2021-23-008-3 B36696 SEFS Narrative S VI_Q1_Q2 050923.docx

Sole Source Justification Form Bulletin Reference Number: 23-478HFS-MEDPR-B-3996 Requesting Agency/University: Illinois Department of Healthcare and Family Services

Section VI. Business Rationale

1. Provide a detailed explanation of the need for the supplies or services:

Under both the Colbert and Williams Consent Decrees, the state must have a system in place to ensure (1) that an individual is not admitted to a Specialized Mental Health Rehabilitation Facility (SMHRF) (under Williams) or a Cook County Nursing Facility (CCNF) (under Colbert) unless the level of care provided in those facilities is necessary for the individual, and (2) the individual does not reside in the CCNF or SMHRF longer than necessary if the individual is able to live in a less restrictive setting and desires to do so. To satisfy these mandates, the state must conduct preadmission assessments of all individuals to determine if admission is necessary and appropriate (and if admission can be for a short term), as well as ongoing assessments to make sure individuals do not remain longer than needed. The ongoing assessments must include consideration of any changes to the individual’s needs during the CCNF or SMHRF stay.

The detailed requirements of the state’s work under the Williams and Colbert Consent Decrees are set forth in annual implementation plans. These plans include changes to the specific implementation mandates for existing requirements and the addition of new requirements every year to address ongoing issues and problems with the state’s work as identified by the Court Monitor. Paragraph 14 of the Williams Consent Decree (enclosed) states that “the Implementation Plan … shall be incorporated into, and become enforceable as part of the Decree.” A similar provision is in Section VIII. D. of the Colbert Consent Decree (enclosed). Over the last four years of implementation in both decrees, numerous significant obstacles to satisfying the decree mandates have been identified by the Court Monitors. Among the most significant obstacles is the lack of (1) a streamlined process for both preadmission assessment of individuals entering CCNFs and SMHRFs and ongoing assessments once they are living in the facilities, and (2) an effective flow of all of the information developed in the assessments so it can be maintained, tracked and acted upon in a timely manner. As discussed below, another significant obstacle to providing transition services in a timely way to a sufficient number of Colbert class members is the failure to effectively and quickly identify individuals with severe dementia.

The Maximus contract was intended to ensure that one vendor would address these obstacles and respond to numerous ongoing implementation requirements in both Consent Decrees. Pursuant to the contract, Maximus:

a) conducts preadmission assessments for individuals before entering CCNFs, SMHRFs and Supportive Living Programs,

b) conducts follow-up visits with CCNF residents who have been assessed as having a higher level of mental illness, and

c) repeats the preadmission assessment for individuals reaching the end of what was initially assessed to be a short-term stay in a SMHRF.

The assessments involve numerous documents – assessment tools, clinical assessments, and quality reviews – and produce written outcomes. Maximus provides AssessmentPro, a web-based platform to support all of the workstreams and document the assessment findings and outcomes. AssessmentPro is a critical part of the state’s effort to meet the Consent Decree requirements and eliminate the obstacles identified above – particularly the lack of an effective, streamlined flow of information that allows all of the entities and individuals involved in compliance with the decrees to track and act upon the information without unnecessary delay. The state also relies extensively on AssessmentPro to respond to ongoing and new questions from the Court Monitor and Plaintiffs’ counsel.

After extensive discussions with the Court Monitor and Plaintiffs’ counsel identifying clear shortcomings in the state’s work to assess SMHRF residents, the Continued Stay Reviews were added as a new mandate stemming from the FY 2022 Williams Implementation Plan (IP, enclosed)). On the top of page 4, the IP states: “the PASRR Plus system will be able to authorize and manage short-term admissions approvals to ensure that individuals requiring only brief periods of stabilization or rehabilitation do not remain in institutions longer than necessary.” (At the time, the state was referring to the redesigned system as PASRR Plus.) The IP was filed on August 18, 2021, while the PASRR procurement was still pending resolution of a protest. HFS agreed to seek to amend the eventual contract once initial implementation outlined in the RFP was complete. The specific program components of Continued Stay Reviews outlined in this procurement justification have been established in conjunction with the federal Court Monitor and represent the best approach to meeting the commitment memorialized in the FY22 IP.

As reflected by their addition to the Implementation Plan, the Continued Stay Reviews are critical to the state’s ability to meet its obligations under the Williams Consent Decree. The state is currently not effectively and comprehensively assessing Williams class members who have been in SMHRFs receiving services and then integrating that assessment information quickly into the overall information about the class member. This lack of effectiveness then contributes to delays in working with class members as needed to transition out of the SMHRF to a less restrictive setting.

The agency also seeks to add dementia assessments. The importance of adding this service is rooted in the Colbert Consent Decree itself. The Decree generally defines the Colbert Class as all Medicaid eligible individuals residing in CCNFs and entitles them to a variety of services and supports to aid in community transition. Section VI.A.7 of the Decree, however, provides an exception for individuals “who have been determined by a medical doctor to have a condition such as severe dementia or other clinically significant and progressive cognitive disorders and are unlikely to improve.” The purpose of this exception is to recognize that the state is not obligated to pursue community transition on behalf of individuals who have “severe dementia or other severe cognitive impairments” – which, in turn, provides the state with more time and resources to pursue transition on behalf of class members in need of the services. Therefore, as part of the state’s assessment of individuals in the class – whether at preadmission to a CCNF or in post-admission assessments – the state should be taking additional steps with individuals who appear to have dementia in an effort to determine whether their condition rises to the level of “severe dementia or other severe cognitive impairment.”

