Safeguards in Conflict-Free Service Planning

A Survey of Michigan’s Behavioral Health Waivers

Summary

People receiving services and supports through a public behavioral health provider, such as a Community Mental Health Service Program (CMHSP or CMH), have the right to receive services without having to worry about conflicts of interest. This right is outlined in the 2014 HCBS Final Rule, to ensure that service providers focus on the needs of people served rather than the financial-interests of their organizations.

The final rule states that “providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual must not provide case management or develop the person-centered service plan, except when the State demonstrates that the only willing and qualified entity to provide case management and/or develop person-centered service plans in a geographic area also provides HCBS.”

Within Medicaid Waiver applications, waiver authorities indicate how they mitigate against risk through the use of structural divisions of labor between service planning and direct service delivery and/or the use of procedural safeguards to mitigate against risk. To learn more about the difference between structural and procedural mitigation strategies and the approaches adopted by individual states see this previous study.

Beyond the approach indicated in waiver applications, it is important to understand how these mitigation strategies are implemented and resourced at the service provider level. The present report analyzes the reported use of four resources made available by Michigan’s CMHs.

What is meant by ‘conflict’?

For the purpose of this analysis, conflict refers to key decision points in the process of service access and planning where service organizations have the ability to place their own interests before those of the person served. This conflict can occur when a single organization facilitates key eligibility or needs assessment activities or service plan development activities AND provides direct services which are indicated by that service plan. Without structural or procedural mitigation strategies, the organization that supports the person to develop the service plan could, knowingly or unknowingly, influence the person to select that organization as a direct service provider.

The scope of the present analysis includes service planning activities and direct service delivery.

Purpose and Methodology

This analysis looks at procedural safeguards made available to Michigan’s Medicaid Waiver recipients, as reported by responding Michigan CMHs. Specifically, it explores activities facilitated through Michigan’s 1915(c) and 1915(i) waivers including MI Children’s Waiver, MI Habilitation Supports Waiver, MI Waiver for Children with SED, and 1915(i) State Plan HCBS (former 1915(b)(3)).

This research inspects implementation trends of four key resources used during service planning and explores the contractual and other relationships that CMHs maintain in order to provide these resources. Michigan refers to the Service Plan as an Individual Plan of Service (or IPOS), therefore all references to service plan are referred to as “IPOS.”

In May of 2021, all 46 of Michigan’s CMHs were asked to complete an eight-question survey. Of the 46 CMHs surveyed, 42 responded and completed the survey. Identified quality improvement professionals at the CMHs were the key survey respondent population, and these respondents were asked to engage in-house experts within their organization to coordinate a single, accurate response per CMH. The survey was developed collaboratively with the Michigan Department of Health and Human Services’ Behavioral Health and Developmental Disabilities Administration (MDHHS-BHDDA), the MDHHS Quality Improvement Council, and TBD Solutions. See the Appendices below for a complete list of survey questions.

Summary of Resources

Four key resources are at the center of this analysis and include¹:

Case Manager and Supports Coordinators facilitate activities for people served and have a key role as connectors and supports to people receiving services.

Independent Advocates includes individuals working for advocacy organizations and attorney advocates. Independent Advocates are the only safeguard in this analysis that are outside of the responsibility of MDHHS to manage and support.

Supports Brokers act as liaisons between the person served and the provider of services. They provide assistance to the person served to discuss housing, services, and supports, and connect them to those resources.

Independent Facilitators facilitate Person-Centered Planning (PCP) with the person and are independent of the CMH. CMHs are required to contract or have access to Independent Facilitators for people served.

For the sake of this analysis, Case Manager/Supports Coordinators are not considered safeguards against conflicted arrangements because Michigan allows for Case Managers/Supports Coordinators, who develop and monitor the IPOS, to be employed by the same organization that ALSO delivers the direct service outlined in the plan. Case Managers/Supports Coordinators are a resource to those served, however the structure of Michigan’s Waivers indicates they are not required to be structurally bifurcated from developing/monitoring plans and providing the services outlined in Individual Plans of Service. For more information about structural and procedural mitigation strategies, see this study.

Resources and safeguards can be used concurrently and are not mutually exclusive. CMHs can have more than one of these resources available to people they serve. To reflect this, the survey’s response options allowed for respondents to indicate the use of more than one resource at a time.

