What is the DIDD Integration Plan, And Why is the State Making this Proposal?

/ July 21, 2020

By Jordan Allen

Editor’s Note: Some readers may not be as familiar with Medicaid waivers, either those of the Department of Intellectual and Developmental Disabilities or those of the Employment and Community First CHOICES program, as some of us are, but all of Tennessee’s waiver programs are focusing on Employment First, helping people with disabilities connect to good jobs at competitive wages in integrated settings. This Integration Plan is an effort, among other things, to align supports and services with that goal. And both DIDD and TennCare have stressed that this proposed plan is still a work in progress, and stakeholders will have numerous opportunities to provide input over the next year. Finally, this plan will require approval by the Centers for Medicare and Medicaid Services. I asked Jordan Allen, DIDD’s deputy commissioner of Program Operations, to explain the proposal in greater depth.

We’ve come quite a long way in the development of supports and services for people living with intellectual and developmental disabilities over the years. Both here in Tennessee and across the nation, people receiving services are experiencing life in a much different way than they were even a decade ago. Tennessee is proud to have left large congregate institutions behind and to have developed an approach that strives to be person-centered and understands that people with disabilities want to live their lives on their own terms, in their own homes and communities.

As people left institutions and started becoming a part of our communities, we developed policies, procedures and programs to support them. And, while the pathway of change is not as linear as we might hope, the markers of success along that pathway are visible. We have the advantage of recognizing success in the most basic of terms; the personal accomplishments of those receiving services. Put simply, success is easy to spot. Are people with disabilities consistently finding the support they need to…well, need less support?

Before we go any further I want to recognize an obvious truth; all people are different. This reality is, at the same time, one of our biggest challenges and one of the most incredible gifts we share. While success for one might mean working, saving for a vacation and helping to support a family, success for another might be fighting through catastrophic challenges to see another day. Our challenge, the charge of DIDD and the disability community as a whole, is to capture every preferred outcome and provide a pathway of achievement for each one. People supported and those that they choose to participate are both in charge and responsible for their own outcomes and their own achievements. This is the fundamental difference between the supports offered a generation ago and those that we contemplate today. While one model was based on the idea that the best approach was to build a life within a shelter, limiting the possibility of outcomes and achievement to options available within those walls, the other seeks to open up all possibilities and to provide the tools needed for a person to reach their own desired life. By supporting and encouraging free will, we have shifted both the burdens and joys of success to their rightful owner: people with disabilities. Here’s how we’ll do it.

The Pathway: Supports and Services

In order to best assure that we are capable of accommodating the diversity of desires within our service system, we have to create options equally as diverse. Supports need to range from those intensive enough to provide clinical and direct supports that help people through the most medically and behaviorally challenging conditions, to those that provide only limited direct assistance and focus more on coaching, counseling and community awareness skills. While many of those components are available within the existing DIDD and Employment and Community First CHOICES programs, there are others that need to be added, updated and even reimagined to better assure we’re offering supports that meet today’s opportunities and demands. These changes will require education and skill acquisition on behalf of DIDD, our managed care organizations (MCOs) and our network of providers. It is important to understand that these changes will occur gradually and only at the point that we are confident they can be administered successfully.

Recognizing the opportunities and the challenges before us, DIDD and the Division of TennCare met to discuss and plan for these changes in early 2019.  The result of these meetings was an agreement on our shared objectives, a commitment to achieve meaningful change for people in supports and the development of a multi-year strategic plan. Contained within this plan and summarized are the following outcomes:

  • Embed person-centered thinking, planning and practices and align key requirements and processes across Medicaid programs and authorities in order to create a single, seamless person-centered system of service delivery for people with IDD.
  • To achieve this outcome several specific areas were identified for alignment in an effort to produce a more efficient and effective single service delivery system. Those areas were:
    • Critical Incident Management
    • Quality Assurance and Improvement processes
    • Direct Support Workforce and Training and Qualifications
    • Provider Qualifications and Credentialing processes
    • The development of a value-based reimbursement model aligned with system values and outcomes
  • Increase the capacity, competency and consistency of the direct support workforce
  • Support the independence, integration, and competitive, integrated employment of individuals with IDD
  • Integrate the budgeting process for programs and services for people with IDD in order to best meet the needs of our community
  • Eliminate the waiting list of persons with IDD who are seeking enrollment in Medicaid services

As you can see, while program and service details for a single system of supports are only just beginning, the concept and value of alignment was communicated well over a year ago. While conditions created by the current pandemic forced us to consider how we might become more aggressive in our pursuit of the program gains and efficiencies, the approach and intended benefits have been a focus for quite some time.

It seems to be well understood by our community that the effects of the nearly 20 years of litigation due to conditions of poor treatment in our institutions produced much-needed changes in services. However, those efforts also produced systems and requirements that have not been modernized to meet the expectations of people in services and are burdensome and expensive. To make a long story short, those requirements produced an environment more focused on the collection of data documenting that services were delivered than it was on the outcomes of those receiving services.

All of this was well-intentioned, because it was important to ensure that the atrocities that occurred in institutions would not carry over into community services.  But that design did not recognize that the community settings are fundamentally different in both experience and expectations for those receiving services. Not long after the move from institutions into new community settings, people in services began to understand the broader world around them. They, like any of us would, began to seek experiences that were previously unavailable and demand services that helped them gain access to everything that people covet about living in their community. And while service demands changed very rapidly, unfortunately, the policy environment did not. The alignment efforts and the initiatives in our strategic plan will enable us to more rapidly enact changes that will meet the demands of those in services while also creating efficiencies for our provider community. This alone makes the pathway to success for those in services much less grueling and empowers our network providers to do what they do best–innovate for people.

Since we’re talking about our network, let’s focus in on that aspect for a bit longer. Very quickly after the launch of the ECF CHOICES program, the network of service providers became nearly the same network of providers that are operating services within the DIDD programs. While this makes sense as these are the providers who are the experts in our work, it has also proven to be very inefficient to operate separate networks in both programs. Because of the differences between the DIDD programs and the ECF CHOICES program, these providers are often required to apply and be approved for services (often called “credentialed”) by four separate administrators—those being DIDD and the three contracted MCOs (BlueCare, Amerigroup and United Healthcare). And while many of the requirements are consistent among each, credentialing is required across all. This burden brings nearly no value but contributes to the cost of providing services.  The process of aligning all services under the direct operational management of DIDD allows the development of credentialing criteria for a single network and credentialing each provider one time. This streamlined process and others will be a primary focus of the early changes as we seek and will provide for a better, more efficient and more sustainable service system.

Strengthening our network of providers by freeing them to devote their full attention to quality, innovation and progress will serve people in ways that are very important.  But, to truly provide a transformative level of change, we’re going to have to also update services. As we’ve been discussing, the pathway to successful outcomes for people is our responsibility. One thing that I want to point out here is that updating services means primarily adding options or updating the way some supports are provided, to increase their efficacy or efficiency. As we begin to consider that process, this will be done in the same way we have worked toward similar goals, by seeking your input and the input of stakeholders across our system. Our intent is to make sure that people receive the supports they want and need, delivered in the most effective and efficient manner.  So, to be clear, persons who need intensive and direct support options in order to maintain their health and safety will continue to have access to those supports. Conversely, people in services who want and need supports to live, work and play independently in their communities deserve that opportunity and will find them in new program designs to come.

