IDD Service Providers Need a Plan: Serving People with Complex Needs

“Change almost never fails because it’s too early. It almost always fails because it’s too late.” -Seth Godin

The hot-topic in the field of Medicaid-funding is the care and service provision of those with complex needs—that is– the top five to twenty percent of Medicaid beneficiaries whose care needs amount to a significant portion of Medicaid expenditures. Do you have a way to identify those with complex needs that are currently receiving services from your agency? Please take special note that IDD service provision is not the exception to this rule. IDD services that are federally-funded must develop data-driven, evidence-based strategies for providing services to people with IDD that may also have complex needs—all IDD services are health care services. Long gone are the days of exceptions!

Mandated reform from Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health and Human Services(HHS) derives from high cost and spending in health care on the whole in the United States, especially when considering the high costs of long-term services and supports for our large aging population.  Those with IDD access the healthcare systems at significantly higher rates than their peers without IDD. The cost of health care for people with IDD is historically high and states including New York are organizing incentivized demonstrations to explore new models and innovations to drive down the high costs while simultaneously and efficiently increasing the quality of individualized services and outcomes. Moreover, valued-based payment models versus the current fee-for-service will make payment to a provider directly based on the quality of care, outcome of care and the cost of care. Consequently, a provider that cannot effectively control costs and support positive person-centered outcomes will ultimately find it impossible to sustain service delivery on federally-funded Medicaid dollars.  Health care reform is the order of the day.

Prepare for the educated beneficiary, advocates and guardians, better equipped to make informed choices. Prepare for managed care organizations deciding on if they may benefit from your agency joining their network as a provider. How might your agency effectively serve the highest-need, highest-cost people that receive services from your agency in a value-driven, effective and efficient way? Think HEALTH CARE. Think about continuity of care. Think about caring for the total person. What are a few things that make the services that you provide unique from similar agencies that people can choose from: why should they even choose your service options to meet their needs? Asking these questions may help your agency become an innovator in the field! Formulate the recipe now. Stay abreast of related state-level and national initiatives and reform …you have to do the research!

Do the Research!

NYS Olmstead Implementation Plan: Your Agency Should Review It. The Most Integrated Setting Coordinating Council holds quarterly meetings in Albany, NY open to the public. The Olmstead Implementation Plan was implemented to addresses integrated housing, employment, transportation, community services and other issues that are paramount for those with IDD. Currently chaired by the Office for People With Developmental Disabilities, the Council now consists of representatives from multiple state agencies and nine appointed public representatives including the other NYS Agency Council Members are: Office of Mental Health, Department of Health, Office for the Aging, Education Department, Office of Alcohol and Substance Abuse Services, Division of Housing and Community Renewal, Department of Transportation, the Office of Children and Family Services, the Office of Temporary and Disability Assistance and the Justice Center for the Protection of People with Special Needs.

OPWDDs Innovative Approach to Healthcare Integration Services: New to NY, Familiar to the Other States! Another example of innovation: the START model, first developed in Massachusetts, is being launched across New York State in phases. START stands for Systemic, Therapeutic Assessment, Resources and Treatment and these services are shown to help bridge the gap in the service system to support the needs of those six years old and up with IDD and behavioral challenges that often lead to hospitalizations and emergency room visits by establishing integrated services. The NY START program offers training, consultation, therapeutic services and technical assistance to enhance the ability of the community to support eligible individuals to help them to remain in their home or community placement.

Health Homes? A Concept, Not a Place! NYS Medicaid Redesign Team (MRT) Efforts.Furthermore, enter the concept of Health Homes which are also premised on reducing emergency room visits and time spent in the hospital by supporting continuity of care and integrated service provisions as an answer for the current system that does not leave much room for such integrated supports because of current regulations that demarcate a clear line between behavioral health, physical health, and waiver programming for example.  Take note that New York reportedly aims to transition at least 80 percent of managed care payments from fee-for-service to value-based payments over the next four years, using financial incentives to encourage provider adoption of care coordination and outcome-based approaches. Through Health and Recovery Plans (HARPs), individuals with serious mental illness and certain chronic conditions can be eligible for an enhanced set of home- and community-based services — including vocational training and supported employment services, supportive housing programs, community-based residential recovery programs, and non-medical transportation (e.g., transportation to job interviews or to a GED course). Finally, New York’s Delivery System Reform Incentive Payment (DSRIP) will reinvest savings from other MRT programs back into the health and safety net system, potentially including health homes, in order to reduce avoidable hospital admissions by 25 percent over the next five years. DSRIP is the main mechanism by which New York State will implement the Medicaid Redesign Team (MRT) Waiver Amendment.

Agency Reform on a Scrutinized, Tight, and Dwindling Budget

Health Care Integration Innovations: The Funding Is Out There, The Work is Getting Done! Review the Rethinking Care Program Integrated Care Collaboratives project, funded by Kaiser Permanente Community Benefit, Aetna Foundation, Robert Wood Johnson Foundation, with local support from NYS Health Foundation and Colorado Health Foundation, Started back in January 2008, ending in January 2012 to design and test new care management interventions for their highest-need, highest-cost beneficiaries. Through Center for Healthcare Strategies, Inc. (CHCS) multi-stakeholder collaboratives were organized in four states including Colorado, New York, Pennsylvania, and Washington to learn more about patients who are most likely to benefit from enhanced care management, innovative care management interventions and ways to measure quality and cost outcomes. New York Medicaid implemented six regional demonstration pilots that tested an interdisciplinary model of care to improve health care quality, ensure appropriate use of services, improve clinical outcomes, and reduce the cost of care for beneficiaries with medically complex conditions. The pilots, based in New York City, Long Island (Nassau County), Western Region (Erie County), and Westchester County, served as the “testing grounds” to inform design and development of the state’s Medicaid Health Home program.

Your Conclusion?

What are some features that make your Agency’s services unique from others? How is your agency meeting the needs of the highest-need, highest-cost people? Keep your eye on state-level initiatives across the nation…you have to do the research and devise a plan! Perhaps agencies and boards of directors can research models of non-OPWDD funded programs for people with disabilities to learn about how to obtain/secure regular support from generous members of the community? Revisit the Agency’s core vision mission? Align with the Cause to become a prime choice in the managed care world. The writing’s on the wall for IDD providers, and soon, the writing will be real and printed on correspondence sent to every IDD provider for better or worse.

For more information, visit:

NYS Olmstead Implementation Plan –


NYS Medicaid Redesign Team (MRT) –

Rethinking Care Program Integrated Care Collaboratives project-


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