may 8, 2013 developmental disabilities individual support and care coordination organizations and...

May 8, 2013

Developmental Disabilities Individual Support and Care Coordination Organizations and Accountable Care Organizations: A New Service Delivery Model for the Intellectually and Developmentally Disabled

YAI International ConferenceMay 6-9, 2013

Presented byDavid A. Gregory, FACHEPartner, Presscott AssociatesA Division of ParenteBeard LLC

Presentation Overview

• ACOs– Healthcare reform – Commercial

• Developmental Disabilities Individual Support and Care Coordination Organizations (DISCOs) – definition

• Synergy: ACO and DISCO service delivery models • DISCO implementation/requirements• DISCO – Core Elements of new service delivery models• Guiding principles for service improvements

2Presscott Associates – A Division of ParenteBeard LLC

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Accountable Care Organizations (ACOs)/ Healthcare Reform • Introduced through the federal Patient Protection and Affordable Care

Act (PPACA) of 2010• Definition: Physicians, hospitals and other health care professionals

working together to coordinate care and share in savings or losses for traditional Medicare beneficiaries assigned to the ACO

• Part of Medicare through the Medicare Shared Savings program in 2012

• Payment tied to achieving healthcare quality goals and outcomes that result in cost savings

• Create incentives for healthcare providers to work together to treat individuals across various healthcare settings

• Providers receive a share of the savings beyond a predetermined threshold amount


ACOs and Commercial Health Plans

• Commercial health plans have emulated healthcare reform • Commercial health plans have implemented various value-based

contracting models • Health plans goals

– Collaboration among providers in delivery system/integrated delivery systems– Coordination of patient care among the continuum of care– Accountability and shared risk among providers– Increased quality and improved patient outcomes– Cost savings– New payment models– Patient satisfaction


Developmental Disabilities Individual Support and Care Coordination Organizations (DISCOs)• Created by the New York Office for People With Developmental

Disabilities (OPWDD) People First Waiver of the Social Security Act• Non-profit organizations that provide individualized supports/services,

care coordination to individuals with developmental disabilities and/or to their families

• Function as fiscal intermediaries (manage care/reimbursed on an individual budgeting, global budgeting or capitation basis)

• Serve individuals with all levels of need by providing supports/services directly or indirectly through sub-contracts with provider agencies.

• Initially, monthly capitation payments based on the disabled individual’s assessed needs, with the state sharing some financial risk

• DISCOs will evolve to full financial risk for meeting service needs within the capitation revenue


People First Waiver

• Develop/implement creative service delivery and payment models that integrate acute and long-term care to achieve improved health outcomes and quality of care while lowering health care costs for the developmentally disabled population

• Target population: 100,000 New Yorkers enrolled in Medicaid who have substantial developmental disabilities as defined in New York State Mental Hygiene Law– 80% of these assessed to need an institutional level of care through

either an ICF/MR or nursing home


People First Waiver will Demonstrate

• Better care coordination for developmentally disabled individuals with extremely complex medical/behavioral health needs can be achieved through specialized systems of care management/coordination

• A transformed long-term care delivery system that places person-centered planning, individual responsibility and self-determination at the forefront can enhance care and individual satisfaction and lower Medicaid costs

• New reimbursement models for institutional and community-based care systems can encourage efficiency, improve accountability and reduce costs

• The continued provision of essential mental hygiene services through the establishment of a safety net care pool will provide lower-cost services that meet individuals’ needs and defer entry into higher costs Medicaid services


Synergy: ACOs and DISCOs

• ACOs: Timely model of healthcare delivery for disabled people with complex care needs

• DISCOs– New person-centered goals/comprehensive plan of care for

individuals with intellectual and developmental disabilities– Care coordination/case management designed for individual’s unique

needs/circumstances

• Community/home-based alternatives replacing old systems of institutionally-based care


ACO Development: First Steps

• Form an organization/infrastructure• Define organizational Mission, Goals and Objectives• Establish leadership/governance• Identify population to be served• Define services and service area• Develop/contract with a provider network• Address legal/compliance issues• Identify financial resources• Develop an operating budget


ACO Development: First Steps (cont.)

