State Spotlight: Minnesota

Setting the Stage

State systems supporting individuals with disabilities are complex. This is due to many factors including state and federal financing structures, governing statutes and regulations, and the sheer fact that these systems must have design features to support individuals with varying support needs and their families throughout their lifetime – sometimes for 80 or more years. State disability systems are largely Medicaid systems.  In fact, state systems supporting individuals with intellectual and developmental disabilities (I/DD) comprise approximately one-third of this nation’s Medicaid long-term services and supports spending.  State I/DD systems include individuals and their families, hundreds of providers of services – often very small non-profit businesses, direct support professionals, local/regional governmental operational partners, multiple state agencies and Federal partners.  In addition to those “inside” the system, there are key stakeholders that help shape the priorities and direction of these systems, including policy makers, legislators, advocacy organizations and research partners.  Given all of the individuals and entities with keen interest in system performance, meaningful and positive change must be thoughtful, inclusive, methodical and pragmatic, all of which can be difficult to achieve in the tight timeframes of budget and election cycles.   Today, we feature the visionary work of Minnesota and their long-range strategies to build a more person-centered system of supports for individual with disabilities and their families.

There are many interconnected and interdependent pieces of state disability services. These systems – already complex in their own right – exist within a broader state–level Medicaid ecosystem that serves as a key foundational system element.  Eligibility criteria, requirements for needs assessment and person-centered planning, benefit design, payment methodologies and quality improvement strategies must all be constructed within Federal requirements for Medicaid and in consideration of other Federal obligations such as the Olmstead decision. Changing one piece of the system impacts other system elements, so a strong roadmap must be utilized to make meaningful and lasting change. Under the leadership of Alex Bartolic, Director the Disability Services Division in the Department of Human Services, Minnesota began meaningful systems change more than 10 years ago.  The changes, sparked by internal and external factors and priorities, are still underway, as Minnesota recognizes the importance of planning and sequencing to ensure system stability during forward progress.

Minnesota’s Building Blocks for Systems Change

Underpinning Minnesota’s systems change efforts is a commitment to building a person-centered system of supports. Specifically, they note

“Minnesota is moving toward person-centered practices in all areas of service delivery. As a state, Minnesota strives to make sure everyone who receives long-term services and supports and mental health services can live, learn, work and enjoy life in the most integrated setting. The goal is for people to lead lives that are meaningful to them. To do this, we must have a person-centered support system that helps people:

• Build or maintain relationships with their families and friends
• Live as independently as possible
• Engage in productive activities, such as employment
• Participate in community life. 

Our support system must reflect that we understand, respect and honor the things each person thinks are important.”^[1]

These efforts are buoyed by a strong, system-wide Olmstead Plan that includes goals in all areas of the system to ensure that these goals are achieved.^[2]

Building a Strong Statewide System while Leveraging Strengths of Lead Agencies

Like other states, Minnesota leverages in-state partners in the successful oversight and operation of its home and community based services system.  Lead agencies, with important local knowledge and expertise, perform a host of functions in partnership with the state. These activities include responsibilities to plan, arrange and monitor services for eligible persons to ensure consistent delivery of supports and services.

Lead agencies play an important role in both assisting individuals to access services and to providing key quality improvement functions in partnership with the state. These parameters of the state/lead agency partnerships have evolved during these times of system change, enabling the state to ensure comparable practices for all Minnesotans while retaining the important on the ground expertise that enables truly person-centered approaches to supports.

Ensuring Individuals Get the Right Services to Meet their Needs

Minnesota has taken strides to ensure that, regardless of a person’s diagnosis, they have access to the supports and services that will best meet their needs and enable meaningful community integration. In a Medicaid system, one pivotal step in this effort is the assessment of needs. Most states in the country are continually striving to identify the assessment strategies that will provide the most accurate depiction of an individuals’ needs – taking into account those elements related to their specific disability(ies) as well as important contextual information about their support system and key social determinants of health.  Minnesota’s unique assessment tool, MNChoices, fulfills multiple required functions for Medicaid, while also providing a comprehensive view of the individual’s needs. Like most states, Minnesota continually strives to make improvements to their tools to ensure that they provide necessary information without posing undue burden on the individuals needing supports and their families.

