Support coordination services performance report CY 2019

2019 Support Coordination
Services Performance Report
GEORGIA DEPARTMENT of BEHAVIORAL HEALTH and DEVELOPMENTAL DISABILITIES
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Figure 1 Support Coordination Performance Report Infographic
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CONTENTS
Figures and Tables ........................................................................................................................................ 4 Support Coordination Services Performance Report for Calendar Year 2019 ............................................. 5
Purpose ................................................................................................................................................. 5 Scope..................................................................................................................................................... 5 Utilization of Findings ........................................................................................................................... 6 Intellectual and Developmental Disability Services.............................................................................. 6 DBHDD Sampling Procedure ................................................................................................................. 7 Interpreting Statistical Tests ................................................................................................................. 8 Support Coordination Services ..................................................................................................................... 9 SC and ISC.................................................................................................................................................... 10 Analysis of IDD Waiver Data ............................................................................................................... 10 Caseload Size............................................................................................................................................... 12 Regional Mapping ............................................................................................................................... 12 Caseload Compliance.......................................................................................................................... 14 Face-to-Face Visits ...................................................................................................................................... 15 SC and ISC ........................................................................................................................................... 15 Health Risk and Suppport Coordination Services ....................................................................................... 16 Individual Quality Outcome Measures Review........................................................................................... 18 IQOMR Positive Answers and Coaching and Referral Outcomes ....................................................... 19 Coaching and Referral Activities ......................................................................................................... 20 Other Outcomes.......................................................................................................................................... 24 HCL Scores........................................................................................................................................... 24 Individualized Service Plan Quality Assurance............................................................................................ 25 ISP Quality Expectations ..................................................................................................................... 25 National Core Indicator Data ...................................................................................................................... 27 NCI Data Analysis ................................................................................................................................ 27 Support Coordination Specific Items .................................................................................................. 28 Summary of Analytic Findings..................................................................................................................... 29 Appendix A: Support Coordination Services, Agency Data..................................................................... 30 Appendix B: SC and ISC IQOMR Ratings, CY19....................................................................................... 31 Appendix C: Coaching and Referrals, Agency Data. Q1 and Q2 Combined ........................................... 33 Appendix D: Individualized Service Plan Quality Assurance Ratings, Agency Data ................................ 37 Appendix E: Agency-Specific NCI Data ................................................................................................... 44 Appendix F: Support Coordination Performance Infographic ............................................................... 47
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FIGURES AND TABLES
Figure 1 Support Coordination Performance Report Infographic .................................................. 2 Figure 2: SC and ISC Population, CY19 ......................................................................................... 10 Figure 3: Percent of Individuals Receiving SC or ISC, CY19.......................................................... 11 Figure 4: Total Waiver Population, CY19 ..................................................................................... 12 Figure 5: SC Waiver Population, CY19.......................................................................................... 13 Figure 6: ISC Waiver Population, CY19 ........................................................................................ 13 Figure 7: Support Coordination Services Caseload Compliance, CY19........................................ 14 Figure 8: Face-to-Face visits per Quarter, SC............................................................................... 15 Figure 9: Face-to-Face visits per Month, ISC................................................................................ 15 Figure 10: SC IQOMR Positive Answers, CY19 ............................................................................. 19 Figure 11: ISC IQOMR Positive Answers, CY19 ............................................................................ 20 Figure 12: Support Coordination Services, Coaching and Referrals, CY19 .................................. 22
Table 1: Agency Face to Face Visits, Mean Difference between Expected and Observed.......... 17 Table 2: Coaching and Referrals Activity, CY19 ........................................................................... 22 Table 3: Difference in HCL December 31, 2018 and June 30, 2019............................................. 24
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SUPPORT COORDINATION SERVICES PERFORMANCE REPORT FOR CALENDAR YEAR
2019
PURPOSE
The Department of Behavioral Health and Developmental Disabilities (DBHDD) seeks to review performance data regarding support coordination services, which includes two distinct waiver services entitled support coordination (SC) and intensive support coordination (ISC).1 This is a report of data analysis assessing the performance of support coordinators, their agencies, and Medicaid waiver support coordination service provision.
SCOPE
Performance review of support coordination occurs on an ongoing basis, and performance metrics are examined regularly (e.g., monthly or quarterly). Formal support coordination performance reports are issued at least annually. DBHDD transitioned from its original case management information system, CIS, to its new case management system, IDD Connects, on September 1, 2019. At the time the data for this report were extracted, the decision was made to use data from prior to the implementation of IDD Connects while DBHDD continues to increase sophistication with capitalizing on utilizing data from IDD Connects. Therefore, the analysis within this report is delimited to January through June of 2019. Consequently, comparison or analysis of SC data collected after July 1, 2019 could not be completed.
The support coordination performance report includes data about children and adults with a primary intellectual/developmental disability (IDD) diagnosis who received services funded by either the New Options Waiver (NOW) or Comprehensive Supports Waiver (COMP) during the first half calendar year 2019 (CY19). Data within this report are from January 1, 2019 through June 30, 2019, except for health care level data, which extends back to December 31, 2018. Where appropriate, data from the first half of CY19 have been broken into two quarters. Quarter 1 (Q1) includes data from January 1, 2019 through March 31, 2019. Quarter 2 (Q2) includes data from April 1, 2019 through June 30, 2019. This allows for comparative analysis between the two quarters.
1 The term "support coordination services" will be used when referring to the overall system of support coordination services and supports. Based on Medicaid guidelines and terminology, this report references "SC" and "ISC." SC will be used to reference the less-intensive level of the two service types, and ISC will be used for the more specialized type of service.
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UTILIZATION OF FINDINGS
The observations and findings in this report will be presented to leadership of DBHDD and Division of Developmental Disabilities (DD) for consideration in identifying questions that may need additional analysis, investigation, and interpretation to improve the performance of support coordination services agencies.