This analysis explores the following questions about the use and implementation of resources and safeguards by Michigan’s CMHs:

• Where in the process are resources used?
• What is the combined use of safeguards across all steps in the process?
• How often do CMHs indicate using resources during the process?
• Which CMHs make safeguards available?
• What types of relationships were used to engage identified resources?
• How was relationship type related to frequency of use?

Waiver Approach

With a single exception (MI Health Link), Michigan’s 1915(c) waivers rely heavily on procedural safeguards and indicate that structural firewalls are not used to mitigate against risk. The table below indicates which safeguards are available within each of Michigan’s 1915(c) waivers.

Safeguards identified in current Michigan Medicaid waivers

Waiver	Advocacy	Supports Broker	Independent Facilitation
MI Children’s Waiver Program (4119.R06.00)	•	•	•
MI Choice (0233.R05.00)	•	•
MI Habilitation Supports Waiver (0167.R06.00)	•	•	•
MI Health Link HCBS (1126.R01.00)	•	•
MI Waiver for Children with Serious Emotional Disturbances (0438.R03.00)	•	•	•

Michigan is among few other states that are safeguard-reliant and depend on the available safeguards within their Medicaid Waivers to protect people from conflicted arrangements. Because Michigan relies on safeguards that are inherently procedural and not structured, it is critical to monitor the quality and consistency of safeguard implementation in the state. Robust, high-quality safeguards ensure individuals served experience similar protections no matter their regional location or provider. Since Michigan’s 1915(c) waivers rely primarily on the use of safeguards to mitigate against risk, those safeguards are the subject of the present analysis.

IPOS Development and Monitoring

Two key service planning processes, IPOS Development and IPOS Implementation and Monitoring, are outlined in the 1915(c) Medicaid Waivers and are used in this report to pinpoint when resources are used.

IPOS Development

During the IPOS Development process, a person and those who they choose to support them develop a plan that addresses their strengths, wants, needs, and preferences for support. This process is facilitated through a Person-Centered Planning (PCP) method where the person served is leading their plan development.

For the sake of this study and as guided by public policy², the IPOS Development process involves the following sub-processes:

• Conducting Pre-Planning
• Conducting PCP Meeting
• Developing Goals and Objectives
• Identifying Relevant Services and Providers
• Completing Service Request

IPOS Monitoring

After a person develops their IPOS, the services are requested to support their identified goals and objectives, and these are either authorized or denied. Authorized services are then directed, facilitated, and monitored.³ The focus of this section is on the monitoring process (referred to as IPOS Implementation and Monitoring or IPOS Monitoring) that occurs concurrently with direct service provision. Those who conduct monitoring activities oversee how the plan is being facilitated with direct service providers and make changes to the plan, services, and provider, as needed and directed by the person served. The IPOS Monitoring process is also facilitated through the PCP method and includes similar processes to IPOS Development as a person re-evaluates their strengths, wants, needs, and preferences for supports. The IPOS Monitoring phase is most likely where a person would address concerns about current supports or providers. As a result, the IPOS Monitoring carries a risk for conflicted interests to arise, if the provider organization conducts IPOS Monitoring AND provides direct services. The specific steps of IPOS Monitoring, for the sake of this study and as guided by public policy⁴, include:

• Conducting Periodic Review
• Making Changes to the IPOS (Addendum)
• Identifying Changes to Relevant Services and Providers
• Completing New Service Request

Where in the process are Resources made available?

The survey asked responding CMHs to point to specific steps of the IPOS Development and Monitoring Processes where each resource was used least once in the last year. In this section, availability of a resource is defined as having used the resource at least once in the last year to support activities in that step for some or all of the identified Medicaid Waivers. The lack of availability of a resource is defined as non-use of the resource in the last year to support activities in that step for any of the identified Medicaid Waivers. Note, this section refers to resources and includes Case Managers/Supports Coordinators.

Case Manager/Supports Coordinator was the most widely reported resource utilized by responding CMHs throughout the IPOS Development and Monitoring. Most responding CMHs (97.6-100%) reported using Case Managers/Supports Coordinators at every step of the process.

Independent Facilitator was available from more CMHs during the IPOS Development process, with up to half of respondents indicating use. Independent Facilitators were not available as frequently for use during IPOS Monitoring, with less than a quarter of respondents indicating availability during these steps.

