1

Day Services and The Transition Plan

2

The Regulation

• Effective March 17, 2014

•  Identifies the characteristics of home and community based services (HCBS) settings

•  Identifies settings that are not home and community based

• Outlines timelines for states to submit transition plans to the Centers for Medicare and Medicaid Services (CMS) to ensure compliance

3

HCBS Characteristics •  Integrated in and supports full access to the

greater community • Selected by the individual among setting options

including non-disability-specific settings • Ensures the rights of privacy, dignity and

respect, and freedom from coercion/restraint • Optimizes, but does not regiment, individual

initiative, autonomy, and independence in life choices

• Facilitates choice in services and who provides them

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Settings not HCB

•  Nursing facilities

•  Institutions for mental disease

•  Intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs)

•  Hospitals

•  Any other setting with the qualities of an institutional setting

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Institutional Qualities •  Located in a building that is also a publicly or

privately operated facility that provides inpatient institutional treatment

•  Located in a building on the grounds of or adjacent to a public institution

•  Any other setting that has the effect of isolating individuals from the broader community UNLESS the Secretary determines through heightened scrutiny that the setting does not have institutional qualities and does have home and community-based qualities

6

Coming into Compliance New rules:

•  Free Choice of Provider Rule Revision – 4/1/15 –  Describe the assistance individuals may receive

–  Ensuring county boards help recruit new providers, where needed

•  New HCBS Waiver Administration Rule – 6/1/15 –  Describes settings where services can/cannot be provided

–  Emphasizes least restrictive services to meet individuals’ needs

•  New Personal Funds Rule – 6/1/15

Ongoing compliance:

•  Develop new HCBS settings evaluation tool – 6/1/15

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Coming into Compliance Waiver changes:

•  Phase-out of the Transitions DD (TDD) Waiver – 7/1/15 through 6/30/17 –  Adding nursing to IO Waiver – 7/1/16

•  Revised Homemaker/Personal Care definition – 7/1/16

•  Revised Adult Day Waiver Services – 7/1/16 –  Supported Employment – Individual

–  Integrated Prevocational Services

–  Integrated Day Supports

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Coming into Compliance Residential Settings

•  No setting has been determined unable to comply

•  Providers will be asked to submit plans to come into compliance by 7/1/15

•  DODD will visit locations –  4 settings who questioned if they could comply – visit by 9/1/15

–  578 settings who think they can comply within 5 years •  Visit 50% by 7/1/16

•  Visit remaining 50% by 7/1/17

–  73 settings that may require permission by CMS to operate – visit by 12/1/16

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Coming into Compliance Day Settings

•  No setting has been determined unable to comply

•  Providers will be asked to submit plans to come into compliance by 7/1/15

•  DODD will visit locations –  14 settings who questioned if they could comply – visit by 6/1/15

–  50 settings who think they can comply within 5 years •  Visit 50% by 7/1/16

•  Visit remaining 50% by 7/1/17

–  Remaining settings that may require permission by CMS to operate – visit by 12/1/17

•  All individuals transitioned to new day services by 3/1/24

10

Coming into Compliance DODD priorities

•  Making sure providers submit plans for compliance

•  Visiting locations to see how providers are implementing compliance plans

•  Working with individuals/providers on strategies to help them comply

•  Working with individuals/providers to gather evidence to send to CMS for heightened scrutiny to show how settings do have home and community based characteristics

•  Making sure county boards help individuals find new settings and/or providers if relocation from a day or residential setting is required

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Common Questions Does this new rule mean that all current day programs have to close?

•  NO – This rule requires that all individuals, regardless of where they receive services, must have the opportunity to participate in community-based activities to the greatest extent possible. As a result, existing providers of day services may need to change how services are offered in order to comply with the rule. Some providers have already started making changes to how they do business that both comply with the rule and offer individuals served new and creative opportunities.

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Common Questions Does “participating in community-based activities” mean that the existing facilities cannot be used and that everyone must spend the entire day in other community-based places?

