we believe the drivers of services should continue to be self-determination and the individual’s aspirations for his or her own life.A person centered planning process based upon self determination is first and fundamental. From there, the FNA acts as the funding mechanism enabling the provision of disability-related supports to meet the aspirational goals of the individual, not the other way around.We believe that an assessment tool intended to be placed at the center of all individual service decisions should be supported by comprehensive testing and computer modeling prior to implementation. The FNA has not yet been subjected to either. Data and real-word application should be established in advance of placing thousands of individual lives at the mercy of any assessment mechanism.  We have particularly strong concerns that some needs related to autism, behavioral and psychosexual disorders in particular will not be effectively articulated in the FNA form. Testing will allow for thoughtful examination of the value the FNA may bring to our Employment First and Executive Order requirements.Our understanding is that the FNA will not be linked to rates on the comprehensive services (24/7) side during initial phases of implementation. We support this approach and ask that similar caution be taken on the support services side. Such an approach allows for testing and modification without disrupting the lives of recipients or the businesses of those who serve and support them.A great many of our customers have exactly the same needs as those in 24/7 settings such as group homes and foster care homes. While the average brokerage customer has a budget of $14,000 per year, a full 7% of our customer base has been assessed through the Base Supplement Criteria Inventory process. They receive an enhanced budget between $20,000 and $24,500 per year due to extensive needs with personal care, caregiver capacity, behavioral support needs, and other high level support with activities of daily living.Recommendation: We recommend a minimum 20% sampling of brokerage customers be tested to prior to formal implementation to determine a baseline from which to budget and consider future options, as well as to address employment and specific disability support issues. It seems the legislature and other administrative staff would require something of this sort in order to budget appropriately for Oregon's future. There are very real fiscal and human repercussions at play here. We will partner in any way possible to help Oregon achieve this aim.

DHS Response: The department agrees that the new functional needs assessment is going to need extensive field testing and we appreciate the offer of brokerages to assist in this effort. We anticipate having a draft ready for some testing as early as the week of June 24. Testing the tool with individuals that we already know will be of great benefit. Initially the new assessment will be used for new people coming into service, and for existing individuals as their assessment renewal is due. This needs to begin on July 1, assuming CMS approval for a July 1 effective date, however, we know that the tool will be a work in progress and will need modifications as we gain experience in utilizing the tool with the I/DD population.

Pre-Payment Review and Quality Assurance Since brokerages first began operation in 2001, we have always practiced high standards of quality assurance by reviewing direct services documentation prior to payment to qualified providers. Every single invoice, timesheet or bill is reviewed by the Personal Agent prior to payment. In order for us to move forward with payment, we must confirm:Customer (or legal designee) signature confirming services

• Progress notes confirming Medicaid-allowable services and how they relate back to the individual's disability-related support need and person-centered goal
• Units, rates, and dates that fall within the terms of the service agreement between the customer and the provider

The review of these invoices offers an immediate opportunity for education, feedback and correction when necessary. We currently employ a proactive approach and work with the customer and provider to assure CMS and state mandates are met. Not a single invoice, timesheet or vendor bill is paid in any of our thirteen organizations without thorough review and vetting.This process permits us to do everything from fixing a basic pro-ration error to identifying fraud. Close review of these documents has led to protective service investigations, sanctioning of fraudulent providers, and the immediate intervention to address health and safety concerns.Currently, these strong quality assurance mechanisms are at risk for a major change. As ODDS moves the brokerage plan of care into its payment system (eXPRS) there has been serious consideration given to permitting providers to go directly into the system to claim payment, bypassing essential quality assurance review and oversight. We have been told that we could do a "statistical sampling every three months or so" and follow up on errors after the fact.We strongly object to a pay and chase system such as this and believe it's at odds with CMS' general shift over the past several years. By reviewing these documents ahead of time, we're playing a proactive role not a reactive one. We believe this approach is consistent with the Department's core values and practices.Recommendation: As fellow custodians of public funds and strong believers of fiscal accountability, we urge ODDS to continue to permit brokerages to provide quality review on 100% of invoices, timesheets and bills received prior to payment to providers through the state's payment system. The current processes within the brokerages have been proven to be principled and effective in financial management. 

DHS Response: The department has already revisited this decision and will be building functionality into the eXPRS system to allow for review and approval by brokerage staff prior to payment being issued. Brokerages will be able to determine their business process for accomplishing this task, including requiring customer authorization, invoices, etc. No payments will be issued without brokerage staff review and approval.

