January 5, 2012

Public Comments on Customized Rates Provider Guidelines:

Thank you for the opportunity to provide input.  By section we submit the following and would be available to discuss if that would be helpful.  CRi has been privileged to support over 20 individuals with Customized Rates(CR) since its inception.  In specific, we have direct experience with supporting individuals from the training centers into an engaged life in a community and know that the resources provided by CRs overall several years have been a key to their ongoing successful transition.

Unfortunately, it appears from our experience, that longer term perspective, having a CR authorized for 12 months, that was present when the program was launched, has been abandoned.  A longer term perspective in terms of CR authorizations is needed to provided consistency in supports which is achieved with dedicated staff, who are not going to be attracted to direct care positions when schedule modifications need to occur every 6 months due to funding changes driven by updates to CR.  We know that positive change takes time, have demonstrated it with several individuals and yet the program’s recent short term focus has placed that progress in jeopardy.  In sum, this particular overall comment is to request a longer more ‘committed’ process for the individuals and providers -- take a longer view.  It is a positive step to have the CR process present this several years, lets also take a several year approach to CR for the individuals.

Comments by Section

1.2 Role Definitions

This document is titled provider guidelines however for the CR process to be successful there needs to be a measure of success.  What does the department consider to be success?  An addition here would be helpful.  2^nd, the CRRC’s process and the role of DMAS needs more transparency.  How often do they meet? what is the sequence of events? What are the metrics? To help improve commitment and support of the process, why not an annual report as part of the DOJ’s provider development process.

2.0 What is a CR?

Overall, the details are not apparent between the CR verse the ‘current waiver rate structure’ beyond a simple dollar amount and specific hours approved.  The current rate structure has assumptions identifying, by tier, an assumption on the hours an individual is not at a group home and therefore ‘out of the program’ and direct care is not provided.  While CRi is not in full agreement with the assumptions in the rate model, it is transparent and allows for a provider to understand the reimbursement.  This same clarity is lacking in the CR process.  At some point in this process the CR should be outlined so that the provider can understand how the funding was developed.  The provider needs to understand, for long term success of the service model, aka the CR, the basic data inputs into the CR and how what was provided by the provider in the application, was used, or not, as part of the rate development.  As an example, if an individual’s current waiver rate structure was $100/day and the CR process provided $150/day along with 10 hours of daily 1:1 supports, is the provider receiving $5/hour (150-100=50/10=5)?  CRi understanding is that while the math is correct it is not an appropriate approach.  Greater transparency of the CR rate development will provide individuals and providers better appreciation of the level and composition of supports. 

2.2 Qualifying Services

Programmatic costs is an area where there has been improvement since the initial launch of CRs.  However, the individuals who are supported by CR need higher levels of operational program management supports, measured by both education and/or experience of the staff.  This should be provided for every CR.  The level of programmatic supports in the standard rate model is a blanket $28/day/NOVA or ~11.5%.  How does this relate or support the hours a QDDP needs to provide individuals and how is an individual with a CR ‘get’ more time of a QDDP or time of a more experienced QDDP?  The opaqueness of the current rate structure for program supports and how it is reflected, or not, in the CR needs clarity.  If this costs is to be incremental, knowing what is, or what is not, in the base is key. 

3.2 Provider Eligibility Criteria

In the last bullet, the statement…….” Demonstrate that they can meet the support needs of the qualifying individual through employment of qualified staff trained to provide the extensive supports required by the individual based on their exceptional support needs.”  This aspirational statement needs to be supported with rate approvals that begin at a minimum 30 days prior to the individual’s admission to the program.  This will allow for the provider to obtain, from existing staff, not new staff who will backfill the openings, staff who can be trained as indicated.  The process needs to reflect that staff are not immediately available.  The provider will be making an investment in training and time so the rate approval needs to reflect that phenome.  Alternatively, the statement should read, ……….” Within 30 days, demonstrate…”  In addition, the current process ends a CR with no transition time provided.  This has led to overnight changes to supports provided individuals as necessary to balance to the ‘approved’ CR supports.  CRi recommends that any reduction occur at a future date, no less than 60 days from receipt, by the provider, of a reduced rate.  These transition times, at the beginning of a CR to train staff and at the end to support the individual to a new model of supports and to transition staff to other areas, are needed to support a system of supports and reflect a commitment to the individual and staff that there is a system of supports and not a daily transaction of care that can be turned on and off in a moment. A daily transaction approach will not lead to longer term success of the individuals and needed levels of staffing supports. 

3.3 Eligible Supports

The meaning of the last bullet in this section is unclear. 

