preliminary draft hcbs public stakeholder discussion discussion document december 8, 2014

PRELIMINARY DRAFT

HCBS Public Stakeholder Discussion

Discussion Document

December 8, 2014

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PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE

Introduction to Arkansas Health Care Payment Improvement Initiative (AHCPII)

▪ The health status of Arkansans has been poor, and the state has been ranked at or near the bottom of all states on national health indicators, such as heart disease and diabetes

▪ The health care system has been hard for patients to navigate, and it has not rewarded providers who work as a team to coordinate care for patients

▪ Health care spending has been growing unsustainably. For example, insurance premiums doubled for employers and families in the past 10 years

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The goal is to improve quality and control costs

Strategy:

Transition to payment system that rewards value and patient health outcomes by aligning financial incentives

Strategy:

Transition to payment system that rewards value and patient health outcomes by aligning financial incentives

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The goal is a comprehensive, client-centered delivery system

Objectives for clients

▪ Improve the health of the population

▪ Enhance the client experience of care

▪ Enable clients to take an active role in their care

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Applying payment improvement to all areas of Medicaid

▪ DHS is now working to ensure that all areas of Medicaid, including LTSS, implement payment improvement changes

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Basic facts about the Medicaid LTSS population in Arkansas

Source: DMS (CFO, OLTC); DAAS; DHS State Statistical Report (2013)

▪ Total LTSS expenditures $890 M

▪ HCBS expenditures $157 M1

▪ Nursing home expenditures $733 M

▪ HCBS agency providers ~250

▪ Nursing homes ~220

▪ HCBS recipients ~14,000

▪ Nursing home residents ~11,000-12,000

▪ We would like to share with you the vision for the HCBS client population

▪ Together we care for some of our state’s most vulnerable populations

1 HCBS expenditures include ElderChoices, AAPD, Independent Choices, Assisted Living, and PACE

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The HCBS journey over the last two years

▪ Improve the health of the population

▪ Enhance the client experience of care


The journey has been ongoing

▪ 2013: Worked with stakeholders to pinpoint areas to strengthen and potential paths forward

▪ Late 2013: Identified specific models to refine with stakeholders

▪ Early 2014: Started development of current proposal

We describe here a proposed set of changes within HCBS and will continue to refine and build upon these changes going forward

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Approach for developing payment improvement model for HCBS

▪ Workshops with providers to identify the key issues and opportunities

▪ Best practices researched across HCBS systems from other states

▪ Meetings with our nurses from across the State

▪ Engagement with a representative set of stakeholders from government organizations (e.g., Department of Health), HomeCare Association of Arkansas, for-profit providers (e.g., Superior), and non-profit providers (e.g., AAAs, CareLink)

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Tenets of the proposed new model▪ Assessment/Reassessment

– Ensure clients are assessed in a standardized approach while also maintaining a client-centered approach

– Implement a new and faster process for appeals and reconsiderations

▪ Billing– Streamline the billing process by consolidating hands-on services into one attendant

care bundle for payment and billing

▪ Provider payment– Increase payments for attendant care, adult companion, homemaker, adult day care,

in-home respite, and personal care for waiver and non-waiver clients

▪ Care coordination– Strengthen current care coordination programs (ongoing effort)

▪ Presumptive eligibility– Increase access to the HCBS system by decreasing the average time for a

perspective client to be eligible to receive services (ongoing effort)

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We are looking to consolidate a set of similar services that are currently fragmented

Attendant care services

▪ Personal care (ElderChoices)

▪ Attendant care (AAPD)

▪ Homemaker

▪ Adult Companion Care

Note: In the new HCBS model, these services will be bundled together as one service for billing purposes

Non-attendant care services

▪ Respite/relief (in-home and in-facility)

▪ Adult Day Care / Adult Day Health Care

▪ Adult Family Home

▪ Home-delivered meals

We are also continuing to work on strengthening care coordination, implementing quality metrics, and potentially

instituting presumptive eligibility

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Overview of current assessment of need process

