Services Facilitators: Overview of Consumer-Directed Services

1. 1 Services Facilitators:Overview of Consumer-Directed Services

2. 2 Service Facilitator Training Overview

3. 3 Service Facilitator Training Overview

4. 4 Service FacilitationWhat Are Consumer-Directed Services Consumer-directed (CD) services means that the individual receiving companion, personal assistance, or respite services through an approved Medicaid waiver is the employer for the attendants. With the choice to be the employer, there come many important responsibilities, including hiring, training, supervising, and, if necessary, firing attendants who will be providing CD services. CD Services can be provided through four Medicaid waiver programs (EDCD, ID/MR, IFDDS, and HIV/AIDS) as well as the Children�s Mental Health Program.

5. 5 Service FacilitationWho can receive CD services? Services may be furnished only to individuals: Who meet the NF or ICF/MR criteria: Who are eligible for Medicaid; For whom an appropriate, cost-effective service plan can be established; Who are not residents of NFs, ALFs, or AFCs; Whose health, safety, and welfare in the home environment can be ensured.

6. 6 Service FacilitationCD Services All CD services require the use of a fiscal agent and a SF who is a DMAS-enrolled provider. All CD services must be preauthorized by the PA contractor. Payment will not be made for services that are not preauthorized. CD Services may be provided only when: The individual is present for services; Services are provided according to the service plan; Services are preauthorized; Services are provided by qualified providers; and There is a viable back-up plan in place.

7. 7 Service Facilitator Training Overview

8. 8 Service FacilitationMinimum Qualifications for SF Providers At a minimum, the SF: Must have the knowledge, skills, and abilities set forth in the regulations and manuals. Should possess an undergraduate degree in a human services field or be a registered nurse currently licensed to practice in Virginia. Should have two years of satisfactory experience in the human services field working with the elderly or persons with disabilities.

9. 9 Service FacilitationThe SF�s Toolkit It is recommended that SFs have or have access to: The appropriate provider manual (especially Chapters II and IV) found at www.dmas.virginia.gov. The CD Employer Manual (www.dmas.virginia.gov/ltc-home.htm) Guide for LTC Services in Virginia (www.dmas.virginia.gov/ltc-home.htm) Copies of forms (e.g., DMAS-225) found at www.dmas.virginia.gov. Waiver services regulations found at http://leg1.state.va.us.

10. 10 Service Facilitator Training Overview

11. 11 Responsibilities of the SFAll Medicaid providers Immediately notify DMAS in writing of any change in the information that the provider previously submitted to DMAS. Comply with all Health Insurance Portability and Accountability Act (HIPAA) guidelines. Accept referrals for services only when staff is available to initiate and perform such services on an ongoing basis. See regulations and policy manuals, as well as the Provider Enrollment Packet, for additional requirements.

12. 12 Responsibilities of the SFAll Medicaid providers Be enrolled as a Medicaid provider and agree to the terms and conditions of the Provider Enrollment Packet. Initiate CD services with the individual, ensuring that he or she is preauthorized for services. Maintain documentation as required by waiver provider manual and regulations. Conduct annual Level of Care reviews on all current waiver participants to ensure they continue to meet medical, nursing and functional eligibility requirements. All supporting documents are to be submitted with level of care review; DMAS 99C, Plan of Care and DMAS 225.

13. 13 Responsibilities of the SFThe Service Plan Develop the service plan with the individual and conduct required and timely reviews of the service plan. The service plan must include Activities of Daily Living IADLS Special needs Bowel and Bladder Range of Motion (ROM)

14. 14 Responsibilities of the SFClosing services SF must notify local DSS using the DMAS-225 when: (prior authorization contractor must be notified) Individual dies; Individual is discharged from services; Any other circumstances (including hospitalization) that case services to cease or become interrupted for more than 30 days. SF should notify DMAS if individual no longer meets criteria for services. When an individual is admitted to Nursing facility or Inpatient Rehabilitation provider. The prior authorizations and LOC for the waiver are closed and must be reopened upon discharge from the provider

