Task 6 Assessment Tools Assessment tools reviewed National

Task 6: Assessment Tools

Assessment tools reviewed • National Tools • inter. RAI • Supports Intensity Scale (SIS) • Inventory for Client and Agency Planning (ICAP) • Tools Developed by Other States • Minnesota – Mn. CHOICES • Washington State – Comprehensive Assessment Reporting Evaluation (CARE)

inter. RAI • Suite of tools developed for LTSS populations • Valid, high inter-rater reliability • Research-informed support tools in each tool • 15 scales used to evaluate clinical status including ADL Hierarchy Scale, Cognitive Performance Scale • Clinical Assessment Protocols/Collaborative Action Plans • Quality Indicators • Resource Allocation – case mix classification

Summary of inter. RAI Tools Assessment Name Population States Tools inter. RAI-Home Care (HC) Older adults/physically disabled CA, UT, SD, KS, IA, MO, CAPs, acuity scales, case AR, LA, MS, GA, IL, IN, OH, mix/resource allocation MI, PA, CT, RI, NJ, MD, HI, TN inter. RAI-Community Health Assessment (CHA) Older adults/physically disabled NY CAPs, acuity scales, case mix/resource allocation inter. RAI-ID IDD population (adult) AR, NY CAPs, acuity scales, case mix/resource allocation inter. RAI-Ch. YIDD population (child/youth) AR, NY CAPs, acuity scales, case mix/resource allocation inter. RAI-Community Mental Health Behavioral health population (adult) AR, NY CAPs, acuity scales inter. RAI-Ch. YMH Behavioral health population (child/youth) AR, NY CAPs, acuity scales

Supports Intensity Scale (SIS) • Validated, reliable, and normed tool developed by the American Association of Intellectual and Developmental Disabilities (AIDD) • SIS-A, adults 16+; SIS-C, children 5 -16 • Focus is on the frequency and level of support rather than documenting performance deficits • Establishes acuity levels (developed by HSRI) • Requires its own proprietary software solution (SISOnline) • Training and certification of assessors by AIDD is required to use SIS • Tool in use in 22 states

Inventory for Client and Agency Planning (ICAP) • Currently in use in Alaska for the IDD population • Designed for both children and adults • Measures functional needs in adaptive (e. g. , motor, communication/ social, personal/community living) and maladaptive behaviors (e. g. , disruptive, hurting self or others) • Produces score from 0 -100, reflecting level of service intensity required • Typically used in combination with other assessment tools • In use in 11 states

State-Specific Assessment Tools • Mn. CHOICES • Development began in 2004; rollout began in 2013 and is ongoing • Designed to integrate assessment tools across multiple populations including individuals with physical disabilities, IDD, children, behavioral health • Based on the inter. RAI-HC • Comprehensive Assessment Reporting Evaluation (CARE) • • Developed in early 2000 s; 3 years to build the tool Built off the inter. RAI-HC Includes 14 acuity groups with resource allocation/case mix SIS integrated into assessment process for IDD population

Summary Matrix of Assessment Tool Features and Functionality

Implementation Issues • Costs of assessment implementation • Assessment tool costs • inter. RAI – Royalty-free license to states for use of the tools • SIS – License fee ($175/assessment) and per-assessment fees ($19/assessment) • IT/Software costs • Varies substantially from state to state • SISOnline is software solution for SIS • Several authorized inter. RAI vendors (including Medi. Ware – AK IT vendor) • Training costs • Unknown for inter. RAI • SIS training - $7, 500 for initial training, additional follow up training costs as well

Approach to Review of State Experiences • Only 4 states have adopted both (i) and (k) • California, Maryland, Montana, and Oregon • From December 2015 to February 2016, HMA reviewed (i) and (k) SPAs for each state of these 4 states and interviewed staff in each state • Goal was to understand how each state is meeting the requirements of (i) and (k), implementation issues, successes/challenges, best practices, and lessons learned

California • 1915(i) – effective 10/2009 • Target population: IDD population under 18 years who require habilitation services, no institutional level of care • Covers population <150% of FPL; provides services to medically needy but does not waive requirements re: spousal income • 1915(k) – effective 12/2011 • First state to get (k) approved; built off existing personal care benefit • Optional benefits covered • Transition costs • Services substituting for human assistance: restaurant meal allowance • CA did not convert any 1915(c) waiver benefits to CFC

Maryland • 1915(i) – effective 10/2014 • Target population: Children or youth with serious emotional disturbance • State is covering the optional categorically needy eligibility group with incomes <150% of FPL, or who are eligible for 1915(c) waiver with incomes not exceeding 300% of SSI rate • 1915(k) – effective 1/2014 • Optional benefits covered: • Transition costs • Services substituting for human assistance: home delivered meals, environmental assessments, technology • Concurrent with CFC implementation, Maryland merged two 1915(c) waivers to cover services not permissible under CFC

Montana • 1915(i) – effective 1/2013 • Target population: Children/youths age 5 -17 with serious emotional disturbance; youth up to 20 years who are still in secondary school may opt in • Projected enrollment: 56 in Year 1 • Covers population <150% of FPL; provides services to medically needy but does not waive requirements re: spousal income • 1915(k) – effective 10/2013 • Montana did not elect to cover the optional CFC services • Retained existing 1915(c) waivers to cover services not required and not permissible under CFC

Oregon • 1915(i) – effective 1/2012 • Target population: Individuals with chronic mental illness • Covers population with Medicaid <150% of FPL; does not extend benefit to medically needy • 1915(k) – effective 7/2013 • Optional benefits covered • Transition costs • Services substituting for human assistance: environmental modifications, assistive devides, community transportation to gain access to Medicaid services, activities, and resources, and home-delivered meals • Oregon maximized CFC by shifting most of its State Plan PAS and 1915(c) waiver services into CFC; very little was retained in the waivers

Key Themes: Planning • Eligibility • Need a solid understanding of eligibility criteria, both financial as well as functional/diagnostic • Oregon noted that CMS has been hammering on the sufficiency requirement; even if the program expands beyond what the state estimated, it cannot be rolled back. • Services • Approach to development of the service array for 1915(k) was similar for CA, MD, and OR: take as much of their existing programs as CMS would permit and move them into CFC in order to maximize the federal match • MT initially sought approval for those services required under CFC and chose not to opt for permissible services • CA, OR, and MT all recommend taking a minimalist approach

Key Themes: Planning (cont’d) • Fiscal Impact • States generally acknowledged that there are still significant costs associated with 1915(k), even in light of the FMAP enhancement • CA and MD both indicated that had they pursued a budget neutral proposal, they would not have been able to implement necessary changes to comply with federal requirements • Development and Implementation Council • Varying levels of engagement with their Councils • All continued to engage their Council during implementation period; most continue to engage them now although on a less-frequent basis