WHN: CFAC Minutes 11/22/10 Special

Members Present: Nancy Baker, Bill Cook,  Debra Hamrick, James Lane, Kristie Sluder, Rosemary Weaver,  Christine Smith, Tracey Turner, Leslie Huntley, Carolyn Burton,  Bob Carey, Howard Graves

Members Excused:   Joe Sentelle, Joseph Crowder, Ruth Ann Bradshaw

WHN Staff: Arthur Carder (CEO), Charlie Schoenheit (COO), Don Herring (Clinical Services Director), Dick Graham (Consumer and Community Relations), Kelley Stines (CFAC support)

Visiting Division Staff: Ken Marsh (DMH/DD/SAS), Kathy Nichols (DMA), Suzanne Thompson (DMH/DD/SAS), Anna Cunningham (DD Family Member Representative on the State Waiver Team), Marc Jacques (Wake CFAC), Bill Bullington (LME Business), Cathy Kocian (Consumer Empowerment Team)

Guests:   Duane Fowler, Teresa Davis, Mary Lawson Norton (phone guest), Barbara Smith (Henderson - helped with most recent CIT Coordination), Nancy Carey, Becky (Nami), a Peer Support Specialist

Team:  Consumer Family Advisory Committee

Date:    11/22/10           

Time Started: 5:30 PM

Time Ended:   8:00 PM

Minutes:  Kelley Stines 

December 13, 2010 – cancelled / bad weather
Next Meeting: January 24, 2011

 Question & Answer Session w/ Group from State (11/22/10)

Opened by
Ken Marsh (DMH)

Thanked WHN CFAC for inviting them to heir meeting.  Gave history of Implementation Team development at state; he was the PBH LME Liaison from the start; described the two consumers (at the meeting) as “finger-on-the-pulse” staff paid by the state to keep up with consumer involvement in waiver developments; advocates for a “Learning Community” among WHN, PBH, Meck and the state reps. Feels it’s important to have input from CFAC going forward, and to involve them as part of the implementation process.

Marc Jacques
(Wake CFAC)

(SA consumer in recovery and operates advocacy business; was on WHN Mercer Review Team; Consumer/Advocate)

Encouragement to look at other state models that had successful waiver implementation. Need to understand the language used around capitation and benefits so that consumers can understand the  pitfalls and benefits. He urged consumers/ CFAC to learn about the complexities. Marc recommended looking at the Waiver Energy Project (document is attached with minutes).

Mentioned “Freedom of Choice”  waiver (1915-b) is a bit misleading (oxymoronic) when it limits freedom of choice. Providers make fewer dollars the more services they provide. Advocates need to educate themselves on issues relating to access of services (benefit plans).

State of NC is looking at WHN closely for how the waiver goes here as relates to expansion.

Anna Cunningham
( DD Family Member Representative)

(mo. of CAP recipient;
has been on Wake Human Services LME Board; on WHN Mercer Rvw Team)

Emphasis on  “COMMUNICATION”.  Important to communicate openly and honestly about issues, about the strengths of your people (citizens/staff), differences in mountain cultures (she has family in TN - Johnson City, the Tri-Cities area of TN, and all along the mountain regions in East TN), and how consumers seek services. Continue to openly discuss the qualities that are here and not in other places.  Huge need for open communication, and opportunities for education. If you haven’t seen obstacles, you haven’t gone far enough.  The way you handle obstacles using your strengths is important.

Question 1: Nancy Baker (WHN CFAC)

It’s hard to trust the State. How do you convince me to trust the state? Mentioned 1:1 staffing problem with her adult CAP recipient child and run-around from “go to state – go to WHN, etc.

Ken Marsh

We welcome feedback.  State cannot convince you that it always knows what the right and left hand are doing.  With this waiver, there is a high level of accountability. Some decisions can be made locally, others not. There are players other than the State in the mix of authority and accountability:

§         RFA for Waiver

§         YOU (WHN) submit the Implementation Plan of how you will do this

§         WHN tells us where they are and the state provides the Readiness Reviews (with Mercer) and thresholds that must be met before state allows “go”.

