Medical Assistance Home Care Ratings of EN, MT, CS

Transcription

1 # Bulletin June 7, 2002 Minnesota Department of Human Services # 444 Lafayette Rd. # St. Paul, MN OF INTEREST TO! County Directors! County Social Service Supervisors! Public Health Nursing! Contracted Health Plans! Administrative Contacts: LTCC, AC/EW, CAC, CADI, TBIW, DD! Personal Care Provider Organizations! PCA Choice Providers! Home Health Agencies Medical Assistance Home Care Ratings of EN, MT, CS TOPIC Information about the Medical Assistance Home Care Rating Decision Tree. PURPOSE This bulletin provides information about the EN, MT, and CS Home Care Ratings and how to access these ratings. Attachment A provides guidelines for assessing consumers with mental illness for PCA services. CONTACT Mickey Ellis mickey.ellis@state.mn.us For TTY, contact Minnesota Relay Service at 1 (800) ACTION Please read. EFFECTIVE DATE May 1, 2002 Minnesota Department of Human Services Community Supports for Minnesotans with Disabilities (CSMD) 444 Lafayette Road North St. Paul, Minnesota SIGNED MARIA R. GÓMEZ Assistant Commissioner Continuing Care

2 Bulletin # June 7, 2002 Page 2 BACKGROUND The Medical Assistance (MA) Home Care Rating Decision Tree is a tool used to assign a care rating and a dollar cap to each consumer eligible for services. There is one tool for use with the MA Personal Care Assistant Program (PCA) and another for use with Private Duty Nursing Services (PDN). The EN category is found on both the PCA and PDN tool. The MT and CS categories are found only on the PCA decision tree. This bulletin will provide clear criteria and directions to access these home care ratings. A copy of the Decision Tree can be found in Attachment C. The goal of the Options Initiative is to strengthen home and community based services so that people with disabilities can choose alternatives to institutions. Consumers will benefit with the added support and choices for community services. Service coordinators will have more options available for the consumer to assure health and safety as the community support plan is developed. Prepaid Health Plans Some consumers receive their MA benefits through prepaid health plans. Prepaid health plans are responsible to provide the MA package of covered home care services. In these situations, all required documentation for authorization of services should be submitted to the appropriate health plan rather than to DHS. Prepaid health plan enrollment should be verified through the EVS system. Contact the prepaid health plan for information on which home care providers are in the health plan s provider network. EN HOME CARE RATING The EN Home Care Rating is a category assessed and assigned to consumers who meet the criteria for being vent-dependent. The individual receives mechanical ventilation for at least six hours per day and is expected to be or has been dependent for at least 30 consecutive days. Different types of mechanical equipment for the purpose to replace or augment normal respiration may provide mechanical ventilation. ASSESSMENT TO DETERMINE EN HOME CARE RATING Private Duty Nursing (PDN) Services A registered nurse (RN) completes the assessment for PDN services. The PDN Assessment Form with directions is available in DHS Bulletin # The RN may be one of the following: (1) a home health care agency nurse; (2) an independent MA enrolled RN; or (3) a RN providing assessments for an independent MA enrolled LPN. The MA Home Care PDN Assessment form along with the other required documentation is completed and submitted to DHS for authorization. Vent-dependent status is indicated on the form. If there is a combination of home care services, the nurse may need to coordinate with other service providers.