ASSESSMENT OF NEED

A DAAS RN conducts a thorough assessment, posing questions from the ArPath system

Providers determine staffing and schedule appointments based on the Plan of Care

Based on a potential client’s responses, the DAAS RN determines

▪ A range of hours of care for attendant care services (e.g., personal care, adult companion care) to address the client’s needs

▪ Whether other non-attendant care services (e.g., Adult Day Care, home-delivered meals) may be needed

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Issues with current assessment of need process

ASSESSMENT OF NEED

While the current assessment process takes a person-centered approach, it can lead to varying allocations of care for clients with very similar profiles.

For example,

▪ A client in Northwest Arkansas could receive up to 1.6 hours MORE per day of attendant care services compared to similar clients

▪ Another client in the Delta could receive up to 1 hour LESS per day for attendant care services compared to similar clients

Providers have stated a desire for more flexibility in their provision of care

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Core elements of the refined assessment of need process

ASSESSMENT OF NEED

1) Resource Utilization Groups (RUGs) to help determine a DAAS RN’s allocation of attendant care bundle services by grouping similar clients together

– Academic research demonstrated that RUGs were the best available method to identify the needs of clients (>70% of states use RUGs)

2) An attendant care bundle has been developed to combine similar, hands-on forms of care (i.e., personal care, attendant care, homemaker, adult companion care)

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What are RUGs?ASSESSMENT OF NEED

▪ RUGs help DAAS RNs determine an allocation of care in a consistent, accurate manner for hands-on care ONLY (i.e., attendant care bundle)

▪ RUGs group clients with similar situations and levels of acuity together based on research from across North America

▪ Based on the questions in ArPath, the system assigns one of 23 RUGs to the client

– This is a “behind-the-scenes” process that will require no additional work by the DAAS RN or provider

▪ Each RUG has a unique allocation of care that is initially based on historical hours utilized by Arkansas clients

▪ The DAAS RN can then adjust the allocation of care based on any applicable extenuating circumstances

▪ NOTE: The current system will be used for non-attendant care services

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What flexibility will DAAS RNs have with the RUGs?

ASSESSMENT OF NEED

In order to ensure a person-centered approach, DAAS RNs will have the option of adjusting the RUG allocation upward or downward based on a defined set of extenuating circumstances

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Proposed extenuating circumstances for upward adjustment

1 If a client qualifies for grandfathering, he/she can only qualify for the “high perceived medical risk” adjustment as an additional upward adjustment

High perceived medical risk (e.g., high risk of fall) Cap: Up to 15% increase in care with expedited reassessment triggered in 2 month

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Informal supports lower than average for RUG Cap: 10% increase3

1 Grandfathering necessary to guarantee safety1 – Client had more care under current system. This level is maintained if needed to safeguard client’s welfare Cap: Up to previous level of care

Remote location and errands assistance required Cap: Up to 2 additional hours of care per week4

All HCBS clients will have an absolute cap on attendant care hours

ASSESSMENT OF NEED

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Proposed extenuating circumstances for downward adjustment

Informal supports higher than average for RUG Cap: 10% decrease2Client receives outside benefits, which render DHS services duplicative No Cap

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1 Client preference – Client opts for less service than is allocated No Cap

Multiple clients in the same home (for relevant services)

No Cap

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ASSESSMENT OF NEED

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DAAS has launched a new website for reconsiderations

Going forward, the ArPath system will be used for

▪ Eligibility determination

▪ Service determination

▪ Allocation of care for attendant care bundle services

ASSESSMENT OF NEED

DAAS has also launched a website to make reconsiderations and reassessments more seamless. The website can help

▪ Trigger an eligibility reconsideration in the case of a client denial

▪ Allow providers to submit information in advance of a reassessment

Please visit www.daas.ar.gov/provrequest.html

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Benefits of new assessment of need process for clients and providers

