Wisconsin RCSC Summary

<A NAME=\"WIRC\"></A> <P ALIGN=\"RIGHT\"><EM>Real Choice Systems Change</EM></P> <H2 ALIGN=\"CENTER\">WISCONSIN</H2> <H3>Identified Problems with the State's Long-Term Care System</H3> <P> <UL> <LI>Existing programs for children lack a single entry point. Consumers have difficulty accessing and navigating the LTC system. Overlapping eligibility and assessment systems add administrative cost and confuse consumers and providers alike.</LI> <LI>Wisconsin ranks 31<FONT SIZE=\"-1\"><SUP>st</SUP></FONT> in the country in per capita Medicaid spending on home and community care for people over age 65.</LI> <LI>Inefficiencies in the administration of the fee-for-service Personal Care benefit and the local care management structures of the waiver programs.</LI> <LI>Flexibility and choice are not maximized; the Medicaid Personal Care programs have some elements of consumer self-direction, but are essentially agency-managed.</LI> <LI>Some people with developmental disabilities may remain in institutions because their parents or guardians lack accurate information about community residential service options.</LI> <LI>Shortage of long-term care workers.</LI> </UL> </P> <H3>Perceived Strengths</H3> <P> <UL> <LI>Wisconsin has a generous state Medicaid program that finances a full range of LTC benefits. The program also has relatively generous financial eligibility criteria, provides the maximum spousal impoverishment allowance, and has a Medicaid Purchase Plan for people with disabilities.</LI> <LI>The state's Community Options Program (COP) is a consumer-centered, comprehensive, and flexible home and community-based care (HCB) program that served 26,044 persons in 2000.</LI> <LI>Standards and training for care managers in Wisconsin's long-term care programs emphasize the primacy of the consumer (or the child's family) and their choices and preferences.</LI> <LI>Wisconsin ranks third in the U.S. for per capita Medicaid spending for all long term care services (including nursing homes) for all disability groups.</LI> <LI>The state's Medicaid has a strong management information system to track participation and expenditures in its programs.</LI> <LI>Children with long-term health care needs are served in multiple programs, most of which have flexible services and supports based upon family-identified needs.</LI> <LI>The community mental health system provides flexible mental health services. Wisconsin's Consumer Support Program (CSP) is a widely recognized intensive case management model of support to enable people with serious mental illness to live in the community.</LI> </UL> </P> <H3>Primary Focus of Grant Activities</H3> <P> <UL> <LI>Increase flexibility in the provision of Medicaid Home Care Benefits.</LI> <LI>Strengthen consumer choice and increase opportunities for consumer direction of services.</LI> <LI>Improve ability to meet the needs of consumers with a mental illness.</LI> <LI>Improve consumers' and their families' knowledge regarding choices and opportunities available in non-institutional settings.</LI> <LI>Develop and implement workforce initiatives to increase access to services.</LI> <LI>Improve quality through a focus on health and social outcomes.</LI> </UL> </P> <H3>Goals, Objectives, and Activities</H3> <P><STRONG>Overall Goal.</STRONG> Increase consumer choice; improve access to services; create a comprehensive and flexible long-term care system; improve quality through a focus on health and social outcomes; and create a cost-effective long-term care system for the future.</P> <P><STRONG>Goal.</STRONG> Strengthen consumer choice and increase opportunities for consumer direction of services.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Explore options for having Medicaid nursing home and ICF-MR funds follow residents who transition to home and community services.</LI> <LI>The Department of Health and Family Services will invite county agencies and consumer or provider organizations to submit proposals to develop protocols and training for care managers, to improve the level of consumer direction for older persons. A county or coalition funded to develop these protocols and training modules will share the innovations through regional forums.</LI> <LI>County aging offices and area agencies on aging organizations will be invited to submit proposals to implement long-term care options counseling as part of their Information and Assistance activities.</LI> <LI>Organize regional forums with county long-term support staff to discuss issues of elderly access and choice.</LI> <LI>The Bureau of Aging and Long Term Care Resources will lead initiatives to address barriers to consumer direction among older persons at the state level by revising policies and procedures, and making grants to the local aging network or community-care programs to demonstrate best practices for overcoming barriers to access for older people.