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Overview of Independence Plus (I+)
What is the Independence Plus Grant?
The Missouri Division of Mental Retardation and Developmental Disabilities (MRDD), the Missouri Planning Council (MPC), and the UMKC Institute for Human Development (IHD), Missouri's University Center for Excellence, in partnership and collaboration, received a 3-year grant from the Center for Medicare and Medicaid Services (CMS). The official title of the grant is the "Missouri Partnership for Self-Directed Support", but it is commonly referred to as the "Independence Plus" grant. The grant period is October 2003-September 2006. [Return to top]
The goal of this project is to plan, develop and implement a life-enhancing consumer-directed system in Missouri that allows people with disabilities, and their family, choices and control in their supports and services. [Return to top]
The pilot will include:
- A choice to use three ways to facilitate a participant directed person centered planning process: Independent person centered plan facilitators, Self-Direct, or use of a MRDD Service Coordinator with no gate keeping functions.
- Identifying ways participants can negotiate an individualized budget, and exercise control of allocated resources within the budget.
- The use of different types of support brokers (self-directed, Independent broker, MRDD Service Coordinator with no gate keeping functions).
- An individual and system back up plan to ensure staff coverage for each participant.
- Quality Assurances that safeguard the health and safety of participants, including emergency back up plan.
- The use of different Fiscal Management services.
- Evaluation of the grant activities.
The pilot must demonstrate that enhancing the current self-direction system will result in improved quality of life and will cost no more than the current system. If successful, at the conclusion of the grant period, the Division will consider applying for a 4th 1915 (c) waiver under the CMS Independence Plus model, or will consider amending one or more of its current waiver(s) that results in conversion of the waiver(s) to the CMS Independence Plus Waiver model. [Return to top]
Thirty to forty pilot participants from five areas in the state will be selected (St. Louis, KC, Kirksville/Hannibal, Joplin and CMRC/Rolla). There is NO age restriction for participation in the pilot. To be considered for participation in the pilot, the person must:
- Currently be participating in one of the MR/DD Home Community Based Services Waivers with funded services, but may not be receiving residential or placement services.
- Desire increased flexibility over their supports/services and determination of how and where their resources are expended.
- Agree to participate in the evaluation process, for example, keeping documents of the planning process, satisfaction surveys, focused interviews, etc.
- Be willing to test components of the pilot project.
- Participate in all the training activities of the pilot project.
- Understand that only their waiver allocated service budget from MRDD will be included through the project at this time. As part of the project, ways to blend or braid services funded through other Medicaid programs will be explored and pursued.
- Understand they will have to work within their current budget allocation; no additional or new money will be available for current waiver services.
- Understand that only supports that can be funded through the waiver service personal assistant may be self-directed. [Return to top]
What do we mean by self-directing?
Self-determination is the ability of individuals to make the choices that allow them to exercise control over their own lives, to achieve the goals to which they aspire, and to acquire the skills and resources necessary to participate fully and meaningfully in their community. [Return to top]
Aspects of Self-direction usually refer to the person or family (if under age 18) being able to:
- Choose an independent person centered plan facilitator to assist, if desired, to facilitate their plan.
- Direct, within agreed upon parameters, how their negotiated individualized budget is to be expended.
- Recruit, hire, and supervise staff themselves, or can select a support broker under their direction to perform these duties.
- Choose a fiscal management service to take care of payroll, taxes, insurance, workers compensation, etc.
- Do some or all of these things themselves or designate a personal advocate to do these things. [Return to top]
What is the foundational tool to accomplish self-direction?
Person-centered planning in conjunction with self-determination will provide a means for people with disabilities to develop meaningful life roles and a high quality of life. Person-centered planning provides the vehicle through which people can determine direction of their lives, identify the supports they will need, and how those supports should be provided to assist them to move in their personally identified direction. Person-centered planning can be defined as a process:
- Directed by the person, with assistance as needed from a representatives. It is intended to identify the strengths, capacities, preferences, needs, and desired measurable outcomes of the person.
- Which may include other individuals freely chosen by the person who are able to serve as important contributors to the process.
- Which enables and assists the person to identify and access a personalized mix of paid and non-paid services and supports that assist him/her to achieve personally defined measurable outcomes in the most inclusive community settings.
The pilot participant, family, or their designated personal advocate may:
- Facilitate his/her own plan;
- Hire an independent facilitator, not connected with an agency; or
- Have a MRDD service coordinator with no gate keeping functions facilitate the plan. [Return to top]
What does a Person-Centered Plan Facilitator do?