Monthly Fixed Allotments Versus Annual BenefitsIn the current system, when a brokerage customer enters services, he/she has an annual benefit amount of around $14,000. She can purchase supports when she likes, as required based on disability-related needs. This sometimes means  she needs zero services for X months and then needs a significant number of services during, say, the summer. The current system allows for her to utilize her services when she needs them based on current availability of resources both paid and not paid.Under the K Plan, there's no such thing as an annual benefit cap. The Functional Needs Assessment (FNA) determines how many hours a person is eligible for per month. If you don't use it, you lose it. For twelve years, brokerage customers have been operating under the annual benefit and have enjoyed the flexibility to meet real-life needs such a system allowed. In our discussions with customers and family members, this is a primary area of concern right now.Recommendation: We understand that the monthly versus annual budgeting model is an Oregon design decision and not something mandated by CMS under the K Plan. We recommend maintaining utmost flexibility for those receiving services and therefore a customer budget developed on an annual basis. Programs should be crafted to fit the needs of people. When we attempt the inverse, the system can't meet needs in the moment and small issues become compounded. People lose options and control.

DHS Response: With the implementation of the “K” State Plan Option, individuals will receive the supports that they need each month. In essence, the idea of monthly or annual budgets goes away – individuals will be authorized for services determined to be necessary through the functional needs and service planning processes. This means individuals with support services can budget at an annual level if that works best for them.

Long Term Fiscal Sustainability ConcernsPrior to 2001, services for adults with I/DD in Oregon were pretty much limited to those with significant need. People living independently (with family or on their own in the community) received very little by way of services and this resulted in a lawsuit brought by concerned families (Staley v. Kitzhaber.) As a result of the 2000 Staley Agreement, a new way of providing services was born. Enter the brokerage system. Well over 7,000 people have enrolled in brokerage community-based services statewide in the last decade. Most people have somewhere around $12,000 to $14,000 available to them annually through their brokerage. This model doesn't provide for every single need - but it does provide support to every single eligible individual.Our concern is this: We serve people with very significant support needs, far beyond anything brokerages can fund. Family members, neighbors, friends, partners, community members and spouses play a role in each person's support system. They provide natural supports to the individual to ensure his/her success without creating dependency on a paid system. A person, whose plan is currently $14,000 per year, could easily be reassessed and suddenly that plan will pencil out to $75,000. Conversely, those with $14,000 today could shrink to $3,000 tomorrow.While we absolutely support the concept of providing disability-related support wherever needed, we must also consider what our budget can sustain over time. Proper assessment of available natural supports is key to the long-term sustainability of our service delivery system.How do we avoid reinventing the system we deconstructed just a little over a decade ago? If costs grow beyond what Oregon's budget can handle, what happens? Do we start re-determining eligibility for these services? Do we start leveling individuals? Do we begin eliminating people from accessing services (as we did with General Fund customers) so that they go back to relying on emergency state and county systems? Do we say "this year we serve people in levels 1 - 12, but next year we can only serve 1 - 10?" Oregon has done it before with Oregon Health Plan and we fear it will happen again here. Do we recreate a system where we can only afford to serve Oregonians with the highest needs while categorically denying services to those with perceived "lesser needs"?One of the most fantastic features of brokerage services has been creating an environment where individuals who had little exposure, integration and inclusion in their communities were finally afforded the opportunity (via disability-related supports) to fully participate. That has been of immeasurable benefit not only to the individuals who are now participating, but to society as a whole. When communities are exposed to people with I/DD, societal opinions, prejudices and assumptions change. We have thousands of people with limited support needs now engaging and flourishing in their communities. We cannot roll backwards - we must ensure the new system serves all people with I/DD, no matter how "limited" their support needs might seem to the outside world. Oregon has made promises to this population and we must make good on them.Recommendation: Again, we recommend extensive testing on the Functional Needs Assessment prior to formal implementation.

DHS Response: The department shares this concern and will be watching expenditures very carefully. Our hope is that we will be able to serve more individuals in the community, costing the state less in the long run. Thorough testing and ongoing review of the assessment tool and associated service plans will be a must.

Closing CommentsThe Oregon Support Services Association membership has effectively managed significant changes throughout the twelve year history of brokerage services. Today, change is present on all fronts. We are prepared as always to adapt to the next system. By communicating concerns and offering solutions, we hope to create a dialogue whose end result maintains and hopefully enhances services for the more than 7,000 adults with I/DD we currently serve.Download a PDF of the Position Paper and DHS's response here: DHS Response to Position Paper from Support Service Brokerages 6 18 13