Residential Services impact by CMS' Final Rule and KanCare

Since 1968 COF has provided the standard types of residential services offered by social services providers to people across the nation with intellectual &/or developmental disabilities. COF owns residential sites in conjunction with the federal program Housing and Urban Development (HUD).  COF has eight group homes in which 24-hour supervision, supports and services are provided.  There are four of these homes in Ottawa, two in Osage City and two in Burlington. Up to 8 individuals can reside in these homes.

Additionally, through HUD, COF owns an apartment complex in Ottawa.  It consists of four units that contain a total of sixteen apartments.  Up to eighteen individuals can reside at this complex. There is also a community center on the complex where residents can congregate if they choose to do so.

Through HUD, COF also owns five homes in which up to three individuals can reside. There are two of these homes in Ottawa, one in Osage City and two in Burlington. There is one additional small group home in Burlington that COF owns that is not owned through HUD.

There are many individuals who reside in residences not owned by COF in Coffey and Osage and Franklin counties who receive residential supports and services from COF. All of the residential supports and services provided for individuals residing in the apartment complex and the smaller group homes and the residences that are not owned by COF rely on intermittent staffing supports instead of the 24-hour supervision that is provided at the larger group homes.

As of 11-20-15 COF provides residential services and supports to approximately 120 people. Though the types of supports and services that a person receives depends upon their individualized needs, they can be described in general terms after accounting for whether or not a person is relying on residential services that require 24-hour staffing or intermittent staffing.

Types of residential supports and services provided in settingsin which 24-hour care is needed:

  • Assistance with basic activities of daily living, such as: feeding; toileting; bathing; grooming and hygiene;  getting dressed and undressed; transferring to and from wheel chairs; repositioning; passing of medications
  • Helping people who are not yet ready to transition to lesser intensive, intermittent supports and services to acquire the skills necessary to be able to do so, such as: meal planning; meal preparation; money management; taking medications properly; scheduling of work and activities; adequate grooming and hygiene; relationships

Types of residential supports and services provided to people who reside in settings in which intermittent staffing is needed:

  • Transportation to and from work, medical appointments, social activities and for shopping
  • Assistance with housekeeping, menu planning, scheduling, money management and problem solving

The determination for whether 24-hour staffing supports and services or whether intermittent supports and services are needed is done through the person centered service plan (PCSP) development process which is in turn determined by assessments.  Of course, there are some people who are intellectually or developmentally disabled who will always need 24-hour care and others who will only temporarily need that level of care. COF is committed to ensuring that nobody is kept in the more expensive 24-hour care any longer than needed.

Funding for these supports is provided through a category of Medicaid funding known as Home & Community Based Services (HCBS).  It is explicitly HCBS-funded services that are being targeted by and subjected to CMS’ Final Rule. The determination for eligibility for these services and amount of funding is determined through an assessment process. These determinations are made by an entity that is independent of COF to ensure that there is no conflict of interest.  This is an important requirement of CMS’ Final Rule as explained in the opening narrative of this website (Final Rule Changes: Introduction). That entity is known as a Community Developmental Disability Organization (CDDO) which operates under the auspices of East Central Kansas Area Agency on Aging (ECKAAA). East Central Kansas Aging And Disability Resource Center | Final Rule Changes: ECK CDDO

Each recipient of COF’s residential services who receives HCBS funding has a Person Centered Service Plan (PCSP) that is specific to that individual’s wants and needs.  The contents of the plan are primarily determined by the individual, their guardians and support team.  CMS’ Final Rule alsorequires that the PCSP be under the auspices of a Targeted Case manager (TCM) who is not an employee of the organization providing the supports and services to further ensure there is no conflict of interest.

