Request for Applications
RFA #:2018-19.2.2b
Cross-System Navigation in a Managed Care Environment
(Case/Care Management)
FUNDING AGENCY: North Carolina Council on Developmental Disabilities (NCCDD), NC Department of Health and Human Services (DHHS), Office of the Secretary
ISSUE DATE: February 13th, 2018
DEADLINE DATE: April 4th, 2018
Receipt of applications online at is preferred, but not required. All applications must be received by 5:00 pm EDT on April 4th, 2018. Please notify at least two weeks in advance of the due date if you need application materials in an alternate format or otherwise require accommodations under the Americans with Disabilities Act.
Direct all inquiries concerning this Request for Applications (RFA) to:
Mailing Address:
NCCDD-RFA
North Carolina Council on Developmental Disabilities
3125 Poplarwood Court, Suite 200
Raleigh, NC 27604
Via Email:
Delivery Information:
Applicants for this RFA are strongly encouraged to submit the application electronically in the DD Suite online database found at Applicants that submit in hard copy are responsible for including all required elements in the submission packet.
Table of Contents
- Introduction...... Page 3
- About NCCDD...... Page 4
- Request for Applications...... Page 5
Intent
Background
Deliverables
Contractor Responsibilities
- Applicant Eligibility...... Page 14
Use of funds
Performance Monitoring/Quality Assurance
- Application Procurement Process and Application Review...... Page 15
- Attachments to be completed upon award...... Page 16
I. INTRODUCTION
The NCCDD makes funds available to fulfill its mission in accordance with the Developmental Disabilities Assistance and Bill of Rights Act (DD Act) and the Council’s Five-Year State Plan. The NCCDD’s major funding source is the United States Administration on Intellectual and Developmental Disabilities. The NCCDD makes funds available primarily through competitive bids or Requests for Applications (RFAs). A general description of the current RFA is included in this document. The complete RFA package is available through DD Suite ( or may be requested in alternate formats or by mail. Please complete and submit the Notification of Intent to Apply if your organization or agency intends to apply.
Applications are welcomed from any university, non-profit, for profit, or government agency that demonstrates that their agency is qualified, responsible, and capable of conducting the activities described. Eligible entities include any organization, agency, or non-profit demonstrating an expertise in the focus area of this initiative. To be eligible, the non-profit private entity that is awarded this contract must submit proof of 501(c)(3) status with a current IRS determination letter. The Council will not consider applications submitted by agencies that do not meet eligibility to apply for funding.
Private non-profit and for-profit applicants must be registered with the North Carolina Secretary of State to conduct business in North Carolina, or be willing to complete the registration process in conjunction with the execution of the contract documents (see
II. ABOUT NCCDD
The North Carolina Council on Developmental Disabilities (NCCDD), authorized under Public Law 106-402, the DD Act, is one of 56 entities of its type in the United States and the territories. The NCCDD is an independent agency located in the NC DHHS. Its activities are governed by a 40-member body, appointed by the Governor, and comprised of at least 60 percent people with intellectual and other developmental disabilities (I/DD) and their families. Other members include legislators and policymakers representing various agencies and organizations having a vested interest in people with I/DD. The Council’s quarterly meetings are open to the public.
The mission of the NCCDD is to assure that individuals with I/DD and their families participate in the design of and have access to culturally competent services, supports, and other assistance and opportunities that promote independence, contribution, self-determination, integration and inclusion in the community. The NCCDD achieves this mission by promoting advocacy and leadership, community capacity building and systems change activities. It also serves in an advisory capacity, under state law, to the NC Department of Health and Human Services (DHHS).
The NCCDD has established goals and objectives in its Five-Year Plan (2017-2021). These goals represent the most pressing needs as identified by stakeholders in North Carolina. These goals are approved by the Council as the framework for its work within the context of the Five-Year Plan.
GOAL 1: By 2021, increase financial security through asset development for individuals with intellectual and other developmental disabilities.
GOAL 2: By 2021, increase community living for individuals with intellectual and other developmental disabilities.
GOAL 3: By 2021, increase advocacy for individuals with intellectual and other developmental disabilities.
This RFA will address Goal 2.
For further information on the work of the NCCDD, please see the NCCDD Five-Year State Plan at our website by clicking here.
III. REQUEST FOR APPLICATIONS
INTENT:
The North Carolina Council on Developmental Disabilities (NCCDD) intends to fund an initiative that will focus on identifying how individuals with I/DD and families can best be supported to effectively navigate across various service systems (cross-system navigation). These recommendations are necessary as the North Carolina Department of Health and Human Services (DHHS) moves toward implementation of managed care to address mental health, developmental disabilities, substance use, and physical healthcare services. NCCDD seeks to engage a broad stakeholder base in providing meaningful recommendations at time when information and decisions are being made to help shape future policy and practice.
