What is CLS? Community Living Supports Assessment and Committee Process 10/20/2015

Transcription

1 Community Living Supports Assessment and Committee Process What is CLS? According to the Michigan Medicaid Provider Manual, Community Living Support services are used to increase or maintain personal self-sufficiency, facilitating an individual s achievement of his goals of community inclusion and participation, independence or productivity. The supports may be provided in the participant s residence or in community settings (including but not limited to, libraries, city pools, camps, etc.). Specifically: Medicaid Services cover assisting, prompting, reminding, cueing, observing, guiding and/or training in the following activities: Meal Preparation; Laundry; Routine, Seasonal, and Heavy Household Care and Maintenance; Activities of Daily Living; Shopping for food and other necessities of daily living Medicaid Services also include Staff assistance, support and/or training with activities such as: Money management; Non-Medical Care; Socialization and Relationship Building; Transportation from the residence to, from and among community activities; Participation in regular community activities and recreation opportunities; Attendance at medical appointments; Acquiring or procuring goods and non-medical services; Reminding, observing, and/or monitoring of medication administration; and staff assistance with preserving the health and safety of the individual in order that he/she may reside or be supported in the most integrated, independent community setting. 1

2 What is the difference between Adult Home Help services through MDHHS and CLS services? Services covered by Adult Home Help are those characterized as unskilled and non-specialized activities including personal care essential to the care of the consumer and maintenance of the home. Services include: Activities of Daily Living (ADL s): Eating & Feeding; Toileting; Bathing Grooming; Dressing; Transferring; and Mobility Instrumental Activities of Daily Living (IADL s): Taking Medication; Meal Preparation and Clean Up; Shopping for food and other necessities of daily living; Laundry; and Housework What is the difference between Adult Home Help services through MDHHS and CLS services? (Cont.) CLS services are often used as a complement to Adult Home Help services; there are differences between these services however. It is important to remember that Adult Home Help Services are generally doing activities FOR the consumer, whereas CLS services are meant to teach skills to the consumer regarding how to perform activities of daily living independently and instrumental activities of daily living. CLS does this by demonstrating, training, assisting (with the consumer present) and encouraging consumers in those task areas. 2

3 In the next slides, we are going to test your knowledge of CLS services. For each question, please choose the response that is the accurate statement regarding CLS services. What is CLS? A. CLS staff are meant to complete activities such as housekeeping/cleaning and cooking on behalf of the consumer. B. CLS is a service that helps consumers learn and assist consumers to become more independent in the community. 3

4 B is the correct answer. CLS is not meant to be a service that does FOR someone, it is not meant to be a housekeeping service for example. CLS staff should be present with the consumer teaching them the skills that the consumer has identified within their individualized plan of service. CLS staff will be assisting, reminding, cuing, observing and guiding consumers on how to perform those tasks independently. What is CLS? A. CLS is provided in community settings such as a consumer s home, the library, and grocery store. B. CLS is provided in the hospital and nursing homes. 4

5 A is the correct answer. CLS services are meant to be provided in a consumer s home and in community settings (such as the library, grocery store, etc.) CLS cannot be provided while a consumer is an institutional setting such as a hospital, nursing home, or jail. This piece is important to remember as while you are reviewing documentation as a case holder, you should also be ensuring that staff are not billing for times when a consumer is in an institutional setting. What is CLS? A. CLS should be approved before other supports are considered. B. CLS is the service of last resort and other supports should be considered first. 5

6 The correct answer is B. CLS should be approved only after natural supports, community supports, and Adult Home Help have been assessed and reviewed. As case holders who ensure that Medicaid services are being approved and provided appropriately, all other supports must be looked at before CLS services can be authorized. CLS services may not supplant Adult Home Help services: what this means is that an assessment by MDHHS for Adult Home Help needs to be requested if CLS services are being requested. **CLS can be authorized during the interim period where the Adult Home Help request is pending, however, if and when the Adult Home Help is approved, we have to ensure that we are not duplicating services. If you have consumers who are receiving CLS services and have never been assessed for Adult Home Help, you should request this as soon as possible and scan the approval or denial into the DHS tab within CIGMMO. What is CLS? A. CLS can be provided when a consumer is sleeping. B. CLS can only be provided when a consumer is awake. 6