</LI> <LI>Revise policies and regulations to assure that consumers have the option to choose relatives or friends to serve as paid caregivers to the extent permitted under federal Medicaid law.</LI> <LI>Conduct training about the use of advance directives for local aging benefit specialists and long-term care managers to inform them about relevant laws, model documents, counseling techniques and educational materials for consumers.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Simplify access to the full range of LTC services.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Demonstrate and adopt a uniform, automated functional screen across all HCB waiver programs.</LI> <LI>Contract with a software developer to adapt the existing adult automated functional screening tool for use with children and for other purposes as found feasible. The adult tool determines nursing home level of care, which is the threshold for waiver programs, while the children's tool determines eligibility for several children's programs, including Katie Beckett, Family Support and children's waivers.</LI> <LI>Determine the feasibility of adopting a standardized LTC functional assessment tool to apply to people with serious mental illness.</LI> <LI>Test the Internet application of the functional screen and make available to counties that have already adopted the screen for adults who are elderly or have a disability. If the adaptation of the tool is successful, funds will be deployed in the following year for a clinical consultant help desk function to assist professionals using the tool.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Increase flexibility in the provision of Medicaid Home Care Benefits.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Explore the use of comparable Internet-based functional screens to determine waiver eligibility and eligibility for Personal Care.</LI> <LI>Provide expanded access to self-directed personal care to eligible Medicaid consumers statewide. Special efforts will be made to facilitate the participation of severely disabled persons in self-direction.</LI> <LI>Explore various models of self-direction, including those targeted to people who need help in self-direction and to the families of children with disabilities.</LI> <LI>Explore models for a fiscal intermediary structure that will support consumer self-direction and meet Medicaid requirements.</LI> <LI>Develop a consumer-friendly care manager structure, targeting the 20 percent of personal care consumers who do not receive care management through the state plan or through MA waivers. Explore ways to assist consumers who do not wish to work with a care manager or for whom the current care manager arrangements are not satisfactory.</LI> <LI>Review current assessment tools (e.g., OASIS assessment, Family Care assessment, etc.) and, develop specifications for an improved automated assessment process.</LI> <LI>Reduce existing regulatory and administrative impediments to self-direction of personal care.</LI> <LI>Study the feasibility of (1) modifying administrative rules and other policy documents to reduce requirements that impose barriers to self-direction of personal care services; and (2) developing an expedited, automated prior authorization (PA) system or an alternative process that will determine the hours of personal care a recipient will receive (PA is now required for services exceeding 50 hours a year, per recipient).</LI> <LI>Develop a quality assurance model for self-direction.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Develop a strategic plan to resolve the systems problems that present service barriers for people with mental illness.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Determine the number of persons with mental illness inappropriately placed in institutional settings and identify the barriers to community living.</LI> <LI>Plan and implement steps to reduce the use of nursing homes for people with mental illness.</LI> <LI>Develop ways to overcome barriers to community placement.</LI> <LI>Work with local housing authorities and adult family home providers to secure supportive living arrangements and assure the development and implementation of community-based treatment through the Community Support Program.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Develop a Guardian Mentor Program at the state Centers for Developmental Disabilities that can be replicated in private and county ICFs-MR to mentor guardians through the community transitioning process.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Develop the Guardian Mentor Program in Northern Center in the first year and expand to the other two centers in subsequent grant years. The program will provide information and advocacy for guardians of individuals living at the state centers. This change was made due to a budget proposal to significantly down-size Northern Center. The Guardian mentor project will assist with this down-sizing.