3 Bulletin # June 7, 2002 Page 3 Personal Care Assistant (PCA) Services The county PHN completes the assessment for PCA services using the MA Home Care Assessment Form and Service Plan. If the consumer is eligible, the PHN will indicate the EN Home Care rating and document other home care services such as PDN. Health and safety with use of PCA services for the vent-dependent consumer must be assessed and approved including information about the ability of the consumer to direct his/her own cares, the need for a responsible party, the number of hours requested, training for the PCA and other identified factors. DHS AUTHORIZATION The PDN and/or PCA assessments are to be sent to DHS according to the process described in the MN Health Care Programs Provider Manual, Chapter 24. Authorization of PCA services is based on the recommendation of the public health nurse assessment. Any assessments utilizing a combination of services will be reviewed and authorized by nurses from Care Delivery Management Inc. (CDMI). The county PHN or home care nurse may be called for additional information about the assessment and request. Authorization results are communicated to the consumer and provider(s) per MMIS service agreement letters. MT HOME CARE RATING The MT Home Care Rating is a category assessed and assigned to consumers determined to be at the level of care provided in a regional treatment center (RTC). The monthly dollar cap is available to provide home care services in the community. The expected outcome for the consumer will be to stabilize the medical and mental health condition, improve functioning, maintain safety, and strengthen family and community support. This rating can be authorized for consumers upon discharge from a RTC or who are residing in the community. Consumers, who meet the RTC level of care criteria, are at risk due to the acuity, severity, and intensity of s and care needs. They have a demonstrated need for structure, medication, supervision, observation, redirection, and intervention on a daily basis. Immediate crisis intervention is a part of the consumer s support plan. Without these in place, the person is at risk of frequent institutionalization. Past history will reveal admissions to psychiatric hospitals or other secure institutions; unsuccessful community living; and a psychiatric diagnosis and treatment. The consumer may have more than one diagnosis. It is expected that consumers will have mental health case management available with responsibilities for the coordination of services including specifics such as appropriate housing, staffing ratios, scheduling of daily activities, medical care, socialization, work opportunities, and other services. The consumer and mental health case manager along with other service providers work together to identify needs, activities and determine health and safety outcomes. It is the responsibility of the mental health case manager to provide

4 Bulletin # June 7, 2002 Page 4 the required documentation to the PHN for completion of the PCA Assessment. Home Care service is one part of a larger plan for community support with the county PHN responsible for the tasks noted in the next section. PHN ROLE IS DETERMINING MT HOME CARE RATING What is the same for the PHN? The county PHN is responsible for completing the assessment for PCA services using the MA Home Care Assessment Tool and Service Plan. The assessment can be completed while the consumer is in the institution or in the community setting. The county PHN uses the current MA Home Care Assessment Tool and Service Plan. The county PHN collects data to complete the assessment tool for recommendation of the home care rating and units of service to DHS. There is no requirement for the PHN to provide ongoing coordination for the service team. What is different for the PHN? The PHN will need to request from the case manager the following required documentation before the initial assessment or request for a 45-day Temporary Start of Service: % Overview of person s past history, including hospitalizations and past community settings and; % Diagnostic assessment information and; % Functional assessment data and; % Individual Community Support Plan(ICSP) for an adult or, for children, an Individual Family Community Support Plan (IFCSP) ; and % If available, an Individual Treatment Plan (ITP) for adults. This documentation must be completed or updated within the past 90 days and reflect the consumer s identified needs for support, treatment, and assistance in the community. The PHN may obtain some of the direct care assessment data from the case manager who knows the consumer and his/her needs The PHN may decide to authorize a 45-day Temporary Start of Service for efficient discharge from the institution and follow up with the face to face assessment in the community setting during the first 45 days. (This gives the consumer and the service providers an opportunity to evaluate the support plan and make changes as needed.)

5 Bulletin # June 7, 2002 Page 5 The PHN may request to have service providers available during the face to face assessment to ensure comprehensive assessment data. It is recommended the PHN refer to the Attachment A for guidelines on assessing and assigning time when completing assessments for consumers with mental illness. Once the assessment is completed the PHN will send to DHS copies of the required documentation to substantiate the need for the MT Home Care Rating along with the MA Home Care Assessment and Service Plan. Send to: Department of Human Services MA Home Care 444 Lafayette Rd. North St. Paul, MN An annual face-to-face assessment with an updated ICSP or IFCSP (within the past 180 days) is required to continue PCA services. An updated ITP may also be available. DHS ROLE IN THE MT HOME CARE RATING DHS MA Home Care Program staff are available to provide technical assistance to county PHNs and service providers. Once the assessment with documentation is submitted to DHS for review the following process is completed: 1. Health Claims Operations(HCO) sends assessment/documentation to DHS representative to review 2. Review is completed with authorization approved or denied. 3. HCO is notified and the appropriate MMIS entry is completed. 4. The consumer and provider are notified via mail per the usual MMIS communication. CS HOME CARE RATING The CS Home Care Rating allows a monthly dollar cap for home care services to be based on the amount Medical Assistance would reimburse for a Nursing Care Facility (NF) or Intermediate Care Facility (ICF/MR). Consumer eligibility for the CS Home Care Rating requires the level of care provided in a NF or ICF/MR. The consumer has medically necessary care needs that cannot be met by a HCBS Waiver or the Home Care Ratings of ZZ or ZC or CB.

