1 cil-net, a project of ilru – independent living research utilization cil-net presents…...

1CIL-NET, a project of ILRU – Independent Living Research Utilization

CIL-NET Presents…CIL-NET Presents…

Personal Assistance ServicesA National Onsite Training

August 16-18, 2011

St. Louis, Missouri

Presenters:Gwen Dean

Phil Pangrazio


Arizona Health Care Cost Arizona Health Care Cost Containment System (AHCCCS)Containment System (AHCCCS)

“AHCCCS” is Arizona’s Medicaid Program

AHCCCS is a Managed Care Model


AHCCCS RoleAHCCCS Role

AHCCCS is responsible for -– Financial Eligibility– Medical Eligibility– Selecting and monitoring the performance

of Arizona Long Term Care (ALTCS) Managed Care Program Contractors

– There are four ALTCS Program Contractors•Mercy Care, Bridgeway, SCAN &

Evercare Health Plans


Financial and Medical EligibilityFinancial and Medical Eligibility

• Our waiver combines, Acute Care Medical services, Institutional Services and a comprehensive Home and Community Based Service managed through Arizona Long Term Care Service (ALTCS) Program Contractors

• Serving people with Developmental or Physical Disabilities, and the Elderly

• Native Americans may choose to receive services through AHCCCS or Indian Health Service

• 65 years of age or older, disabled and requiring nursing facility level of care

• Income limit 300% of SSI maximum $1,656 per month for an individual


Financial and Medical Eligibility, Financial and Medical Eligibility, cont’d.cont’d.

• Resource limit is $2,000 for an individual• A home, vehicle and irrevocable burial plan

are not counted toward resource limits• AHCCCS eligibility takes up to 90 days• Family members, friends and a spouse can

be paid to provide service• Parents with children under the age of 18

are not allowed to be paid

6CIL-NET, a project of ILRU – Independent Living Research Utilization6

Arizona Long Term Care Services Arizona Long Term Care Services (ALTCS)(ALTCS)

• Personal Care

• Homemaking

• Attendant Care

• Respite Care

• Self-directed Attendant Care

• Assisted Living

• Nursing Homes

7CIL-NET, a project of ILRU – Independent Living Research Utilization7

Managed Care Program ContractorManaged Care Program Contractor

ALTCS Program Contractors are responsible for –

•Selecting and monitoring the performance of provider agencies•Monitoring Self-Directed Care Services•Assigning the Consumer an ALTCS Case Manager•The coordination and authorization of services•Ensure that new consumers have services provided within 30 days•Semi-annual consumer re-assessment of services


Philosophical Benefits and Value of Philosophical Benefits and Value of Being a Managed Care Sub-Contract Being a Managed Care Sub-Contract Provider of PASProvider of PAS

• Increase the Center’s consumer base

• Discretionary dollars


Provider Agencies ServicesProvider Agencies Services

• Personal Care

• Homemaking

• Attendant Care

• Respite Care

• Prescriptions

• Transportation to medical appointments

• Home modifications

• Visiting nurse services

• Durable medical equipment

• Doctors and hospitals


Personal Care Assistant ServicesPersonal Care Assistant Services

• Personal Care – 2 to 3 hours, 2 to 3 times per week

ShoweringDressingShoppingMeal

preparation

• Homemaking – 2 to 3 hours, 1 to 2 times per week

HousekeepingChange linens &

make bedLaundryShoppingMeal preparation


Personal Care Assistant Services, Personal Care Assistant Services, cont’d.cont’d.

• Attendant Care – 15 to 40 hours, 5 to 7 days per week Personal CareHomemakingSupervision

• Respite Care – 720 hours annuallyPersonal CareHomemakingSupervision


Self-directed Attendant CareSelf-directed Attendant Care

The consumer can access all HCBS Services through their ALTCS Case Manager. In addition their PCA is allowed to do the following tasks -

•Bowel care•Bladder catheterization (non-indwelling)•Wound care (non-sterile)•Glucose monitoring•Permanent tube feeding•Insulin injections


Self-directed Attendant Care, Self-directed Attendant Care, cont’d.cont’d.Consumer is responsible for -

• Recruiting• Interviewing/hiring/terminating• PCA Training • Acquiring CPR and First Aid training before

employment• Directing their care• Developing a Service Plan • Developing a Service Agreement between a

consumer and the PCA


Self-directed Attendant CareSelf-directed Attendant Carecont’d 2cont’d 2

• Ensuring that all applicant documents are accurately completed and submitted to the Fiscal and Employer Agent (FEA)

• References and Criminal Clearance card is optional

• Scheduling and monitoring their services hours• Submitting the PCA/consumer signed timesheets• Monitor their quality of care and potential

Medicaid fraud • Notify the ALTCS Case Manager of any changes,

i.e. service hours, health changes, hospitalization etc.