The director of the Division of DD is responsible for using the information within this report. DBHDD's organizational alignment provides a platform for clarified roles and responsibilities in addressing support coordination performance issues for the DBHDD IDD population. This includes analysis, implementation of targeted action steps, and determination of the impact of selected initiatives. Both expertise and responsibility exist in other areas within the department to assist the Division of DD to accomplish improvement strategies; the Division of DD has the responsibility to utilize these resources. The Division of DD has at its disposal department resources to accomplish improvement initiatives with the assistance of support functions provided by the Division of Accountability and Compliance and the Division of Performance Management and Quality Improvement.
INTELLECTUAL AND DEVELOPMENTAL DISABILITY SERVICES
DBHDD is committed to supporting opportunities for individuals with intellectual and developmental disabilities to live in the most integrated and independent settings possible. A developmental disability is a chronic condition that develops before a person reaches age 22 and limits his or her ability to function mentally or physically. DBHDD provides services to people with intellectual and other disabilities, such as cerebral palsy and autism, who require services similar to those needed by people with an intellectual disability. State-supported services help families continue to care for a relative at home or independently in the community when possible. DBHDD also contracts with external providers to provide home settings and care to individuals who do not live with their families.
DBHDD serves as the operating agency for two 1915c Medicaid waiver programs (NOW and COMP). Both waivers provide home and community-based services to individuals who, without these services, would require a level of care comparable to that provided in intermediate care facilities or skilled nursing facilities for people with intellectual and developmental disabilities. A complete description of waiver services can be found at DBHDD's website (www.dbhdd.ga.gov).
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DBHDD SAMPLING PROCEDURE
DBHDD carefully considers information and data to analyze to answer analytical questions. High quality, valid information, and data are the basis of useful, practical, and valid research findings and conclusions. Ideally, analysis occurs from data on an entire population, and DBHDD strives to accomplish this when feasible; this produces maximum validity. However, when data on the entire population are not available or feasible, then DBHDD carefully considers how the analytic data sample is built, as the sampling procedure has great impact on the quality, validity, and generalizability of research findings.
DBHDD's sampling procedure proceeds in the following manner:
First, when available, DBHDD utilizes data on the full population under study (e.g., all individuals who received services within a given period such as calendar or fiscal year).
Second, if some individuals within the full population have missing data for variables being used for analysis, DBHDD considers widely-accepted procedures to address missing data. For example, individuals with missing data typically are excluded from analysis using listwise deletion,2 resulting in a subset of the full population. DBHDD may consider other theoretically-sound methods and procedures to understand or address missing data.3
Third, in some cases, DBHDD utilizes some form of random sampling4 (e.g., a random subset of providers or random subset of all events that occurred). For this approach to be valid, one must be able to define the entire population from which it is being drawn, and each unit (e.g., individual, situation, etc.) must have an equal chance of being included in the sample. This method is unbiased, and the resulting sample is representative of the full population under study.
Fourth, DBHDD also occasionally makes use of purposive sampling, a non-probability sampling method. This method is typically reserved for specific instances (e.g., identifying when a situation occurred, selecting specific cases, identifying specific errors, etc.). Purposive sampling is a selective, non-probabilistic method, and purposive sampling is not representative of the full population under study; therefore, findings or results based
2 Listwise deletion is a method for handling missing data, whereby an entire record is excluded from analysis if any single value is missing. 3 Sensitivity analyses are conducted to evaluate the pattern of missing data, wherein missing data are determined to be either missing completely at random (MCAR) or missing at random (MAR). Data are determined to be MCAR when the probability of missing data on a variable is unrelated to any other measured variable and is unrelated to the variable with missing values itself. Data are determined to be MAR when the missingness can be explained by variables that do not contain missing values. DBHDD may use multiple imputation for data that are MCAR or MAR, which allows missing data to be accounted for in a statistically valid and unbiased way. Multiple imputation assumes that data are from a continuous multivariate distribution and contain missing values that can occur for any of the variables. If these key statistical assumptions are satisfied, then this method can be used for data that are missing completely at random or missing at random. 4 The leading component of simple random sampling is that every case (e.g., individuals or providers) has the same probability of being selected for inclusion in analysis.
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on purposive sampling are not generalizable to the full population, rather only to the cases from which data were sampled. Fifth, a goal of inferential statistics is to make inferences about the population based on a sample smaller than the population. DBHDD considers sample sizes carefully and analytically to create empirical samples large enough to have sufficient statistical power to detect associations or differences and allow valid inferences to be drawn from and generalized about the population being studied.
INTERPRETING STATISTICAL TESTS
Some of the following sections report statistical analyses. Statistical analyses are useful to identify associations and trends among variables. Statistics commonly refers to "statistical significance." Sometimes associations or patterns occur due to random chance. A statistically significant difference for a result or relationship has a likelihood that it is caused by something other than mere random chance. It is a natural tendency to assume when there is a statistically significant difference or association that it must result from the something other than a random chance and that the difference must have a specific cause. It is important to exercise caution when interpreting statistical significance in this manner, as sufficient facts may not necessarily be present to conclude a specific idea of what that something is. Statistical significance should be studied further by gathering additional information and by completing a more extensive analysis through additional steps. Also, statistical significance does not equate to importance or meaningful significance. Meaning and importance of findings can only be determined by more careful examination of additional information. This report does not make conclusions about any differences or statistically significant findings. As such, the statistical findings will be presented to DBHDD to be considered along with other information for further exploration to understand the causes and implications of the statistical findings. Where there are specific information, findings, observations, cases, and issues that warrant additional investigation, analysis, consideration, and work is underway.
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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 CY19, support coordination services were provided by seven agencies tasked with employing a sufficient number of support coordinators to meet the support coordination service needs of individuals receiving IDD waiver services. Support coordinators are responsible for monitoring the implementation of the individualized service plan (ISP), assisting in the coordination of ISP revisions, assisting the individual or representative in locating a service provider, direct observation, review of documents, and follow-up to ensure that ISPs 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.
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 analyzes 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. For the purposes of this report, however, the findings and analyses are provided from the perspective of support coordination services providers and the system as a whole.
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)
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SC AND ISC
ANALYSIS OF IDD WAIVER DATA
The following sections contain analyses on the performance of support coordination services. Outcomes may be evaluated between time periods (e.g., quarterly) when appropriate. The purposes of this report are to provide data analysis and to quantify the performance of support coordinators, their agencies, and Medicaid waiver support coordination service provision. DBHDD evaluates performance of support coordination services using performance standards, such as classifying acceptable performance to be at least 86 percent. As such, this report compares performance to those performance standards (and in some places comparisons between quarters within the same year). This report does not make performance comparisons across years, as it is appropriate to evaluate performance against performance standards, where they exist. Not including cross-year comparisons simplifies the presentation of information and draws attention to performance evaluation of support coordination services against performance standards. Comparisons across years may be requested in consideration of quality improvement and other performance improvement initiatives.