As we’ve said, people moved from segregated, institutional settings where their life experience was very limited. They then began to experience life in integrated settings and, expectedly, grew more curious about options, saw some inequalities and began to demand supports to address those gaps. While the logical assumption here is that I’m specifically addressing employment opportunities and the services that help support this desire, that is a not completely accurate. Employment is a focus for us and for the community of providers and stakeholders at large, for sure. But one of the things that we’ve learned, largely from self-advocates and families is that of equal importance is true community training. So, what is that? Well, when we think about the things that specifically empower each of us on our life journey today, what are the essentials? Transportation? Community relationships? Technology? When we think about these three things in a vacuum, they are pretty separate service initiatives. However, in today’s life, none are realistically achievable without all of these things working together. Today, our system does an adequate job with employment services. We’ve got pre-employment services; we’ve got job development services, and we’ve got supports that can continue as long as they are needed once work is found. However, for those choosing to pursue work, their ability is somewhat diminished the current array of available services. We’re just not meeting the demand. We’ve worked hard for people to expect and desire employment, but we haven’t given them all the tools, such as reliable transportation or the tools needed to navigate public transportation, to allow them to truly succeed.  That’s a system failure, and one we’re going to address.

We’ve heard a lot about technology lately. Since the announcement of our intent to align systems I bet we’ve all heard multiple times that DIDD and TennCare intend to take everyone’s services away and replace those services with a camera in their home. I can understand the fears when someone, for the first time, hears that we’re actively supporting the use of technology-enhanced supports in our system. To help better define the scope of our intent I want to explain that we have learned A LOT about technology supports for people living with IDD over the past few years. While it is certainly true (and documented in some awesome videos) that technology-enhanced environments have given some people the opportunity to live completely independent of any direct supports, the vast majority of people using technology-enhanced support packages today are using it to speak to others using their own voice,  take control of their home environments in a way that was not previously possible due to physical limitations and are using them to add safety to their homes through sensors and emergency response systems. All of that is achieving independence.

Imagine someone sleeping in their own bed without a staff person in their room or peering in from the hallway simply because they were able to utilize motion sensors or technology that detects seizures to eliminate that need. I would argue that is empowerment beyond words. So, technology can empower in many ways and has advanced very quickly. Applications that allow people to navigate public transportation and hail support if needed, applications that help people choose appropriate attire, applications that can both discreetly coach people at work and provide immediate access to their own live job coach are all a reality. These are not inventions yet to be developed, these are services that are available today.

Our intent is to fund these, but, more importantly, our intent is to assure that people know of them, understand them and can try them and learn them before they use them. This leads me back to our provider network and those providing essential case management services. In addition to aligning requirements, DIDD intends to help the network providers and case managers become these experts and, in doing so, assure that people supported can make informed decisions about services that can place them in better control of their own lives. For, it is options and information that will drive an improved pathway.

Preferred Outcomes: Planning

Providing a toolbox filled with all the tools needed to build the life you want is a great start if we’re looking for real outcomes. That said, the best tools on earth can’t make a great build if you don’t have a plan. This is the next section of focus for DIDD as we move into an aligned and single system of supports. A major source of frustration is, and has been, the Support Plan and the Support Planning process. While we have seen significant progress in the development of these plans, we can do better. There is agreement that the best approach to service planning is the utilization of a Person-Centered Planning approach. DIDD is also well-positioned to lead the continued development of this model as we have invested heavily in training and are recognized nationally as both a teacher and leader. The system only benefits if everyone who is charged with both planning and supporting people becomes an expert. It is in that approach that we intend to make systemic progress. In addition, if people supported are truly going to be equipped to make meaningful and informed decisions about their services, those helping them plan for their outcomes must understand and empower informed choices about all the potential outcomes available.

Just as we intend to help provider agencies gain additional understanding of all that is available to people, we intend to bring case managers along in their skills and knowledge. Metrics of achievement will be developed, in collaboration with these groups, that will help us better define if the plan is truly what the person desires, and if they are achieving outcomes that are helping them reach their desired life. DIDD will directly assist but the goal will be to achieve a level of expertise within our network that drives meaningful outcomes and provides for achievement.

