Support coordination services performance report, 2022

2022 Support Coordination
Services Performance Report
GEORGIA DEPARTMENT of BEHAVIORAL HEALTH and DEVELOPMENTAL DISABILITIES
June 2023

CONTENTS
Executive Summary....................................................................................................................................... 3 Support Coordination Services ..................................................................................................................... 4
General Impact of COVID...................................................................................................................... 4 Support Coordination and Intensive Support Coordination......................................................................... 6
Support Coordination Agencies and Counts of SC and ISC Recipients ................................................. 6 Caseload Size Compliance..................................................................................................................... 7 Regional Mapping ................................................................................................................................. 8 Required Contacts and Individual Quality Outcome Measure Reviews ..................................................... 10 SC and ISC............................................................................................................................................ 10 Individual Quality Outcome Measures Review (IQOMR)............................................................................ 12 Coaching and Referral Activities ......................................................................................................... 13 Summary & Key Findings ............................................................................................................................ 15 Appendix A: Support Coordination Services, Agency Data, CY22........................................................... 16 Appendix B: IQOMR Tool ........................................................................................................................ 17
FIGURES
Figure 1: SC and ISC Population, December 2022........................................................................................ 6 Figure 2: ISC Waiver Population, December 2022 ........................................................................................ 9 Figure 3: SC Waiver Population, December 2022 ........................................................................................ 9 Figure 4: Waiver Population, December 2022............................................................................................. 9 Figure 5: Support Coordination Quarterly Contact Requirements, Mean Contacts.................................. 11 Figure 6: Intensive Support Coordination Monthly Contact Requirements, Mean Contacts.................... 11
TABLES
Table 1: Support Coordination Services Caseload Compliance, CY22 ......................................................... 8 Table 2: Coaching and Referrals Activity by IQOMR FOA, CY22 ................................................................ 14
2

EXECUTIVE SUMMARY
The Department of Behavioral Health and Developmental Disabilities (DBHDD) seeks to review performance data regarding support coordination, which includes two distinct waiver services entitled support coordination and intensive support coordination. This is the seventh annual report assessing the performance of support coordinators, their agencies, and Medicaid waiver support coordination service provision. Performance review of support coordination occurs on an ongoing basis, and performance metrics are examined regularly (e.g., monthly or quarterly).
The COVID pandemic forced changes in how healthcare services are organized, delivered, and what and how data were collected due to changes in data systems that support them. The Centers for Medicare and Medicaid Services approved Georgia's amendment (Appendix K) to both the NOW and COMP waivers. 1 Appendix K enables DBHDD to implement necessary flexibilities in services and supports during and for 180 days following the Public Health Emergency. These flexibilities were implemented to support uninterrupted service delivery while also reducing risk of transmission of and maximizing the containment of COVID. Necessary adjustments in services and data systems due to COVID resulted in some metrics not being reported. Despite that, DBHDD achieved performance expectations on most measures that could be calculated. Review of the purpose and value of each performance measure yielded a set of measures that provide insight into the key operations and performance of support coordination.
The Division of Strategy, Technology, and Performance conducts and communicates analytical findings (including strengths, limitations, and potential implications of the findings) to other divisional leadership. Senior operations and programmatic leadership partner with quality improvement experts to apply study results to improve quality and enhance performance of DBHDD's programs and initiatives.
The scope of this annual report is performance of support coordination services rendered during January 1, 2022, through December 31, 2022 (CY22).
1 Appendix K 3