• Develop a marketing plan• Establish clinical integration/care coordination/

management• Develop information systems for data collection/

management/sharing• Address patient engagement • Draft implementation agenda and timing


DISCO Goals 1

• Provide individualized planning for all enrollees that focuses on individual outcomes

• Promote OPWDD’s four valued outcomes for individuals: – Live and receive services in the most integrated settings – Meaningful and productive community participation, including paid employment; – Develop meaningful relationships with friends, family, and others in their lives – Experience personal health, safety and growth

• Ensure that each individual who chooses to do so can self-direct his or her services including the option for budget and employer authority

• Maintain a well trained workforce that minimally meets all OPWDD requirements and is culturally competent to meet the needs of the individuals seeking or receiving supports and services in the communities in which they live.

1 OPWDD Application


DISCO Organization and Management/ Governing Board• Governing Board to establish/oversee DISCO

policies• Participate in OPWDD-required abuse and training• Meet 4 times per year• Within 1 year of becoming operational, have 20%+

individual/advocate board membership, or advisory council with board input


DISCO Organization and Management/ Service Delivery Network• Contracted provider network• Providers with specialized expertise for individuals

with developmental disabilities/special populations• Choices of at least 2 providers for each provider

type• Responsive to community cultural considerations,

including language


DISCO Organization and Management/ Contract Management• Established service contracts with network providers• Policies and Procedures for contract monitoring• Contracts must include:

– Service standards– Staff/agency qualifications– Provider compliance monitoring and remedies– Reportable events (“Unusual Incidents”) and processes– Billing processes and rates for service units– Appeals/grievance processes for resolution of payment issues


DISCO Organization and Management/Enrollment Monitoring and Disenrollment Reporting

• Qualified individual, all ages, will be eligible to enroll in DISCO pilot with authorization of OPWDD Regional Office

• Qualifications– Qualifying developmental disability– Meets ICF/DD level of care– Medicaid enrolled (included dually eligible)

• Not included during pilot phase– OPWDD state operated residential and day services– SNF, OASAS/OMH or private psychiatric hospital residents

• Enrollment, disenrollment, service utilization, encounter data, enrollee satisfaction, marketing, grievance/appeals, fiscal data


DISCO Organization and Management/ Assessment of Prospective Members• OPWDD developing an assessment tool (CAS)• State will complete initial assessments• DISCOs will use assessment tool to support care

plan development and monitoring• Current instrument (DDP2) must also be completed

for enrollees


DISCO Organization and Management/ Care Management• Establishment/implementation of written care plan• Assistance to enrollees to access services reflecting person’s

communicated choices/needs• Application process assesses DISCO’s readiness to provide

care management, health/safety monitoring, OON referrals (as needed)

• Primary care manager and care management team• Quality assessed by qualifications of care coordinators,

quality outcome measures


DISCO Organization and Management/ Financial Requirements• Initial capital to comply with DOH Regulation Part

98-1.11 escrow and contingent reserve requirements

• Must identify sources of initial capital• Reserve and escrow requirements (exception for

“start-up” period)• Minimum net worth equal to greater of escrow

requirement or contingent reserve


DISCO Organization and Management/ Accounts Receivable-Payable

• Receivable: Management of capitation revenues (based on member months)

• Payable: Payment of claims received from the subcontract network providers

• OPWDD examining methodologies for establishing standardized fees for cap rate and provider payments


DISCO Organization and Management/ Budget-Finance-Accounting• Monitoring and reporting of all financial aspects of

the DISCO operation• Budgets

– Number of enrollees– Service delivery costs– Administrative operating costs

• Required reports– Annual Financial Statements: Medicaid Managed Care

Operating Report– Quarterly Financial Statements


DISCO Organization and Management/ Utilization Management and Review Systems

• Assure maximum system use of available community-based and integrated services

• Direction/link to care coordinators, enrollee/advocates, caregivers regarding services promoting objectives of People First Waiver