Between 14% and 33% of responding CMHs indicated use of Independent Advocate in the IPOS Development and Monitoring process. There was not a compelling difference in use of Independent Advocates between steps. Respondents indicated lower use than other resources but seemed to indicate consistent availability across all steps.

No more than 19% of responding CMHs reported using Supports Brokers at any step in the process. Their use did not vary greatly between IPOS Development and IPOS Monitoring.

No safeguard was made available by more than 52.4% of responding CMHs during any step of the service planning process.

What is the combined use of safeguards across all steps in the process?

This segment analyzes the average combined use of all safeguards across each step of IPOS Planning process as reported by CMH respondents. Here, the reported use of safeguards can be viewed and analyzed by step. Case Manager/Supports Coordinator was removed from this section as the focus was specific to safeguards. Data in this section can help pinpoint which steps in the process have more or less reported use of safeguards. Steps with less safeguard use likely have less protection against risk.

In the chart below, the dotted line indicates the maximum number of potential safeguards that respondents could indicate in this survey. When the blue bar is at or near the dotted line, safeguards were used in combination with each other and provide additional protection against conflict of interest.

At every step in the IPOS Development and Monitoring process, except for Developing Goals and Objectives, the average number of safeguards used was less than one. On average, responding CMHs used one or no safeguard at most steps. Developing Goals and Objectives received the highest average use of safeguards (1.05 average safeguards used).

The lowest average use of safeguards were in all steps of the IPOS Monitoring (ranging between .48 and .74 average reported safeguards) and in Completing a Service Request (.52 average reported safeguards). Although there is a risk of conflict of interest at every step of the IPOS Planning process, steps that consider financial or administrative support for a person’s plan (Completing a Service Request) and those that address concerns about service delivery (All IPOS Monitoring steps) bear additional risk of conflict. These steps also received the lowest reported use of safeguards by CMH respondents.

How often do CMHs indicate using resources during the process?

The survey asked responding CMHs to report the frequency at which they use specific resources. Data in this section can be used to look beyond if the resource was made available to see roughly how often a CMH reported using it.

Most (33 out of 42) CMH respondents indicated they use Case Managers/Supports Coordinators “Frequently” during both the IPOS Development and IPOS Monitoring process. Supports Broker was the only other resource to be used “Frequently” by one CMH despite it being the resource with the lowest reported overall use. This indicates there was a pocket of CMHs (9 in total) that reported some use of this service and remaining CMHs reported never using this resource.

Independent Facilitation was reported to be used “Often” by one CMH during both IPOS Development and IPOS Monitoring. Respectively, 38% and 57% of CMHs reported “Never” using Independent Facilitation during IPOS Development and IPOS Monitoring. All other CMHs reported using this resource “Occasionally” or “Rarely.” The frequency at which CMHs reported using this was lower in IPOS Monitoring than in IPOS Development.

Independent Advocate was used, at most, “Occasionally.” However, most CMHs indicated using this resource “Rarely” or “Never.”

Other than the frequency of use for Case Manager/Supports Coordinator and Independent Facilitation (during IPOS Development process), respondents as a whole indicated “Never” more than any other frequency for every resource.

Which CMHs make safeguards available?

This section explores the responding CMH’s capacity for making safeguards available across the IPOS Planning process. Responding CMHs were considered to have capacity when they indicated they used a safeguard one time in the last year to provide support in the IPOS Planning process. This section of the report does not consider the frequency of use or the number of people that utilized safeguards during IPOS Planning. Responding CMHs are displayed in two maps below to explore how much of the IPOS Planning process had minimum capacity and additional capacity.

Minimum Capacity: One safeguard was used at least once in the last year. The map on the left indicates minimum capacity by county. The color of the county indicates the percentage of steps with minimum capacity. The darker the color, the more steps had minimum capacity. The lighter the color, the more steps without minimal capacity. Counties indicated in a lighter color had at least one step in the IPOS Planning where the CMH has no capacity to mitigate against risk.

