ACAP

1

• ACAP
• A program of Keystone Human Services and the
• Pennsylvania Department of Public Welfare
• Bureau of Autism Services
• NYSACRA Presentation
• Robert J. Baker
• Vice President, Keystone Human Services
• rbaker_at_keystonehumanservices.org

2

• ACAP is a fully integrated, comprehensive system
  of care for adults with Autism Spectrum Disorder
  (ASD). The program incorporates vocational,
  behavioral, social, health, recreational,
  transportation, therapeutic, educational, crisis,
  in-home support and independent living aspects of
  Participants lives.

3

• Three Unique Characteristics
• Pre-paid Capitation Payment Approach
• Healthcare Services Fully Integrated into the
  Model
• Outcome Measures Agreed Upon and Placed in the
  Contract

4

• Competitive Bid
• Selected in competitive bid process
• The competition were experienced managed care
  organizations
• Selected because of human service experience,
  reputation

5

• Reason for Keystone Interest
• Develop a system of care for the autism community
• Try new models of care-in this case managed care
• Innovation

6
PURPOSE

• The purpose of the ACAP program is to help adults
  with ASD to be valued and fully participating
  members of their society.
• The program works to build competence, confidence
  and independence so people can, as much as
  possible, lead full and meaningful lives.
• Over time, the program works to increase
  independent functioning and decrease the need for
  highly structured professional services.

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ACAP PRINCIPLES

• Every person living with an Autism Spectrum
  Disorder (ASD) can experience a meaningful and
  quality life.
• Every person with ASD can grow and learn for the
  entirety of their life.
• Services are comprehensive, highly
  individualized, flexible and continuously adapted
  to the persons needs and preferences.

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ACAP PRINCIPLES Cont

• Services are community based and make maximum use
  of the capacity of the family, friends, neighbors
  and community at large.
• Therapeutic strategies are evidence based and are
  carried out by a highly qualified clinical team.
• The effectiveness of the program is continuously
  measured.
• The program makes maximum use of innovation,
  creativity and technology to support successful
  functioning.

9
ACAP ELIGIBILITY

• Be twenty-one (21) years old or older
• Be eligible for Medical Assistance
• Have a diagnosis of an Autism Spectrum Disorder
  (ASD)
• Be able to live in a community setting (such as
  the persons home or other family-members) safely
  without 16 hours or more per day of awake
  staffing and supervision

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ACAP SAMPLE SERVICES

• Supported Employment
• Physicians Services Health Care
• Dental Services
• Behavioral Support Services
• Service Planning Supports Coordination
• Respite
• Recreation Social

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ACAP SAMPLE SERVICES cont

• Crisis Intervention
• Non-Medical Transportation
• Family Counseling
• Physical Therapy
• Individual Counseling
• In-home services

We are not locked into service definitions can
provide any medically necessary service.
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ENROLLMENT PROCESS

• Referrals or individual applications go to the
  Bureau of Autism Services (BAS)
• BAS does preliminary eligibility determination
• Referral to Keystone We do comprehensive
  assessment and gathering of baseline data
• Propose ISP to Individual. They decide whether
  to enroll.

13
Person-Centered Planning

• Clinical assessments and the development of each
  persons Individual Service Plan (ISP) is
  provided by a highly qualified internal team.
• ACAP services are dynamic, having the capacity to
  vary intensity and an individualized response
  dependent upon current and/or changing needs.
  Services can be deployed in real time.
• Services are designed to include meaningful
  community inclusion and promote independence and
  self sufficiency.
• The persons dreams and choices are core
  considerations in ACAP person-centered planning.
• The family is a central resource and partner in
  all planning and progress.

14
Clinical Capacity

• ACAP meets the full range of defined needs when a
  person enrolls in the program.
• Services are assessment and outcome driven.
  (Scales of Independent Behavior-Revised(SIB-R))
• Authorizations are based upon medical necessity
  following a comprehensive clinical assessment and
  the development of individualized service plans.
• Clinical assessments are conducted by a highly
  skilled team of Masters level clinicians working
  under supervision of a Licensed Psychologist.
• ACAP is responsible for providing and/or
  arranging all services for Participants - doing
  so in a manner that assures effective service
  integration and continuity.

