Training for Case Managers

1

• Training for Case Managers
• Erika Robbins and Kim Donica
• Office of Ohio Health Plans
• Ohio Department of Job Family Services

2
Referral Process

• Referrals to Home Choice
• ODJFS 02361
• Can come from a variety of sources including
• Consumers
• Family Members
• Advocates
• Nursing Facilities
• AAAs
• CILs

3
Referral Process

• ODJFS 02361 is submitted to ODJFS Home Choice
  Intake and Care Coordination Unit (HCICCU).
• HCICCU reviews and determines which waiver would
  most appropriately meet consumers needs.
• If PASSPORT, then HCICCU sends a copy of ODJFS
  02361 along with a request for HC assessment to
  ODA.
• ODA sends referral to AAA for PASSPORT and HOME
  Choice Assessment.

4
Referral Process

• If during the course of normal business a case
  manger finds a consumer who appears eligible and
  interested in HOME Choice,
• the case manager can assist the consumer in the
  completion of the ODJFS 02361. The case manager
  can wait to submit form to the ODJFS HCICCU until
  eligibility determination is completed and
  eligibility packet is submitted.

5

• HOME Choice Eligibility Requirements
• OAC 51013-51-02

6
Eligibility

• To participate consumers must
• Reside in NF, ICF/MR or hospital for at least 6
  months
• Stay must be continuous
• Can include a combination of NF, ICF/MR or
  hospital stay
• If at time of assessment the consumer does not
  meet this requirement, but it is anticipated they
  will prior to discharge, the consumer could still
  be eligible for program.

7
Eligibility

• To participate consumers must
• Be receiving Medicaid benefits in the
  institutional setting for at least 30 days prior
  to discharge.
• Consumers may be admitted to facility under a
  different funding source and switch to Medicaid
  during the course of their stay. As long as 30
  day requirement met, consumer would meet this
  eligibility requirement.

8
Eligibility

• To participate consumers must
• Be receiving Medicaid benefits in the
  institutional setting for at least 30 days prior
  to discharge.
• If the consumer does not meet this requirement at
  the time of assessment, but it is anticipated
  that they will prior to discharge, the consumer
  could still be eligible for the program.

9
Eligibility

• To participate consumers must
• Meet an Institutional Level of Care (SLOC, ILOC,
  ICF/MR LOC)
• For purposes of HOME Choice only, ODJFS is
  presuming level of care.
• Consumers do not have to be waiver eligible in
  order to participate in program.

10
Eligibility

• To participate consumers must
• Relocate to a qualified residence
• A home owned or leased by the consumer or family
  member
• An individually leased and lockable apartment
  rented by the consumer or family member
• A community-based residential setting with no
  more than four unrelated persons

11
Eligibility

• Qualified Residence
• A community-based residential setting with no
  more than four unrelated persons.
• Adult Foster Home (AAAs)
• Adult Family Home (ODH)
• Non-ICF/MR Residential Facilities (ODMR/DD)
• Type 1 Residential Facilities (ODMH)
• Type 2 Residential Facilities (ODMH)
• Supported Living (ODMR/DD)

12
Eligibility

• Qualified Residence
• A community-based residential setting with no
  more than four unrelated persons.
• Group Home for Children
• Family Foster Home (ODJFS)
• Medically Fragile Foster Home (ODJFS)
• Pre-adoptive Infant Foster Home (ODJFS)
• Specialized Foster Home (ODJFS)
• Treatment Foster Home (ODJFS)
• HCBS Adult Foster Care (ODMR/DD)

13
Eligibility

• The case manager assess HOME choice eligibility
  at the same time they are assessing waiver
  eligibility.
• HOME Choice eligibility is determined via the
  HOME Choice Eligibility Checklist.

14
Eligibility

• HOME Choice Eligibility Checklist is fillable-can
  be completed electronically and printed.
• HOME Choice Eligibility Checklist has a section
  for each of the eligibility criteria.
• Includes a place to indicate consumers interest
  in employment.

15
Eligibility

• Home Choice is built on Ohios existing system of
  services and supports.
• HOME Choice participants will be enrolled on
  either
• One of Ohios existing HCBS programs
• or
• State Plan Services

16
Eligibility

• The case manager recommends a qualified program
  of services and supports (either waiver or state
  plan) or
• recommends denial of HOME Choice program.
• Transitions Carve-Out Waiver opened for HC
  consumers over the age of 60 who have on-going
  nursing needs that cannot be met through existing
  State Plan nursing services.

