SKIP Submits RFI for 1115 Waiver

SKIP OF NY Comments to OPWDD People First Waiver RFI

II. General

6. Describe any historical organization experience which may be applicable to the proposed care management or capitation reimbursement method of New YorkState.

For almost 30 years, SKIP OF NY has been providing a range of services for more than 3,000 individuals/children a year through Care at Home, Medicaid Service Coordination, the Home and Community Based Services Waiver and the Nursing Home Transition and Diversion Waiver. An expert in the field in advocating on behalf of developmentally disabled and medically fragile individuals/children and their families, SKIP knows first hand about the essential components to ensuring a child/individual is safely cared for in their home. As OPWDD continues to develop its People First Waiver proposal, SKIP calls on the state to ensure that the following core principles are adhered to throughout its planning, development and implementation:

§ CHOICE: Ensure DISCOs offer a comprehensive choice of providers for the wide range of services and medical needs of developmentally disabled and medically fragile individuals/children;

§ ACCESS: Develop a nuanced assessment tool that guarantees access to the full range of services and medical care that individuals/children and their families need to remain in their home. Avoid a “one size fits all” service determination process that might preclude our most vulnerable individuals/children from receiving the appropriate care and services that they need.

§ SUPPORT: Maintain critical case management and service coordination that has become the lifeline for families as they try to navigate complicated eligibility and enrollment processes while also trying to coordinate the delivery of their services. Any plan for “care management” needs to clarify the distinction between case management for receiving appropriate services and care management for coordinating medical care. Without this distinction, individuals/children will be at risk of losing essential service coordination that has been the backbone for their care, health and safety.

§ PROTECT: Protect our most vulnerable populations by establishing a robust checks and balances system including an internal appeals process within the DISCOs and an Ombudsman program outside of the DISCOs. As the delivery of services gets rolled up into large DISCOs there is great risk that service delivery decisions could be driven by fiscal constraints. An internal and external appeals process will be essential to ensuring individuals/children, their families, and their advocates have a venue to challenge decisions regarding their services and care so that they can optimize their ability to live in the community

7. Provide a brief and succinct description of your organization’s years of experience, particularly in the area of developmental disabilities, and other information, such as the size of your organization, that is pertinent to the provision of supports.

SKIP OF NY, Sick Kids [Need] Involved People of New York, has been providing service coordination and case management since 1983. SKIP’s mission has been to ensure severely sick and/or developmentally disabled individuals/children in New York are able to remain in their home and live with their families. Through service coordination, advocacy and hands-on problem solving, more than 150 SKIP case managers and supervisors serve more than 3,000 individuals/children, annually. Services SKIP advocates for include but are not limited to home care/nursing services, environmental modifications, Assistive Technology, Family Education and Training, respite, community habilitation, family support services, Early Intervention and pro bono advocacy in memory of Julia Mikol. True to SKIP’s mission of providing the best possible childhood for special needs individuals, SKIP also navigates the system for families to connect them with schools, extracurricular programs and summer camps that are specially designed to meet their needs. SKIP has a demonstrated track record in serving the needs of individuals/children in their home, and ensuring they get the services and care that they need.

In further testimony to the effectiveness of SKIP’s approach to service coordination and advocacy, shortly after being launched, SKIP was awarded a federal Special Project of Regional and National Significance (SPRANS) Grant to demonstrate that its case management/service coordination model could secure the discharge of children residing long-term in hospital intensive care units to the community with proper supports and services. The project was so successful, the federal government extended the grant so that the model could be integrated into NY State programs. It now forms the basis of Care at Home.

III. Care Coordination

1. As New York State transitions to a care management system, how would you recommend evaluating the expectation that a person centered planning process is used effectively to develop supports for individuals?

SKIP strongly believes that OPWDD should develop Guiding Principles for DISCOs, before any application for pilot projects are considered, and definitely before any widespread enrollment begins. This is the approach DOH adopted as it expanded managed long term care options to include new Care Coordination Models.

As previously articulated, the following are SKIP OF NY’s recommended guiding principles: (1) Choice of providers; (2) Access to the full range of services individuals/children need to be safely cared for in their home; (3) Support through case management and service coordination; and (4) Protect our most vulnerable populations by establishing an internal and external checks and balances system.

