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    • About Us
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News

ARTICLE

Date ArticleType
5/21/2015 Professional Interest Sections

Preparing for Change in Residential Services: The New RHS Daily Rate
Member agency representatives on the RHS Daily Rate Implementation Work Group

 
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Background
- Rate Reform Effort Began in 2013
- Initial Work Group Charge
  - Develop Daily Rate for Residential Services
  - Address the Ratios for Day Services
- Work Group Included:
  - Steve Cook
  - Jim Van Dyke
  - Pat Cockrum
  - Jon Burlison
  - Misty Woltman
  - Jane Wear
  - Steve Sacksteder
  - Tracy Mitchell
  - INARF Staff

Purpose/Goals
- Current System:
  - Administratively Cumbersome
  - Focused on Inputs
- Daily Rate Approach Intended to:
  - Shifts Focus to Outcomes, Quality & Satisfaction
  - Reduce Administrative Complexity
  - Streamline Billing and Documentation
  - More Attention to Consumer Experience
  - Increase in Natural Supports

Rate Development
- Available to individuals who are
  - Assessed as an Algo 3, 4, or 5 and
  - Live with housemates and sharing staff
  - Live outside the family home
- Rates Established, as follows: 
             Grid Hours Based on Algo and Living Situation 
         X Current Hourly Rate 
             Residential Habilitation Daily Rate

- RH Daily Rate "Grid"
Service
Description
Nat'l Code Mod 1 Mod 2 Mod 3 Mod 4 Rate Unit Size  ALGO Level People in Setting  INsite Sub_Code
 RHS Daily Level 1  T2016 U7 U5 UN UA $155.29  1 Day  3  2 RD32 
RHS Daily Level 2  T2016  U7  U5  UN UB $219.00  1 Day 4  2 RD42
 RHS Daily Level 3  T2016 U7  U5 UN UC $238.92  1 Day 5 2 RD52
 RHS Daily Level 4  T2016 U7  U5 UP UA $155.29  1 Day 3 3 RD33
 RHS Daily Level 5  T2016 U7  U5 UP UB $201.09  1 Day 4 3 RD43
 RHS Daily Level 6  T2016 U7  U5 UP UC $219.01  1 Day 5 3 RD53
RHS Daily Level 7   T2016 U7  U5 UQ UA $145.34  1 Day 3 4 RD34
 RHS Daily Level 8  T2016 U7  U5 UQ UB $187.15  1 Day 4 4 RD44
 RHS Daily Level 9  T2016 U7  U5 UQ UC $199.10  1 Day 5 4 RD54

Move to Implementation
- Assembled Implementation Work Group
  - Familiar with Day to Day Realities
  - Understand BMR, BRQ, and related processes
- Work Group Includes:
  - Margie Cantey
  - Amy Flint
  - Chrissie Biek
  - Cheryl Schade
  - Danielle Blake
  - Peter Zubler
  - Holly Piggot
  - Jacque Pulling
  - Pat Cockrum
  - Steve Sacksteder
  - Jon Burlison
  - INARF Staff

Reimbursable Activities
- Assistance with acquiring, enhancing, and building natural supports
- Working with participant to meet ISP goals
- Training participant to enhance home-making skills, meal preparation, household chores, money management, shopping, communication skills, and positive behavior
- Provision of transportation to fully participate in social and recreational activities
- Provision of transportation to community employment and/or volunteer activities
- Coordination and facilitation of medical and wellness services to meet the healthcare and wellness needs
- Individual must be present and receive RHS Daily services for at least a portion of any day the provider bills
- Electronic Monitoring