7 The correct answer is B; again CLS services are a face-to-face training and skill building service, so what this means is that CLS involves the beneficiary being awake, doing something, or being trained to do something. CLS is not meant to solely monitor or supervise individuals while they are asleep. If a consumer does need assistance transferring at night, or assistance using the bathroom, Adult Home Help services do cover these types of activities. Please note that Expanded Home Help may also need to be assessed through the Michigan Department of Health and Human Services (MDHHS). There may be cases where a consumer is receiving CLS staffing interventions during nighttime hours, so there are some exceptions to fully saying that CLS cannot be provided while a consumer is sleeping. These cases where some CLS staffing may be approved are an exception, and should be rare. Clear documentation of the services and interventions provided are necessary to approve this exception, and the most cost effective, least restrictive options must be reviewed and considered; the Personal Emergency Response System (PERS) being a great example of an alternative service to review for a consumer. How does CLS fit in with Utilization Management? First, we have to start with the definition of what Utilization Management is responsible for: The goal of Utilization Management is to identify, monitor, evaluate, and RESOLVE issues that result from an inefficient delivery of service. Part of Utilization Management is to review chart documents and determine if services are being provided according to the Medicaid Provider Manual and are medically necessary for a consumer. Surprise, you all have done Utilization Management work! Whenever you get a report to see if someone is overutilizing or under-utilizing their authorizations, you are doing UM work. Whenever you are adjusting authorizations based on medically necessity, you are doing UM work. All of these things are components of Utilization Management. 7

8 Background on this Project Why is the CLS Authorization Process being changed? Previously, there was not a Utilization Manager (UM) within CMHCM to develop a CLS process and review CLS authorization requests for medical necessity on an individualized or on a macro level. Once a UM was hired in February of 2015, CLS was identified as a main issue to be evaluated. Upon first review by Utilization Management of CLS services, it was found that for the first quarter of the 2015 fiscal year, 1083 consumers were receiving CLS services (this is a fifth of all CMHCM consumers). To ensure that CLS services were/are being provided equitably across the six CMHCM counties, a Committee was developed, and new tools and a new CLS review process were recommended. Again, CLS services need to be reviewed concurrently to ensure that consumers are receiving medically necessary services. What is the overall goal of the Committee? The CLS Utilization Review Committee exists to standardize the assessment, monitoring, and approval process of CLS services to promote the equitable provision of service throughout the six CMHCM counties. 8

9 Committee Tier Structure Tier 1= Year 1 40 hours or more Tier 3= Year 3 Tier 2= Year 2 Between 20 and 40 hours Between 0 and 20 hours For the first year/first tier of implementation, which will run from December 1 st of 2015 to November 30 th of 2016, the Committee will be focusing on consumers who receive 40 hours or more of CLS services per week during the first year/first tier. These consumers will come up for CLS review when their Person-Centered-Plan (PCP) is due, as the CLS assessment should be completed concurrently with the psychosocial assessment, and will also be a part of the PCP process. For anyone receiving less than 40 hours a week of CLS services; supervisors will continue to review the CLS requests, however, caseholders will still be expected to complete the CLS assessment that was developed and put in the CLS goals, objectives, and interventions that correspond to the assessed needs of the consumer. The Committee will be reviewing the second year/second tier from December 1 st of 2016 to November 30 th of This second tier encompasses consumers receiving 20 hours of CLS services or more. The Committee will then move towards the third year/third tier which will be from December 2017 to November of The end goal of the Utilization Management and Review Committee is to be reviewing all of the CLS cases that are in place to ensure medical necessity. 9

10 Pilot Group Once the Committee developed the tools (such as the CLS Handbook, CLS Assessment, and CLS process) a Pilot Group was identified. These individuals were asked to review and assess 1-2 consumers using the assessment process that was developed. The caseholders completed this work with the families and consumers. A debriefing occurred on July 22 nd where the process as well as the tools were reviewed and updated based on consumer and caseholder feedback. The Committee wanted to give a huge shout out to the Pilot Group members who helped make this process possible. THANK YOU! Clare/Gladwin Jenise Evans Daniel Sheppard Jennifer Dunlop Isabella Cindy Seger Karen Dodds Deb Bauman Midland Valerie Yurgaites Jenny Marshall April VonEitzen (Selective Case Management) Mecosta/Osceola Angela Zywicki Katie Kearney Michelle Summit Writing CLS Goals/Objectives and Interventions 10

