Waiver Reimagine Advisory Committee Aug. 25 meeting summary

Committee members present:  Don Barnes, Kathryn Barton, Tricia Brisbine, Rosalie Eisenreich, Lisa Evert, Kelly Friesen, Zahnia Harut, Dr. Katrina Jirik, Susan Mackert, Meredith McKinnon, Julie Morrison, Polly Owens, Rijuta Pathre, Sherri Pickthorn, Phyllis Reller, Kathy Rogers, Bud Rosenfield, Elizabeth Scheel-Keita, Lauren Thompson, Chad Wilson, Dr. Arbdella Hudson, Val Barnes, Wa Xiong, Saudade SammuelSon, Mary Fenske, Jennifer Drganc, Myrna Petersen

Committee members not present: Annie Braun, Cathy Chavers, Ali Kofiro, Lisa Harvey, Abigail Gertken, Danielle Otto, Pat Wright

DHS staff present: Leah Zoladkiewicz, Hannah Lamb, Curtis Buhman, Colin Stemper, Maria Trueblood, Stephen Horn, Elliott Rankin, Matt Knutson, Emmanuel Nwala

Meeting notes

Agenda

· Welcome, WebEx tips, meeting practices and participant roles

· June Meeting recap/DHS updates

· Guiding principles

· Break

· Group discussion: History of reshaping waivers

· Break

· Group discussion: Policy development

· Confirm meeting schedule, next steps review, adjourn

Introductions

· Introduction of new member (Myrna Peterson)

June meeting recap

Major policy themes of discussion and questions:

· Proposed budget amounts

MnCHOICES and individual budgets

Dependency and reliance

Self-direction

· What happens to CDCS?

· What will expanded self-direction look like?

· Budget exceptions

If I need more funding what will be the process and who will qualify?

· Lead agency consistency

· Equity

· Performance measures

· How will we know if we meet the goals?

· DHS will:

Update frequently asked questions

Use the major themes to direct meeting topics

June 30 meeting materials:

Agenda | Presentation (PDF) | Meeting summary | Chat transcript (PDF)

Updates

· DHS will update FAQ and post it to the Waiver Reimagine webpage soon.

· DHS sent a survey to the public in July on reshaping the waivers.

· In April, DHS held a focus group with people and families to discuss possible changes to habilitation requirements.

· DHS is drafting a summary page of purpose and intent for the equity analysis document. We will post the equity analysis and summary document to the Waiver Reimagine website in mid/late September.

Guiding principles for reshaping the waivers

WRAC members shared hopes and concerns during and after the March 3 meeting.

During the April 28 WRAC meeting, members worked in small groups to convert hopes and concerns into guiding principles for reshaping the waivers that will act as guideposts for future policy development. Visit Waiver Reimagine Advisory Committee minutes April 2022 for more details.

Principle #1: Make the waiver system easier for all to understand and use

Guiding principles:

· Create a waiver system that is easier for all to use.

· Expand service options.

· Improve access to services, including accessibility and usability.

· Develop policies/programs that people with disabilities can understand and navigate.

· Create uniform policies/processes that are administered consistently across the state.

· Streamline paperwork and other processes, so that it is easier for professionals and caregivers.

Outcomes:

· Create resources for people receiving services that describe waiver programs, services and related policy in a simple way, so they can make more informed choices when planning their services and supports.

· Train/educate case managers on waiver programs/services and related policy as a result of Waiver Reimagine changes to assure consistency with implementation. 

Principle #2: Increase choice and control

Guiding principles:

· Empower people with information, so they have more choice and control over their services.

· Create clear pathways to options for people receiving services.

· Shift power from the lead agencies to people receiving services.

· Keep person-centered practices at the forefront.

· Less focus on independence; more focus on interdependence.

Outcomes:

· Develop resources to educate people on waiver service options, informed choice and self-determination.

· Reduce administrative work to build case manager capacity to educate themselves and people receiving services on their options.

· Maintain current self-directed service policy. 

· Define interdependence for people with disabilities. 

Principle #3: Equal access to services

Guiding principles:

· Create a system that provides equal access to services, regardless of disability, regardless of waiver and in which county or tribal nation a person lives. 

· Recognize barriers to service access due to workforce and housing shortages.

· Create a process that will enable lead agencies and residential providers to respond effectively to change in need and change in demographics.

Outcomes:

· Conduct an assessment of gaps in service access.

· Define equity as it relates to access to waiver programs and services (consider demographics, geography, workforce and housing shortages).

· Increase cultural awareness and capacity to support people with different cultural backgrounds/needs.

WRAC input:

· Add to the equal access to services guiding principle “equal access no matter the type of waiver a person is on.”

· DHS action: Phrase added in first bullet under Principle #3: Equal access to services.

· An outcome should be equal access to funding regardless of which waiver is assigned. Ensure that other services needed won’t defund other budgets.

· DHS action: Add to individual budgeting guiding principles.

