Waiver Reimagine Advisory Committee Meeting 13 Notes

Thursday, Feb. 22, 2024

Committee members present: Charlene Abramson, Jennifer Ballinger, Kathryn Barton, Annie Braun, Amanda Briggs, Tricia Brisbine, Jennifer Drganc, Rosalie Eisenreich, Lisa Evert, Kelly Friesen, Abigail Gertken, Elizabeth Iddings, Jessica McKane, Meredith McKinnon, Sue Mackert, Addyson Moore, Julie Morrison, Polly Owens, Rijuta Pathre, Phyllis Reller, Saudade SammuelSon, Gretchen Spier, Chad Wilson, Gina Winter, Pat Wright, Wa Xiong

Committee members not present: Don Barnes, Cathy Chavers, Mary Fenske, Zahnia Harut, Arbdella Hudson, Katrina Jirik, Ali Kofiro, Danielle Otto, Sherri Pickthorn, Kathy Rogers, Elizabeth Scheel-Keita, Fartun Weli

DHS attendees: Sara Beauchene, Peter Beierwaltes, Curtis Buhman, Adrienne Hannert, Stephen Horn, Amber Jepperson, Sarah Jones, Andrew Johnson, Matt Knutson, Meghan Lindblom, Mai-Ling Mui, Brenna Slabaugh, Linda Wolford, Sandy Zuhlsdorf

Introductions

Facilitator Lea welcomed new committee members and asked them to introduce themselves:

· Jessica McKane – Parent of a child who receives services

· Addyson Moore – Recipient of services and a parent to two daughters who also receive services

· Charlene Abramson – Person who has moderate support needs.

· Jennifer Ballinger – Works for the Mille Lacs Band of Ojibwe and is the waivered services relations liaison manager

· Gretchen Spier – Human services program manager for Hennepin County and long-term services and support. She supports the area of annual assessment; her teams do annual assessments on people accessing the DD and CADI waivers

· Elizabeth Iddings – Works for Wright County and is a waiver supervisor

· Amanda Briggs – Director of residential services for NorthStar Community Services in Carlton County

· Linda Wolford – Heidi Hamilton is out and asked if she could attend today. She’s the new deputy director and started her position in December. Here to listen and observe.

Meeting objectives

· Provide input and recommendations on whether to keep or remove Habilitation policy.

· Receive input on how decision impacts informed choice to receive habilitation.

Habilitation 

· Stephen Horn, HCBS waiver policy lead, presented slides on habilitation.

· Reference to previous discussion of habilitation in December’s meeting.

· Habilitation requirements that are within the DD waiver.

· How do we move forward with a two-waiver structure with different policy requirements on different waivers?

· This policy affects approximately 70,000 people on the disability waiver as of July 23, 2023.

24,518 people received DD waiver services in 2023 (35-percent of total)

45,544 people received BI, CAC or CADI waiver services in 2023 (65-percent of total)

· Why explore the change?

Per CMS regulations, a consolidated waiver structure cannot apply different requirements to each target group (e.g., level of care) within a single waiver. Same requirements, but offerings will be broader.

Want a balance as we consolidate. Don’t want disruptions to current waiver programs.

DHS is considering removing the residential habilitation requirement because: 

§ We want to eliminate confusion around habilitation requirements 

§ All waivers need to have the same eligibility requirements

§ To uphold and align with informed choice principles

· What is habilitation?

Centers for Medicare & Medicaid services (CMS) core definition:

§ Services designed to assist people in acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in home and community-based settings.

Minnesota’s DD Waiver requires all people to:

§ Have at least one residential habilitation service authorized and delivered.

§ Have a residential habilitation service in place within 90 days of the person starting on the waiver.

People on the BI, CAC or CADI waiver do not have a requirement to receive residential habilitation services. Other training services are available.

· Services that meet the residential habilitation requirement

There are many ways to meet habilitation requirement today: Individualized housing supports (HIS) with training, unpaid primary caregiver when homemaker or respite is authorized, Community residential services (was foster care), Consumer Directed Community Supports, Family residential services (was foster care), Integrated Community Supports and HIS with family training.

Habilitation will cross all disability waivers. Habilitation will be in-person, through a support plan, and with adoptive skills to meet goals and outcomes.

· Habilitation – Stakeholder feedback efforts to date

DHS conducted habilitation focus group in 2022 and three public surveys between 2021 and 2022 requesting input on options for keeping or removing the residential habilitation requirement

Majority of feedback received across input from 300+ responses to surveys and the focus group is to remove the residential habilitation requirement

In addition to WRAC input, there will be further public stakeholder input requests (e.g., surveys) in 2024 on this topic

· What may change regarding residential habilitation?

If the residential habilitation requirement is removed:

Services will still have habilitation components identified

If you need habilitation, you can get habilitation

If you want to work on goals, you can.

· What may change?

Residential habilitation may not be required

Goals may not be required. 

· Identical services will remain available with or without the habilitation requirement

· Habilitation discussion questions

Recommendation to keep or remove habilitation requirement?

Feedback requested for four questions:

§ What do you like, or not like, about the current residential habilitation requirement?

§ What do you like about removing the residential habilitation requirement?

§ What are your concerns about removing the residential habilitation requirement?

§ What other information is important to consider if this transition occurs?

WRAC questions and feedback on habilitation discussion questions

· What is the purpose of habilitation component? Why does it only apply to the DD waiver and not others?