Additional Capacity: More than one safeguard was used at least once in the last year. The map on the right indicates of additional capacity by county. The color of the county indicates the percentage of steps with additional capacity. The darker the color, the more steps had additional capacity. The lighter the color, the more steps without minimal capacity. The counties in a lighter color had at least one step in the IPOS Planning process that had non-comprehensive risk mitigation. The counties in the darkest color in this map had capacity to provide overlapping risk mitigation strategies at every step in the IPOS Planning process.

*The maps below display data by county. Note, data was collected at the CMH level. Data displayed in counties that belong to a multi-county CMH represent information shared from a single CMH representative.

Nearly a quarter of responding CMHs (9 out of 42, or 21%) indicated at least minimum capacity for all steps in the IPOS Planning process. About the same amount of responding CMHs (11 out of 42 or 26%) indicated they did not have minimum capacity for any steps. Most CMHs (22 out of 42 or 52%) had minimum capacity for some but not all steps.

Two (or 5%) of responding CMHs indicated they had additional capacity for all steps of the IPOS Planning process. In total, 16 responding CMHs (or 38% of respondents) had additional capacity for some steps of the process. Most responding CMHs (26 out of 42, or 62%) had no steps with additional coverage.

Relationships with Resources

The relationships responding CMHs had with resources offers insight on the nature of conflict or mitigation strategy as relationship types vary in their ability to comprehensively mitigate against conflict. This section explores the ways in which responding CMHs engaged with resources by asking the following key questions:

• What types of relationships were used to engage identified resources?
• How was relationship type related to frequency of use?

What Types of Relationships Were Used to Engage Identified Resources?

The survey asked CMHs to identify the types of relationships they had with each resource. Respondents were able to select more than one relationship type for each resource. This section highlights if there were trends in relationship type by resource. Resources with multiple similarly-sized bars below indicate lack of significant trends in relationship type and suggest CMHs related to this resource in different ways. Resources with one or two large bars and small remaining bars indicate a trend toward one or two specific types of relationships.

Per the CMH and State contract⁵, CMHs are barred from employing Independent Facilitators as to prevent conflicted interests between the organization and this resource. No CMH indicated they employed this resource. In order to offer an array of options and opportunities for those served during Person-Centered Planning and for Self-Directed Arrangements, CMHs are required to offer options for Independent Facilitation and Fiscal Intermediary services. In some instances, responding CMHs indicated these services were not available.

The majority of responding CMHs reported employment relationships with Case Manager/Supports Coordinators, while few reported this relationship with any other resource. Most survey respondents, (40 out of 42 CMH respondents) reported that Case Manager/Supports Coordinators were employed within their organizations.

Two-thirds of respondents (28 out of 42 CMH respondents) reported that Supports Brokers were not available at their organizations, nor were they independently offered.

Each resource had at least one CMH indicate “contracting for resource as needed,” however Independent Facilitation had the most CMHs responding with this relationship type.

How Was Relationship Type Related to Frequency of Use?

This section explores the relationship type of a resource to frequency of use. The graph below displays if a relationship type was related to higher reported frequency of use. On the left side, the relationship types are displayed from top to bottom based on “closeness” of the relationship to the CMH. “Employment” was the closest type and “Independently Offered” or “Not Available” was farthest relationship type, or the relationship type most removed from the CMH.

Generally, the closer the relationship to the responding CMH, the higher the reported frequency of use. Responding CMHs were slightly more likely to report a higher frequency of use for those resources they employed. Resources that were independently offered were more likely to be reported at a lower frequency. This was true for both IPOS Development and IPOS Monitoring. Case Managers/Supports Coordinators were more likely to be employed and reportedly used more frequently. Independent Facilitation had various relationship types reported and was reported to be used occasionally or less in most instances. Supports Brokers were reported generally in two groups, employed and used more often, or not available and never used. This indicates a dichotomy of CMH use, where some organizations used and employed supports brokers at their organization with some frequency, while others did not use them at all. Responding CMHs reported ‘never’ using several resources while also reporting some relationship with them, indicating that the resource exists in some capacity, but it was not commonly used.

Considerations

As as safeguard-reliant state, Michigan is among few others that offer safeguards as the primary defense against conflict in service provision. In states that provide structural protections, such as firewalls, between IPOS planning and direct service provision, safeguards offer additional procedural protections. In states like Michigan, safeguards are the first and last line of defense against biased decision-making that benefits the financial interests of providers. For safeguards to comprehensively protect all people served, safeguards would need to be consistently made available and used across all regions.

