INABC Professional Liaison
Announcements, Questions and Answers:
PCISP, Systemic Changes and Related Notes
At the last INABC meeting we discussed some of the “growing pains” if you will, regarding recent systemic changes including 1) PC-ISP process, 2) Transition from Advocare for doc management to something else and 3) The loss of structure leading to a need for clarification for therapeutic supports. Since our meeting I have also had a few complaints about BC’s having their services drastically reduced or eliminated because the case manager is advising “that is a really expensive service – you can get more of something else.”
After good discussion with our partners at DDRS, I feel like it is fair to offer the following statements – I have also tried to include some valuable references:
- The PC-ISP process is not just a shift in the “how” we do things – but really changes the culture and puts the focus on “why “ we do it – and that is to empower desired life change for the individual in supports. Understand this is not what the staff, family, or the case manager finds important. This is about the INDIVIDUAL that you support. We are not the “providers” of this goal accomplishment – but the “provider” of supports to help them achieve those goals. For example – one comment was that Case Managers are saying that “goals are directional – not habilitative.” This again is a cultural shift. Goals should be directed by the individual – who does that person want to be, what do they want to accomplish, what supports and natural supports do they need in place to accomplish those goals…..to go that direction. There are some great links that you should fully explore if you are not completely understanding the new PC-ISP process. Here is the link to the PC-ISP GUIDE https://www.in.gov/fssa/files/PCISP%20Guidelines%20v3.6%20FINAL.pdf Additionally if you go to this page – you will see a number of helpful resources! https://www.in.gov/fssa/ddrs/5437.htm
- There is concern of where the “accountability” entity is….ie, if we are not relying on document uploading and case managers as a “watch dog” how does this impact the role of BQIS and what we are doing. If you want to read some exciting Indiana Administrative Code – you can see here that BQIS is mandated by code: http://iga.in.gov/legislative/laws/2017/ic/titles/012#12-12.5 Essentially – BQIS’s job is to monitor services to individual by organizations and providers under the authority of DDRS. This essentially applies to all providers who have entered into a provider agreement with the state to provide Medicaid funded in-home waiver services. Essentially our first priority is to provide supports ethically and in line with best practices within the guidelines provide in BMAN services.
- If you are unsure of anything in the waiver program – this is a great link to have on your computer desktop: http://provider.indianamedicaid.com/media/155628/ddrs%20hcbs%20waivers.pdf as this will always give you the most up to date Waiver Manual. Essentially if something is not working – and the team level has failed, BQIS uses the complaint process and the Incident Reporting date to further monitor outcomes. The entire system is NOT INTENDED to be a “gotcha” system but is intended to monitor appropriate outcomes are occurring at the point of service delivery. In other words – that the individual has a team that is effectively working together to help them become the person they want to become. I would hope we can get to the point where we are working harder at doing the right thing than we are worrying about who is watching. Understandably there is a lot of liability within the area of Behavioral Management Supports – as you, as a clinician, are relied upon to understand the complexity of rights, dignity of risk and helping to keep people safe. It is typically when we are outside the scope of our expertise or we are relying on restrictive interventions (calling the police, etc) that our effectiveness or value is called into question.
- Over all, people establish their goals/desires through the PC-ISP process. There is an identification of what stands in the way of them achieving those goals. Those “needs” are identified and might be met by supports (both natural and paid) who will focus on their strengths to achieve these goals. These relationships are all by CHOICE of the individual.(Personally, as a clinician I suggest someone might need BMAN when they have (a) behaviors that are harmful to self/others, (b) behaviors infringe on the rights of others, or (c) who have symptoms of a psychiatric diagnosis that require psychotropic medications.) If BMAN supports are being cut and you feel it is not in the best interest of the individual – or the client is being manipulated to make decisions that they don’t completely understand – you should always handle this through the team process. If that does not resolve the issue, then you can use the IR or complaint system through BQIS.