SUPPORT COORDINATION SERVICES
Support coordination services are a set of interrelated activities for identifying, coordinating, and overseeing the delivery of services to enhance the health, safety, and general wellbeing of waiver participants within the context of the person's goals toward maximum independence. Support coordination services cover two distinct waiver services known as support coordination (SC) and intensive support coordination (ISC).
During CY22, support coordination services were provided by seven agencies contracted by DBHDD and tasked with employing support coordinators to meet the support coordination service needs of individuals. Support coordinators are responsible for developing individual service plans (ISPs), monitoring the implementation of the ISP, assisting in the coordination of ISP revisions, assisting the individual or representative in locating a service provider, direct observation of individuals in service, review of documents, and follow-up to ensure that service plans have the intended effect. Support coordinators are also responsible for the ongoing evaluation of the satisfaction of individuals and their families with the ISP and delivery of waiver services utilizing a person-centered philosophy. ISC includes all the activities of SC, with additional activities that reflect specialized coordination of waiver, medical, and behavioral support services on behalf of individuals with complex medical and behavioral needs.
This report analyzed performance data from the perspective of the entire system of support coordination services as well as from the perspective of individual support coordination provider agencies. Since this is a support coordination services performance report, the content of this report is from the perspective of analyzing and reporting performance findings about the support coordination services "system" and "provider." DBHDD acknowledges that it may be more accurate to indicate that the performance of support coordination services and agencies, as well as the outcomes individuals experience, are dependent upon an entire system of DBHDD programs, administration, and providers of supports and services.
GENERAL IMPACT OF COVID
Most often, DBHDD's formal analytical reports are delimited to performance information and insights from the previous year(s). It is critical that one recalls the events of the COVID pandemic, i.e., the public health emergency (PHE), that spanned most of 2020 through 2022. Many factors challenged DBHDD and providers during this time that may not be discernable in the data. Though the impact of the PHE has diminished, the data in this report does not compare CY22 to previous year(s) of performance, for the data are not similar in terms of the context and reality within which they were produced.
Some responses to COVID introduced new ways of collecting data or had no substantial impact on performance data collection. In some cases, new data systems were put in place or existing ones were modified to collect or measure data in these dynamic systems. Ultimately, DBHDD and other organizations have attempted to balance the needs of continued service delivery
4

through nimble adjustments and collecting and analyzing data with methodological and scientific rigor. Ongoing effective operations would not have been possible without Appendix K. As a result of these necessary adjustments in service delivery and documentation protocols, certain data elements are not reported this year. DBHDD's decision not to use some data due to lack of validity or usefulness for the current situation was similar to and validated by other state- and national-level organizations impacted by the COVID pandemic.
5

SUPPORT COORDINATION AND INTENSIVE SUPPORT COORDINATION
SUPPORT COORDINATION AGENCIES AND COUNTS OF SC AND ISC RECIPIENTS
This report focuses on system and provider levels of performance. Seven support coordination agencies served 13,400 individuals receiving SC (11,124) and ISC (2,276) as of December 2022.
Georgia's Support Coordination Service Agencies Benchmark Carestar Creative Consulting Services (Creative) Columbus Community Services (Columbus) Compass Coordination (Compass) Georgia Support Services (Georgia Support) Professional Case Management Services of America (PCSA)
Figure 1: SC and ISC Population, December 2022 (n = 13,400)
2,276 17%
11,124 83%
ISC SC
6

CASELOAD SIZE COMPLIANCE
This section provides caseload size compliance information. One negative outcome of the PHE was that the seven support coordination agencies experienced the same staff hiring and retention challenges faced by the IDD provider network. DBHDD policy regarding the caseload size of SC and ISC support coordinators specifies upper limits for each type of support coordination service. 2 The policy also specifies how caseload ratios may be adjusted to accommodate having both SC and ISC recipients on an individual support coordinator's caseload. Annual caseload size compliance is computed by adding the count of support coordinators across four quarters who met caseload size compliance standards (1,448) divided by the total count of support coordinators at the same points in time (1,707). DBHDD's caseload size compliance was 84.8 percent, which is below the DBHDD caseload size compliance standard of 86 percent.
2 At the time of the writing of this document, DBHDD policy regarding the caseload size of support coordinators (Support Coordination Caseloads, Participant Admission, and Discharge Standards, 02-432) states that support coordinators providing intensive support coordination must have no more than 20 individuals in their caseload, and those providing standard support coordination must have no more than 40. If a support coordinator has a mixed caseload with both support coordination and intensive support coordination individuals, the 1:3 rule applies, counting each intensive support coordination individual as being equal to three support coordination individuals. If a mixed caseload has more than 10 individuals receiving intensive support coordination, then they may have no more than 20 individuals, and the 1:3 rule no longer applies. The policy specifies how caseload ratios may be adjusted to accommodate having support coordination and intensive support coordination recipients on an individual support coordinator's caseload, which has been used for these analyses.
7

Table 1: Support Coordination Services Caseload Compliance, CY22

500

84.3%

450

427

400 360
350

300

250

200

150

85.2% 427 364

85.0% 426 362

90%

84.8%

427

80%

70% 362
60%

50%

40%

30%

20%

10%

100 CY22 Q1

CY22 Q2

CY22 Q3

0% CY22 Q4

In compliance

Total SCs

Percent in compliance

There are various issues impacting caseload compliance, not all of which are addressed in this report. As an example, workforce shortages highlight challenges of caseload size compliance given the differences in population density across Georgia.