15. 15 Responsibilities of the SFClosing services Instruct participants that they could be responsible for payment of attendant if they do not have an authorization. This will occur if the waiver participant no longer meets eligibility requirements based on their annual level of care review, and they have been terminated from the waiver and services continue to be provided. (12VAC30-120-980)

16. 16 Responsibilities of the SFRecordkeeping The SF must maintain a record for each individual. Specific information to keep in the record includes: Assessments Service plans Individual Service Authorization Request (ISAR) Prior Authorizations (PA) Current DMAS-225 (Send discharge DMAS-225 to DSS and the discharge to KePRO or DMHMRSAS.) Document all contacts Quarterly reviews (face-to-face) Any APS/CPS complaints filed Note: Refer to applicable provider manual for specific program requirements.

17. 17 Responsibilities of the SFRequired Activities

18. 18 Responsibilities of the SFI - Initial/Comprehensive Visit Initial/Comprehensive Visit � an assessment of the individual�s current medical, functional, social support status, and a complete summary of all services to be received. Documents to Complete: (this will vary by waiver) DMAS-99 Full assessment to ensure the individual meets waiver criteria DMAS-225 DMAS-97A/B Plan of Care For MR forms, consult the appropriate provider manual.

19. 19 Responsibilities of the SFI � Initial/Comprehensive Visit - continued

20. 20 Responsibilities of the SFI � Initial/Comprehensive Visit - continued

21. 21 Responsibilities of the SFII � Consumer/Management Training Consumer Training - training provided by the SF upon the individual�s request to prepare the individual for their role as the employer. Documents to complete: (varies with waiver) Individual/management training must be documented on the DMAS-99 in the notes section. For MR forms, consult your manual.

22. 22 Responsibilities of the SFII � Consumer/Management Training (continued) The SF must provide the individual with training within seven days of the completion of the comprehensive visit. The SF can complete the comprehensive visit and management training on the same day. During the management raining, the SF must train the individual and/or caregiver, as appropriate, on their duties as an employer and provide them with the CD Employer Manual available on the DMAS website at www.dmas.virginia.gov.

23. 23 After the initial visit, two routine visits must occur with 60 days to monitor care and the employment process. The SF follows an outline & checklist for CD individual training to ensure that the training content meets the minimum acceptable requirements. The SF checks each subject on the form after it has been covered and has the required signatures and dates. The training checklist must be maintained in the individual�s file and available for QMR. The checklist will vary by waiver. Responsibilities of the SFII � Consumer/Management Training (continued)

24. 24 Responsibilities of the SFII � Consumer/Management Training (continued)

25. 25 Responsibilities of the SF II � Consumer/Management Training (continued)

26. 26 Responsibilities of the SFII � Consumer/Management Training (continued) Management training: Allowable Services EDCD Waiver: Upon request of the individual or family/caregiver. Must document reasons for training and billed in hourly units. EDCD Waiver: Must be billed in management training units and documented. IFDDS Waiver: Up to 4 hrs in any 6 months. MR Waiver: Up to 4 hrs in any 6 months. Must be billed in management training units and document.

27. 27 Responsibilities of the SFIII - Routine Follow�Up Definition: Routine Follow-Up - a visit to the individual�s home to provide ongoing support. Documents to Complete: (this will vary by waiver) DMAS-99. For MR forms, consult your manual.

28. 28 Responsibilities of the SFIII - Routine Follow-up (continued)

29. 29 Responsibilities of the SFIII - Routine Follow-Up - continued During routine visits, the SF must: Observe, evaluate, and document, in writing, the adequacy and appropriateness of the attendant services; Review the attendant�s time sheets, if available; Discuss the individual�s satisfaction with services; Review medical and social needs; Review the established service plan; and, Comply with all other documentation as listed in the waiver regulations and manuals to assure, the individual�s welfare.

30. 30 Responsibilities of the SFIII - Routine Follow-Up - continued Also, during routine visits, the SF must: Identify any indicators of abuse, neglect or exploitation; and, Report any suspected abuse, neglect or exploitation to the appropriate local department of social services for investigation. REMEMBER � SFs ARE MANDATED REPORTERS UNDER THE ADULT PROTECTIVE SERVICES STATUTES IN VIRGINIA.