2. What would you envision as the most effective system to ensure that there is a comprehensive clinical team of experts available to develop a plan of care in line with an individual’s expressed interests and needs?

Before a “comprehensive clinical team of experts” is convened, it is much more logical to do an assessment prior to the design of any plan. It is not realistic or sustainable to have a clinical team devise plans for 125,000 people then meet annually for plan updates.

It is our suggestion that the same approach be used in assembling a team as is required by the Federal ICF/MR client entry process. In addition, an independent service coordinator should be part of the team to carry out the plan to ensure the health and safety for each individual. Also, each individual requires a comprehensive team that includes service coordinators integrated with the clinical team to effectuate the full range of medical care and other services. While clinical teams will be essential for coordinating medical services, they are not the best equipped to coordinate the full range of services an individual is receiving (such as attending an IEP meeting). Care coordination must include a holistic team of clinical experts and service coordination experts in order to achieve the most effective and efficient outcomes.

Are you aware of best practice models that could be duplicated?

If yes, please describe.

The DOH Care at Home Program service delivery has been a very successful program with strong emphasis on the social care needs as well as the individual’s medical needs with a very succinct eye to cost efficiencies. The design of the program demonstrated that the program developers understood the needs of the population to be served. The Care at Home Program began with a relatively small census but served a population that prior to its inception was 100% institutionalized.

Current case management and service coordination offered through agencies such as SKIP are also a best practice model that should be replicated throughout the DISCOs. Establishing a plan of care must be a team of individuals who are well versed in all aspects of each individual’s life and care needs. This requires the distinction between case management for service coordination and care management for medical care coordination.

The most important part of effective service coordination/case management is the relationship developed over months and years between the agency and the person with a developmental disability and his or her family. There is no replacement for getting to know individuals and their families, gaining their trust, and developing a complete picture of their needs and interests. It will be critical to ensure an expanded system does not become unwieldy, impersonal and potentially undermine the trust and relationships that have been established through service coordinators and the families they serve. Losing these relationships could seriously impair the health and safety of individuals served.

3. The sharing of information across providers who support individuals is critical to ensure quality, integrated care plans and consistent proactive treatment strategies to help individuals maintain and/or achieve desired health, functional and personal outcomes. What strategies and Information Technology (IT) solutions would you recommend to ensure effective information sharing?

Do you know of or currently use IT systems that are effective? If yes, please identify and describe.

SKIP OF NY has made a considerable investment in creating a responsive, effective and efficient IT system. All parties acquainted with it find it user friendly, interactive and highly effective. In yet another demonstration of SKIP’s hallmark of exceeding prescribed mandates, our IT system has facilitated accurate, responsible record keeping allowing us to capture complete consumer historical information. Built on meticulous case note keeping in which we document each individual collateral contact, the system allows us to easily navigate any problems that arise. SKIP would welcome the opportunity to follow up on previous IT system demonstrations to OPWDD with additional presentations.

4. Effective Care Management calls for sharing pertinent information between involved providers of supports and services. As we transition to more flexible and natural models of support, do you foresee obstacles or challenges to information sharing as the result of confidentiality standards and HIPAA Privacy requirements that are currently in place?

Intentionally left blank.

5. Supporting a person to establish and maintain natural supports through relationships with their family members and their home community is key to ensuring that they are fully integrated and included in the community of their choosing. What strategies would you suggest to ensure that these relationships are fostered through an effective care coordination process?

As previously stated, the most important strategy for every aspect of effective service coordination is maintaining, to the maximum extent possible, existing relationships with service coordinators currently serving individuals through the Medicaid Service Coordination program. These service coordinators already know the family and the community involved, and can develop individualized solutions that maximize community assimilation.

Additionally, there must be a well-configured service delivery system that supports primary care givers and those “natural supports within the community” so that their direct caregiving capacity does not burn out. There are effective systems within Medicaid and the Home and Community Based Waiver that are models for replication.