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Capitation Approach

• Uses the federal Prepaid Inpatient Health Plan
  funding
• model. This is the same authority used to
  fund PACE programs on the national level.
• Funding consists of a single per member per
  month
• payment for the full array of program
  services.
• Rates are negotiated annually.

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Outcome Measures

• Improvement in behavioral stability of the
  Participants as measured by
• 1. Fewer Episodes of
• Law Enforcement involvement
• Psychiatric Emergency Room care
• Psychiatric Inpatient Hospitalization
• Crisis Intervention Plan use
• Mental Health crisis interventions

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Outcome Measures cont

• Improvement in behavioral stability of the
  Participants as measured by
• 2. Increases in
• Percentage of Participants with jobs or engaging
  in volunteer work
• Number of hours Participants work or are engaged
  in volunteer work
• Participants independence and social skills
• Parental satisfaction and quality of life
  indicators
• Participants quality of life

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Outcome Measures cont

• Improvement in behavioral stability of the
  Participants as measured by
• Improvement in access to medical services
  including
• Initial visit with a PCP within three weeks of
  enrollment
• Annual dental exams
• Improved diabetes management
• Annual gynecological exams

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Outcomes
Employment, Volunteer, Education
Unduplicated Count
Time Period Working of Enrollment Working Volunteering of Enrollment Volunteering Education of Enrollment Education
7/2011-9/2011 32 38 21 25 5 6
May 2012 45 46 40 41 12 12
December 2012 61 56 45 42 11 10
Time Period Enrollment Count W/V/E Total W/V/E of Enrollment
7/2011-9/2011 84 58 69
May 2012 97 83 86
December 2012 108 101 94
20
Outcomes
SIB-R Scores Baseline to Time 3 Scores (In
Program 3 Years)(n19) With
Increases Broad Independence
84 Motor Skills
89 Social/Communication
79
Personal Living
84 Community Living
74

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Outcomes

• Improved access to health care
• Frequency of incidents
• Participants Quality of Life Scores
• Parental Satisfaction and Quality of Life scores

22
Outcomes

• Participant Testimonials
• ACAP helped me identify what I wanted to with my
  life. I didnt know where to go in life or how
  to make things happen. ACAP staff guided me and
  supported me, but they didnt do it for me.
• I had input and control about my services with
  ACAP. I was able to determine my own services
  and goals with the help of very supportive staff.
• ACAP should be available in other counties. I
  know people who could really benefit from ACAP
  and because they are at home with protective
  parents. ACAP would help change that and help
  them do more. I wouldnt be where I am today
  with out ACAP.
• I am living on my own and without ACAP support, I
  never would have moved from living with family to
  living independently in my apartment.
• A Participant shared that on a weekend when they
  were having a difficult time they called for ACAP
  support. Services were increased and helped to
  avoid a crisis. The availability of ACAP
  services made the Individual comfortable with
  seeking help, which as a big step for them.

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Financial Results

• Grant provided start-up support
• Start-up line of credit reached 747,578
• Month 9 of the program was the first profitable
  month
• Program reached Life to Date Profitability in
  month 13
• Positive cash position is now over 2,000,000

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SAFEGUARDS

• Extensive and valid measurements of outcomes
• Family advocates on governing board
• Family advocates on Plan Advisory committee
• Bureau of Autism Services clinical team reviews
  all ISPs
• Comprehensive reporting of all incidents
• Easy external appeal to BAS

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SAFEGUARDS Cont

• Extensive quality system
• Highly credentialed clinical team
• Extensive family communication
• Family advocate
• Annual cost report and review of rate
• Right to transfer to Adult Autism Waiver

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Uniqueness of the Model

• One Agency Responsible-One Agency Accountable
• Comprehensive services
• Full Coordination and Integration of Services
• Inclusion of Health Care Services
• Person Centered
• Dis-intermediated
• Fully integrates risk and service delivery

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BROAD APPLICABILITY
The ACAP model is fully approved by CMS and has
broad applicability to autism, intellectual
disabilities, behavioral health, aging, children
and youth and criminal justice services
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FEE FOR SERVICE PARADIGM

