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New York Disability Supports Community Readies for ‘Care Coordination’ Change

August 9, 2016

By Mendy Hecht, Hamaspik Gazette

Top OPWDD Advisor: Hamaspik “Well Positioned” for Transition, All-around Services

Under a federal rule first enacted in 2014, the New York State OPWDD and its non-profit partners are readying for a big change to how Medicaid Service Coordination (MSC) is provided.

The vital MSC service has been provided by the OPWDD via Hamaspik and community non-profit partners for decades. With MSC, Medicaid Service Coordinators (MSCs) help assigned beneficiaries navigate the many Medicaid-funded supports for people with disabilities.

As such, employees who work as MSCs are a fixture in state human-services bodies and non-profits everywhere.  At Hamaspik, where devotion beyond the call of duty is par for the course, the agency’s corps of MSCs in three counties has built a loyal community following of its own.

But with the rise of the conflict-free case management concept, the federal Centers for Medicare and Medicaid Services (CMS) has lain down a key change for state agencies and non-profits alike whose services include your friendly and helpful MSC.

As of September 30, 2015 (more on that deadline later), the 21 states that got funding from a federal grant called the Balancing Incentives Program (more on that later) are providing MSC services conflict-free.

In plain English, that means that your MSC now doesn’t work for the same organization that provides you with any of your other disability support services.

Instead, you’ll get so-called care coordination provided by a different organization.

The thinking is that having a care coordinator outside your support services organization is more objective towards your needs, fairer to all provider organizations, and more person-centered—in short, free of any conflicts that may put other interests above yours.

Roots of change

The shift to conflict-free case management is one of the several federal changes to disability public policy brought to bear by the Affordable Care Act (ACA).

Specifically, a section of the 2010 “ObamaCare” law gave teeth to the Supreme Court’s 1998 Olmstead decision—which in turn gave teeth to the 1990 Americans with Disabilities Act (ADA).

Under Olmstead, it is a violation of the ADA to not provide people with disabilities with the most independent support settings.  ObamaCare built on that by quietly including the Balancing Incentive Program, which funded state programs that ostensibly enhance independent support settings.

Among these is conflict-free case management.

According to the text of the conflict-free case management rule enacted by the federal government in 2014, “Conflicts can arise from incentives for either over- or under-utilization of services; subtle problems such as interest in retaining the individual as a client rather than promoting independence; or issues that focus on the convenience of the agent or service provider rather than being person-centered.”

“Many of these conflicts of interest may not be conscious decisions on the part of individuals or entities responsible for the provisions of service,” the rule also notes.

Among the required elements of conflict-free case management are for case managers to not be family members of the individual getting or applying for services (or to anyone financially responsible for the individual), monitoring and oversight, and firewalls within single entities responsible for providing both case management and service delivery.

The CMS and partner states now believe that much of any existing conflicts of interest will be successfully reduced or even eliminated now that states that participated in the Balancing Incentive Payment program have had each provider agency transition their in-house MSC services to outside, objective care coordination.

The long run

But 13 states are still in the game.

Of the 21 states that participated in the Balancing Incentive Program grant during its 2011-2015 run, 13—including New York—have perpetuated their participation well past its initial September 30, 2015 concluding date.

The Empire State, for its part, is currently laying the groundwork for its MSCs’ eventual shift from in-house to coordinated care—particularly within the New York State Office for People With Developmental Disabilities (OPWDD), where MSCs remain a critical pillar.

The OPWDD is one of nine state bodies affected by the federal push to care coordination, and responding with internal plans as such.

Being quite early in the transition process as it is, the OPWDD is now only looking at several ideas for how the services now provided by MSCs would be moved over to care coordination. 

Among these is having care coordination provided by existing organizations called health homes—non-profit or even for-profit healthcare providers that care for patients not with the traditional fee-for-service model but with a team-of-specialists approach that rewards caregivers for patient results.

Regardless of what structure or model ends up being adopted by the OPWDD, the roughly 600 non-profits across the state that employ approximately 2,500 MSCs need not worry for those MSC jobs just yet—the OPWDD’s three-phase plan to switch to care coordination will only be first implemented in 2018, according to the agency’s current transition schedule.

On the front lines

With all those sweeping changes looming in the background, Hamaspik was honored to host Michael “Mike” Mascari at an official visit this past August 8.  Mr. Mascari was recently recruited as Senior Advisor to OPWDD Acting Commissioner Kerry A. Delaney after decades of disability non-profit leadership.

The visit opened with a comprehensive guided personal tour of Hamaspik’s Rockland County hub.  The sprawling nerve center is also headquarters to the successful and growing HamaspikCare home-care agency and Hamaspik Choice managed long term care (MLTC) program.

Mr. Mascari spent close to an hour meeting and chatting with those entities’ dozens of employees, garnering first-hand familiarity with Hamaspik’s multifaceted human-services programs, and the faces and names behind them.

“Everyone has more than one job!” he affably noted at one point, as he and his entourage were shown about the offices.

Talking with the professionals manning desks and directing departments across the complex, the OPWDD leader came away impressed by the employees’ command of their job duties.