However, the PCSP is meant to be a living document.  It is to be used by the staff responsible for providing supports and services to determine what and how those supports and services are delivered. It is incumbent upon the organization that provides the supports and services to use the PCSP and adhere to its contents. This organization is known as a Community Service Provider (CSP). COF is a Community Service Provider. If COF wants to be a provider of HCBS funded supports and services it cannot determine an individual’s eligibility, the amount of their funding nor the contents of their PCSP. This is a marked departure from the way things have been done in Kansas and in many other parts of the country for years. As stated elsewhere, COF, which used to have its own CDDO and TCM unit, has separated itself from those functions because COF wants to continue to be a Community Service Provider. (Final Rule Changes: Community Service Provider).

CMS’ Final Rule calls for other changes that affect the way residential services are provided. Much of the traditional style of supports and services are being called into question by CMS’ Final Rule. If a CSP hopes to continue receiving its HCBS funding in order to provide supports and services it will have to adapt to CMS’ Final Rule. Additionally, KanCare, which was implemented to achieve optimal cost efficiencies to optimize scarce tax resources spent on Medicaid, will have an effect on the way residential supports and services are provided.

Particularly impactful to Community Service Providers (CSP’s) such as COF that own and/or operate housing in which residential supports and services are provided is that CMS’ Final Rule will subject these settings to “heightened scrutiny.”  This is being done to ensure that the CSP does not exert too much control over all aspects of the lives of persons receiving services. Every setting (e.g., group home) will be assessed.  The fundamental determination to be made will be whether or not the setting has the effect of isolating people who are disabled from people who not disabled. Even though many group homes are actually in typical middle class neighborhoods many others are located in remote locations without nearby residences. And, even though many group homes are physically integrated amongst other family homes, a resident might still be isolated or segregated in other ways.

Group homes came into prominence in the 1980’s as an alternative to institutional settings in which large numbers of people with intellectual and developmental disabilities were warehoused together and segregated from the rest of society. Institutional settings were typically operated in a highly regimented manner. Personal choice was not a priority. Rigid scheduling was needed to meet staffing needs without due regard to the needs of residents. The large numbers of residents, sometimes up to 100, necessitated feeding everybody the same menu at the same time, bussing them to and from their day programs at the same time, bathing on schedules conducive to staffing needs, facilitating outings in large groups, residents waking up and going to bed at the same time, strictly regimenting the passing medications, etc. Unfortunately, in many ways those institutional ways of doing things often carried over to group home settings even though they were smaller and more integrated in middle class neighborhoods.

Thus, group homes that are owned and/or operated by COF and organizations like it will be subjected to heightened scrutiny, not only to determine whether or not the group homes have the effect of isolating their residents from non-disabled citizens, but to ensure that they are not operated by CSP’s as mini-institutions in which residents lack substantive control over their day-to-day lives.

Thus, for example, COF’s larger group homes, in which up to eight people can reside and whose residents need 24-hour care, will need to ensure that residents have ready access to food and are not required to sit down and eat the same thing at the same time as a group.  They will need to ensure residents are not regimentally scheduled to get on a bus full of exclusively intellectually and developmentally disabled individuals to be transported to a day service setting, a setting where the only non-disabled people present are staff paid to provide them with supports and services.  Each resident should have keys to their house and also their own bedroom so they can keep it locked to ensure that staff and other residents cannot access their private space without their knowledge or permission.  Each resident should have a legal lease that provides the same rights and protections that any other renter has when leasing a place to live.  Each resident should not be refused visitors of their choosing at times they wish to have them. In other words, the intent is to ensure that each resident has as much personal choice and freedom from being controlled by the Community Service Provider organization as possible.

With regards to the eight larger group homes at which 24-hour care is provided, COF is promptly proceeding with transitioning to be in compliance with CMS’ Final Rule to the extent that it is possible to do so before “compliance authorities” are sent out to assess each and every “setting.”  So, for example, meals in these types of homes are now being served buffet-style over an extended 2-hour time period to ensure that residents do not have to sit down together to the same meal at the same time. Also, COF is no longer transporting all residents of these homes together so that they arrive at a segregated day service center for the convenience of COF’s staffing schedules. Residents can choose when or if they want to go into a day service center and COF will adjust the scheduling of its operations to suit the needs of people who use its services instead of expecting these people to adjust to COF’s scheduling and transportation needs.