We’ve worked closely with Mecklenburg. The changes and lessons learned with Mecklenburg and PBH are helping to improve the process.  Changes will hopefully improve the process of how voices are heard.

Marc Jacques

How your voice gets heard is what this is about – your door of communication. It’s common under waiver entity – allows local decisions.

Anna Cunningham

Put a strong emphasis on your voice, on self empowerment to affect change. The more we understand the system, the more we can help ourselves and others.

Communication – gets to the “how.” Allows local control and clarifies who has the decision-making authority. Plus the provider will get paid by LME.

Question 2: Bob Carey

(WHN CFAC)

State advocates (Coalition 2001) – DD advocates are asking for (b) and (c) parts of the waiver to be split out and to “slow the process” of waiver expansion. Has there been discussion around a different kind of waiver?

Ken Marsh

It’s not our intent. There’s been lots of discussion. Legislature [mainly from the DD community] asked state to:

1)      Slow down implementation and be more methodical so that no one gets hurt. They asked PBH not to expand, which was under consideration.

2)      Select two other entities going forward. We selected Mecklenburg and WHN.

3)      Study in 2012 to uncover impacts of waiver on ID/DD community - interview community/family members on quality of care before/after the waiver.

4)      Engage stakeholder groups in the waiver process

5)      Consider the impact on ICF-MR communities. Plan to engage National Association of DD State Directors to find independent consultant to do this study (reduce state bias). We will also study other alternate waivers – splitting is one alternative.

6)      We recommend visiting the state waiver web pages:
DMHDDSAS:  http://www.ncdhhs.gov/mhddsas/waiver/index.htm
DMA: http://www.ncdhhs.gov/dma/lme/MHWaiver.htm

Marc Jacques

Look at Texas STAR and Michigan 1915(b)(c) waiver results; NC chose the largest options list from possible 1915(c) services list.

Question 3: Bill Cook
(WHN CFAC Chair)

SA is in a sorry state in NC. How can changes be made within our 8 counties, especially in smaller counties like Mitchell? [ Px with OP services for mixed abusers/addicts – 1 OP session/week]. In new waiver world, how do we promote change for adequate treatment in SA?

Ken Marsh

The waiver is not a “magic bullet” and will be hard pressed to resolve SA issues as most SA consumers do not have Medicaid and are IPRS-funded. It gives the LME new tools, which is a huge asset to state dollars. It can help close the provider network to ensure there enough providers for services needed; helps LMEs ensure that providers are financially sound; helps determine who are the providers, how much they can contract.

The waiver helped PHB who wanted to build SA services – not where they want to be, but have more tools to help. Future Healthcare Reform allows the SA/MH populations, who generally don’t have insurance, a way to access more services.

Marc Jacques

Fee for service model supports over-diagnosing and over-servicing due to provider incentives to bill. As advocates come forward, there may be better balance of where service resources are going.

Anna Cunningham

Think of funding as coming from a number of doors. The Waiver opens a certain number of doors that can be locally controlled to meet the needs identified. CFAC’s role is key. Is charged with helping identify service gaps.

Question 4: Kristie Sluder (WHN CFAC)

[I’m also very interested in how to get more beds funded in the new waiver world.] What are PBH’s top 3 strengths?

Ken marsh

1)      How they engage their stakeholders. PAG (Provider Advisory Group) works monthly with PBH. Every other month they have in disability-specific groups.

2)      Becoming a waiver entity has forced them into thinking and acting like a business entity. Must have good IT (Information Technology) and QM (Quality Management) systems. These are core infrastructures that allow management by data using patterns/trends.. PBH has become a good manager – more proactive, less reactionary.

3)      Allowed creative innovations – housing; employment (consumer-developed businesses); focused on cultural diversity in provider network to reflect community diversity; focus on consumer recovery models and WRAP.

Question 4:
Rosemary Weaver
(WHN CFAC Member
& State CFAC Chair)

How is the waiver going to help the rural counties?

 Ken Marsh

That’s WHN’s job. Geomapping is critical to analyze and fill gaps in provider network.