6. Please describe how you would foster relationships and coordinate best practice interactions with providers from other systems to ensure the most appropriate evidence based, coordinated treatment approaches which reduce the likelihood of stays in high cost and at times inappropriate settings? (e.g., if you are a provider of services to persons with developmental disabilities, how would you foster relationships and coordinate best practice interactions with providers such as behavioral health programs, inpatient hospital medical and psychiatric settings, dental care settings and substance abuse treatment programs?)

For almost 30 years, SKIP has proven itself as an expert in the field in providing case management and service coordination for developmentally disabled and medically fragile individuals/children living in their home. To ensure service delivery and coordination is properly effectuated, it will be essential that DISCOs contract with case management and service coordinating entities such as SKIP OF NY who have demonstrated an ability to provide the highest level of care while being fiscally responsible. As a subcontractor of DISCOs, SKIP OF NY would provide case management and service coordination for individuals/children to ensure they have access to the services for which they are entitled and the support they need to navigate service delivery. SKIP’s mission has been to ensure individuals are cared for in their home and receive much lower cost and more appropriate services than if they were in institutional care. SKIP OF NY’s case management and service coordination is a best practice and OPWDD should design its Waiver Proposal with the guarantee that individuals enrolled through a DISCO receive the type of case management that SKIP OF NY currently offers individuals/children and their families.

IV. Assessment

1. Consistent needs assessment tools will be utilized to make determinations about support needs, care plan development and resource allocation. Are you aware of, or currently using, a particular tool that you would recommend? If yes, please describe the scope, benefits and challenges for the identified tool.

SKIP OF NY is not aware of any assessment tool that currently exists that accurately determines the appropriate level of service coordination and medical care coordination.

2. What experience have you had with assessment tools for the purposes of care planning and identification of levels of supports and what lessons have you learned that could benefit NYS?

It has been our experience that serving a small but ever-growing population of medically fragile individuals requires tools, plans and service delivery tailored to different life circumstances and life stages. Therefore any effective assessment tool must be dynamic/able to capture ever-changing health and safety needs. Additionally, a child’s developmental goals progress as the child grows—and the plan driven by the assessment tool must be designed to ensure that children can reach age-appropriate milestones.

Also, medically fragile individuals need to be assessed differently than individuals with less complex medical conditions. Living with a complex medical condition affects every facet of an individual’s life. Therefore, the needs assessment tool must be capable of capturing how an individual’s medical condition intersects with other aspects of that individual’s physical, social and cognitive development.

On a purely practical level, SKIP remains unclear as to how and by whom OPWDD expects complex, multi-specialty assessments to be conducted. From the necessary medical exams, the

family and community assessments the psychological evaluations to the patient interest inventory, it’s a huge, complex undertaking. It takes enormous time, flexibility and patience to glean the comprehensive information needed to build a succinct, effective and cost-efficient, equitable care plan.

3. Have you used a needs assessment process for the allocation of resources?

If yes, please describe your experiences from both a benefits and challenges perspective.

As discussed above, crafting assessment tools capable of informing comprehensive plans of care is a challenge for any agency. Creating an assessment tool that can also be used to develop a budget for an individual’s care is an even more daunting task. We reiterate our concerns above—the assessment tool must be capable of addressing the special needs of all developmentally disabled persons in an individualized way that captures their unique needs.

4. Have you had experience with a strength based needs assessment tool that incorporates a review of natural community based supports available to the individual?

In our experience, “strength-based” tools result in a decrease in services despite the demonstrated need of the individual/child.

Please identify a tool that you would recommend:

As discussed above, SKIP is concerned that a “one size fits all” tool could result in our most vulnerable individuals/children not receiving the appropriate services that they need. In the almost 30 years in providing services to individuals/children and their families, SKIP has not yet encountered one tool that can appropriately determine the adequate services and medical care a child needs. If such a tool is to be a requisite to enrolling in a DISCO then such a tool must be nuanced enough to guarantee access to the full range of services and medical care individuals/children and their families need to remain in their home.

5. Would you be willing to work with OPWDD to test tools for their validity and predictive capacity outside of a comprehensive demonstration project?