REGIONAL MAPPING
Georgia is made up of mostly low-density population areas which challenges support coordinators in achieving caseload size and mix compliance. In densely populated areas, support coordinators can more easily achieve caseload compliance. Sometimes, ISC individuals reside 100+ miles from metropolitan areas, and in one county, no one receives SC services; in more than 20 counties, no one receives ISC services. The preference is for caseloads to be all SC or all ISC. However, due to sparse populations throughout much of Georgia, caseload mix (when an SC meets Staff Qualifications per SC/ISC Waiver Manual Part III Section 703) is required for geographic and travel concerns. In areas with less dense SC and ISC recipients, then caseload compliance is more likely to vary from precise caseload compliance ratios specified in policy.

8

Figure 2: ISC Waiver Population, December 2022

Figure 3: SC Waiver Population, December 2022

Figure 4: Waiver Population, December 2022

9

REQUIRED CONTACTS AND INDIVIDUAL QUALITY OUTCOME MEASURE REVIEWS
To protect the health and safety of individuals by limiting exposure to COVID during the PHE, DBHDD sought and received approval from the Centers for Medicare and Medicaid Services to design and implement new services and supports, or adjustments to extant services and supports. Telehealth was a major mechanism to allow people to receive services that once were delivered face-to-face such as quarterly or monthly in person reviews. With the implementation of telehealth protocols via Appendix K, CY22 data related to contacts included some contacts in person and some by telephone conversations or video conferencing. Even though traditional face-to-face visits did not always occur, the number of required contacts remained the same.
SC AND ISC
At a minimum, all individuals receiving waiver services receive a quarterly contact whereby the SC or ISC completes an Individual Quality Outcome Measures Review (IQOMR). The dashed line in Figure 5 represents the minimum number of contacts required for individuals by support coordinators. Individuals receiving SC services are to receive at least one contact per quarter. Individuals receiving SC received more than the required number of contacts over the year. Individuals receiving ISC services are to receive at least one contact per month. Individuals receiving ISC received on average more than the required number of contacts over the year as illustrated in Figure 6. Therefore, from a compliance perspective, SC and ISC recipients are receiving the required number of contacts.
10

Figure 5: Support Coordination Quarterly Contact Requirements, Mean Contacts

0

0.5

1

1.5

2

Q1

1.39

Q2

1.53

Q3

1.35

Q4

1.36

Mean Contacts SC

Dashed line = Minimum required contacts

Figure 6: Intensive Support Coordination Monthly Contact Requirements, Mean Contacts

0

0.5

1

1.5

2

Q1

1.21

Q2

1.28

Q3

0.99

Q4

1.12

Mean Contacts ISC

Dashed line = Minimum required contacts

11

INDIVIDUAL QUALITY OUTCOME MEASURES REVIEW (IQOMR)
The IQOMR tool, comprised of fifty-five questions, is divided into seven focus outcome areas (FOA) which include:
Environmental; Appearance/Health; Supports and Services; Behavioral and Emotional; Home/Community Opportunities Financial; and Satisfaction.
COVID forced changes in how healthcare services are organized, delivered, and what and how data were collected due to changes in data systems that support them. COVID affected services in such a way that did not allow for some performance data to be gathered or analyzed in a way that is meaningful. Appendix K Operational Guidelines identified the IQOMR questions that may require face-to-face observations. The IQOMR questions which were affected by Appendix K, include the following: 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 41, 42, 43, 44, 46, 47, 48, 49, and 50. Though CY22 IQOMR detailed data is not included in this report, the IQOMR process produced useful and meaningful data on coaching and referrals.
12

COACHING AND REFERRAL ACTIVITIES
Another aspect of support coordination performance is engaging in resolution activities and documenting related coaching and referral actions. The coaching and referral activities indicate productivity and performance of support coordination agencies.

Coaching Referrals

Required when a concern/issue/deficit is discovered in an element of a focus area question, and, in the support coordinator's professional judgment, (s)he determines that the concern/issue/deficit can be resolved in collaboration with the staff members or natural supports without intervention by the DBHDD field office or clinical staff.
Required for more serious risks than those addressed by coaching. Referrals are first addressed by the Support Coordinator/Intensive Support Coordinator along with the provider/natural supports attempting to resolve the concern. Unresolved referrals are made to the Division of DD or to clinical staff to address serious concerns in the areas of the IQOMR. Referrals can also be used to escalate the urgency of a coaching due to slow response or worsening circumstances.