12,000 10,000
8,000 6,000 4,000 2,000
0

Figure 2: SC and ISC Population, CY19
11,014

11,224

2,022 Q1

ISC SC

2,049 Q2

10

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Figure 3: Percent of Individuals Receiving SC or ISC, CY19

84%

85%

16%

15%

Q1

Q2

ISC SC

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CASELOAD SIZE
This section takes a closer look at how support coordination services agencies are performing with caseload sizes. DBHDD policy regarding the caseload size of SC and ISC support coordinators specifies upper limits for each type of support coordination service.5 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.
REGIONAL MAPPING
Georgia's IDD population is mostly concentrated in more densely populated, metropolitan areas such as Atlanta, Savannah, August, and Columbus. Georgia is made up of mostly low-density population areas, which results in extraordinary challenges for support coordinators in achieving caseload size and mix compliance.
Figure 4: Total Waiver Population, CY19
5 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 aforementioned 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.
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Figure 5: SC Waiver Population, CY19
Figure 6: ISC Waiver Population, CY19
In densely populated areas, support coordinators can more easily achieve caseload compliance. Sometimes, ISC individuals reside more than a hundred miles from metropolitan areas.
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CASELOAD COMPLIANCE
It is important to remember the challenges of caseload size compliance given the differences in population density across Georgia. DBHDD's compliance standard is that 86 percent of support coordinator caseloads are in compliance. Support coordination services agency caseload compliance for CY19 was on average 86 percent (Figure 7). The vast majority of individuals are seen at the proper frequency according to policy. Additionally, analysis indicates that when not in compliance with caseload size, most support coordinators were out of compliance by only a small number of individuals. DBHDD questioned, "Is being out of compliance with caseload size associated with negative outcomes?" Poisson regression analysis indicated caseload noncompliance is not significantly related to increased negative outcomes such as increased hospitalizations and emergency department visits.
It is critical to note the limitations of these findings. Most support coordinators are within caseload size compliance. For the few support coordinators out of compliance, the noncompliance is by only a few individuals. Therefore, these analyses can only be extended or interpreted as being non-compliant by a limited number of individuals on a caseload. It would be reasonable to assume that non-compliance beyond a few individuals could be related to negative incidents, and that is not the case with the data analysis for DBHDD.

Figure 7: Support Coordination Services Caseload Compliance, CY19

*Performance Threshold is 86%.

600

100%

550

86%

85%

87%

88%

86%

86%

75%

500

450

443

442

443

449

450

449 50%

400

382

377

387

393

386

387

25%

350

300 2019/01

2019/02

2019/03

2019/04

2019/05

In Compliance Total SCs Percent Compliance

0% 2019/06

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FACE-TO-FACE VISITS

SC AND ISC

Individuals receiving support coordination services are to have a minimum number of face-toface visits in a specific time period. The dashed line in Figure 8 represents the minimum number of face-to-face visits required for individuals by support coordinators. Individuals receiving SC received on average more than the required number of face-to-face visits for each quarter. Individuals receiving ISC (Figure 9) received on average more than the required number of faceto-face visits for each month. Therefore, from a compliance perspective, SC and ISC recipients are receiving the required number of visits.
Figure 8: Face-to-Face visits per Quarter, SC

