STATE OF MAINE DEPARTMENT OF BEHAVIORAL AND DEVELOPMENTAL SERVICES 40 STATE HOUSE STATION AUGUSTA, MAINE 04333-0040 JOHN ELIAS BALDACCI SABHA C. BUHDICK GOVERNOR ACTING COMMISSIONER BDS Plan of Implementation Prepared in Response to incl Report of Clarence dated Jitly Z4, 2003 August 5, 2003 Introduction Pursuant to an agreed?upon order of the United States District Court, District of Maine, dated February 12, 2003, Clarence J. Sundram was retained by EDS to advise the defendants in Risinger v. Concannon, how to achieve compliance with the Settlement Agreement expeditiously and effectively. In July 2003, Mr. Sundram issued a report containing his recommendations. In a memorandum dated July 14 that accompanied that report, Mr. Sundrarn proposed that BDS prepare a Plan of Implementation with speci?c deadlines for each recommendation. BDS offers this plan for evaluation and comment. Attached to this plan as Exhibit A is a chart that tracks the plan and provides speci?c timelines and identifies persons responsible for implementation plan items. Expanding Service Capacitv Report Recommendation 1.Re-examine the reimbursement rate structure and adjust it to cover the reasonable and necessary costs of providers to support a stable workforce. Response BDS will follow this recommendation. In a letter dated July 30, 2002 and sent to all Section 24 (in-home support services) Children?s Habilitation Service providers, BDS solicited FY02 actual cost information for review in the development of rates. BDS sent a follow up e-mail solicitation with electronic forms on August 2, 2002. BDS received responses from 9 providers out of 36. BDS reviewed the information it received and concluded that there was not a suf?cient basis for a rate increase. LOCATION: MARQUARDT BUILDING, 2ND FLOOR, HOSPITAL STREET, AUGUSTA, ME PHONE: 287-4223 (V) (207) 28?-2000 (TTY) FAX: (207) 287-4268 BDS made similar attempts to gather rate information from providers of Section 65 services. In a letter dated December 26, 2002, which was sent to all Section 65 providers, BDS solicited FY02 actual cost information for review. A follow up e?mail with electronic forms was sent on December 30, 2002. BDS received response from 14 providers out of 24. Again, BDS concluded that the survey information did not provide a suf?cient basis to support a rate increase. In order to properly support any request to the Legislature for a rate increase, BDS is mandating that any providers who have not already submitted their FY02 actual cost information submit that information by September 2, 2003. BDS will compile that information and analyze it to determine whether the rates are suf?cient to cover reasonable and allowable costs also factoring in for in?ation. BDS will review the type (wages, bene?ts, travel) and amount of expenses to determine if the correct costs are being considered and Whether there is unaccounted variation between the agencies. BDS will complete its study in time to submit to the Legislature any necessary request for an increase in funding to support the recommended rate. The next legislative session at which a supplemental budget request could be considered begins January 1, 2004. Any increase in funding approved by the Legislature would not take effect until July 1, 2004. In order to make use of any rate increase improved by the Legislature BDS will also need to change MaineCare rate setting policy. In connection with preparing for the September rate study, BDS is considering a proposal to adopt new rate setting approaches. With respect to section 24 services, BDS is evaluating the feasibility of a fee-for?service arrangement with providers as opposed to a year-end audit of a provider?s allowable costs. BDS is also evaluating allowing for a negotiated rate with providers of section 65 services rather than the set-rate method currently employed. Report Recommendation 2. Support the creation of a Katie Beckett coordinator position in each region. Response BDS will follow this recommendation. BDS is jointly responsible with DHS for the administration of the Katie Beckett Option under MaineCare. BDS will collaborate with DHS/Bureau of Family Independence (BFI) to ensure that accurate and consistent information regarding the initial determination of eligibility and services available through the Katie Beckett Option is made available statewide. These efforts will include additional and targeted training for DHS and EDS staff about the Katie Beckett Option, so that they can better inform clients, as well as directtraining for case managers, parent/family organizations, and families. BDS will also train and designate BDS Resource Development Coordinators in order to serve as regional contacts for providers and EDS staff. A MaineCare brochure regarding The Katie Beckett Option was produced in collaboration with BDS in May 2003 and is available to the public. The information contained in the brochure will be added to the BDS web page. Report Recommendation 3. Develop a mechanism authorizing families, who have been waiting beyond the 180 day timeline for in-home support services in unserved and underserved areas, and for whom there is no clear prospect of service in the reasonable future due to the unavailability of providers, to secure the services of quali?ed independent contractors for an interim period. Once this system is in place, consider the appropriate use of vouchers well in advance of the maximum timelines for service. Response BDS will follow this recommendation. BDS has surveyed rural New England states and reviewed the approaches that those states have ad0pted to address this issue. BDS has concluded that the program used in New Hampshire, commonly called the Independence PLUS waiver, has the greatest promise for application in