- DDRS does not endorse or support presenting a service or services merely on their cost/price merits, but whether or not the service or supports will serve to meet the individual’s overall goals. This is also not how the PCISP planning process was outlined to case managers last fall. That training is available online, and the abbreviated training is available as well. Families and providers are encouraged to watch it to learn more about the planning process so they are educated and aware of the best practice case managers should be applying in the planning of someone’s services and supports. https://indiana.adobeconnect.com/p9h4yybijad1/?launcher=false&fcsContent=true&pbMode=normal
- Lastly – the absence of Advocare as a “holder of the documents” will at some point in the future be replaced by a system that is more comprehensive and efficient. Yes, keep doing your job in a timely manner. Assure you are completing processes according to the guidelines set forth in 460 IAC 6 and DDRS policy. If you are doing that – and sending appropriately to team members – then you should be good to go.
At the end of the day – if any of us were fully immersed in all the moving parts and influences on the system – it would make us crazy. There is Medicaid, the specific HCBS rules, the forthcoming and evolving CMS mandated settings rule, law, code, policy – and so many state and federal guidelines that dictate how these things have to all work together to meet the needs of the people in our system, in the fairest, most cost efficient, least restrictive method. It is overwhelming and sometimes the system gets bogged down in it. Rest assured – I feel like this DDRS team is doing all that they can to make the right decisions.
As always if there is anything I can do to help you or can answer questions, please do not hesitate in letting me know!
BMAN in School Settings
After our conference, I had some questions asking for clarification regarding service delivery of BMAN supports in the school setting. Based on feedback from DDRS, I wanted to share the following:
Providing direct BMAN supports TO the student, in the school setting is not reimbursable. However, in looking at the service definition, some activities engaged in by behavior providers in the school ARE reimbursable. For example, behavior services specifically for the purpose of observing the participant in that environment for the purpose of conducting the functional behavioral assessment, and developing the BSP would be permissible.
Behavior providers could also bill for training of school staff (‘other appropriate individuals’) for the implementation of the behavioral support plan, but that activity could not occur during the actual school day.
“Consultation with team members” is also permissible – but overall be mindful that the Waiver Manual notes the following is an “Activity Not Allowed: Therapy services furnished to the participant within the educational/school setting or as a component of the participant’s school day.”
For further information on definitions reference: http://www.in.gov/fssa/files/DDRS_Waiver_Manual_Fall_2012.pdf
Go to page 11 in section 10 for BMAN!
I hope you find this information helpful – if you have questions, certainly let me know.
Indiana Service System Analysis
It is an exciting time for the people we support across the state. As I shared at our annual conference, the Indiana Service System Analysis was completed by the Institute on Disability at the University of New Hampshire. Thank you again to all who participated in the data collection, focus groups, and sharing of information – we were able to gather expansive input from about 1400 stakeholders statewide.
This report has now been cleared for public circulation and is attached to this Email. Now that this has been shared with key legislators and Dr. Wernert, Secretary of FSSA, the DDRS staff are looking for the best ways to address these gaps while maintaining the strengths of our current system. INABC will be an integral voice in how this moves forward.
Should you have questions after reviewing this report – please do not hesitate in letting me know.
Kelly Hartman, MA
Professional Liaison, INABC
IMPORTANT: New CMS rules re: 1915c Waivers
As I mentioned briefly at our recent conference – there are new rules issued from CMS that will change the way that Indiana waiver providers deliver supports. With all the things out there for “public comment” from DDRS it may seem confusing…..essentially the new rules (included in the ACA,) ask that states with 1915c waivers (both CIH and FSW here in Indiana) have a transition plan to address how we, as a state, will be fully compliant in a five year period.
Coincidentally – both of our waivers are also up for renewal….so as you sort through these changes, it is helpful to know that DDRS has begun to show our steps toward transition in our these proposed renewal docs. YOUR VOICE is important – please carefully consider how this will impact our service delivery model and the ultimately the lives of the people we support. Please take time to make public comment.