Self-directed Attendant CareSelf-directed Attendant Carecont’d 3cont’d 3

Program Contractor is responsible for - • Authorizing Consumer training services:

Recruitment tips Interviewing techniques Developing a Job DescriptionDeveloping a Service AgreementHow to manage your PCAHow to monitor the performance of their PCA

• Authorizing agency to provide back up PAS services

• Monitoring the quality of all services


Self-directed Care Model and Self-directed Care Model and Provider Agency ModelProvider Agency Model

The Consumer’s role is to -

• DIRECT their Care

• Make CHOICES

• Make DECISIONS

• Live INDEPENDENTLY


Provider Agencies Provider Agencies Agencies are responsible for -•Recruitment – Local newspapers, flyers, brochures, word of mouth•Employing PCAs – Character, stability and ability •PCA Training – Fundamentals and disability related competencies•Identifying consumer needs – Intake Assessment•Referring PCAs – Character, PCA skills, location, availability•Quality of service – Joint responsibility with consumer•Contract Compliance – Adhere to agency & contract requirements


Five Components to Agency ModelFive Components to Agency Model

• Case Management • Hiring PCAs• Payroll• Claims• Policies and Procedures


Case Management -Case Management -Provider Agency Service IntakeProvider Agency Service Intake

• Independent Living Overview• Intake Assessment Summary • Consumer Training Overview • Consumer Needs Assessment • Consumer/PCA Service Agreement• After Hours Service• PAS Policies and Procedures


Case Management -Case Management -Independent Living Overview Independent Living Overview

• Independent Living Philosophy• Consumer Rights• Independent Living Center Programs &

Services • Identify interest in developing an

Independent Living Plan• Encourage consumer to get involved in

Advocacy • Assist with voter registration


Getting to know your Consumer

Case Management -Case Management -Intake Assessment SummaryIntake Assessment Summary

• Living arrangements

• Language spoken• Cognitive abilities• Vision, hearing, literate• Consumer’s health

condition

• Accessibility & condition of home

• Safety issues• Lifestyle (i.e., pets,

smoking, etc.)• Identify days & hours

of service• Consumer’s

contingency plan


Case Management -Case Management -Consumer Training OverviewConsumer Training Overview

• PCA referral process • Interviewing your PCA• Selecting a PCA / replacement Process • Contingency plan• Monitoring your PCA performance• Reportng Requirements


Case Management -Case Management -Consumer Needs AssessmentConsumer Needs Assessment

• Identify the consumer’s Personal Care and Homemaking tasks, be specific

• Identify who will provide medical tasks that the PCA is not allowed to perform, be specific

• Identify days and hours of services preferred

• Ensure the ALTCS Case Manager has allowed enough hours to complete the task


Case Management -Case Management -Consumer Needs Assessment Consumer Needs Assessment cont’d.cont’d.• The consumer can use the Needs

Assessment as an interview tool for potential PCAs

• The agency will use the Consumer Needs Assessment to identify PCAs who have the skills, knowledge, ability and availability to provide the service


Case Management -Case Management -Consumer/PCA Service AgreementConsumer/PCA Service Agreement

• Avoid problems by including all tasks that the consumer and PCA have agreed upon, be specific

• Include hours and days of service that have been agreed upon by the consumer and the PCA.

• Ensure both parties have a clear understanding and agree on how service will be provided


Case Management -Case Management -Consumer/PCA Service Agreement cont’d.Consumer/PCA Service Agreement cont’d.

• The agency will use this agreement to complete Consumer Service Evaluations and PCA performance evaluations

• If issues arise, refer back to the agreement

• The consumer will contact the agency if the agreement requires revision


Case Management -Case Management -After Hours ServiceAfter Hours Service

Provided after normal business hours

• Monday through Friday, 5pm to 8am

• Week-ends and ABIL holidays 24 hours

• Consumer contingency plan


Case Management -Case Management -After Hours Service cont’dAfter Hours Service cont’d

Provided after normal business hours

• List of available PCAs

• Ensure the consumer and the PCA have the contact information

• Ensure the consumer and PCA know to only contact the service after hours


Case Management -Case Management -Provider Agency Consumer Provider Agency Consumer Monitoring Monitoring

• On-site Service Evaluation is conducted 5 days after the initial service date for new consumers only. This is to ensure the PCA has the skills, knowledge and ability to meet the consumer needs.

• 30 day, (60 day if necessary), and 90 days from the initial service date an on-site service evaluation is completed to ensure the consumer needs are being met and the PCA continues to have the skills and is satisfied with his/her position.


Case Management -Case Management -Provider Agency Consumer Provider Agency Consumer Monitoring cont’d Monitoring cont’d

•Onsite service evaluations are then completed every 90 days thereafter.