0

0.5

1

1.5

2

2.5

3

Q1

2.14

Q2

2.09

Mean Visits per Quarter SC

Figure 9: Face-to-Face visits per Month, ISC

0

0.5

1

1.5

2

2.5

3

Q1

1.35

Q2

1.29

Mean Visits per Month ISC

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HEALTH RISK AND SUPPPORT COORDINATION SERVICES
The Health Risk Screening Tool (HRST) is a standardized mechanism used to determine an individual's vulnerability to potential health risks and early identification of deteriorating health. The HRST measures health risk using a distinct rating scale related to functional status, behavior, physiological condition, and safety. HRST results are incorporated into the ongoing health care surveillance process. The HRST is completed to inform an individual's approval for community IDD services. After its initial completion, the HRST is conducted annually and whenever an individual experiences significant health events or changes in health, functional, or behavioral status. The HRST guides providers in determining the individual's need for further assessment and evaluation, services, or modifications to his or her service plan to address identified health risks.
The HRST generates a health care level (HCL) which is a risk level score on a scale of 1 (lowest score) to 6 (highest score). The risk level is directly related to an individual's or their caregiver's responses to a series of questions related to functional status, behavior, physiological condition, safety, and frequency of services.
The average HCL of all individuals for CY19 was approximately 2. Though a low HCL level indicates a relatively low risk level, it is important to note that most IDD individuals receiving support coordination services have at least one area of elevated risk. The average CY19 HCL for individuals receiving ISC is much higher, at a score of 5. Increasing health risk levels may indicate a need for additional support and more frequent visits to support the health of individuals.
A question to consider beyond compliance is, "Is the number of face-to-face visits associated with individuals' level of need versus compliance with a standard number of face-to-face visits?" The answer is a resounding "yes."
Mortality analyses over the past several years have demonstrated the importance that should be placed on a person's health risk level and age to understand the intensity of services they should receive. In other words, people with higher health care levels or ages should be receiving more frequent visits, while those with lower health care levels are indicated to have less measured health risk and may need fewer visits (and the same for younger ages).
A Poisson regression model was generated to show that age and HCL are associated with the number of face-to-face visits received by individuals enrolled in support coordination and intensive support coordination.6 Poisson distribution modeling indicated that the number of face-to-face visits increased with increasing need, which indicates a level of performance and quality beyond compliance standards. These are positive findings that have been evidenced
6 These analyses are available upon request.
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across all support coordination performance reports: as age and health risk levels increased, the number of face-to-face visits also generally increased.
Using the results from the abovementioned statistical model, the number of SC or ISC visits each person would be "expected" to have based on her or his risk level and age was calculated and compared with the actual number of visits she or he received. Table 1 shows, on average, support coordination agencies are delivering support coordination services as expected--the expected number needed based on need (age and HCL). On average, the support coordination agencies are within one visit of what would be expected when you take into consideration a person's age and HCL (after adjusting for what type of support coordination services the person received).
Recall that previous analytical findings in this report demonstrated that support coordination service providers exceeded the required number of face-to-face visits; therefore, the negative differences listed in Table 1 do not indicate too few visits. These analyses demonstrate, moreover, as the level of health risk and age increase the number of face-to-face visits also increase, oftentimes in excess of what is required.

Table 1: Agency Face to Face Visits, Mean Difference between Expected and Observed

Agency
Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

Mean Difference Between Expected and
Observed Visits
-0.49 0.22 0.13 0.11 0.22 -0.21 -0.36

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INDIVIDUAL QUALITY OUTCOME MEASURES REVIEW
The individual quality outcome measures review (IQOMR) is the services and support evaluation tool used for support coordination services. The IQOMR is divided into seven focus areas: Environment, Appearance and Health, Supports and Services, Behavioral and Emotional, Home and Community Opportunities, Financial, and Satisfaction. Each focus area contains one or more questions that guide the support coordinator to do the following:
Observe and interact with the participant as it relates to the elements of the item reviewed;
Observe the setting for evidence pertaining to the item reviewed; Review any pertinent documentation relating to the item reviewed; Engage in discussion with staff members or natural supports who may have information
on the item reviewed; and Observe staffs' or natural supports' interaction with the individual as it relates to the item
reviewed.
Based on the support coordinator's completion of the above steps, each focus area question is evaluated based on the following standards:
Acceptable standards are reached when elements of the focus area question have been fully evaluated by the support coordinator and there are no concerns to report. All elements of the focus area question have been met satisfactorily and services/supports are being provided in an adequate manner; or
Coaching is required when a concern, issue, or 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 field office or clinical staff; or
Referrals are made to DBHDD or clinical staff to address serious concerns or untimely responses to coaching in the areas of the IQOMR.
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IQOMR POSITIVE ANSWERS AND COACHING AND REFERRAL OUTCOMES

In this section, DBHDD analyzed IQOMR response data and activity related to coachings and referrals. Figures 10 and 11 compare support coordination IQOMR positive answer performance for the first quarter (January through March) and second quarter (April through June) of CY19. The dotted line indicates the 86 percent performance benchmark set by DBHDD.

SC services recipients sustained at well over 86 percent positive outcomes in five of the seven of the IQOMR focus areas. The Behavioral and Emotional and Financial focus areas were the only areas that fell below the threshold of 86 percent for both the first and second quarters of CY19.

100%

91% 91%

Figure 10: SC IQOMR Positive Answers, CY19

*Performance Threshold is 86%.

92% 92%

94% 93%

92% 92%

99% 98%

80%

74% 73%

72% 72%

60%

40%

20%

0%

Environmental Appearance/Health Supports & Services Behavioral and

Home &

Emotional

Community

Opportunities

Q1 Q2

Satisfaction

Financial

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Analysis indicates ISC services sustained positive outcomes in four of seven areas for CY19. Positive outcomes for Home and Community Opportunities fell slightly below the 86 percent performance threshold. As with SC services, ISC services fell below the threshold in the focus areas of Behavioral and Emotional and Financial.

100%

97% 97%

80%

60%

Figure 11: ISC IQOMR Positive Answers, CY19

*Performance Threshold is 86%.

90% 92%

89% 92%

82% 85%

97% 98%

78% 77%

56% 57%

40%

20%

0%

Environmental Appearance/Health Supports and Behavioral and

Home and

Services

Emotional

Community

Q1 Q2

Opportunities

Satisfaction

Financial

COACHING AND REFERRAL ACTIVITIES
Previous analyses indicated that the vast majority of individuals are receiving the required number of face-to-face visits, and the face-to-face visits are based on increasing risk posed by increasing age and increasing health risk levels. These findings underline the support coordinators' workload in delivering at least the required number of visits, tailored to increasing risk. Beyond the number of visits individuals receive, another way of understanding better the productivity and workload performance of support coordination agencies is to examine a key component of support coordinator value that they deliver: coaching and referrals.
According to current DBHDD policy, support coordinators can report and record concerns within the IQOMR using coaching and referrals. 7 Analyzing coaching and referrals provides an additional understanding of activities support coordinators deliver to effect positive outcomes for individuals.

7 DBHDD Policy: Outcome Evaluation "Recognize, Refer, and Act" Model, 02-435 20

Coaching
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 field office or clinical staff.

Referrals
Required for more serious risks than those addressed by coaching. Referrals are made to DBHDD or 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 the amount of effort and productivity of support coordinators in working with providers to assist individuals. When taken together, support coordination agencies provided 7,724 coaching sessions aimed at addressing issues to provide improved outcomes for individuals from January through June 2019. Support coordinators also provided 3,035 referrals in response to individuals' needs in order to facilitate positive outcomes. To understand more fully the tremendous efforts beyond achieving face-to-face requirements, consider that combined, support coordinators initiated and followed up on 10,759 coachings and referrals to improve the services, supports, and outcomes of individuals they serve--within a six-month period. See Appendix D for the coaching and referral activity of each support coordination services agency.

