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.
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.
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.
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.