Maine. BDS will write and submit an application to Centers for Medicare, Medicaid, and Child Health Insurance Services (CMMS), formery called Health Care Finance Administration (HCFA) for an Independence PLUS waiver similar to that submitted by New Hampshire. BDS will also meet with DHS by August 18, to determine if there are any other options along the lines of a voucher program to provide services to unserved/underserved areas that do not require the approval of a waiver. Report Recommendation 4. For children who do not have an Individualized Treatment Plan (ITP) within 90 days of the Start Date, the Department should ensure that they are assigned to Level 1 case management for the preparation of an interim treatment plan. Response BDS offers the following as an alternative to this recommendation. The central enrollment process will be modi?ed to identify children who do not have ITPs after waiting 90 days. BDS anticipates that with the full implementation of central enrollment and the regular use of the triage process, BDS will be able to identify the provider agency that is most likely to be the agency that will serve each waiting child. In order to ensure that the interim treatment plan is clinically sound, BDS proposes using the provider agency BS-II employees to prepare the interim ITP rather than Level 1 case managers. On a case?by?case basis, BDS will work with the provider agency most likely to be serving the child and encourage that agency to use its BS-Hs to prepare an interim ITP for the child before 120 days of waiting. If the agency most likely to serve the child cannot be identi?ed, BDS will work with to authorize reimbursement for any to develop an ITP before 120 days of waiting. BDS pr0poses this alternative because it believes that this altemative is the better clinical approach although it may be less effective in helping BDS to meet the ITP deadline established by the Settlement Agreement. This tension between the Settlement Agreement and clinical practice is centered on the unique purpose of an ITP: I An ISP is a product of the case management planning process and is a broad delineation of the kind of services that would be appropriate outpatient services, in home supports, etc.) An Individualized Service Plan (ISP) is deve10ped with the family by a Case Manager and must be completed within 30 days after service initiation (licensing regulation). Service initiation is when the actual service, case management, begins. Some children do not request or require case management, therefore, they would not have a broadly-based services plan (ISP). Instead they would have an ITP for in home supports de?ned below. I An ITP is a speci?c clinical treatment plan that would delineate what kinds of interventions are indicated cognitive behavior therapy, Applied Behavioral Analysis (ABA), medication, practice use of appropriate social welcomes, hand over hand instruction with face washing). Licensing regulations require that the ITP must be completed within 30 days of starting treatment. An ITP can only be developed bv a licensed clinician in collaboration with the family and should only be prepared after treatment has revealed the most appropriate plan. The Settlement Agreement states that an ITP for in?home support services will be developed within 120 days from the Start Date even though the outer time limit for the service is 180 days. This presents BDS with a clinical dilemma in that a treatment plan may be required before the treatment is initiated and the treating professional is engaged to develop a thorough and appr0priate clinical treatment plan. On this point, the Settlement Agreement appears to be inconsistent with sound clinical practice. Report Recommendation 5. Provide start up funding for case management when providers have fewer than 15 children assigned to serve ?children who are nearing the ISO-day deadline.? Response BDS will review the policy implications for negotiating a different rate for case management providers carrying a partial or reduced caseload in unserved geographic areas of the State. However, as re?ected in Mr. Sundram?s ?nal report, a total of 5857 children were provided case management services in fiscal year 2002, and of that total, only 9 children were waiting greater than 180 days as of July 1, 2003. Therefore, BDS offers the following as an alternative to this recommendation: For every child who is nearing the 180 day limit for waiting for in?horne support services, BDS will review the particular circumstances of that child and identify the barrier to service--e. g. geography or population base. BDS will work closely with the family, local agencies and other community groups to remove the barrier and obtain services for that child as soon as possible. Report Recommendation 6. Institute a procedure to waive training requirements for BS-Is with equivalent quali?cations. Response BDS will follow this recommendation. We note that in order to start employment as a BS-I, an employee with a four-year degree need only complete the required four- hour video training. That employee is permitted the ?rst year of employment to complete the remaining 46 hours of training. However, BDS does recognize that equivalent training and quali?cations may allow a BS-I candidate to perform his or her job well without the required training. BDS will, therefore, contract with Behavioral Health Sciences Institute (BSHI) to develop a test for competency. BDS would offer these tests to employees who have a four-year college degree and those employees would have the option of seeking to test out of the ?fty hours of training. Utilization of Existing Resources Report Recommendation 1. Develop a quality assurance program to evaluate the quality, responsiveness, and effectiveness of in?home