medicaid infrastructure grant program annette shea division of community systems transformation...
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Medicaid Infrastructure Grant Program
Annette SheaDivision of Community Systems Transformation
Disabled and Elderly Health Programs Group
Medicaid Infrastructure Grant (MIG) Program: Promoting Successful Employment Outcomes for People with Disabilities through Systems Change
Medicaid Infrastructure Grants (MIG)
• Title II of the Ticket to Work and Work Incentives Improvement Act of 1999 (TWWIIA) established the Medicaid Infrastructure Grant (MIG) Program.
• MIG program funding began in FY01 and will end in 2011. CMS has awarded more than $450 million in MIG funding. Currently, 43 States have active Medicaid Infrastructure Grant programs.
• CMS expects many States to request no-cost extensions to continue grant-funded activities into 2012.
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• The Medicaid Infrastructure Grant (MIG) program provides funding to States to strengthen the infrastructure necessary to assist individuals with disabilities who work or who want to work through employment promoting and supporting policies and services.
• States have utilized MIG resources and expertise to obtain authority to implement Medicaid Buy-In (MBI) programs, build linkages between State Medicaid agencies and Vocational Rehabilitation, Developmental Disability and Mental Health agencies including integrating employment supportive policies into key Affordable Care Act provisions.
Medicaid Infrastructure Grants (MIG)
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Medicaid Buy-In
• The Medicaid Buy-In program allows adults with disabilities to work, access Medicaid benefits and earn more than would otherwise be possible while enrolled in traditional Medicaid.
• Typically States allow participants to “buy into” the Medicaid program by paying premiums based on income.
• There are 43 States operating Medicaid Buy-In programs with 153,000 enrollees nationally.
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Medicaid Infrastructure Grant (MIG)
• Recently CMS awarded an additional $2.8 million in supplemental funding to 15 MIG Grantees to leverage established MIG expertise to support their respective States in ensuring that employment supportive policies and supports are integrated into their State’s design and implementation of long-term care Affordable Care Act provisions, including Money Follows the Person programs.
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TEXAS DEPARTMENT OF ASSISTIVE AND REHABIL ITATIVE SERVICES’ D IV IS ION OF REHABIL ITATION SERVICES
MEDICAID INFRASTRUCTURE GRANT 2011 SUPPLEMENTAL
IN PARTNERSHIP WITH TEXAS DEPARTMENT OF STATE HEALTH SERVICES’ MENTAL HEALTH AND SUBSTANCE ABUSE
OCTOBER 2011
COGNITIVE ADAPTATION TRAINING:
MONEY FOLLOWS THE PERSON
MONEY FOLLOWS THE PERSON (MFP) IN TEXAS
Promoting Independence Initiative
• 2000 Texas Health and Human Services Commission (HHSC) implements Promoting Independence Initiative in response to U.S. Supreme Court ruling in Olmstead v. Zimring and Texas Governor’s Executive Order GWB99-2.
• 2001 SB 367 codifies the initiative.
Texas Money Follows the Person
• 2007 Texas’s Department of Aging and Disability Services (DADS) receives MFP demonstration grant. M
FP Behavioral Health Pilot
• 2008, Texas implements the Behavioral Health Pilot (BH Pilot) within the larger MFP Demonstration to transition adults with severe and persistent mental illness and/or substance abuse disorders from nursing facilities to the community.
Texas MIG 10-2011
COGNITIVE ADAPTATION TRAINING (CAT)
A series of intervention strategies developed in 1993 by the University of Texas Health Science Center San Antonio (UTHSCSA), Department of Psychiatry.
Similar to successful model of wraparound services for persons with head injury and intellectual and developmental disabilities.
Originally designed to compensate for cognitive impairments associated with schizophrenia and improve adaptive functioning .
Recognized as an evidence-informed practice, CAT services compensate for neurological issues that create barriers to performing activities of daily living
Texas MIG 10-2011
COGNITIVE ADAPTATION TRAINING (CAT)
CAT has similarities to intensive case management techniques, including small caseloads, home visits, and actively working one-on-one with the person on specific issues. CAT differs from this model in that it implements more systematic and specific supports in the person’s environment.