Principle #4: Flexible and self-directed service options

Guiding principles:

· Create processes that lead to a variety of service options, including expanding self-direction regardless of waiver type/living arrangement.

· Create flexible service policy to allow alternative support options such as remote support/assistive technology.

· Assure self-directed service options are individualized, not requiring people to fit into a specific category of service. 

· Shift emphasis on congregate living by incenting flexible service options and self-directed services.

Outcomes:

· Define levels of self-direction.

· Define flexible as it relates to waiver program and service access.

· Create a liaison position in each county to work between case managers and client (out of scope).

· Create equal access to technology funding and training.

WRAC feedback from 1:1 meetings

Member recommendations were turned into outcomes, such as: 

· Define equity, independent/interdependent, self-direction, flexible

· Create resources for people that describe waiver programs and related policy in a simple way

· Conduct an assessment of gaps in service access

DHS action: Outcomes recommended were added to the guiding principles

Additional member recommendations were added to the principles:

· Less focus on independence and more focus on interdependence

· Recognize barriers to service access due to workforce and housing shortages

DHS action: Additional principles recommended by WRAC members were added to the guiding principles.

WRAC general feedback on guiding principles

· There needs to be a reference to action plans as many of these things can be done now prior to finalizing Waiver Reimagine.

DHS action/next steps: WRAC to determine what of the action plans/outcomes can be completed prior to finalizing Waiver Reimagine.

· Streamline paperwork so that it is easier for caregivers to do and less work

DHS action: Added this principle to guiding Principle #1.

WRAC feedback on how to use the guiding principles and outcomes going forward:

· Whenever a policy or procedural decision is made we need to assure it fits within the guiding principles.

· Use them as criteria as aspects are discussed piece by piece to assure consistency.

· The guiding principles serve as a great reference to guide success and failure as decisions are made.

· Each time we decide a policy, review it carefully in line with principles.

· It would be great to formally circle back to these principles more often...maybe call out the times when our discussion and decisions made directly relate to these principles.

· The principles may need to be fluid and change as we progress.

· DHS staff could reference specific guiding principles when presenting us with options or questions to decide.

· At the conclusion of topic discussion, we should refer to the principles to see if suggestions are advancing the principles. It should be a guide, but not control discussion.

· Balance guiding principles with rules/statutes and federal requirements.

History of reshaping the disability waivers

· Minnesota’s four disability waivers were developed at different times, which resulted in each waiver having a menu of services to meet a person’s specific diagnosis and level of care need.

· Over nearly four decades, the Disability Services Division and the disability community have largely moved away from narrow diagnosis-based care to being more person-centered, with flexible services to meet a variety of needs. The services and supports for a person’s needs are not dictated by their clinical diagnosis alone. People with the same diagnosis may lead very different lives. 

· In 2017, the Legislature asked DHS to conduct a study to identify improvements to the four disability waiver programs including reducing the number of waivers. 

· After more than three years of researching other states and revised federal laws, reviewing the existing systems and policies in Minnesota and soliciting extensive feedback from interested parties, DHS recommended combining the four disability waivers into a two-waiver system that reflects support needs based on the type of living setting in which the person resides.  

2017-2018 waiver reconfiguration studies:

· Analysis of Federal Authorities & Research Into Other State Activities: a comparison of waiver authorities and structure, and how they are used in other states (PDF) (4/13/18)

· Stakeholder Focused Discussions: a summary of the stakeholder engagement effort (PDF) (6/4/18)

· Feasibility & Recommendation Report: reconfiguration options and preliminary recommendation (PDF) (9/14/18)

· Waiver Transition Report: a plan and additional considerations for waiver implementation (PDF) (10/19/18)

Topics outside of the scope of the WRAC (e.g. housing/workforce shortage)

The scope of the WRAC does not include building recommendations for:

· Developing alternatives to combining the four disability waivers into a two-waiver structure that reflects support needs based on the type of living setting in which the person resides.

· Other out-of-scope topics such as workforce/housing shortage.

Out of scope input/solutions identified by the WRAC

· There should be a third option called "Transitioning" to help people transitioning from one waiver to another (one housing type to another).

· One waiver would be the most simplified approach and ensure equal access to services.

Input/solutions on out-of-scope topics from previous meetings, public input and future meetings will be documented in the draft Waiver Reimagine legislative report.

Additional WRAC Input:

· The transition to two waivers should not result in loss of services or pushing higher functioning people out of the system.

· Services available under each of the waivers must meet everyone’s needs regardless of setting.

· Support simplification.

· Moving between the waivers is going to have to be an easy and readily available process, to support informed choice and timely access to needed and preferred services.

· It might be helpful if we better understand the benefits of this two-waiver system as viewed by DHS.

WRAC feedback related to Fiscal/budget impacts:

· I am concerned that the two-waiver system based on where you live will (maybe unintentionally) fiscally support congregate living facilities vs. living in home of choice supported by family and/or staff of choice.