The following considerations are intended to draw a connection between the need for mitigation strategies to support HCBS Final Rule compliance and the current implementation of those strategies as reported by CMHs:

Reported use of safeguards was low. In most instances, less than half of responding CMHs reported using safeguards during any step of the IPOS Development and IPOS Monitoring process. Although this data does not indicate that safeguards could not be utilized or were denied, it does point to a lower risk mitigation. CMHs that indicated gaps in safeguard use during the IPOS planning process have a risk of conflict of interest. People served by CMHs with these gaps may have additional difficulty accessing safeguards. Without regular practice working with these resources, CMH staff may face challenges offering and acquiring these resources for those served. This low reported use of safeguards could be caused by a variety of circumstances including barriers to providers of safeguards services, or lack of awareness about how to use the safeguard or the benefits.

Steps with clear financial conflict-of-interest had the lowest safeguard use The steps with the lowest average use of safeguards were also the steps that involve financial conflict (Completing a Service Request/New Service Request) or at the time and place a person would discuss concerns they had with their services or providers (Conducting a Periodic Review and Making Changes to the IPOS). These steps have unique conflict concerns due the nature of services requests, periodic reviews, and making changes to the IPOS. Ideally, these steps would have overlapping and comprehensive use of safeguards to mitigate against risk.

Monitoring received low average number of safeguards used. There are inherent risks in IPOS Monitoring steps as there is an opportunity for providers to incorporate/reincorporate their own services into a person’s IPOS. During this process is when a person can identify services that are inadequate or providers who are not meeting quality standards. If the Case Manager/Supports Coordinator is employed by the same organization as the provider, as allowable in Michigan, the Case Manager/Supports Coordinator is placed in a conflicted position. They are obligated to address the inadequacies in care identified in IPOS Monitoring AND they are faced with addressing these sub-standard services provided by their colleagues. With fewer safeguards used on average, CMHs have lower ability to protect against this conflict.

Frequency of safeguard use was low: Respondents who reported they used safeguards most often reported they used them occasionally or rarely during IPOS planning. Of all of the safeguards, only one CMH indicated using a safeguard more than “Often.”

Close resource relationships were used more frequently. Although close relationships, such as employment, carry more risk of conflicted interests, resources engaged in this way tended to be used at a higher frequency. The closer a resource was to the CMH, the more often it was used. An increase in use of safeguards could be fostered through close relationship types to CMHs. While employment options may need to be excluded to avoid conflict, other closer relationships could enrich the use of helpful safeguards. For example, responding CMHs most commonly reported Supports Brokers being not available. The second highest relationship type for Supports Brokers was Employment.

Acknowledgements

TBD Solutions LLC conducted the analysis, writing, and publication of this study with the support of the Michigan Department of Health and Human Services (MDHHS), Behavioral Health and Developmental Disabilities Administration (BHDDA).

For inquiries about this report, please contact TBD Solutions at info@tbdsolutions.com or 1-877-823-7348.

Endnotes

Appendices

Survey Questions

Survey Questions

1. Michigan’s waivers allows for the use of various resources during the process of IPOS Development. This question seeks to understand which resources have been actively used by your organization or its contracted providers. Definitions:Independent Advocate examples include individuals working for advocacy organizations and attorney advocate.Shared Decision-Making: A structured communication process by which people receiving services work with behavioral health care professionals to align services with what matters most to them. Which resources have BEEN USED within the last year to ACTIVELY ASSIST a beneficiary with… a. Conducting Pre-Planning

Independent Facilitation

Independent Advocate

Supports Broker

Case Manager/Supports Coordinator

Shared Decision-Making

b. Conducting PCP Meeting

Independent Facilitation

Independent Advocate

Supports Broker

Case Manager/Supports Coordinator

Shared Decision-Making

c. Developing Goals and Objectives

Independent Facilitation

Independent Advocate

Supports Broker

Case Manager/Supports Coordinator

Shared Decision-Making

d. Identifying Relevant Services and Providers

Independent Facilitation

Independent Advocate

Supports Broker

Case Manager/Supports Coordinator

Shared Decision-Making

e. Completing Service Request

Independent Facilitation

Independent Advocate

Supports Broker

Case Manager/Supports Coordinator

Shared Decision-Making

Please provide a brief description of the IPOS Development process and include any policies you use to inform your approach.