•Unannounced onsite visits are conducted when necessary.


Program pitfalls Program pitfalls

• Lack of communication between Case Managers, Agency Supervisors, Consumers, Payroll and claims

• Liability Insurance• Workers comp Insurance• Unemployment Insurance• Overtime• Turnover


Program pitfalls cont’dProgram pitfalls cont’d

• Family members taking advantage of the consumer’s service

• Designate one spokesperson when family has oversight of service


Paid Family Member Pros and ConsPaid Family Member Pros and Cons

• Majority of paid family members provide excellent care.

• Difficult to know who is providing the care when several people live in the home.

• Failure to report consumer’s change in health condition, hospitalization.

• Submitting hours for payment when the consumer is in the hospital, out of town or has been disenrolled from Medicaid benefits.


Paid Family Member Pros and Cons Paid Family Member Pros and Cons cont’dcont’d

• Some family members will only provide care if they are being paid.

• Some only want the consumer Social Security check.

• Some family members threaten the consumer with nursing home placement if they admit the care is not being provided.


Paid Family Member Pros and Cons Paid Family Member Pros and Cons cont’d 2cont’d 2

• Reduces recruitment cost• Reduced training cost• It would be difficult to fill all positions

without family members• Potentially increases workers comp• Increases unemployment insurance


Hiring Requirements – Hiring Requirements – Personal Care AssistantPersonal Care Assistant

• Application• 3 References – 1 should be an employer• Criminal History Self-Disclosure – should

be notarized • Federal Criminal Fingerprint Clearance

Card• E-Verification qualification• Federal Health Care Exclusion qualification


• Negative TB skin-test or x-ray indicating free from pulmonary tuberculosis

• Complete and pass PCA training and CPR/1st Aide

• New hire orientation• Appropriate Employment Identification• Completed tax documents, i.e. I9, W4, & A4• Policy and Procedure signed

Acknowledgement

Hiring Requirements – Hiring Requirements – Personal Care Assistant cont’dPersonal Care Assistant cont’d


Personal Care Assistant TrainingPersonal Care Assistant Training

Family Members-Homemakers • Fundamentals of Caregiving -2 day training

Philosophy and Values when providing care and support

Roles and Responsibilities within an Agency

Ethical and Legal IssuesObserving, Reporting and Documenting Communication and Cultural CompetencyJob Management Skills/Time ManagementInfection ControlSafety and Emergencies


Personal Care Assistant TrainingPersonal Care Assistant Trainingcont’d.cont’d.

Nutrition and Food PreparationHome Environment MaintenanceBody Mechanics and Techniques for Maintaining

Back SafetyTransfer / Positioning – disability specific Personal Care – disability specificCPR and First Aide

• Students must demonstrate their skill and ability to perform the task

• Disability specific training, if necessary


Personal Care Assistant TrainingPersonal Care Assistant Trainingcont’d 2cont’d 2General Personal Care Assistant• Fundamentals +one module: 4 day training• Elderly/Physical Disabilities or Developmental

DisabilitiesChronic Diseases and Physical DisabilitiesPhysical and Emotional Needs of an IndividualTransfers and PositioningPersonal CareActivities and Activity PlanningDementia-Specific CareGrief and end-of-life IssuesCPR and First Aide

Students must demonstrate their skill and ability to perform the task


Payroll ProcessPayroll Process

• Service hours cannot be paid without a timesheet

• Service hours paid must have the Case Managers’ and Agency authorization

• Timesheets must have both Consumer and Personal Care Assistant signature before payment is issued

• Payment can not be paid if the consumer is in the hospital or disenrolled from the Medicaid program


Payroll Process Payroll Process ccont’d.ont’d.

Agencies should - • Develop a Payroll verification Report• Verify Case Manager authorization before

payment is issued• Verify Supervisor’s authorization before

payment is issued• Verify hospitalization and services not

provided


Payroll Process Payroll Process Cont’d 2Cont’d 2

• Set a due date for timesheets to be submitted

• Clearly inform the PCA when their regular payday is and when payment will be issued when payday falls on a holiday

• Not allow early payment to the PCA• Not allow a payroll advance• Always pay on time - Never have

insufficient funds


Payroll PitfallsPayroll Pitfalls

• Issuing payment without a Case Manager’s authorization

• Poor communication between Case Managers, Supervisors and payroll

• Issuing payment without appropriate PCA employment documents

• Forgery• Fraud / falsification


Claims ProcessClaims Process

• Authorization must be received before billing a claim• Submit a clean claim; complete all required

information on CMS 1500

Agency name

Provider ID #

National Provider ID number (NPI)

Consumer name

Consumer Medicaid ID number

Diagnosis (ICD9 code)

Procedure Code –Service

Modifier code – Service provided

Service dates and hours

Bill rate


Claims TipsClaims Tips

• Claims are billed using the PCA timesheet

• Bill only hours submitted on the PCA timesheet

• Reject PCA timesheet that are incorrect or missing information

• Bill only your agreed upon unit rate


Claims PitfallsClaims Pitfalls

• Not receiving payment

• Claims are paid 30 to 45 days after received by the Program Contractor

• Case Managers authorizing a service, then not informing their claims department

• Failure to be notified by the Case Manager that hours have been decreased and continuing to pay the PCA for hours you can’t bill.