In addition, cues and compensating measures are left in place for lengthy periods of time, even in the absence of the trainer or therapist.
Original model contains employment intervention for a person diagnosed with schizophrenia who is attempting to maintain employment.
Texas MIG 10-2011
Example from CAT ManualWork Skill
Apathy — Poor Executive Functioning
Potential Behaviors Suggested Interventions• May not initiate work task.
• After completing a task, may sit or stand around. May not ask “What can I do next?”
• May fail to initiate each step in a multi-step task.
• May perform tasks very slowly.
• Give simple, repetitive, single-step tasks for work, e.g. placing typed labels on files.
•Use tape recorded work message to step through each task. (E.g. “Pick up a manila folder with no label on it. Take a label off the sheet of typed labels,” etc.) Message can repeat over and over. Record encouraging statements /reinforcement. (E.g. “You have all ready made 4 folders –great work. Let’s keep going.”)
•Give checklist w/ each step in task broken down into one-step components. (e.g. 1. Place a label on a manila folder. 2. Find the matching hanging file ,etc.). Have place at the bottom to check off each completed task.
• Provide verbal prompt to begin task, (e.g. “It’s time to place labels on files now. I’d like you to start by…”). Use to initiate each step.
• Place a large sign at eye level stating, “When this job is done ask X “What can I do next.?” Texas MIG 10-2011
CAT and MFP Behavioral Health Pilot (BH Pilot)
Services available up to six months prior to discharge from institutional setting, and up to one year after discharge.
By-product of increased functioning produced via CAT for some was secondary, post-secondary education and employment.
New CAT pre-employment intervention being developed via 2011 MIG supplemental will provide basic environmental modifications and simple household items necessary to support the individual in finding and maintaining employment. Texas MIG 10-2011
CAT and MFP Behavioral Health Pilot (BH Pilot)
Focus will be on persons currently receiving MFP-BH Pilot services and Mental Health and Substance Abuse (MHSA) consumers who are at risk for institutionalization.
Employment can act as a buffer against negative health outcomes and increase positive perceptions of self, giving the employed person a sense of pride, and a reason to maintain health, wellness, and recovery.
CAT employment interventions will be incorporated into the evidence-informed strategies at multiple points in the recovery process.
Texas MIG 10-2011
CAT and MFP Behavioral Health Pilot (BH Pilot)
Success of CAT and other interventions used in the MFP-BH Pilot will be determined by 2016. If proven effective, techniques will be disseminated within Texas’ long term care system.
Evaluation of CAT employment intervention to be conducted by UTHSCSA; proposed to include qualitative life histories; additional analysis on the standardized measures to determine efficacy and fidelity; and comparison, where possible, to outcomes in the absence of CAT intervention.
Meets MFP Benchmark Three – Individuals Served through Behavioral Health
Texas MIG 10-2011
CAT and MFP Behavioral Health Pilot (BH Pilot)
Plan for dissemination of information and training on CAT employment intervention for CAT specialists, mental health workers, case managers, and home health agencies, and other key stakeholders.
MIG offering basic foundational knowledge about benefits and work incentives planning supports and services statewide; training will be sustained after MIG ends. DSHS staff statewide participating in part to support and enhance CAT employment intervention.
Texas MIG 10-2011
THE REAL DEAL
Mike : Age 24
Schizoaffective disorderInsulin dependent diabetesStreet drug and alcohol addictionEmaciated and physically debilitatedLacked social, living skills and family supportsConsidered a “behavior problem”In and out of nursing facilities or homeless for most
of his adult life
Texas MIG 10-2011
THE REAL DEAL
Mike’s dream was to have a job and a place of his own. With the help of CAT, Mike set employment goals, learned to interview. got some vocational training and began working 20 hours a week.
