transition coordinator & intensive case manager training · •meet with resident within 10...
TRANSCRIPT
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Colorado Department of Health Care Policy and Financing
Transition Coordinator & Intensive Case Manager Training
Presented by: CCT Team
Colorado Department of Health Care Policy & Financing
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Colorado Department of Health Care Policy and Financing
Improving health care access
and outcomes for the people we serve while demonstrating sound
stewardship of financial resources
Our Mission:
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Colorado Department of Health Care Policy and Financing
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Purpose
• Understand Colorado Choice Transitions (CCT)
• Guide a client through a successful transition to the community
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Explore Interest
Identify Needs
Secure Resources
Move to Community
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Colorado Department of Health Care Policy and Financing
Overview
Colorado’s Money Follows the Person (MFP) initiative, CCT, facilitates transition of people from Long-Term Care (LTC) facilities to community living
$22M grant for 5 years from Centers for Medicare and Medicaid Services (CMS)
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Colorado Department of Health Care Policy and Financing
• MFP born of Supreme Court’s landmark decision Olmstead v. L.C, 527 U.S. 581 in 1999
• Authorized in Deficit Reduction Act of 2005
• Expanded through the Affordable Care Act
History of Money Follows the Person
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Colorado Department of Health Care Policy and Financing
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CMS Goals for CCT
• Increase HCBS
•Eliminate barriers to client’s choices for community living
•Ensure continuous quality assurance
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Colorado Department of Health Care Policy and Financing
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Colorado’s CCT Goals
•Transition 490 people by 2016
• Increase investments in HCBS
• Streamline access to LTSS
• Increase housing options
•Expand consumer direction
•Expand array of LTSS
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Colorado Department of Health Care Policy and Financing
Increased Federal reimbursement for CCT services
25 ¢ of each dollar received dedicated to rebalancing fund Funding & Reform
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Colorado Department of Health Care Policy and Financing
CCT Eligibility
• Meet long-term care Medicaid eligibility requirements
• Currently residing in long-term care facility (minimum 90 consecutive days)
• Move into qualified housing
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Colorado Department of Health Care Policy and Financing
Home owned or leased by individual or individual's family member
Residence in community-based setting with no more than 4 unrelated individuals
Apartment with individual lease
• Living, sleeping, bathing & cooking areas
• Lockable access and egress
• Services not condition of tenancy
Qualified Housing
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Colorado Department of Health Care Policy and Financing
CCT Eligibility Span
365 days of CCT Services
365 days post
transition
Client in facility;
Medicaid begins
Transition to
community
HCBS Waiver Services
State Plan Benefits 11
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Colorado Department of Health Care Policy and Financing
System Collaboration
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Colorado Department of Health Care Policy and Financing
Elements of Positive Interdependence
Sharing
Task
Role
Info
Goal
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Colorado Department of Health Care Policy and Financing
Regional Transition Committee (RTC)
Sustain
community living
Problem identification &
resolution Process
evaluation
Ongoing communication & collaboration
Promote & support
transitions
Develop Regional Transition Strategy
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Colorado Department of Health Care Policy and Financing
RTC Members
• Transition Coordinators
• Service Providers
• Nursing Facilities
• Mental Health Centers
• Community Centered Boards (CCBs)
• Single Entry Points (SEPs)
• Housing Authorities
• Area Agencies on Aging (AAAs)
• Ombudsmen
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Colorado Department of Health Care Policy and Financing
Regional Transition Committees
Moffat
Rio Blanco
Routt
Jackson Larimer
Weld
Morgan
Logan
Sedgwick
Washington Yuma
Kit Carson
Cheyenne
Kiowa
BentProwers
BacaLas Animas
Otero
Crowley
Lincoln
Elbert
Arapahoe
Adams
Jefferson
Douglas
El Paso
Pueblo
GrandBoulder
GarfieldSummit
Clear Creek
Gilpin
Mesa
Delta
Montrose
Gunnison
San Miguel Hinsdale
San
JuanDolores
Montezuma
La PlataArchuleta
Mineral
Rio
Grande
Conejos
Alamosa
Costilla
Huerfano
Saguache
Chaffee
Fremont
Park
Custer
Teller
Denver
Larimer
AAD
CO Spgs
Phillips
Pueblo
Mesa
Eagle
Lake
Pitkin
Ouray
Jeffco
B & B
Northeast
West Central
Park
4 Corners
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Colorado Department of Health Care Policy and Financing
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Community Transition Services (CTS)
• Services provided by a Transition Coordinator to help an individual relocate to the community
• Provided through the HCBS-EBD waiver and the Colorado Choice Transitions program
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Colorado Department of Health Care Policy and Financing
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What’s the difference? HCBS – EBD
• Clients must meet HCBS EBD waiver eligibility criteria
• Informed Consent Form not required
• No length of stay requirement
• TC rate = $850.00
• Household Set up = $1150
• Housing options do not have to meet CCT “Qualified Housing” criteria
• Will not receive CCT services after discharge
CCT • Must meet eligibility criteria for at
least one waiver
• Must sign CCT Informed Consent Form
• Must be LTC resident for 90 days not including rehab
• TC rate = $2000
• Household Set Up = $1500
• Must move into “Qualified Housing”
• Will receive CCT services after discharge
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Colorado Department of Health Care Policy and Financing
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How Are They The Same?
