HCS Strategic Plan Feedback

Strategic Plan Feedback Prepared by Dawn M Williams 2021 for the 2023-2025 Strategic Plan

Our Strategic Plan is the blueprint for how we transform lives by ensuring Washingtonians can choose where they want to live and receive long-term care, as well as remain safe and have access to quality services. Our Strategic Plan shows our assessment of areas where we excel, and where we can grow. In addition, it summarizes action plans that we are undertaking to continually improve.

All of what we do matters.

Background

• The Aging and Long-Term Support Administration (ALTSA) Strategic Plan is developed to support the six Department of Social and Health Services (DSHS) Strategic Priorities as established by the Secretary of DSHS. ALTSA has developed strategic objectives that helps us achieve each of those priorities. Success measures allow us to assess our progress in achieving our strategic objectives.

Since every position in ALTSA plays a vital role in our success as an administration, it is important that everyone review the Strategic Plan at least annually and have the opportunity to provide their ideas on how we can better meet our objectives, measure our success and improve the services we provide to our clients.

• In June of 2021 Home and Community Services (HCS) was given the task to review the Strategic Plan and request that staff answer the following three questions: • Which objectives align most with the work you do to transform lives?

• Do our action plans align with our objectives?

• If any current success measure shows room for improvement, what actions do you think we can take to improve the performance of the measure?

• HCS’s hope is this document will help you see your role in the Strategic Plan and that your feedback is important.

Q1: What Strategic Objectives align mostly with the work you do? # of Staff Responces SO 1.1 Serve individuals in their homes and community settings…

SO 3.1 Conduct quality assurance activities SO 1.2 Approaches to serve adults, Medicaid recipients and Caregivers…

SO 2.1 Transition from Acute Care Hospital…

SO 3.2 Create and foster organizational culture...

SO 3.5 Promote EDI practices…

SO 2.9 Complete abuse and neglect investigations timely…

SO 2.4 Consumer Directed Employer…

0

10

20

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50

60

70

80

90

100

Q2: Do our action plans align with our objectives?

Q3: If any current success measure shows room for improvement, what actions do you think we can take to improve the performance of the measure?

Your feedback is important.

• The following slides will walk you through: • Each objective that had feedback from staff will have three slides.

• The first slide will state the objective with staff comments in themes.

• The second slide will have leaderships comments to staff feedback.

• The third slide will have the changes we will make to the 2023-2025 ALTSA Strategic Plan based on staff feedback.

Staff feedback on Strategic Objective 1.1: Serve individuals in their homes or in community-based settings of their choice.

Overall themes: • Add workforce development actions x2 • Improve communication • Increase PNA • Training staff on services/resources x3 • Increase resources X8 • Workload impacts/FTE x4 • Rate increase

Having an available workforce is critical to our LTC system and of priority importance to ALTSA. Workforce development strategies are a key focus around the 10% FMAP funding and request for additional Federal funding. While this requires approval by the legislature ALTSA will continue to seek and strategize on how to meet this need.

Leadership comments on SO 1.1

We are continuously challenged to keep pace with the needs of the changing and growing population we serve. We need providers and resources to be available, timely and effective, as well as goals for our division that respect our clients and communities. There is a shortage of direct care workers across all LTC settings and a recognition of the challenges for ALTSA staff during this time. Increased wages for direct care workers (in-home and facility) are underway. HCS continuously looks for ways to serve clients with different resources. Coordinated Personal Care (CPC) is an example of this work. It was developed by regional leadership and in partnership with AAA, Home Care Agencies and Supported Housing Providers to serve as a flexible personal care delivery system that is based on geographical efficiencies. ALTSA is advocating for wage increase for the Long-Term Care workforce.

There is a decision package moving forward to raise the personal needs allowance (PNA). Moving forward raising the in-home PNA has been identified as a priority by SEIU and AAAs as well.

Most recently, from 2019 through 2020, HCS HQ and Field have met to discuss workload impacts, including the increased case management needs for complex clients. This work has contributed to the development of a decision package request to reduce case management caseloads through the addition of more FTE. It is not known whether this request will be moved or accepted, but the need is recognized.