Yes. We would be happy to compare OPWDD tools to our current approach to evaluate their efficacy and establish if the outcome information is comparable.

V. Effective Provision of Supports, Choice, and Network Capacity

1. How would you recommend evaluating the adequacy of a person centered plan to ensure it appropriately addresses the changing life needs of an individual receiving supports; including building and maintaining naturally supportive relationships, addressing future and contingency

planning, and building models of support most in line with an individual’s expressed interests and needs? Please describe specific measures that you feel would be appropriate to make such a determination, where possible.

The keys are communication and flexibility in terms of timing. Their milestones happen at their own pace, following no set pattern. Frequency of evaluations must evolve with problems and situations rather than follow a set schedule. Honest, open communication with a trusted representative/service coordinator is critical to staying on top of individual needs, and evaluations must be informed by future planning, ongoing discussion and contact with consumers. As OPWDD moves toward rolling up services into large DISCOs, it will be critical that personalized, independent service coordination is preserved.

2. How would you afford individuals with developmental disabilities and their family/advocate the opportunity for choice related to DISCOs and service providers within a care management environment?

It is crucial that OPWDD move slowly on implementing the DISCOs, to allow the agency, families, and advocates to fully and thoroughly evaluate the effects of the first pilot projects. After those evaluations are complete, and if agency and stakeholder evaluations find that the DISCO structure appears to offer benefits for individuals, then individuals, families and advocates should be offered substantial time and support for evaluating the services provided by each DISCO available to them.

Consumers should be given an option to opt-out of the DISCOs especially if the DISCO does not provide the range of services or provider choice that they had prior to enrollment in the DISCO.

Major questions regarding choice and access remain unanswered. Additionally, how will individuals access services not offered by the DISCO they join—will such services that qualify for Medicaid reimbursement continue to be offered on a fee-for-service basis? How does OPWDD envision the residential opening management system working if all services are provided through an individual’s DISCO? Will some individuals have shorter or longer wait times for housing based on which DISCO they join?

OPWDD needs to establish a clear, accessible process for appealing plans of care, service denials, and provider access denials before DISCO pilots are implemented. Consumers should have the option of both the Medicaid Fair Hearing Process or the Article 44 Insurance Law process.

Ideally, OPWDD should base its process on Article 44 of the Insurance Law, used by all other managed care entities in the State. Health care providers, insurers, and advocates are already familiar with the Article 44 process and the administrative apparatus for implementing that process already exists, so that adhering as closely as possible to that process will provide individuals, families, and advocates with some ability to anticipate what their rights will be and will reduce the administrative expenditures associated with creating an entirely new system.

OPWDD regulations and administration of the appeals process will need to account clearly and practically for the differences between a managed care organization managing health care and the managed care organizations managing multifaceted services that DISCOs are envisioned to be. However, extreme care must be taken to make the appeals process accessible to individuals with developmental disabilities and their families and advocates.

Moreover, an independent advocate role needs to remain outside the DISCO system, and the independent advocate must be funded separately from the DISCOs. Independent advocates ensure that individuals and families have a place to turn for assistance when they have been denied a necessary service. This is a role that is currently filled by MSC. MSC coordinators will be unable to continue in that role if MSC becomes part of a DISCO.

3. What mechanisms would you put in place to evaluate the adequacy of the opportunity for individuals with developmental disabilities and their family/advocate to have choice in providers? The choice of providers should incorporate cultural and programmatic diversity and clinical experience in the unique medical and clinical needs of individuals with developmental disabilities, in regions of the state which have limited participating providers.

To ensure CHOICE, OPWDD should establish the requirement that in order to become certified as a DISCO, the proposed DISCO should be required to demonstrate they have subcontracted with a wide range of providers for adults and also for children. Each DISCO should be able to demonstrate a robust provider network that serves medically fragile individuals/children, with a care coordination component that is specially tailored to meet the needs of medically fragile individuals/children.

If regions are limited to only two DISCOs there is a real concern that individuals will not have adequate choice and our most vulnerable populations will be at risk. Capacity is central to all managed care models yet no managed care model has succeeded in achieving it for the special needs population. Therefore, the only possible alternative would be to allow consumers to opt out without penalty for services in which the provider choices are inadequate within their DISCO.

