Wednesday, July 25, 2012

Bait and Switch: Do proposed CMS rules on person-centered planning undermine decision making by the person-centered planning team?

This is one issue that I did not cover in my comments  on the Centers for Medicare and Medicaid Services (CMS) proposed regulations [CMS-2249-P2] for Medicaid Home and Community Based Services (HCBS) waivers. Although the CMS explicitly endorses the use of person-centered planning in determining services for people using HCBS waivers, at the same time it takes away some of the authority of the PCP team to make decisions concerning the individual with a disability by allowing a "functional needs assessment" to determine clinical and support needs.

This is from background information on the proposed rules:

The person-centered service plan must identify the strengths, preferences, needs (clinical and support), and desired outcomes of the individual. The person-centered planning process is conducted in a manner that reflects what is important for the individual to meet identified clinical and support needs determined through a person-centered functional needs assessment process and what is important to the individual to ensure delivery of services in a manner that reflects personal preferences and choices. [emphasis added]

I think the most accurate translation of this is that a so-called "person-centered functional needs assessment process", probably a standardized state assessment, will determine the clinical and support needs of the individual. Although the individual will necessarily be the object of the needs assessment, there is no guarantee that the individual or his or her guardian will have any say in the identification of needed services. By the time the person-centered planning process occurs, the needs that will be written into a service plan will already be determined. The PCP process will be reduced to an exercise in self-expression by the individual who will be allowed to express preferences within the limits of the needs already determined, rather than allowing the individual and people who know and work with the person to determine what, when, where, how, and by whom the services will be provided.

Although in any program that uses public funds to pay for services, there is a need to determine overall eligibility for the program, but that is essentially an administrative function and should not be confused with the practical aspects of working out the details of what services will be needed and the conditions under which they will be provided.

The Michigan Developmental Disabilities Council submitted comments on this issue to the CMS. [Developmental Disabilities Councils are mandated by the federal Developmental Disabilities Assistance and Bill of Rights Act to advocate for people with developmental disabilities and to pass on federal funds in the way of grants to further the goals of the DD Act.] 

These are the comments  from the Michigan DD Council:

Under ‘Person-Centered Planning,’ it says, “A requirement for a person-centered functional assessment is set forth in the proposed rule which ensures that an objective assessment is the cornerstone for determining level of need.”

Michigan advocates do NOT support standardized functional assessment. State law requires that the Person-Centered Plan determines what a person’s needs are and what supports he or she should receive. When service providers have used a functional assessment, it has been typically to establish funding levels, which should only be determined by a person-centered planning process. Allowing such an instrument to overrule the Person-Centered Plan completely negates the PCP process. Advocates in Michigan have repeatedly opposed this over a period of many years. I understand that CMS does not endorse using functional assessment for this purpose, but experience tells us that, when it is used, it becomes a rate-setting process.

Other comments:

•    Too many professionals will use those tools to rationalize taking choices away from an individual. It is too often used as an excuse to allow someone else to totally control decisions for another person's life. A standardized test should never be used as an excuse to segregate or exclude someone. They should not be used to decide someone's competence or have a huge weight in major life decisions.
•    Standard assessment can be a way to impose the professional’s opinion on the person whose life it is. It becomes a barrier rather than assistance.
•    The major question is how a standard assessment process would interact with person-centered planning, because it is often used to overrule the PCP.
•    Assessment may not truly reflect a person’s wants versus identified and recognized needs and quality of life issues.
•    Assessment always implies that you know something that the person being assessed doesn't, and professionals feel obligated to use it regardless of the choice of the person.
•    When standard assessment has been used before, and in other circumstances, it has worked out badly for the person being assessed. Standard assessment can be a way to impose the professional’s opinion on the person whose life it is. It becomes a barrier rather than assistance.

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