HOWELL GROUP

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HOWELL GROUP
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• Michigan Resident Populations
• Centers for Developmental Disabilities
• Last day of each Fiscal Year, 1960 - 1996

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TRADITIONALInstitutions and Programs

• Smaller
• Larger
• Still Smaller
• The concept of Least Restrictive Environment has
  us running from larger institutions to smaller
  and smaller ones
• Still using the SAME MODEL

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Promise of Community A Vision Statement of the
Howell GroupChange is a more enduring principle
than permanence

• We believe that each person has a unique
  contribution to add to acommunity of us, where
  the whole is more than the sum of its parts.
  That freedom, cooperation, and self-respect for
  all of us, from all of us, will give our
  community a sense of integrity that will enrich
  our relationships, our perspectives and our
  humanness.
• We believe in a community of us that emphasizes
  the relations between each of us and all of us.
  A community where everyone is assured of basic
  human needs food, clothing , shelter, health
  care and safety and where every one of us has
  control over our personal economy, allowing us to
  purchase these basic human needs with dignity.
• We believe the practice of diagnosing people and
  assuming deficiencies based on those diagnoses
  must end. That labels which restrict people by
  definition must be eliminated. That the
  capacities of all people should be appreciated
  and accepted as the basis of providing supports.
• We believe those of us with disabling conditions
  must have access to supports which assist us to
  interact in our community. The fundamental
  reason for supports is to promote growth rather
  than to accentuate deficiency. Because we are
  all individuals, supports must be structured to
  meet individual needs. Supports may include but
  are not restricted to human, technological and
  public service. They must be controlled by the
  user.
• We believe that because some of us have
  experienced historical, physical, and economic
  segregation, and have been seen as less than full
  citizens, we need to aggressively use existing
  legislation to assure full recognition, respect,
  and access for inclusion in our community for
  future generations.
• We believe that we can no longer accept the
  standard of what is possible, given an
  individuals personal and social condition.
  Rather, we affirm the standard that all people
  deserve the opportunity to grow according to
  their own visions of what is best for them.

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The Howell Group

• Values Based Systems Change
• VOW to effect systems change
• causing the system(s) to
• fund and do what we
• already know is
• right what
• people
• want.

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STATEWIDE ADVOCACY CAMPAIGN(To make change)

• RESEARCH (Increase knowledge and information to
  Set Goals and Plan Campaign.)
• 1. Fact Finding Plan What? Where? Who?
• 2. Open Research Plan Who? Where? What?

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ANALYSIS

• Facts Importance? Relevance? Implications? Mo
  re Needed?
• Open Research Importance? Fit? Opportunities?
  More needed?
• If More is Needed, -- Repeat

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NEXT STEPS

• DESIGNING A CAMPAIGN
• Build a Political Base
• Numbers
• Influence
• Seek Opportunities
• Political
• Positive or Negative
• Staying Power
• Political Power (non-partisan)

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Principles of Michigans Waiver Renewal and
Tenets for Managed Care

• The honoring of each persons preferences and
  choices including the presumption of competence
  and interpreting behavior as communication
• Doctors and other professionals would serve in
  consultative roles and their involvement would be
  only as desired or needed.
• Regular consumer feedback and a focus on the
  outcomes an individual wants would form the basis
  for quality assurance.
• Self-determination would govern peoples lives
  and they would have choice and control over their
  own budgets according to their desires.
• The person who coordinates supports would play a
  personal agent role to help an individual achieve
  the outcomes they wished.
• Informal and generic supports would be considered
  prior to the implementation of supports through
  the Waiver
• External people and anyone unwanted would not
  intrude in the lives of the individuals served by
  the waiver

