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Reports and data

Round III Findings

The following findings are taken from the HCBS Lead Agency Review Summary Report for lead agencies reviewed between August 2015 and concluded in 2018. For the time period reflected in this report, August 2015 to September 2016, a total of 37 lead agencies were reviewed. Quantitative and qualitative information was gathered during these reviews, including over 2,800 case files reviewed, 786 surveys received from HCBS providers, and over 350 lead agency case managers and assessors shared their insights with DHS in focus groups.

Planning practices

As the emphasis on the use of person-centered planning practices continues, lead agency assessors and case managers are being challenged to focus not only on ensuring the health and safety of people with disabilities and older Minnesotans, but also on providing opportunities for them to live, learn, work, and enjoy life in the most integrated setting.

  • Results of the Lead Agency Reviews show that case managers are consistently meeting requirements for visiting people on HCBS waiver programs. The average number of visits made by the case manager and/or assessor in the 18 months prior to the lead agency’s site visit was 3.9 visits.
  • Case managers and assessors in the focus groups consistently reported that they have found it challenging to keep up on the numerous and substantial changes that HCBS programs have undergone in the past few years.
  • Although the majority of people receive their initial assessment within the mandated timeline, performance is below the CMS quality assurance benchmark of 86%. This illustrates the challenges faced by some lead agencies with their intake, assessment, and/or eligibility determination processes.

Organizational design and processes

Case managers and assessors that are able to communicate and collaborate across work teams are better able to ensure people’s needs are being met.

  • The Lead Agency Review Team found that those with multidisciplinary teams, primarily having both nurses and social workers, were better able to meet the needs of the people they serve. The integration of the two disciplines facilitated a culture of peer learning and problem-solving.
  • Overall lead agency staff ranked their working relationships with other internal areas as good.
  • Lead agency staff, primarily supervisors and lead workers, are keeping up to date with changes in expectations for how they manage their allocations and waitlists. Waitlists have been significantly reduced for both the CADI and DD waiver programs. 

Choice, community access and inclusion

The mix of urban and rural regions within the state means that provider capacity often varies greatly across lead agencies. This impacts their ability to support people to live as independently as possible and access their communities.

  • Since SFY2011, the percent of people accessing the DD waiver, who are predominantly under age 65, living in their own home has increased by 6.9%. Although progress has been slow, there is improvement in providing people with meaningful options about where and with whom they want to live.
  • From 2011 to 2015, the percent of working-age people earning more than $250 per month increased slightly statewide for both the DD and CCB programs. During the on-site review, each of the 37 counties received information on its portion of the Minnesota Olmstead Plan’s benchmark to increase competitive employment and earnings for people with disabilities. With the added focus on this topic prompted by the Olmstead Plan, there is an opportunity for real progress in this area.
  • Staff frequently cited the lack of providers in rural communities as the most motivating factor for using non-MHCP enrolled providers. Of the 37 lead agencies reviewed, 25 (67.6%) utilized nonenrolled Tier 2 providers.
  • Lead agency staff report an increase in workforce shortages that is, at times, resulting in providers no longer accepting new referrals or delaying the delivery of services.
  • It is the lead agency’s responsibility to monitor the on-going provision of services for efficacy and people’s satisfaction. Respondents to the provider survey noted that case managers primarily monitored their provision of services through phone and email updates and face-to-face visits, both planned and unannounced.

Technical compliance

Since the first round of Lead Agency Reviews, overall compliance has improved significantly for many items. Appendix A shows the results of the case file review for 27 items of technical compliance for all case files reviewed from August 2015 to September 2016.

  • CMS’s current quality assurance benchmark is 86% compliance. Of the 27 items currently reviewed for general case file technical compliance, only three fall below the 86% compliance benchmark when data for all six HCBS programs is totaled. They are the AC Program Client Disclosure Form, the ICF/DD Related Conditions Checklist, and the inclusion of service details (e.g. frequency, type, cost, and provider) in the support plan.
  • Lead agencies working with individuals who were members of the Jensen Settlement agreement, individuals with Positive Support Transition Plans, and/or individuals who have recently experienced a transition in their living setting, are also reviewed for relevant technical compliance requirements. Findings from the reviews of this information indicate that although there are many areas of strong compliance, additional technical assistance from DHS would be beneficial.

Person-centered planning

Respondents to the case manager and assessor survey overwhelmingly reported that the lead agencies they work for direct them to use person-centered planning and tools and provide them with the resources and supports needed to provide person-centered supports and services.

