Steps for Success. Personal Care Assistance

Transcription

1 Steps for Success Personal Care Assistance

2 Why are you here? An overview of: PCA Program guidelines Eligibility Covered services How a person gets services 2

3 Why are you here? Program policy requirements and responsibilities for PCA agencies Individual workers Qualified Professionals (QP). 3

4 Licensing? Agencies do not need to be licensed under M.S. 245D to be a PCA agency. For employment related information: 4

5 What is Personal Care Assistance (PCA)? Services and supports that assist people with daily activities so they may live independently in the community. It is authorized by M.S. 256B

6 DHS websites PCA Consumer website PCA Provider Agency website 6

7 Background Minnesota offers health care programs to residents for coverage of medical services. PCA services are included in the benefit sets for some of the programs.

8 Background To have a Minnesota Health Care Program (MHCP) pay for PCA services, a person must be eligible for one of the health care programs that includes PCA services as a covered service. 8

9 Background Programs that cover PCA services: Medical Assistance (MA) - Minnesota s Medicaid program. MinnesotaCare children enrollees. Emergency MA (EMA) with an approved Care Plan Certification. MA Waiver programs & Alternative Care (AC). 9

10 MA Waiver Programs Brain Injury (BI). Community Alternative to Care (CAC). Community Alternatives for Disabled Individuals (CADI). Developmental Disability (DD). Elderly Waiver (EW). 10

11 History People with disabilities were institutionalized in regional centers or nursing homes. The movement to enable people to live in the community began in 1970s. Over time, people have more choices and control over their services.

12 Program use and costs In SFY 2014: about 26,876 participants at a cost of about $684 million. 7/1/2014: 39,343 individual PCA workers provided service 7/1/2014: 630 enrolled PCA agencies

13 What are PCA services? 4 areas of covered services Activities of daily living (ADLs). Health-related procedures and tasks. Observation and redirection of behaviors. Instrumental activities of daily living (IADL). 13

14 Service Authorization Provider agencies must receive authorization for services before billing. Services are authorized in units. A unit equals 15 minutes.

15 Who plays a role in PCA? Participant. Lead Agency. DHS. Individual PCA worker. Provider Agency. All have different responsibilities for the participant to receive PCA services.

16 Definition: What is a lead agency? Lead agency is the term that we use when referring to county or tribal agencies or managed care organizations (MCO).

17 PCA Process Overview Person requests assessment. Lead agency conducts assessment. Lead agency identifies needs, type and amount of services. Service authorization is issued.

18 PCA Process Overview Person chooses provider agency. Provider agency and person develop care plan. Qualified Professional (QP) works with person to train workers.

19 PCA Process Overview Individual PCA provides services according to care plan. QP and person oversees and evaluates care. Person must have an annual reassessment.

20 Resources Forms (edocs) website Provider Call Center or nter 20

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22 What do providers need to know? What services are covered in PCA? What assessed needs should be included in a care plan? What does the worker need to know about the services to meet those needs?

23 What do workers need to know? Workers need to know; what tasks they can do what tasks are out of the scope of PCA services. 23

24 1st category: ADLs Dressing Grooming Bathing Eating Transfers Mobility Positioning Toileting 24

25 2 nd category: Healthrelated tasks Criteria: Delegated or assigned by licensed medical professional. Trained and supervised by a QP who is a RN. PCA demonstrates competency. 25

26 Health-related tasks Examples include: Assist with self-administered medications. Monitor or observe for seizure disorders. Range of motion to maintain a person s strength and muscle functioning.

27 Complex health needs include: Tube feeding Wounds Parenteral/IV Therapy Respiratory Interventions Catheter Other Congenital/Acquired Diseases

28 Tracheostomy & Ventilator Tasks PCA may assist with tracheostomy suctioning and services to ventilator dependent persons if: Trained on individualized, specific needs of the person. Specialized training on procedures, tasks, equipment. Non-sterile only. QP must be a RN.