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• Sec. 100a (1) Abilities means the qualities,
  skills, and competencies of an individual that
  reflect the individuals talents and acquired
  proficiencies.
• Sec.222. (1) The composition of a community
  mental health services board shall be
  representative of providers of mental health
  services, recipients or primary consumers of
  mental health services, agencies and occupations
  having a work involvement with mental health
  services, and the general public. At least 1/3
  of the membership shall be primary consumers or
  family members, and of that 1/3, at least 2
  members shall be primary consumers. All board
  members shall be 18 years of age or older.
• (g) Person-Centered planning means a process
  for planning and supporting the individual
  receiving services that builds upon the
  individuals capacity to engage in activities
  that promote community life and that honors the
  individuals preferences, choices, and abilities.
  The person-centered planning process involves
  families, friends, and professionals as the
  individual desires or requires

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Person Centered Planning

• A person centered plan assists individuals to
  create a personalized image of a desirable
  future. The development of a plan suggests a
  process that can organize and guide community
  change in alliance with people with disabilities
  thus building a bridge from both sides.
• Essential to all person centered plans are the
  following characteristics
• Person Directed_ The plan for the person is that
  persons vision of what he or she would like to
  be and do. The plan is not static, but rather it
  changes as new opportunities and obstacles arise
• Capacity Building Planning focuses on the
  persons gifts, talents and skills rather than
  deficits. It builds upon the individuals
  capacities and affords opportunities which will
  reasonably encourage individuals to engage in
  activities that promote a sense of belonging in
  the community.
• Person Centered The focus is continually on the
  person for whom the plan is being developed, and
  not on plugging the person into available slots
  in a program. The individuals choices and
  preference must be honored.
• Network Building The process brings together
  people who care about the person and are
  committed to helping the person articulate their
  vision of a desirable future. They learn
  together and invent new courses of action to make
  the vision a reality.
• Outcome Based The plan focuses on increasing
  one or all of the following experiences which are
  valued by the individual
• Growing in relationships or having friends
• Contributing or performing functional/meaningful
  activities
• Sharing ordinary places or being part of their
  own community
• Gaining respect or having a valued role which
  expresses their gifts and talents
• Making choices that are meaningful and express
  individual identity

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Desirable Elements of Managed Care are

• A single funding stream
• Capitation with growth
• Local discretion
• Shared risk or stop loss
• People on waiting lists must be served

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• There are significant barriers to giving people
  what they want.
• Relief from restrictive, unnecessary and costly
  rules and regulations
• Individuals assisting and supporting people must
  get a living wage
• Health care must be adequate and accessible

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Howell Group Premises for Managed Care

• We welcome change
• We want what the waiver promised
• Since prospects for new money are low, the
  re-direction of public dollars offers the most
  efficient possible use of public dollars
• Control the growth rate of expenses
• Carve out presents an opportunity

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Howell Group Proposal on Managed Care
Implementation

• Goals
• Fulfill the promise of the Code revisions
• Individualize Supports
• Eliminate barriers
• Contain the rise of costs for services that do
  add value
• Provide needed and desired services for those on
  waiting lists

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Managed Care in Michigan

• Medicaid Comprehensive Health Care
• Childrens Specialized Health Care Services
  (currently voluntary Medicaid and on-Medicaid)
• Long Term Care Plan (serving persons who are
  elderly or disabled and generally who would be
  eligible for a nursing facility)

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Two Carve-Out Specialty Plans(serving persons
through the Public Mental Health System)

• BEHAVIORAL HEALTH PLAN(persons with mental
  health needs and those who abuse substances)
• DEVELOPMENTAL DISABILITIES PLAN(for persons with
  developmental disabilities, Medicaid and
  non-Medicaid and all covered services)

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Managed Care System for Developmental Disabilities

• Carved out
• Administered through local entities
• Separate from physical health care
• State is provider of last resort
• Shift from state to county
• Constitutional mandate for CMHSP

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VALUES

• Michigans public mental health system for
  persons with developmental disabilities should
  promote individuals to be
• Empowered to exercise choice and control over all
  aspects of their lives
• Involved in meaningful relationships with family
  and friends supported to live with family while
  children and independently as adults
• Engaged in daily activities that are meaningful,
  such as school, work, social, recreational, and
  volunteering
• Fully included in community life and activities