More needs to be understood on where and how staff see that specialized programs and services are being tightly controlled, and possibly resulting in a barrier to access for clients. Access to services can be impacted at both HQ and Regional levels. As we have worked to increase creative services and supports to address the needs of a complex and changing LTC population, it has created challenges for staff to stay informed and effectively able to implement. Feedback on the limited use of certain programs is topic of discussion that will be included in HCS fall "road show". There have been policy changes to improve access. An example is with telephonic versus in-person intake assessments for Adult Day Health Programs.

Changes to SO 1.1 for 23-25 Plan • Change success measure to read at or above 89% • Changes to Action Items: • ALTSA will work with clients and their families to assist individuals moving into a setting of their choice with long-term services and supports that fit their unique needs.

• ALTSA will create new services for specialized populations and individuals with multiple needs and inform community providers of these services.

• ALTSA will work with Tribal governments and regional Area Agency on Aging leadership teams to plan and simplify processes, review and improve access to services and develop resources to help staff support the changing needs of clients.

Staff feedback on Strategic Objective 1.2: Develop and expand approaches to serve adults who are older, Medicaid recipients and caregivers.

Overall Themes: • Medicaid vendors • Caseload too high • Make a permanent program • Finding caregivers

There are challenges with obtaining certain service providers especially with providers willing to work with Provider One, navigating the system can be challenging and the availability of providers in rural areas. Area Agencies on Aging are monitoring this and keeping HCS informed of the on-going challenges.

Leadership comments on SO 1.2

Collaboration with the AAAs is on-going regarding outreach and marketing. The goal is to catch a caregiver as early as possible. Being creative on how to communicate resources and identifying care givers remains important for HCS and the AAAs.

HCS has a request to CMS to extend the five-year demonstration another year due to COVID impacts resulting in lack of data collection. HCS intends to submit a renewal for another five-year period.

Most recently, from 2019 through 2020, HCS HQ and Field have met to discuss workload impacts, including the increased case management needs for complex clients. This work has contributed to the development of a decision package request to reduce case management caseloads through the addition of more FTE. It is not known whether this request will be moved or accepted, but the need is recognized.

We are continuously challenged to keep pace with the needs of the changing and growing population we serve. We need providers and resources to be available, timely and effective, as well as goals for our division that respect our clients and communities. There is a shortage of direct care workers across all LTC settings and a recognition of the challenges for ALTSA staff during this time. Increased wages for direct care workers (in-home and facility) are underway. HCS continuously looks for ways to serve clients with different resources.

Changes to SO 1.2 for 23-25 Plan • Change strategic objective to read “Develop and expand approaches to serve older adults at risk of Medicaid and Caregivers” • Change success measure to read “To divert or delay individuals' need for more intensive Medicaid LongTerm Services and Supports, emphasizing support of family care givers, increase the proportion of dyads to individuals enrolled by 5% by December 2025.”

• Change Action Items: • ALTSA will partner with Area Agencies on Aging to develop system and policy enhancements, personcentered planning, staff and provider training and data analysis.

• ALTSA will increase outreach, enrollment, and support of dyads.

• ALTSA will develop a sustainability plan for legislative consideration that shows results and cost effectiveness of supporting care recipients and caregivers.

Staff feedback on Strategic Objective 1.3: WA Cares Fund – Conduct planning and outreach activities for implementation of the LongTerm Services and Supports Trust Act which will deliver benefits to eligible individuals beginning January 2025.

Overall Themes: • Train staff on WA Cares Fund x3 • General questions about the program x2 • Educate the public • Why is this mandatory/ estate recovery?

WA Cares Fund has an email box where you can ask these types of questions: WACARESFund@dshs.wa.gov. They are also holding webinars for any interested person seeking to learn more about the WA Cares Fund. Visit Learn More page for a list of dates and times these are offered. http://www.wacaresfund.wa.gov/learn-more/.

Leadership comments on SO 1.3

The WA Cares fund team is scheduling educational webinars for ALTSA Staff and is in the process of hiring staff to work on provider networks and community relations and outreach.

Universal Social Insurance programs like Medicare and WA Cares Fund only work actuarially if they are truly universal (mandatory). If they are voluntary, you get adverse selection, and this drives up premiums for everyone else. Estate recovery perpetuates intergenerational poverty.

