Request for Information (RFI)

November 2011

Request for Information

I. Background and Introduction Purpose: Through the implementation of the People First Waiver planning process the Office for People With Developmental Disabilities (OPWDD) has embarked on a course of system change that is focused on increasing flexibility, responsiveness and the effectiveness of the supports and services provided to individuals with developmental disabilities in NYS. A comprehensive overview of the People First Waiver process and related recommendations and action plans can be found at www.opwdd.ny.gov/2011_waiver/index.jsp. It is the intent of the Office for People with Developmental Disabilities to provide the broadest range of support options for people receiving services. Through the People First Waiver the agency seeks to support individuals in the least restrictive setting possible, as true citizens of their communities, in line with their expressed interests and needs through effective care coordination and a balancing of resources using a consistent needs assessment tool. This document is a public Request For Information (RFI) related to the transition of the current program driven Medicaid supports and services for people with developmental disabilities to a care management model of supports and services. This transition is proposed through the implementation of the People First Waiver. The specific intent of this RFI is as follows: To gather input related to New York States transition from a fee for service program model to a care management model with the intent to improve the effectiveness and the efficiency of supports and services for people with developmental disabilities. To gather information in the key waiver design areas, explored and recommended by the People First Waiver Design Teams, regarding the practical implementation of operational systems to support and sustain the proposed concepts; and To utilize the information obtained through this RFI to initiate a sufficiently comprehensive Request for Applications (RFA) for pilots that will test the hypotheses outlined in the waiver design through People First Waiver demonstration pilots.

Request for Information

By responding to this RFI, you will have valuable input into shaping the future reforms that will be demonstrated throughout the five year period of the waiver. All input provided by prospective providers will be used for informational purposes only and no approvals or awards will result from submission of a response to this RFI. People First Waiver and the Establishment of Developmental Disability Individual Support and Care Coordination Organizations (DISCOs)

Review of the Waiver Development Process to Date A complete description of the process related to the People First Waiver is outlined in the Statewide Comprehensive Plan. Additionally, information related to the waiver is posted on the OPWDD web site. In summary, the following actions have been taken related to the waiver implementation: A Concept Paper has been submitted to CMS. Ongoing communication has been maintained with CMS through both written correspondence and meetings of cross agency representatives and leaders in state government to clarify information and planfully address any concerns or issues that arise. Public input has been sought through a variety of forums to ensure that stakeholders have a clear voice in the process. A Steering Committee has been established to provide oversight and guidance to Commissioner Burke during the waiver design process.

Providing supports and services to individuals with developmental disabilities in locations where they choose to live, with maximized natural community supports, that are in line with their interests and needs and result in desired personal outcomes, is at the heart of the People First Waiver design. By providing the appropriate level of supports to meet the persons needs in a timely and responsive fashion, thus avoiding either over-supporting or under-supporting the person, it is anticipated that the system of supports will truly be person centered and will be sustainable over time. Under the People First Waiver, the function of care management will be the responsibility of not-for-profit organizations that have experience and expertise providing supports and services to people with developmental disabilities and that demonstrate the fiscal, quality and person centered competencies necessary to perform care management effectively. The not-for-profit organizations that will be authorized and overseen by OPWDD to perform care management responsibilities will be called Developmental Disabilities Individual Support and Care
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Throughout the summer months, appointed design team members met to develop recommendations for the identified charters for the teams focused on Access and Choice, Benefits and Services, Quality, Care Coordination, and Fiscal Sustainability. The teams issued recommendations which have been outlined in the Statewide Comprehensive Plan. (www.opwdd.ny.gov/507plan/images/waiver_507_comprehensive_plan. pdf).