11 Why is the PCP Important? Fosters self-reliance and recovery in a strengths-based way instead of fostering dependency Helps consumers express their desires, wants, needs, and dreams in a standardized, measurable way Provides a systematic way of measuring progress for consumers by including the amount, scope and duration of services to be provided Outlines the mutually agreed upon set of services and supports that the individual wants/needs with what CMHCM has agreed to provide based on medical necessity Provides communication between the agency and external providers on services that should be provided The PCP is a requirement put in place by regulatory agencies which provide funding to CMHCM because we need to provide an explanation for the medical necessity of services What Does a Good PCP Need to Include? What is a PCP composed of? Goals Objectives Interventions But wait, aren t goals and objectives basically the same thing? NO; Goals are less structured and are what a consumer wishes to accomplish in their own words. Objectives are measurable and concrete. 11

12 Writing a Good Goal Goals must be clearly stated Goals should reflect why the individual is seeking support Goals should be written in plain language that a consumer will understand Good goals are meaningful and relevant to the consumer Goals are NOT general quality of life statements It is difficult to develop measureable objectives, activities, and supports unless the goal is specific. Think about how you will evaluate success in terms of the goal; this will help you write the goal to ensure that objectives are measureable. Writing a Good Goal Contd. When writing goals, ask yourself: What am I measuring? How will I measure it? How do I know when the goal has been accomplished? Example: Jane s goal: I want to find a job in the community that pays at least minimum wage. The objectives will then provide measureable steps that the consumer will take towards this goal. 12

13 Writing Good Objectives Need to be measurable and include the necessity for the amount, scope, and duration of the service. Need to be related to the overall goal that the consumer has expressed. Are the steps that the consumer is going to take to accomplish the overall goal they have in place. Are Action Oriented and Strengths-based The action needs to be on the part of the consumer, NOT support staff (interventions should include what staff will be training the client to do). Need to be achievable and reasonable (meet the consumer where they are) Should describe a positive change that builds on accomplishments rather than a decrease in symptoms Example Going back to the previous consumer, Jane, remember her overall goal is; I want to find a job in the community that pays at least minimum wage. Some examples of objectives for this consumer would include: Jane will work with staff for an hour, three days a week to search for job opportunities in the community through paper ads, online, and in person applications. Jane will apply for at least three jobs a month in the community in the food and hospitality industries until she finds a job she enjoys. 13

14 What do Interventions Need to Include? AMOUNT, SCOPE, AND DURATION of services. Amount= How much of the service is being recommended (an ACTUAL number is allocated, this MUST match the authorization being requested for the service)? Scope= What service is being recommended based on medical necessity? Duration= How long will this service last (generally this is for the entire year, but certain goals may be time limited)? **For our intent and purpose in speaking about CLS; the interventions of a consumer s plan are going to be where the bulk of your work as a caseholder is done. The interventions section is where CLS staff look to for guidance on what steps they should perform with the consumer, and this is what they are trained on. Example: CLS staff will assist Jane for 2 hours per week with medication management. Staff will verbally prompt Jane to participate in this process, and will supervise that her medications are being taken correctly each morning and at night with dinner. Writing Interventions The interventions section of the PCP should clearly define: Delineation of roles and responsibilities Natural supports/community Supports Adult Home Help services CMHCM services CLS staff 14

15 What is Needed for the CLS process? As a caseholder, you will complete the PCP process as normal. The CLS Assessment will be completed concurrently with the consumer s psychosocial assessment. These will help inform the consumer s goals, objectives, and interventions. The PCP draft will be saved and authorizations will be requested for the consumer. If the consumer is under 40 hours a week of CLS services, your supervisor will review the CLS assessment and documentation. If the consumer is over 40 hours a week of CLS services, you will sign up for a CLS Committee time (this will be covered later on). The most important piece of the individualized plan of service in relation to CLS staff is that the targeted interventions are identified and detailed so that the Committee can ensure that all areas/hours are covered so that staff know what they are supposed to be providing. To help with this task, we have developed templates to remind you that each designated service area should have an intervention associated with it within your plan of service. Here is the Authorization list and templates that were previously discussed. You will see after each area of questions, there are templates present for caseholders to refer to. It is important that these are individualized to the consumer, and should spell out exactly what services are needed by support staff so they can follow these interventions. These are meant to serve as a guide/suggestions for what you should consider when writing a consumer s interventions. 15