•  NO – Each person’s level of participation in community-based activities will be determined through the person-centered planning process. For example, some individuals may require a place where medical care can be provided or personal care needs are met. However, all people, even those with complex medical or behavioral needs should be offered the opportunity to access the community and get to know other people who may not attend or work at the day program.

13

Common Questions Does the new rule require everyone to work?

•  NO – The new rule requires everyone to have access to the broader community to the same extent as people without disabilities, including opportunities for employment. However, some people don’t have enough information about working to know if they want to do it or not. For others, work is not a priority. The new services are being designed to give people who want to work the opportunity to do so and also to offer other services they may enjoy when not working.

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Common Questions Will people get fewer hours of service than they do today if they don’t want to participate in community-based activities 100% of the time?

•  NO – A fundamental principle of the employment and day service redesign was that individuals will have the same level of service/support available under the new services as they do today.

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Common Questions Will people be able to keep their current providers?

•  People who are currently receiving day services from private providers will be able to continue working with those providers, as long as the setting in which services are provided meets the rule requirements.

•  Due a provision in the rule that prevents providers from also being responsible for case management activities, individuals will not be able to receive both SSA (case management) and day services from the county board. DODD has asked CMS for the ability to transition services from boards to private providers by March 2024.

FUNDING SYSTEM RE-DESIGN FOR EMPLOYMENT AND DAY SERVICES Where%Are%We%Now%and%How%Will%We%Move%Forward?%

16#

•  DODD%has%contracted%with%two%policy%and%systems%change%experts,%Allan%I.%Bergman%and%Lisa%Mills,%PhD%to%review%current%funding%system%for%day%and%employment%services%

•  This%process%dovetails%with%the%CMS%Transition%Plan%Work%for%HCBS%Settings%compliance%

FUNDING RE-ALIGNMENT PROCESS

17#

•  Researched%multiple%states%with%high%performance%in%integrated%employment%and%day%services%

•  Report%can%be%found%at%www.ohioemploymentfirst.org%

FUNDING RE-ALIGNMENT PROCESS

18#

•  Twelve%Community%forum%meetings%held%to%seek%input%and%feedback%

•  More%than%700%stakeholders%attended%%

•  Feedback%shaped%the%Guiding%Principles%for%Funding%System%RePdesign%

FUNDING RE-ALIGNMENT PROCESS

19#

•  Laura%Zureich,%Shelby/Champaign%DD%•  John%Pekar,%Fairfield/Vinton%DD%•  Jason%Umstot,%OPRA%•  Chris%Filler,%OCALI%•  Pete%Moore,%OACB%•  Dan%Ottke,%Clermont%DD%•  Brenda%Smith,%OAAS%•  Greg%Dormer,%OOD%•  Vic%Gable,%Wood%DD/Ohio%APSE%•  David%Reichert,%Cuyahoga%DD%•  Rick%Black,%Butler%DD%•  Carmen%Shelton,%selfPadvocate%•  Mary%Vail,%Goodwill%Columbus%•  Steve%Koons,%Cincinnati%Goodwill%•  Lori%Horvath,%Clay%Weidner,%Greg%Swart,%Kristen%

Helling,%Debbie%Hoffine,%DODD%

WORKGROUP PARTICIPANTS

20#

•  Consider%what%the%Ohio%employment/day%service%array%should%include%

•  Develop%recommendations%for%service%definitions,%provider%qualifications%and%rate%methodologies%

WORKGROUP CHARGE

21#

•  Eight%%workgroup%meetings%(October%2014PMarch%2015)%

•  60%workgroup%facePtoPface%hours%•  Assignments%between%meetings%%

WORKGROUP TIME LINE

22#

Service#Definitions#and#Array#

Provider#and#Staff#

Qualifications#

Methodology##for##

Determining#Cost#Per#

#Hour#of#Service#

Unit#Type:#Time#

Outcome#Combination#

Reimbursement#Rate#

Methodologies#

WORKGROUP APPROACH

23#

•  Proposed%Service%Array%has%been%developed;%%

•  Service%definitions,%provider%and%staff%qualifications%%have%been%finalized%

•  Finalizing%rate%methodology%•  Expect%to%file%waiver%amendment%with%CMS%in%early%2016%with%new%services%to%be%implemented%in%July%2016.%