These assessment steps are necessary to effectively identify which individuals must receive services and supports for transitioning pursuant to the Colbert Consent Decree. Without effectively identifying which individuals fall within this exception, the state is failing to target limited resources to transitioning class members appropriately. Approximately 7,700 individuals currently residing in CCNFs have a diagnosis of Alzheimer’s dementia or non-Alzheimer’s dementia in nursing facility records. As is obvious from that number, it is possible that a very large portion of CCNF residents are not eligible to transition pursuant to the Colbert Consent Decree. To meet the Colbert Consent Decree requirements to provide transition services in a reasonable time frame (and given limited resources), the state must effectively determine whether individuals currently residing in CCNFs have severe dementia and whether individuals seeking admission going forward have severe dementia. The State must also ensure it has the capacity, as part of ongoing follow up assessments, to determine whether a CCNF resident has developed severe dementia or other severe cognitive impairments while residing in a CCNF.

The addition of the dementia assessment service has been identified by the federal Court Monitor as a critical and urgent need for the state to ensure compliance with the Colbert Consent Decree. The state is struggling to provide transition services in a timely manner to a sufficient number of Colbert class members on an annual basis. Without being able to effectively identify the CCNF residents who should not be the focus of the many steps in the transition process, the state is not effectively using limited resources.

2. Provide a list and describe in detail the specifications required to satisfy the need:

Continued Stays:

The vendor will configure a process to enable the agency to track compliance and quality of discharge plans, ensure SMHRF residents are connected to community resources, and identify barriers to provision of services in accordance with the Williams Consent decree. AssessmentPro will cue SMHRF staff to submit essential record information, and to answer key questions about the individual, the individual's service plan, and the status of treatment and services.

A Maximus SMHRF Clinical Evaluator will complete an onsite visit at the SMHRF. During this visit, the SMHRF Clinical Evaluator will interview the SMHRF resident and their guardian as well as SMHRF staff to make sure an appropriate discharge plan is in place and that community connections have been established. Additionally, the SMHRF Clinical Evaluator will review documentation, including Care Plans, Progress Notes, any Recent Medical and/or Psychiatric records, daily activity reports, History & Physical documentation, Medication Administration Records, and Discharge Planning Notes. The SMHRF Clinical Evaluator will evaluate the status of the individual’s discharge plan and any reported barriers to transition activities, and confirm the individual is aware of the service and support options available to them and complete referrals to relevant community services and/or agencies.

After the assessment, the SMHRF Clinical Evaluator will complete the SMHRF Continued Stay Report and submit it in AssessmentPro. AssessmentPro will generate a determination letter, designed to be actionable and easy to understand. Notices are mailed to the individual, the SMHRF and available to HFS in AssessmentPro.

Residents receiving a continued stay visit will be determined based the SMHRF facility census. Maximus will conduct a minimum of two visits per year for every SMHRF Resident. Minimum bi-yearly visits will allow for follow up on discharge activities and referrals made during the previous visit.

The Continued Stay Reviews will be more comprehensive than the preadmission assessments, which is necessary for the state to identify the appropriate next steps required for each class member and will include consideration of how the SMHRF has been addressing the individual’s needs since admission. These more comprehensive reviews will help to avoid another gap in information that leaves individuals more likely to have to wait for appropriate services or transition efforts.

Dementia Assessments:

Partnering with HFS, the vendor will identify data sets that could enable appropriate identification of Colbert Class Members residing in CCNFs likely to have a primary or co-morbid condition of severe dementia. Such sources may include the federal Minimum Data Set (MDS), Medicaid health plan assessment findings, and pharmacy records.

The presence of “severe dementia or other clinically significant and progressive cognitive disorders that are unlikely to improve” will be determined based on a screening and documentation review process.

The components of the screening and review process will include at minimum:

a. Maximus obtains resident-specific documents from CCNFs, which may include:

History and physical dated within the past 12 months MDS data specific to cognitive abilities Current Medication Administration Report Progress notes Nursing notes Any facility level dementia screenings (e.g., Mini-Mental Status Exam)

b. CCNFs submit requested documents to Maximus

c. Maximus tracks request dates and CCNF responsiveness and reports to HFS

d. Maximus Clinical Reviewers review submitted records and:

Determine if available information is sufficient, making follow up request to CCNF as needed Determine whether or not evidence supports that dementia is present, severe, and unlikely to improve Document determination with brief written justification Submit for Physician review and confirmation of final outcome Notify HFS of outcome Issue determination notice to individual and/or guardian, and submitting CCNF Appeal rights will be included with the determination notice.

e. Clinical Reviewers will be licensed nurses or licensed social workers with at least five years of experience working with persons with dementia and/or psychiatric conditions.

f. Physician Reviewers will be Medical Doctors or Doctors of Osteopathy.

Neither Clinical Reviewers nor Physician Reviewers will have conflicts of interest with CCNFs.