17
Eligibility

• Approval for program cannot occur until consumer
  actually is discharged from facility and moves
  into qualified residence.
• HOME Choice Participation has three distinct
  periods
• Pre-Transition Period (period of time where
  activities occur prior to moving to community)
• Demonstration Period (begins the date of
  discharge and runs 365 calendar days)
• Post-Demonstration Period (begins day 366 after
  discharge from facility)

18
Eligibility

• If consumer is ineligible for the HOME Choice
  program, the ODJFS HCICCU notifies the consumer
  in writing and issues hearing rights.
• All hearings related to the denial of HOME Choice
  are led by the ODJFS HCICCU.

19
Informed Consent

• HOME Choice Informed Consent required for all
  HOME Choice participants.
• If case manager determines consumer will be
  eligible for HOME Choice then informed consent is
  completed.

20
Informed Consent

• The case manager should review all components of
  informed consent with consumer and/or authorized
  rep and/or guardian and obtain all needed
  signatures.
• Special section that outlines guardian
  requirements.
• Guardian must report level and type of contact
  with consumer during past six months.
• Required information that must be reported to
  CMS.

21
Screening Tools

• TBI Screening Tool
• Can be used as a tool to help identify a possible
  TBI and possible need for referral.
• Brain Injury Association of Ohio is a provider of
  Transition Coordination Services.
• Tool and instructions in tool box.

22
Transition Coordination

• If a consumer appears to be eligible for the HOME
  Choice program, the case manager assists the
  consumer in choosing a Transition Coordination
  Provider.
• List of Transition Coordination Providers by
  county
• Consumer has free choice of provider

23
Transition Coordination

• Available to all HOME Choice consumers in the
  pre-transition period to help consumers plan and
  arrange for services and supports they will need
  as a result of relocating from an institution to
  the community.
• Transition Coordination is discontinued once a
  consumer moves into the community except in cases
  where housing navigation may be needed during the
  demonstration period.

24
Transition Coordination

• Includes
• Housing Navigation
• Benefits Coordination
• Assistance with Accessing Transition Services
  (goods and services)
• Linkage with community resources
• Coordinating actual physical move

25
Transition Coordination

• Once a consumer chooses a Transition Coordination
  provider, the case manager completes the HOME
  Choice Demonstration and Supplemental Service
  Plan indicating the chosen Transition
  Coordination Provider.

26
HOME Choice Service Plan

• Transition Coordination is authorized on the HOME
  Choice Demonstration and Supplemental Service
  Plan by the case manager.
• The HOME Choice Demonstration and Supplemental
  Service Plan is an electronic fillable form.
• Includes basic information such as date,
  identified need/problem, goal, intervention/action
  , units/date span and provider.
• The case manager submits the HOME Choice
  Demonstration and Supplemental Service Plan to
  the ODJFS HCICCU.

27
Eligibility Determination

• Once assessment process is complete the case
  manager submits to the ODJFS HCICCU
• ODJFS 02361 (if needed)
• HOME Choice Eligibility Checklist
• HOME Choice Informed Consent Form
• HOME Choice Demonstration and Supplemental
  Service Plan

28
Eligibility Determination

• The ODJFS HCICCU
• Reviews and enters information into the HOME
  Choice tracking system.
• Verifies Medicaid eligibility and
  institutionalization dates.
• Sends a letter notifying consumer of their
  preliminary approval for their program (pending a
  move to a qualified residence).
• Waiver administrative agency ccd on letter

29
Eligibility Determination

• The ODJFS HCICCU
• Contacts the identified TC provider and verifies
  their willingness/ability to provide transition
  coordination services to the consumer.
• Authorizes the payment of the first deliverable
  to the Transition Coordination provider.
• Notifies the case manager of the TC providers
  acceptance of referral and initiation of TC
  services.

30
Pre-Transition Activities

• During the consumers pre-transition phase the
  case manager
• Schedules and leads team meetings for the
  purposes of discharge planning.
• Works to identify post discharge services and
  supports and develops a service plan.
• Coordinates activities and consumers discharge
  date with the transition coordinator.

31
Pre-Transition Activities

• During the consumers pre-transition phase the
  case manager
• Assists the consumer with securing service
  providers.
• Authorizes goods and services on the HOME Choice
  Demonstration and Supplemental Service Plan as
  needed.
• Submits the request for the Quality of Life
  Survey to the ODJFS HCICCU at least two weeks
  prior to consumers discharge.