6 Bulletin # June 7, 2002 Page 6 COUNTY RESPONSIBILITIES A county Long-Term Care Consultation Team or DD Screening Team completes an assessment for determination of the consumer s home care needs and level of care. When personal care assistant services are required, the county PHN completes the MA Home Care Health Status Assessment and Service Plan. If private duty nursing, home health aid or skilled nurse visits are required, a home care agency RN completes an assessment. A LTCC Screening assessment and screening document are completed and entered into MMIS. Documentation required for submission to DHS: LTCC Documentation (including case mix) via MMIS Screening Document; and Copy of the assessments for MA Home Care Services; and Memo to the department requesting the CS Home Care Rating and the nursing facility where the consumer is residing or would reside Mail to: Department of Human Services MA Home Care 444 Lafayette Road, North St. Paul, MN CS Home Care Rating requires an annual face-to-face assessment. If the consumer continues to need the Home Care Rating, it is the responsibility of the county staff to submit the above information to DHS for review. DHS RESPONSIBILITIES DHS reviews the documentation submitted and determines the monthly dollar cap based on the identified nursing facility. Notification to the county is to be completed within 20 working days. The MA Home Care assessment data will be entered into a MMIS Service Agreement. Comments about the LTCC screening, the CS Home Care Rating, and the name of the nursing facility will be added to the MMIS service document.

7 Bulletin # June 7, 2002 Page 7 LEGAL AUTHORITY MN Statutes, sections 256B.0625 and 256B.0627 MN Statutes, section and and MN Rules and Code of Federal Regulations, title 42, part 440 RESOURCES ON THE INTERNET Minnesota Statutes and Rules: DHS bulletins: Click on Bulletins and Manuals # Accessing CADI for persons with mental illness Other resources: A to Z Topics - click on M - Mental Health Publication: Toward Better Mental Health In Minnesota ALTERNATIVE FORMATS This information is available in other forms to persons with disabilities by calling (651) , or contact us through the Minnesota Relay Service at 1 (800) (TTY) or 1 (877) (speech-to-speech relay service).

8 Attachment A MA HOME CARE PCA ASSESSMENT Guidelines Used When Assessing People With Mental Illness/Behavioral Needs BACKGROUND Mental illness can be generally defined as: health conditions that are characterized by alterations in thinking, mood, or (or some combination thereof) associated with distress and/or impaired functioning. Surgeon General s Report on Mental Health (1999) The term mental illness is used to refer to all the mental disorders that can be diagnosed. At this time there are 283 mental disorder diagnoses as defined by the Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV). People who have a mental illness may be physically capable of carrying out activities of daily living (ADLs), but may not be able to do so without repeated prompts due to an inability to concentrate or to initiate activities, or due to delusional beliefs and hallucinatory symptoms. Prompts and encouragement for people with mental illness may take more time than a situation in which a person requires these services to be performed for them. Mental illnesses sometimes result in a disconnection from reality that may impair judgement and interfere with social interactions. Out-of-context comments and s, wandering and poor judgement should be considered as indicators that substantial supervision might be required to ensure safety. Involving family or direct care staff who are very familiar with the person is essential in assessing the needs of a person with mental illness. Family or staff who have been providing support and service to the individual can be an invaluable resource, and are best able to suggest the services needed to maintain stability. ASSESSMENT PROCESS The PHN will need to use a different perspective with the assessment for consumers with mental illness. The following is a review of assessment categories along with suggestions and guidelines on how to collect the information to determine time and a home care rating. The current MA Health Status Assessment Form will continue to be used. 1