Table 2 highlights coaching and referral activities across the seven IQOMR focus outcome areas. Support coordination agencies completed 7,345 coaching sessions. For each coaching session, at least one concern/issue/deficit was detected, and the individual benefitted because staff, natural supports, and the support coordinator collaborated to resolve the issue without involving others. Support coordination also made 3,890 referrals for more serious risks and situations. Referrals occur when individuals require additional resources to address or resolve an issue. Support coordination's referrals actuate additional staff (especially clinical staff) to assure the individuals' healthcare and other service needs are met. Combined, SCs and ISCs initiated and followed up on 11,235 coachings and referrals to improve the services, supports, and outcomes of individuals they serve.
These coachings and referrals are important because their primary goal is to encourage a collaborative relationship between the support coordinator, provider agency staff, natural supports and DBHDD staff. This collaboration serves as a pathway to effectively identify any unmet needs for the individual, working together to reduce or eliminate any associated risks, and ultimately achieve the best outcomes for the individual. Support Coordinators identify a Targeted Close Date for coaching and referrals based on the acuity of the concern or deficit as
13

well as the ability to resolve it in an acceptable timeframe. When the identified deficit is addressed to meet the support needs of the individual are met coachings and referrals are closed in the information management system. Should a referral not be resolved by the targeted close date, the acuity is reviewed by the support coordinator. Based on the acuity, the provider/natural support may get an extension for addressing the concern if there is no immediate concern. If there is concern about the health and safety of the individual, the support coordination agency may contact DBHDD staff for intervention.
Table 2: Coaching and Referrals Activity by IQOMR FOA, CY22

Coaching and Referrals Activity

Number of
Coachings

Number of Referrals

Percent of Referrals Closed by Intended Close
Date

Appearance/Health Behavioral and Emotional Environment Financial Home/Community Opportunities Satisfaction Supports and Services Total

4,709 354 607 352 159 57 1,107 7,345

3,152 190 142 75 22
3 306 3,890

73.8% 59.3% 59.0% 65.6% 29.4% 50.0% 64.0% 71.5%

14

SUMMARY & KEY FINDINGS
In CY22, the effects of responses to COVID interfered with calculating and reporting some metrics. Despite not being able to calculate or collect some support coordination performance metrics this year, support coordination achieved most performance expectations in CY22 on the performance metrics that could be calculated.
The seven support coordination agencies provided services to 13,400 individuals receiving NOW or COMP waiver services.
The provider network supporting individuals with IDD experienced challenges in hiring and retention of staff and this was also evident with support coordination agencies, reflecting lower compliance in meeting caseload compliance criteria. Support coordination's caseload size compliance was 84.8 percent, which is below the caseload size standard of 86 percent.
Contacts with individuals encompassed traditional face-to-face visits, telephone conversations and video conferences. Individuals receiving SC received more than the required number of contacts over the year. Individuals receiving ISC received on average more than the required number of contacts for each month.
Support coordinators initiated and followed up on 11,235 combined coachings and referrals to improve the services, supports, and outcomes of individuals they serve, including the following: o Support coordinators delivered 7,345 coaching sessions; o Support coordinators provided 3,890 referrals; o Seventy-one point five percent of referrals were closed by their intended close date.
15

Appendix A: Support Coordination Services, Agency Data, CY22

Agency
Benchmark CareStar Columbus Compass Creative Georgia Support PCSA
Totals

ISC
417 168 587 156 523 190 235 2,276

SC
423 301 3802 339 3150 1282 1827 11,124

Proportion ISC 50% 36% 13% 32% 14% 13% 11% 17%

16

Appendix B: IQOMR Tool Individual Quality Outcome Measures Review

Individuals Name: Physical Address: ADA Population:

Date & Time of Visit: Location of Visit: Funding Source:

For each focus area question Evaluation Options:

the reviewer selects a

Acceptable

response from the evaluation Clinical Referral - Immediate

options list. The reviewes is Clinical Referral - Critical

able to add further detail

Coaching

through comments/actions Non-clinical referral - Immediate

needed.