• Transition Coordinator Roles & Responsibilities
• Community Living Process Transition Model
• Documentation
• Reporting
• BUS
• Billing & Reimbursement Procedures
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Colorado Department of Health Care Policy and Financing
Community Living Options Process
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Explore Interest
Identify Needs
Secure Resources
Move to Community
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Colorado Department of Health Care Policy and Financing
Providing Options
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Explore Interest
Identify Needs
Secure Resources
Move to Community
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Colorado Department of Health Care Policy and Financing
Referrals
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• Referrals for transition services can come from any source:
– The resident
– NF social worker
– Family and/or friends
• TCs follow same procedure for all types of referrals
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Colorado Department of Health Care Policy and Financing
Minimum Data Set (MDS) Assessment
• MDS assessment is required for all nursing facility residents – Upon admission
– Quarterly
– Upon significant change in condition
Are you interested in speaking to someone about the possibility of returning to the community
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Colorado Department of Health Care Policy and Financing
MDS Q Referral to Transition Coordinator Agency
“Are you interested in speaking to someone about the possibility of returning to the community?”
Does not commit a resident to leave NF at a specific time More information regarding
community living options & transition process is given
YES
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Colorado Department of Health Care Policy and Financing
Role of Local Contact Agency
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• Meet with resident within 10 days of referral
• NF staff consultation regarding referral
• Provide information about community living options, transition process & TC role
• Answers resident’s questions and helps explore transition options
• Residents asked if they want to explore transition
– If yes, referral to TC is made
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Colorado Department of Health Care Policy and Financing
Roles & Responsibilities Transition Coordinator
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Colorado Department of Health Care Policy and Financing
Relationship Building & Transition Coordination
Facilitating meetings
Assist with paperwork
Encourage client participation & self-assessment
Clarify client’s personal goals
Support client decision-making
Explain transition process & procedures
Explain client responsibilities
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Colorado Department of Health Care Policy and Financing
Identify Needs
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Explore Interest
Identify Needs
Secure Resources
Move to Community
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Colorado Department of Health Care Policy and Financing
Transition Options Team
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Colorado Department of Health Care Policy and Financing
Transition Assessment • Assessment
– Self-reflection guide
– Assessment areas completed by experts
– Reflecting full range of clients needs , preferences, desires
– Must include type, scope, amount, duration & frequency
• Continually assess client’s strengths, challenges, commitment, abilities, motivation
• Transition options team determines if assessment is accurate & complete
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Explore Interest
Identify Needs
Secure Resources
Move to Community
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Colorado Department of Health Care Policy and Financing
Transition Plan
• Details how transition will be implemented
• Contains specifics about client needs, desires, and preferences
• Includes every need and risk factor identified on assessments
• Identifies available services
• Addresses unmet need
• Includes Transition Options Team agreement 31
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Colorado Department of Health Care Policy and Financing
Final Review of Transition Plan
• Team reviews Transition Plan
– Ensure assessed needs, preferences, desires are met
– Risk mitigation plans in place
– Services and Supports arranged
• Team determines Transition/Discharge Date
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Colorado Department of Health Care Policy and Financing
Secure Resources
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Explore Interest
Identify Needs
Secure Resources
Move to Community
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Colorado Department of Health Care Policy and Financing
Role Play Exercise
Identify your client’s needs and create a transition plan
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Colorado Department of Health Care Policy and Financing
Discharge Requirements
• All supports & services have been arranged
• Health, welfare and safety of client ensured
• Qualified providers are available
• Transition Options Team is in agreement
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Colorado Department of Health Care Policy and Financing