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• Designated CMHSPs will administer general fund
  appropriations for developmental disability
  services and manage (through a sole source
  contract) nearly all Medicaid-funded
  developmental disabilities benefits on a
  capitated, shared risk, prepaid basis.
• The plan incorporates the elements of an
  insurance paradigm (i.e. enrolled recipients or
  covered lives) with the traditional safety net
  model (covering a target population with
  statutorily mandated access to funded programs
  and services)

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SUPPORTS AND SERVICES

• Federal officials have indicated it is acceptable
  to
• continue to provide existing Medicaid
  coverage,
• OR
• provide other services as alternatives to the
  existing Medicaid coverage.
• The state defines
• the alternatives it wants to provide based on
  Michigans planning framework

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SUPPORTS AND SERVICES

• The reason for defining the alternative
  supports and services is to
• Identify an acceptable array of service/support
  options
• Which can be provided on an individualized and
  very flexible basis
• Depending on the desires and needs of the person
• To establish mechanisms to track what
  services/supports are delivered

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SUPPORTS AND SERVICES

• Alternatives are
• Broadly defined
• Flexible array of community based
  services/supports
• Addressing the desires and needs of people
• As articulated through person-centered planning.

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COVERED SERVICES

• Alternatives for
• Targeted Case Management
• Clinic and Rehabilitation Services
• Personal Care
• AIS/MR
• ReNEWed Habilitation/Supports Waiver
• Outside of the Plan Childrens Waiver

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INDIVIDUALIZED SUPPORTS AND SERVICES

• Many people receiving services want
• To receive individualized supports
• Services targeted toward their specific needs and
  preferences
• To receive their services in typical community
  locations
• A benefit package including only their
  desired/needed supports and services

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INDIVIDUALIZED SUPPORTS AND SERVICES

• To accomplish thisAll planning must be person
  centered
• Each persons benefit package will look
  different because people have different
• needs
• desires
• natural supports
• community supports

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ELIGIBILITY

• Eligibility established by the Mental Health
  Code
• DD Definition parallels federal definition
• Mental Health Code specifies that
• priority shall be given to the provision of
  services to individuals in urgent or emergent
  situations (Chapter 2, 330.1208)
• Eligibility for Medicaid establishes an
  entitlement

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ACCESS

• Individuals will engage in a person-centered
  planning process to identify how DD Specialty
  Supports and Services can respond to the
  identified needs.
• Persons in emergency situations will receive
  immediate crisis stabilization response without
  having to first proceed through access steps

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CHILDRENS WAIVER

• DD Managed Care Plan excludes children served
  under the Childrens Waiver
• This was because the Waiver contained special
  eligibility criteria which would disregard their
  parents income in order to make children
  Medicaid eligible
• Children meeting the special eligibility criteria
  would have lost their Medicaid eligibility if
  this specific Waiver was not retained
• The DD Managed Care Plan does not use this type
  of Waiver as its enabling authority.

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DD Managed Care and Case Management

• Services previously provided to persons with
  developmental disabilities under Medicaid
  Targeted Case Management are incorporated into
  the services now called Support and Service
  Coordination
• Supports Coordinators have broader
  responsibilities, specifically in regards to
  Person-Centered Planning.

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State of MichiganChapter III of the Medicaid
Policy Manual Revision

• New Section 17 Additional Mental Health
  Services (B3s)
• Certain Medicaid-funded mental health supports
  and services may be provided in addition to the
  Medicaid State Plan Specialty Supports and
  Services or Habilitation Waiver Services, through
  the authority of 1915(b)(3) of the Social
  Security Act (hereafter referred to as B3s)

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Definitions of goals that meet the intents
purpose of B3 supports services

• Community inclusion and participation means The
  individual uses community services and
  participates in community activities in the same
  manner as the typical community citizen.
• Independence means freedom from anothers
  influence, control and determination. (Websters
  New World College Dictionary, 1996) Independence
  in the B3 context means how the individual
  defines the extent of such freedom for
  him/herself during person-centered planning.