 Arthur Carder

WHN recently looked at geo-mapping software that can import Medicaid data to show per county where consumers/providers are (by disability and service). WHN plans to do a gap analysis.  We can’t afford it now, but can with waiver. WHN will use feedback from providers, CFAC, and data from Access to make decisions about how to use its resources.  WHN has already requested a Provider Eligibility File.

Anna Cunningham

Use of good data can help you write grants for more dollars. For example, there are federal grants to help with transportation.  Using data helps you be proactive instead of reactive. You can use data to help with IPRS resources as well; spend less on support activities and put funds in IPRS services.

Ken Marsh

(b)3 Services savings can be used to create additional services – LME can create unique services

Marc Jacques

For example, powerful IT system helped Piedmont. At the Winston-Salaam presentation Eerie PA went totally paperless saving money and freeing physical space for new services Both PBH and Eerie did B-3 services with efficiency savings.

Question 6: Carolyn Burton (WHN CFAC)

We hear from small providers who are going out of business, and from some consumers who use providers outside of network. Will they be able to keep their providers that are out of network?

Ken Marsh

Good point of dialog to have with the LME. LMEs who applied said they would use existing network providers, and then begin to limit the networks. This type of issue should come up in readiness reviews. Part of the answer involves how WHN manages its implementation plan, and establishes a quality provider network.

Don Herring

WHN has said we will contract with all present providers.  One of the first things we’ve asked for was a file containing all of our consumers’ providers. We will send a letter to each provider asking them to contract with us.

Question 7: Leslie Huntley (WHN CFAC)

What about at Quality Measures - How do we assure quality at the consumer level?

Ken Marsh

CMS requires EQRO (External Quality Review Organization) reviews 2/year that report measures for evaluating internal quality. How will it translate into consumers receiving quality care, and what is the trip alarm? It depends on WHN ‘s ability to implement effectively.

Don Herring

Quality Measurement ensures that people get treatment, and that people get the right treatment.  We’ll have a lot more resources to ensure we’re doing our job.

Follow-up Q: Leslie Huntley

Where do consumers and families enter into the monitoring process?

Don Herring

I’d love to see them on a monitoring process team.

Question 8: [WHN CFAC]

How is local CFAC going to engage with State CFAC?

Anna/Marc

Hopes at the state level to start a “Learning Community” –  group of 7 from PBH, State, WHN and Meck CFACs.  We are a learning community. Let’s learn from others.  You can contact us any time.

Marc: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
Anne: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Critical to keep lines between LME and CFAC groups open.

Leslie Huntley: This CFAC is in support of this waiver.

Arthur Carder

Is there any money to help with costs in traveling to Charlotte,? Help with lodging for consumers and families?

Ken Marsh

Must find a way to cover consumer involvement costs at LME

Don Herring

Mentioned that Leslie was asking about consumer-level QM and not just patterns/trends and this will occur with increased Care Coordination/Care management staff to replicate what occurred with BSH Inpatient Pilot Project..

Suzanne

We have a group that tries to determine ways to work with Mecklenburg, PBH, and WHN.  It’s a big logistical issue the State has discussed. We’re looking at ways to communicate without traveling. Increasing timely communication efficiencies is vital.

Need to determine how we get all three groups to work together. We need your ideas, and suggestions on what works well.

Question 9 – Nancy Baker (WHN CFAC)

How do you suggest that the local WHN CFAC get across to the Board about moving forward with the waiver?

Arthur Carder

Biggest concern is how do we convince the Board that this is not an attempt by the state to screw the LME (referred back to Nancy Baker’s earlier question)?

Ken Marsh

We’ll defer that one to Arthur Carder.

[Response]

Suggestion to ask someone from the division to attend a Board Meeting? Or asking someone from PBH to present at a Board meeting?

Arthur Carder: Yes we have considered these suggestions.

(follow-up question)

How will CFAC convince the Board to trust the state?

Ken Marsh

Defer to Arthur Carder on this. Dialogue over the pit-falls; bring in PBH representatives as a possibility; politics => the state is moving this way (waivers).