Changes to SO 1.3 for 23-25 Plan

• Change strategic objective to read “WA Cares Fund – Conduct planning and outreach activities for implementation of the Long-Term Services and Supports Trust Act which will deliver benefits to eligible individuals ”

Staff feedback on Strategic Objective 2.1: Support people to transition from acute care hospitals to services in their homes or communities.

Overall Themes: • Change wording in the measures x9 • More resources for clients (Mental health/ Behavioral Health/ AFH) x7 • Housing options • Pressure of staff to transition x2 • Increase vendors x3

Agree there is pressure to transition clients to the community or settings that the client wouldn't choose before they are ready. The goal is always honor client choice.

Leadership comments on SO 2.1

HCS continues to advocate for additional resources in the behavioral health system and increased coordination across systems. Funding requests to build community and case management resources needed to continue client transitions has been submitted. This requires approved by the legislature.

A lot of work has gone into developing the success measures and action plans for this new objective. It’s important to start with base line data and continue to have work groups to discuss potential changes in the measure after there has been adequate time to analyze. Action Plan #1 will change to read: ALTSA will hold weekly statewide case staffing meetings with regional staff, HCS managers, providers and executives to review individuals with complex needs and increase Care Coordination efforts using various tools and programs to enhance service delivery and outcome.

Changes to SO 2.1 for 23-25 Plan • Strategic Objective 2.1 will be a new objective around long-term care workforce. “Build longterm care workforce to meet the needs of clients while creating resources to retain current high quality, long-term care workforce.

• This objective will have three success measures: • Increase the number of high schools, skills centers, tribal and compact schools delivering home care aide certification training to students, summer programs, community programs, and community colleges by June 2025.

• Design and deploy resources that increase retention of the direct care workforce by June 2025.

• Increase the visibility of direct care workforce by educating workforce boards, centers and health care providers about competencies and values of the work by June 2025.

Changes to SO 2.1/2.2 for 23-25 Plan • Change success measure to read “Maintain the quarterly average percentage of clients whose hospital stay is 100 days or more from the date of referral to HCS not to exceed 5% through June 2025.”

• Change Action Items:

• ALTSA will hold weekly statewide meetings to review individuals with complex needs to increase care coordination efforts.

• ALTSA will hold statewide acute care hospital weekly meetings with regional staff to share communication and problem solving strategies, medical records, policy changes and best practices that improve discharge planning activities.

• ALTSA will carry out quality assurance actions and give report to staff about acute hospital referrals and discharges to help manage transitions, analyze trends, and identify barriers and use of resources.

Staff feedback on Strategic Objective 2.2:

Mental Health Transformation – Provide long-term services and supports for individuals transitioning or diverting from state psychiatric hospitals

Overall Themes: • • • •

Change wording in the measures x6 More resources for clients (Mental Health/ Behavioral Health/ AFH, RSW, ECS) x6 Greater resource development Caseloads X5

We are continuously challenged to keep pace with the needs of the changing and growing population we serve. We need providers and resources to be available, timely and effective, as well as goals for our division that respect our clients and communities. Understand there is a provider shortage.

There are decision packages underway to increase the number of Behavior Health providers and to build community and case management resources.

This must be approved by the legislator.

Leadership comments on SO 2.2

Decision packages have been sent forward to build community and case management resources needed to continue client transitions from state hospitals to ALTSA settings. Examples include rental subsidies and supportive housing, ESF capital and services, and reduced caseload sizes for clients served through behavioral health specialty contracts.

Behavioral management education and training is not within the scope of work for HCS. Hands on assistance is available through HCS behavioral support specialist but it is limited. Ongoing coordination with AFHC, HCA and MCOs to assist in providing additional resources.

Changes to SO 2.2/2.3 for 23-25 Plan • Change success measure to read “Achieve a quarterly average of 72 clients diverting from psychiatric hospital to community setting by June 2024.”

• Change Action Items:

• ALTSA will work with providers to improve their skills and the capacity to serve specialized populations.

• ALTSA will coordinate across systems to successfully transfer individuals with complex needs by using an individualized and person-centered approach and intensive care coordination in order to achieve and maintain community stability.

