OUTCOME BASED REIMBURSEMENT

FOR JOB COACHING:

A WISCONSIN MODEL

2012 National APSE ConferenceBecky Hebda, Community Care of

Central Wisconsin

Lisa Mills, Medicaid Waiver Employment Services Consultant

IMPORTANT NOTE The following presentation is not

complete. For a copy of the full presentation or to contact the presenters, please email:

Becky HebdaBecky.Hebda@communitycarecw.org

Lisa MillsLMills67@charter.net

HISTORY Previously paid for job development and

job coaching as service provider hours worked:

Disincentive to providers who did well with fading

Inconsistent Expectations: Training Quality indicators Fading Use of technology

State Grant-$25,000 Collaboration with Providers

ACRONYMNS MCO: Managed Care Organization

CCCW: Community Care of Central Wisconsin (A Managed Care Organization funding long term care Medicaid participants)

IDT: Interdisciplinary Team (Registered Nurse Service Coordinator, Social Work Service Coordinator)

SE: Supported Employment

DVR: Wisconsin Department of Vocational Rehabilitation

LTCFS: Long Term Care Functional Screen LOC: Level of Care

INCENTIVE OF OUTCOME-BASED REIMBURSEMENT MODEL

This payment methodology incentivizes providers by: Increasing provider net revenue if member hours

worked increase without increasing the support percentage needed from provider.

Increasing provider net revenue if member maintains hours worked but is able to do so with lower support percentage from provider.

Encouraging provider to assist member to avoid reduction in hours worked whenever possible

Facilitating provider use of best practices (e.g. technology, natural supports, systematic instruction) to avoid the need for job coaching whenever possible

Encourages providers to assist members to find jobs with paid time off and other benefits.

INCENTIVES OF TIERED PAYMENT RATES BASED ON ACUITY

Differential reimbursement of providers aligned with differential reimbursement paid to managed care organizations by state long-term care agency.MCO is paid a higher capitated rate to extent members have higher acuity needs

Model uses the same approach for SE provider reimbursement

ACUITY TIERS Based on a member’s individual capitation payment

which is derived from characteristics on the Long Term Care Functional Screen (LTCFS)

As needs change, individual capitation payment adjusted which can change tier placement

Identified range of individual capitation rates for all current working-age members in CCCW: Low: $277.45 High: $10,393.75

Divided range into 4 equal tiers: Tier 1 members typically have the highest and most complex

support needs; Tier 4 members typically have the lowest and least complex support needs.

Bottom tier starts slightly lower than actual and top tier ends slightly higher than actual to accommodate minor changes in end points of range.

RANGE OF ACUITY TIERSLow High Difference

Tier 1 $7,927.00 $10,502.00 $2,575.00

Tier 2 $5,351.00 $7,926.00 $2,575.00

Tier 3 $2,775.00 $5,350.00 $2,575.00

Tier 4 $199.00 $2,774.00 $2,575.00

JOB COACHING MATRIX EXPLANATION

Acuity Tiers: Logic based on each member’s characteristics as documented on the member’s Long Term Care Functional Screen (LTCFS). Characteristics are used to determine a member’s individual capitation payment. The range of current working-age member capitation payments are broken into four tiers for the purpose of payment. Tier 1 members typically have the highest and most complex support needs; Tier 4 members typically have the lowest and least complex support needs.

Graduated Support Percentages: The average support percentage anticipated is based on the length of time a member has been in his/her job. In keeping with the supported employment model, average support percentage decreases as the member’s length of time in the job increases.

Reimbursement Rates: Provider reimbursement for each of the 12 categories in the matrix is determined based on a rate-per-hour-of-service negotiated between MCO and provider. This rate is then multiplied by the average support percentage for each category to arrive at the reimbursement rate per hour worked by the member.

Hours Worked: Member hours worked per month includes paid time off (e.g. vacation, personal days, paid sick time)

ACTUAL AVERAGE PERCENTAGE OF COACHING SUPPORT-

FEBRUARY 2012: 30%0-11

Months12-24

Months25+

Months

Tier 1 - - -

Tier 2 46% 86% 66%

Tier 3 48% 84% 48%

Tier 4 25% 28% 21%

JOB COACHING PERCENTAGES FOR RATE CALCULATION IN

NEW MODEL= OVERALL 30%0-11 Months 12-24

Months25+ Months

Tier 1 95% 78% 60%

Tier 2 80% 60% 45%

Tier 3 60% 40% 30%

Tier 4 35% 30% 24%

ACTUAL # SERVED-FEBRUARY 2012-194 MEMBERS

0-11 Months 12-24 Months

25+ Months

Tier 1 0 0 0

Tier 2 2 1 11

Tier 3 9 4 27

Tier 4 30 23 87

ONGOING PAYMENT FOR JOB COACHING

Payment for member hours worked will be made on an ongoing basis, according to the matrix, if the member remains employed in his/her job.

Payment is made based on member hours worked, regardless of how much job coaching the member may be receiving from the provider.

There is a financial incentive to maximize member hours worked and minimize job coaching supports.

POTENTIAL FOR “OUTLIERS”

We recognize that the model must account for members who have unique support needs which mean the provider cannot fade job coaching to levels otherwise expected

Outlier category created to address this

“OUTLIER” DEFINITIONThere is potential for members to be designated as an “outlier” if one or more of the following is true:

1. 24 Hour Supervision required as indicated on LTCFS-Protective Service Order

2. Certain Criminal Convictions3. Annual update of LTCFS results in

movement of member into a lower tier

“OUTLIER” PROCEDURE Collaboration between Provider, IDT, and DVR (if

involved) to determine if outlier status is warranted and to identify appropriate payment tierVariety of techniques to affirm “outlier” criteria:

Review of member LTCFS by IDT and CCCW Screen Division to assure accuracy of individual capitation rate

Review of member’s criminal history (if relevant) to confirm presence of issues that meet criteria for outlier determination

Review of member’s historical service data to assure request for outlier determination is supported by longitudinal data and experience

Review of provider agency’s past use of technology and other strategies to achieve fading with the individual member

JOB COACHING BILLING AUDIT

A random sample of all bills submitted will be audited monthly

CCCW will request documentation from SE provider showing proof of member hours worked Provider responsibility to obtain written documentation

from employer and submit this information within 14 days of request

Acceptable forms of documentation: o Copies of member time cardso Copies of pay stubso Signed confirmation from member supervisor/HR

department (electronic is acceptable)

TIERED OUTCOME-BASED REIMBURSEMENT FOR JOB

DEVELOPMENT Member Acuity

One Time Payment

Tier 1 $1600/One Time

Tier 2 $1200/One Time

Tier 3 $900/One Time

Tier 4 $650/One Time

The primary funding source for Job Development should always be the Department of Vocational Rehabilitation (DVR).

THE PILOT Base line date collected July 2011 Piloted September 1, 2011-March 31,

20128 of 9 contracted providers in our

immediate service area participated in the pilot

Required Duplicate Billing for pilot period

All Participating providers received financial compensation based on number of SE members being served$500-$2500 per providerAt least one iPad 2 per providerHD Video camera with tripod, SD card, etc.