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Table 2: Coaching and Referrals Activity, CY19

Coaching and Referrals Activity

Number of Coachings

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

4,151 1,837 609 445 330 294
58 7,724

Number of Referrals

Number of Referrals Open beyond Intended Close Date

Percent of Referrals Open beyond Intended Close Date

1,996

161

8%

495

50

10%

131

14

11%

69

6

9%

287

20

7%

46

6

13%

11

1

9%

3,035

258

9%

Figure 12 compares coaching and referral data between the first quarter and second quarter of CY19. T-test analyses indicate that the number of coachings between the first and second quarters of CY19 were not significantly different. The number of referrals opened remained consistent throughout the reporting period. Additionally, the number of referrals open beyond their intended close date showed no significant change between the first and second quarters of the year.

Figure 12: Support Coordination Services, Coaching and Referrals, CY19

5,000 4,000

3,869

3,000

2,000 1,000
-

1,471

124

March

Number of Coachings

Number of Referrals

3,855
1,564 134
June Number of Referrals Open beyond Intended Close Date

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Recall that the IQOMR data for SC services remained above 86 percent for five of the seven focus areas, and ISC services remained above 86 percent in four of the seven focus areas, indicating the decrease in number of coachings, steady number of referrals, and steady number of referrals open beyond the expected close date are associated with positive outcomes. Therefore, the reduction in coaching can be seen as a positive indicator that individuals, their families, and providers are benefitting from support coordination services. Also, when an issue must be raised to a higher level of urgency, those issues are being addressed in a timely and efficient manner.
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OTHER OUTCOMES
DBHDD also investigated other areas to determine how support coordination activities, as well as the combination of other services and supports, impacted outcomes.
HCL SCORES
Though measured health risk level is not a direct measure of outcomes, the analyses below report on changes over time. Below, Table 3 indicates that the average HCL has increased over time for those receiving support coordination services. Though small, increases were found to be statistically significant for both SC and ISC. These findings substantiate previously completed analyses that showed the IDD population health risk is increasing.
Though it may seem that health risk should decrease over time with more intensive support coordination services, one must keep in mind that there is a difference between "health risk" and "health status." The HCL is a measure of risk; when one becomes at risk for adverse health, the risk tends to persist, especially in this population. Health status (e.g., symptoms, functioning, physiological outcomes, diagnosis, etc.) are more likely to vary over time, and DBHDD continues to investigate opportunities to identify and operationally define population-level health status indicators for analysis. Health risk is a critical factor for managing service provision to these populations, and health risk will remain prominent in DBHDD analyses and planning.

Table 3: Difference in HCL December 31, 2018 and June 30, 2019

SC Type in CY19
Support Coordination* Intensive Support Coordination*

Mean

Difference (Increase)

SD

Median

HCL

0.09

0.53

0

0.08

0.77

0

*Indicates statistical significance

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INDIVIDUALIZED SERVICE PLAN QUALITY ASSURANCE
DBHDD is committed to providing high-quality care to individuals receiving IDD services. Support coordinators are responsible for the development of individualized service plans (ISP) as described in policy.8 An approved ISP authorizes the provision of safe, secure, and dependable support and assistance in areas that are necessary for the individual to achieve full social inclusion, independence, and personal and economic well-being. The ISP is developed based on assessed needs identified through the HRST, Supports Intensity Scale, clinical assessments, and additional documentation as needed. It identifies the individual's personally-defined outcomes and planning goals and describes the services and supports needed to assist the individual in attaining those outcomes and goals.
Support coordinators are responsible for the development of ISPs with input from the individual and the individual's support team, monitoring of the implementation of the ISPs, recognizing the individual's needs and risks (if any), promoting community integration, and responding by referring, directly linking, or advocating for resources to assist the individual in gaining access to needed services and supports.
The Georgia Collaborative Administrative Service Organization (ASO), as part of the DBHDD quality management system, carries out specific quality review processes. The quality review processes for IDD services determine whether the current service delivery systems are promoting positive outcomes and independence through person-centered practices.
The ISP quality assurance (ISP QA) checklist was developed by the Division of DD to assess the support plan. The ISP QA checklist helps to determine an overall rating of the ISP, monitor certain specific requirements, and determine the extent to which the ISP addresses different aspects of the person's life. ASO reviewers complete the ISP QA checklist as part of their quality review process.
ISP QUALITY EXPECTATIONS
The ASO collects information from a stratified, randomly-selected sample of individuals across the DBHDD delivery system to be representative of the population served by DBHDD. Data presented in this section are indicators from the ISP QA checklist that were selected as approximate indicators of support coordination quality for creating ISPs. Agency-specific data can be found in Appendix E. The current tool does not allow for delineation between SC and ISC.
8 DBHDD Policy: The Service Planning Process and Individual Service Plan Development, 02-438
25

Figure 13 shows the state average for all ISP QA scales for the first half of CY19. Support coordinators met or exceeded 86 percent positive performance on six of the seven ISP QA quality expectation indicators. Figure 15 indicates support coordinators met or exceeded overall quality expectations 91 percent of the time.
Figure 13: State Average, ISP QA Ratings, January June 2019
(N = 658)

Map demonstrates the person is connected to the community. 6%

Communication chart provides meaningful information staff can use to support the person best.

2%

Profile is detailed and includes person-centered information. 12%

Summary describes changes in the person's life in the last year and the supports/plans needed to address the change with the 2%
person.

Summary reflects the person's community life.

24%

Health and Safety section includes how all current issues, needs, and risks are addressed.

