11/26/2012. Quality Management tool

Transcription

1 Utilization Management Functions Works with everyone to make the plan reflect the right services for the person Plan of Care Approval Level of Care Performance Indicators Utilization Management Criteria Clinical Design Plan Clinical Practice Guidelines Role of the Care Coordinator Hands-on Strategic tool that enables the MCO to assure individuals access to appropriate and ongoing care. Administrative Function Both a Risk Management tool and a Quality Management tool Functions of the Care Coordinator Treatment Planning Case Management Educating participant/family/providers about services, waiver requirements, options Assessment of support needs (completing, arranging for, obtaining) Linkage to needed NC Innovations resources (includes ensuring provider choice) Facilitation of Planning / Plan Development Monitoring plan implementation, including health and safety Medicaid eligibility coordination Linkage to primary and preventative health care providers 12

2 Plan Development Individual Support Plan and Individual Budget are developed by Care Coordinator, including Positive Behavior Support Plan as required or otherwise indicated Care Coordinator reviews plan with participant/legally responsible person and obtain signatures (including Freedom of Choice for Innovations participants) Plan (with all accompanying documents) submitted to Utilization Management per PIHP guidelines. Individual Support Planning Team Educate and guide all members An opportunity for empowerment A very important step to ensure that people receive the right care Community Guide advocacy is very important to help the person prepare. Strong planning processes are critical to manage care and ensure the needs and desires of the individual are met. Individual Budget In combination the Base and Add On budgets may not total more than $135,000 (cost limit) Base Budget Services- the services that are the core habilitation and support services in the waiver. Add On (Non Base) Budget Services services which are provided to ensure prevention, education or enhanced independence. If the individual decides to participate in Individual Family Direction, they will additionally have a Self Directed Budget 13

3 Individual Support Plan-ISP New A standardized Plan Tools Form Is unique to NC Innovations Focus on the person s voice Demographics at the end Summary of the Risks that need to be mitigated are in the plan Requires a back-up staffing plan be documented Crisis Plan is embedded in the plan Only Long Range Goals There is a section for information individual to document dis- agreement The annual plan contains the Freedom of Choice statement and the Level of Care statement MCO units involved: Care Coordination Plan of Care Approval New The plan of care is submitted to an MCO UM vendor Tools Management of both all resources within the operational unit May use MCO developed UM criteria to make needed decisions May authorize services based on a rate structure that the MCO designed Motivated to approve the correct services Need a system to track all information received and to ensure that the plan is approved on a timely basis MCO units involved: Utilization Management No wrong door to disagree There are may opportunities for individuals to disagree throughout the planning and approval process: May document disagreement in the ISP May request reconsideration of an adverse decision May request a Fair Hearing Can file a grievance or complaint Can ask the Community Guide to advocate on their behalf 14

4 Providers develop short-range range goals and accompanying interventions/strategies/ task analyses Staff Training Plan Implementation Provision of service as outlined in plan Documentation of the services provided Monitoring of plan implementation by Care Coordinator Shaping the Service System Facility size Own Home/Private Family or Residential Facility of: 6 beds or less 3 beds if newly constructed Must meet the Home and Community characteristics Policies to make expectations clear within the system School Policy Equipment and Supplies Location of Service Services in the Home of the Employee Out of State Travel Use of One Waiver Service Provider Qualifications 15

5 Service Options through NC Innovations Traditional Provider Directed Option Individual/Family Directed Option (Self Direction) - Agency with Choice and the Employer of Record If the person tries an option and is not satisfied they can change The person has the flexibility to direct only the services that they choose Choices, Choices, Choices You want to encourage individuals to try new things There are no penalties for changing your mind Develop systems that promote seamless movement between options Ensure that providers understand that the goal is to move individuals to a system that is less reliant on formal service s. Role of Community Guide Key to the change in Culture and advancing community membership Advocacy Support Linkage to community resources Teaches the skills needed to be successful in Individual and Family Directed Services option Helps prepare for ISP/IEP or other planning meetings 16

6 Individual/Family Directed Supports Changing the Future Agency With Choice (Managing Employer) Employer of Record (Employer) The individual has the opportunity to be in control of the management of their own services Providers have an opportunity to showcase their partnership to change the culture Care Coordinator functions in Individual Family Direction Completes the assessments Completes the process for appointment of the representative, if needed Completes referrals to the Agency With Choice and Community Guide Completes the Individual and Family Supports Agreement Completes the ISP/Update to ISP Sends the ISP to UM for approval Community Guide functions in Individual Family Direction Empowers the employer to define and direct services Understands employers needs and preferences May not be the employer, representative or family may not be paid to provide service Service can be mandated 17