SA/IH Case Management: An In-Depth Look

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SA/IH Case Management An In-Depth Look

• Presented By
• NC Division of Aging and Adult Services
• Adult Services Section
• Adult Programs Representatives

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Objectives for This Workshop

• Understand the SA/IH Case management process
• Understand the importance of good communication
  between Eligibility and Services
• Review the Adult Services Functional Assessment
• Review the SA/IH Economic Assessment Worksheet
• Create a Service plan
• Complete a Transmittal

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Objectives for This Workshop

• Review budgeting and uses of the SA/IH payment
• Discuss reassessments/continued need for
• SA/IH and services
• What to do when the client is no longer eligible
  for SA/IH Notices and Hearings
• Discuss Wait Lists
• Review SA/IH Payment Tracking Tool

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What is the SA In Home Program?

• The State/County Special Assistance In-Home
  Program for Adults (SA/IH) provides a cash
  supplement to help low-income individuals, who
  are at risk of entering an Adult Care Home, to
  remain at home safely
• The payments are intended to help maintain the
  individuals health and safety while remaining in
  the community

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History

• September 2000
• Demonstration project with 400 slots
• 22 participating DSSs
• In 2003
• The General Assembly approved 800 slots total
  through June 2005
• 61 participating DSSs
• 2005
• 1000 slots were authorized
• Payment amount increased from 50 to 75 of
  payment for ACH

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History

• Legislation in 2007
• Established SA/IH as a permanent program under
  General Statutes
• Allowed the caseload to expand up to 15 of the
  total statewide SA caseload 108A-47.1.
• DSSs continue to participate voluntarily
• Ninety-one counties had slots assigned

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History

• 2012 Legislation SL 2012-142
• The monthly payment to individuals enrolled in
  the SA/IH program was increased to 100 of the
  monthly payment an individual would receive if
  they resided in an ACH.
• SA/IH Program requires all DSSs to participate
• Participating DSS must maintain at a minimum,
  average number of cases from SFY 2011-2012.
• DSS with assigned slots and no active cases must
  begin participating effective February 15, 2013,
  by filling all their assigned slots

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History

• 2012 Legislation SL 2012-142
• A DSS with no established slots must begin
  participating, effective February 15, 2013. DAAS
  has recommended the slot numbers for these
  counties.
• Allows the Department of Health and Human
  Services to waive the 15 cap on slots on or
  after February 15, 2013
• Changes are implemented within the current
  authorized budget for 2012-2013 (same as
  2011-2012)

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Developing the SA/IH Program

• Outreach
• Educate Community Partners
• Expand the program - If all of a countys
  allotted slots are filled, and the county has
  decided not to request additional slots, this
  should be discussed with the Adult Programs
  Representative prior to initiating a waiting list

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US Department of Justice (DOJ) Compliant

• The complaint cited an institutional bias where
  People who enter an ACH or other type of
  facility can obtain certain financial assistance,
  services, and supports that are not equally
  available to people with similar levels of
  disability and financial need who choose to
  remain in their own homes.
• The States failure to redirect resources and
  its failure to prioritize community-based setting
  over institutional care has confined thousands of
  people with mental illness unnecessarily and
  indefinitely in adult care homes and puts many
  others at risk of unnecessary institutionalization
  .

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US DOJ Specifically regarding Special Assistance

• Instead of allocating resources to
  community-based settings, the State has opted to
  fund a substantial portion of the cost of
  providing care in adult care homes. Through its
  State-County Special Assistance Program, NC
  subsidizes the cost for individuals with
  disabilities to live in adult care homes...Aside
  from limited circumstances, the State has not
  made this supplement available to persons with
  disabilities living in the community.

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Transitions to Community Living Initiative
(formerly US DOJ)

• The US DOJ Settlement Agreement between NC and
  the US DOJ is now referred to as the Transitions
  to Community Living Initiative
• Eligible individuals will receive Supported
  Housing Slots which provide rental subsidies for
  community-based supported housing and transition
  and tenancy support
• The SA-IH Program has been identified as a
  valuable resource for these individuals if they
  are determined to be eligible for the program

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Transitions to Community Living Initiative
(formally DOJ), cont

• A DAAS staff member will notify the DSS Adult
  Services Supervisor in the county of SA/Medicaid
  eligibility and in the county which the
  individual is interested in moving to verify that
  a Supported Housing Slot has been assigned by
  DHHS
• DSS is responsible for SA eligibility
  determination and assignment of the SA/IH slot
  number