Establish Discharge Date
Collaboration between ICM &TC
CCT Service Plan
Household Set Up
Community Integration Activities
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Colorado Department of Health Care Policy and Financing
Moving Plan
Set moving date & plan
Obtain physician orders
Facility discharge plan 37
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Colorado Department of Health Care Policy and Financing
Getting Client Set Up
• Security deposits
• Utility fees
• Essential household items & furnishings
• Moving expenses
• Health & safety assurances
• Groceries $100
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Colorado Department of Health Care Policy and Financing
Household Set-up Expenses
• Items purchased shall be property of client
• Reimbursement for items listed on transition plan with accompanying receipt
• Will not exceed established amount, unless authorized
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Colorado Department of Health Care Policy and Financing
CCT Authorization & Reimbursement
Complete client’s Authorization & Reimbursement worksheet
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Colorado Department of Health Care Policy and Financing
Authorization Request/Cost Report (AR/CR)
Transition
Coordinator
• Includes copies of cancelled checks & receipts for purchases
• Ensures all expenses requested are on Transition Plan
Case Manager
• Reviews AR/CR
• Confirms client is in community-based residence
• Notifies TC of approval within 10 business days of receipt of the AR/CR
Transition Coordinator
• Submits claim to Department's fiscal agent for reimbursement
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Colorado Department of Health Care Policy and Financing
ICM/TC Monitoring
Services & supports are in place
Check health, welfare, & safety
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Explore Interest
Identify Needs
Secure Resources
Move to Community
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Colorado Department of Health Care Policy and Financing
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Good Documentation
Reports significant service provision issues
Monitors client safety, health and welfare
Allows review of work and track changes
Is accurate, timely and complete
Provides continuity for others who work with the individual
Identifies opportunities for quality improvement
Provides evidence required by the state to meet federal assurance
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Colorado Department of Health Care Policy and Financing
Risk Management
Potential for realization of unwanted, adverse consequences to human life, health, property or the environment.
– Oxford English Dictionary
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Colorado Department of Health Care Policy and Financing
Risk Management
• Decisions and activities undertaken to improve a client’s health, safety and environment
• Each risk concerns possibilities of detrimental consequences and likelihoods
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Colorado Department of Health Care Policy and Financing
Critical Elements of Risk Management
• Risk assessment
• Risk mitigation plan
• Risk monitoring and remediation
– Interventions
– Communication and collaboration
– Ongoing assessment
– Documentation
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Colorado Department of Health Care Policy and Financing
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The Balancing Act
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Safety Dignity of Risk
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Colorado Department of Health Care Policy and Financing
Identification of:
• Risks associated with daily life in the community
– Health
– Behavior
– Personal safety
• Risk preparedness
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Risk Assessment
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Colorado Department of Health Care Policy and Financing
Risk Mitigation
• Planning to reduce risk of harm
• Strategy identification
• Client involvement
– Risk assumption agreement
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Colorado Department of Health Care Policy and Financing
Risk Monitoring & Remediation
RISK
Interventions
Ongoing assessment
Documentation
Communication and
collaboration
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Colorado Department of Health Care Policy and Financing
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Emergency Backup Plan
Emergency Backup Planning: One strategy for risk mitigation
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Colorado Department of Health Care Policy and Financing
ICM Roles & Responsibilities
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Explore Interest
Identify Needs
Secure Resources
Move to Community
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Colorado Department of Health Care Policy and Financing
ICM Role in Transition Process
• Joins client’s Transition Options Team
• Reviews client’s universal LTC assessment tool (ULTC 100.2)
• Conducts new ULTC 100.2 if needed
• Participates in transition assessment/ planning process
• Completes Service Plan
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Colorado Department of Health Care Policy and Financing
