RE: Centers for Medicare and Medicaid Services

Please see the information attached below. Please see the second page the next to last bullet. It reads as follows;

It is necessary for the new waiver case managers to meet with the clients and conservators privately – without the providers present.

The Person-Centered process as described by CMS is as follows; CMS requires that a person-centered planning process and assessment be used to develop a person-centered plan. The process is directed by the individual, with assistance as needed or desired from a representative of the individual's choosing. It is intended to identify the strengths, capacities, preferences, needs, and desired measurable outcomes of the individual. The process may include other persons, freely chosen by the individual, who are able to serve as important contributors to the process. The planning process must also include planning for contingencies such as when a needed service is not provided due to the worker being out sick. The contingency or "back-up" plan must become a part of the individual's person-centered plan. As part of the contingency planning process, an assessment of the risks to the individual must be completed and a discussion about how the risks will be addressed must be held.

The key portion is as follows;

The process may include other persons, freely chosen by the individual, who are able to serve as important contributors to the process.

Clearly there is a disconnect here!

Please see meeting minutes below

BIAC Providers Council Meeting
Location:
Brain Injury Alliance of CT
(1st floor in training room)
200 Day Hill Road, Windsor, CT 06095

Welcome & Introductions

Bonnie Meyers welcomed everyone and began the meeting with introductions. Guest Speaker: Barbara Nadeau, Ph.D., OTR/L, Assistant Clinical Professor ABI Waiver staff perceptions of their clients and the client’s perception of their staff: Results from a qualitative study

Barbara provided an overview of a qualitative study she conducted through interviews and assessments of 8 individuals, including 4 caregivers (ILSTs) and 4 care recipients (ABI Waiver participants). A copy of the PowerPoint she presented will be included as an attachment when the minutes are distributed.

Points covered in Barbara’s presentation:

• Barbara conducted 34 interviews with 8 participants over 6 months.

• Caregivers viewed their role more from the medical model standpoint – seeing the individuals as needing to be fixed.

• The care receivers looked to the ILSTs to help them, not necessarily fix them.

Kathy Bruni, DSS, indicated that a Participant Experience Survey is going to be implemented in the ABI Wavier to determine level of satisfaction and quality of life.

Provider Updates

• BIAC Updates:

O BIAC is down to 4 ½ staff with no Fund Development Director at the time of the meeting. O The 12th Annual Walk for Thought will take place on Sunday, October 2 at Rentschler Field in East Hartford. Information regarding exhibiting, sponsorship and registration were shared, and are also available online at www.biact.org.

• Kennedy Center: There have been some challenges with the new waiver case managers, but they are working through them. Staffs are attending the EVV training next week.

• DMHAS: DMHAS hosted a meet and greet with DSS and the new waiver Case managers/Axis Agencies, which was well received. Devon Brien-Rushford is at DMHAS for those with substance abuse and brain injury issues.

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• Marrakech: Staff had a rough time with new waiver case managers/Axis Agencies but communication improved and it has been a positive experience. Staff also attended the EVV training.

• Goodwill: Staff experienced some bumps with the new waiver case managers, but they are moving along. They’ve also had some EVV challenges but are working through them.

• Mindscape: Staff have had good experiences with the new waiver case managers. There was some rushing in the beginning to get care plans established but they’ve been very responsive. Staff attended the EVV training. The organization branched out in Norwich and will host a grand opening in September or October.

• Kindred: Nicole Spencer is new to Provider Council, and represents Kindred’s locations in Braintree Manor in Massachusetts. It is inpatient and short-term, with an average length of stay of one year.

• Peter Love: Peter is having a mixed experienced with the new waiver case managers – some are very good, while some are very young with not a lot of knowledge about brain injury and lacking empathy/understanding. Recently attended a training regarding the opioid epidemic, with Charles Watkins presenting.

Provider Standards Workgroup
The group continues to meet to develop Provider Standards. The group is meeting again after the Provider’s Council meeting, and all are welcome to join even if you have not previously attended. Open Discussion: ABI Waiver - Kathy Bruni & George Chamberlin: Department of Social Services (DSS)

• The EVV (Electronic Visit Verification) system for billing will begin September 1 through HP, although an extension can be requested for November 1 as a start date. Bills for August 31st and prior will go to Allied, but beginning September 1 all bills must be submitted through HP. Welcome packets for EVV are coming soon. There is also an FAQ on the HP website, and if the answer is not there you can add the question or reach out to Kathy to get an answer.

• As part of a follow up requested by CMS, DSS will be going out to providers through September to conduct supported employment surveys.

• Kathy has received no negative feedback regarding the new waiver case managers/Axis Agencies – with the exception of one that had not worked with the case managers yet. If agencies have feedback they are encouraged to share that with Kathy so she can follow up. It is necessary for the new waiver case managers to meet with the clients and conservators privately – without the providers present. This is necessary for conflict free case management, required by CMS. As of June 1 the new waiver case managers were responsible for each client and case plan, which is why there was rushing initially. Waiver case managers conduct a reassessment with a structured and comprehensive review of ADLs, cognitive issues, etc. and then they work on a case plan.

• A few agencies have begun implementing the new ABI Group Day, including Mindscapes and Kennedy Center - others have not begun yet, including Goodwill and Employment Options. Providers see it as a good alternative, although some had difficulty initially

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getting participants interested. Kennedy Center hosted an open house which led some participants to reconsider joining. The ABI Group Day is different from the already existing option of adult day health (non-ABI specific) that is available.