In particular, Mascari was impressed with a brief discussion on present growth and future plans with Yoel Bernath, the seasoned industry veteran currently serving as Executive Director of Hamaspik Choice.

Getting to know you

At a working business luncheon with agency leadership that followed, nearly two dozen Hamaspik top brass formally introduced themselves and their departments or divisions to the guest of the hour.

Of Hamaspik of Rockland County, those were: Executive Director and agency founder Meyer Wertheimer, Quality Assurance Director Eliezer “Lazer” Appel, Com Hab and Early Intervention (EI) Program Director Eliezer Eizikovits, Development Coordinator Zalman Stein and Public Relations Director Pinchus Weinstock.

Also present from Hamaspik of Rockland were Comptroller Solomon Wertheimer, Director of Day Services Shloime Kornbluh, Residential Services Director Moshe Sabel, longtime MSC Supervisor (and self-described “Hamaspik tour guide”) Nechama Nissenbaum, RN, veteran Intake Coordinator Mrs. Rachel Tress, and NHTD/TBI Director Tzivi Frommer, LMSW.

Representing Hamaspik of Orange County was: Executive Director Moses Wertheimer, Director of Residential Services Joel Weiser and Quality Improvement Coordinator Joel Gross.

Joel Freund, Executive Director of Hamaspik of Kings County and Director of the New York State Hamaspik Association (NYSHA), introduced himself and his operations next.

Rounding out the introductions around the tables were Asher Katz and Mordechai “Mordy” Wolhendler, respectively the Director and Downstate Regional Director of HamaspikCare.  Last but not least were Chaya Back, RN, Hamaspik Choice’s energetic Clinical Director, and 14-year Hamaspik veteran Raizy Mermelstein, Hamaspik Choice’s Intake and Enrollment Coordinator.

As lunch was served and conversation turned informal, a short, catchy video overview of Hamaspik was shown. 

“I think it captures the spirit of the organization,” Mr. Mascari said.

Appreciation for shared mission

Hamaspik of Orange County’s Moses Wertheimer opened the luncheon’s working discussion with a heartfelt message of thanks from Hamaspik to Acting Commissioner Delaney and the entire OPWDD for the recent approval of two new IRA residences for individuals in desperate need.

Those individuals, all of whom have been in “the system” for years, have “tremendous” challenges, Mr. Wertheimer elaborated.  “It’s very difficult for the parents, for the family, to have the individuals at home,” he said, “and they keep on begging, ‘What can you do for us?’ ”

“We can go along with whatever’s available,” he continued.  “But this direction that you took, approving us [for] two new homes, shows that with the effort, the willingness, to do that, it is available to do so, and we appreciate all the effort that you did.  We thank you for that.”

A strong and genuine round of applause ensued.

A prolonged dialogue between Mr. Mascari and Hamaspik leaders followed, with burning issues like the need for more community group homes, the Family Care program and so-called self-directed services discussed at length.

The lead OPWDD advisor expressed support for an ongoing grassroots push for more residential housing as recently exemplified by Hamaspik’s beneficiary community.

“You’ve got to be able to bring the reality to the people in government; they need to know that… there are individual people with names behind them that have needs,” he said.  “And I think you did a good job of translating a policy into the concrete reality of who these families are.”

Responding to Meyer Wertheimer making the case for enhanced Family Care supports, Mascari praised Hamaspik for sticking with the program—matching the often-uncompensated personal dedication of Family Care providers with compassion of its own.  “You have done everything probably beyond what most agencies do,” he said.  “It’s going to take agencies that really go the extra mile and continue to do that as opposed to agencies that are struggling just to survive.”

Various ideas for supporting or even expanding the Family Care program were mentioned as the conversation proceeded, like combining it with the popular home-care programs offered via numerous non-profits by the New York State Dept. of Health (DOH).

Mr. Mascari urged Hamaspik to craft new solutions to the housing and Family Care problems.

Leading into the future

The high-ranking OPWDD guest next engaged his hosts in a dialogue on a looming issue at hand—that of the impending transition of MSC to conflict-free care coordination.

The issue is two-pronged, according to Mr. Mascari—with one being compliance with “conflict-free” itself, and the other how the sea change will affect existing provider organizations like Hamaspik, as well as the numerous MSC provider organizations in each region.

The state’s current plans are to divide the state into a handful of regions, with one or two designated conflict-free care coordination entities serving each region come 2018.

“That’s where it’s going in the next five years,” Mascari pointed out.  “I think you’re well positioned to be at the forefront of that change.”

A brief discussion followed on the future of the Individualized Residential Alternative (IRA) and Intermediate Care Facility (ICF) group home models, as well as NYSHA’s Article 16 Clinic.

The meeting then began wrapping up.

“I appreciate all the time and thought that went into this agenda here. I leave not only with a better understanding of the work that you’re doing here, but some of the discussion here,” Hamaspik’s guest offered—“some thoughts that I might talk to the Commissioner about, in addition to the recommendations that you brought up already.”

He concluded by saying, “I think your organization’s going to be one that will continue to be a leader.”