Pee who reside in COF’s smaller group homes and COF’s apartment complex already have all of the freedoms and choices that are required by CMS’ Final Rule. No substantive changes are needed. The exception to this might be that the compliance authorities sent out to assess settings might view the clustering of 18 people with I/DD into a single apartment complex in which non-disabled people do not live as not being sufficiently integrated.  If or when that is the determination of compliance authorities, COF will have to facilitate the relocation of some of the residents of its apartment complex to other residences that are not owned by COF and are fully integrated among residences in which non-disabled people reside.

The key point to bear in mind is that the intended effect of CMS’ Final Rule is to unravel the unintended consequences of a long established provider-centric service delivery system in which service recipients have inadvertently been subordinated to the organization from which they receive supports and services.

COF is promptly proceeding to be in full compliance with regards to its residential services just as it is with conflict of interest issues pertaining to the determination of eligibility, funding needs and the control of the PCSP.  In some regards, it is a marked shift from the way things have been done for many years across the nation. But, in many ways it is all common sense and the transition for many organizations such as COF is relatively easy because these organizations have long understood and abided by the underlying principles being conveyed in CMS’ Final Rule.

COF embraces the core principles of CMS’ Final Rule. Adherence to these core principles provides reasonable assurances that the organization that is providing residential supports and services is delivering supports and services as is intended by the Federal Government’s CMS Final Rule.

The following is a COF self-assessment checklist to ensure that it is compliant with CMS’ Final Rule:

While the Federal Government’s CMS Final Rule is having a profound impact in the way that residential supports and services are provided, it is not the only outside force that is significantly impacting how residential supports and services are provided. KanCare (Final Rule - Changes Ahead: KanCare) is a Kansas (not federal) initiative implemented to reign in control of the spiraling costs of Medicaid. Kansas is imposing a decided capital market influence on all providers of Medicaid funded social and medical services by assigning control of Medicaid funding and the medical and social services funded by Medicaid to Managed Care Organizations (MCO’s).  MCO’s are large insurance companies skilled at operating in the capital market system. This is a dramatic departure from the way things have been done for decades, but it is reasonable to assume that spiraling costs will be brought under control and contained because there is now profit incentive to make this happen that did not previously exist.<<MCO tier rate chart spreedsheet possibly>>

As stated above, the amount of funding needed to provide the HCBS-funded supports and services which people with I/DD rely upon at COF is determined by an unbiased assessment process. The higher the assessed need is the higher the HCBS-funding allocated to cover the costs of the supports and services to be provided. The present (as of 11-20-15) assessment system is broken down into five levels or tiers of funding.  The MCO’s, however, are locked into a three-tier system in which they are at risk of losing money for services rendered to  people funded at the highest levels while making a profit at the other end of the spectrum.

From the perspective of the KanCare funding model for the MCO’s, 24-hour staffed group homes (and the persons living in them receiving that level of care) are generally going to be money losing propositions due to the high costs involved in 24-hour care.  It remains to be seen what the impact of the KanCare funding model will have on group homes in such settings.

However, COF is committed to diligently working with the MCO’s to deliver HCBS-funded supports and services in the most cost effective ways. So, for this reason, COF is actively preparing to diversify into alternative service delivery models in which quality services can be provided in more cost effective ways.    

These more cost effective service delivery models include:

  • Working Healthy / WORK / ILC

Financial Management Service (FMS) is also offered by COF.  Through this service COF is a payroll agent for individuals who hire their own Personal Assistance Services (PAS).   Personal Assistance Services allow an individual to continue to live in a community setting with a PAS worker coming into their home to provide the individualized services they require.  This is a more cost efficient means of providing services as only those specific services and time required are reimbursed through KanCare.  The individual hires, trains and manages their PAS with COF performing only the payroll function of that process.

  • Shared Living