• Aggregate reporting of uses and costs of services and trends

• Recommendations based on utilization data/reports


DISCO Organization and Management/ Quality Assurance System• QA/PI program and approved written quality plan addressing

– Ongoing assessment– Implementation– Evaluation of overall quality of care and services– Specific measurable activities– Meet requirements of Article 44 of PHL and regulations of 42 CFR

438.240 (QA/PI)– Approved by Commissioner of OPWDD– Board-level accountability– Objective, measurable and relevant quality indicators


DISCO Organization and Management/ Management Information System• Compliant with Statewide Policy Guidance –

common information policies, standards and technical approaches governing health information exchange

• Maintenance of health information system that collects, analyzes, integrates and reports data

• Data available to State and upon request to CMS


DISCO Organization and Management/ ADA Compliance Plan• Compliance with Americans with Disabilities Act• Compliance plan to be submitted with

Application• State guidelines addressed• SDOH guidelines found in the Model Contract• Must be approved by OPWDD• ADA checklist must be completed


DISCO Service Area

• Geographic area for certificate of authority to operate a DISCO

• Sufficient provider network– Services availability to enrolled population– Services accessibility to enrolled population


DISCO Marketing Strategy

• Marketing plan must be submitted– Goals– Strategy– Address information needs of eligible persons

• Limitations on marketing activities defined• Monitoring to ensure compliance with state/

federal requirements


DISCO Self-Direction Services

• Self-directed services must be available• DISCO must provide description of how it will

offer self-direction• Education and supports for self-direction


DISCO Person-Centered Planning

• Individualized Service Plan (ISP) developed by the care coordinator, person and person’s circle of support

• DISCO must describe process and principles for ISP

• Training for care management staff, individuals and families

• Measurement of outcomes


Productive Community Participation and Competitive Employment• Support individual with I/DD to fully participate in

their communities, including employment• DICSO must describe process/methods for

increasing volunteerism and employment for enrollees


Core Elements of New Service Delivery Models• Integrated primary/acute care, behavioral health,

long-term services• Stakeholder input in design/management of care

models• Addressing individuals’ support/caregivers’ networks• Maintenance of provider relationships• Integrated funding (Medicare, Medicaid, State)


Core Elements of New Service Delivery Models (cont.)• Risk assessment for individual-centered goals for

resource allocation• Performance measurement• Information technology for data collection and

measurement• Reimbursement design (EOC, risk, P4P)• Life-long planning for persons with I/DD


Guiding Principles for I/DD Service Improvements• Consistent with Developmental Disabilities and Civil Rights

Act and ADA of 1990• Access to services and supports• Ability to have choices/make decisions• Achieve outcomes (e.g., independence, meaningful work,

dignity, well-being)• Service delivery that integrates/coordinates programs and

funding• Systems demonstrate value to consumers and purchasers

(need data and measurements)


Essential Elements for Success

• Strong leadership• Provider input• Clear Mission Statement (addresses integration)• Realistic Goals• Objectives that are tangible, measurable, can be

validated• Provider commitment/engagement


Essential Elements for Success (cont.)

• Care management– Evidence-based clinical guidelines– Clear, concise processes– Provider accountability– Preventive care and wellness orientation– Performance goals/measurements

• IT: EHR, data sharing for informed decision-making• Communication, feedback (internal, external)


Essential Elements for Success (cont.)

• Organizational culture• Strategy: Formal Business Plan, Implementation

Agenda and timeframes


Summary

• Essential elements in provider integration are part of a Business Plan

• Integration is relationship-building• Relationship building required concerted effort• Successful relationships beyond affiliation are

crafted by having a Plan of Action

Result: Achievable accountability and competitive positioning for the DISCO


David A. Gregory, Partner

Presscott Associates – A Division of ParenteBeard [email protected]

office 201.612.0561

The Empire State Building

350 Fifth Avenue, 68th Floor

New York, NY 10118


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Contact Information

may 8, 2013 developmental disabilities individual support and care coordination organizations and...

Documents

quality of care

longterm care

health care costs

health care professionals

disco service delivery

affordable care act

improved health outcomes

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