  • Overall, the Lead Agency Review Team found that when a support plan was drafted using the DHS-6791B CSSP template, it received higher scores both in areas of technical compliance and person-centered planning quality indicators.
  • The use of multiple methods and sources for data collection by the Lead Agency Review has shown that, in some instances, there are discrepancies in what lead agency staff believe they are doing and what is actually being documented. For example, 81% of case managers responding to the case manager and assessor survey stated that they include information on a person’s dreams or wishes for the future in their support plan. However, a review of case files found that only 19% of support plans reviewed included this information. 
  • The review team provides feedback to the lead agencies on areas identified as strengths and areas needing improvement regarding its use of person-centered practices. This educational review is currently scheduled to continue through the end of 2017. For lead agencies with site visits taking place on or after January 1, 2018, the Lead Agency Review will enforce person-centered planning protocols by issuing corrective actions when patterns of non-compliance are identified and requiring incidental remediation for all case files reviewed. 

Round II Findings

The following findings are taken from the HCBS Lead Agency Review Summary Report for lead agencies reviewed between July 2012 and May 2015. A total of 83 lead agencies (87 counties and two tribes) were reviewed during the second round of the Lead Agency Review. Over the past three years, a large amount of data has been collected through the review of these lead agencies, including the review of 6,446 case files and talking to 1,117 lead agency staff.

Case Management

Case managers play a significant role in providing quality services and advocacy for waiver participants.

  • Case managers work across lead agency departments and disciplines to serve participants. By working together with other units, case managers are better able to navigate the system on behalf of waiver participants and ensure participant needs are being met.
  • Case managers have regular contact with participants and their families, which allows them to maintain strong relationships and monitor the participant’s health and safety needs. On average, case managers visited participants 3.9 times in the 18 months prior to the lead agency’s waiver review site visit.

Assessment and Care Planning

A majority of the care plans reviewed contained detailed information addressing the required elements.

  • Lead agencies have seen improvements in results for completing assessments within required timelines since the first round of reviews. Seventy-six percent (76%) of assessments/screenings across programs were completed within the required timelines.
  • A majority (82%) of care plans were written using participant-friendly language which could include using the participant’s name and avoiding use of acronyms or medical jargon. In addition, 68% of care plans included individualized and meaningful goals.

Case File Technical Compliance

Three lead agencies case files were found to be 100% compliant with all requirements. Lead agencies have 60 days after their review to submit evidence that they had brought all cases reviewed into full compliance.

  • The areas where lead agency case files were most frequently found to be compliant include: current DD screening documents (98%), OBRA Level One documentation (98%), and participants’ acknowledgement of choice in services (96%).
  • Certain areas of case file compliance posed challenges for lead agencies; only 71% of case files contained documentation of current right to appeal information and 79% had complete emergency back-up plans.

Internal and External Relationships

Case managers are connected to their communities and aware of resources available. Case managers develop close working relationships with providers, which allow them to collaborate to meet the needs of participants.

  • Most lead agencies (71%) indicated in the Quality Assurance Plan (QA) survey that they always have case managers document provider performance, and that case managers always provide oversight to providers on a systematic basis (69%).
  • 82% of providers surveyed indicated they submit monitoring reports to the lead agency, and 87% indicated that they received the needed assistance when it was requested from the lead agency most or all of the time.

Provider Service Capacity and Development

Although waiver programs present the opportunity and flexibility for lead agencies and providers to develop new and creative services, progress in emerging areas has been slow.

  • Lead agencies are partnering with providers to develop creative housing solutions for participants including incorporating assistive technology so that participants can have more independent living situations. However, the percentage of waiver participants served at home remained level from 2011 to 2013 for AC/EW (75% in 2011 and 2013) and DD participants (35% in 2011 and 2013), but fell slightly for CCB (63% in 2011 and 62% in 2013).
  • Lead agencies are working to create more meaningful employment opportunities for participants by building relationships with local businesses. However, the percentage of working age adults employed and earning at least $250 per month improved only marginally between 2011 and 2013 for CCB (from 10% to 11%) and DD participants (from 22% to 23%).

Non-Enrolled Vendor Monitoring

In order to improve access and vendor choice for waiver participants, many lead agencies act as the pass through billing agent for non-MHCP enrolled vendors.

  • Since this change to DHS and lead agency operations is new, the review of the non-enrolled vendor monitoring process is meant to be educational and advisory. DHS is not issuing corrective actions for the requirement at this time. However, if any non-compliance is identified, the lead agency is required to remediate any required documentation.
  • DHS continues to issue guidance and sample templates via the CBSM to assist lead agencies in documenting that non-enrolled vendors meet all applicable service standards.

Waiver Allocation and Management

Some lead agencies had room in their budgets to enhance services or add more participants to programs.

  • In the first year, 11 of 24 lead agencies (46%) were given the recommendation to reduce their budget reserve because they had a more than adequate allocation left to manage risks associated with new high cost participants while also providing services to current participants. However, by the third year, only nine out of 30 lead agencies (30%) were issued this recommendation.
  • Over the course of Round II, several lead agencies have developed alliances with other nearby counties to pool and manage their allocations. This allows them to serve more participants with the waiver programs while better managing risk.
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