Through CAT, Mike learned social skills needed to get along in the community. He now handles daily activities like catching the bus, taking medication, doing laundry and caring for himself. CAT also helped him learn to manage his blood sugar level and change his diet to a healthier one for his condition. His waiver service coordinator helps him get the health services he needs.
Through substance abuse counseling, Mike was able to understand issues in his past and is reconnecting with his natural family.
Texas MIG 10-2011
MIG/MFP Collaborations in IowaMIG – MFP SummitOctober 19, 2011
Tammie Amsbaugh MIG Project [email protected]
Iowa MIG Focus areas:
• Public/Consumer awareness and education- Medicaid Buy-in, SSA work incentives, Ticket to Work, self employment, self direction, self sufficiency
• Medicaid Services Supporting Employment – HCBS waivers, Consumer Choice Option (self direction), Consumer Directed Attendant Care (Personal assistance), HCBS service providers, Money Follows the Person (MFP)
• Linkages with other employment related services- Work Incentive Planning and Assistance (WIPA), Iowa Workforce Development, Vocational Rehabilitation (VR), SSA, Ticket to Work, Employers Disability Resource Network (EDRN), Promise Jobs (TANF), and Transition Youth
MIG and MFP
• Early 2008-Employment workgroup participation in early stage work with the operational protocol
• November 2008- Creative Employment Workshop held for transition specialist relating to Customized Employment and how it fits into the transition process
• 2009- Provided trainings for the transition specialist covering work incentives, customized employment and discovery methods and included MFP participants in all consumer education and awareness activities
• 2009 and 2010- funded Technical Assistance opportunities for transition specialist to consult about specific situations
• 2010- Provided in-depth trainings for Community Providers to learn customized employment concepts to address provider capacity and willingness to provide supported employment services to MFP participants.
• 2010 to present- working to address provider capacity through mini projects to encourage community based employment services, created funding examples using Ticket to Work and showing the funds available for supported employment services.
• 2011 and looking forward- Through Iowa’s Olmstead plan implementation and using the results from the State Employment Leadership Network (SELN) survey and findings report we are addressing systemic issues around the Employment vision (Employment First) provider availability and capacity to deliver supported employment services.
MIG Supplemental Projects
1) Determine a methodology to reverse Iowa’s investment of service dollars in facility based employment using Iowa’s Money Follows the Person project In Iowa about 80% of our HCBS funding for work services is spent in facility based settings. We know from SELN findings and from statewide provider surveys that the stability of the funding methods for facilities based services trumps the outcomes based funding for supported employment services. Providers are “incented” by the funding structure to provide facility based services. This project will use data and results from other states through SELN to develop a cost neutral funding and rate methodology designed to eliminate the disincentive to providing community based employment services. Prototypes will be tested using MFP Participants and providers taking advantage of the “demonstration” aspects of MFP if necessary. Ultimately, the rate structure and funding methodology would be used statewide for all HCBS services and result in a more balanced system.
MIG Supplemental Projects2) Determine the costs and the feasibility of establishing benefits planning as a credentialed
service using Iowa’s Money Follows the Person project participants.The complexities of disability benefits systems and the real fear people feel about the loss of the safety net benefits of SSI/SSDI and Medicaid are well known. The ramifications of uninformed decisions are serious. Qualified benefits planners assist in walking through the complexities, making informed choices and increasing self sufficiency. Iowa Medicaid currently does not fund benefits planning services. Developing the service description, rates and required credentials for providers for this service is a first step for any new service. For cost neutrality we will also have to do a details cost benefit analysis. This service would be implemented first with MFP participants and, based on outcomes statewide.
3) Target Iowa’s Medicaid Buy-in members for supported employment services and employment related attendant care services using 1915iData in Iowa and other states has shown that Buy-in members cost less in Medicaid claims. In Iowa we know that this is true. We also know our Buy-in members are minimally employed. With this part of the supplemental funds we want to update and solidify the data and quantify the cost savings employment generates to Medicaid. We then hope to use identified saving to add supported employment services to the Buy-in coverage group to facilitate more robust employment outcomes. These saving would also be used to fund the addition of benefits planning services.