Anna Cunningham

Suggests reading Consumer Action Handbook – Federal publication found at http://www.consumeraction.gov/ to help educate CFAC and other consumers how to be better at public advocacy.

Question 10 [WHN CFAC]

Can you comment on the politics involved on the state level?

Ken Marsh

Yes, there are politics. Any time you talk about changing the system, everybody has an opinion. Many have written white papers about the waiver.

Marc Jacques

Overall message is that they want waiver implementation to be successful, and go forward. It was built into the Governor’s budget. Consumers and Advocates have the most at stake and really want it to be successful.

Anna Cunningham

The Consumer Action Handbook 2010 is a fee resource. You can get free copies for information on various issues.

Question 11: Bob Carey (WHN CFAC)

What are PHB’s biggest problems/challenges?

Ken Marsh

1)      Information Technology  (IT) was weak for 1^st two years and they almost lost the waiver because they could not adequately manage data nor generate the necessary reports. [Mercer Report identified IT as critical for WHN as well.]

2)      I/DD learning curve – Managing care in DD community in appropriate ways.  They had inside Case Management within the LME.  They hired a consultant on how to more effectively manage DD care. As part of this process, they now send out “Waiver Alerts” once a month, before rollout of changes. CFAC has helped with this.

The power of a waiver is that it makes you look at internal systems and see how to improve the systems going forward. It makes us collectively stronger.

 Question 12: Howard Graves

(WHN CFAC)

How much flexibility does waiver give to the CEO as far as determining the services offered?  Issue in Madison County of main-streaming and inclusion with children who have I/DD issues, RECs in Madison, 30 day treatment/contracts with hospitals

Ken Marsh

Take care of the consumer not the service; state – unknown local issues; 30 day programs are over for the most part

Arthur Carder

Part of what WHN is supposed to be able to do is say to providers what we need in the community. Part of the problem is that providers want to do other stuff, only what pays the most. We can’t say to them we’ll go elsewhere for the services under the present system. Under the waiver, we can find ways  that families need and determine how we can meet those within our limits.

Anna Cunningham

Look at IDEA and know what the schools are supposed to provide first. Medicaid cannot cover what schools are supposed to provide under IDEA and so must hold schools to the “letter-of-the-law” vis-à –vis IDEA.  She emphasized using IDEA Law for Public School issues and gave reference for the Virginia-based Wrightslaw website for further resources on Special Education Law and IDEA.

Someone else added that PHB has had and utilizes the PSS definition, and they staff effectively.

Question 13: Howard Graves (WHN CFAC)

Have there been any LME’s who have built their own Recovery Education Centers such as Meridian in Transylvania County?  Is PBH leaning towards pushing out private companies and doing their own stuff?

[Response]

East Carolina Health has “The Oasis”.

PHB hasn’t done this but has worked hard on a Recovery Program.

Ken Marsh

They cannot provide any services. They must manage care, not provide care as a waiver entity. PBH did contract with Providers to provide these services. WHN must plan how to incorporate service system because of its ‘rural’ communities.

WHN Closing Comments

Don Herring: We have three Recovery Education Centers in our Network. I do see us having more in our rural areas. Example in Transylvania is having great success. We were hurting for providers. It’s a model that works.

The Waiver brings about a change of mindset. Division of MH has been very prescriptive on what they wanted don. Now, they’re saying this is your waiver. There is flexibility here. Now we need to take our quality work and make it a way of life. Charlie is working hard on these issues to make use live regularly as a Quality Improvement LME. There is a lot of latitude in how you go about doing things, but you have to prove that you’ve done it. It encourages creativity.

Important is the LME’s attributes, it’s relations with CFAC. It’s a paradigm shift from scrapping for what we can get.

The waiver stresses Integrative care. I think with the 2014 Health Care changes that the federal government will be looking at how we’re doing integrative care. PBH excelled. It’s a waiver requirement. May be easier for us because of our rural communities.

Follow-up: Leslie Huntley (WHN CFAC)

We have Integrative Care Model in Polk County. What do you do with psychiatric consumer who is more complicated?

Don Herring

That’s when you have specialized help/referral to specialist. We have CCNC staff person in house.