· The major difference is the rate at which that living setting is supported; there is a large portion of the budget that goes to support the setting, where if it is a family setting, there isn’t a budget to support that so the title needs to reflect the actual difference.

Topics inside the scope of the WRAC:

· The scope of the WRAC includes building recommendations for (not an inclusive list):

· Alternative names for two new waivers. 

· Additional/alternative ways to describe eligible living settings/service arrangements by waiver.

· Policy changes to habilitation (a current requirement for people on the DD waiver).

· Service menus for each of the new waivers (including self-directed services). 

· Criteria and processes for moving between waivers. 

· Resources and tools for people and families to help them navigate the new waiver system.

· Identification of gaps in the current service menu.

· Recommendations developed by the WRAC related to these policy areas will be documented in the WR legislative report and used to revise or develop policy/procedural guidance.

Reshaping the waivers survey

DHS staff provided a sneak peek of information to the WRAC. Survey information will be used to inform WRAC policy decisions in future meetings.

WRAC feedback regarding the reshaping the waivers survey:

· Prioritize person-centered practices by including external stakeholders in the survey development process.

· For future surveys a focus should be on getting responses from people with disabilities and non-white stakeholders.

· The number of responses is very small and not as diverse as we'd probably like. The WRAC needs to be very cautious about how we use the survey data.

· Send the survey to case managers and mandate that it be shared with stakeholders.

· Could increase survey response if you circulate it through natural touch points – through service providers, case managers, support planners, etc.

· Share survey with county public health departments. With the pandemic, many established excellent networks for rural, non-white and all other interested parties.

· Be intentional when you want feedback from people.

Naming the two new waivers

WRAC members were asked to recommend names for the two new waivers, based on the descriptions below.

Minnesota’s proposed waiver names/examples of living arrangements and services:

Waiver 1: For people who live in their own home or family home

Example: A person is living with their family and has a community provider come in to provide assistance with meeting their goals, support them in the community (individualized home supports with family training). There is a second

community provider who supports the person in reducing unwanted behavior (positive supports services)

Definition of own home: A single-family home or multi-family home (e.g., apartment) where a person age 18 or older lives or a person, regardless of age, lives with their family, and the person or their family owns/rents and maintains control over the individual unit, demonstrated by a lease agreement (if applicable). The term “own home” is used for technical program requirements to ensure appropriate services, regulations and protections are in place. We recognize where a person lives is considered their home regardless of the technical program terminology. A person should have control over their home as much as possible

Waiver 2: For people living in provider owned/managed residential settings

Example: A person lives in a corporate residential setting. There are shift staff who come into their house. The person has several roommates. The person has supports around unwanted behavior due to positive symptoms of schizophrenia which manifest as auditory and visual hallucinations, physical aggression toward others, self-harm, property damage and elopement. The person has difficulty sleeping through the night and there is always a staff person awake.

Definition of provider-owned/managed residential setting: A service provider owns, operates or leases the home/unit and/or has direct or indirect financial interest in the person's housing.  The technical and federal term is “provider-controlled.” However, for purposes of renaming and defining waivers, a more person-centered term is preferred (provider owned/managed).

WRAC input on names of two new waivers:

Waiver 1 (alternatives to Individual Supports):

· Own/family home waiver

· Unlicensed setting waiver

· Individual and Family Directed Waiver

· Individual Living Support Waiver

· Family support waiver

· Individual and Family Settings Waiver

Waiver 2 (alternatives to Residential Supports):

· Residential support waiver

· Provider managed setting waiver

· Licensed setting waiver

· Integrated supports waiver

· Managed supports waiver

· Managed settings waiver

· Corporate supports

Note: DHS explained that there are licensed settings and licensed services. Most services are licensed, regardless of the type of setting services are provided in.

Additional WRAC input:

· CDCS should be in all descriptors/examples.

· Licensed and Unlicensed might make more sense but I’m not sure that encompasses why there is such a big discrepancy in funds.

· Do not call the waivers licensed and unlicensed. Need a better term than provider-controlled.

· Provider “managed” is more politically correct than “controlled.”

· Individual support that doesn’t really explain the living situation, so maybe both names should emphasize where you live – it should be clear.

· For Waiver 1, the intent is for people to receive individualized supports, so the name should reflect that.

· Clarify which waiver people living in a group of apartments owned by one person who provides people to help them all would fall under.

· It may take a while before naming the waivers evolves beyond the placeholders.

Closing/Next steps

· In December, the WRAC will finalize recommendations for the names of the two waivers and associated descriptors.

· Future meetings will include agenda topics prioritized by WRAC members:

Habilitation requirement currently on DD waiver for eligibility.

Moving between waivers; transitioning needs to be easy.

Services by waiver (including self-directed services) – what will be available.

Resources for people and families; also need to support case managers.

Other policy associated with the transition to two waivers.

Adjourn

The meeting was adjourned. The next meeting of the WRAC will be Thursday, Oct. 27, 2022 (individual budgets). Meeting details can be found on the Waiver Reimagine Advisory Committee website under the Meetings tab.