4. The opportunity for individuals with developmental disabilities (with support from their family/advocate, if necessary) to self direct their supports and plan of care is an integral expectation in the People First Waiver. How do you recommend ensuring that self direction of resources and support plan is streamlined and readily available to individuals?

Ensuring self direction is a paramount priority as OPWDD develops its DISCOs. To ensure individuals are receiving the services they need they will need appropriate support through case management and service coordination.

5. Although there may be some period of transition needed initially, ultimately the resources for all medical, behavioral health and dental services will also be included within the capitated payment provided to the DISCO. What strategies do you see as effective to ensure a competent network of providers to meet the unique needs of individuals with developmental disabilities?

We must be cognizant of the fact that the State is comprised of different geographic areas. As such, all of the local resources must be folded into the DISCO lest consumers living in rural areas be left without services.

6. What provider or other community coalitions might be encouraged to develop needed service capacity for medical, behavioral health and dental services?

In order to ensure DISCOs provide choice of providers, access to the full range of services individuals/children need, and protection in navigating service delivery, SKIP OF NY recommends that DISCOs be required to subcontract with the full range of service providers who have demonstrated an ability to serve vulnerable populations in the most cost-efficient way. One key component of DISCOs will be to provide case management and service coordination to the individual and, in order to be certified, DISCOs must show that they have subcontracted with a wide range of service coordinators and case managers with experience meeting the diverse needs of the population the DISCO will serve.

7. Recognizing that individuals will be transitioning from highly structured state operated institutional settings, design team recommendations identified the need for effective clinical support models and crisis intervention models; what models have you found to be effective and how would you develop an appropriately responsive system of supports to ensure adequate individual safety and evidence based treatment approaches?

We do not have an answer for this as our focus has always been on supporting community-based services.

8. A key hypothesis of the waiver is that a fiscal structure that provides resources based upon a consistent needs assessment process will incentivize the development of innovative support plans that are more aligned with individual’s interests and needs and which ensure that resources are allocated equitably. What innovative models of support have you heard about, implemented or would recommend within the People First Waiver that would be consistent with this hypothesis? (please describe)

VI. Quality

1. What approaches would you recommend to incentivize the provision of quality supports and services that are driven by a person centered plan of care and result in desired personal outcomes?

The best incentive is success which will bring more people to the DISCO. This is what has fed SKIP’s growth. Success is built on good programs and service which include good conflict resolution and an open, trusted approach which allows families to articulate what they don’t understand and share honestly and thoroughly.

A key component in establishing a successful entity is robust collection of feedback via a combination of satisfaction surveys, in-person interviews and unannounced site visits conducted by individuals well-trained to observe and assess accurately. Using feedback to adapting to consumer needs will help assure the high levels of customer satisfaction that will promote DISCO growth and success.

2. What advantages and disadvantages are there to the approaches that you selected in question #1?

We did not select one of the listed approaches rather we recommend customer satisfaction as the best incentive with includes: Choice, Access, Support and Protection. Additionally, there must be thorough, independent reviews of providers/DISCOs coupled with the will to discontinue contracts for low performers.

3. What information technology systems do you envision utilizing to manage and coordinate information, gather and aggregate pertinent data, and create meaningful and useful reports?

See Section III (Care Coordination), Question #3

4. The provision of person centered supports is directly impacted by the relationships and interactions between direct support professionals and the people they support; how would you ensure that the direct support workforce is competent, well trained and empowered to provide support in a manner that brings the best possible quality of life to the individuals receiving supports?

As part of our annual and semi-annual evaluations, we ask the families and consumers to describe their experience with us. We adjust as needed based on feedback we receive.

5. Through effective care coordination and with resource levels established based on the consistent assessment of strengths and needs, it is anticipated that plans of care will be delivered across a variety of settings in line with individuals expressed interests and needs. Quality must be measured based on the outcomes realized by the individuals supported in their health status, functional capabilities and personal outcomes. What strategies do you recommend to effectively measure these outcomes for people receiving supports and services?