As the state devised strategies to meet the needs of individuals based on what is both important to them as well as what is important for them, Minnesota recognized the importance of equalizing the service offerings across an array of programs serving different disability groups.  In addition to robust home care services, and a new early intensive intervention service for children under age 21 with autism or a related condition, Minnesota currently operates four Section 1915(c) Home and Community Based Services (HCBS) serving individuals with disabilities:

Brain Injury (BI) Waiver: For people with a traumatic, acquired or degenerative brain injury who require the level of care provided in a nursing facility that provides specialized services for people with BI, or who require the level of care provided in a neurobehavioral hospital

Community Alternative Care (CAC) Waiver: For people who are chronically ill or medically fragile and require the level of care provided in a hospital

Community Access for Disability Inclusion (CADI) Waiver: For people with disabilities who require the level of care provided in a nursing facility

Developmental Disabilities (DD) Waiver: For people with developmental disabilities or related conditions who require the level of care provided in an intermediate care facility for persons with developmental disabilities (ICF/DD)

Minnesota has been working diligently to ensure that all individuals, regardless of their identified target group, had the ability to receive the services and supports that best meets their needs. To that end, a multi-year effort has been underway to align the service offerings across these programs, forming a foundation for the future vision of a consolidated program design that meets the needs of all individuals with disabilities based on support need, not diagnosis.  Initial steps included development of a new licensing standard that is based on the person’s support plan, statewide rate setting methodologies, and strengthening provider enrollment while eliminating county contracts with waiver service providers.  The next phase is embodied in Minnesota’s Waiver Reimagine Project.  Over the next four years, the Waiver Reimagine project will accomplish the following:

• Ensure equitable access and benefits across disability waiver programs. The programs will be responsive to a person’s needs, circumstances and preferences.
• Align benefits across waiver programs for people with disabilities, including consistent limits and allowable services
• Provide flexible and predictable benefit changes that recognize life changes and an increased use of technology
• Allow simplified administration that make waivers easier to understand for people who receive services, county and tribal administrators and service providers.
• Enhance information and resources for people who receive services and their families to give them choice and control to live their best life.

These efforts leverage the learning from some key initiatives within the state to increase opportunities for employment for individuals with disabilities, to increase engagement of individuals and families throughout the lifespan and to deploy meaningful person-centered practices statewide.

Ensuring Financing Strategies that Promote Equal Access and Strong Capacity

Essential to any systems redesign effort are the finance strategies that support it. In accordance with Federal Medicaid requirements, Minnesota engaged in a multi-year effort to bring a statewide methodology to rate-setting in HCBS, culminating in the Disability Waiver Rate System in 2014.  Goals of the system are to create statewide rate-setting methodologies that: 

• Are transparent, fair and consistent across the state; 
• Establish rates based on a uniform process of structuring component values for service; 
• Promote quality and participant choice; 
• Recognize a person’s assessed need for particular components within each service;
• And comply with federal requirements for administration of waiver programs. 

Because rates had been previously established through local channels, the state-level system enables Minnesota to ensure that individuals with comparable needs are supported similarly across the state, furthering the goal to ensure that all Minnesotans have the ability to live and thrive in their homes and communities. 

Building a Culture of Quality to Ensure Continuous Learning and Improvement

While work continues to achieve the ultimate vision for the system, Minnesota is simultaneously undertaking some key efforts to ensure that the system will continue to learn and improve.  Minnesota has engaged in a comprehensive effort to move from a culture of blame, particularly as it relates to critical incident management and follow up, to one of learning and performance improvement. Minnesota is broadening this effort to deploy a culture of quality in every aspect of system performance. Utilizing tools for continuous quality improvement in day-to-day activities all the way through major redesign efforts, Minnesota seeks to use a strategy of ‘Plan, Do, Study, Act’ to assess the impact of change and make needed improvements in real time, embracing the opportunity to learn and improve at all system levels.

The Benefit of Leadership, Vision and Time

As is readily apparent, each of these system components is integrally connected to the other. As such, the forward momentum achieved in Minnesota is a product of strong and consistent leadership with a values-based compass. State I/DD systems are extremely large and complex and the ability to devise thoughtful, thorough multi-year plans is essential to their successful execution.  Minnesota’s Disability Services Director, Alex Bartolic, has provided that leadership – both within Minnesota and nationally.  Alex has announced her retirement from state service at the end of 2019. We wish her the best in retirement and fully expect that her successors will continue to the forward march toward a person-centered system of supports for all Minnesotans.

FMI:  See the Minnesota Department of Human Services website at https://mn.gov/dhs/