Claims Pitfalls cont’dClaims Pitfalls cont’d

• Billing without an authorization

• Research on denied claims is very time intensive

• Re-submitting denied claims


Important Considerations in Important Considerations in Developing Policies and ProceduresDeveloping Policies and Procedures

• In-house operations, Consumer and PCA.

• Consumer and PCA policies and procedures are the same. You will communicate the same information to both parties

• Develop policies/procedures that will reduce the agency’s liability

• Inter-connect all components when developing policies/procedures


Important Considerations in Important Considerations in Developing Policies and ProceduresDeveloping Policies and Procedures cont’dcont’d• Create timelines for each process

• Case Management based on the contract requirements, Agency policies and philosophy

• Hiring which reflects State & Federal Department of Labor guidelines

• Payroll and claims reflects contract requirements and agency policies


Important Considerations in Important Considerations in Developing Policies and ProceduresDeveloping Policies and Procedures cont’d cont’d 22• Ensure all PAS staff have a responsibility for

each component• Job descriptions must reflect the components• Ensure the consumer understands agency

policies and procedures• Consumers and PCAs will sign and

acknowledge they understand and adhere to those policies and procedures

• Provide each consumer and PCA with a copy of agency policies and procedures


Potential LiabilityPotential Liability

• PCA providing medical services• PCA or Consumer failing to report; when a

service is not being provided, consumer health has significantly changed, hospitalization, abuse, neglect or disenrollment from Medicaid services

• PCA providing transportation in their own vehicle or driving a consumer’s car without signing a waiver

• Consumer giving the PCA the key to their home without signing a waiver


Potential Liability cont’dPotential Liability cont’d

• Entering the consumer home when they are not present

• PCA assisting with banking such as using the consumer’s credit card or knowledge of a pin number

• PCA assisting with personal affairs such as Medical or durable Power of Attorney (POA)

• PCA accepting gifts or borrowing money from the consumer


Potential Liability Potential Liability cont’d 2cont’d 2

• Knowingly placing your consumer or PCA in harms way

• Theft, fraud and forgery • Leaving the consumer stranded• PCA using alcohol or drugs before or during

work• PCA failing to call 911 when necessary


Potential Liability Potential Liability cont’d 3cont’d 3

• PCA taking children, pets, husband or other family member to the consumer’s home

• Eating the consumer’s food • Consumer and PCA maintaining a

professional relationship• Consumers who fail to adhere to policies

may be better to use the Self-Directed Care option


Recommended Policies & ProceduresRecommended Policies & Procedures

• PAS Program description and philosophy

• Consumer Rights

• Consumer Intake & Assessment

• Quality of Care / Incident Report

• Duty to Report


Recommended Policies & Recommended Policies & Procedures cont’dProcedures cont’d

• Transportation / waiver

• House Key / waiver

• PCA Hiring & Compliance

• PCA Rights/Code of conduct

• Supervisory monitoring – Consumer/PCA Evaluations


Recommended Policies and Recommended Policies and Procedures Procedures cont’d 2cont’d 2

• Deficit Reduction/False Claims Act

• Criminal Background Checks

• Substance Abuse

• Disciplinary Process – a progressive approach


• Family Medical Leave Act (FMLA)• Injury Management/Claims• After-Hours Service• Payroll• Claims• File maintenance

Recommended Policies and Recommended Policies and Procedures Procedures cont’d 3cont’d 3


For more informationFor more information

Contact:Phil Pangrazio, Executive [email protected]

Gwen Dean, PAS Unit [email protected]

Arizona Bridge to Independent Living(602) 296-0513


CIL-NET AttributionCIL-NET Attribution

Support for development of this training was provided by the U.S. Department of Education, Rehabilitation Services Administration under grant number H132B070002-10. No official endorsement of the Department of Education should be inferred. Permission is granted for duplication of any portion of this PowerPoint presentation, providing that the following credit is given to the project: Developed as part of the CIL-NET, a project of the IL NET, an ILRU/NCIL/APRIL National Training and Technical Assistance Program.

1 cil-net, a project of ilru – independent living research utilization cil-net presents…...

Documents

selfdirected care services

acute care medical services

managed care model slide

authorization of services

institutional services

individual slide

living nursing homes

gwen dean phil pangrazio