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FY 2012 Performance Measures: Department of Health Care Finance (DHCF)

Agency Mission:

The mission of the Department of Health Care Finance (DHCF) is to improve health outcomes by providing access to comprehensive, cost-effective and quality healthcare services for residents of the District of Columbia.

In addition to the Medicaid program, DHCF also administers insurance programs for immigrant children, the State Child Health Insurance Program (S-CHIP or CHIP) and Medical Charities (a locally funded program).

DHCF’s evolving Olmstead Initiative is a reflection of its commitment to providing a continuum of high quality long term care services and supports for all Medicaid beneficiaries who have a disability. The need for an Olmstead Initiative that evolves is based on the principles of “continuous quality improvement” - an approach to improving health care that emphasizes meeting (and exceeding) consumer needs and expectations, and using scientific methods to continually improve care.


The new DHCF Administration has identified the need for a comprehensive DHCF plan for providing services and supports to individuals with disabilities in the most integrated setting appropriate. In FY12, DHCF plans to build upon and strengthen existing Medicaid programs and assess the advantages of providing services through alternative strategies made available to states, territories, and the District of Columbia under federal Medicaid laws.

Vision:

Provide services and supports to all Medicaid beneficiaries who have a disability, in the most integrated setting appropriate, through a continuum of high quality long term care services and supports in accord with a comprehensive plan that:

  • Involves Medicaid beneficiaries with disabilities in the design of the long term care system;
  • Provides access to a broad range of high-quality long term care services and supports through a network of providers to meet the needs of eligible beneficiaries;
  • Provides care more efficiently, through ensuring program integrity, while maximizing federal resources; and
  • Strengthens the partnership between DHCF and a broad network of quality providers, as well as with other government agencies, to expand healthcare services.

FY 2012 Community Integration (Olmstead) Initiative Outline:

In FY 12, the Initiative will address:

  1. Initial analysis of the needs of persons with disabilities in the DC Medicaid program, a review of barriers and the drafting of policies and procedures;
  2. Restructuring and realigning Medicaid personnel and resources to provide stronger focus on community-based long term care services and supports and the quality of those services;
  3. Review of the performance of the array of community-based long term care (CB-LTC) services and supports in the Medicaid program; and
  4. Development of a 12-month work plan for strengthening the safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity of long term care services1 including home and community-based long term care to prevent institutionalization and to ensure that individuals with disabilities receive services in the most integrated setting appropriate to their needs.

DHCF conducted preliminary analysis of the magnitude of need in the DC Medicaid program. The DC Medicaid program offers CB LTC services through multiple Medicaid pathways: as a benefit under the DC Medicaid State Plan; through two waiver programs that offer more intensive services to persons with physical or intellectual disabilities; and through a Money Follows the Person (MFP) initiative aimed at helping people living in nursing facilities or Intermediate Care Facilities for the Intellectually or Developmentally Disabled (ICF – ID/DD) return to the community.

The initial focus for reform was on the Money Follows the Person (MFP) program and State plan personal care aide (PCA) benefit as the PCA benefit serves the greatest number of people, incurs the greatest cost, and historically had less attention than other CB LTC waiver programs. By more appropriately deploying these services, people who need support in the community can receive it while overutilization is controlled, freeing resources to provide other critical supports.

Reform is unfolding in three phases: 1) short term actions that could be taken within 30-60 days without a state plan amendment (SPA) or new regulations; 2) more substantial modifications to existing DC Medicaid CB LTC benefits that would likely require some combination of SPA / regulations and/or contracting and therefore more time to implement; and 3) analysis of new ways to best provide CB LTC service in the future in the face of multiple delivery options.

1These six goals have been embraced nationally as the aims of good quality health care towards which all involved in health care should focus their efforts. (See IOM. 2001. Crossing the Quality Chasm. A new health system for the 21st century. National Academy Press. Available online at: http://www.nap.edu/catalog.php?record_id=10027)

FY 2012 Community Integration (Olmstead) Performance Measure:

In FY 2012, DHCF’s Olmstead performance measures will focus on MFP activities, tracking the number of people transitioned out of institutions and into HCBS waiver settings (see item 4 above). The bulk of the agency’s activities involve planning ahead. During 2012, DHCF will aid a minimum of 60 people to transition out of institutions (i.e., ICFs/MR, Nursing Homes, Mental Health Facilities) into Home and Community-Based Services waiver (HCBS) settings.

Agency Future Planning:

The foundation for DHCF planning efforts is the development of a Comprehensive DHCF Olmstead Initiative in FY 13. This will include focus on the Money Follows the Person program, as well as the continuum of other CB-LTC Medicaid benefits.

With respect to MFP, the CMS-approved Operational Protocol (OP) outlines a deinstitutionalization strategy for MFP-eligible people with Intellectual and Developmental Disabilities (I/DD) through the Intellectual and Developmental Disabilities (IDD) HCBS Waiver administered by the Developmental Disabilities Administration (DDA). In FY 2010, CMS approved the expansion of the OP to reach people who are eligible for the Elderly and Physical Disability (EPD) HCBS Waiver administered by DHCF.

Through MFP, DHCF has also been collaborating with the Department of Mental Health and advocacy organizations on strategies to transition people with mental health diagnoses from St. Elizabeths Hospital, Mental Health Community Residential Facilities and Nursing Facilities.

Agency Identified Population and the Definition of this Population:

The DHCF strategy will focus on adults (22 years old and older) who:

  1. Live in DC long-term care institutions or are at risk of institutionalization; and
  2. Receive DC Medicaid

For the target population, funding will shift from payment for Medicaid Inpatient Services delivered by institutions to payment for Home and Community-Based Services through one of three HCBS options:

  1. Intellectual and Developmental Disabilities (IDD) HCBS Waiver - Administered by the Developmental Disabilities Administration (DDA)
  2. Elderly and Physical Disability (EPD) HCBS Waiver-Administered by DHCF
  3. Rehabilitation Option of the State Plan for people with Mental Illness/Mental Health Diagnoses-Administered by the Department of Mental Health (DMH)

Agency’s Identified Barriers Unique to the Population the Agency Serves:

Perceived benefit of move. At an average size of about 6 beds, DC’s ICFs are relatively small group homes. It is sometimes challenging to convince residents, their families, other decision-makers and caregivers that a move to a home of 4 or less is beneficial.

Funding for housing. DDA funding for room and board has recently been reduced. Increasingly, it will become a challenge to support home and community-based living options for IDD Waiver recipients.

EPD HCBS Waiver Eligible

Isolation. Isolation after the move is a fear for both older and younger people transitioning from nursing homes, and it is a reality for some in the community who DHCF is connected to through existing deinstitutionalization efforts.

Funding for housing. Diverse funding sources need to be cultivated. Currently, Housing and Urban Development Housing Choice Vouchers have been identified as an option.

MH Rehabilitation Option Eligible

Community-based Housing. DHCF is working with DMH to search for available and affordable housing options that can provide the necessary supports for people who are transitioning from St. Elizabeths Hospital and from contractual Mental Health Community Residential Facilities (CRFs).