Request for Information

Coordination Organizations (DISCOs). These DISCOs will be the organizational foundation of our new service system. Upon this foundation the key concepts of person centered planning and individualized models of support will grow through the expectation that desired personal outcomes will be achieved and through more flexible funding mechanisms for innovative support models. Within the care management infrastructure each DISCO will be responsible to perform at least two primary roles for the people it supports: a) care coordination and b) fiscal intermediary. In its care coordination role, the DISCO will facilitate co-management and information sharing between the persons Medicaid funded services and supports and other services included in the persons Individualized Service Plan (ISP). In its fiscal intermediary role, the DISCO will receive a monthly capitation payment to fund all covered services (Medicaid and/or non-Medicaid) identified in the individuals service plans.

Each DISCO will be responsible for delivering care to the enrolled individuals, either by providing the supports and services directly to individuals and/or by contracting with a diverse and culturally competent group of providers across systems to deliver comprehensive supports and services. There are many unanswered questions about how best to structure DISCOs to meet the objectives of the new waiver. In order to ensure that these issues are identified early on and resolved prior to statewide roll-out, OPWDD intends to operate pilot DISCOs during the first years of the People First Waiver. This RFI will help shape the parameters of the pilot DISCO entities. Who can participate in the RFI This RFI process is geared toward any stakeholders who want to provide input regarding the provision of supports on a comprehensive and practical level. The People First Waiver process has and will continue to provide every opportunity to seek input from stakeholders, and the opportunity for more general input remains available through the People First email at [email protected]. All costs of responding to this RFI will be entirely the responsibility of the responder and will not be reimbursed by OPWDD or the State of New York. No claim will be made against OWPDD for any costs incurred by the responder for preparation of responses to this RFI. It is not required that you divulge any proprietary information or trade secrets in response to this RFI, and OPWDD requests that you not divulge any such information in your response.
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Request for Information

Please complete the following questions: II. General Information 1. Primary Contact Information a. b. c. d. e. f. g. h. i. Name: Street Address: City: State: Zip code: Telephone Number: Telephone Number Extension: Fax Number: E-mail Address:

2. Please choose the best description of your organization (choose one): o Self Advocacy or Parent Organization o Individual receiving supports and services o Family member or advocate of individual receiving supports and services o Current Provider of OPWDD Services (choose all that apply) Residential Day Supports Employment Supports Consolidated Supports & Services Respite Service Coordination Other (describe): o Clinical/Medical Provider (choose all that apply): Provider for people with developmental disabilities Community based practitioner General Hospital or Care Organization Other (describe): o Governmental o Provider Association o Managed Care Organization o Health Insurance Provider
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o Other (describe): 3. Are you a Corporation? If Yes, please provide the following information: a. Name: b. Street Address: c. City: d. State: e. Zip code: f. Telephone Number: g. Telephone Number Extension: h. Fax Number: i. E-mail Address: 4. Are you a subsidiary or an affiliate of a parent organization? If yes, corporate information of the parent organization: a. Name: b. Street Address: c. City: d. State: e. Zip code: f. Telephone Number: g. Telephone Number Extension: h. Fax Number: i. E-mail Address: 5. In what counties, if any, do you currently offer services? o Counties o Out of state 6. Describe any historical organization experience which may be applicable to the proposed care management or capitation reimbursement method of New York State. 7. Provide a brief and succinct description of your organizations years of experience, particularly in the area of developmental disabilities, and other information, such as the size of your organization, that is pertinent to the provision of supports.
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8. In what capacity are you responding to this RFI? How might you envision your participation (choose all that apply)? o Operator of a pilot DISCO o Member of DISCO provider network o Member of an association of persons receiving supports and services, o Member of an association representing family members of persons receiving supports and services o Individual receiving supports and services o Family member or advocate of individual receiving supports and services o Other(describe): III. Care Coordination The provision of person centered care coordination that ensures the appropriate implementation of an individuals plan of care, as defined by the comprehensive assessment of interests and needs, is critical to the model of supports as defined in the People First Waiver. Effective care coordination builds on a persons strengths, seeks to develop a support plan in line with an individuals interests and needs in the least restrictive setting possible and is responsive to presenting changes in the persons life in a timely and sensitive manner. 1. As New York State transitions to a care management system, how would you recommend evaluating the expectation that a person centered planning process is used effectively to develop supports for individuals? 2. What would you envision as the most effective system to ensure that there is a comprehensive clinical team of experts available to develop a plan of care in line with an individuals expressed interests and needs? Are you aware of best practice models that could be duplicated? If yes, please describe. 3. The sharing of information across providers who support individuals is critical to ensure quality, integrated care plans and consistent proactive treatment strategies to help individuals maintain and/or achieve desired health, functional and personal outcomes. What strategies and Information Technology (IT) solutions would you recommend to ensure effective information sharing?