BACKGROUND:
As the North Carolina DHHS proposes to roll out a managed care system integrating both physical and behavioral health in 2018, NCCDD wants to study the cross-system navigation components (which may pull from case management, care management, and/or community navigator roles and similarly defined roles) that will accompany these plans, assess the options available to individuals with I/DD who are on Medicaid (both the state plan and the Innovations Waiver), and provide recommendations to meet needs of individuals with I/DD being served. In addition, NCCDD intends to examine what type of navigation supports are needed for individuals with I/DD on the registry of unmet needs waiting for waiver services and for individuals with I/DD who have private insurance or no insurance (i.e., are not in the Medicaid service system).
Individuals with I/DD and their families often need assistance to navigate the complex Medicaid/Medicare and state systemsof long-term services and supports (LTSS). In a traditional fee-for-service model, case managers typically assume the responsibilities of assisting individuals in gaining access to necessary care through assessment, person-centered planning, referral and linkages to other community-based resources for monitoring and follow-up. Case management and targeted case management provided to specific populations such as those with I/DD were designed to assist with identifying and assisting to coordinate services and supports the individuals needed in order to live in their communities and stay healthy.
As a result ofthe transition to the North Carolina Innovations Waiver starting in 2005,[1] case management and targeted case management functions (which supported individuals with and without Medicaid waiver services) were largely substituted with care coordination and community guide services, which were less robust. Care coordination was offered to individuals receiving services through the newly created Local Management Entity / Managed Care Organizations (LME/MCOs), and Community Guide services were authorized for some waiver recipients, often on an intermittent basis. With the evolution from an LME system to an LME/MCO system, families and individuals have described taking on greater care coordination and community and service definition exploration without the informed expertise previously provided by case managers leading to confusion, reduced efficacy, and unnecessary service interruption or costly outcomes. With over 40 definitions of care coordination services around the nation, providers themselves are often unclear of their specific mandate for service provision. The structure of care coordination is inconsistent across the state, which has further complicated the ability of individuals with I/DD and their families to help each other navigate such a complex landscape as what works in one region will not work the same in another.
Therefore, rather than define terms, NCCDD seeks to examine North Carolina’s I/DD system of navigation services and how it can be tailored to be more effective in meeting identified outcomes individuals with I/DD desire. This knowledge can assist all entities collaborating in North Carolina’s I/DD system(s) of services to better understand the rolethey play and how to provide effective services in the most efficient manner possible to enhance the health and community living outcomes of North Carolinians with I/DD. Such outcomes will positively impact the effectiveness ratio in financial performance of the Medicaid program in North Carolina by reducing the need for more costly and disruptive crisis-based services with more proactive decision-making leading to less financial waste going forward.
Since the transition to capitated long-term services and supports for people with I/DD, mental health, and substance use disorders, there are still approximately 12,000 North Carolina citizens without an Innovations Waiver as identified on the registry of unmet needs who cannot access waiver services and may not be aware of other supports that could be available to them while waiting for a waiver slot. Additionally, with nearly 200,000 individuals with I/DD living in North Carolina, it is critical to have knowledgeable and experienced professionals to assist individuals with I/DD in their efforts to understand and navigate across specialized and generic services, leading to better health and community engagement outcomes and an intentional person-centered focus on the individuals and families.
Indeed, in its final report in February 2017 to NCCDD for theBridging Practice and Policy: Transitions from Adult Care Homes (ACH) initiative, Disability Rights North Carolina identified some of the issues facing individuals not receiving services, such as the lack of access to a case manager, as barriers to a successful transition to the community.[2] The report pointed out that “case management was eliminated with the implementation of managed care and, as a result, North Carolina’s complicated and confusing service system is more difficult to navigate.” This system “burdens the rights of individuals with I/DD to choose to live in the least restrictive setting appropriate to their needs and enjoy the benefits of their communities.” The report noted the statewide inconsistency in the provision of services for individuals with I/DD, saying, “While the process for obtaining services is different for each MCO, each requires an updated assessment and/or evaluation to confirm eligibility for services.” The report then cited the numerous barriers that existed for various individuals trying to complete the required assessments. In its Blueprint for Transition section, the report highlighted that “In every case of a successful transition, the linchpin was intensive case management.” The report specifically recommended that “intensive case management should be provided by an independent case management agency with staff trained in I/DD and co-occurring conditions, and who are familiar with the state’s system of LME-MCOs, service providers, and housing resources.”
This initiative will build on the lessons NCCDD learned from the Adult Care Homes initiative in order to minimize the occurrence of individuals with I/DD ending up in an institutional setting or other inappropriate placement because they were unable to navigate the system or access the services they were eligible for.