2. In the last year, approximately how often was this resource used during IPOS Development across all waivers? (Never, Rarely, Occasionally, Often, Frequently, Always)

Independent Facilitation

Independent Advocate (e.g., individuals working for advocacy organizations and attorney advocate)

Supports Broker

Case Manager/Supports Coordinator

3. Michigan’s waivers allows for the use of various resources during the process of IPOS Implementation and Monitoring. This question seeks to understand which resources are actively used by your organization or its contracted providers.Definitions: Independent Advocacy examples include individuals working for advocacy organizations and attorney advocate.Shared Decision-Making: A structured communication process by which people receiving services work with behavioral health care professionals to align services with what matters most to them. Which resources have BEEN USED within the last year to ACTIVELY ASSIST a beneficiary with… a. Conducting a Periodic Review

Independent Facilitation

Independent Advocate

Supports Broker

Case Manager/Supports Coordinator

Shared Decision-Making

b. Making a Change to the IPOS (Addendum)

Independent Facilitation

Independent Advocate

Supports Broker

Case Manager/Supports Coordinator

Shared Decision-Making

c. Identifying Changes to Relevant Services and Providers

Independent Facilitation

Independent Advocate

Supports Broker

Case Manager/Supports Coordinator

Shared Decision-Making

d. Completing New Service Requests

Independent Facilitation

Independent Advocate

Supports Broker

Case Manager/Supports Coordinator

Shared Decision-Making

Please provide a brief description of the IPOS Implementation and Monitoring process and include any policies you use to inform your approach.

4. In the last year, approximately how often was this resource used during IPOS Implementation and Monitoring across all waivers? (Never, Rarely, Occasionally, Often, Frequently, Always)

Independent Facilitation

Independent Advocate(e.g., individuals working for advocacy organizations and attorney advocate)

Supports Broker

Case Manager/Supports Coordinator

5. What types of relationships does your organization have with providers of the resources listed below? a. Independent Facilitation

Standing Contract with Provider Organization

Employed by My Organization

Contracting for Resource as Needed

Independently Offered (People served access this resource outside of my organization)

Not Available (This resource is not available at my organization nor is it independently offered)

b. Independent Advocate (e.g., individuals working for advocacy organizations and attorney advocate)

Standing Contract with Provider Organization

Employed by My Organization

Contracting for Resource as Needed

Independently Offered (People served access this resource outside of my organization)

Not Available (This resource is not available at my organization nor is it independently offered)

c. Supports Broker

Standing Contract with Provider Organization

Employed by My Organization

Contracting for Resource as Needed

Independently Offered (People served access this resource outside of my organization)

Not Available (This resource is not available at my organization nor is it independently offered)

d. Case Manager/Supports Coordinator

Standing Contract with Provider Organization

Employed by My Organization

Contracting for Resource as Needed

Independently Offered (People served access this resource outside of my organization)

Not Available (This resource is not available at my organization nor is it independently offered)

e. Fiscal Intermediary

Standing Contract with Provider Organization

Employed by My Organization

Contracting for Resource as Needed

Independently Offered (People served access this resource outside of my organization)

Not Available (This resource is not available at my organization nor is it independently offered)

6. If you DO NOT use these resources (independent facilitation, independent advocacy, supports broker, case manager/supports coordinator, fiscal intermediary) during IPOS Development, Implementation, and Monitoring; what are the barriers to increasing use? If you DO use these resources, what practices have you implemented to increase their use?

Conflicted Answers

The following are instances where CMH respondents provided conflicting answers to survey questions:

• One CMH respondent reported using Independent Advocates in some waivers to actively assist beneficiaries with Completing New Service Requests, however they reported that this resource is not available at their organization nor is it independently offered.

• One CMH respondent reported using Supports Brokers “Rarely” during IPOS Development, however they reported that this resource is not available at their organization nor is it independently offered.

• One CMH respondent reported that they did not use Independent Advocates during any step of IPOS Development, however they reported the frequency of use as “Occasionally”.

• Three CMH respondents reported that they did not use Independent Advocates in any step of IPOS Development, however they reported the frequency of use as “Rarely”.

• One CMH respondent reported that they did not use Supports Brokers during any step of IPOS Development, however they reported the frequency of use as “Rarely”.