A person centered planning facilitator is someone selected and works under the direction of the person, parent/guardian (if under age 18) to facilitate the planning process. The facilitator's role is to:
- Make sure the planning and work go smoother.
- Ensure that the values and assumptions of person-centered work are used in the planning process.
- Facilitate the group learning process; keep the planners focused on the individual and their vision, and assist planners in translating ideas into action.
- Ensure use of good communication and interpersonal skills in the planning process.
- Encourage all to participate, keep the work moving, and assist planners to summarize and clarify their ideas, and use group graphics to capture discussion, direction, and action steps.
- Ensure that the planning process occurs in an efficient, effective, and timely manner; and that summarized planning outcomes are disseminated to all group members. [Return to top]
What does a Support Broker do?
A support broker is someone who is chosen by, and works under the direction of the participant, parent/guardian (if under age 18), or the designated personal advocate. The broker serves as the participants' personal agent to secure supports that meet the needs identified by the participant in their support plan and applies the principles of self-determination. The support broker's responsibilities can include, but are not limited to:
- Assisting the person/family in evaluating various options and available resources, as well as in understanding the pros and cons of each option/resource.
- Navigating community resources.
- Developing community connections.
- Recruiting, hiring, managing, and negotiating rates and contracts with the chosen providers of personal assistance services, when desired by the participant or family.
- Establishing work schedules for supports based upon the person-centered plan, when desired by the participant of family.
- Training and supervising personal assistants, when desired by the participant or family.
- Discharging providers of support when necessary.
- Developing and implementing a back-up/emergency plan to meet his/her needs as designed in the persons' support plan.
- Assisting with managing the individualized budget when requested/needed.
The pilot participant, family, or their designated personal advocate may:
- Choose to be their own broker;
- Hire an independent facilitator, not connected with an agency; or
- Have a MRDD service coordinator with no gate keeping functions be their support broker. [Return to top]
An individual budget is the total dollar value of the services and supports, as specified in the person-centered plan, is individually negotiated, and under the control and direction of the program participant. An individual Budget is:
- Based on actual service utilization and cost data and derived from reliable sources;
- Developed using a consistent methodology to calculate the resources available to each participant;
- Open to public inspection; and
- Reviewed according to a specified method and frequency. [Return to top]
What are Fiscal Management Services?
There are three approaches to providing fiscal management services. They are fiscal conduit, fiscal employer agent, and agency with choice. Each of these approaches can be either centralized or decentralized, as well as receive and distribute support services funds on behalf of an individual according to an Individual Support Plan. The fiscal management service provider responsibilities may include activities and records related to payroll and payment of employer-related taxes and fees as an agent of individuals who employ persons to provide care, supervision, or training in the home or community. In this capacity, the fiscal agents do not recruit, hire, supervise, evaluate, dismiss, or otherwise discipline employees. The person, family or Support Broker would perform these functions. Services a fiscal management entity could potentially include are:
- Purchasing approved goods and services on behalf of the participant.
- Tracking and monitoring individual budget expenditures providing continual account balance information by providing declining balances, (i.e. keeping a checkbook), to assure the participant is kept current about expenditure of their support dollars.
- Representing participant with the IRS, State, and Department of Labor for payroll reporting purposes should an issue or questions ever arise.
- Providing training to participants on being an employer.
- Managing approved funding streams for the participant, when necessary. [Return to top]
How is the pilot project being funded?
- Funding for waiver support services will need to fit within the participants' current budget/allocation through the MRDD Home and Community Based waiver.
- Funding for independent person-centered facilitators, independent support brokers, and for fiscal management services are outside the current DMH Medicaid Waiver contract and will be provided with grant funds. [Return to top]
Will the person still have a MRDD Service Coordinator?
Yes, a coordinator will still be responsible for all of the monitoring for health and safety, competing waiver monitoring and documentation requirements, advocating for the individual (when needed), etc. [Return to top]
If circumstances arise, where the person, family, or designated personal advocate choose to change the pilot components they want to implement/test such instances will be handled on a person-by-person basis while in the pilot. If they decide they do not want to self-direct their supports, services, and budget- they may change back to the way services were provided prior to entering the pilot. [Return to top]
What happens when the pilot ends?
- The pilot demonstration and evaluation will operate from October 2004-September 2006.
- Once the pilot demonstration ends, there is no guarantee that the service options tested in the pilot will continue to be available.
- Continued Personal Assistant services will be provided through the MRDD waiver.
- DMRDD will continue to offer Fiscal Intermediary services from their contracted vendor. [Return to top]