ASSESSMENT OF NEED

Applicable AHCPII tenets:

▪ Reward providers for high quality, efficient care

Client

▪ Clearly allocated amount of care (no range) for attendant care bundle

▪ Greater transparency in decisions around allocation of care

Providers

▪ Clearly allocated amount of care (no range) for attendant care bundle

▪ More straightforward billing process with the attendant care bundle (individual services of attendant care, personal care, homemaker, and adult companion allocated and billed together)

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Personal Care

Home-maker

Utilized

34.1

Plan of Care

52-69

48-56

4-13

Client examples: Historical versus future care allocation (1/2)

Source: ArPath (InterRAI-HC) assessment data, MMIS claims

ASSESSMENT OF NEED

Allocation of care

70.3

Current

Hours/month

Future

Hours/monthNote: The nurse may adjust this allocation of care based on any applicable extenuating circumstances

According to the nurse notes, the client has fall risk, is frail-appearing, and lives alone. Therefore, the future allocation of care will be slightly higher than the historical allocation

Rationale

ContextClient’s RUG: PB0 (Category: Reduced physical functions)

Reported informal care: 2.0 hrs/day (less than average)

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123.2

Allocation of care

Current

Client examples: Historical versus future care allocation (2/2)

Source: ArPath (InterRAI-HC) assessment data, MMIS claims

ASSESSMENT OF NEED

Hours/month

Future

Hours/month

Adult Com-panion

Utilized

PersonalCare

86.6

Plan of Care

143-164

52-64

91-100

Note: The nurse may adjust this allocation of care based on any applicable extenuating circumstances

No nurse notes available, but new allocation, while lower than plan of care allocation, is closer to utilized number of hoursRationale

ContextClient’s RUG: CC0 (Category: Clinically complex)

Reported informal care: 0.0 hrs/day (less than average)

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Overview of current plan of care and provider selection processes

PLAN OF CARE / PROVIDER SELECTED

Following the completion of the assessment, a DAAS RN discusses provider options with a client

Providers are responsible for the services for which they have been selected

The client then selects the provider(s) that fulfill(s) his/her needs best

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Issues with current plan of care and provider selection processes


The current system can lead to:

▪ A limited ability for hands-on care providers to tailor the offerings of similar services, depending on the individual needs of the client

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Benefits of new plan of care and provider selection processes for clients and providers



▪ Enhance the client’s experience of care


Client

▪ For attendant care services, only one provider will be used by the client

▪ Any changes for non-attendant care services (e.g., home-delivered meals, respite) are under review

Providers

▪ Providers of 1) personal care, 2) attendant care, 3) homemaker, and 4) adult companion services must be able to offer all four services in the attendant care bundle

▪ Any changes for non-attendant care services (e.g., home-delivered meals, respite) are under review

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Overview of current and new processof rendering services

SERVICES RENDERED

Providers work with their clients to render services at times that work for them

Services rendered under the new HCBS system will continue to remain the same

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Overview of current billing processBILLING

Providers report each of the hands-on attendant care bundle services (i.e., personal care, attendant care, adult companion care, homemaker) separately for each time the service is provided at 15 minute increments

Providers submit billing information to the State within 365 days

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Issues with current billing processBILLING

The current system can lead to:

▪ Administrative burden for providers as they are currently required to report similar hands-on care (i.e., attendant care bundle services) separately using 15-minute increments

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Benefits of new billing process for clients and providers

BILLING



Client

▪ Clients will receive their hands-on, attendant care services in a more seamless manner

Providers

▪ Providers will experience less administrative burden in their interactions with the State

▪ Providers will have flexibility to tailor their hands-on, attendant care services based on client need

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Client example – Billing process

Billing report

▪ Adult companion:

– 16 fifteen-minute increments in August over 4 days

▪ In-home respite:

– 8 fifteen-minute increments in August over 5 days

Billing report

▪ Attendant care services:

– 4 hours in August

▪ In-home respite:

– 2 hours in August

BILLING

Current system Proposed system

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Overview of current provider paymentPROVIDER PAYMENT

Providers are reimbursed at various rates for Adult Family Home, chore service, in-facility respite, home-delivered meals, assisted living, and PERS

Providers are reimbursed $7.68 per hour for Adult Day Care

Providers are reimbursed $16.76 per hour for homemaker, personal care, attendant care, adult companion care, and in-home respite

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Issues with current provider paymentPROVIDER PAYMENT

▪ The current rates have not changed since 2009

▪ Providers raised that their costs have increased significantly in that time

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Benefits of provider payment for clients and providers

PROVIDER PAYMENT



Client

▪ Clients will receive higher quality and more client-centered care as a result of lower caregiver turnover and provider scale

Providers

▪ Providers will receive higher reimbursement rates for the attendant care bundle, in-home respite, personal care (non-waiver), and adult day care

▪ Providers will be measured on quality going forward

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July 1, 2015 is the expected effective date of the new HCBS system

▪ The new rates for attendant care services, in-home respite, personal care (non-waiver), and Adult Day Care are expected to go into effect

▪ RUGs and extenuating circumstances will become part of the assessment process

▪ Providers will be able to roll over unused hours month-to-month (up to 20% of allocation of care)

▪ Quality metrics will go into effect for reporting purposes only

▪ Quarterly reports will be sent out to providers on their utilization of HCBS

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Areas of implementation going forward

▪ Policy design

▪ IT requirements

▪ Training materials and sessions

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There are four remaining areas of policy designfor the HCBS system

Care coordination

Quality metrics

Provider reports (DAAS to receive and disseminate guidance from CMS and DoL on reporting requirements)

1

2

4

Access to HCBS (e.g., presumptive eligibility)

3

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Strengthening current care coordination programs

▪ We anticipate that going forward, care coordinators will take a more active role in ensuring that clients receive the right level of care, according to their plan of care, at the right cadence from the right providers

▪ The objective is for care coordination providers to have– A single, comprehensive view of a client’s

full needs across a continuum of care– A clear, tangible set of care coordination

activities – Accountability for delivering service

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Quality metrics to ensure providers are meeting client needs effectively

▪ We are working with providers to identify draft quality metrics for attendant care and care coordination

▪ We are also working to be able to use as much of the currently-reported information to populate the metrics

▪ We will disseminate quality metrics with providers prior to implementation

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Example quality metrics for attendant care and care coordinationCategory Proposed metric

Adherence

▪ Hours or units of service provided as specified on Plan of Care

▪ Amount of time between Plan of Care issuance and initiation of service delivery

Health-related metrics

Institution-alization

Critical incidents

Client satisfaction

▪ Functional (e.g., cognition), clinical (e.g., follow-up after falls), social (e.g., prevalence of client distress), and utilization (e.g., emergent care utilization) healthcare quality indicators (HC-QIs)

▪ Rate of institutionalization

▪ Substantiated allegations of abuse, maltreatment, neglect

▪ Client quality of life

▪ Client satisfaction with provider and services delivered

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Improving access to HCBS

▪ The State intends to improve access to the HCBS system and strengthen an eligible client’s ability to receive services more quickly

▪ One mechanism to reduce the number of days to receive services may be through presumptive eligibility whereby likely potential clients undergo an abbreviated assessment process

▪ DAAS is currently conducting an ABLE screen pilot to determine if and how the State would pursue presumptive eligibility

▪ The data is being analyzed, and the State will communicate its approach to providers at a later date

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Engagement with stakeholders

Engagement will continue with the full stakeholder group through email, phone, and in-person meetings on a periodic basis

Please submit any additional questions after this meeting through the AHCPII website: http://www.paymentinitiative.org/Pages/ default.aspx

Please review the full presentation and recording of the September 23, 2014 public stakeholder meeting

preliminary draft hcbs public stakeholder discussion discussion document december 8, 2014

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