Non-clinical referral - Critical

Comments/Action Needed: Concerns, Barriers, Successes

Focus Area: Environmental 1 The home/site is accessible to the individual. 2 The individual has access to privacy for personal care. 3 The individual has a private place in the home to visit with friends or family. 4 The individual has access to privacy for phone discussions with friends or family. 5 The individual has access to receive and view their mail/email privately. 6 The individual is able to have private communications with family and friends through
other means. 7 The home setting allows the individual the option to have a private bedroom. 8 All assistive technologies are being utilized as planned. 9 All assistive technologies are in good working order. 10 The individual has adequate clothing to accommodate his/her needs or
preferences/choices. 11 The individual has adequate food and supplies to accommodate the individual's needs or
preferences/choices.
17

Focus Area: Environmental (cont.) 12 The Residential/Day setting is clean according to the individual's needs and preferences.
13 The Residential/Day setting is safe for the individual's needs.
14 The Residential/Day setting is appropriate for the individual's needs and preferences.
Focus Area: Appearance/Health 15 The individual appears healthy. Describe any observations regarding health since the last
review. 16 The individual appears safe. Describe any observed changes related to safety since the
last review. 17 There have been no reported changes in health since the last review.
18 The HRST aligns with current health and safety needs.
19 The ISP is available to staff on site. If there have been ISP addendums, they are available to staff on site.
20 Staff are knowledgeable about all information contained within the individual's ISP.
21 Indicated healthcare plans are current and have been reviewed by a nurse within the past year.
22 Indicated healthcare plans are available to staff on site.
23 All staff are knowledgeable about all of the individual's healthcare plans.
24 Indicated healthcare plans are being implemented.
25 Documentation is present to indicate that skilled nursing hours are being provided as ordered.
26 All medical/therapeutic appointments have been scheduled and attended.
27 All follow-up appointments have been scheduled and attended.
28 All physician/clinician recommendations are being followed.
29 All prescribed medications are being administered, as ordered, and documented accurately.
30 All required assessments/evaluations have been completed.
31 Since the last review, the individual has been admitted to a hospital or has visited an emergency room or urgent care clinic.
32 If applicable, hospital/ED/urgent care discharge plan instructions have been followed.
18

Focus Area: Supports and Services 33 The individual's paid staff appear to treat his/her with respect and dignity. 34 The individual's natural supports appear to treat this/her with respect and dignity. 35 Supports and services are being delivered to the individual as identified in the current ISP.
36 The individual is being supported to make progress in achieving their goals (both ISP goals and informally expressed goals). Indicate the status of the individual's progress toward achieving established goals.
37 There is no need for additional services/supports at this time.
Focus Area: Behavioral and Emotional 38 Since the last visit, there are no emerging or continuing behavioral/emotional responses
for the individual. 39 Current supports and behavioral interventions are adequate to prevent engaging external
interventions. 40 If needed, the individual has a Behavioral Support Plan, Crisis Plan, and/or Safety Plan
relating to behavioral interventions. 41 If applicable, the plan(s) is/are available on site for staff review. 42 There is evidence of implementation of the Behavioral Support Plan, Crisis Plan, and/or
Safety Plan. Staff are knowledgeable about the plan(s) and able to describe how they are implementing the plan. 43 Since the last review, GCAL or the Mobile Crisis Response Team has been accessed in response to a behavioral emergency. If applicable, the BSP/Safety Plan/Crisis Plan has been adapted to reflect any new recommendations or interventions needed. 44 Since the last review, the individual has had contact with law enforcement. If applicable, the BSP/Safety Plan/Crisis Plan has been adapted to reflect any new recommendations or interventions needed.
19

Focus Area: Home/Community Opportunities 45 The individual has unpaid community connections. If needed, describe steps being taken
to further develop community connections. 46 The individual is receiving services in a setting where he/she has the opportunity to
interact with people who do not have disabilities (other than paid staff). 47 The individual is being offered/provided documented opportunities to participate in
activities of choice with non-paid community members. 48 The individual has the opportunity to participate in activities he/she enjoys in their home
and community. Describe steps being taken to increase opportunities to meet this objective and allow choices to be offered while in services. 49 If desired, the individual is actively supported to seek and/or maintain employment in competitive and integrated settings and/or offered customized opportunities. 50 The individual has the necessary access to transportation for employment and community activities of his/her choice. Focus Area: Financial 51 The individual is able to access and spend his/her money as desired. Focus Area: Satisfaction 52 Overall, the individual is satisfied with his/her life activities since the last review. 53 Overall, the individual is satisfied with his/her service providers since the last review. 54 Overall, the individual is satisfied with the type of services received since the last review. 55 Overall, the individual is satisfied with his/her family relationships/natural supports since the last review.
20