3%

Goals and objectives are person centered. 12%

67% 76% 58%
82% 70%
64% 65%

27% 22%
30% 16% 6%
33% 23%

State Average 9%

69%

0%

25%

50%

Needs Improvement Met Exceeding

22%

75%

100%

26

NATIONAL CORE INDICATOR DATA
Whenever possible, DBHDD attempts to cross-validate and combine findings from multiple areas and data systems to create a more complete understanding of the performance and outcomes of support coordination. DBHDD incorporated benchmark data from a nationally-recognized Centers for Medicare and Medicaid Services-approved survey called the National Core Indicator Survey (NCI). DBHDD participates in the NCI survey annually.
The core indicators are used to assess the outcomes of intellectual and developmental disability services provided to individuals and families. They address key areas including employment, rights, service planning, community inclusion, choice, and health and safety. The core indicators also provide information for quality improvement and programmatic management. They are intended to be used in conjunction with other state data sources.
A component of the NCI survey is the Adult In-Person Survey. This survey was developed for the purposes of collecting information directly, yet anonymously, from individuals; these data do not allow for comparison between SC and ISC. In Georgia, this survey is administered by the ASO as part of the DBHDD quality management system.
NCI DATA ANALYSIS
The following section looks at how DBHDD and support coordination are performing compared to national NCI averages. Scores include seven survey questions directly related to the provision of support coordination services. Support-coordination-specific items were chosen because they are national indicators of support coordination performance, allowing for national benchmark comparisons on the important functions, processes, and outcomes associated with support coordination.
For the support coordination-specific items, each state's percentage was compared to the weighted NCI average, and the differences between the two were tested for both statistical significances, as well as effect sizes. Effect sizes are used in addition to statistical significance because statistical significance of a state's result depends, in part, on the size of the state's sample: the larger the sample, the more likely it is that even a small difference will be found statistically significant.
T-test analyses established whether the state's percentage was...
Higher than the NCI average, and the difference was statistically significant; Within the average range (i.e., not statistically different from the NCI average); or Lower than the NCI average, and the difference was statistically significant.
Statistical significance was determined at the p .01 level.
27

SUPPORT COORDINATION SPECIFIC ITEMS
The provision of support coordination services was assessed using seven indicators related to an individual's familiarity with their support coordinator, support coordinator responsiveness, and ISP development. Individuals responded at or near national averages on support coordinationspecific items 67 percent of the time; moreover, support coordinators performed significantly above the national average 33 percent of the time. One indicator related to a person having an ISP does not allow for national average comparison. These findings are additional indicators that support coordinators are meeting the requirements of the services they provide and are responsive to the needs and goals of the individuals they serve.
Figure 14: NCI Data Analysis, Support Coordination, CY19

Have you met your Case Manager/Service Coordinator?

96% 94%

Case Manager/Service Coordinator asks what you want?

86% 89%

Are you able to contact your Case Manager/Service 87%

Coordinator when you want to?

88%

Do you have a service plan? 99%

At the service planning meeting, did you know what was being 82%

talked about?

81%

Did the service planning meeting include the people you 96%

wanted to be there?

92%

Were you able to choose the services that you get as part of 87%

your service plan?

73%

Significant higher performance between Georgia and National data

0%

20%

40%

60%

80%

100%

Georgia National

28

SUMMARY OF ANALYTIC FINDINGS
Caseload sizes are, by large measure, aligned with requirements. Analyses also indicated that being out of compliance with caseload size requirements by a small amount was not associated with adverse outcomes. Furthermore, not only are the vast majority of individuals receiving the required face-to-face-visits, but also the number of face-to-face visits is positively associated with the level of need indicated by risk factors such as age and health risk. IQOMR data also indicate that support coordinator processes and procedures are being followed and producing positive outcomes in most areas; however, improvement can be made, especially in the Behavioral and Emotional and Financial Outcome areas, and support coordinators could use additional supports in resolving some referrals that remain open past their expected close date. Analysis of scores on the ISP QA checklist indicate support coordination agencies are performing at a high level in assuring that ISPs contain specific requirements such as community integration and are addressing an individual's goals and needs. What's more, support coordinators were performing as well as or better than national averages on all NCI support-coordination-specific items; therefore, external, nationally-accepted, reliable, and valid data buttress the effectiveness of Georgia's support coordination services. Overall, data and analyses indicate that support coordinators perform well in assisting individuals receiving quality services, supports, and outcomes.
29

Appendix A: Support Coordination Services, Agency Data
Proportion of SCs to ISCs, CY19

