apd 2016 regional training apd ltc... · •switch roles and the other talk and the other listen...

APD 2016 REGIONAL TRAINING

DAY 2

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AGENDA – DAY 2

Day 2

• Person Centered Planning

• Home & Community Based Services Overview

• CM Responsibilities related to HCBS

• Individually Based Limitations (IBLS)

• Q&A

Why• New Federal CFRs• Positive Changes for

Consumers• Impact on providers• Impact on CMs

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PERSON-CENTERED PLANNING

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ACTIVITY

• Please find a partner

• Each of you pick a number between 1-10 your number will determine who you are for the day from the “People” handout.

• One be the listener and one the talker

• When told to start: The one talking will introduce themselves as the person you selected and will continue to add details about themselves for 2.5 minutes while the other listens.

• Switch roles and the other talk and the other listen

• Thank you, we will follow-up later

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PERSON-CENTERED APPROACH

Golden Rule: Treat others how you would like to be treated

Treat people as individuals - not like a number

Do not use cookie cutter approaches – one size does not fit all

High level view

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Planning is different than Assessing.

Assessing in Medicaid determines:

• Eligibility

• ADL assistance need level

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Person-Centered Planning:

• Focuses on the strengths of the individual

• Utilizing individual, natural and creative supports and services

• Defining life goals and how to achieve

• Valuing what is important to the individual while not ignoring, family, funding, and community supports

Assessing and Planning should be viewed as two important but separate activities

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Person-Centered Planning Process

Driven by the

individual

People chosen by individual

Convenient time and

place

Easy to

Understand

Informed consent

Choices

Some key concepts: Process

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Some key concepts: Plan

Person-Centered

Plan

Setting choice

Strengths/ Preferences

Clinical support needs

Goals and OutcomesServices

and Supports

Risks

Easy to

Understand

Informed consent

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How do we assure the Person “leads” the process?

• Are they at the table when others are making plans about them?

• Does the group include the person or ask for their input?

• Did we ever inform the person that “they are in charge” and our job is to support their goals and preferences?

• Other ideas? – Group discussion

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What is important to the person

What are the person’s goals

Important to What do

others/society think is important for the person

What are others goals, motivations, interests for the person

Important for

Two important person–centered planning concepts

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Conflict - Do you think there could ever be conflict between what is important to the person and what is important for the person?

Facilitating Conversations - A big part of person-centered planning can be the Case Manager facilitating the conversations between the person and those that “know” what is important for the individual.

Tools - There are many good tools available that have been created to help facilitate discussions about the conflicts between important to and important for. Most are designed to help present both sides in a non-judgmental and factual manner.

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Person’s Goals:

• Are genuine and not artificially created

• Should be arrived at naturally, not as an assignment

• Clue: Any action you take on behalf of someone should be related to their goals

• If goals seem unreasonable or unattainable – pursue anyway

Don’t take away a person’s right to dream

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Goals and the relation to Direct or Indirect contacts

The purpose of the Direct or Indirect contact is to check-in with ourselves (our action steps) and the individual, to make sure we are making progress on the individual’s goals.

When we think of goals as being tied to action steps, at the Direct/Indirect we are pausing and assessing whether there are any actions we should have made or need to make to support the person in meeting their goals.

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PERSON-CENTERED PLANNINGELICITING GOALS

Establish Trust:

• By listening to the individual and not discounting what is important to them.

• Ask questions not in our jargon but how people talk.

Some samples:

• Where do you see yourself in a month, year, five years?

• What’s on your bucket list?

• What excites you most about life? Worries you most?

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Eliciting goals is again about trust and getting to know the person.

It is also about getting the person to open up and talk to you.

One method you can try is using opposing questions:

• What does a bad day/good day look like?

• What do others think is important for you?/What is important to you?

• What is working/not working for you?

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Once you think you have a sense of the persons goals:

• State the goals the way you have heard them or inferred them from the conversation. Adjust as informed by the person

• It may help to organize them into short-term, mid-term, and long-term goals. Or, to prioritize, most important to least.

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• Finally, don’t just focus on Medicaid related goals; life goals such as being a rock star, marrying a super model, or going to Mars are important to capture and document.

• It’s not about the services but how the services help the individual reach his/her goal

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PERSON-CENTERED PLANNINGACTIVITY

Please spend five minutes with your partner from this morning:

• First, see if you can identify some of the persons goals from this mornings discussion by asking the other person.