29 3 rd category: Observation & redirection of behaviors PCA service may include observation of a person who: Has episodes of behaviors Needs redirection to remain safe in his or her environment. 29

30 Examples of behaviors: Socially inappropriate behaviors. Resistive to care including verbal aggression. Physical aggression towards self, others or destruction of property that requires an immediate response.

31 4 th category: IADLs Examples include: Travel to participate in community activities. Assist with paying bills. Assist with communication. Meal planning and preparation. Shopping. Household tasks integral to PCA services. 31

32 What does PCA not include? Services without authorization. Services not included in a service or care plan. Services that are the responsibility of a residential or program license holder. Services in provider controlled housing.

33 What does PCA not include? Child care or babysitting. IADLs for persons under age 18 (with exceptions). Home maintenance or chore services. Homemaker services not integral to assessed PCA needs.

34 What does PCA not include? Use of restraints. Sterile procedures. Injections of fluids and medications into veins, muscles or skin.

35 Community Participation A person can receive services where their normal life activities occur. Driving is not a covered PCA service. Remember: MA includes medical transportation as a benefit. 35

36 Covered Services & care plans An assessor evaluates the person s need for all of these covered services to arrive at the home care rating and service authorization which the agency uses to develop a care plan. 36

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38 Assessments A review and evaluation of a person s need for PCA.

39 Who completes assessments? Lead agencies: Complete initial assessments. Enter service authorizations into MMIS or their system. Complete the annual reassessments or when there is a change in condition.

40 PCA Assessment Components Document health status. Determine need for services. Identify appropriate services. Authorize service level. Refer to other resources. Educate person about service options.

41 MnCHOICES Lead agencies use MnCHOICES to complete initial assessments. Web-based tool. Comprehensive, personcentered assessment and support planning. Includes all PCA components.

42 MnCHOICES Produces an assessment summary to inform person of their services and support options. Assessment summary used to develop an individual Community Support Plan (CSP).

43 MnCHOICES The summary and CSP are used to develop a Coordinated Services and Support Plan (CSSP). The combined form DHS-6791B, MnCHOICES Community Support Plan with Coordinated Services and Supports Form, is available on edocs.

44 MnCHOICES Will roll out to MCOs in Reassessments being rolled out to county or tribal agencies now. Unlaunched agencies continue to use DHS-3244 (PCA Assessment & Service Plan)

45 MnCHOICES More information: MnCHOICES link Fact sheet: DHS-6477 available on edocs

46 45-Day Temporary Start Immediate need for PCA services. Can be done by telephone. Followed by face-face. Lead agencies may choose not to complete the temporary starts if they can complete a timely faceface.

47 45-Day Temporary Increase Change in condition. Can be done by telephone. Followed by face-face, if person needs services longer than 45 days.

48 Service Authorization Depends on Home Care rating: Base units for a minimum 1 ADL and/or 1 Level 1 Behavior, complex health needs. Additional units for critical ADLs (eating, transfers, mobility, toileting), complex health needs, behaviors.

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50 How does a participant get services? To receive PCA, a person must: Be on MA or on the MinnesotaCare expanded benefit set or be eligible for Alternative Care. Be able to direct their own care or have a responsible party act on their behalf. Live in their own home. Have an assessment that identifies their need for and authorizes PCA services.

51 MA Eligibility If a person needs to apply for MA, refer them to the county or tribal financial services department.

52 Living in their own home does not mean: Hospital. Nursing Facility. Intermediate care facility. Health facility licensed by the MN Dept. of Health. Foster care setting licensed for more than four residents.

53 Who must have a responsible party (RP)? Person must have an RP they are: A minor. An incapacitated adult with court-appointed guardian. Unable to direct their own care. Assessor determines need for RP.

54 Who can be a responsible party (RP)? 18 years of age or older. Parents. Licensed family foster parent. Listed on the person s service plan, service agreement and PCA care plan. Need identified at time of assessment. Two people can be RPs.