For some people, “outcomes” are a moot point due to the dynamic nature of their situation and diagnosis. Measuring quality based on outcomes lends itself to bias and stagnation. We’ve seen this in IEPs that remain constant with their goals for years on end. Evaluations for services are going to need to be as dynamic and fluid as the needs of the clients who are receiving them.

6. The quality design team created a quality measurement scale that identified expectations for provider performance and a 1 through 5 rating system that would be available to the public (www.opwdd.ny.gov/2011_waiver/images/quality_final_report.pdf). What strategies would you utilize to implement quality improvement activities to be rated, or, as a DISCO, to ensure that provider agencies are rated, as high performers?

Intentionally left blank.

7. What quality measures do you feel are appropriate to establish to rate the effectiveness/performance of a DISCO?

Intentionally left blank.

VII. Fiscal Administrative and Organizational Structure

1. To effectively manage a network within a capitation reimbursement model, based on a consistently administered needs assessment tool, it will be necessary to provide supports and services to a minimum number of individuals with variation in defined support needs. Based on your historic knowledge or initial research, approximately how large would a DISCOs enrollee pool need to be to remain fiscally viable and still implement effective care plans derived from person-centered planning practices?

It is crucial for OPWDD to recognize that there are certain small populations, such as medically fragile developmentally disabled individuals/children, whose needs are so specialized that they are never going to be best served in a large undifferentiated DISCO. OPWDD should be thinking about

creating small, nimble DISCOs that can respond creatively to the needs of niche populations for whom they offer highly specialized networks and expertise. One size will never fit all in the worlds of individuals with developmental disabilities, given the wide diversity of abilities, needs, and interests among those individuals.

To ensure the financial stability of small, specialized DISCOs, the state may need to create risk corridors or other risk-shifting arrangements that are tailored to the size of the DISCO, so that smaller DISCOs are more protected from risk than their larger counterparts. Additionally, the state may want to create—or encourage others to create—an entity that can provide centralized administrative services to allow smaller DISCOs to benefit from economies of scale like larger DISCOs. The state should not let the financial investment in smaller DISCOs stand in the way of appropriate care for niche populations of developmentally disabled individuals.

Further, the state should avoid creating DISCOs so large that they can wield inappropriate levels of bargaining power with the state. If only a few DISCOs are created and the fee-for-service and state programs have been dismantled, the state will become dependent on the DISCOs’ service capacity. This dependence would create real risks for individuals in the OPWDD system if DISCOs become “too big to fail,” and can demand state bailouts or waivers of quality controls.

2. The following questions relate to organizational structure and network requirements for potential DISCOs that you would recommend, from the perspective of a potential pilot DISCO operator, member of a DISCO provider network or recipient of supports and services.

a. What geographic location are you focused on? Statewide

b. Please provide a general description of how OPWDD should evaluate whether a DISCO pilot applicant is proposing a provider network that is sufficiently inclusive of self directed support models, habilitative supports that are responsive to individuals’ and families’ interests and needs, for services that include family supports, care coordination, medical care, behavioral health care and dental care.

Intentionally left blank.

c. How can OPWDD best support the development of DISCO pilots?

OPWDD needs to prioritize developing, in concert with DOH, OMH, OASAS, OMIG, and all other regulatory bodies with oversight over any aspect of the services that will be managed by DISCOs, streamlined regulations that address the unique nature of the multi-services payor the DISCOs are envisioned as being. Without such streamlined regulations, competing or misaligned requirements will lead to tremendous administrative expenses. Further, providers stand at great risk with OMIG if the changes created by the waiver are not fully understood and respected by OMIG’s audits.

Providers transitioning to DISCOs will need support, both monetary and legal, in adapting their corporate governance to models appropriate for their new roles. This support will be needed early in the process to ensure proper qualifications for those with ultimate fiduciary responsibilities for these new kinds of organizations. In this transition from social service delivery models to healthcare providers, you must keep a case management and service coordination role in place. Additionally, the State must facilitate the adaptation to this model from all vantage points.

3. How would you suggest that DISCOs incorporate programmatic and administrative efficiencies into their network model while ensuring that individuals receive quality, person centered supports and services and that direct support professionals receive competitive benefits and wages; meet core competencies and are well trained?