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Definitions of goals that meet the intents
purpose of B3 supports services

• Productivity means engaged in activities that
  result in or lead to maintenance of or increased
  self-sufficiency. Those activities are typically
  going to school and work. The operational
  definition of productivity for an individual may
  be influenced by age-appropriateness.

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B3 Supports Service

• Prevention Direct Service Models
• Respite Care Services
• Skill-Building Assistance
• Support and Service Coordination
• Supported / Integrated Employment Services

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B3 Supports Service

• Assistive Technology
• Community Living Supports
• Enhanced Pharmacy
• Environmental Modifications
• Family Support Training
• Housing Assistance
• Peer-Delivered or Operated Support Services

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Self-Determination Principles

• Freedom The ability to plan a life, rather than
  purchase a program
• Authority Ability for a person with a disability
  to control a certain sum of dollars to purchase
  supports
• Support Arranging resources and personnel, both
  formal informal, to achieve meaningful
  participation
• Responsibility Acceptance of a valued community
  role, through employment, affiliations, spiritual
  development and caring for others, as well as
  accountability for public dollars.

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Self-Determination

• Michigans Policy Practice

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Core Values of Self-Determination Policy

• Freedom
• Authority
• Support
• Responsibility

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Policy Guideline

• people who require supportmust have the
  freedom to define the life they seek, and obtain
  assistance to achieve that life. They need to
  have access to meaningful choices, and to be
  assured of control over the course of their
  lives.

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Policy Guideline

• Arrangements that support self-determination
  mustassure methods for the person to exert
  direct control over how, by whom, and to what
  ends they are served and supported.

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Policy Guideline

• Person-centered planning (PCP) is a central
  element of self-determination. self-determination
  recognizes the rights of a personto have a life
  with freedom, and to access needed supports that
  assist in the pursuit of their life, with
  responsible citizenship.

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Policy Guideline

• The person determines and manages needed
  supports in close association with chosen
  friends, family, neighbors, and co-workers as a
  part of an ordinary community life.

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Policy Guideline

• Consumers shall have access to
  self-determination upon request.

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Policy Guideline

• The funder shall offer and support easily
  accessed methods for consumers to control and
  direct an individual budget including providing
  them with methods to authorize and direct the
  delivery of services and supports from qualified
  providers selected by the consumer.

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Medical Necessity Criteria

• Necessary screening, assessing a mental illness
  developmental disability
• Required to evaluate
• Intended to treat, ameliorate diminish or
  stabilize the symptoms of
• Expected to arrest or delay the progression of

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State of MichiganMEDICAID POLICY

• Changes to Program Requirements
• Effective Oct. 1, 2004
• Providers Manual
• 2.5 MEDICAL NECESSITY
• The following medical necessity criteria apply to
  Medicaid mental health and developmental
  disabilities supports and services
• 2.5A MEDICAL NECESSITY CRITERIA
• Mental health and developmental disabilities
  services are supports and services designed to
  assist the beneficiary to attain or maintain a
  sufficient level of functioning in order to
  achieve his goals of community inclusion and
  participation, independence, recovery or
  productivity.

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• 2.5A MEDICAL NECESSITY CRITERIA
• Mental health and developmental disabilities
  services are supports and services designed to
  assist the beneficiary to attain or maintain a
  sufficient level of functioning in order to
  achieve his goals of community inclusion,
  participation, and independence

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State of MichiganChapter III of the Medicaid
Policy Manual RevisionNew Section 17 Additional
Mental Health Services (B3s)

• Certain Medicaid-funded mental health supports
  and services may be provided in addition to the
  Medicaid State Plan Specialty Supports and
  Services or Habilitation Waiver Services, through
  the authority of 1915(b)(3) of the Social
  Security Act (hereafter referred to as B3s)