55 Who cannot be a RP? Individual PCA. PCA provider agency owner, manager or staff member. Qualified Professional (QP). Lead agency staff or contractors acting as an employee.

56 What does an RP do? On behalf of client, the RP: Make choices. Plan and direct services. Monitor services. Assure client s health and safety. Request changes. Sign forms, agreement, time sheets.

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58 How do MA clients get PCA services? Participants receive services through three methods: Managed Care Organization (MCO) Fee-for-service (FFS) Waiver and Alternative Care 58

59 MRRP-Minnesota Restricted Recipient Program Person cannot use flexible PCA service options. Agencies do not receive notification. You must check person s eligibility on MN.ITS. 59

60 Definition - FFS Recipient can receive medical services from any provider who is enrolled as a MA provider. The provider follows DHS procedures for direct billing and payment.

61 Definition Managed Care Person enrolls in a managed care organization (MCO) to receive medical services through their provider network. DHS pays the MCO a fixed rate for each enrollee.

62 Managed Care Check client eligibility monthly. Certain managed care products do not authorize PCA services. E.g. SNBC Enrollees must use providers who are part of the MCO s provider network. 62

63 Participants who transition from Managed Care to FFS, provider must: Submit service authorization requests to DHS within 30 days of disenrollment. Request new assessment by lead agency within 60 days of disenrollment. Check client eligibility monthly.

64 Waivers and Alternative Care Brain Injury (BI). Community Alternative to Care (CAC). Community Alternatives for Disabled Individuals (CADI). Developmental Disability (DD). Elderly Waiver (EW).

65 Options for receiving PCA Services Traditional. PCA Choice. Shared Service. Flexible Use.

66 PCA Services Options Assessor advises person of their options. Person/RP chooses the option they feel would best meet their needs. Agency does not choose the option for the person.

67 Traditional PCA Agency responsible for staffing and employment related activities. Person responsible to: Sign time and activity sheets. Develop their care plan with QP. Direct their care with QP. Evaluate staff with QP.

68 PCA Choice Who provides PCA Choice services? The person is the participant employer. Person/RP find staff. Person uses a fiscal intermediary (FI) for payroll and billing functions. Person/RP maintains written agreement with FI. Person/RP can only use one agency.

69 PCA Choice Person/RP duties Find, hire, train, schedule, fire their staff. Find emergency or back up staff. Monitor and evaluate staff. Develop care plan. Document PCA tasks and actions. Sign time and activity sheets.

70 Who cannot choose PCA Choice? Persons/RPs who failed to comply with written agreement. Assessor health and safety concerns. Abusive or fraudulent billing. Client on MRRP.

71 PCA Choice Workers are members of a collective bargaining unit by state law. Participant employer and FI must comply with the terms and conditions of the SEIU union contract. This includes reporting requirements. 71

72 Spreadsheet includes: Worker identifying information Employment dates Pay information Paid Time Off (PTO) information Union dues information 72

73 PCA Choice Resources DHS PCA Choice web page DHS Participant Employer Option web page

74 Shared Services Worker provides services at the same time by the same worker for 2 or 3 consumers who agree to share PCA services.

75 Shared Services Person chooses at assessment. Same: Setting Time Individual PCA worker PCA provider agency

76 Shared Services Does not affect person s authorized PCA units. Person can return to 1:1 PCA at anytime. Reimbursed at different rate. Person/RP s choice.

77 Flexible Use Divide total hours/units between two 6-month periods. Use hours/units flexibly within each period to meet needs. Cannot use more than 75% in one 6- month period. Cannot transfer from one period to another.

78 Flexible Use Cannot add hours/units unless a change in condition occurs. Include monthly use of hours in care plan. Person & provider agency monitor use.

79 Who cannot use services flexibly? DHS or lead agency denies or revokes. Person is assigned to the Minnesota Restricted Recipient Program (MRRP).

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81 What is a Care Plan? A written description that identifies the PCA services that a person is to receive, based on the assessment and service plan. The person develops it with assistance from the QP.

