Waiver Review Initiative Executive Summary TODD COUNTY August 2009

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1 Executive Summary Prepared with the assistance of

2 Acknowledgements This report was prepared by the Minnesota Department of Human Services with assistance from the Improve Group. The findings presented in this report are based on a comprehensive review process made possible through the help and assistance of Todd County. ABOUT THE MINNESOTA DEPARTMENT OF HUMAN SERVICES The Minnesota Department of Human Services helps people meet their basic needs by providing or administering health care coverage, economic assistance and a variety of services for children, people with disabilities and older Minnesotans. The Minnesota Department of Human Services touches the lives of one in four Minnesotans with a variety of services intended to help people live as independently as possible. DHS is the state's largest agency, with an annual budget of approximately $8 billion and 6,600 employees located throughout Minnesota. ABOUT THE IMPROVE GROUP The Improve Group is an independent evaluation and planning firm with the mission to help organizations deliver effective services. The research design, data collection, analysis and reporting expertise of the Improve Group particularly emphasizes building the capacity of local organizations to make information meaningful and useful.

3 Executive Summary In June 2009, the Minnesota Department of Human Services conducted a review of Todd County s Home and Community Based Services (HCBS) programs. Todd County is a rural county located in central western Minnesota. Its county seat is located in Long Prairie, Minnesota and the County has another 9 cities and 28 townships. In Fiscal Year 2008, Todd County s population was approximately 24,029 and it served 478 people through the HCBS programs. In 2006, Todd County had an elderly population of 16%, placing it 47th (out of the 87 counties in Minnesota) in the percentage of residents who are elderly. Less then thirteen percent (12.8%) of Todd County s elderly population are poor, placing it 19th (out of the 87 counties in Minnesota) in the percentage of elderly residents who are poor. In Todd County, out of every 1,000 persons had a 2006 federal disability determination, 1 placing it 16th (out of 87 counties) in the proportion of residents with a federal disability determination. Public Health is the lead agency for all of the long-term care (LTC) waiver programs: EW, AC, CAC, CADI and TBI. Social Services is the lead agency for the DD program. South Country Health Alliance, UCare, Medica and Blue Plus are the health plans available in the County for Minnesota Senior Health Options (MSHO); Todd County provides care coordination for all four health plans. A public health nurse conducts initial LTCC assessments with a social worker from Social Services. The public health nurse case manager does one-person reassessments. Social workers usually do one-person screenings for participants in the DD waiver program. CADI participants with a development disability or mental health diagnosis are being served by a public health nurse as the lead case manager and a social worker as the secondary case manager. These participants have a public health nurse that manages the CADI program and a social worker that does Rule 185 (developmental disabilities) or Rule 79 (mental health) case management. Todd County is working to consolidate case management functions across Social Services and Public Health; they want to streamline services and have one lead case manager. Social workers will become the lead on some of these cases in the near future, as they have expertise serving participants with developmental disabilities. 1 This includes persons using social security insurance (SSI), old age, survivors, and disability insurance (OASDI) and persons with dual federal determinations. Executive Summary - i

