Overview of Clinical Criteria Changes S. St. Francis Drive Santa Fe, NM Phone: Fax: nmhealth.
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- Harriet Heath
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1 Overview of Clinical Criteria Changes
2 Objectives 1. Understand changes to the Clinical Criteria (CC) document as a whole 2. Understand how discontinuation of the SIS affects Budget Guidelines 3. Development of Clinical Criteria Changes and Stakeholder Input 4. Starting with Person Centered Planning 5. Review of Proposed Budget Levels Process
3 General Changes to CC Remove language related to SIS and NM DDW Groups included in Family Living, BSC, CCS, CIE, SL, Non Ambulatory Stipend Incorporate memos and guidance since the last issue (June 15, 2015) Remove DDW Standards and provider requirements from the CC Minor clarifications in most services
4 General Changes to CC Format for Each Service: Description of service and overall intent of service Bulleted criteria Additional Required Documentation Applicable limitations on amounts, frequency and availability
5 Discontinuation of the SIS Issues that need to be addressed: Budget amounts are currently proposed/suggested based on DDW Group Assignments Tiered rates for group service models have been tied to NM DDW Group assignments Core Budget Amounts for Behavior Support Consultation have been tied to NM DDW Groups
6 Values and principles behind the decisions 1. Simple, transparent, fair and consistent 2. Timely implementation/feasible by July 1, Use existing information, team input, and information from multiple sources 4. Fiscally responsible 5. Accountability to Centers for Medicare and Medicaid Services 6. Consistent with current process as much as possible.
7 Stakeholder Input October 2016 through May 2017 included presentations to : Letter to field and individuals ACQ: Policy and Quality (P&Q) Subcommittee OR Implementation Group Case Management Advocacy and Action Council (CMAAC) Case Management Directors Preview Webinar with Invitation to comment (May 2017) Association of Developmental Disabilities Community Providers (ADDCP) BWS Beta Testing
8 Comments from Partners and Individuals. Association of Developmental Disabilities Community Providers Advisory Council on Quality Behavior Therapy Association Case Management Advocacy and Action Council Disability Rights New Mexico Developmental Disabilities Planning Council Direct Therapy Services Survey Monkey and Individuals Nursing Community of Practice Beta Testers (Budget Worksheet)
9 Made clarifications and changes including: Description of nursing, BSC, Person Centered Planning, and other minor edits Review of Current Rate Assumptions in the Training Corrections to Budget Worksheet during Super User Beta testing
10 Reminder Everything starts with Person Centered Planning
11 Person Centered Planning Person Person- Centered Assessment Individual Service Plan Person-Centered Thinking Person-Centered Planning Person-Centered Practice
12 Finding the Balance What is important to this person What is important for this person Assessment Person-centered planning meetings Writing the person-centered plan (Individual Service Plan) Reviewing the person-centered plan
13 Person-Centered Planning ISP *The ISP should reflect what is important to the individual to ensure delivery of services in a manner reflecting personal preferences and ensuring health and welfare. *Waiver Supports and services are provided only to the extent there is a demonstrated individual need and link to the ISP.
14 Proposed Budget Levels 1-7 Written descriptions of 7 levels that do not rely on the SIS assessment results Descriptions are essentially the same, based on the same characteristics
15 Suggested Budget Dollar Amounts: Budget Level Assumptions Suggested budget dollar amounts are based on the type of living care arrangement, assumptions about types and amounts of services, intensity of staffing needs, and support needs in each level Dollar amounts and rates are the same OR continues to approve services based on clinical justification AND approvals may be over or under the suggested amount
16 Process: Proposed Budget Levels and Developing a Budget Case Manager guides team in Person Centered Thinking IDT looks at descriptions of Proposed Budget Levels IDT makes determination of which level an individual falls based on history, assessments, and support needs IDT uses both Proposed Budget Level and Suggested Budget Dollar amounts as a tool/ guide
17 Proposed Budget Levels and Developing a Budget PBL s are a tool to guide the budget development process The dollar amounts and services associated with the PBL were designed in 2012 to meet the needs of most individuals The OR does not verify or approve of the IDT s determination of a PBL The PBL does not limit the request for services or require that the budget be developed within a set amount
18 Process: Proposed Budget Levels and Developing a Budget Person Centered Thinking Preserve rights and choice Budget must be linked to implementation of the ISP When disagreement in IDT prevent decisions that are program centered versus person centered
19 Program Centered Decisions that Can Affect PBL Determinations by the Team Backing into dollar amounts first Arriving at the ISP meeting with completed Desired Outcomes before the person s Vision has been fully developed and the Vision Analysis discussion has taken place Basing someone s described level of need on whether they fit nicely into the way the program traditionally operates daily schedules and transportation.
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