• Second, if time use some of the questioning techniques to draw more out of the person.

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PERSON-CENTERED PLANNINGDOCUMENTING GOALS

Once you understand a persons goals:

• Document in Oregon ACCESS

• Track progress during Indirect/Direct contacts

• Ask the care provider what they are doing to support the person’s goals

• Talk with the consumer about their goals

• Take additional actions to support the individual in achieving goals

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PERSON-CENTERED PLANNINGSAFETY

• Honoring Preferences, Lifestyle, Culture, Personal Choices

• Informed consent when risks are identified

• Does the individual understand the consequences of the choice or behavior?

• Danger to self – needs assessed – may be ok or may need intervention

• Danger to others – never ok

• Illegal activities – never ok

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PERSON-CENTERED PLANNINGSAFETY

Responsibility for safe placement

• Assisting narrow the list based on knowledge of person’s goals, interest, preferences, and care needs

• Closing the door to unsafe or failing settings

• Offering move options when current setting not working

• Intervening at the Case Management level to resolve problems/improve services

• Involving Licensing/Adult Protective services

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PERSON-CENTERED PLANNINGACTIVITY

Earlier you paired up with another and heard their personal introduction and discussed goals. Please take a few moments and fill out the Personal Profile form to the best of your abilities based on what you heard.

Group discussion

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At it’s roots, Person-Centered Planning is about providing

Excellent Customer Service

Remember the golden rule - always treat others the way you would want to be treated.

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HOME AND COMMUNITY-BASED SERVICES (HCBS) OVERVIEW

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HOME AND COMMUNITY-BASED SERVICES (HCBS)

• March of 2014 the Center for Medicare and Medicaid Services (CMS) published new rules defining qualities of home and community-based services

• These rules define what is institutional and what is not.

• States must ensure that HCBS services meet the new requirements to continue to receive Federal HCBS funding for those Services.

• This is the new Normal

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HCBS:ALL IN-HOME, RESIDENTIAL, NON-

RESIDENTIALKey Concepts for all HCBS settings:

• Individuals have the ability to control their own lives

• Individuals have access to the broader community,

• Facility is Integrated into the community

• Individuals have the same degree of access as those not on Medicaid.

• In Oregon, the rules apply to private pay and Medicaid

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KEY CONCEPTS FOR ALL HCBS SETTINGS

• Individuals have the ability to:

• Engage in community life

• Receive Services in the community with the choice of:

Private Room

Non-disability specific setting (integrated)

• Control one’s personal resources

• To work, if desired

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HCBS: IN-HOMEStates may presume that In-Home settings meet HCBS requirements

But…

States must correct areas found that do not meet HCBS.

To Restate: In-Home settings must meet all the qualities and expectations outlined in the HCBS rules.

Note: There is no provision for limiting rights in In-Home settings.

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HCBS: IN-HOME

For Example:

If someone is living with relatives and is restricted to the bedroom or their home that is not ok.

The individual has the right to the common areas of the house and to go out in the community.

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HCBS: IN-HOME

• What if an In-Home case does not meet HCBS?

• Usually: Case Manager provides education to the family or other provider about the rights of individuals

• Sometimes: May need to refer to Adult Protective Services

• Rarely: If the home is purchased for the purpose of isolated care for individuals, referral to Central Office

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HCBS: RESIDENTIAL SETTINGS

• The purpose of these new rules are to:

• Remove institutional qualities in residential settings

• Make residential settings more home-like

• Because CMS found that residential settings can control and regiment individuals’ lives they created additional:

• Rights

• Freedoms and

• Protections

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HCBS: RESIDENTIAL SETTINGS• Rights, Freedoms, Protections:

Written residency agreement

Locks for privacy in bedroom or unit

Ability to decorate and furnish

Choice of roommate if sharing a room

Access to food 24/7

Access to visitors 24/7

Ability to control one’s own schedule

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RIGHTS, FREEDOMS, PROTECTIONS

Residency Agreement

• Oregon will require for all residential settings – new for Adult Foster Homes.