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Transitions to Community Living Initiative
(formally DOJ), cont

• These individuals cannot be placed on the SA-IH
  waiting list
• If these individuals apply and are determined
  eligible for SA/IH, the LME is responsible for
  the ongoing case management
• Refer to DAAS Administrative Letter 13-07

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Open Lines of Communication Are KEY to a
successful SA/In-Home Program
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Communication between Eligibility and Services
must include

• Determination that the client meets all
  eligibility criteria
• Determination that the clients needs can be met
  safely at home after completing the functional
  assessment
• Amount of the SA/IH payment
• Redeterminations and changes in situation
• Status of SA/IH slot availability

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Communication, continued.

• Status of the waiting list
• Income Maintenance Caseworker (IMC) will
  communicate the maximum SA/IH payment
• Case Manager will communicate the SA/IH payment
  authorized based on the needs of the client
• The SA/IH Program Interagency Transmittal form
  will be used by social workers as the
  communication tool

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Tools to guide the Case Manager through the
process

• SA/IH Flow Chartoutlines the referral process
• SA/IH Case Managers Checklistexcellent tool for
  organization and to assure critical time limits
  are met

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Referral and Screening

• Referrals may come either through Eligibility or
  Services. One should communicate to the other
  that a referral has been received
• If the IMC determines a client is potentially
  eligible, communicate with the case manager so
  the Adult Services Functional Assessment can
  begin
• Complete the SA/IH Pre-Screening Form

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Referral and Screening

• Referral to the case manager must include the
  Slot authorization number and EIS ID number
• A staff member must be designated to maintain and
  distribute slot authorization numbers (can be
  eligibility or services)
• The designated staff member must communicate the
  ongoing status of available slots to both
  services and IMC staff

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Referral and Screening

• Case manager initiates the Adult Services
  Functional Assessment within 10 workdays of the
  referral from the IMC
• IMC continues to process SA application

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SA/IH Eligibility Criteria

• Client is at least 18 years old.
• Client is eligible for Medicaid as a
  categorically needy aged, blind, or disabled
  individual
• Needs ACH level of care and lives in, or desires
  to live in a private living arrangement
• Requests SA/IH payments and services at home in
  order to remain there safely
• With appropriate services and the SA/IH payment
  he/she can have his/her health, safety and
  well-being maintained at home

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Eligibility Process

• IMC determines SA benefits eligibility and
  communicates that decision to the case manager
• Case manager determines the need for the program
  using the Adult Services Functional Assessment
  and the SA/IH Economic Assessment Worksheet
• Final determination of the payment is made by the
  case manager and communicated to the IMC
• All communication between the SA IMC the adult
  services case manager should be documented on the
  SA/IH Program Interagency Transmittal Form

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SA In-Home and SA Program Eligibility
Comparisons
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SA In-Home SA Program Eligibility and
Budgeting Comparisons
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Eligibility for OtherBenefits SA-5400

• SA/IH is a non-countable benefit for the
  following programs
• Supplemental Security Income (SSI)
• Medicaid
• Subsidized housing (HUD Section 8) and other
  federal housing programs

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Eligibility for Other Benefits

• SA/IH is a countable benefit for the following
  programs
• Food Stamps
• LIEAP

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Case Managers Role

• Advocate
• For the clients
• For the Program
• Gatekeeper
• Communicate
• Educate
• Prioritize

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IMC Role

• Source of referrals for potential recipients
• Determination of SA/IH financial eligibility
• Communicate approvals/denials/changes/
• redetermination of eligibility to the Adult
  Services case manager
• Communicate changes in
  payment to the client

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How Do Counties Pay for the Case Management
Related to SA/IH?

• Social Services Block Grant
• Some activities related to medical and mental
  health services may be reimbursed using Medicaid
  Administrative Claiming

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Case Management Process

• Assessing
• Service Planning
• Monitoring/follow up
• Ongoing contacts
• Reassessing (quarterly, annually)

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Assessment

• Must begin within 10 workdays of SA/IH IMC
  referral
• 30 days to complete assessment
• Adult Services Functional Assessment (DAAS-6220)
  is used
• Must include the Economic Assessment Worksheet to
  determine financial need and SA/IH payment

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Assessment

• Needs to indicate how the client meets the target
  population and is eligible for the service
• The assessment and economic worksheet will
  identify needs that will be included in the
  service plan

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What is the purpose of the Economic Worksheet?