Request for Information

Do you know of or currently use IT systems that are effective? If yes, please identify and describe. 4. Effective Care Management calls for sharing pertinent information between involved providers of supports and services. As we transition to more flexible and natural models of support, do you foresee obstacles or challenges to information sharing as the result of confidentiality standards and HIPAA Privacy requirements that are currently in place? 5. Supporting a person to establish and maintain natural supports through relationships with their family members and their home community is key to ensuring that they are fully integrated and included in the community of their choosing. What strategies would you suggest to ensure that these relationships are fostered through an effective care coordination process? 6. Please describe how you would foster relationships and coordinate best practice interactions with providers from other systems to ensure the most appropriate evidence based, coordinated treatment approaches which reduce the likelihood of stays in high cost and at times inappropriate settings? (e.g., if you are a provider of services to persons with developmental disabilities, how would you foster relationships and coordinate best practice interactions with providers such as behavioral health programs, inpatient hospital medical and psychiatric settings, dental care settings and substance abuse treatment programs?) IV. Assessment The People First Waiver will develop and/or adopt needs assessment tools that are person centered and include assessing the strengths of the person, the family, natural supports as well as recognizing the persons support needs. The assessment tool will need to assess predictive risk factors and transitional support needs. 1. Consistent needs assessment tools will be utilized to make determinations about support needs, care plan development and resource allocation. Are you aware of, or currently using, a particular tool that you would recommend? If yes, please describe the scope, benefits and challenges for the identified tool.

Request for Information

2. What experience have you had with assessment tools for the purposes of care planning and identification of levels of supports and what lessons have you learned that could benefit NYS? 3. Have you used a needs assessment process for the allocation of resources? If yes, please describe your experiences from both a benefits and challenges perspective. 4. Have you had experience with a strength based needs assessment tool that incorporates a review of natural community based supports available to the individual? Please identify a tool that you would recommend: 5. Would you be willing to work with OPWDD to test tools for their validity and predictive capacity outside of a comprehensive demonstration project? V. Effective Provision of Supports, Choice, and Network Capacity Design Team recommendations identify the need to move away from historical institutional and care-taking approaches to supports and services. Instead, the proposed People First Waiver model reinforces person centered planning. Such planning takes an individuals interests, needs, natural supports, and paid supports under careful consideration and develops a plan that seeks to meet the life needs of the person. By establishing person centered planning as the foundation for effective support, we move away from a system that moves people into available slots and programs to a system that builds on a persons strengths. 1. How would you recommend evaluating the adequacy of a person centered plan to ensure it appropriately addresses the changing life needs of an individual receiving supports; including building and maintaining naturally supportive relationships, addressing future and contingency planning, and building models of support most in line with an individuals expressed interests and needs? Please describe specific measures that you feel would be appropriate to make such a determination, where possible. 2. How would you afford individuals with developmental disabilities and their family/advocate the opportunity for choice related to DISCOs and service providers within a care management environment?

