Services My Way Request for Information: Summary of Responses February 2021

Executive Summary

In November of 2020, the Department of Health Care Finance (DHCF) published a Request for Information (RFI) to solicit information from interested parties regarding the policies, operation, and oversight of the Medicaid Participant-directed Services (PDS) program known as Services My Way. DHCF greatly appreciates the feedback stakeholders provided in order to improve the PDS program and beneficiary experience. The RFI respondents, comprised of organizations operating Medicaid PDS programs across the country, suggested improvements in the following areas: enrollment process, budgeting and authorization process, communication and education.

The District’s PDS program has grown very rapidly since its inception in March of 2016. The program currently has over 1,100 participants, which is more than five times the original forecasted enrollment. The program’s unexpected growth yielded operational pressures and revealed many opportunities for improvement. These opportunities allow DHCF to explore possible innovative solutions at different levels of the program: contractual, systems, and administrative.

At a higher level, DC Medicaid is undergoing several program-wide changes in order to deliver services in a cost-effective manner while improving health outcomes. These changes range from transitioning into new service delivery models to implementing new technologies like Electronic Visit Verification (EVV). The dynamic nature of the Medicaid program in the coming years calls for flexible solutions that will stand the test of time in this ever-changing healthcare environment.

Respondents underscored the importance of implementing new technologies and system solutions to improve efficiencies in the various areas of the PDS program. Respondents noted that PDS participant enrollment would be one of the areas that benefited the most. Respondents proposed investing in a cloud-based system that integrates live data feeds for enrollment status, eligibility, prior authorizations, and payroll information. This system would also serve as a process tracker accessible by participants so that they can track their enrollment in real time. One respondent commented that a potentially more- immediate solution would be to make all the enrollment forms electronic with the ability to pre- populate demographic information.

Respondents suggested investing in technology-based solutions to improve the budget and authorization processes. Respondents proposed automating the budget process by integrating it into a rules-based IT system. One component of the proposed system would be the ability to generate automated utilization reports to prevent overspending. Another suggestion was acuity-based budgets (i.e., a set number of preformed budgets that only require certain selections). All respondents agreed that the budget template should be simplified to the greatest degree possible. One respondent suggested that combining the sick leave and participant-directed care services prior authorization into one will lead to faster processing.

When asked about communication and education, all respondents suggested making all content as simple as possible. This includes trainings, educational resources, and forms. Respondents suggested that trainings be broken out into multiple sessions to reduce the volume in information presented on complex topics like EVV. Respondents also suggested the program provide the material in a variety of formats (webinars, Q&A sessions, video-graphics, and one-pagers). Respondents highly suggested distributing one-pagers that outline the responsibilities of each organization involved in the PDS program. Increased staff training and competency development were encouraged for case managers and support brokers.

Other noteworthy proposed solutions include the following:

• Simplification of the background check process, potentially by transitioning responsibility for the program
• Personalized trainings that are conducted in-person, via phone, email, or video conference depending on participant’s preference
• Implementation of a performance-based payment model for the FMS/EA vendor.

A detailed report of responses received by topic is displayed in Table 1 in the pages that follow.

Table 1: Summary of Request for Information Responses – December 2020

Questions   with Synopsis of Responses

How can the enrollment process be improved or streamlined?    

• Electronic enrollment packets that are pre-populated with the participant’s demographic informationbefore orientation
• Participants sign all forms as they review them with the support broker during the initial visit
• Streamline onboarding by having the case manager develop the budget during the development of the PCSP (prior to orientation and enrollment)
• Once approved, phone contact to communicate approval to minimize start delay
• Updating all participant forms to read no higher than a 6th grade level
• Consider providing participants with FAQs and training videos
• Simplify budget format
• Consider online certification for PDWs that need CPR/First Aid training
• Cloud-based portal that houses all participant-related data; IT system that tracks every step from intake to payroll

What documentation / forms may be eliminated without inviting risk to the program’s integrity or management?

• Voluntary Participant Termination Forms
• Justification for PDS Budget Modification Request
• Combine Participant Consent Form and Participant/Representative-Employer Agreement to eliminate redundancies between the two forms
• Consider collaborative effort including program staff and vendor to review forms and decide what needs to be revised or eliminated

How can PDS programs balance beneficiary / PDW enrollment experience with program needs?    