</LI> <LI>Develop training materials for guardians and form a network of guardians throughout the state. Recruit Guardian Mentors in each county or region within the state.</LI> <LI>Develop an orientation and training manual for Guardian Mentors outlining the protocols, information and support systems.</LI> <LI>Begin development of a community services resources guidebook that describes services on a statewide and county specific basis.</LI> <LI>In Year Three, develop a strategy to expand Guardian Mentors to private and county ICFs-MR.</LI> </UL> </P> <P><STRONG>Goal.</STRONG> Develop and maintain a workforce that is competent and committed to meeting the needs of consumers and their families in the long-term care system.</P> <P><STRONG><EM>Objectives/Activities</EM></STRONG> <UL> <LI>Develop and disseminate core curricula for training universal workers.</LI> <LI>Expand the work of the UW Alzheimer's Institute to provide a sustained training program to teach vital work and life skills to personal assistance workers.</LI> <LI>Use the successful North Carolina child care worker training retention strategy, demonstrated in Wisconsin community-based residential care facilities by the University of Wisconsin and the Wisconsin Assisted Living Association.</LI> <LI>Develop and disseminate training for the managers/supervisors of caregivers in long-term care to create positive work environments, foster personal growth and career development.</LI> </UL> </P> <H3>Key Activities and Products</H3> <P> <UL> <LI>Revision of polices and regulations to allow long-term care funds to follow the consumer.</LI> <LI>Adapt the existing adult automated functional screening tool for use with children.</LI> <LI>Develop a consumer-directed personal care option-initially as part of home and community-based waivers and ultimately under the state plan.</LI> <LI>Define long-term care needs of consumers with mental illness and develop methods to better meet those needs (e.g., a potential 1915(c) waiver).</LI> <LI>Employ guardian mentors at state centers for persons with developmental disabilities to help address concerns of guardians and overcome their reluctance to consider community placements for their wards.</LI> <LI>Fund training and technical assistance activities related to workforce recruitment and retention.</LI> </UL> </P> <H3>Consumer Partners</H3> <P> <UL> <LI>Wisconsin built the Consumer Task Force for this project around the consumer and advocate members of the ADA Title II Advisory Committee. Additional consumer and advocacy members rounded out the Task Force for ethnic and geographic diversity and to balance target groups.</LI> <LI>The Council on Long Term Care, whose fifteen members include consumers, providers, counties and an interfaith organization, is appointed by the Governor to advise the administration and the legislature on general long term care policy, and monitor Family Care implementation and complaints.</LI> <LI>The ADA Committee was dissolved at the end of 2002, but a subcommittee called the Grant Advisory Group is continuing under the auspices of the Council on Long-Term Care and will act as the Consumer Task Force for the Real Choice Grant. This group comprises consumers, advocates and providers.</LI> </UL> </P> <H3>Consumer Partners and Consumer Involvement in Planning Activities</H3> <P>The Consumer Task Force met for one and half days to provide input into the application process.</P> <H3>Consumer Partners and Consumer Involvement in Implementation Activities</H3> <P> <UL> <LI>There will be extensive involvement in grant activities through the use of the Grant Advisory Group and through the ongoing use of target group-specific councils and advisory groups as appropriate.</LI> <LI>The Grant Advisory Group and the Community Options Program Long Term Care Advisory Committee will be asked to review policies and procedures of HCB waiver programs to examine options for strengthening consumer direction.</LI> <LI>Consumer organizations will be encouraged to apply for sub-grants to develop training, curricula or materials.</LI> </UL> </P> <H3>Public Partners</H3> <P> <UL> <LI>Division of Health Care Financing.</LI> <LI>Division of Care and Treatment Facilities.</LI> <LI>Office of Strategic Finance, Budget and Planning.</LI> <LI>Center for Delivery System Development.</LI> <LI>County systems.</LI> <LI>One tribal delivery system.</LI> <LI>Council on Long Term Care (described under Consumer Partners).</LI> <LI>Board on Aging and Long Term Care (ombudsman).</LI> <LI>University of Wisconsin Medical School Alzheimer's Institute.</LI> <LI>School of Nursing Center for Excellence in Long Term Care.</LI> <LI>WI Counties Human Services Association LTC Technical Advisory Committee.</LI> </UL> </P> <P>Recently the Division of Supportive Living (the lead agency for the Grant), the Division of Care and Treatment Facilities and the Center for Delivery Systems Development were combined into a single Division of Disability and Elder Services.