• ALTSA staff will implement a monitoring plan for specialty contracts.

Staff feedback on Strategic Objective 2.3: Support people to transition from nursing homes to care in their homes or communities.

Overall Themes: • • •

Change wording in the measures x6 LTC staff/ provider shortage x3 Provider shortages x5

Changed measure: Success Measure 2.3.1: Increase quarterly average of nursing facility-to-community settings transitions from 800 in June 2021 to 976 June 2023. The housing team is currently working on increasing AL capacity.

Leadership comments on SO 2.3

ALTSA provides staff with ongoing technical assistance, education, tools and resources that help with the changing needs of clients. There is on-going support for community living. There is a Nursing Facility Case Management (NFCM) workplace. This workplace provides ongoing education and support. There is also quarterly NFCM team meeting to assist in additional training and education. Understand there may be a nursing homes shortage.

The nursing facility admitting practices limits the number of Medicaid beds so this could limit availability.

Most recently, from 2019 through 2020, HCS HQ and Field have met to discuss workload impacts, including the increased case management needs for complex clients. This work has contributed to the development of a decision package request to reduce case management caseloads through the addition of more FTE. It is not known whether this request will be moved or accepted, but the need is recognized.

We are continuously challenged to keep pace with the needs of the changing and growing population we serve. We need providers and resources to be available, timely and effective, as well as goals for our division that respect our clients and communities. There is a shortage of direct care workers across all LTC settings and a recognition of the challenges for ALTSA staff during this time. Increased wages for direct care workers (in-home and facility) are underway. HCS continuously looks for ways to serve clients with different resources.

Changes to SO 2.3/2.4 for 23-25 Plan • Change success measure to read “Maintain the quarterly average of nursing facility-tocommunity settings transitions at 976 by June 2025.”

• Change Action Items:

• ALTSA will support community living by offering temporary or long-term community services and will provide staff and contracted providers with ongoing technical assistance, education, tools and resources that help with the changing needs of clients.

• ALTSA will collaborate with nursing facilities, residents and families, as well as expand resources, services and strategies to support residents transitioning to their preferred community setting.

• ALTSA will implement the rental subsidies funded by the legislature to support the individuals transitioning from nursing facility to independent housing with the support of long-term community service.

Staff feedback on Strategic Objective 2.4:

Consumer Directed Employer Implement an employment structure for in-home care providers that increases case management time available for clients and decreases administrative burden on the Department while maintaining consumer choice and consumer direction.

Overall Themes: • •

Success measure only speaks to meeting deadlines Increase of IPs

Leadership comments on SO 2.4

Meeting scheduled with CDE team and OAS to see if there will be any changes to the success measure.

Changes to SO 2.4 for 23-25 Plan

• This measure will not be in the 2023-2025 ALTSA Strategic Plan.

Staff feedback on Strategic Objective 2.5:

Process financial applications, complete new Comprehensive Assessment Reporting Evaluation (CARE) assessments and reassessments and develop service plans in a timely way so that individuals can be supported in the setting of their choice.

Overall Themes: • • •

Comments regarding reaching goals x6 Timeliness of processing applications x3 Caregiver shortages x2

The measure to process at least 35% financial application within 20 days was determined by looking back to what was being accomplished prior to the Public Health Emergency (PHE) and success in the regions during pre-PHE processing timeframes. This percentage was not based on what is being done currently or with our current flexibilities. The Financial Eligibility and Policy unit is looking to implement some of the flexibilities that CMS has allowed during the PHE to streamline Medicaid processing. DSHS/Healthcare Authority are partnering to determine the feasibility of flexibilities with verification processes.

Leadership comments on SO 2.5

Within Medicaid Rule applications must be processed within 45 days or 60 if a disability determination is needed unless there is "good cause" for the delay. This policy is in Federal Rule and is will not be changed by the 2.5.4 added measure. The system allows "for good cause" to be updated when the standard of promptness is not met. The system should be updated according to the SOP not the added measure.