9 Attachment A Direct Own Care Section Expected Outcome Consumer or responsible party directs PCA services PHN action Assessment and documentation of the following: It is documented the consumer can direct his/her own care with current supports; and/or There is a crisis plan in place with a responsible party identified; and/or The consumer resides in an adult foster home providing 24-hour staffing with a house manager who assumes the responsibility for directing care and case management is provided. Please refer to MN Statute 256B.0627; subd 1; (k) Diagnosis Section It is recommended that the consumer s psychiatric diagnosis and ICD9 code be entered as the primary diagnosis with indication of number of years since first diagnosed Medication Section Desired Outcome Consumer is compliant with medication regime PHN action Indicate total number of minutes/day to reach outcome May have increased times assessed due to need for incentive programs, delusional thinking, withdrawn s, or other s. Example JC is assessed for 12 units/day (3 hr) in this category due to her resistance to taking medications, especially in the evenings. Living Arrangement Desired Outcome Consumer lives in least restrictive setting to maintain health and safety. PHN action Communication and data collection to confirm desired outcome Indicate current residence on assessment tool A reminder - If over 4 residents in a licensed residential setting, PCA services cannot be used Indicate presence of community supports in Directing Own Care or Health Description section Sensory Section Desired Outcome PHN understands how presence of sensory issues affects the total assessment. PHN action Communication and data collection required to address these issues. 2

10 Attachment A Even though there is no time assessed in this category, it offers much information about the consumer which affects the ability to meet identified needs There may be sensory hallucinations and delusions Examples: 1. Auditory hallucinations telling consumer to not take shower or meds with time added to Medication or ADL sections 2. Tactile sensations has consumer rubbing or scratching skin until excoriation leading to bleeding and potential for infection time would be indicated in other sections. Health Description Section Desired Outcome Short description of a consumer s physical and mental health. PHN action Data collection, review, and analysis PHN to provide a short summary of past history indicating treatment and number of hospitalizations along with any requirement for supervision to maintain safety and health PHN can indicate consumer with mental illness may not recognize their physical and/or mental disability leading to noncompliance with treatment Complex Medical Section Expected Outcome Complex medical health needs are met PHN Action Communication, data collection, analysis of current care The consumer may deny the need for complex medical care and resist when offered. May take extra time to provide care, monitor condition and provide follow up due to the denial, resistance, and other symptoms of mental illness Treatment Section Expected Outcome Maintaining consumer s optimal level of functioning PHN Action Review of the Individual Treatment Plan (ITP), Individual Community Support Plan (ICSP) or Family Community Support Plan (FCSP) for identified treatments to meet expected outcome Time is assessed in this area only when there is a current ITP, ICSP or FCSP with documented clear expectations and directions for the following: 1. Ongoing supervision required to maintain health and stability (not age related) 2. Immediate crisis intervention required 3. Daily intervention strategies for redirection and continual prompting to address identified s 4. Treatments would otherwise require institutional care 3

11 Attachment A Time cannot be assigned for a consumer without an ITP, ICSP, or FCSP. An Individual Education Plan (IEP) is not the same as an ITP, ICSP, or FCSP. Behaviors Expected outcome Consumer remains safe with supports PHN action -- Assign time for continued observation, close monitoring, verbal redirection, and intervention to maintain level of health and stability. The assessed time is added in the ADLs and/or Behavior Sections. Level I Behaviors Behaviors are present at current time of assessment or there is current documentation of past incidences. Behaviors may be decreased due to ICSP/IFSP and amount of supervision, without which, would escalate resulting in decompensation of health status Level I Behavior documentation from a mental health professional dated in the last year is required. Level II Behavior! Named in MN Statute: Unusual/Repetitive Habits, Withdrawal, Socially Offensive Behaviors. These three categories may include impulsiveness, inappropriate sexual activity, wandering, intrusiveness, and susceptibility to victimization and other s as identified through documentation and observation.! Must occur on a daily basis to be eligible for Home Care Rating using Level II Behaviors Must interfere with completion of personal care services Time is entered in other categories For the MT rating level II s are constant and pervasive. Level III Behavior Assessed time is added in other categories Because this section includes the prompting and assistance in completion of personal care tasks, time is to be added to ADLs Activities of Daily Living Section Expected Outcome Consumer completes activities of daily living PHN action Identify all the time it take to complete ADLs Verbal and other prompting is generally necessary 4