• Identifies sources of income
• Indicates how income is being used
• Reveals a surplus or deficit
• Helps identify unmet needs

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Completing the Economic Assessment

• The SA/IH payment benefit is to be used for those
  health, safety, and basic needs that will allow
  an individual to remain safely in their home as
  opposed to residing in a residential care facility

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Calculating the Budget

• Observe the following principles
• Explore regular monthly expenses expenditures
• Do not arbitrarily divide monthly household bills
  by the number of adults living in the household
• Explore unusual expenses reported by the client
• Example a client reports 150.00 allowance for
  clothing. Consider if this is a one-time need
• Note As of 7/1/15 FNS benefits cannot be
  counted as income or a resource

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Calculating the Budget, cont

• Remember the client is entitled to a personal
  needs allowance of 66.00 to purchase items
  outside of basic needs, i.e. cigarettes, cable,
  pet food (if it is a therapeutic animal, that can
  be calculated as part of a need) etc.
• If the expenses reported by the client exceed
  his/her income when combined with the maximum
  allowable SA/IH payment, the client may not be
  able to remain safely at home
• Reasonable expenses should be viewed in terms of
  the clients particular circumstances

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Uses of the SA/IH Payment

• The SA/IH Payment should be used to help the
  individual remain in the community by focusing on
  the following
• Health/Medical
• Safety
• Basic Needs

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Uses of the SA/IH Payment (Medical/Health)

• Payments for health needs include items that are
  not covered by Medicaid or other health insurance
  or funding source but are recommended by the
  health care provider(s). These are services or
  items that the client needs to maintain or
  improve his/her health and mental health
  functioning

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Uses of the SA/IH Payment (Medical/Health)

• Medications including OTC recommended by the
  physician
• Co-payments for prescriptions physician visits
• Nutritional Supplements
• Incontinence supplies
• Durable medical equipment
• Additional PCS hours and/or IHAS

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Uses of the SA/IH Payment

• Transportation to medical appointments
• Mental Health Treatment and Services
• Dental and Eye Care
• Adult Day Services

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Uses of the SA/IH Payment (Safety)

• Safety needs are related to those items and
  services that will enable the client to be safe
  in his/her environment. Please note that the
  client does not have to own his/her home for
  these items or services to be purchased. Please
  check the rental agreement to see what the
  landlord is legally responsible for providing.
  The client should also obtain permission for any
  adaptations for items not covered by the lease.

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Uses of the SA/IH Payment (Safety)

• Safety items may include the following
• Home Repairs or modifications necessary to
  maintain safety
• Essential technology for communications
  (lifeline, telephone systems)
• Smoke Detectors
• Extermination Services for rodents and insects
• Home alarms

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Uses of the SA/IH Payment (Safety)

• Annual inspections related to air and heating or
  other safety inspections
• Cleaning services
• Repair or replace damaged appliances
• Environmental factors related to safety i.e.
  scatter rugs, outlets

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Uses of the SA/IH Payment(Basic Needs)

• Basic needs are those items or services that help
  ensure the overall well-being of the client is
  maintained

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Uses of the SA/IH Payment (Basic Needs)

• Rental or mortgage payments
• Essential furnishing
• Appliances
• Utilities
• Food
• Essential clothing

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Uses of the SAIH Payment (Basic Needs, cont.)

• Cleaning supplies
• Personal care items
• Property Taxes
• Pre-Need burial

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Priority of SA/IH Payment

• Ensuring that the Health and Safety needs of the
  client are met is the first priority of the SA/IH
  payment
• The SW should always try to link the client to
  community resources that the adult is eligible to
  receive but may not be knowledgeable about
  (Medicaid transportation, volunteer services,
  discounted telephone services, HUD etc.)
• The SA/IH payment is not intended to replace or
  duplicate services and resources already
  available to the client

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Things to Consider

• What are the health/safety issues that are not
  currently being addressed?
• How will the SA/IH payment be used to help
  address these concerns/issues?
• Are there services that the client is eligible
  for but they have not been linked to?
• How were needs being met prior to the SA/IH
  payment?