services and supports provided to families. Response BDS will follow this recommendation. BDS has initiated the development of a separate Children?s Program (Quality Improvement/Quality Assurance). BDS has designated a QA coordinator in the central of?ce to supervise the effort and work closely with the existing Department?s QI Of?ce. This position is responsible for the development and implementation of the ongoing quality assurance efforts in the evaluation of the quality, responsiveness, and effectiveness of the in?home services and supports provided to families. To date, the QA Coordinator has undertaken the following efforts to establish the QA children?s program: a) Oversee the Due Process Noti?cation for informing parents and others when a denial, reduction, or termination of services is determined; Speci?c to in?home supports, Section 24, and Home and Community Based Services, Section 21; b) Development and implementation of Provider Compliance Protocol covering the due dates for Central Enrollment Form, Status Update Form, and the Regional Triage Form; c) The QA Coordinator and a member of the Department?s Quality Improvement O?ice met with regional staff in July to initiate the Department?s Quality Improvement Plan for the Children?s Program area and to ensure consistency with other BDS QI efforts; this represents the ?rst quality improvement review of children?s services and will continue on a quarterly basis. Report Recommendation 2. Full implementation of central enrollment for in?home services to help improve the ef?cient use of existing resources. Resgonse BDS will follow this recommendation. BDS fully implemented the statewide central enrollment process for in-home support services (Children?s Habilitation Services and Children?s Behavioral Health Services) on July 2003. Training for the providers of in-home support services and case management services was conducted in late May and in June. The Enterprise Information System (EIS) is prepared to support the implementation of central enrollment. The BDS children?s work group has established the process for data collection and entry for in-home support services and has made the programming changes in EIS necessary to. confonn to that process. BDS has completed sending letters to families waiting for in?home support services as of July 1, 2003. These letters explain the central enrollment process and provide points of contact for more information. The implementation of central enrollment will continue to be monitored and modi?ed as necessary. Data collection and data entry processes are reviewed on a basis with the BDS Program Staff (Systems Manager, QA Coordinator, and Team Leaders). BDS regional staff will continue to provide technical assistance to provider agencies regarding the implementation of central enrollment. Administration Recommendations Report Recommendation 1. Develop a tickler system to: identify cases that are 30 days from the maximum waiting period and assign them for special review; and keep track of dates when re- evaluations are due, or Katie Beckett renewal is due. Resgonse BDS will follow these recommendations. The existing tickler system in EIS will be reviewed and evaluated to determine whether it can perform the tasks identified in the recommendation. If the existing system in EIS cannot be modi?ed to perform the necessary functions, the Of?ce of Information Systems will develop a tickler system that can perform those functions. In connection with the effort to establish a tickler system that tracks the tasks above, BDS will develop a data collection'and management process to ensure that BDS staff and providers collect and report the required information. For example, BDS will determine how to track re?evaluation dates and Katie Beckett renewal dates and will develop a plan for training providers to allow this information to be reported to BDS As noted above, tracking for Katie Beckett enrollment and renewal dates will require that BDS develop an agreement with DHS to facilitate the collection and sharing of this information. EIS data entry training for department staff will be developed and implemented by Muskie, Center for Learning. Report Recommendation 2. Develop a practice of providing EIS reports to providers for all children assigned to that agency with a request to verify accuracy and current status of all information. Response BDS will follow this recommendation. BDS has the capability to run reports from EIS. BDS will require provider agencies to periodically review EIS reports to verify the accuracy and current status of children assigned to that agency. BDS will review and evaluate provider contracts and determine whether it is necessary to modify the contracts to include a separate requirement that provider agencies provide veri?cation of EIS report data. BDS will review the data entry process to determine to determine whether it needs to be modi?ed to support the new veri?cation reports. Training of staff and providers will be developed and implemented for any new data entry processes . Report Recommendation 3. Adopt and formalize a policy and procedure to inform providers of the rami?cations for failure to timely complete reports required to track children on the waiting list. Response BDS will follow this recommendation. Contracts between provider agencies and BDS contain a provision that requires agencies to submit timely information to BDS as a standard of full contract performance. In order to give force to this provision, BDS will develop a policy and procedure for graduated penalties to react to agencies that persistently fail to meet their reporting requirements in a timely way. It is unlikely that this will require rulemalcing, so the formalization will be through contract amendments.