Research and Solutions

PCG reviewed claims data from past fiscal years to understand the use of community provider services and TCM across the state. Doing so also helped them gauge the scope of Kansas’s conflict of interest (COI) issue. PCG found that:

• 37% of individuals received TCM and at least one waiver service from the same agency.

• While 42% of individuals received zero services from the same agency providing their TCM, 32% received two services, and 17% received one. Some even received as many as three or four services from the same agency administering their TCM.

• Common services received from the same agency supplying TCM included habilitative residential, day habilitation, supported employment, and wellness assessment.

PCG met with five focus groups to get a holistic picture of Kansas’s HCBS system. Here are some of the key points from these focus groups.

• CDDOs, CSPs, MCOs, and TCM agencies wanted standardized training from the State.

• CDDOs and MCOs wanted more consistency in contracts and quality assurance measures.

• CDDOs, MCOs, and TCM agencies were concerned about how COIs might limit individual choice.

• CSPs and TCM agencies were worried about staffing shortages and limited provider presence in certain regions.

• Multiple focus groups wanted to improve communication between providers to streamline meetings and make things easier for individuals and their families.

• Individuals receiving services and families asked for better resources and information during the provider selection process.

PCG compiled information about each level of the service system in Kansas. Then, they created process maps to pinpoint improvements.

PCG created high-level flowcharts for each group: CDDOs, MCOs, TCM agencies and individuals. PCG identified issues related to assessments, billing, roles, and timelines that kept these groups from working together properly.

PCG surveyed key audiences to gather information and feedback on the current system.

• Stakeholder survey: 46% of respondents said that TCM being a function of all agencies would work best for Kansas. All respondents said that a phased approach for any changes would work best. 54% of respondents chose “regional” as the best way to do a phased approach.

• Individual, family, and guardian survey: 60% of respondents indicated that they received HCBS from the same agency or individual who completed their support plan. That shows the clear conflicts of interest..

• MCO survey: When asked if they found targeted case managers accessible for collaboration, 100% of respondents said, “No.” They shared that how accessible these targeted case managers were varied by person and agency. CDDO referral was named the most popular method (75% of responses) for telling individuals about available providers.

• CSP survey: 47% of respondents indicated that they would be open to providing services through other waivers, including the Autism (AU) Waiver, Brain Injury (BI) Waiver, and Frail Elderly (FE) Waiver. When asked what prevented them from expanding to provide additional waiver services, 53% of respondents pointed to their lack of staff. 46% of respondents said that their agencies have a waitlist, which most respondents said was because they struggled to recruit and retain staff. Respondents said they needed more more funding and training opportunities to boost staff and applicant quality.

• Targeted case manager survey: 49% of respondents worked for a service agency providing both direct services and TCM. Of those working for a service agency, 83% provided residential supports and day supports, 52% provided supported employment, and 43% provided wellness services. 83% of respondents shared that they work with providers—including their own agencies—with waitlists.

PCG asked stakeholder groups about their feedback on or concerns with how Kansas’s system might change. Their key thoughts are listed below.

• Individuals, families, guardians: Training and resources could use a boost. County boundaries often limit choice. A more consistent approach across the state would make it easier for individuals seeking or receiving services.

• CDDOs: Limited provider capacity in certain areas could make the transition more difficult. Identifying roles and responsibilities in the State system would help reduce multiple people doing the same work. KDADS should provide clear communication and education on COIs and why they need to be addressed.

• MCOs: A lack of targeted case managers and/or CSPs could hurt people on the waiting list. Clarifying roles and responsibilities would increase collaboration between MCOs and targeted case managers. Publicizing deadlines, advertising transition meetings, and providing additional education will benefit the community.

• Targeted case managers: Clearly separating roles and responsibilities for care coordinators and targeted case managers will boost efficiency and promote better relationships. Training will improve the quality of TCM and the overall system in the state.

In January 2024, PCG conducted a two-day in-person visioning session with KDADS and the Kansas Department of Health and Environment (KDHE) to understand their goals for TCM in Kansas. Nailing down the state’s short- and long-term priorities helped PCG develop options for coming into compliance. Their goals are listed below.

• Support case management and direct support staff. Educate direct line staff and recruit people with behavioral knowledge. Invest in KDADS staff, as many key leaders are relatively new.

• Comply with the Final Rule. Look to other states as examples when devising the plan to become conflict-free. Remember that providers will want to know about relevant actions, decisions, and timelines.

• Optimize operations and business processes. Quality control and consistency is critical. Eliminate silos and work to understand the system’s business model broadly. To solve the waitlist problem, do the necessary structural and communications work upfront. Everyone central to KDADS’s work must be intentional about knowledge management and documenting their work and processes. The way funds are disbursed matters. Research the root cause of issues—and respond to them—to avoid future snags.

• Prioritize communication and relationship building. Keep in close touch with KDHE. Prioritize tasks and communicate smartly, always highlighting the “why” of tasks. Consider partnerships with advocacy organizations and providers to generate buy-in. Make sure KDADS is aware of their team and network resources. Increase awareness of community resources.

PCG prioritized learning about people’s experiences with the TCM system and hearing their opinions about coming into compliance. The conversations showed what is working well within the current system and what could be improved.

Participants highlighted positive experiences with their targeted case managers and current providers. They were worried about losing TCM and their current case managers as a result of the transition to compliance.

Interviews with KDADS staff helped PCG understand leaders’ vision for conflict-free case management. PCG left the interviews with the following conclusions:

• It may be harder for independent targeted case managers to build relationships with HCBS providers once TCM is no longer conducted in-house.

• To increase the quality of TCM, Kansas should consider providing statewide training.

• Provider capacity must expand as part of the transition. No individual should be left behind in the transition to compliance.

• Person-centered support plans and service plans should be reviewed to make sure targeted case managers and care coordinators are not doing the same work.

PCG interviewed staff from six states similar to Kansas in some way: Colorado, Minnesota, New Hampshire, Ohio, South Dakota, and Wyoming.

Some of these states had already implemented changes to become conflict-free. Others were currently working on eliminating COIs. Finally, some states didn’t have COIs but had a similar HCBS system to Kansas.

States shared why they started this work, how long the transition to compliance took, and more:

• Transition times varied from 1–2 years to 9 years, with two states still in progress.

• States should develop a comprehensive training plan to ensure the workforce is prepared and that the system functions effectively.

• Communication with community members is crucial when it comes to making large system changes.

• States should review roles and responsibilities for agencies involved in eligibility, case management, and service and support planning.

• States should collaborate closely with their CMS representatives.

• States should establish appropriate transition timelines with clear deadlines.