32
Enrollment

• The case manager completes the HOME Choice
  Enrollment Form once the consumer is actually
  discharged from the facility.
• Information regarding qualified residence is
  obtained from the transition coordinator.

33
Enrollment

• The completed HOME Choice Enrollment Form is
  submitted to the ODJFS HCICCU as soon as consumer
  moves from the facility to the community.

34
Enrollment

• The ODJFS HCICCU
• Reviews the HC Enrollment Form and enters
  information into the HC tracking system.
• Verifies Medicaid eligibility and
  institutionalization dates.
• If at this time consumer has not met either the
  30 days of Medicaid requirement or the 6 months
  institutional stay they will be denied HOME
  Choice enrollment.

35
Enrollment

• The ODJFS HCICCU
• Notifies the consumer and the state waiver
  administrative agency in writing of consumers
  enrollment on HOME Choice.
• Starts the 365 Demonstration Period clock.

36
Enrollment

• Consumer is enrolled on PASSPORT and HOME Choice
  and services begin.

37

• Questions?

38

• HOME Choice
• Services and Supports
• OAC 51013-51-04

39
Services

• Three Categories of Services
• Qualified Services
• Demonstration Services
• Supplemental Services

40
Services

• Qualified Services
• Existing waiver and state plan services
• Available during the both the demonstration and
  post demonstration periods.
• Eligible for enhanced federal match.

41
Services

• Demonstration Services
• Available only during the 365 day demonstration
  period (except for transition services i.e. goods
  and services that can be accessed during the
  pre-transition phase).
• Eligible for enhanced federal match.
• Authorized on the HOME Choice Demonstration and
  Supplemental Service Plan.

42
Services

• Demonstration Services
• PASSPORT Consumers may receive certain HOME
  Choice Demonstration Services including
• HOME Choice Nursing
• Independent Living Skills Training
• Community Support Coach

43
Services

• Demonstration Services
• HOME Choice Nursing
• Defined at intermittent nursing in amounts
  greater than what is available via the state plan
  (intermittent nursing 14 hours).

44
Services

• Demonstration Services
• HOME Choice Nursing
• Can receive up to 44 hours a month.
• Providers include MCHHA, other accredited
  agencies and non-agency nurses
• Must have existing provider agreement and sign a
  HOME Choice provider addendum.

45
Services

• Demonstration Services
• Independent Living Skills Training
• Training focused on
• Financial Management Skills
• Social Skills Development
• Health Management Skills
• Home Management Skills
• Personal Skills
• Community Living Skills

46
Services

• Demonstration Services
• Independent Living Skills Training
• Can receive up to 144 hours during the 365-day
  demonstration period (in individual, group or
  classroom setting).
• New service-providers could include CILs,
  mental health providers.
• Must be approved by ODJFS

47
Services

• Demonstration Services
• Community Support Coach
• An individual who provides guidance, education
  and works to empower the consumer, authorized
  representative and family members.

48
Services

• Demonstration Services
• Community Support Coach shall assist the consumer
  in
• Making informed independent decisions
• Setting and achieving short and long term goals
• Identifying options and problem solving
• Managing multiple tasks

49
Services

• Demonstration Services
• Community Support Coach
• Can receive up to 72 hours during the 365-day
  demonstration period
• New Service-Providers can be either agencies or
  non-agency providers
• Must be approved by ODJFS

50
Services

• Supplemental Services
• For PASSPORT consumers these include
  Service Animals
• Communication Aids
• Transition Coordination
• Available only during the 365 day demonstration
  period (except for Transition Coordination)

51
Services

• Supplemental Services
• Service Animals
• May include but are not limited to
• Seeing eye dogs
• Hearing dogs
• Service monkeys

52
Services

• Supplemental Services
• Service Animals
• Includes
• First years costs associated with the raising of
  the animal
• Housing, feeding, upkeep and medical care of the
  animal during training
• Actual training of the animal, student training,
  and related transportation, room/board and
  administrative activities
• Equipment and Supplies

53
Services

• Supplemental Services
• Service Animals
• Providers are existing service animal providers
  who sign a HOME Choice provider addendum
• Up to 8,000 ----one time maximum

54
Services

• Supplemental Services
• Communication Aides
• Includes
• Augmentative Communication Devices or Systems
• Computers and Computer Equipment
• Other Mechanical and electronic Devices
• Cable and Internet Access
• Cost of Installation, Repair, Maintenance and
  Support of Any Covered Communication Aide

55
Services

• Supplemental Services
• Communication Aides
• Providers could be existing DME providers who
  sign HOME Choice addendum
• Up to 5,000----one time maximum

56
Services

• A list of eligible providers for each
  demonstration and supplemental service will be
  provided at later date.