ICM Responsibilities - Post Transition
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Explore Interest
Identify Needs
Secure Resources
Move to Community
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Colorado Department of Health Care Policy and Financing
• Monitors Client’s
– Services
– Health, welfare and safety
– Quality of Life
• Ongoing assessment of functional status
• Revises the service plan
• Assesses client’s progress on necessary independent living skills acquisition
• Monitor and revise risk mitigation plans
ICM Post Transition Monitoring
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Colorado Department of Health Care Policy and Financing
Continuity of Care
Prepare client for transition from CCT program to HCBS waiver program if the client continues to meet the eligibility requirements for a waiver
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Colorado Department of Health Care Policy and Financing
CCT Benefits & Services
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Colorado Department of Health Care Policy and Financing
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CCT Benefits & Services
• Promote independent living and choice • Facilitate a successful transition • Support stability in the community
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Colorado Department of Health Care Policy and Financing
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Qualified vs Demonstration Services
Qualified Services
• State plan benefits
• Home and Community Based Services (HCBS) Waiver services
Demonstration Services
• CCT services
• Compliment qualified services
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Colorado Department of Health Care Policy and Financing
Service Plan & Authorization
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Explore Interest
Identify Needs
Secure Resources
Move to Community
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Colorado Department of Health Care Policy and Financing
CCT Service Plan
Approved by CCT Transition Administrator before transition occurs
Informed by • Transition assessment/plan • Client’s level of functioning • Client goals and needs • Available resources
Developed by ICM with input from
• Transition Coordinator
• Discharging facility
• Client or guardian//Family
Additional Documents
• Risk mitigation Plan
• Emergency Backup Plan
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Colorado Department of Health Care Policy and Financing
Person-Centered Service Planning
• Intensive Case Managers (ICMs) engages and empowers clients in
– Identifying strengths, capacities, preferences, and needs
– Achieving personal goals
– Designing service plan
– Accessing community services
• Matches transition plan/Plan of Care (POC) to services
• Allows real-time changes in services and supports
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Colorado Department of Health Care Policy and Financing
Resource Development
• Recruit providers to serve CCT clients
• Identify community resources
• Use service plan as way to identify unmet needs/gaps in services
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Colorado Department of Health Care Policy and Financing
Prior Authorization Request (PAR) Process
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Send PAR to Dept
CCT Team reviews
If DD, DHS reviews also
Xerox reviews
CCT Team sends PAR letter
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Colorado Department of Health Care Policy and Financing
Monitoring
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Explore Interest
Identify Needs
Secure Resources
Move to Community
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Colorado Department of Health Care Policy and Financing
Monitoring Activities
• Independent Living Skills
• Goals
• Health, Welfare and Safety
• Risk
• Services and Supports
• Emergency Backup
• Reinstitutionalizations
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Colorado Department of Health Care Policy and Financing
Readmission Stay < 30 Days
• Readmission:
– Hospital
– Nursing Home
– ICF-IDD
• 365-day demonstration period resumes upon re-entering the community
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Colorado Department of Health Care Policy and Financing
Re-Enrollment Process
• Reenrollment in CCT is allowed after:
– Readmission to an institution
• Eligible client:
– Re-enrolls as new client and meets all CCT eligibility criteria
• A new 365-day demonstration period begins
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Colorado Department of Health Care Policy and Financing
Post Readmission Review Review original transition thoroughly
Identify and address issues contributing to readmission
Create risk mitigation plan for identified risk factors
Draft new Service Plan
Update information from Transition Assessment/Plan
Obtain input from client, informal support network, Intensive case manager, transition coordinator and other providers
Mitigate potential problems for a second transition
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Colorado Department of Health Care Policy and Financing
Nora Brahe, Transitions Administrator
Kathy Cebuhar, CCT Community Liaison
Tim Cortez, Project Director
Nicole Storm, Project Manager
Web: Colorado.gov/hcpf/CCT
Email: [email protected]
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