• Four CMH respondents reported that they did not use Independent Facilitation in any step of IPOS Development, however they reported the frequency of use as “Rarely”.

• Seven CMH respondents reported that they did not use Independent Facilitation in any step in IPOS Implementation and Monitoring, however they reported the frequency of use as “Rarely”.

• Four CMH respondents reported that they did not use Independent Advocates in any step in IPOS Implementation and Monitoring, however they reported the frequency of use as “Rarely”.

• One CMH respondent reported using Independent Advocates in some waivers to actively assist beneficiaries with Identifying Changes to Relevant Services and Providers and Completing New Service Requests, however they reported the frequency of use as “Never”.

• One CMH respondent reported using Independent Advocates in some waivers to actively assist beneficiaries with Completing New Service Requests, however they reported the frequency of use as “Never”.

• One CMH respondent reported using Independent Facilitation in some waivers to actively assist beneficiaries with Making a Change to the IPOS (Addendum), however they reported the frequency of use as “Never”.

Table: Which CMHs make safeguards available?

Percent of IPOS Process Steps Covered

CMH	Minimum Capacity	Additional Capacity
Allegan County	66.7%	0%
AuSable Valley	0%	0%
Barry County	100%	0%
Bay-Arenac Behavioral Health Authority	100%	22.2%
CEI	88.9%	77.8%
Central Michigan	NA%	NA%
Copper Country	44.4%	0%
Detroit Wayne Integrated Health Network	44.4%	0%
Genesee Health System	0%	0%
Gogebic	100%	77.8%
Gratiot Integrated Health Network	11.1%	0%
HealthWest	NA%	NA%
Hiawatha Behavioral Health	44.4%	0%
Huron Behavioral Health	100%	44.4%
Integrated Services of Kalamazoo	66.7%	33.3%
Lapeer County	100%	0%
Lenawee	0%	0%
LifeWays	77.8%	0%
Livingston County	100%	100%
Macomb County	100%	100%
Manistee-Benzie	NA%	NA%
Monroe	88.9%	44.4%
Montcalm Care Network	0%	0%
Network180	44.4%	22.2%
Newaygo County	0%	0%
North Country	0%	0%
Northeast Michigan	44.4%	33.3%
Northern Lakes	33.3%	0%
Northpointe Behavioral Healthcare Systems	0%	0%
Oakland Community Health Network	66.7%	44.4%
Ottawa County	100%	88.9%
Pathways	66.7%	0%
Pines	NA%	NA%
Riverwood Center	11.1%	0%
Saginaw County	55.6%	0%
Sanilac County	0%	0%
Shiawassee Health & Wellness	55.6%	11.1%
St. Clair County	0%	0%
St. Joseph County	0%	0%
Summit Pointe	22.2%	0%
The Right Door	100%	66.7%
Tuscola Behavioral Health Systems	44.4%	22.2%
Van Buren	33.3%	0%
Washtenaw	55.6%	33.3%
West Michigan	0%	0%
Woodlands Behavioral Healthcare Network	22.2%	0%

Frequency Intervals

The following interval definitions were provided to survey respondents for questions asking about frequency: Never Rarely (Almost never) Occasionally (Less than half of the time) Often (More than half of the time but not all of the time) Frequently (Almost all of the time) Always

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1. Fiscal Intermediary and Supported Decision-Making were identified as safeguards in the survey and were excluded from this analysis. Fiscal Intermediaries were excluded as they engage in specific and exclusive activities in self-directed arrangements. Supported Decision-Making was also removed from this analysis as it is difficult to measure fidelity and use in IPOS Planning and Monitoring.↩︎

2. § 441.540 Person-centered service plan.↩︎

3. The process of authorization, denials, appeals, and direct service delivery is outside the scope of this study. However, authorizations, denials, and appeals carry additional risk of conflict when a single provider organization both authors a service request and has the power to authorize, deny, or support the appeal process.↩︎

4. § 441.540 Person-centered service plan↩︎

5. Requirements regarding independent facilitation, including the prohibition of direct employment can be found on page 164 of the MDHHS and CMH contract or by visiting https://www.michigan.gov/documents/mdhhs/FY21_CMHSP_Contract_Bundle_709007_7.pdf↩︎