• May not be more restrictive than the standard rental agreements of local community

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Locks on doors

• The default is a lock must be available, provider should not be asking if the person wants a lock for privacy,

• The lock is not removed if the person doesn’t want one, they just don’t lock their door

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Ability to Decorate and Furnish (per residency agreement)

• Can’t be more restrictive than local rental agreements

Choice of roommate if sharing a room

• Refusing roommates can not be used as a way to obtain a private room

• Individuals should ideally meet or minimally told about the new person moving in before the move takes place

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Access to Food

• Does not change provider obligation of three nutritious meals an two snacks

• Does mean that personal snacks desired and purchased by the individual or others are stored and the person is supported to access them as desired

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Access to Visitors

• Providers cannot have visiting hours

• Check-in can be required but not making the visitor sign-in (provider can keep log)

• Visiting is not moving in

• It’s not the visitor that has the right, it is the resident, including the right to not have visitors or reject certain visitors.

• Individuals have the responsibility to control their visitors

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Control of own schedule:

• Individual controls when to get up or go to bed, when to shower, when to eat.

• It means the freedom to leave the setting

• It means the setting is flexible with providing replacement meals if one returns after scheduled meal time

• It means you can choose to eat in your room and not be charged if you are a Medicaid individual

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HCBS: TIMELINE

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HCBS- TIMELINE

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HCBS - TRANSITION

We want to acknowledge that HCBS is new for providers, Licensors, Surveyors, and Case Managers. We are all transitioning and learning together.

• We will be rolling out new “Individually-based limitations” at new assessments throughout 2017.

• It is important that we practice and gain skills during the HCBS transition period so we can be in full compliance as a state by March 2019.

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HCBS - CASE MANAGEMENT RESPONSIBILITIES

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HCBS: CASE MANAGEMENT RESPONSIBILITIES – RESIDENTIAL SETTINGS

HCBS: Rights, Freedoms, Protections

• Written residency agreement

• Locks for privacy in bedroom or unit

• Ability to decorate and furnish (within residency agreement)

• Choice of roommate if sharing a room

• Access to food 24/7

• Access to visitors 24/7

• Ability to control one’s own schedule

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Case Managers have an important role and responsibility as the “eyes and ears” of the system to assure that individual’s are able to exercise their rights and freedoms wherever they live.

Case Managers are in a unique position to alert, react, and support individuals when their basic rights are threatened.

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What are some indications that you might come across in a residential setting that may indicate that HCBS philosophy might be lacking?

Activity

Spend some time as a group brainstorming some things you might be able to observe.

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WHAT DO YOU DO IF YOU THINK THERE ARE HCBS ISSUES?

• Check with the residents

• Do residents feel it is an issue?

• Does the resident(s) have solutions?

• Facilitate a discussion with the provider

• Seek to understand the provider’s perspective.

• Does the provider have a solution?

• Unless abuse or neglect, try to solve at case manager level first.

You can staff a situation with your Manager or Central Office

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If unable to solve a problem related to HCBS, it may be necessary to refer the issue to Licensing or Adult Protective Services.

• Any abuse or neglect should be immediately reported to Adult Protective Services! All DHS/AAA employees are Mandatory Reporters.

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• All other HCBS non-compliance issues (not abuse or neglect) should be referred to the Safety, Oversight and Quality Unit Complaint team or the local office for Adult Foster Homes.

• If uncertain whether there is an issue, or for advice, consultation is available with the Central Office HCBS Policy Analyst.

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INDIVIDUALLY-BASED LIMITATIONS (IBL)

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HCBS: INDIVIDUALLY-BASED LIMITATIONS TO THE RULES

• Some individuals may not be able to safely exercise their new rights given to them under HCBS.

• There is a defined process for “limiting” an individual’s rights.

• Case managers play a critical role for Medicaid consumers

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INDIVIDUALLY-BASED LIMITATIONS TO THE RULES

• OARs 411-004 are the “overarching” HCBS rules for:

• Aging and People with Disabilities

• Office of Developmental Disabilities Services

• Addictions and Mental Health

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• In addition to the OAR 411-004 rules:

• Licensed setting’s rules incorporate the HCBS expectations

• These include:

• AFH: OAR 411-050

• ALF/RCF: OAR 411-054

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• In specific situations we can limit the rights provided by the new HCBS regulations. Limits may be applied to:

Locks for privacy in bedroom or unit

Ability to decorate and furnish

Choice of roommate, if sharing a room

Access to food 24/7

Access to visitors 24/7

Ability to control one’s own schedule54


• The following requirements must be met before a limit can be applied:

The individual has a defined and specific individualized need.

The provider must have proof that they have:

Tried positive interventions and supports prior to requesting a limitation.

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• The provider must have proof that they have:

Have tried less intrusive methods of meeting the need but those methods did not work.