WAIVER CHANGES

24#

Current Waiver Services Ac#vity( Voc(Hab( SE0(Enclave( SE0Community( OOD(

Voca#onal(Assessment( X( X( X( X(Voca#onal(Profile(Development( X( X( X( X(On0going(Support( X( X( X( X(Developing(Systema#c(Plan(of(Instruc#on(and(Support,(Task(Analysis(

X( X( X( X(

Support(for(integra#on(at(worksite( X( X( X( X(Transporta#on(Training( X( X( X( X(Problem0solving(Assistance/Mee#ng(Job(Expecta#ons( X( X( X( X(

Natural(support(facilita#on( X( X( X( X(Skill(Training((hygiene,(work(skills,(self0determina#on(goals,(social(skills,(behavior(modifica#on)(

X( X( X( X(

Developing(and(implemen#ng(a(plan(for(transi#on(to(employment(

X( X( X( X(

Self0medica#on(support(or(medica#on(admin( X( X( X( X(

Job(development(and(placement( (( X( X( X(Resume((development( (( X( X( X(Job(seeking(skills(training( (( X( X( X(Worksite(Analysis(,(including(job(customiza#on( (( X( X( X(

Employer(outreach(and(awareness( (( X( X( X(Job(training/coaching( (( X( X( X(Follow0along/reten#on( (( X( X( X(Iden#fying(worksite(accommoda#ons( (( X( X( X(Purchasing(or(modifying(equipment(for(worksite(accessibility(

(( X( X( X(

Self0employment(support( (( (( X( X(

Proposed Waiver Services

26#

Ac#vity( Informed(Choice(Process(

Employment(Naviga#on(

Integrated(Skill(Building(for(Employment((prevoc)(

SE0(Individual((1:1)(

OOD(

Conflict0free(informed(choice(( X( ((((

(( (( ((

Coordina#on(of(progress(on(path(to(employment(and(access(to(services(

(( X( (( (( X(

Skill(building(before(and(during(job(search((small(group;(non0job(specific)(

(( (( X(((

(( ((

Skill(building(post(job(development((small(group;(non0job(specific)(

(( (( X( (( ((

Skill(building(before(and(during(job(search((small(group;(job0specific)(

(( (( (( (( ((

Assessment/discovery( (( (( (( X( X(Employment(or(self0employment(planning(

(( (( (( X( X(

Job(placement( (( (( (( X( X(Job(training/coaching( (( (( (( X( X(Skill(building(before(and(during(job(search((1:1;(job0specific)(

(( (( (( X( X(

Career(Advancement( (( (( (( X( X(Benefits(Planning/Support( (( (( (( (( X(

•  Initial%Meeting%to%discuss%concerns,%hopes%and%expectations%

•  Orientation%to%Supported%Employment%Services:%%discussion%about%process%and%roles%of%various%agencies%

•  Career%Exploration:%discovery%to%inform%career%opportunities%%

•  Facilitated%Exploration%of%Community%Employment%Opportunities:%%employment%tours,%informational%interviews%and/or%job%shadows%to%inform%goals%

•  Summary%and%Planning%Meeting:%summarizes%process%and%identifies%next%steps%

27#

INFORMED CHOICE PROCESS Combination%of%%Employment%Navigator%and%Supported%EmploymentPIndividual%%provider

Place(4:((I(don't(think(I(want(to(work,(but((

may(need(to(learn(more(about(it.(

Place(3:((I(think(I(want(to(work,(but(need(help(to(understand(my(op#ons.(

Place(2:((I(want(to(work!(Help(me(get(a(job.(

Place(1:((I(have(a(job(but(need(support(to(keep(it(or(get(a(be`er(

job.((

Who Am I?