31. 31 Responsibilities of the SFIV - Reassessment Visits Reassessment Visit - a visit to conduct a full assessment of the individual�s current medical, functional, and social support status and a complete summary of all services received. It updates and summarizes the activity of the last 6 months and updates the plan of care as needed. Documents to complete: (varies with waiver) DMAS-99 must include a complete review of the individual�s needs, available supports, and a review of the service plan. For MR forms, consult your manual.

32. 32 ResponsibilitiesIV - Reassessment Visit Individuals have freedom of choice in selection of service providers, including SFs and service package, reflected on their plan of care. When these changes occur: Reassessment visit is required; and, this update information is critical for the waiver participants annual level of care review. DMAS-99 documents change in SF or CD service. Individuals must be told that their attendants will not be paid unless there is an authorization in place. The individual could be held liable for the payment of attendants. (12VAC30-120-980)

33. 33 ResponsibilitiesV - Annual Visits ID/MR Waiver ONLY If the individual is receiving CD services in the MR waiver, the SF must work with the CSB case manager to assure all documentation is updated and the individuals needs are meet.

34. 34 Under extenuating circumstances, a family member or caregivers living in the same home as the Waiver individual may be permitted to be the attendant of the individual. There must be clear documentation in the individual�s plan of care) that there is no one else available to provide the care. Newspaper or other advertisements indicating that an attempt to hire an attendant was made. Copies of interview notes if applicable. The attendant may not be the parent of a minor child or the spouse. Regardless of who the attendant is, they may not receive respite if they are the paid caregiver.

35. 35 The aide must meet the following requirements: Be 18 years of age or older; Have the required skills to perform consumer-directed services as specified in the individual�s supporting documentation; Be able to read and write in English to the degree necessary to perform the tasks expected; Possess basic math, reading, and writing skills; Possess a valid Social Security number;

36. 36 Submit to a criminal records check and, if the individual is a minor, consent to a search of the DSS Child Protective Services Central Registry. The aide will not be compensated for services provided to the individual if either of these records checks verifies the aide has been convicted of crimes described in �32.1-162.9:1 of the Code of Virginia or if the aide has a founded complaint confirmed by the DSS Child Protective Services Central Registry; Be willing to attend training at the individual�s or family/caregiver's request; Understand and agree to comply with the Waiver requirements; Receive tuberculosis (TB) screening as defined in regulations. Refer to the Virginia Department of Health for TB screening guidelines.

37. 37 Supervision Supervision is a covered service within the personal care Plan of Care when the purpose is to supervise or monitor those individuals who require the physical presence of the aide to ensure their safety during times when no other support system is available. The inclusion of supervision in the Plan of Care is appropriate only when the individual cannot be left alone at any time due to mental or severe physical incapacitation. This includes individuals with a disability who cannot use a telephone to call for help.

38. 38 Supervision Supervision will not be authorized for family members to sleep either during the day or during the night unless the individual cannot be left alone at any time. Supervision cannot be considered necessary, because the individual�s family or provider is generally concerned about leaving the individual alone or would prefer to have someone with the individual. There must be a clear and present danger to the individual as a result of being left unsupervised. Supervision cannot be authorized for persons whose only need for supervision is for assistance exiting the home in the event of an emergency. Supervision may be authorized if there is no one else in the home competent to call for help in an emergency.

39. 39 Respite Respite services are personal care that are specifically designed to provide temporary, substitute care that is normally provided by the family or another unpaid primary caregiver/family member of an individual. Respite is for the relief of the caregiver due to the physical burden and emotional stress of providing continuous support and care to the individual. These services are provided on a short-term basis because of the emergency absence, or need for routine or periodic relief, of the primary caregiver. The maximum amount of combined respite care services that a individual may receive is 720 hours in a calendar year. individuals who are receiving CD, and AD respite services cannot exceed 720 COMBINED hours per calendar year.