• A clear description of the specific limitation that is directly proportionate to the specific assessed need.

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• In addition to specific need and defined limitation, the limitation must also include:

Regular collection and review of data to measure the effectiveness of the limitation(s).

Established time limits for periodic reviews to determine if the limitation(s) is still necessary or can be terminated.

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• In addition to specific need and defined limitation, the limitation must also include:

The informed consent of the individual.

An assurance that interventions and supports will cause no harm to the individual.

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TIMELINE ON INDIVIDUALLY-BASED LIMITATIONS TO THE RULES

• New tools to help ensure compliance:

New Form: Individual Consent to HCBS limitations

ORACCESS: screening, documenting, and printing of Individual Consent to HCBS limitations form.

• Rolling implementation beginning in January 2017, limitations needed are assessed and decided at next review.

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INDIVIDUALLY-BASED LIMITATIONS TO THE RULES: PROCESSES

• The request for a limitation may come from any source,

The family

A friend

The case manager or other

APD worker (Licensor/Adult Protective Services)

But most often the request will come from the provider.

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SOME BASIC RULES ABOUT INDIVIDUALLY-BASED LIMITATIONS TO THE RULES

• They are not portable or transferrable.

When a person moves the limitation does not follow them.

The new provider must again demonstrate that they have tried alternatives.

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SOME BASIC RULES ABOUT INDIVIDUALLY-BASED LIMITATIONS TO THE RULES

• Limitations are only considered if there is a risk to the individual or others health or safety.

• Limitations are not for the convenience of the provider.

• If an individual understands the consequences to their decisions, it is a choice.

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BASIC STEPS - CREATING INDIVIDUALLY-BASED LIMITATIONS TO THE RULES

• Limitation requested

• Need for limitation confirmed

• Limitation defined

• Consent from consumer or representative

• Implementation of the limitation

• Review of the limitation at scheduled times

Indirect & Direct contacts

Reassessments

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SCREENING FOR AN INDIVIDUALLY-BASED LIMITATION TO THE RULES

• ORACCESS will help CMs screen requests for limitations.

• Three areas are screened:

Cognition – the individual must have a cognitive impairment that is causing the need for the limitation;

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SCREENING FOR AN INDIVIDUALLY-BASED LIMITATION TO THE RULES

Health or safety risk – there is a significant risk to health and safety of the individual or others; and

Ability to understand the risk - person does not understand the risk.

• If yes to all of the above, a limitation may be considered.

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CONSIDERING A LIMITATION

• If the request for a limitation passes the screening criteria then the CM should gather additional information from the provider.

• CMs may do this through:

A conversation on the phone or in-person; or

Having the provider complete the information in the “APD Provider Limitation Request Form” in the handouts

• The information will be logged into OACCESS

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OBTAINING CONSENT FOR THE LIMITATION

• Once the needed information is gathered the CM documents in ORACCESS and prints the Individual Consent to HCBS Limitations form.

• Case Manager meets with client, provider, and others to discuss proposed limitation.

• If individual (or legal rep) consents (agrees) the limitation is put into effect for the time period agreed to (can be no longer than a year).

• If there is no consent (no agreement) the limitation can not go into effect.

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INDIVIDUALLY-BASED LIMITATION TO THE RULES MOST COMMON QUESTION

• What if the person does not have the ability to consent and has no legal representative?

We are currently working with stakeholders on a legislative solution.

During the 2017 roll-out we will use the proposed procedure for those that may be at risk due to the inability to consent.

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TIMELINE

• You receive more detailed training in December and January

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CM Training

Dec - Jan

IBLs start

Jan 2017

IBLs initiated at assessment-

reassessment

Initial IBLs Completed

12/2016

A FINAL THOUGHT

• When considering a limitation…you are considering taking somebody’s rights away.

• You are balancing this against the individuals safety and ability/right to make poor decisions.

• This is serious and important work you are entrusted with and should not be taken lightly.

• Thank you for all you do and will be doing

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INDIVIDUALLY- BASED LIMITATIONS TO THE RULES

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Thank You

Contacts:

Bob Weir Email: [email protected]

Chris Angel Email: [email protected]

PERSON-CENTERED PLANNING HOME AND COMMUNITY-BASED SERVICES

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mailto:[email protected]

mailto:[email protected]

apd 2016 regional training apd ltc... · •switch roles and the other talk and the other listen...

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