Create functionality within CARE and consider allowing tasks to be assigned to a "pseudo provider" (awaiting coordination) until a qualified personal care provider can be found. This would allow an assessment to be moved to Current more quickly. Once financial eligibility is complete, the client can at least access their Medicaid benefit. Currently “Good Cause Reasons" have been added in the performance metric while this does not mark the case complete it does provide an explanation for why it has not been completed.

Conversations have been made with the CARE team to try and improve processes. Somethings are out of the CARE team’s control. Understand that people are overwhelmed and yes, the paperwork/administrative process is necessary because of policy both at the state and federal level. Most recently, from 2019 through 2020, HCS HQ and Field have met to discuss workload impacts, including the increased case management needs for complex clients. This work has contributed to the development of a decision package request to reduce case management caseloads through the addition of more FTE. It is not known whether this request will be moved or accepted, but the need is recognized.

We are continuously challenged to keep pace with the needs of the changing and growing population we serve. We need providers and resources to be available, timely and effective, as well as goals for our division that respect our clients and communities. There is a shortage of direct care workers across all LTC settings and a recognition of the challenges for ALTSA staff during this time. Increased wages for direct care workers (in-home and facility) are underway. HCS continuously looks for ways to serve clients with different resources.

Changes to SO 2.5 for 23-25 Plan

• No changes to the 2023-2025 ALTSA Strategic Plan.

Staff feedback on Strategic Objective 2.9:

Complete abuse and neglect investigations timely and thoroughly.

Overall Themes: • •

Create action item to develop/secure protective payee and guardians Provide preventive options for vulnerable adults and retain staff

Leadership comments on SO 2.9

Developing resources in our communities is important in serving vulnerable adults. APS has hired three SHPCS at HQ that will work to build resources in the respective regions. Funding for the Office of Public Guardian has been an ongoing concern as funding falls short for increasing the number of guardians in some areas. APS is required to make referrals which may include a referral for long term care services to support the individual remain independent in their own home.

APS does not receive funding to provide case management services. APS did receive a grant which will be used to provide services to individuals under protective services. Staff shortages has been impacting many employers across the state. APS is working with HRD to gather data on the reasoning people exit APS and working to convene a work group on core competencies to address how to better define the needed skills to provide quality APS investigations. Regional leadership is also working diligently trying to fill vacancies.

Changes to SO 2.9 for 23-25 Plan

• Change Action Items:

• ALTSA will improve onboarding process to retain trained, skilled staff and build in-training units for Social Service Specialists one and two (SSS1/SSS2)..

• ALTSA will work with the Human Resources Division to improve and streamline the recruiting process and work to build core competencies of Adult Protective Services Field staff.

• ALTSA will increase staff training on investigation and case closure policy and procedures.

Staff feedback on Strategic Objective 3.1:

Conduct quality assurance (QA) activities and comply with federal, state and program requirements.

Overall Themes: • •

Change wording in the success measures x7 Adding action plans (program integrity, payment systems, audits of RND contracts) x4

Leadership comments on SO 3.1

Action Plan #2 has been changed to read: ALTSA will analyze statewide trends in compliance with programmatic and payment systems policy guidance and adopt training, technical assistance, policy revisions or other actions as necessary.

Leadership is considering adding another measure and actions items related to nurse contracts. On-going meeting with QA and nursing staff to flush out what this would look like.

Changes to SO 3.1 for 23-25 Plan

• Success Measure 3.1.1 will be managed in the Office of the Assistant Secretary (Laura Holloway).

• Success Measure 3.1.2 will continue to be managed by Home and Community Service.

Staff feedback on Strategic Objective 3.2:

Create and foster organizational culture that promotes employee engagement.

Overall Themes: • •

Add an objective of employer of choice General comments

Leadership comments on SO 3.2

One thing to note is our efforts to create and foster an organizational culture that promotes employee engagement is because we know that leads to better outcomes for the people we serve. But it also attracts new employees, making us an employer of choice for current and future staff. It also supports being person-centered. This will get re-worded to clearer. Will also add a measure about staff development, using Focal Point, Lessons in Leadership, and The ALTSA Way data.

Changes to SO 3.2 for 23-25 Plan • Change success measure 3.2.2 to read “To measure our success in creating a culture of innovation, increase the positive ALTSA responses to the DSHS survey question, “I am encouraged to come up with better ways to do things” from 54% to 57% by June 2025.”