40. 40 Service Facilitator Training Overview

41. 41 Quality Management Review (QMR) Process DMAS conducts QMRs: To assure the health and safety of waiver individuals. To assure that services rendered according to regulation. To assure individuals� needs are being meet through CD services. To assure that the individual is satisfied with the services he or she is receiving.

42. 42 QMR Process Provider/individuals identified for review. QMR may be on-site or as a desk audit. On-site may last 1-5 days or longer, if necessary. individuals and caregivers will be interviewed either face-to-face or via telephone. DMAS staff will review a time period, which may be expanded if necessary. DMAS staff will provide a list of the individuals to be reviewed. An exit conference will be held. DMAS staff will send a letter of the findings of the review, technical support, and, as necessary, a request for corrective action.

43. 43 QMR ProcessExamples of Items That May Be Cited Visits/services not being performed as required in regulations, policy, procedures or as the individual�s condition changes. Documentation did not support services. Different dates for visit and documentation. DMAS-96 not signed prior to services started. Forms not completed or not completed properly. Individual was in NF, hospital or intensive rehabilitation facility, or out of the country. Documentation for person living in the household caring for individual does not meet requirements. Visits were conducted late.

44. 44 QMR Process  Examples of Items That May Be Cited Attendants began prior to having all paperwork cleared through and authorization received from DMAS via KePRO. (They will not be paid by DMAS.) Documentation not shared with other providers as necessary (i.e., case managers in MR Waiver). During visit, a change is noted, but there is no change in the frequency of follow-up visits. Change in mental status. Change in physical condition. Change in caregiver status, which may necessitate more frequent review.

45. 45 QMR Process Examples of Items That May Be Cited Individual has incident of abuse, neglect, exploitation or other health and safety concern that was not reported. Provider qualifications and/or credentials are not adequate or current, or there have been changes to ownership/management that were not reported to DMAS.

46. 46 QMR Process Examples of Items That May Be Cited Staff qualifications and/or credentials are not adequate or current. Documentation does not meet DMAS� requirements. No indication of coordination between agency directed and consumer directed services.

47. 47 Service Facilitator Training Overview

48. 48 Future Directions Changes are coming within the consumer directed model: Automated Time-Sheets PPL, in collaboration with DMAS, is piloting the use of automated timesheets to: Make the payroll easier and quicker Minimize the errors associated with manual timesheets Provides easy access to check status of timesheet Ensures security for timesheet approval and submission PPL is piloting the prototype with roll-out mid-summer 2009 � Demonstrations of the e-timesheet have been included in Service Facilitator monthly telephone calls since January 2009.

49. 49 Future Directions The DMS Consumer Directed Employer Manual will be revised mid-July 2009 to include: A voluntary �Attendant Documentation Form� to aid individual identify tasks completed by attendants A checklist for use in the provision of training by the service facilitator to the EOR Updated links to resource for EORs and service facilitators

50. 50 Service Facilitation and Technical Assistance: Resources The DMAS Division of Long-Term Care recognizes the challenges of consumer direction and provides the following technical assistance to SFs: Program questions should be directed to LTC waiver staff at 804-225-4222. Authorization questions should be directed to KePRO at 1-888-827-2884. Attendant payroll questions should be directed to Public Partnerships LLC at 1-866-857-0089 for customer services.

51. 51 Service Facilitation and Technical Assistance: Resources Web-based resources: DMAS: www.dmas.virginia.gov PPL: ww.publicpartnerships.com/ vaclients.asp (username is VACLIENT; password is PCGVA67) VCU: (information on CD services & training modules): www.vcu.edu/partnership/ cdservices/index.htm KePRO: http://dmas.kepro.org

52. 52 Service Facilitation and Technical Assistance: Resources Please mark your calendars for the upcoming monthly SF telephone conferences. Contact Jacki Cahoon at DMAS at 804-225-2875 if you do not receive advance notice and instructions to call in. This is a great forum to hear program updates, ask questions, and meet your peers. July 29, 2009 � 10:30 to 11:30 August 26 � 10:30 to 11:30 September 30 � 10:30 to 11:30 October 28 � 10:30 to 11:30 November � No scheduled call December � No scheduled call

53. 53 Questions & Conclusion