28#

Employment*Navigation*•  1:1%•  Proposed%to%add%to%SSA%Role%as%a%

function%of%Targeted%Case%Management%(TCM)%

•  Assures%facilitation%and%coordination%of%a%seamless%transition%among%needed%employment%services%and%supports%from%various%systems,%including%education,%VR,%workforce%development%and%benefits%counseling%

I#may#want#to#pursue#community#

employment,#or#I#am#already#

pursuing#or#working#in#community#

employment,#and#I#need#help#to#

navigate#systems#and#services#

available#to#me#

29#

Place(4:((I(don't(think(I(want(to(work,(but((

may(need(to(learn(more(abou(it.(

Place(3:((I'm(not(sure(if(I(want(to(work,(but(

need(help(to(understand(my(op#ons.(

Informed*Choice*Process*•  1:1%•  Abridged%discovery%•  Career%exploration%•  Informational%interviews%•  TimePlimited%•  Approximately%24P28%hours%

I#am#not#in#community#

employment##and#not#sure#I#

want#to#pursue#community#

employment#

30#

Supported*Employment;Individual*•  1:1%•  Supported%employment%

assessment%•  Discovery%process%

•  Other%funding%source:%OOD%

I#want#to#pursue#community#

employment#but#I#need#help#to#

identify#the#type#of#job(s),#task(s),#

and#conditions#for#employment#

that#I#want/need#

31#

Integrated*Skill*Building*(prevocational)*•  1:2;%1:3;%1:4%•  Integrated%skill%building%•  TimePlimited%%

I#am#seeking#community#

employment#and#I#have#a#need#for#

immediately#available,#waiverV

funded#daytime#supports#that#

have#a#focus#on#building#general#

skills#for#community#employment#

32#

Supported*Employment;Individual*•  1:1%•  Work%Incentives%Benefits%

Counseling%

•  Other%funding%source:%OOD%

I#want#community#employment##

and#I#have#a#need#for#a#

comprehensive#benefits#analysis#

to#move#forward#

33#

Supported*Employment;Individual*•  1:1%•  Initial%job%training%

•  Other%funding%source:%OOD%

I#just#got#community#employment#

and#my#employer#and#I#have#a#

need#for#training#and#onVtheVjob#

support;#or#I#just#got#selfV

employment#and#I#need#training#

and#support#to#maintain#the#selfV

employment.#

34#

Supported*Employment;Individual*•  1:1%•  Job%Advancement%

•  Other%funding%source:%OOD%(possibly)%

%

I#have#community#employment#

but#I#want#more#hours#in#the#same#

job.#

35#

Supported*Employment;Individual*•  1:1%•  Extended%Job%Training/Coaching%

•  Other%funding%source:%OOD%%

I#have#community#employment#but#

my#employer#and#I#have#a#continued#

need#for#training#and#coaching#so#I#

can#become#more#independent#on#

the#job;#or#I#have#selfVemployment#

and#I#have#a#continued#need#for#

training#and#coaching#so#I#can#

become#more#independent#in#selfV

employment.#

36#

Integrated*Community*Supports*•  1:2,%1:3,%1:4%•  WrapParound%supports%%

I#want#and#have#a#need#for#waiverV

funded#daytime#supports#to#help#me#

have#an#integrated#life#during#the#

hours#I#am#not#working,#while#I#am#

pursuing#CE,#or#if#I#have#made#an#

informed#choice#not#to#pursue#CE#at#

this#time.#

37#

•  Analyze%data%from%shortPterm%data%collection%activity%to%determine%how%current%acuity%tool%indicates%level%of%support%

•  Small%workgroups%are%continuing%to%meet%to%develop%steps%for%implementation%

•  Finalize%rate%methodologies%and%explore%sidePbyPside%billing%comparisons%

NEXT STEPS

38#

•  Post%service%definitions,%rate%methodology%and%Workgroup%recommendations%for%public%input%

•  Build%internal%infrastructure%to%implement%new%services%and%outcome%billing%

•  Submit%waiver%amendment%to%CMS%

•  Implement%new%services%

NEXT STEPS

39#