• The following recommendations were made for improving the enrollment experience:
• Ensure that all materials are written at a 6th grade reading level when possible and format to improve readability
• Personalized trainings that are conducted in-person, via phone, or video conference depending on participant’s preference
• Provide training webinars, quick start rack cards, one-pagers, and animated videos; variety of formats makes information more digestible for participants

 
What mechanisms could streamline the issuance of prior authorizations?    

• Automating the budget process by integrating it into an IT system
• Acuity-based budgets (i.e., 10 preformed budgets that only require certain selections, not infinite combinations of hours, staff, wages, etc.)
• Simplifying the budget template
• Issue one prior authorization that account for the cost of sick leave and participant-directed community supports

Are there ways the District can adopt process modifications reflecting best practices from other states to improve the PDW qualification process?    

• In other programs, centralizing the background check and having the PDS vendor perform this task streamlined the enrollment process and eliminated confusion
• Providing prospective PDWs with a list of disqualifying offenses before they complete a background check
• Consider working with DC Health to allow a grace period in which the PDW can work before a background check is complete

Do other PDS programs use a guidebook that explain the program in detail? If yes, is it a helpful training document?    

• All respondents agreed that other PDS programs use guidebooks and provided the following feedback:
• Supplementing the guidebook with training materials/educational resources is essential
• Have materials that clarify FMS processes
• Webinars, trainings with interactive question-and-answer period, one-pagers, user guides, rack cards, informational videographics
• Helpful when written at a low reading level
• Include a lot of images/graphics and bullets rather than lengthy text

Are there any specific training activities or documents that have been particularly successful in other states or programs?    

• Simple materials that explain EVV and payroll
• Different of types of material (recorded webinars, recorded process instructions, and videographics) that break down program processes
• Materials should incorporate graphics
• Group education sessions
• FAQs

How can DHCF clearly educate the community on the various roles in PDS, from DHCF to the vendor, the case manager and even the participant?    

• Increased training for case managers and community as a whole
• Keep information on website simple
• One-pager highlighting the differences between traditional agency-based services and the PDS programs
• One-pager that outlines the stakeholders in the PDS services and a list of their responsibilities

How can PDS programs implement effective oversight of utilization, enrollment, and other program operations to ensure they remain effective stewards of public funds?    

• Leveraging IT systems to automate reports and processes
• Automated utilization report to monitor spending
• More trainings for participants
• System solutions that house all data in one place

How do payment structures differ in different states’ programs? Does one payment structure appear easier to manage or to offer more benefits for a wider array of stakeholders?    

• Performance-based payment structure that outlines specific milestones and compliance metrics for the vendor to achieve before payment is made, penalizing missed milestones and non-compliance

How was the PDS program designed during MLTSS contracting or program planning in order to preserve existing PDS philosophy and design? How much flexibility was given to the MCO to alter certain program practices or processes?

• MCOs are relatively new to self-direction; state agencies should consider a person-centered philosophy training for all MCO staff involved in the PDS program
• MCOs may bring certain efficiencies and technological advances to improve programs
• Involve stakeholder input whenever possible
• Ensure there is still a strong channel for communication between the PDS vendor and the state
• Please describe successful strategies, and any recommendations for, continued education and training on EVV within self-direction. 

Is there a training plan or schedule found to be the most helpful, such as written instructions, webinars, a dedicated support line?    

• Five trainings a week for six weeks and then refresher trainings twice a month
• Variety of materials (webinars, Q&A, video-graphics, written materials) all available on website (centralized location)
• Dedicated phone lines for technical support
• Allow experimental period where participants can test out the new system
• Provide multiple avenues for participants and PDWs to reach out for assistance or provide feedback

Are there clear best practices to decrease the need for visit maintenance in EVV? Is there a threshold for errors a participant or their worker should be allowed prior to a notice of non-compliance and/or requirement to return to traditional home health care services?    

• First and second demonstration of non-compliance could result in a notice sent to require additional training and call for case manager’s intervention; after third demonstration of non-compliance another notice is sent and the state/MCO decide if self-direction if the right fit for the participant
• EVV is new for most states. Errors by participants and PDWs are to be expected, especially during the transition period

In programs using EVV for more than six months, was there anything the program might have done differently in hindsight?    

• Break up training into two or more separate sessions so the volume of information is more manageable; feedback given from attendees said a single training had too much information
• Outreach campaign to contact participants who haven’t attended training on a monthly basis
• Early communication
• Having PDWs and participants confirm contact information
• Integration of EVV functions into existing systems that process claims data
• Automating the billing process and fostering a streamlined claim lifecycle
• Provide a member advocate who uses the system available to provide support to participants