6.0 Programmatic Oversight

CRi notes the long term commitment required of staff as evidenced by criteria listed within each of the ‘Approval Levels’.  Long term commitment to a system of community supports will improve individuals lives and lower the cost of supports to that individuals by the entire system.  In specific, under the bullet on Oversight of medical and behavioral data --- change the order to read,…… to achieve a higher quality of engaged life with the community and family and may result in a less intense level of staffing and resources.  The orientation towards an engaged life, however supported is key.  CRi’s experience is this area is of note.  CRi supported an individual with a CR that provided 2:1 in the community.  CRi supported the individual in the community with few incidents and was on a path to expansion of the type and frequency of community events.  At this point, after 12 months is it time to drop the 2:1 due to its success, no incidents, no ER visits and greater integration or should the 2:1 be continued for another 12 months to provide that support to the individual and the confidence to the staff to support the individual in more varied locations?  CRi advocates for continuation of supports and trust the judgement of those with programmatic oversight.  CRi recognizes that a provider may be more conservative in this realm but the opportunity costs, intangible in terms of an ‘engaged life’ and tangible in terms of ER or Crisis visits make a compelling position for continuing supports.

7.1 Rate Information

2^nd bullet is confusing.  The first phrase is understandable but the second phrase in that sentence is not.  CR should cover the cost of direct support staff for an individual.  The second sentence should reference ‘the same assumptions as the standard rate model’….  What assumptions is this referring? As mentioned above, there needs to be more clarity on the CR. 

7.2 Sponsored Residential

Overall comment – If a DSP is hired, trained and paid by a sponsor then the hours worked by the DSP should be counted toward the CR regardless of where they live or any other status they may hold such as spouse, significant other, adult child or live in DSP.  This would not increase the identified or contracted Sponsored Provider payment or 40 hours, simply recognize the other staff necessary to provide the service who are hired by the sponsor/host.

8.0 Application and Forms

WaMS’s introduction into the ‘process’ provide some positive and some needed improvements.  In specific;

1. During the in-progress stage, notes can be left in WaMS requesting additional information. However, the challenge has been inconsistency among processors in type of documentation requested and a lack of follow-up to inquires after documentation has been submitted. Attempts to rectify this issues did not occur until August 2021, when the customized rate team began sending word documents detailing the information needed prior to moving to under consultant review status. Thank you.
2. Prior to WaMS, DBHDS would contact CRi to schedule a review of the application, request any additional documentation to support the application or discuss the timeframe of when the application will move to committee review. Since the creation of the application process in WaMS (11/2020), contact has decreased to being non-existent, inconsistent or no longer proactive, and only responsive to inquires at this time.
3. The lack of proactive communication has decreased to status changes left in WaMS, which are minimal and DBHDS staff do not respond to when CRi enters notes.  As a result, weekly inquires on when the individual will be scheduled, committee documentation needs, or general information requests on meaning of status have resulted in the application moving to next step.
4. There have also been inconsistencies in the committee dates given. Greater clarity on the process and que would lead to a more effective process.
5. Length of time to receive NOA is inconsistent and also the date of the received NOA is often not the date the letter was approved (varies up to 5 days later). For example, one application NOA was dated 4/12/21, but not received until 4/19/21. In 2021, the average length of time from submission to approval is approximately 60 days. The average time frame to receive NOAs is approximately 7-9 days after approval.
6. Length of time applications were approved for, which was one year on average in 2019-20, is an estimated maximum of six months. We are requested additional funding approximately every five months.

10.4 Annual Requirements

DBHDS should introduce a transition period into the CR process.  The section on Possible Outcomes can be modified to included language indicating that when the level of supports is to begin and when they will end, for example, a transition period of 60 days from notice for reductions, or for termination of the CR will be recognized.  A flash cut, at times retroactively communicated, is not conducive to successful outcomes for the individual. 

10.5 Contingent Approval Requirements

CRi encourages DBHDS to take advantage of this capability while approving individuals new to the CR process.  As noted earlier, it takes time for a provider to obtain and train appropriate staff on an individual’s specific needs and to gather the data on an individual’s baseline.  CRi’s experience is that establishing an individual’s baseline has been especially insightful when the individual is transitioning from a family home to a more independent community setting with a provider.  The system needs to recognize the unknowns, as represented by the lack of data, and support those individuals who are willing to move to a more engaged and independent life in the community.  Providers will not have credible data for months and to manage the risk the CR process need to allow for this in the level of supports during this initial period.

11 Service Authorizations

See notes on transition periods, at the beginning and end of authorizations, and in section 10.4, to assist in the successful development and delivery of supports.

Lastly, the exclusion of those individuals with customized rates from the October 6, 2021 announcement of a 12.5% temporary HCBS rate update effective 7/1/21 is not understood or supported.  The DBHDS and DMAS departments are encouraged to end this exclusion, in effect a carve out, or provide an explanation to individuals, families, and providers as to the basis.  The departments are also encouraged to include CR in scope for all rate initiatives, such as the Governor’s annual budget under development, as it strives to provide appropriate levels of supports and rates.  We believe all individuals, whatever the service, should be included in the needed temporary funding provided by the ARPA and the longer term updates that are reflected in the commonwealth’s annual budget process.

Thank you again for this opportunity, For CRi by Terry Hurley, EVP & CFO