Request for Information

3. What mechanisms would you put in place to evaluate the adequacy of the opportunity for individuals with developmental disabilities and their family/advocate to have choice in providers? The choice of providers should incorporate cultural and programmatic diversity and clinical experience in the unique medical and clinical needs of individuals with developmental disabilities, in regions of the state which have limited participating providers. 4. The opportunity for individuals with developmental disabilities (with support from their family/advocate, if necessary) to self direct their supports and plan of care is an integral expectation in the People First Waiver. How do you recommend ensuring that self direction of resources and support plan is streamlined and readily available to individuals? 5. Although there may be some period of transition needed initially, ultimately the resources for all medical, behavioral health and dental services will also be included within the capitated payment provided to the DISCO. What strategies do you see as effective to ensure a competent network of providers to meet the unique needs of individuals with developmental disabilities? 6. What provider or other community coalitions might be encouraged to develop needed service capacity for medical, behavioral health and dental services? 7. Recognizing that individuals will be transitioning from highly structured state operated institutional settings, design team recommendations identified the need for effective clinical support models and crisis intervention models; what models have you found to be effective and how would you develop an appropriately responsive system of supports to ensure adequate individual safety and evidence based treatment approaches? 8. A key hypothesis of the waiver is that a fiscal structure that provides resources based upon a consistent needs assessment process will incentivize the development of innovative support plans that are more aligned with individuals interests and needs and which ensure that resources are allocated equitably. What innovative models of support have you heard about, implemented or would recommend within the People First Waiver that would be consistent with this hypothesis? (please describe)

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VI. Quality Ensuring the health and safety of individuals and the highest quality of supports and services is an integral part of the People First Waiver. The quality design team made strong recommendations that the measure of quality be clearly related to the outcomes realized by the individuals receiving supports and services, and not based solely on compliance with rules and regulations. Ensuring strong quality improvement plans and a focus on best practice standards for all providers of supports is at the heart of the quality expectations outlined in the waiver design. Additionally, specific measures of quality for the DISCO in their care coordination and fiscal intermediary roles have been recommended by the design team; they include care coordination effectiveness, responsiveness to advocacy, fiscal viability, corporate compliance measures and the effective separation of duties (i.e. provider vs. DISCO role). 1. What approaches would you recommend to incentivize the provision of quality supports and services that are driven by a person centered plan of care and result in desired personal outcomes? Financial incentives Change to oversight process for high quality providers Fines for providers/DISCOs that fall short of established standards Increased responsibility for demonstrations of accountability Restriction of use for low performers Other (describe): 2. What advantages and disadvantages are there to the approaches that you selected in question #1? 3. What information technology systems do you envision utilizing to manage and coordinate information, gather and aggregate pertinent data, and create meaningful and useful reports? 4. The provision of person centered supports is directly impacted by the relationships and interactions between direct support professionals and the people they support; how would you ensure that the direct support workforce is competent, well trained and empowered to provide support in a manner that brings the best possible quality of life to the individuals receiving supports? 5. Through effective care coordination and with resource levels established based on the consistent assessment of strengths and needs, it is anticipated that plans of care will be
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delivered across a variety of settings in line with individuals expressed interests and needs. Quality must be measured based on the outcomes realized by the individuals supported in their health status, functional capabilities and personal outcomes. What strategies do you recommend to effectively measure these outcomes for people receiving supports and services? 6. The quality design team created a quality measurement scale that identified expectations for provider performance and a 1 through 5 rating system that would be available to the public (www.opwdd.ny.gov/2011_waiver/images/quality_final_report.pdf). What strategies would you utilize to implement quality improvement activities to be rated, or, as a DISCO, to ensure that provider agencies are rated, as high performers? 7. What quality measures do you feel are appropriate to establish to rate the effectiveness/performance of a DISCO? Fiscal Administrative and Organizational Structure: VII. As identified above, the DISCO is the proposed entity that will serve in both a care coordination role and a fiscal intermediary role. The following questions are geared to gather additional input regarding the DISCO function and suggestions on how demonstration projects should be structured. 1. To effectively manage a network within a capitation reimbursement model, based on a consistently administered needs assessment tool, it will be necessary to provide supports and services to a minimum number of individuals with variation in defined support needs. Based on your historic knowledge or initial research, approximately how large would a DISCOs enrollee pool need to be to remain fiscally viable and still implement effective care plans derived from person-centered planning practices? 2. The following questions relate to organizational structure and network requirements for potential DISCOs that you would recommend, from the perspective of a potential pilot DISCO operator, member of a DISCO provider network or recipient of supports and services. a. What geographic location are you focused on? o Counties b. Please provide a general description of how OPWDD should evaluate whether a DISCO pilot applicant is proposing a provider network that is sufficiently inclusive of
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Request for Information