SC/ISC Agency
Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

SC 384 79 3,660 110 3,192 1,412 2,177

Q1

ISC Proportion ISC

378

49.61

138

63.59

476

11.51

154

58.33

478

13.02

181

11.36

217

9.06

SC 411 85 3,752 137 3,246 1,419 2,174

Q2

ISC Proportion ISC

383

48.24

142

62.56

481

11.36

154

52.92

489

13.09

178

11.15

222

9.27

Face to Face Visits, SC and ISC, CY19

SC/ISC Agency
Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

SC Percent Compliance
95% 96% 96% 93% 99% 98% 94%

ISC Percent Compliance
95% 98% 95% 97% 98% 99% 92%

30

Appendix B: SC and ISC IQOMR Ratings, CY19

Q1

SC Agency

Environmental

Appearance/ Health

Supports and
Services

Behavioral and
Emotional

Home and Community Opportunities

Satisfaction

Financial

Benchmark

87%

CareStar

83%

Columbus

82%

Compass

96%

Creative

99%

Georgia Support

98%

PCSA

89%

90%

85%

78%

85%

80%

90%

57%

92%

94%

97%

86%

91%

100%

48%

67%

82%

93%

93%

67%

91%

92%

96%

80%

93%

94%

94%

64%

95%

Q2

96%

50%

87%

58%

99%

71%

89%

93%

99%

78%

99%

86%

99%

61%

SC Agency

Environmental

Appearance/ Health

Supports and
Services

Behavioral and
Emotional

Home and Community Opportunities

Satisfaction

Financial

Benchmark

85%

CareStar

78%

Columbus

84%

Compass

92%

Creative

99%

Georgia Support

96%

PCSA

90%

92%

86%

66%

82%

95%

91%

69%

93%

93%

94%

84%

90%

97%

75%

79%

77%

93%

93%

66%

92%

93%

95%

80%

94%

92%

92%

66%

95%

96%

56%

93%

71%

97%

70%

96%

94%

99%

78%

98% 82%

99%

60%

31

Q1

ISC Agency

Supports Behavioral Home and

Environmental Appearance/Health and

and

Community Satisfaction

Services Emotional Opportunities

Financial

Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

95% 98% 96% 100% 97%
99%
98%

90%

89%

62%

82%

97%

78%

95%

94%

67%

90%

97%

94%

91%

91%

55%

81%

99%

74%

91%

89%

46%

76%

100%

38%

86%

85%

51%

78%

95%

77%

89%

92%

65%

81%

99%

93%

94%

91%

44%

93%

100%

72%

Q2

ISC Agency

Supports Behavioral Home and

Environmental Appearance/Health and

and

Community Satisfaction

Services Emotional Opportunities

Financial

Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

96% 96% 94% 99% 97%
100%
99%

90%

92%

58%

81%

98%

78%

95%

95%

72%

89%

99%

89%

93%

92%

65%

88%

97%

80%

91%

94%

52%

76%

100%

38%

89%

88%

51%

81%

96%

72%

98%

96%

70%

89%

99%

91%

96%

94%

39%

96%

100%

67%

32

Appendix C: Coaching and Referrals, Agency Data. Q1 and Q2 Combined

Agency
Benchmark CareStar Columbus Compass Creative Georgia Support PCSA Grand Total

Appearance/ Health

Number Number

of

of

Coachings Referrals

Number of Open / In Progress Referrals Beyond
Date

Percent of Open / In Progress Referrals Beyond Date

106

31

2

6%

8

74

2

3%

677

105

5

5%

96

42

0

0%

1,092 964

80

8%

523

435

26

6%

1,649 345

46

13%

4,151 1,996

161

8%

Supports and Services

Agency

Number Number

of

of

Coachings Referrals

Number of Open / In Progress Referrals Beyond Date

Percent of Open / In Progress Referrals Beyond Date

Benchmark

54

8

2

25%

CareStar

5

2

0

0%

Columbus

342

64

3

5%

Compass

49

9

0

0%

Creative

752

275

39

14%

Georgia Support

345

108

2

2%

PCSA

290

29

4

14%

Grand Total

1,837 495

50

10%

33

Environment

Agency

Number Number

of

of

Coachings Referrals

Number of Open / In Progress Referrals Beyond
Date

Percent of Open / In Progress Referrals Beyond Date

Benchmark

32

1

0

0%

CareStar

1

0

0

0%

Columbus

113

17

3

18%

Compass

18

3

0

0%

Creative

130

58

6

10%

Georgia Support

59

23

0

0%

PCSA

256

29

5

17%

Grand Total

609

131

14

11%

Home and Community Opportunities

Agency

Number Number

of

of

Coachings Referrals

Number of Open / In Progress Referrals Beyond
Date

Percent of Open / In Progress Referrals Beyond Date

Benchmark

49

6

0

0%

CareStar

1

2

0

0%

Columbus

50

7

0

0%

Compass

40

10

0

0%

Creative

86

12

4

33%

Georgia Support

101

19

1

5%

PCSA

118

13

1

8%

Grand Total

445

69

6

9%

34

Behavioral and Emotional

Agency

Number Number

of

of

Coachings Referrals

Number of Open / In Progress Referrals Beyond
Date

Percent of Open / In Progress Referrals Beyond Date

Benchmark

27

27

0

0%

CareStar

7

19

0

0%

Columbus

48

32

0

0%

Compass

20

17

0

0%

Creative

67

89

12

13%

Georgia Support

64

70

1

1%

PCSA

97

33

7

21%

Grand Total

330

287

20

7%

Agency
Benchmark CareStar Columbus Compass Creative Georgia Support PCSA Grand Total

Financial

Number Number

of

of

Coachings Referrals

Number of Open /
In Progress Referrals Beyond
Date

12

8

1

2

0

0

40

6

0

9

2

0

37

9

4

63

10

1

131

11

0

294

46

6

Percent of Open / In Progress
Referrals Beyond Date
13% 0% 0% 0% 44% 10% 0% 13%

35

Satisfaction

Agency

Numb er of Coachi ngs

Number of
Referrals

Number of Open / In Progress Referrals Beyond
Date

Percent of Open / In Progress
Referrals Beyond Date

Benchmark

3

0

0

0%

CareStar

0

0

0

0%

Columbus

13

1

0

0%

Compass

3

0

0

0%

Creative

18

5

1

20%

Georgia Support 11

5

0

0%

PCSA

10

0

0

0%

Grand Total

58

11

1

9%

36

Appendix D: Individualized Service Plan Quality Assurance Ratings, Agency Data

Columbus Community Services Average ISP QA Ratings by Expectation
CY2019 January through June (N = 205)

Map demonstrates the person is connected to the community.

7%

Communication chart provides meaningful information staff can use to support the person best.

2%

Profile is detailed and includes person-centered information.

17%

Summary describes changes in the person's life in the last year and the supports/plans needed to address the...

5%

Summary reflects the person's community life. 32%

Health and Safety section includes how all current issues, needs, and risks are addressed.

1%

Goals and objectives are person centered. 13%

72% 80%
64% 88%
65% 81%
60%

21% 18% 20%
7% 3% 19% 27%

State Average 11%

73%

0% Needs Improvement

25%

50%

Met Exceeding

17%

75%

100%

37

Carestar Average ISP QA Ratings by Expectation CY2019 January through June (N = 16)

Map demonstrates the person is connected to the community.

24%

Communication chart provides meaningful information staff can use to support the person best.

0%

Profile is detailed and includes person-centered information.