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Completion of the Assessment Process

• SW and client identify priorities from the
  Functional Assessment and the Economic Assessment
  Worksheet
• SW and client develop a service plan together

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Service Plan (DSS-6221)

• The service plan should identify problems/needs
  from the assessment
• Goals should be developed to address identified
  needs
• List activities necessary to meet the goals
• Identify persons responsible for carrying out
  goals/activities
• Plan must include specific target dates

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Service Plan

• Must include case management services provided
• Must include the amount of the payment and how
  the payment is being used
• Must be signed by the CM, client or their
  representative within 7 days after authorization
  of SA/IH payment by CM
• Needs to be reviewed at least quarterly
• Must be revised and updated as the clients needs
  change
• New service plan must be completed at least
  annually or as needed and signed by the client
  and CM

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Goal Planning

• GOALS SHOULD BE SMART
• Specific
• Measurable
• Achievable
• Realistic
• Time limited

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Case Management Activities

• Regularly review the service plan with the client
• Communicate to the client how the SA/IH payment
  is to be used
• Monitor to assure that the SA/IH payment is being
  used appropriately
• For large projects or items encourage
  client/family to obtain estimates
• Link client to available services in the
  community

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Case Management Activities

• Help the client establish payment plans, if
  needed
• Regularly discuss with the client progress in
  meeting goals
• Continue to assess and document how the SA/IH
  program is helping the client remain safely at
  home
• Ask for receipts, when necessary, if there is
  concern regarding how the money is being spent

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Case Management Activities

• Monitor to assure that all service needs are
  being met, not just financial needs
• Monitor to assure that the services and payment
  that are put in place are adequate in meeting the
  clients health, safety and basic needs

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Case Management Activities

• Follow up with all persons identified in the
  service plan to assure that clients needs are
  being met
• Document and address any concerns related to
  service delivery
• Document how you, as the case manager, and the
  client will address the concerns/issues related
  to clients resistance or non-compliance with the
  service plan

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How has SA/IH helped people remain in the
community?

• A 62 year old woman with a diagnosis of formal
  thought disorder diabetes, COPD, osteoarthritis
  and with limited ability to make decisions
• She lives in a rent-subsidized apartment
• She has some support from sister
• Receives Medicaid PCS during week
• SA/IH pays privately for weekend help provided by
  same aide who assists during the week
• Also pays for monthly Lifeline service and
  household furnishings

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How has SA/IH helped people remain in the
community?

• This gentleman is 58 years old and has mild
  mental retardation and traumatic brain injury
• He came to the attention of the Program as an APS
  report. His previous rep. payees were exploiting
  him. He did not have heat or food and was living
  in substandard housing. He was determined to be
  eligible for the SA/IH Program
• The SA/IH funds helped to pay moving expenses
  into an improved trailer, helped pay to
  demolish/haul off the old trailer and assisted
  with providing furniture and appliances for the
  new trailer

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Case Continued

• With the help of SA/IH, he was able to pay back
  property tax bills and install a telephone for
  safety reasons. He also needed clothes and
  household items that SA/IH funds have helped him
  afford
• He now lives in safe and adequate housing
• This is a successful example of a person who
  benefited from SA/IH funds and was able to
  maintain an independent living status as a result
  of the SA/IH program

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Ongoing Case Management Monitoring

• Monthly contacts At least monthly, contact the
  client, appropriate family members and service
  providers to review the provision of payments and
  services
• Quarterly Reviews - Must be done in person to
  review the provision of service and utilization
  of the payment
• Annual Reassessment must also be done
  in person.

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Annual Reassessment Process

• Complete the Adult Services Annual Assessment
  (DAAS-6224) and Economic Worksheet
• IMC will inform the client of what is needed for
  eligibility redetermination
• FL-2 form which reflects domiciliary level of
  care must be current (within 90 days)
• Social Worker should be prepared to assist the
  client to obtain necessary information

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Annual Reassessment Process

• Advise IMC of continued eligibility decision on
  the Interagency Transmittal Form
• IMC should send any required notices to the
  client as appropriate or needed
• Social Worker should complete a new service plan
  before the anniversary date

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Changes in Situation

• After a hospital or Nursing Home stay, the
  recipients needs may have changed - make sure
  that the FL-2 is still appropriate for SA/IH
• If not, SA/IH must be terminated
• If still appropriate, make any changes to the
  assessment and service plan as needed
• SA/IH must be terminated when an absence is over
  30 days