• Fee for service (focus on human service widgets)
• Compliance focus on unit of service, claims
  process
• Highly defined service codes (commodities)
• Individual need must accommodate authorized
  services
• Utilization driven incentives
• Highly structured service models
• Exclusion of natural capacity of community and
  family

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FEE FOR SERVICE PARADIGM cont

• Exclusion of technology and innovation
• Complex systems, regulation and licensing demands
• Very expensive infrastructure
• Rigid structures and processes
• External case management and authorizations
• Minimal integration across service models and
  need
• Authorized service may have no relevance to need

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EMERGING HUMAN SERVICE PARADIGM

• Focus on the person, not human service widgets
• Capitated funding aligning risk and authority
  to manage service resources
• Comprehensive services and supports
• Flexible and responsive
• Highly Individualized
• Compliance focus on outcomes not claims
• No service codes
• Highly credentialed clinical staff effective
  clinical models

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EMERGING HUMAN SERVICE PARADIGM cont

• Focus on growth and capacity building vs.
  utilization
• Dynamic deployment of resources as peoples needs
  change
• Extensive range of service models
• Extensive use of natural capacity of community
  and family
• Extensive use of technology and continuous
  innovation
• Moderate infrastructure cost
• Highly integrated across service systems and
  needs
• Cost reporting and limit on profits

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PUBLIC POLICY BENEFITS (ACAP)

• The Department of Public Welfare knows its exact
  financial
• liability at the beginning of the fiscal
  year.
• The Provider is responsible for all changes in
  need during
• the year.
• The model makes effective use of public
  resources.
• The ACAP model provides relevant, valid and
  reliable
• outcome data on performance.
• The ACAP model has the potential for extensive
  costs
• savings.

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PUBLIC POLICY BENEFITS cont

• The model caps (retention) profits at a level
  appropriate to
• public policy interests.
• The model supports innovation and use of
  technology.
• The model incurs no intermediary (middleman)
• administrative costs and intermediary
  profits.
• The model has high accountability and
  transparency.
• The model is applicable to a wide range of
  services to include intellectual disabilities,
  behavioral health, aging and criminal justice.

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Are we a Provider or a Managed Care Company

• You have to take on the role of a Managed Care
  Organization
• Provide medically necessary services vs. services
  that are wanted
• Claims processing experience
• Do you need a risk license
• Do you need reinsurance
• How do you build Risk Reserve

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Start up experiences

• Structure must be in place
• More expensive than you think
• Start up is slower than you think
• How to bridge that period

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Should health care be included

• Clear advantages in treating the whole person
• Education of families and Participants
• Provider Network Challenges
• Credentialing of Providers
• Medical Director

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The capitation rate

• You live or die based on the Capitation Rate and
  what is included
• Clearly define and understand what the rate
  includes
• How was the rate developed
• Annual negotiations
• Actuarial soundness

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Items of interest

• Our staff have to learn to take advantage of the
  flexibility
• We need to improve our use of technology
• The role of families
• The role of Advocates

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LESSONS FOR NEW YORK STATE?

• We arent necessarily advocates for managed care.
  The ACAP model is simply a better alternative to
  the current Pennsylvania reimbursement
  methodology
• Accountability and authority should be aligned.
  You dont want to be in a system where you have
  all the responsibility and little control.
• Costs, Complexification and Crisis
• Government's Human Services Contracting
  System Hurts Everyone
• (October 7, 2010-National Council on
  Non-Profits)
• If Managed Care comes to New York State and
  providers are simply in a fee for service program
  with Managed Care Organizations the only thing
  that will change is there will be less money in
  the system for providers.
• The same thing could happen in Pennsylvania

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WILLIAM PENN HUMAN SERVICES

• Not for Profit Corporation by Pennsylvania
  Providers
• If Pennsylvania moves to a Managed Care model
  William Penn Human Services will be positioned to
  bid as a managed care company
• William Penn is proactively developing a proposed
  service model for Pennsylvania.
• Lessons are being taken from the ACAP model