0%

Summary describes changes in the person's life in the last year and the supports/plans needed to address the...

0%

Summary reflects the person's community life. 32%

Health and Safety section includes how all current issues, needs, and risks are addressed.

0%

Goals and objectives are person centered. 4%

51%

24%

51%

49%

72%

28%

96%

4%

68%

0%

59%

41%

92%

4%

State Average 9%

70%

0% Needs Improvement

25%

50%

Met Exceeding

21%

75%

100%

38

Benchmark Average ISP QA Ratings by Expectation CY2019 January through June (N = 22)

Map demonstrates the person is connected to the community.

23%

Communication chart provides meaningful information staff can use to support the person best.

8%

Profile is detailed and includes person-centered information.

17%

Summary describes changes in the person's life in the last year and the supports/plans needed to address the...

8%

Summary reflects the person's community life. 26%

Health and Safety section includes how all current issues, needs, and risks are addressed.

8%

Goals and objectives are person centered. 17%

74% 86% 60% 83%
74% 68%
77%

3% 6% 23% 8%
24% 6%

State Average 15%

75%

0% Needs Improvement

25%

50%

Met Exceeding

10%

75%

100%

39

Creative Consulting Services Average ISP QA Ratings by Expectation
CY2019 January through June (N = 192)

Map demonstrates the person is connected to the community.

5%

Communication chart provides meaningful information staff can use to support the person best.

2%

Profile is detailed and includes person-centered information.

1%

Summary describes changes in the person's life in the last year and the supports/plans needed to address the...

0%

Summary reflects the person's community life. 6%

Health and Safety section includes how all current issues, needs, and risks are addressed.

1%

Goals and objectives are person centered. 1%

69% 73% 49% 76%
84% 75% 69%

State Average 3%

71%

0% Needs Improvement

25%

50%

Met Exceeding

26%

27%

50%

24%

10%

25%

31%

27%

75%

100%

40

Georgia Support Services Average ISP QA Ratings by Expectation
CY2019 January through June (N = 102)

Map demonstrates the person is connected to the community.

6%

Communication chart provides meaningful information staff can use to support the person best.

1%

Profile is detailed and includes person-centered information.

6%

Summary describes changes in the person's life in the last

year and the supports/plans needed to address the...

3%

Summary reflects the person's community life. 5%

Health and Safety section includes how all current issues, needs, and risks are addressed.

1%

Goals and objectives are person centered. 3%

51% 61% 53%
75% 83%
77% 56%

State Average 4%

65%

0% Needs Improvement

25%

50%

Met Exceeding

43%

39%

42%

22%

13%

22%

42%

32%

75%

100%

41

Professional Case Management Services Average ISP QA Ratings by Expectation
CY2019 January through June (N = 105)

Map demonstrates the person is connected to the

community.

5%

Communication chart provides meaningful information staff can use to support the person best.

1%

Profile is detailed and includes person-centered information.

9%

Summary describes changes in the person's life in the last year and the supports/plans needed to address the...

3%

Summary reflects the person's community life. 7%

Health and Safety section includes how all current issues, needs, and risks are addressed.

3%

Goals and objectives are person centered. 3%

64% 78% 68% 81% 86% 79% 72%

31% 21% 24% 16% 7% 18%
26%

State Average 5%

76%

0% Needs Improvement

25%

50%

Met Exceeding

20%

75%

100%

42

Compass Coordination Average ISP QA Ratings by Expectation CY2019 January through June (N = 16)

Map demonstrates the person is connected to the community.

20%

Communication chart provides meaningful information staff can use to support the person best.

7%

Profile is detailed and includes person-centered information.

0%

Summary describes changes in the person's life in the last year and the supports/plans needed to address the...

10%

Summary reflects the person's community life.

23%

Health and Safety section includes how all current issues, needs, and risks are addressed.

10%

Goals and objectives are person centered.

26%

58% 65% 65%
90% 78%
61% 52%

23% 29% 35%
0% 0% 29% 23%

State Average 14%

67%

0% Needs Improvement

25%

50%

Met Exceeding

20%

75%

100%

43

Appendix E: Agency-Specific NCI Data

Agency
Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

Total # of NCI Surveys
12 12 125 9 131 73 77

Were you able to choose the services that you get as part of your service plan?

Agency Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

Total Scored 7 3 77 2 75 46 53

% Yes 86% NR 94% NR 83% 94% 87%

*NR: Not Reportable due to fewer than 5 responses.

Did the service planning meeting include the people you wanted?

Agency Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

Total Scored 7 3 77 3 84 48 53

% Yes 71% NR 99% NR 95% 94% 100%

*NR: Not Reportable due to fewer than 5 responses.

44

At the service planning meeting, did you know what was being talked about?

Agency Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

Total Scored 7 3 78 3 79 48 51

% Yes 71% NR 87% NR 80% 75% 82%

*NR: Not Reportable due to fewer than 5 responses.

Do you have a service plan?

Agency Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

Total Scored 7 3 79 3 84 49 55

% Yes 100%
NR 98% NR 95% 92% 95%

*NR: Not Reportable due to fewer than 5 responses.

Are you able to contact your Case Manager/Service Coordinator when you want to?

Agency Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

Total Scored 6 3 69 2 74 44 48

% Yes 100%
NR 87% NR 93% 86% 83%

*NR: Not Reportable due to fewer than 5 responses.

45

Case Manager/Service Coordinator asks what you want?

Agency Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

Total Scored 6 3 73 2 80 46 51

% Yes 100%
NR 82% NR 86% 96% 78%

*NR: Not Reportable due to fewer than 5 responses.

Have you met your Case Manager/Service Coordinator?

Agency Benchmark CareStar Columbus Compass Creative Georgia Support PCSA

Total Scored 7 3 80 3 88 49 55

% Yes 86% NR 95% NR 97% 98% 96%

*NR: Not Reportable due to fewer than 5 responses.

46

Appendix F: Support Coordination Performance Infographic
47

48