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Changes in Situations

• The Case Manager and IMC must communicate with
  each other if it is determined that the client
  has been incarcerated
• If it is determined that the client has been
  incarcerated, the termination process for SA/IH
  payments should begin (SA-3310, III.B.5)

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Denials and Terminations

• Financially ineligible/not eligible for Medicaid
• No Need for SA/IH Payment or Services
• Failure to meet programmatic qualifications
• Death
• Absence of over 30 days
• Move out of county or state
• Client voluntarily withdraws
• Clients safety, health and well-being cannot be
  maintained at home
• Incarceration

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Waiting Lists for SA/IH

• When all SA/IH slots are filled and the county
  has decided not to request additional slots, a
  client has the option of making an application
  (which will be denied) or have their name placed
  on a waiting list (inquiry list is not an option
  for SA/IH)
• In either case, refer client for other services
• The exception is Transitions to Community Living
  Initiative clients - TCLI clients cannot be
  placed on a waiting list (If all slots are
  filled a county must request a slot)

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Waiting Lists for SA/IH

• Each county DSS must designate a staff person to
  be responsible for maintaining the waiting list.
  The purpose of the waiting list is to make the
  SA/IH slots available on a first come, first
  serve basis
• Waiting list policy requires that the
  individuals placed on a waiting list be contacted
  at least every 90 days regarding their status.
  If no slots are available they must be given the
  option to remain on the list or be removed

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Waiting Lists for SA/IH, cont.

• Be sure the individual understands that this
  contact does not constitute an application, and
  that they or their representative must make an
  application
• Document on the waiting list if an applicant on
  the waiting list chooses not to wait for a slot
  and/or enters an ACH

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Establishing a Waiting List

• Counties that wish to increase their current
  number of slots should request additional slots
  prior to filling all assigned slots in order to
  avoid having to use a waiting list
• If it is decided that a waiting list is
  appropriate, individuals may request to be placed
  on a waiting list. Appendix C in the SA/IH Case
  Management 5600 Manual is the waiting list form
  for SA/IH and instructions for completing the
  waiting list form. Use of this SA/IH Waiting List
  form will ensure that consistent information is
  obtained

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Maintaining the Waiting List

• Please use and maintain this waiting list in
  accordance with the Requirements
  for Provision of Services Manual,
  Section VI Prompt Provision
  of Services

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Required SA/IH Reporting

• Reports are now completed via a web-based SA/IH
  Payment Tracking Tool
• Case managers are required to complete the tool
  monthly
• Completion of the tool is required by the 5th day
  following the payment month
• SA/IH Payment Tracking Tool Site
• https//saihpay.dhhs.state.nc.us

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SAIH Tracking Tool Client List
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SA/IH Payment Tracking Tool

• The Payment Tracking Tool provides categories
  under which to report to DAAS how the SA/IH
  payment is spent
• This web-based tool allows your agency to
  document and gather information about uses and
  amounts of the SA/IH payment and to generate
  statistical reports based on the data entered

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SAIH Tracking Tool Expense Services
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Client Expense Service Detail Report
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Programmatic Monitoring for SA/IH

• SA/IH monitoring will follow the 4-year
  monitoring cycle that is currently in place
• The SA/IH Monitoring tools will be used in
  conjunction with other current monitoring tools
• Scoring on the tools is by element just like on
  the SSBG Tool
• A score of 70 or lower will require a Corrective
  Action Plan to be developed
• A final monitoring report will be sent to each
  county once monitoring is completed

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Monitoring Sample-SA/IH Program

• For a Level I County, 5 cases
• For a Level II County, 7 cases
• For a Level III County, 10 cases
• Cases identified for this sample may also be
  cases identified in other programmatic monitoring
  samples. If so, multiple monitoring tools will
  be used on the same case
• A list of Sample Cases will be sent to the agency
  10 work days prior to the monitoring visit

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APR Listserv - DAAS Dear County Director Letter
AFS 09-2012

• The APRs now have a listserv for questions
  DAAS.AdultServices_at_dhhs.nc.gov
• Expect a response within 2 business days for
  questions that are not time-sensitive
• Time-sensitive questions, such as APS, or
  requests for technical assistance will be handled
  accordingly

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Questions????
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Thanks for coming!!