Waiver Reimagine Advisory Committee meeting 17 notes

Oct. 23, 2024

Committee attendees: Kathryn Barton, Annie Braun, Tricia Brisbine, Rosalie Eisenreich, Lisa Evert, Kelly Friesen, Mary Fenske, Arbdella Hudson, Katrina Jirik, Meredith McKinnon, Sue Mackert, Julie Morrison, Polly Owens, Rijuta Pathre, Sherri Pickthorn, Gretchen Spier, Chad Wilson, Gina Winter, Pat Wright

Not present: Charlene Abramson, Jennifer Ballinger, Jennifer Drganc, Abigail Gertken, Zahnia Harut, Elizabeth Iddings, Addyson Moore, Saudade SammuelSon, Fartun Weli, Wa Xiong

DHS attendees: Sarah Beauchene, Peter Beierwaltes, Iwalani Else, Heidi Hamilton, Matt Knutson, Natasha Merz, Darcie Thomsen

Welcome

Facilitator Lea

· Live captions: https://www.streamtext.net/player?event=WRAC

Meeting notes

· Facilitator Lea welcomed everyone to the meeting.

Meeting practices

Facilitator Lea

· When speaking, re-introduce yourself (and who you represent)

· Speak slowly so the captioner can accurately capture what you share

· Share your main thoughts/key points early when speaking

· All members have the right to share their ideas and all ideas are valuable

· Assume positive intent – embracing a mindset that will lead to something good

· Please be mindful of the distracting nature of chat messages to both presenters and other members and use chat to add to the conversation when you are unable to directly share your thoughts

Today’s meeting objectives

Facilitator Lea

· To present information on Waiver Reimagine survey

· To confirm member input from August 

· To learn more about WRAC member concerns

MnCHOICES update

Heidi Hamilton, director of Disability Services Division

· As of Oct. 1, DHS is fully into MnCHOICES revision 2.0

· It was known as 2.0, but going forward will only be referred to as MnCHOICES

· Work continues on MnCHOICES

· Working on lead agency’s prioritization of changes

· Positive feedback, especially for second assessments

· Changes being made create more efficiency for agencies to process reductions and budgets

· Some CDC budgets were reduced and some were increased; equal amounts of both

· DHS is asking assessors to contact DHS to report situations where CDCS budgets changed and there was no change in condition

· If you know of an assessment where CDCS budgets have changed but conditions did not, reach out to DHS for follow-up

· MnCHOICES team heard from 40 people who received reductions without condition changes

· DHS is adjusting those situations individually

· Some of the 40 situations reviewed have resulted in a change in guidance

· DHS is monitoring this work closely to ensure MnCHOICES is a stable assessment tool for Waiver Reimagine

· This is a large system change, so some teething challenges will occur

· Let WRAC networks know to contact DHS with unexpected situations such as a budget change without a change in condition

Questions/comments;

· Member and ARC volunteer: Half the people (they see) have had a significant change in budget without a change in condition. Who do they reach out to at DHS?

· Heidi Hamilton: Use the DSD Contact Form.

· Member: Similar situation outside of CDCS using 2.0 for the first time. People mentioning at county level that supervisors are not supporting people with appeals. If DHS is only getting data from appeals, there are a lot of road blocks to make an appeal. How can we support gap of people needing appeals? This is happening in practice and on the ground.

· Heidi Hamilton: DHS is looking at data through appeals and working from a larger, system level, researching what is driving the increase or decrease of budget changes. DHS knows there’s a concern and wants to hear about these instances to continue development work.

· Member: Already seeing some discrepancies with MnCHOICES budgets. How will MnCHOICES be validated as an effective tool? System isn’t asking about meds any more. Reconsider asking this question with MnCHOICES 2.0. How do we know MnCHOICES is successful?

· Heidi Hamilton: Good feedback. There will be some changes as we move to statewide assessment. DHS wants to ensure this new tool is effective. DHS is looking at scores and circling back with assessors to have a deeper level of conversation to ultimately include in training and education.

· Natasha Merz: DHS is looking at this from a system level. There were challenges moving from version 1.0 to 2.0 and dealing with questions regarding the tool. DHS knows reliability is needed when moving from one tool to another. DHS is working with a vendor to make changes to the tool and to assess the long-term reliability. DHS is also looking at report of challenges from a person level so people know they can file an appeal and/or contact DHS. DHS is balancing trying to make assessments not feel like interrogations, which does create a little more opportunity for discretion which could potentially reduce reliability, but we are trying to balance this; we do want to hear from people individually.