I have read and deciphered several documents out there that describe the changes required by the new rules – and watered it down into some basics that will be helpful for you to understand. I have included this in the attached document. If you are really jazzed and want additional resources – you can also go to:
Understanding these foundational building blocks for changing the culture from a national perspective (federal rule,) I hope you will better understand WHY some of the changes in our waivers are being proposed. Overall – I think these changes are positive – but as we all know, change is difficult for large systems sometimes. Most importantly – I want you to have every opportunity to be informed.
As always please do not hesitate in letting me know if there are questions.
Kelly Hartman, MA
Professional Liaison, INABC
Liaison Report October 2014:
There have been a lot of inquiries regarding solicitation, especially when a BC changes employment from one provider agency to the other.….After collaboration with DDRS, I hope this will provide some clarity:
Professional Liaison Clarification / Answer:
The number one driving factor is client choice…. We also have to consider that there are differences between issues of “employment” and issues of “contractual obligation” under the waiver. Undeniably in a “human” service….there are relationships built that are client to professional specific. For example – the emotional connection to either a BC can be immense – in that, our role as professionals, is to champion success and advocacy for that client. This should be respected without regard for issues of specific agency employment.
For example – let’s say a Billy BC leaves AGENCY A as an employee and goes to AGENCY B.
- 1. If there is a non-compete or employee contract – that agreement is between the employee and their previous employer. Therefore, it is Billy BC’s legal responsibility to act in good faith on that contract.
- 2. If a family/individual inquires with AGENCY A…. “Where did Billy BC go, I want him to continue working with me/us?” Although there is nothing saying that the agency is not able to inform that family – they are not obligated to report the employment choice of their previous BC.
- 3. If the family/individual calls the case manager and asks, “Where did Billy BC go, I want him to continue working with us?” that the case manager should in fact (if they know) inform the family. It is not the case managers responsibility to advocate for any agency involved….but to advocate for the right of the client who is expressing their desire for a choice of service providers.
- 4. If Billy BC leaves AGENCY A…..and the client/guardian wishes to stay with AGENCY A, then they should be afforded the opportunity to choose a new BC within AGENCY A. It is up to the client/guardian whether they would like to interview more than one BC, or allow the leadership to offer an appropriate alternative.
- 5. If a family/client contacts Billy BC directly and says “Where did you go, I want you to continue working with us?” Billy BC is not obligated to keep this a secret – unless Billy BC has entered into a legal agreement stating otherwise.
- 6. Under NO CIRCUMSTANCES is Billy BC allowed to contact the families verbally or in writing, or inform their previous clients of their employment change. Once Billy BC leaves AGENCY A – they should also “lose” all client contact information that is protected by HIPPA. That information is confidential and is the “property” of the agency who holds the contract for service. Any action otherwise would be considered SOLICITATION.
At the end of the day, CMS and the intent of the 1915c waiver program(s) prioritize client choice in service provider, here are some technical references that maybe helpful from the waiver application:
Appendix D: Participant-Centered Planning and Service Delivery
D-1: Service Plan Development
Informed Choice of Providers. Describe how participants are assisted in obtaining information about and selecting from among qualified providers of the waiver services in the service plan.
An electronic database is maintained by the operating agency that contains information regarding all qualified waiver providers for each service on the Community Integration and Habilitation Waiver. Case Managers are able to generate a list of all qualified providers for each service on the waiver for the participant’s use. Case Managers can assist the participant with interviewing potential providers and obtaining references on potential providers, if desired by the participant.
The participant can request a change of any service provider at any time while receiving Community Integration and Habilitation Waiver services. The Case Manager will assist the participant with obtaining information about any and all providers available for a given service.
Case Managers are not allowed to give their personal or professional opinion on any waiver service provider. The case manager is responsible for the coordination of the transition of a provider once determined by the participant.