12 Attachment A For some consumers, this may be the only need identified for the PCA Program. With the flexible use option, the daily units may be utilized so that a PCA can visit 2 or 3 times per week to help complete the needed ADLs. Some consumers with mental illness will have an incentive program in place for completion of some ADLs. Ask how much time is involved in the program. ADDITIONAL GUIDELINES Use a 24-hour day to determine needs Daily units could be used in a flexible option to provide the needed service. Example: Consumer is assessed for 6 units/day for prompting for bathing and grooming. The consumer and service provider choose to have the PCA provide 4.5 hr. 3 days/week to allow for assistance with the ADLs and any IADLs that are identified. For some consumers, the use of PCA services could be episodic and still be appropriate. Example: A consumer who needs electro-convulsive treatment one time a month. A PCA could provide observation and monitoring before and after the treatment to ensure safety. Learn about sleep patterns of consumer to better understand needs during a 24 hour day. Example: The consumer who lives in an adult foster home sleeps from 1AM to 8 AM and there is not a need for 1:1 staffing during the sleep time; shared PCA is appropriate. For consumers residing in adult foster setting, shared PCA service is always an option if appropriate. Adult foster care payment includes payment for room, board, basic supervision, and monitoring for safety. Time assigned indicates time over and above the basic services provided in the adult foster contract Obtain data from other service team providers as appropriate as well as the consumer. County policy can be developed to provide a consistent assessment process for all consumers with mental illness. Example: A policy stating for consumers or providers who request the MT Home Care Rating that there is a mental health case manager available at time of the assessment. PCA services need to be one part of a larger Community Support Plan for the consumer. 5

13 Attachment B DEFINITIONS FOR MENTAL HEALTH DOCUMENTATION Case Management Services (Adult) - MN Statutes, section subd. 6 Activities that are coordinated with the community support services program and are designed to help adults with serious and persistent mental illness in gaining access to needed medical, social, educational, vocational, and other necessary services as they relate to the client s mental health needs. Case management services include developing a functional assessment, an individual community support plan, referring and assisting the person to obtain needed mental health and another services, ensuring coordination of services, and monitoring the delivery of services. Case Management services (Child) - MN Statutes, section Activities that are coordinated with the family community support services and are designed to help the child with severe emotional disturbance and the child s family obtain needed mental health services, social services, educational services, health services, vocational services, recreational services, and related services in the areas of volunteer services, advocacy, transportation, and legal services as they relate to the children s mental health needs. Case management services include assisting in obtaining a comprehensive diagnostic assessment, if needed, developing a functional assessment, developing an individual family community support plan, and assisting the child and the child s family in obtaining needed services by coordination with other agencies and assuring continuity of care. Case managers must assess and reassess the delivery, appropriateness, and effectiveness of services over time. Diagnostic Assessment - MN Statute , subd. 9 A written summary of the history, diagnosis, strengths, vulnerabilities, and general service needs of an adult with a mental illness using diagnostic, interview, and other relevant mental health techniques provided by a mental health professional used in developing an individual treatment plan or individual community support plan. This assessment is a face to face interview and also considers the referral needs for further examinations and evaluations. Functional Assessment - MN Statue , subd. 11a An assessment by the case manger of the following: 1. Adult s mental health symptoms and needs as presented in the adult s diagnostic assessment; 2. Use of drugs and alcohol; vocational and educational functioning; 3. Social functioning, including the use of leisure time; 4. Interpersonal functioning, including relationships with the adult s family; 5. Self-care and independent living capacity; 6. Medical and dental health; 7. Financial assistance needs; housing and transportation needs; and 8. Other needs and problems. 1