Limitations
- RHS Daily Provider may not provide more than 10 hours/mo of CHIO to individual
  - Exception process for instances where CHIO is the primary component of an individual’s day due to medical or behavioral reasons
  - Upon conversion, RHS Daily provider CHIO will be capped at 10 hours.
     - Remaining balance under the DAYS Reserve if any will remain on plan with Provider TBD.
     - IST determines how to proceed – i.e. exception, select new provider, reconfigure services
- BMR will not be considered or granted for loss of housemate(s).
  - IF 2 person setting, individual remaining transitions to RHS20 Default. If needed, team can seek BMR
  - If +2 person setting, individuals remaining adjust to Daily Rate Grid based on new living situation.
    - Provider and Case Manager will have duty to timely report housemate changes
    - If additional support needed, team should first consider BRQ, then consider transition to RHS20 and seek BMR.
- BMRs will only be considered for extraordinary Health and Safety or Behavioral Issues.
  - Use the newly published BMR policy and procedure
  - When approved, individual will transition to RHS20 with BMR for duration of the temporary, extraordinary support.
- Providers will not be reimbursed separately for Electronic Monitoring. If used as part of RHS Daily, must adhere to EM Service Definition
   - Provides flexibility and options in considering how to use resources associated with the Daily Rate to support the individual’s identified goals and desired outcomes
- Providers may not bill for RHS Daily reimbursement for
  - When staff/paid caregiver is asleep
  - When participant is admitted to hospital
    - Can be billed on the day of a hospital admission and day of discharge, if services provided on these days.
- Activities Not Allowed
  - Services to individuals in Structured Family Caregiving
  - Services that are available under Medicaid State Plan

Board Identified Issues
- Individuals with authorized services above the daily rate grid for their Algo level and setting size
  - Individuals with special rulings or identified with extraordinary support needs will not be converted.
  - Request to advise providers of who is in or out of daily rate, prior to implementation.
- Addressing individuals who shift resources from Other Allocation to DAYS Reserve
  - Work Group completed significant analysis of individuals who budgeted over the DAYS Reserve
  - After analysis, only about 700 individuals appear to actually utilize above the DAYS Reserve
  - Notification to be sent to Case Manager and DAYS Provider(s)
  - IST determines how to proceed
    - reconfigure services to fit within DAYS reserve
    - request exception due to qualifying event

Other Considerations
- Sites with Daily and Non-Daily Individuals
  - Mix of Rates, but all DD-Model Waivers
  - Mix of DD-Model and Aging-Model Waivers
- RHS Daily Rate and PA Services
- Transportation and RHS Daily
- Wellness and RHS Daily
- Finalizing Documentation Standards
- Still Waiting for CMS Approval
  - Target Implementation Date 07/01/15

What To Do Now?
- Review current supports for those you serve
  - With the greater flexibility offered by the daily rate, are there opportunities to consider options / approaches that increase flexibility within the setting, promote greater independence, and facilitate natural supports?
- Is the individual receiving more than 10 hours of CHIO from the residential provider?
  - If so, how / why is the service being used?
  - What is the expected outcome for the service?
  - What alternative service options / approaches could be used to achieve this outcome?
  - Have they been tried? If so, what was the result?
  - Is an exception needed? If so, what documentation is needed?
- Is the individual shifting resources from OTHER to DAYS Reserve?
  - If so, how / why is the service being used?
  - What is the expected outcome for the service?
  - What alternative service options / approaches could be used to achieve this outcome?
  - Have they been tried? If so, what was the result?
  - Is an exception needed? If so, what documentation is needed?
- Other Considerations
  - Ensure living situations are accurate in Advocare
  - Consider impact on DAYS Providers
  - Case Management Perspective

Final Thoughts
- Not just a change in billing practice or a means to reduce administrative complexity – though it does accomplish both.
- Not intended to maintain services where they are today – though can if consistent with the individual’s needs.
- Opportunity for teams to work collaboratively to
  - use good person centered planning practices
  - identify appropriate expectations to ensure health and safety and 
  - support the individual in building a valued life.
- Proof of the change is not in counting inputs, but rather the outcome of the effort –the individual is healthy, safe, and living a life consistent with their values and expectations.

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