57
Service Planning

• The case manager determines the type and amount
  of demonstration and supplemental services that
  are needed.
• All HOME Choice Demonstration and Supplemental
  Services must be authorized by the case manager
  on the HOME Choice Demonstration and Supplemental
  Service Plan.

58
Service Planning

• The HOME Choice Demonstration and Supplemental
  Service Plan must be sent by the case manager to
  the ODJFS HCICCU.
• THE HCICCU then forwards the HOME Choice
  Demonstration and Supplemental Service Plan to
  the FMS.
• The provider submits claims to the FMS and the
  FMS pays the provider.

59
Service Planning

• Service Planning Considerations
• Demonstration and Supplemental Services are time
  limited.
• Case Manager needs to consider the consumer's
  ability to maintain service animal or
  communication device such as a computer prior to
  authorizing service.

60
Service Planning

• If the case manager determines that it is not
  medically necessary for a consumer to receive a
  requested demonstration or supplemental service
  it is appropriate for the case manager to deny
  the request.
• Notice of denial of service and hearing rights
  must be sent to the consumer.

61
Service Planning

• Information regarding denials of HOME Choice
  Demonstration and Supplemental Services and
  hearing information related to such denials must
  be tracked and reported to ODJFS.

62

• Questions?

63

• Case Manager Responsibilities

64
Incident Reporting

• The case manager educates the consumer and/or
  family about PASSPORTs incident reporting
  measures.
• Providers of HOME Choice services must adhere to
  PASSPORTs incident reporting procedures.

65
Back-Up Plans

• In addition to typical back-up planning CMS
  requires specific elements in consumer back up
  plans.
• These include
• Transportation
• Direct Service Workers
• Repair and Replacement of needed equipment

66
Complaints

• Complaints about HOME Choice program from
  consumers and family members must be tracked and
  reported.
• This includes specific complaints about the
  failure of back-up systems.

67
Change in Status

• It is the case mangers responsibility to notify
  the ODJFS HCICCU of a change in the consumers
  status.
• Changes should be communicated in a timely
  manner.
• Change in status is communicated via the HOME
  Choice Change in Status Form.

68
Change in Status

• Changes that require reporting include
• Move to a new qualified residence
• Includes type of qualified residence and type of
  housing assistance received, if applicable.

69
Change in Status

• Changes that require reporting include
• Institutionalization
• Includes admissions to hospital or NF.
• Must report admission and discharge dates.
• 365 Demonstration Period clock stops while in
  hospital or NF. Clock resumes upon discharge.

70
Change in Status

• Changes that require reporting include
• Disenrollment from HOME Choice
• Due to
• permanent placement in NF
• move to unqualified residence
• voluntary withdraw
• death
• completion of demonstration period

71
Disenrollment

• If consumer is in hospital or NF for longer than
  60 days they will be dis-enrolled from HOME
  Choice.
• If after discharge, the consumer has time and
  services left in their demonstration period they
  may re-enroll in HOME Choice.

72
Disenrollment

• All disenrollment notices and applicable hearing
  rights will be generated from the ODJFS HCICCU.
• The ODJFS HCICCU will lead all hearings related
  to disenrollments from HOME Choice.

73
Post Demonstration Planning

• 90 days prior to the end of the demonstration
  period the ODJFS HCICCU will send the consumer
  and the waiver administrative agency a letter
  notifying them of the upcoming end of the
  demonstration period.

74
Post Demonstration Period

• The case manager should discuss with the consumer
  their service needs and adjust service plans as
  needed to address the end of the demonstration
  period.
• The case manager should assist the consumer with
  community referrals, if needed, to help
  compensate for the loss of the demonstration/suppl
  emental services.

75
Tool Box

• Includes
• CM step-by-step process flow
• Copies of all required forms
• OAC Rules
• Transition Coordination Maps and Contact Info
• ODJFS Contact Info
• Other Important Resource Information

76

• Questions?

77
Next Steps

• ODA conducts training of PAA Staff
• ODJFS forms fiscal management and program
  management groups to begin meeting post
  implementation-Need ODA reps
• What do you need from us?

78

• Thanks!