16 The following slide is an example of a summary of a consumer s interventions section of their PCP. You will see that all of the services are spelled out, and explain what intervention support staff should be providing each day, and for how many hours per week. It is important that these are well thought out and detailed, because after approval, this is what CLS staff see and are trained on for your consumer. Again, it is important to ensure that each area has interventions so that staff know what they should be working on. 16

17 Assessment Tool Assessment Tool This tool is meant to be used agency-wide regardless of the amount of CLS hours being requested. This tool is meant for both adult consumers and child consumers. The difference in process occurs when a consumer is requesting over 40 hours of service, if they are requesting over 40 hours of CLS services, these consumer cases will also be reviewed by the CLS Utilization Management and Review Committee. When should the CLS assessment be done? In conjunction with the psychosocial assessment process. This allows for the CLS assessment to help inform the discussion around the PCP goals/objectives/interventions. 17

18 This assessment process is participative and should include the consumer, guardian, family and supports to fully identify the areas that the consumer may need help with. Again, the CLS assessment should be completed during the consumer s psychosocial assessment process. This is a tool that is meant to help guide further discussions around the goals/objectives/interventions for the individualized plan of service. The Medicaid Provider Manual Definition for CLS provided to Children under Age 18 Community Living Supports (CLS) provides support to a beneficiary younger than 18, and the family in the care of their child, while facilitating the child s independence and integration into the community. This service provides skill development related to activities of daily living, such as bathing, eating, dressing, personal hygiene, household chores and safety skills; and skill development to achieve or maintain mobility, sensorymotor, communication, socialization and relationship-building skills, and participation in leisure and community activities. These supports must be provided directly to, or on behalf of, the child. These supports may serve to reinforce skills or lessons taught in school, therapy, or other settings. For children and adults up to age 26 who are enrolled in school, CLS services are not intended to supplant services provided in school or other settings or to be provided during the times when the child or adult would typically be in school but for the parent s choice to home-school. 18

19 We are going to be going over the CLS assessment tool in the following slides: please open the tool which was sent to you called CLS Assessment Tool and Authorization Worksheet to follow along. There are four tabs that you will see at the bottom of the spreadsheet. Below is a snapshot of the tabs that are within the spreadsheet. Included are an Information tab, the Assessment tab (this is where the majority of your work as a caseholder will be done), and two colored tabs that represent the detail tab (blue) and the summary tab (green). 19

20 Here is a snapshot of the Information tab of the assessment tool. This tab will provide you with background information around CLS services, as well as further general information about what the differences are between CLS and Adult Home Help and additional clarification. I would suggest that caseholders read these areas over as a background on CLS services. In addition, this information can also be found throughout the CLS Handbook that you were also provided. Assessment Areas Before we move on to the Assessment tab; it is important to note that the below nine areas have been identified as the overall assessment categories: Behavioral Supports and Management Community Activities/Socialization & Relationship Building Food Prep/Kitchen Safety Health, Safety & Home Security Medical & Medication Management Money Management Personal Hygiene Routine Cleaning Routine Maintenance 20

21 Here is a snapshot of the Assessment tab of the CLS Assessment. The top area of the assessment asks you to fill out demographic information such as the consumer s name, ID, the name of the staff completing the tool, whether this is an initial assessment (this means that the someone is requesting CLS services for the first time) or whether it is an update (this will be for anyone requesting continuation of CLS services), the date of the assessment, the date of the UM Committee Review Date (this is the date you sign up to review the case with the committee, we will talk about that process more in a little bit). In addition, this section asks for a breakdown of current authorizations for H2015, H2014, and H2023. The Committee is requesting these different areas to gain a full picture of what other services the consumer is currently receiving. After this section, additional questions are asked around Adult Home Help; again Adult Home Help must be requested if a consumer is receiving CLS services. If the consumer was approved, the Time and Task form should be accessible in the consumer s chart under the DHS tab. If they are denied, the denial letter should also be scanned in to the consumer s chart under the DHS tab. If you are presenting to the committee, this letter of approval or denial must be provided in conjunction with the CLS assessment to ensure that we are not supplanting Adult Home Help services. 21