4 Between 2002 and 2007, enrollment in the EW and AC waiver programs has declined 11% from 282 to 252 participants (a decline of 30 participants); while enrollment was down in the AC program by 80 participants during this timeframe, the number of EW participants rose by 50. During this time frame, the number of participants with higher acuity (case mix B and above) grew by six participants. This indicates that Todd County s population of EW and AC participants with high needs is growing, even as the overall population in elderly programs is declining. Between 2002 and 2007, enrollment in the CCT waiver programs has grown 68% from 73 to 123 participants (a gain of 50 participants). During this time frame, the number of participants with higher acuity (case mix B and above) grew by 36 participants. This indicates that much of the growth in Todd County s CCT population has come from an increase enrollment of participants with high needs. Between 2002 and 2007, enrollment in the DD waiver programs has declined 10% from 86 to 77 participants (a decline of 9 participants). During this time frame, the number of participants with higher acuity (profile 1, 2 or 3) declined by seven participants. This indicates there are fewer participants with high acuity in the program in 2007 than there were in Introduction and Methods The primary goal of the is to support the assurances that the Minnesota Department of Human Services (DHS) makes to the Centers for Medicare & Medicaid Services (CMS) about Home and Community Based Services. The HCBS programs, including five waivers (EW, CAC, CADI, TBI and DD) and the Alternative Care program, are overseen by the Minnesota Department of Human Services. When developing the Waiver Review Initiative, DHS intends to both monitor compliance with state and federal regulations and identify successful practices that improve the quality of service to HCBS participants. The Waiver Review Process employed seven methods for collecting data to substantiate the State s assurances: (1) participant case files; (2) contracts held by Todd County for services; (3) policies developed by Todd County to guide it in administering the HCBS programs; (4) a survey instrument completed by County staff; (5) interviews with administrative and supervisory staff; (6) a focus group of staff working across the six HCBS programs; and (7) Executive Summary - ii

5 county operational indicators developed using state data. Sixty-one (61) case files and thirteen (13) provider contracts were examined during the Todd County visit. The systematic way the data was collected during this review will be used in other lead agency waiver reviews over the next five years. Much of the data was collected on-site through a three-day site visit process during which participant records and contracts were reviewed and staff participated in interviews and the focus group. The HCBS quality framework developed by the Centers for Medicare & Medicaid Services was used as a guiding force for this review and includes the following seven framework areas: (1) Participant Access; (2) Person-Centered Planning and Delivery; (3) Provider Capacity and Capabilities; (4) Participant Safeguards; (5) Participant Rights and Responsibilities; (6) Participant Outcomes and Satisfaction; and (7) System Performance. 2 Waiver Review Findings- County Strengths and Promising Practices The following findings around Todd County s promising practices and strengths are drawn from reports by County staff, reviews of participant case files and provider service contracts and observations made during the site visit. Data from multiple sources indicate that quality case management services are a key strength in Todd County. Case managers are responsive to participant needs and knowledgeable about program and community resources. Case managers help connect participants with resources across the agency. Case managers have developed longstanding relationships with the participants and communities they serve. In spite of high caseload size, Todd County case managers are in frequent contact with their HCBS participants through face-to-face visits. Most participants in the long-term care programs are seen at least quarterly by their case manager. The Public Health and Social Services agencies and staff have good working relationships with one another. Case managers across Public Health and Social Services are supportive and use each other as resources. A public health nurse and social worker conduct joint initial assessments for all long-term care participants. The Public 2 Executive Summary - iii

6 Health case aide is an effective resource that is used across the agencies to support the case managers. Outreach to elderly participants is considered a strength in Todd County. Public Health is a Medicare Certified Home Healthcare Agency, so the nurses can easily provide referrals to EW and AC case managers. Case managers specialize in geographic areas of the County and are well-known in the communities they serve. Participants tell their neighbors about the services they receive, which helps with outreach. In Todd County, 89% of EW and AC participants live at home at the time of first screening compared with 69% of EW and AC participants in a cohort of similarly sized counties and 75% of EW and AC participants statewide. Participant case files and care plans were generally well-organized and complete. All cases included evidence that participants gave informed consent and 95% of cases included evidence that participants were informed of their rights and responsibilities. All long-term cases include the OBRA Level One form. All DD screening documents had the required signatures. Additionally the CAC cases included the CAC Application and Reassessment Support Plan and the TBI cases included the TBI Waiver Assessment and Eligibility Determination Form. All care plans reviewed met or exceeded documentation expectations regarding goals and outcomes, and health and safety issues. Additionally, all care plans documented that all needed services would be provided and included choice questions. Across all programs, case managers systematically and consistently collect information about participant satisfaction. Reviewers examined case notes and other documents to determine if participant satisfaction was documented in the case file; 25 (of 27) EW participants, seven (of eight) AC participants, nine (of 11) CADI participants, two (of three) CAC participants, two (of four) TBI participants and two (of eight) DD participants included this documentation in the case file. Todd County has worked to develop consumer directed community supports (CDCS) as a viable option for Todd County residents. This program helps meet a broader range of participant needs and is especially helpful for participants living in geographically isolated areas. Currently, nine CCT participants and six DD participants use CDCS. Executive Summary - iv