Achievement: Holistic Support

Of course, all the tools, planning and support mean very little if they do not lead to success as envisioned by the person receiving services. To achieve that successful journey all components must work together. The greatest driver cannot win with a vehicle that is not up to the challenge, and the most dynamic car cannot overcome poor driving. We believe that we have a plan that will produce both an expert driver and a winning vehicle. That confidence stems from the belief that by providing a collection of premium parts and skilled mechanics (i.e. innovative support options and training) we can produce a winning car. And, by equipping the driver with an in-depth understanding of the track and car (services available and network to support them), we can help produce a driver capable of taking both the pride and prize of the win. Let’s take a look at some of the planned efforts.

First, it will be essential that our network understand the potential benefits of all services available and the most effective process by which those services are provided. It’s hardly effective to simply tell a person that there are employment services, or that we offer technology supports. However, when an expert explains how pre-employment services are designed to help people make work possible, it gives them a more complete picture and tells them what is expected to be accomplished. By assuring that providers and case managers have a high level of expertise in the services available, we believe that we’re better equipped to capture the diversity of demand within our service population.

With the establishment of expertise through training programs for agencies and case management, we can then focus on how we measure and incentivize great performance. There is a cost to becoming an expert, and network health is essential to this overall effort. We believe that we can develop a value-based payment structure that supports agencies on their journey to expertise and then rewards them when they arrive. By rewarding, financially, the development of superior plans and outcomes, goals and objectives that truly align with the desires of people supported, and then also rewarding agencies when they move people along the pathway to success and achieve their goals, we believe the system can make significant progress, and quickly. While this value-based payment structure will first apply to those in the DIDD Waiver programs, as we move to develop a single program approach, these efforts will give us opportunity to understand how incentives drive progress and, working with our network of providers, make any changes needed along the way, while ensuring the lessons learned are brought to bear across the system.

Finally, let’s focus specifically on our driver. If we truly invest, if we throw all our energy and resources into assuring that a person receiving services has a quality network of providers, trained and accomplished in the most innovative and effective service options and funded in a way that allows them to be healthy and strong, drivers then have to deliver. People supported and their families have to own the responsibility of their roles and, ultimately, their outcomes.  But, also, providers and case managers have the responsibility of educating families and individuals on the opportunities that these outcomes present. How this translates is, people need to understand and trust that we can help them reach heights that are, at times, difficult to imagine. As mentioned earlier, we would never intend to force anyone to choose anything. We will, however, ensure that every person supported is aware of their true potential and also aware of the supports that are available to help them achieve their goals.

We’ve come quite a long way in the development of supports and services for people with intellectual and developmental disabilities. With those changes we’ve see an awakening of confidence and personal desires of people in services and also a new awareness that recognizes the value all people bring to our lives and communities. We should all be very proud of what we’ve accomplished thus far as it’s been no easy ride. However, now, even in the face of extraordinary challenges, is the time to consider how we might capitalize on our momentum and in doing so, provide the current and future generations of people seeking support with a pathway to their personal success.

My thanks to Jordan and Cara Kumari, DIDD assistant commissioner for Communications and External Affairs, for responding to my late request for this blog post. I know both of them have been extremely busy between dealing with COVID-19 concerns among people supported and provider agencies and the unveiling of the proposed DIDD Integration Plan. Thank you to you both! As always, if you have questions or concerns, please email me at janet.shouse@vumc.org, and I will strive to get answers. Thanks for reading!

Jordan Allen smilingJordan Allen is the deputy commissioner of Program Operations for the Tennessee Department of Intellectual and Developmental Disabilities. Allen has career experience spanning nearly 25 years, within multiple state service delivery systems, supporting persons with intellectual and developmental disabilities as well as persons with behavioral health diagnoses. These experiences include direct supports, development and implementation of Quality Assurance and Improvement strategies across multiple service systems, executive leadership within the private not-for-profit sector and senior and executive leadership within state government.  Allen has been a champion of community integration strategies, vocational training and integrated employment supports for persons with disabilities.

July 21, 2020

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