• Add success measure 3.2.3 “To measure our success in being an employer of choice, increase the positive ALTSA responses to DSHS survey question, “I would recommend my agency as a great place to work” from 67% to 69% by June 2025.”

• Add success measure 3.2.4 “To measure our success in supporting people development, increase positive ALTSA responses to the DSHS survey question, “I have opportunities to learn and grow” to measure supporting people development from 71% to 73% by June 2025.”

• Addition of nine new action items for success measure 3.2.2, 3.2.3 and 2.2.4.

Staff feedback on Strategic Objective 3.3:

Develop tools to support staff’s core work and the service delivery system, including updates to technology and payment systems and improvements in applications and data analysis.

Overall Themes: •

Completing CARE Web

Leadership comments on SO 3.3

A plan is in place for functional eligibility and then work will be done with financial eligibility. Voice signatures pilot will go live November. Create functionality within CARE and consider allowing tasks to be assigned to a "pseudo provider" (awaiting coordination) until a qualified personal care provider can be found. This would allow an assessment to be moved to Current more quickly. Once financial eligibility is complete, the client can at least access their Medicaid benefit.

Changes to SO 3.3 for 23-25 Plan

• Change success measure to read “To reduce paper based processes while improving electronic based systems, ALTSA will continue to implement paperless documentation systems across ALTSA divisions by December 2025.”

• Change action item to read “ALTSA will develop an integrated document management system.”

Staff feedback on Strategic Objective 3.4: Address risks and plans for emergencies.

Overall Themes: •

Concerns if this is measurable

Leadership comments on SO 3.4

It is measurable through the Action Plan bullet 3 “ALTSA will identify six-in-house staff that can be activated during an emergency. Identified in-house staff must attend incident management team (IMT) training to understand IMT structure and roles. ALTSA will identify two staff members from Communications to take the basic online courses offered by FEMA on the Public Information Officer role.”

Changes to SO 3.4 for 23-25 Plan • Change action items to read:

• ALTSA will support a Long-Term Care Incident Management Team by providing ongoing training to members and continued participation in the Washington Incident Management Team Coalition.

• ALTSA will annually review and update the Emergency Preparedness Plan to effectively and efficiently respond to future public health emergencies.

• ALTSA will maintain a risk register, perform quarterly updates and make recommendations to ALTSA leadership to avoid or minimize future risks.

• ALTSA will maintain a risk program that is integrated with other risk elements such as tort claims, safety reports, incident reports and public disclosure requests.

Staff feedback on Strategic Objective 3.5: Promote equity, diversity, and inclusion (EDI) practices.

Overall Themes: • • •

General word changes to success measures Training x3 Improving workplace and client service delivery x2

Leadership comments on SO 3.5

Training has been provided in ALTSA as all of our Directors, RAs, DRAs and Office Chiefs have been certified. Work to provide the learning to supervisors has been paused due to the DES statewide training being develop for all staff. Training of clients and providers is a little bit different and not sure its ALTSA’s responsibility. Looking in to if there are CEs available for providers.

Improving workplace is measured through employee surveys and based on results focus groups are established to improve the measure.

Changes to SO 3.5 for 23-25 Plan • Change success measure 3.5.2 to “Operationalize EDI principles throughout the organization, as measured by completion of ALTSA’s identified goals in the DSHS Truth, Social Justice and Dismantling Racism Action Plan by December 2025.”

• Change action items to read:

• ALTSA will continue to train management and staff about Equity, Diversity and Inclusion principles.

• ALTSA will continue to meet or exceed the Culturally and Linguistically Appropriate Services (CLAS) Standards by supporting a diverse workforce, creating and supporting programs to retain staff, removing any potential biases identified within policies and procedures and working with Tribes to identify barriers and unintended consequences of hidden bias in current practices.

• ALTSA will continue to provide opportunities for staff and leadership to acquire shared language and practices on equity through diversity workshops, discussion opportunities and resource sharing on Equity, Diversity and Inclusion topics.

• ALTSA will continue to use art, videos, storytelling and employee recognition to generate sustained personal dialogue and enterprise-wide appreciation for transformational systemic change.