</P> <H3>Private Partners and Subcontractors</H3> <P> <UL> <LI>Providers of Medicaid services (personal care agencies, nursing homes, etc.).</LI> <LI>Aging Advisory Committee.</LI> <LI>Community Options Program Long-Term Care Advisory Committee.</LI> <LI>Medicaid Advisory Committee.</LI> <LI>Home Care Advisory Committee.</LI> <LI>Council on Developmental Disabilities.</LI> <LI>The Physical Disabilities Council.</LI> <LI>Mental Health Council.</LI> <LI>Children's LTC Redesign Advisory Committee.</LI> <LI>Blue Ribbon Commission Advisory Committee on Mental Health.</LI> <LI>The above groups are convened and staffed by public entities, but include consumers, providers and other private sector members.</LI> </UL> </P> <H3>Public and Private Partnership Development/Involvement in the Planning Phase</H3> <P>The main public and private involvement in the planning phase was through the Consumer Task Force and the ADA Title II Advisory Committee. Through these groups, partners attended meetings and commented on components of the grant.</P> <H3>Public and Private Partnership Development/Involvement in Implementation</H3> <P> <UL> <LI>All grant activities will rely heavily on coordination and collaboration among all the long-term care programs across Divisions in the Department of Health and Family Services.</LI> <LI>Because Wisconsin's Real Choice Grant has several components, different groups will be involved in different parts of the grant. Depending of the activity, some partners may be providing advice and input, others may receive subcontracts to carry out grant activities, while still others will participate in policy development.</LI> </UL> </P> <P><STRONG>Existing Partnerships That Will Be Utilized to Leverage or Support Project Activities</STRONG> <UL> <LI>The project will build on existing contracts for developing an Internet-based application of the functional screen.</LI> <LI>The project will expand the work of the UW Alzheimer's Institute to provide a sustained training program to teach vital work and life skills to personal assistance workers.</LI> <LI>The project will use the successful North Carolina child care worker training retention strategy, demonstrated in WI community-based residential care facilities by the University of Wisconsin and the Wisconsin Assisted Living Association.</LI> <LI>All grant activities complement or relate directly to Wisconsin's current major system redesign efforts: Family Care, MH/AODA Managed Care and Children's Redesign, and address key development areas in Medicaid and the HCB waivers.</LI> </UL> </P> <H3>Oversight/Advisory Committee</H3> <P> <UL> <LI>Management staff in the Department of Health and Family Services, primarily in the Division of Disability and Elder Services, are responsible for project oversight. Oversight includes ensuring that grant activities are proceeding as scheduled and that major department initiatives such as budget requests and policy decisions are consistent with and reflect the goals of the grant.</LI> <LI>The Grant Advisory Group will be involved in monitoring and advising on grant activities overall.</LI> </UL> </P> <H3>Formative Learning and Evaluation Activities</H3> <P> <UL> <LI>The Guardian Mentor project will start with one Guardian Mentor in one state center in Year One. Learning from that first year will enable the department to fine tune the project as it expands to the remaining state centers.</LI> <LI>Through in-home or on-site interviews and data collection, each project will assess the impact of program reforms in the communities in which they operate, using a common interview process and measurement. The staff and oversight committees will be able to compare outcomes in different system change arenas and recommend changes.</LI> </UL> </P> <H3>Evidence of Enduring Change/Sustainability</H3> <P> <UL> <LI>Grant activities are part of or building on many existing state activities, and are redirecting resources rather than creating changes that will require new funding.</LI> <LI>Many protocols, experiments or solutions will be locally developed, not mandated.</LI> <LI>The Workforce Development Specialist will be responsible for broad dissemination of successful retention strategies, within the State of Wisconsin and to other interested states.</LI> <LI>Curricula and training developed under the grant will be in continuous usage, subject to revisions, for at least 5 years.</LI> <LI>Grant activities will both improve the LTC system for current participants and lay the foundation for enduring reforms by using grant funds to support planning, demonstration and implementation of key building blocks for a more rational and person-centered system.</LI> <LI>Grant activities are enduring investments in state-level planning and program development, local service demonstrations, and consumer participation.</LI> </UL> </P> <H3>Geographic Focus</H3> <P>Statewide.</P>