· Member: Waiver Reimagine was to do a side-by-side comparison of 6,000+ people. This is a great mini test to flush out issues. Don’t just rely on appeals. Suggest DHS implements communication plan with counties. Need more messages at the county/worker level.

· Member via chat: MnCHOICES 2.0 does not address behaviors or severe medical. Because of that, FRS homes have significant rate change and counties are saying to just accept it.

· Member: So many steps to appeals. People who don’t have a lot of resources may not bother.

· Heidi Hamilton: DHS is also analyzing the data about the changes and understands appeals may be difficult for some people.

· Member: At the county level we are not finding a lot of variation in the CDCS budget. When this happens, we counsel with another assessor to identify anything missed, then we reach out to DHS. Haven’t had to reach out to DHS much.

· Member via chat: Regarding which data points to use when tracking MnCHOICES 2.0, track the percentage of participants that have CDCS budgets reduced and increased using 1.0 vs. 2.0. Similarly, with PCA/CFSS hours in 1.0 vs. 2.0. Finally, track if 2.0 has resulted in more waiver termination vs. 1.0.

Waiver Reimagine survey background

Darcie Thomsen and Iwalani Else, DHS Research & Evaluation

· Presented an overview of the Waiver Reimagine survey results

Who responded to survey?

· One quarter of those surveyed and responded were younger

Top 5 counties who responded to survey

· What would this look like if more than the 39 counties responded?

Categories of who responded to survey

· Those with a disability had the smallest number of people responding

Waiver Reimagine familiarity

· Providers were more apt to know about Waiver Reimagine than those receiving waivers

Waiver Reimagine – Top 3 concerns

· Read down the columns. Each column in rank order of pre-determined concerns

Column 1 = All are concerned. Graduation of those concerns

Column 2 = Varies depending on who responded

Column 3 = Varies depending on who responded

Difficulties when using waiver services

· Additional responses to the themes:

1. Waiver system is complex. Need guidelines to access.

2. Don’t trust county agencies. Felt decisions they made are arbitrary. Counties are gatekeepers. Poor communication form case managers.

3. Inconsistencies in services allotted depending on geography and services needed.

4. Insignificant training of providers. Service gaps. Specific needs not met, especially if the need doesn’t fit well in a category.

5. Increased need/decreased budget. Paper process takes away from care.

6. Led to reduced services and quality of life. Leading to institutional care versus independent living.

Suggested changes to waiver services

· Further responses to the themes:

1. Frustration of complexity of the process

2. Clearer communication process and availability. Improve training of case managers. More transparency. Need clear channels to respond.

3. Want more control.

4. Need staff training and consistency of case managers. Support families in crisis. Provide training to navigate waiver system.

5. Equitable assessment across counties. Differ in funding consistency across waivers.

6. More effective channels to consider feedback. Collaboration between all involved.

7. Changes may affect people negatively.

Cultural needs

· Additional engagement strategies and overall efforts. This is one strategy.

· Next steps: Ewa and Darcie are working on a findings report and will share this with WRAC and others. There are other engagement efforts also going on. Strategies for those will be discussed with WRAC members.

More questions?

· Thank you for input. Contact information given on the slide for questions/comments, or send to WRAC email address

Questions via chat

· Member via chat: The survey is echoing what we discussed earlier about the MnCHOICES 2.0 concerns. Self direction is really the concept behind CDCS. We have discussed in past meetings that CDCS is going away. I ask that we add CDCS/self direction as a future agenda item so we know how WR will impact them both.

· Member via chat: Did the survey break down how many respondents were people of color?

· Darci via chat: Yes, we do have that information and it will be included it in the more detailed report results.

· Member via chat: Summary of the survey segment today: There are 67,000 waiver users in Minnesota. 4,000 showed interest in giving feedback. 404 people were actually surveyed which is less than 1% of the population. The majority of the 247 indicated they knew “little or nothing about Waiver Reimagine.” So the 247 are giving us feedback on something that they don't have knowledge of. This is concerning. We only had feedback from 39/87 counties. Need to keep moving forward with engagement process. Your work is appreciated.

· Member via chat: It is problematic that you are basing decisions on how waivers are being used when there are numerous instances of services not available.

August meeting recap

Natasha Merz, assistant commissioner for Aging and Disability Services

· Walks through outcomes of previous WRAC input on what was working well and what wasn’t working well for members. Meeting responses grouped into themes/buckets showing how many people responded.

Addressing Waiver Reimagine concerns

Natasha Merz

· Summarized issues and explained what DHS is doing to address some of the noted issues.