self directed support models, habilitative supports that are responsive to individuals and families interests and needs, for services that include family supports, care coordination, medical care, behavioral health care and dental care. c. How can OPWDD best support the development of DISCO pilots? 3. How would you suggest that DISCOs incorporate programmatic and administrative efficiencies into their network model while ensuring that individuals receive quality, person centered supports and services and that direct support professionals receive competitive benefits and wages; meet core competencies and are well trained? 4. Please provide suggestions regarding what controls/fire walls should be applied to DISCOs that also function as direct providers of service to ensure adequate network choice and not unduly influence care coordination efforts toward their own provider agency? 5. What incentives, disincentives and strategies do you recommend to ensure that individuals who present with more complex needs are not excluded from participation in a DISCO of their choice and that high quality expectations for all individuals is achieved and maintained at both the DISCO and provider level? 6. How would you ensure that the network of providers established by the DISCO is sufficiently multi-cultural and able to serve the diverse interests and needs of the enrolled individuals? 7. As described above, a DISCO is the entity that would serve as a care management organization and receive funding based on a capitated model of reimbursement, which is based on a determination of need levels of the people served, through a consistently administered needs assessment tool. The DISCO would contract with providers to deliver supports based on a person centered plan. OPWDDs objective is that ultimately the DISCO operations are characterized by the following three elements: a. Payment to a DISCO is an actuarially established capitated rate which reimburses the DISCO for the enrolled individuals full spectrum of Medicaid and non-Medicaid funded supports and services (preventive, acute and long-term support services), and b. The DISCO is responsible for comprehensive care coordination for enrolled individuals covering both long-term care and health care, and
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c. The DISCO is at risk for the full cost of supports and services for their enrolled individuals. While the ultimate objective is that DISCO operations are characterized by all three of the above elements, there may need to be a gradual transition in one or more of these areas. In order to incentivize existing NYS providers to apply to serve as a pilot DISCO operator, would you recommend a transition phase for any of the above three elements? If yes, how would you recommend that the transition take place? 8. Have you had any experiences with cost sharing or shared savings models of reimbursement? If yes, please describe the benefits and challenges. 9. Do you have ideas on cost sharing or shared savings models that you would suggest be considered in the implementation of the People First Waiver? If yes, please describe. VIII. Focused Study Opportunities: As we prepare to issue a Request for Applications (RFA) to implement Demonstration Pilots that will initiate the comprehensive DISCO care management model, it is our intent to gather data and expertise related to some of the key concept areas discussed in the Statewide Comprehensive Plan through a series of focused studies. These studies would occur within a limited capitated funding model for OPWDD funded services within an agency. As we are testing concepts and innovations that differ from our traditional models of support and we need to ensure the use of best practice supports and services, we will complete these studies within agencies that have attained a high performing quality status through identification as a Compass agency (www.opwdd.ny.gov/compass/index.jsp) or who have comparable quality practices that are consistent with the standards measured through the Compass process. 1. Are you interested in the opportunity to participate in focused studies of the People First Waiver concepts? 2. Do you have Compass status?

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3. Do you have quality practices consistent with those measured in Compass agencies, through the use of a nationally recognized accreditation process or integral to your agencies quality processes that could be verified by OPWDD DQM review, to allow participation in this testing phase? 4. Please describe:

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