7 Waiver Review Findings- County Barriers and Areas for Improvement The following findings around Todd County s barriers and areas for improvement are drawn from reports by the County s staff, reviews of participant case files and provider service contracts and observations made during the site visit. Only 64% of LTC screenings for new CCT participants are conducted within 10 days of referral to the program. Only 75% of LTC screenings for new EW and AC participants are conducted within 10 days of referral to the program. None of the eight DD cases reviewed in Todd County included ICF/MR level of care 3 documentation. It is required that ICF/MR level of care criteria are reviewed annually for DD participants and that the findings are documented in the case file. Two of eight DD individual service plans are not signed and dated by the participant and another DD individual service plan is not signed by the case manager. It is required that the DD individual service plan is signed and dated by the case manager and either a participant with their own guardianship or a participant s legal representative. Todd County did not have evidence that one of the host county contracts sampled was current for services being provided. In the case file reviewed of two DD waiver participants with public guardianship, only one county staff member was signing care plan documents. As a result, two of eight DD care plans did not have the required signatures and one case did not include documentation of rights. For HCBS participants with public guardianship, it is required that one staff maintains the role of case manager and a separate staff member maintains the role of guardian. When one person is holding both roles, they are unable to provide informed consent or true choice on behalf of the participant. 3 The ICF/MR Level of Care form can satisfy this documentation requirement. The form can be accessed at: DocName=id_ Executive Summary - v

8 Recommendations and Corrective Action Requirements The following are recommendations and required corrective actions developed by the Waiver Review Team. The recommendations are intended to be ideas and suggestions that could help Todd County work toward reaching their goals around HCBS program administration. Corrective action requirements are areas where Todd County was found to be inconsistent in meeting state and federal requirements and will require a response by Todd County. Correction actions are cited when it is determined that a pattern of noncompliance is discovered. There may be needed follow-up with individual participants when the noncompliance is more incidental in nature. Recommendations The following recommendations would benefit Todd County and its HCBS participants. Streamline the contracting process by creating one umbrella contract for all HCBS programs across agencies. Stagger contract renewal dates over several years to reduce the amount of contract maintenance required. Update credentialing information in contracts, including basic licenses and insurance information. Require Assisted (Customized) Living, family foster care, contracted homecare and other providers to send case managers reports on individual participants on a regular basis. Specify the reporting requirements in contract attachments. Provide training for case managers on basic provider contractual expectations, such as staffing levels and provider reporting requirements. Add language to the contracts that will help support participants to stay in their place of residence as their needs become more challenging. For residential providers, define the process for changing rates in the contract. For Assisted (Customized) Living Providers that are attached to a nursing facility, add requirements that providers must notify the County before a participant is moved to the nursing facility. This will encourage providers to continue serving participants in their current place of residence as their needs change whenever possible. Consider working with providers to address Todd County s unmet needs for services particularly in the area of community-based employment in the CCT and DD programs Executive Summary - vi