As pointed out above, NCCDD is attempting to be very broad in characterizing case management and navigation supports to gather recommendations for responsiveness in these functions for individuals with I/DD and their families within managed care as the service system evolves. What is case management? The Case Management Model Act defines ideal case management as “A collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes.”[3] Meanwhile, the North Carolina Division of Medical Assistance (DMA) defines Intellectual and Developmental Disabilities Targeted Case Management (I/DD TCM), available for children ages six through 18, as:
an activity that assists recipients with gaining access to necessary care: medical, behavioral, social, educational, and other services appropriate to their needs. Case Management is individualized, person centered, empowering, comprehensive, strengths-based, and outcome-focused. The functions of case management include:
- Case Management Assessment;
- Person Centered Planning;
- Referral/linkage; and
- Monitoring/follow-up.[4]
This document notes that the case manager “gathers information regarding all aspects of the recipient, including medical, physical/functional, psychosocial, behavioral, financial, social, cultural, environmental, legal, and vocational/educational areas,” and the case management assessment includes periodic reassessment at least annually “to determine whether a recipient’s needs or preferences have changed.”
Generally speaking, “Case management services assist Medicaid beneficiaries in obtaining needed medical and related services. Targeted Case Management (TCM) refers to case management for specific Medicaid beneficiary groups.”[5] In reality, however, many individuals with I/DD in North Carolina and their families are not receiving the needed medical and related services to be able to live healthy, productive lives in their communities. Feedback from family members of individuals with I/DD indicates issues such as family members not feeling as if they could trust care coordinators, to family members constantly being referred to entities that say they are unable to assist the individual with I/DD for various reasons ranging from geographical barriers to providers not accepting Medicaid.
Another service North Carolina has made available to individuals with I/DD is the community guide service, now known as Community Navigator, which aims to “promote self-determination, support the individual in making life choices, provide advocacy and identify opportunities to become a part of their community.”[6] The Community Navigator “provides support to individuals and planning teams in developing social networks and connections within local communities” and “coordinates the use of generic resources to address the individual’s needs in addition to paid services.” Thus, the Community Navigator acts as an advocate assisting individuals with I/DD in identifying services and supports. However, Community Navigator services have intermittent authorization and widely varied utilization across catchment areas; therefore, there is no guarantee that individuals with I/DD will be able to receive or maintain this service.
The transition to the LME/MCO system brought a shift away from case management to care coordination, which, according to the 2018 Prepaid Inpatient Health Plan (PIHP) contracts with the Local Management Entities/Managed Care Organizations (LME/MCOs), directs the individuals involved in an individual’s care to “facilitate the appropriate delivery of health care services, connect Enrollees to the appropriate level of care, and identify and address Enrollee needs and barriers to treatment engagement.”[7] Because the structure of care coordination can be different in different regions of the state, this service provision lacks statewide consistency.
Similar to care coordination is the care management service provision. The North Carolina DHHS Division of Aging and Adult Services (DAAS) defines care management as “a coordinated care function which incorporates case finding, assessment/reassessments, negotiation, care plan development and implementation, monitoring, and advocacy to assist functionally impaired older adults with complex care needs in obtaining the services necessary to be safely cared for within the home and community setting.”[8] The philosophy and purpose of care management services is “to assist older adults with complex care needs by identifying, accessing and coordinating services which are necessary to enable the individual to remain in the least restrictive environment.” These services “maximize the individual’s ability to function independently and assist with preserving his/her personal dignity.”
NCCDD’s Medical and Health Homes initiative from 2014-2016 engaged stakeholders and developed key recommendations to ensure that people with I/DD receive the right healthcare at the right time in the right setting for the right cost.[9] These recommendations included acknowledging the benefit of navigation, as it helps people connect to and move between services and systems of care, with an emphasis on access to and continuity of healthcare, Medicaid services, and long-term supports.
Another key recommendation was to establish a system of “care navigation” from prevention to complex care that offers direct assistance to individuals with I/DD and their families.
Along with this came a recommendation to expand the number of people with I/DD who receive active care management through Community Care of North Carolina (CCNC), with an emphasis on individuals with I/DD who are not on the Innovations Waiver. The momentum established by the Medical and Health Homes initiative continued in 2017 with NCCDD’s From Planning to Action: Integrated, Collaborative Care for People with Intellectual and Developmental Disabilities initiative led by a partnership of key I/DD organizations and cross-sector leaders as well as an expert in I/DD and health is developing consultation services that offer a multidisciplinary resource to improve the knowledge, skills, and ability of primary care providers to care for patients with I/DD in their practices.
In its Behavioral Health and Intellectual/Developmental Disability Tailored Plan Medicaid Managed Care Proposed Concept Paper released on November 9th, 2017, the North Carolina DHHS proposed requiring Behavioral Health I/DD Tailored Plans “to provide face-to-face, community-based care management services” and that these plans “will ultimately be the single point of accountability for all services delivered to their enrollees, including integrated physical health, BH, pharmacy, I/DD services, home- and community-based services, long-term services and supports, and care management.”[10]