82 Care Plan Develop: Within 7 days of the start of services. Annually at reassessment. Update when there is a change in need or condition. Use own template. Can only include covered services.

83 Care Plan Keep copies at: Person s home. Provider agency s file as part of its assurance statement. Shared services delivery location. Workers must know its location.

84 Care Plan Components Person s contact information. RP s contact information. Start and end date. Dated signatures of person, RP and QP.

85 Care Plan Components Emergency Procedures: Emergency telephone numbers. Procedures for unexpected situations that require action immediately. Procedures to identify and manage safety and vulnerability issues. Back-up staffing plan.

86 Care Plan Components Detailed description of: The person s needs. The services the worker will provide. Special instructions or procedures. Monthly planned use of units.

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88 Who provides PCA services? Individual PCA Worker requirements. Provider Agency Requirements. Qualified Professional (QP) Requirements.

89 Who can be an individual PCA worker? Be employed by a PCA provider agency. Pass a background study. Complete and pass required DHS online training. Enroll with DHS as an MA provider.

90 Who can be an individual PCA worker? Be 18 years of age or older, or, 16 or 17 years old if: Employed by only one agency. Comply with current labor laws. Supervised by QP every 60 days.

91 Worker responsibilities Communicate with client, QP, PCA agency. Complete training and orientation on client s needs. Provide services according to care plan. Respond appropriately to person s needs.

92 Worker responsibilities Be supervised by the person and the QP. Maintain daily written record, time and activity documentation. Provide and be paid for no more than 275 hours per month of PCA services.

93 Individual Workers By state law, workers who provide services to people who participate in the PCA Choice program are part of a bargaining unit. Their terms and conditions of employment are covered by a union contract. Participant employers/fis must comply with the union contract for these workers.

94 Who cannot be an individual worker? Participant s spouse. Parent or step-parent of participant under age 18. Legal guardian of a minor participant. Paid legal guardian of an adult participant. Licensed foster provider. Recipient of PCA services. RP of the participant.

95 Mandated Reporter By law, individual PCA workers are mandated reporters. Workers who know or have reason to believe maltreatment of a vulnerable adult or child is or has occurred must report it.

96 Who is a vulnerable adult? Every adult recipient of PCA or home care services. Maltreatment includes: Abuse. Neglect. Financial Exploitation.

97 Adult Reporting Adults beginning July 1, 2015: Minnesota Adult Abuse Reporting Center Available 24 hours per day, 7days per week: Toll-free number DHS-6303-ENG Web-based report that worker can complete and submit online. If person is in immediate danger, call 911.

98 Child Maltreatment Includes: Physical or sexual abuse. Neglect. Mental injury. Maltreatment occurring currently or within the past 3 years. Prenatal exposure.

99 Child Reporting Call 911 if child is in immediate danger. Call the local social service agency. Follow your agency s procedures for notifying them about any maltreatment you have reported.

100 Resources DHS Adult Protective Services website: ervice=get_dynamic_conversion&revis ionselectionmethod=latestreleased&ddocn ame=id_005710# DHS Child Protection website: ervice=get_dynamic_conversion&revis ionselectionmethod=latestreleased&ddocn ame=id_000152# Both include links to online courses.

101 Data Privacy Workers may see or have access to personal data or information in the course of doing their jobs. Workers notes and documents about providing care to that person are private information. Federal and state laws control what can or cannot be done with that data. MN Data Practices Act (M.S. 13) HIPAA

102 Data Privacy It is a worker s responsibility to protect a person s private data. The worker should not share any information with anyone else without the person s written consent. Agencies must have policies and procedures regarding a worker s access to a person s private information. Both the worker and the agency can be penalized or prosecuted for violations of that person s privacy.

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104 What are an agency s responsibilities? Request reassessments timely. Follow PCA policies & procedures. Ensure all individuals complete required training. All owners, managing employees, supervisors, QPs, designated billing person. Train workers on data privacy, mandated reporting laws and your agency s policies. Document that all workers and QPs continue to meet requirements.