What is the best approach when an emancipated client tells us they would like to have more freedom, less staff coverage, and more control over their lives? ….especially when the residential provider at the table takes the position that they are unable to do this because the client needs “24/7 support”….this also sometimes happens for individuals who do not have 24/7 support.
Professional Liaison Answer:
I have talked directly with DDRS about the “abuse and neglect” question and surrounding confusion. Unfortunately, in some cases, from the provider perspective – often looking more at liability and bottom line, keeps them from maintaining the perspective of “point of service delivery.” Here is a synopsis of our discussion:
Basically this is HOW IT SHOULD WORK – getting back to the basics:
In the team meeting – and also supported in your BMAN notes, and probably the FBA……document the individual’s desires with regard to needed services. The waiver program is not an ENTITLEMENT program. Because someone’s needs dictate an ALGO 3 and affords the allocations associated with that data…..does NOT mean the client is not able to make informed decision, and use LESS than the budgeted services. That individual should be able to CHOOSE what they desire in terms of service. If the individual is emancipated and can give informed consent – they get to make choices about their own lives….whether we think those are the right decisions or not…..is really irrelevant. We can train toward making safe decisions that involve little risk to the individual….but we are NOT allowed to restrict their right to choose based on our own bias.
In the case of 24 hours supports…Quite frankly ALGO3 or higher was intended to mean that the individual “requires” (again based on their data) 24/7 supports. HOWEVER – it is understood that this is in a shared setting. Again, I would still assure that the INDIVIDUALS needs/desires are the driving force of what happens. And from a legal perspective…for an emancipated adult – no team has the legal right to restrict choice – unless of course there is clear evidence of harm to self or others – in which case you can continue to offer support and training, but the team cannot restrict those choices….even if it doesn’t jive with our values.
2014 INABC Professional Liaison:
Kelly Hartman, MA
Insights Consulting, Inc., President & CEO
Outside the Box, Inc., President of the Board
Professional Liaison at Indiana Association of Behavioral Consultants
Kelly has been working with people with developmental disabilities for over 20 years – most specifically with those who have behavioral challenges. In 1996, Kelly started her own consulting firm, Insights Consulting, Inc., which provides behavioral and residential support to individuals with developmental disabilities.
Professionally, Kelly has been named Indy’s Best & Brightest Young Professional in Health and Life Sciences and was honored by the YWCA for being a Woman of Achievement. She is a member of Indiana Association of Rehabilitative Facilities (INARF) and the Arc of Indiana. She was the founding President and has served as Professional Liaison for the Indiana Association of Behavior Consultants since 2006. It is her passion to help people achieve better outcomes in life and by building on what a person CAN do through teaching a non-aversive, person centered approach to personal success.
Kelly received her education at Ball State University in Muncie, Indiana where she earned a Bachelors of Science in English in 1989 and Master of Arts in Counseling and Psychology in 1991.
More about the INABC Professional Liaison Position:
In 2007, given the need for a clear point of contact for the association’s ongoing interactions with representatives of state government, and other industry advocacy organizations, the members of INABC voted to appoint a Professional Liaison. The primary responsibility of this role is to act on behalf of the greater good of all people with intellectual and developmental disabilities, as well as protecting the interest of all behavioral consultants who support them.
While primary partnerships are maintained with INARF, The Arc of Indiana and The Division of Disability and Rehabilitative Services, the Professional Liaison is also available, and often advocates, for our profession with regard to legislative issues, best practice and quality assurance.
Current assignments unique to the role currently include involvement with; DD Advisory Council, DDRS Director Stakeholder Group (formerly known as the Advocates Group) and The Arc Health and Wellness Legislative Committee.
INABC recognizes that the role of Professional Liaison is not a full time job, nor does it preclude the appointed liaison from engagement in independent professional endeavors in his or her own right with his or her own agency affiliations. INABC expects that the Professional Liaison will be clear to every audience about who he or she is representing at all times.
Periodic Reports, Notes and Updates:
** [TBA links to PDF files / reports from Liaison to membership]
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