• Regarding applying for the ABI Waiver, there was a question as to whether or not a neuropsychological exam is required. Although it would be required at some point to assist in care plan development and/or the absence of ABI verification it is not required at the time of initial application. There is an understanding that it can be cost prohibitive, depending on an individual’s insurance at the time of application.

Future Meetings

The group discussed inviting the new waiver case managers and Axis Agencies to attend a future provider council meeting as an opportunity for open discussion between DSS, Wavier Providers and new waiver case managers. Bonnie will look to schedule something for a future meeting.

RE: Federal Regulations differ from DSS policy RE: Care Plan and Assessment Meetings

Department of Social Services (DSS) has directed the new case managers of the Acquired Brain Injury Waiver to inform Waiver participants that they are required to meet with case managers without providers of services present during meetings when their plan of care is discussed. Many providers, believing this is the new policy they must adhere to, have not attended meetings or have left during the assessment or development of the plan of care. This is the statement made by Department of Social Services:

"It is necessary for the new waiver case managers to meet with the clients and conservators privately – without the providers present. This is necessary for conflict free case management, required by CMS."

However, this unprecedented new policy restricting participants and providers from discussing the plan of care is being challenged and some providers are in fact attending Assessment and Service Plan Development meetings just as they have done for more than 18 years since the origination of the ABI Waiver. Federal regulations protect the rights of disabled brain injury survivors and outline the process for person-centered planning. In regards to this new policy, Federal guidelines from Centers for Medicare and Medicaid (CMS) are very different from the policy recently set by DSS:

Person-Centered Planning Process: "CMS requires that a person-centered planning process and assessment be used to develop a person-centered plan. The process is directed by the individual, with assistance as needed or desired from a representative of the individual's choosing. It is intended to identify the strengths, capacities, preferences, needs, and desired measurable outcomes of the individual. The process may include other persons, freely chosen by the individual, who are able to serve as important contributors to the process [emphasis added]. The planning process must also include planning for contingencies such as when a needed service is not provided due to the worker being out sick. The contingency or "back-up" plan must become a part of the individual's person-centered plan. As part of the contingency planning process, an assessment of the risks to the individual must be completed and a discussion about how the risks will be addressed must be held."

It appears that participants cannot be forbidden from having anyone they choose, in accordance with federal regulations, at their care plan meetings (Assessment and Service Plan Development). CMS describes the Plan of Care as follows:
Service plan: "A service plan is the written document that specifies the services and supports that are to be furnished to meet the preferences, choices, abilities and needs of the individual, and that assist the individual to direct those services and supports and remain in the community."

The development of a service plan must follow a person-centered planning process as detailed by CMS:

Person-Centered Planning Process: "The process may include other persons, freely chosen by the individual, who are able to serve as important contributors to the process."

Service Delivery Discussions with Providers and the Rights of Brain Injury Survivors in Having Those Discussions

When a brain injury survivor chooses to discuss their service plan with their provider in regards to service delivery, because the participant believes it is important because it relates to service delivery, that participant is well within their right to do so. Many of you may not be aware of the addendum DSS added to your provider's service agreement; the language prevents providers from discussing details regarding changes to the Plan of Care with survivors and conservators. This essentially prevents brain injury survivors from directing the process in regards to their own person-centered planning - please read the language in the "new" ABI Waiver Service provider agreement addendum:

"The Care Manager, not the Provider, is responsible for communicating with a client regarding the Plan of Care, including proposed changes to such Plan of Care. The Provider shall not discuss details regarding the Plan of Care with a client including, but not limited to, the Provider’s desire to change or terminate services, without the Care Manager’s prior approval."

The Plan of Care details all of the services to be provided! If the Plan of Care cannot be discussed by brain injury survivors with their providers then any and all services provided cannot be discussed. This provision goes against the rights of the participant per Federal Regulations and is a manner of control forced upon brain injury survivor that has never existed before.

Release Forms

There are also issues with the release forms participants are being asked to sign, some of the concerns are listed below:

Forms have been presented to participants with no specific end date as to the length of the Release of Information.

Information requested is unnecessary and invasive, the release requests information regarding the:

Family and living situation

Medical

HIV information

Financial

Employment history

Alcohol and/or drug records

And finally, the form states:

"I understand that the information I authorize the Department of Social Services to receive may be redisclosed and no longer protected by privacy regulations, although the Department of Social /Services is subject to the requirements of the privacy regulations."

This is a form no one should be asked to sign, especially not a disabled brain injury survivor!

Please share the language above about the federal regulations and understand your rights when you are asked to schedule any meetings. There are a number of challenges during this time of transition, for example, in some cases the new case manager's do not even have the correct care plans, this of course leads to concerns as to how survivors plans will be discussed and reassessed when the correct information is not available. We are asking DSS to change the language in the Waiver addendum so that those who are "freely chosen by the individual, who are able to serve as important contributors to the process” are fully included in the planning and assessment process of the service plan. Providers are essential to person-centered planning and especially during this difficult time when every single case manager has been replaced by someone not only new to the survivor but new to the ABI Waiver program, the language preventing them from being included must be removed.

Thank you
CTBISN - Elaine Burns

This is all you need to do

Craig Sears
Brain Injury Survivor