The program elements e.g., fiscal and programmatic, must be separately reported and separately monitored. Fiscal monitoring should be done by actuaries monthly. Program monitoring should be ongoing and matched to claims, satisfaction and service delivery. A key component of the efficiencies to be gained will come from constant information sharing among DISCOs and between DISCOs and OPWDD. No DISCO should be expected, or allowed, to spend taxpayer money to reinvent the wheel, and formal mechanisms must be established to ensure that effective innovations in service delivery are rapidly shared with the field.

4. Please provide suggestions regarding what controls/fire walls should be applied to DISCOs that also function as direct providers of service to ensure adequate network choice and not unduly influence care coordination efforts toward their own provider agency?

Each individual in the system must have or at least have access to an independent advocate who is not employed by the DISCO.

DISCOs must be required to disclose all service delivery contracts and partnerships.

OPWDD must establish strong conflict of interest provisions that separate assessment, coordination, service provision, and payment functions within the organization or into separate organizations.

Note: For additional guidance, reference existing State and Federal laws governing managed care organizations.

5. What incentives, disincentives and strategies do you recommend to ensure that individuals who present with more complex needs are not excluded from participation in a DISCO of their choice and that high quality expectations for all individuals is achieved and maintained at both the DISCO and provider level?

Give individuals an independent voice with independent service coordination and a system of appeals.

6. How would you ensure that the network of providers established by the DISCO is sufficiently multi-cultural and able to serve the diverse interests and needs of the enrolled individuals?

The system must be established in such a way that informed consent is always required and received from individuals or, if the individual does not have that capacity, from the appropriate decision-maker on behalf of the individual. Protecting this requirement will require that provider networks contain enough diverse and multi-lingual providers be adequately able to communicate with individuals and will allow individuals, families, and advocates to demand improvements in provider networks which are lacking culturally competent providers. See established laws and adhere to them.

7. As described above, a DISCO is the entity that would serve as a care management organization and receive funding based on a capitated model of reimbursement, which is based on a determination of need levels of the people served, through a consistently administered needs assessment tool. The DISCO would contract with providers to deliver supports based on a person centered plan. OPWDD’s objective is that ultimately the DISCO operations are characterized by the following three elements: a. Payment to a DISCO is an actuarially established capitated rate which reimburses the DISCO for the enrolled individuals full spectrum of Medicaid and non-Medicaid funded supports and services (preventive, acute and long-term support services), and

b. The DISCO is responsible for comprehensive care coordination for enrolled individuals covering both long-term care and health care, and

c. The DISCO is ‘at risk’ for the full cost of supports and services for their enrolled individuals.

While the ultimate objective is that DISCO operations are characterized by all three of the above elements, there may need to be a gradual transition in one or more of these areas.

In order to incentivize existing NYS providers to apply to serve as a pilot DISCO operator, would you recommend a transition phase for any of the above three elements?

If yes, how would you recommend that the transition take place?

Intentionally left blank.

8. Have you had any experiences with cost sharing or shared savings models of reimbursement?

If yes, please describe the benefits and challenges.

Intentionally left blank.

9. Do you have ideas on cost sharing or shared savings models that you would suggest be considered in the implementation of the People First Waiver?

If yes, please describe.

Intentionally left blank.

VIII. Focused Study Opportunities

1. Are you interested in the opportunity to participate in focused studies of the People First Waiver concepts?

This must be done by independent, well-versed in current and project models who can do comparison studies. They must have strong New YorkState experience and be devoid of any conflicts of interest.

2. Do you have Compass status?

SKIP OF NY has applied for Compass status. We are unclear as to the outcome as we did not receive a response.

3. Do you have quality practices consistent with those measured in Compass agencies, through the use of a nationally recognized accreditation process or integral to your agencies quality processes that could be verified by OPWDD DQM review, to allow participation in this testing phase?

Yes.

4. Please describe:

SKIP of New York is a consistently high performer in both fiscal and program-based audit reviews. Our program growth is normally attributed to these reviews and comments.

Press Contact

Recent News