Stephen Horn: Historical design of the federal government that has continued. Medicare and Medicaid have adjusted over time to not be mandated. States have the flexibility to keep or remove that assessed habilitation need as an eligibility requirement.

· What is the functional purpose for the recipient? Why do we need it?

Stephen Horn: How we (globally) support needs of DD waiver. Expectation of needing and building skills so people could live independently in the community. Historical perspectives of how to support the target population.

· There was much support for recommending to end the habilitation requirement.

Seems restrictive and forcing people to “better” themselves.

Focus on the person instead. Have person-centered plans and goals people identify themselves.

It is condescending to tell people they must develop toward imposed goals.

Members who are professionals in the waiver system expressed a desire to drop the habitation requirement.

· There was also support for keeping the requirements.

It speaks to the Olmsted Plan and trying to support people to function in the least restrictive environment.

Concerned taking this away is going to keep people from getting out into the community which is already difficult due to staff shortages.

· Some people were undecided

Need to focus on systemic issues. Shouldn’t be just for DD. Should be a requirement across the board. This is a medical model.

People need to be habilitated in a special way for those who can work, but there are barriers. Need spaces and purposes beyond work.

Helpful to have more about history. Know where we’ve been so we can know where to go.

Member feedback on ensuring informed choice

· Stephen Horn explained that habilitation requirements, kept or removed, won’t change residential care. There will still be the services that help those who want to be out in the community. There may be a change how the service flows. How do you continue to have accountability when there are changes to the plan?

Member asked a clarifying question: When we move to two waivers, the Olmsted requirements and person-centered planning concepts are mandatory. Wouldn’t you, by default, meet the habilitation requirement in both waivers in this new structure?

Stephen Horn confirmed both requirements still apply. Engagement in community still exists. Foundational requirement still exists.

The habilitation requirement doesn’t seem to serve the individual. If people are not interested in having habilitation, and they can still be served through a waiver whether it is the DD waiver or another waiver, this would simplify and streamline things.

Self-direction should cover this. There doesn’t appear to be a need to keep habilitation.

I vote against the habilitation requirement because interdependence is ok and the habilitation requirement leans toward independence and can be condescending and ableist.

· Stephen Horn asks: What do you recommend assessors and case managers know when they are talking to people about habilitation being a choice? How does it impact your support plan? How does that impact the informed choice process and requirements that are present?

· Sara Jones gave some background on informed choice meaning providing complete and accurate information so all people can make their own decisions about their plans, their goals, and their own services. There is a viewpoint that keeping habilitation as a requirement might not fit with informed choice requirements related to people choosing their own services. We have heard from WRAC members that choice and understanding people's unique goals are really important. If the habilitation requirement is removed, but the services are still available, what do planners, assessors, and case managers need to know to communicate this change? Tell us how to talk about the change.

Don’t think habilitation requirement should exist. Most people don't realize it’s a requirement.

Well-trained case managers should be asking: What do you need to acquire, retain, improve your self-help, socialization, and adaptive skills necessary to reside successfully in home and community-based settings? Ask people what they need to successfully live their lives.

If we were to require habilitation services for the BI , CAC and CADI waivers it could make the staffing shortage more difficult.

· Facilitator Lea asks: What do you recommend assessors and case managers talk about with people when offering habilitation as a choice? How do they inform people on DD that habilitation is no longer a requirement? What choices should people be offered, and what information will be important for people to know to make decisions about their needs related to habilitation?

When doing an assessment, there is a menu of items to be eligible for or not. Determine what will help them get where they want to go. Then the case manager has enough information to let them know what services would do this.

We need to focus on people’s strengths. Ask, what's holding you back? Is there something we can put in place to help you move through it?

Clearly laying out services is important because people may not know what exists. This helps them know what to ask.

· Stephen Horn thanks members for sharing this important information and for having the courage to speak in public. We can create better opportunities for people with disabilities in Minnesota to live independently.

Other updates

Safety

· Sara Jones: The division is involved in an effort called Culture of safety. All WRAC members, if interested, can join the orientation on March 5th.

· Open to people supported by our services, their families, lawmakers, providers, state agencies, and advocacy organizations.

· Look at critical incidents in our systems.

· Fixing or learning about complex issues such as safety; how are policies and procedures, from the federal to the local level, impacting people and caregivers.

· An email with dates and registration information will be sent to members.

Linda Wolford

Thanks members for their responses. Great accomplishments today.

Meeting adjourned

Future meetings:

· Thursday, April 25, 2024

· Thursday, June 27, 2024

Survey being sent on Feb. 29, 2024, to WRAC members about the April 25, 2024, meeting.

· Survey to include feedback about Feb. 22 meeting, possible future topics and WRAC member input on additional topics not listed

· WRAC members to rank topics in order of importance

· If topic isn’t chosen, will be on future road map

· Thank you in advance for responding.

Key points/themes

· The habilitation requirement can be seen as ableist and imposing unwanted goals.

· The majority of WRAC members expressed an interest in getting rid of the habilitation requirement.

· WRAC members preferred that habilitation services exist for people receiving services to request them if they want them and if they align with their own, personal choices.

· The training of case managers and others working with people with disabilities to know about all available services and to use person-centered practices is seen integral to good service provision.

· Increasing availability of services across waivers may strain an already strained workforce.

Full meeting chat

· Chat was not available this month.