105 What are an agency s responsibilities? Maintain written agreement between RP and agency, if applicable. Maintain MHCP provider enrollment. Complete background studies. Perform payroll functions for worker and QP. Follow MHCP billing and payment procedures. Document agency s marketing practices and costs.

106 What are an agency s responsibilities? Pay PCA workers wages & benefits equal to 72.5% of MA revenue. Comply with DHS program integrity activities. Initiate own quality improvement projects.

107 What are an agency s responsibilities? Conduct and document service verifications. An unscheduled call with the PCA person and the PCA worker to verify that the worker is providing scheduled services. More info in Provider Update PCA-15-01: =GET_DYNAMIC_CONVERSION&RevisionSelection Method=LatestReleased&dDocName=dhs16_ Decide if your agency will offer traditional PCA, PCA Choice or both methods of service delivery to customers, and maintain written agreements with all participants, regardless of method.

108 Traditional PCA agency s responsibilities Find, hire, train, schedule, fire staff. Find emergency or back up staff. Monitor and evaluate staff. Assist person with care plan. Maintain written agreement with person indicating their choice of traditional delivery method of PCA services.

109 PCA Choice agency s responsibilities Obtain and maintain written agreement with person that includes the person s decision to use PCA Choice. Be the only agency providing FI services to the person. Comply with terms and conditions of union contract including reporting requirements. Not be the parent, child, sibling or spouse to the person, PCA worker or QP.

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111 What is a Qualified Professional (QP)? A professional who provides training, supervision and evaluation of PCA services and staff.

112 Who can be a QP? Registered nurse per M.S Licensed social worker per M.S. 148E.010 and M.S. 148E.055. Mental health professional per M.S , subd.18 or M.S subd.27. Qualified developmental disabilities specialist per M.S. 245D.081 subd. 2(b).

113 QP Requirements Clear a criminal background study. Work for a PCA provider agency. Only deliver services within scope of practice.

114 QP Requirements Complete required training within 6 months of hire, or if switching PCA agencies more than 3 years later. Exception: if employed by a Medicare-certified home health agency.

115 Who cannot be a QP? The person s: Family foster care provider. PCA worker. Paid legal guardian. Parent/step-parent of minors. Responsible party. Spouse.

116 What are a QP s responsibilities? Assist person as needed with developing their care plan including scheduling. Train PCA staff on person s needs including the care plan. Ensure PCA competency to provide PCA services. Ventilator and tracheostomy training only by RN. Monitor and evaluate effectiveness of PCA services and staff. Ensure person s health and safety needs are met.

117 QP Documentation A QP must maintain documentation including the date, time and details about: Person s PCA care plan and individualized training for care of the person. Monthly use of PCA units. Changes in person s condition. Reassessment requests. Evaluations from supervisory visits and any corrective actions. All communications with person and their staff.

118 What are QP Visits? A visit to provide qualified professional services that may include: Develop the care plan. Orient, train and evaluate individual PCA staff. Oversee the delivery of PCA services.

119 When are QP visits made? A QP must meet with the person/rp: Within 14 days of start date of traditional services for the initial visit. Every 90 days for the first year of traditional service. Every 120 days after the first year of traditional service. Every 180 days for PCA Choice service. Every 60 days to evaluate year old PCAs at the service location. Every 180 days at the shared service location.

120 When are QP visits made? After 180 days, the QP may alternate inperson visits with telephone or web visits. The lead agency will automatically authorize 96 units per year to use flexibly. MCOs have authority to require that all visits are in-person.

121 QP Resources Provider Call Center or PCA QP website:

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123 Future Change - CFSS DHS is developing the Community First Services and Supports (CFSS) program and will need federal approval to implement. CFSS will replace PCA and Consumer Support Grant (CSG). It will offer participants more control, flexibility, responsibility and choice.

124 CFSS CFSS website:

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