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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
Improving Discharge Processes
Updates on Waiver Changes
Heidi DixAssistant Commissioner of Development Services, DBHDS
October 13, 2011
Page 2
DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
DOJ Findings
• Lack of adequate care within the Training Centers• Insufficient waiver slots to transition individuals to the community• Limited ID waiver program capacity to serve everyone in need• Current waiver rate structure and design does not allow the flexibility
needed to serve individuals with the most complex needs in the community
• Many day programs do not provide individuals with opportunities for meaningful work.
• The Commonwealth’s Treatment and Discharge Planning process does not meaningfully identify people’s needs, barriers to discharge, and ways to address those barriers
• Specialized community services (medical, dental, crisis) are not adequate to serve those in the community
• Lack of sufficient oversight of community providers.
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
CATEGORIES EXPECTATIONS
Family Reluctance &Family Education/Support
-ARS should be involved in treatment planning and support-If AR is opposed to moving, the TC should document the steps taken to
ensure that they are making informed choice and implement strategies
-Educate individuals and ARs about the community and various community living options on a routine basis.
Staff Education/Training Staff must be knowledgeable of available community services and coordinate with providers to ensure support needs are met
Person-Centered Planning Process Virginia’s PCP should be consistently applied, and discharge planning process should meaningfully indentify people’s needs, barriers to discharge and ways to address those barriers
Collaboration with CSBs CSBs must closely coordinate with TC to develop Person-centered discharge plans that address most integrated setting
Providers Providers must be given information necessary to plan supports to serve individuals in TCs ,and participate in educating staff
Community Capacity/Resources State should develop and implement a plan to expand supports needed to move individuals into the community, including individuals with complex health care needs, behavior problems and/or mental health diagnosis.
Post Monitoring Develop and implement a system, to monitor community-based homes and supports to ensure that they are in accordance with PCP and the individualized discharge plan.
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
Components of Discharge Assessment
Gathered written
procedures and protocols
Reviewed job descriptions
Met with key members
Discussed what has/has not worked
Discussed how key players envision Virginia’s system
Discussed how data is
collected
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
Overall Strengths
Great Attendance & Candid input
Best Practices
Creative thinking
Increased focus on educating
staff
Increased focus on family
reluctanceIncreased
coordination between TC and
CSB
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
Areas for Improvement
PCP/PCT implemented in varying degrees
ISPs varied in relation to supports
needed for movement
Barriers addressed inconsistently
Large variation in knowledge of
community options
Large variation in discharge processes
and timelines
Lack of PST cohesiveness and
role clarity
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
Next Steps
Develop a consistent discharge process across TCs/regions
Clarify key players and responsibilities
Implement system to identify supports needed to move
individuals and match them with
providers/supports
Identify gaps in services & work with regions to
develop capacity building strategies and address
system barriers to moving
Improve system of training and supports
Improve system of checks and balances
(accountability)
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
Current System:Training Center Census Trend
Trends in Training Center Average Daily Census (ADC) FY 1976 - FY 2009
01000
20003000
40005000
1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2009
Training Center Average Daily Census (ADC) FY 1976-FY2009
• There is a shift in what families are choosing
• Average discharges = 70 per year
• Average long-term admissions = 16 per year
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
9
Waiver Capacity
Data from DMAS alpha claims report & wait list for DD & DBHDS 7/1/11
Variance between capacity and enrollment resulted from 1 month lag in data processing
805
745
1012
8937
8672
5783
300285
5783
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
DD Waiver MR/ID Day Support
Current Wait list
Current Enrollment
Waiver Capacity
Slots approved by CMS & GA
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
24 hour awake overnight (21.6%)
24 hour asleep overnight (19.2%)
Supervised Apartment (9.6%)
In-Home (49.6%)0
500
1000
1500
2000
2500
958851
424
2197
*CSB Survey (Dec 2011) 32 of 40 responding; Estimates generated for non-re-sponses
Current System:Persons with ID/DD Awaiting Services by
Type of Service, FY10*
Community waiting lists – 5,472 for ID waiver (2,940 urgent need) and 1,100 for DD waiver
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
Re-Examining Waiver Programs
• Item 397, paragraph BBBBB of the 2011 Appropriations Act mandates a study of waiver programs due October 1, 2011
• Revised submission date – December 1, 2011• In July 2011, a meeting was held with stakeholders to discuss:
– Creating a waiver(s) that matches needs to services, not diagnosis to waiver– Ensuring people with the most complex medical and behavioral needs can be
served– Expanding capacity for those on the wait list for services– Modifying waiver rate structure for residential care and encourage placement in
the most integrated setting– Enhancing waiver payment rates for critical services (behavioral, nursing, etc.)– Reducing documentation requirements– Moving self-direction further towards individual budgets and individual resource
allocation
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
12
Medicaid Waiver Strengths
• Less restrictive home environment• More cost effective, in the aggregate, than
alternate institutional settings• Cost sharing with CMS (50%)• Offer individualized services• Maintains individuals homes in
communities• Coordination of services
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
13
Medicaid Waiver Challenges
• Inadequate capacity (e.g. slots)• Rates inadequate in some service
categories• Service categories need updating• Not set up to serve those with the most
complex medical and behavioral needs
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
14
Data Shows Variation in Costs to Meet Different Levels of Need
FY2010 Recipients Average Per Person Expenditure
Training Center (Public ICF/MR) 1,296 $160,964
Private, Community ICF/MR 391 $137,552
ID Waiver Recipients 8,010 $75,465
ID Waiver Recipients --NOT Using Congregate Residential
3,186 $46,266
ID Waiver Recipients --Using Congregate Residential
4,824 $95,279
Training Center Discharges to ID Waiver 25 (sample) $104,255
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DBHDSVirginia Department of
Behavioral Health andDevelopmental Services
Budget- Item 297, BBBBB
15
Short Term Options Long Term Options
•Adjust Medicaid provider rates to increase availability of smaller residential settings
•Create an exceptional rate for individuals receiving residential support services (high medical and/or behavioral needs)
•Increase number of services available in the Day Support Waiver
•Modification of target population
•Modification of the case management structure
•Adjustment to the waiting list process