9 and the development of bundled homecare packages to support participants in their homes. Bundled service packages that include assistive technology, home modifications, ILS services, transportation and skilled nursing services will help support these participants in their homes. When developing these services, work across programs to ensure they can be accessed by all participants regardless of the program. Consider partnering with neighboring counties who have similar needs for this type of service capacity. Consider training mental health case managers about HCBS program requirements to provide more streamlined services for participants. Currently, participants with mental health needs may have two case managers; one for Public Health (for the waiver case management) and one for Social Services (for the mental health case management). This could also help integrate mental health services across the waivers and reduce the number of case managers assigned to a single participant. Require contracted case management providers to use the Todd County care plan format to improve the care planning process for participants served in this arrangement. Corrective Action Requirements The following are areas in which Todd County will be required to take corrective action. Beginning immediately, ensure that 80% of LTC Screenings for CCT and elderly programs occur within 10 days of referral. State legislation requires that LTC screenings should be conducted within 14 days (10 business days) of a request for screening, which is defined as the date the assessment is requested. Currently, 64% of screenings for CAC, CADI and TBI participants and 75% of screenings for EW and AC participants occur within the 10 business day timeframe. If a screening cannot take place in the required time period, document the reason for the delay in the participant s case file. Executive Summary - vii

10 Complete ICF/MR level of care documentation for all participants in the DD program that do not have this documentation in the next 30 days. 4 Maintain a copy of the findings in the participant s case file. It is required that ICF/MR level of care criteria are reviewed annually for DD participants and that the findings are documented in the case file. All eight DD cases did not have ICF/MR level of care documentation in the case file. Beginning immediately, ensure that all DD individual service plans have the two required signatures. It is required that the DD individual service plan is signed and dated by the case manager and either a participant with their own guardianship or a participant s legal representative. Thirty-eight percent of DD individual service plans (3 out of 8 cases) do not include the two required signatures as two individual service plans are missing participant signatures, and another individual service plan is missing a case manager signature. Beginning immediately, obtain copies of all host county contracts and current signature pages to ensure a current host county contract exists and is valid for the services purchased by Todd County. Todd County did not have evidence that one host county contract was current for services being provided. Securing evidence of a current service contract is the responsibility of the County. 4 The ICF/MR Level of Care form can satisfy this documentation requirement. The form can be accessed at: DocName=id_ Executive Summary - viii

11 Appendix: Additional Information Glossary of Terms AC is the Alternative Care program CDCS refers to Consumer-Directed Community Services CAC is the Community Alternative Care Waiver CADI is Community Alternatives for Disabled Individuals Waiver Care Plan is the service plan developed by the HCBS participant s case manager (also referred to as Community Support Plan, Individual Support Plan and Individual Service Plan) CCT refers to the CAC, CADI and TBI programs, which serve people with disabilities CMS is the federal Centers for Medicare & Medicaid Services DD is the Developmental Disabilities Waiver Disability waiver programs refers to the CAC, CADI and TBI Waiver programs EW is the Elderly Waiver DHS is the Minnesota Department of Human Services HCBS are home and community-based services for persons with disabilities and the elderly: For the purpose of this report, HCBS include the Alternative Care program, CAC, CADI, Elderly, DD and TBI Waivers Home care services refers to extended home care services, including personal care attendant services Local Lead Agency (LLA) is the local organization that administers the HCBS programs: LLA may be a county department, health plan or tribal community Appendix: Additional Information - 1

12 Participant case files were examined for much of the evidence cited in this report. They included the written participant records and information of case management activity from electronic tracking systems Operational process- refers the actual methods and activities used by a LLA to accomplish business objectives Promising practice: An operational process used by the LLA that consistently produces a desired result beyond minimum expectations Participants are individuals enrolled and receiving services in a HCBS program Policies are written procedures used by LLA s to guide their operations Provider contracts are agreements for goods and services for HCBS participants, executed by the LLA with local vendors Site visits were conducted to collect most of the data used in this report TBI is the Traumatic Brain Injury Waiver Resources A catalog of promising practices, recommendations and corrective actions can be found at Useful tools for HCBS programs used by other agencies can be found online through a Yahoo Group. Instructions on joining the group can be found at The MACSSA-developed County Best Practices website can be found at: Appendix: Additional Information - 2