· No surprises to what DHS is hearing. WRAC attendee comments are consistent with survey findings.

· Issues #2 and #3: State is setting a methodology

· Issue #4: Consistent across the state. Case management is a huge topic that is being addressed.

· Natasha Merz asked for feedback to Issue 1: What should DHS do to address what’s not working? What have we missed or what are we not hitting the mark on? What else should we be doing? What should we stop doing?

· Member: Response to issue #1: Challenging when we start dissecting feedback. What’s working is access to services – shown in both lists – of individual and county situations. Issues can be looked at so many ways and it shows how complicated this all is. We may be trying to change too much. Start small.

· Natasha Merz: Thank you for articulating the problems. Lived experience is true and valid. We need to find the balance between individual and system-level experiences to inform future change.

· Member: Concerned with survey. Many survey respondents felt the survey was long and only surveyed the predetermined outcomes and had an agenda. Appreciate Natasha being here. One suggestion for all four issues is for DHS to authentically partner with waiver recipients on the design, implementation and evaluation of all these methods. Success equals sharing of power to design, implement and evaluate the policies, programs and methods.

· Member: Authentic partnership = WRAC co-creates agendas for every meeting, working on the roadmap and timeline, DHS works with WRAC to write and present the legislative report and pause the current timeline to revisit the two-waiver system.       

· Member via chat: To answer question of defining success: people most impacted are developing the policies WITH DHS from the start, and people with disabilities on waivers are the key and primary decisionmakers.

· Natasha Merz: we’ve heard it loud and clear that this group wants to look at one budget and how that changes spending; changes in spending would need legislative approval; the fact that we haven’t made big changes doesn’t mean we aren’t working on it but we must follow the legislative process. We can talk more about this in a future meeting.

· Member: Project foresight = one assessment tool and budget for each person. Assess needs, make a plan and provide budget. Simplify things. What’s not working = direct budget based on where person lives. Difference in funding for home vs. being institutionalized. Take county out of the equation when determining budget. Separate service manager and put in hands of person working with the individual.

· Member via chat: The concern is that no two counties are the same with how they interpret Waiver Reimagine. How can the county component be more consistent and enforced?

· Matt Knutson: https://mn.gov/dhs/partners-and-providers/news-initiatives-reports-workgroups/long-term-services-and-supports/waiver-reimagine/scenarios/ This is a link to the service menu which was launched January 2021.

· Member: There was a group that spent 18 months discussing CDCS which was meant to interact with DHS and hasn’t gone anywhere; would like to get response from DHS on group’s charter. Out of 18 states, Minnesota did really well. Regarding the portal, would like to hear more about this in a future meeting. It could help with a lot of challenges if there is a person that could be called and reroute the calls.

· Natasha Merz: Minnesota has been a leader in self-directed care programs which is a product of many people over many years. Part of the goal of individualized budgets was to give better access to self-direction. People can call Disability Hub MN or use the DSD Contact Form for further questions. We can explore this in a future meeting to talk about what else we can add to our capacity or discuss our approach to getting questions asked.

· Member: System navigation challenges; there’s so much to know. Issue #4: So much turnover with case managers. They are burning out over workload and information to know. Access is limited in rural communities. People don’t have access to services because services are limited in their areas.

· Natasha Merz: Case management is very challenging to be successful. One approach is to give people the ability to manage themselves. A second approach is taking a hard look at case management under the programs to understand the expectations and what is doable.

· Member: Time to complete assessments has increased.

· Member: Case managers are putting an additional stress on families to be case managers and to research options.

· Member via chat: Part of the reason that there are not enough providers is that the 245D requirements have become so cumbersome that you need to be a small corporation in order to meet all of the state mandates. CDCS is also an answer to this. Let people decide how their needs can best be met, without having to only rely on 245D providers. Regulations are becoming a huge restraint.

· Natasha Merz: Due to a lack of time remaining, DHS requests your top three topics to discuss for future agendas. Thank you for your engagement.

· Member via chat: Discuss and create a plan for in-depth data collection on the pain points discussed today.

· Member via chat: More on portal for HCBS with time for design input discussion

· Member: Discuss basing WR on where a person lives; base it on their needs. Discuss how DHS will partner with WRAC.

· Member via chat: how to involve more waiver users in this process.

Wrap-up and future meeting information

Facilitator Lea

· Future meetings:

Thursday, Dec. 12, 2024

Thursday, Feb. 27, 2025

· Note: December meeting will be earlier than usual because of the holidays

· The post-meeting survey will also ask for members’ top three topic picks so all members get the opportunity to give input in future meetings.