14 Attachment B This assessment is completed within 30 days of intake and is reviewed and updated every 6 months with consumer involvement. Individual Community Support Plan - MN Statute , Subd 13 A written plan developed by a case manager on the basis of a diagnostic assessment and functional assessment. The plan identifies specific services needed by an adult with serious and persistent mental illness to develop independence or improved functioning in daily living, health and medication management, social functioning, interpersonal relationships, financial management, housing, transportation, and employment. Individual Family Community Support Plan - MN Statutes , subd. 4 A plan that incorporates the child's individual treatment plan. The individual treatment plan may not be a substitute for the development of an individual family community support plan (IFSCP). The case manager is responsible for developing the IFCSP within 30 days of intake based on a diagnostic assessment and a functional assessment and for implementing and monitoring the delivery of services according to the IFCSP. The case manager must review the plan at least every 180 calendar days after it is developed, unless the case manager has received a written request from the child's family or an advocate for the child for a review of the plan every 90 days after it is developed. To the extent appropriate, the child with severe emotional disturbance, the child's family, advocates, service providers, and significant others must be involved in all phases of development and implementation of the IFCSP. The child's individual family community support plan must state: the goals and expected outcomes of each service and criteria for evaluating the effectiveness and appropriateness of the service; the activities for accomplishing each goal; a schedule for each activity; and the frequency of face-to-face contacts by the case manager, as appropriate to client need and the implementation of the individual family community support plan. Individual Treatment Plan - MN Statute , Subd. 14 A written plan of intervention, treatment, and services for an adult with mental illness that is developed by a service provider under the clinical supervision of a mental health professional on the basis of the diagnostic and functional assessments. The plan identifies the following: 1. Goals and objectives of treatment; 2. Treatment strategy 3. A schedule for accomplishing treatment goals and objectives; and 4. The individual responsible for providing treatment to the adult with mental illness. 2

15 Attachment C All Recipients Personal Care Limit Decision Tree Effective Vent Dependent? (on vent at least 6 hrs/day for at least 30 days) NO Referred to Commissioner by RTC PAS Evaluation Team? Referred to Commissioner by PAS Team or ICF/MR Screening Team? NO NO NO Exhibits Level I? YES YES YES YES $27,592/month EN $10,602/month MT Call PHN line at or CS $6,333/month CB Low ADL (0-3) Med ADL (4-6) High ADL (7-8) No complex medical need $2,579/month Complex medical need or Level II RC or RB No complex medical need RU $3,568/month Complex medical need or Level II UC or UB No complex medical need $6,426/month Complex medical need or Level II ZC or ZB or ZZ UZ $1,149/month No Level III P $1,370/month Level III Q $2,030/month No Level III S $2,360/month Level III T Heavy eating (0-2) Very heavy eating (3-4) or neurological diagnosis Recipients with complex medical need and Level II (s) $2,688/month No Level III V (Note: Not using clinical monitoring for R, U, or Z) The cap amount is calculated over and applied to the time period of the entire service agreement. The cap must cover any combination services, except PDN, even if the added service is only temporary. The cap is exceeded ONLY when total services authorized on the service agreement are greater than the cap calculated over the time period of the entire service agreement. $3,239/month Level III W $5,110/month No Level III X $5,548/month Level III Y MS-0520B 7-01

16 Attachment C Private Duty Nursing Service Decision Tree Effective Recipient requires private duty nursing service Is the recipient ventilator dependent? (on vent at least 6 hr/day for at least 30 days) NO Is the recipient applying for CAC or appealing insurance coverage? NO Does the recipient meet hospital admission criteria? NO Up to $10,712/month; $352.17//day PD YES YES YES $27,592/month; $907.13/day EN Up to $26,368/month; /day during CAC application or insurance appeal process CA or IN $17,578/month; $577.92/day HL NOTE: If recipient requires private duty nursing services plus personal care, skilled nurse visits, and/or home health aide visits, use appropriate limit as specified on Private Duty Nursing Service Decision Tree. The cap amount is calculated over and applied to the time period of the entire service agreement. The cap must cover any combination services, even if the added service is only temporary. The cap is exceeded ONLY when total services authorized on the service agreement are greater than the cap calculated over the time period of the entire service agreement. MS-0655/MS 7/01