22 You will see on the bottom half of that particular page is a general information section. This section is to provide the Committee or your supervisor who will be reviewing this case with a more in-depth glance at this consumer s life. Each of these questions provides further information as to what the consumer is doing during the week as well as the supports they may have. The bottom two narrative questions are also meant to provide further information to the Committee and Supervisor while also allowing the consumer and their guardian/supports input into what they are requesting to determine if we can provide this based on medical necessity. Individual vs. Agency Provider of Adult Home Help (AHH) Within assessing for CLS services, it is important to address the differences between an Individual AHH Provider as well as an Agency AHH Provider: Individual AHH Provider is someone who is paid directly by MDHHS; for example a friend, relative or neighbor. The person s name, Joe Smith will be listed on the Time and Task Assignment as the Provider. Agency AHH Provider is either an agency that is contracted through CMHCM or CMHCM may be the agency provider if Self-Determination arrangement. The agency name, Community Mental Health for Central Michigan will be listed as provider on the Time and Task Assignment. Please read all of the directions/instructions carefully throughout the CLS assessment tool as these areas of assistance need to be captured. 22

23 Instructions For each question, please enter Y or y for yes and N or n for no. If the consumer states they need assistance based on the question and they are unable to perform a task independently, you will then be asked if natural supports, community supports, or if adult home help (an individual provider) provides the assistance needed (yes or no). If they do not, and the answer is no, you will move on to state whether or not the consumer requires full, partial, or verbal assistance based on their needs. You will only mark Y for one of these areas (full, partial, or verbal). Full Physical Support - All, or nearly all, steps need to be done for the person. All speaking needs to be done for the person. Partial Physical Assistance - Some steps need to be done for the person. Some, but not all, steps require hand over hand. Some steps require speaking for the person. Verbal Assistance- giving a verbal direction, giving a gestural direction, visual prompts, modeling. Detail Tab Here is a screenshot of the Detail tab. 23

24 Detail Tab Times are automatically calculated based on the level of support (full, partial, or verbal) indicated in the assessment. This eliminates guesswork and calculations done by case holders, and this will be calculated into minutes/week within the detail tab. The Detail tab provides a column(yellow boxes) where case holders can request additional time in each area for consumers (since each consumer has individualized needs and levels of functioning). This area allows case holders to put in positive amounts of time to increase the requested amount, or if a negative time is put in, this will reduce the amount of time which is calculated (if a consumer needs less assistance in a specific area. Summary Tab 24

25 Summary Tab Finally, the last tab on the worksheet is the Summary tab. This is where your consumers total amount of supports (the assessment totals, as well as any additional times that have been requested) will be calculated into a total hours per week. Each area of the assessment will have a total amount of hours, and then the overall total can be seen under that. You will use this total and these area totals to begin the development of the consumer s individualized plan of service interventions. There is also an area of the summary tab that allows you to put in an agency provider, and the total amount of approved AHH services. This will allow you to see the breakdown of what should be requested for AHH and what should be requested for CLS services within the PCP and the authorizations. To provide you with an example of how one of these areas should be completed, we are going to walk through an area of the assessment: for this example, we are going to be looking at C. Food prep/kitchen safety (which you will find on page 4 of the Excel spreadsheet under the assessment tab). Please follow along and enter these in to your excel spreadsheet so you can see how this works. 25

26 Let s pretend this consumer, John, has no other needs other than food prep/kitchen safety right now. I would begin this area of the assessment by asking, John, are you able to store food safely?, if the consumer answers, No, I don t know how to do that but I would like to learn. We would enter N, for no. As a follow-up question we would ask John if there is anyone that can help him learn this skill such as family or friends. In some instances, you may know that the consumer does not have any natural or community supports. It is still important to inquire about these, and you can do this at the very beginning of the assessment. It is important that as caseholders, we try to build those natural and community supports up for the consumer. John is a case where he does not have any natural or community support and he is rather isolated. He has also been denied for Adult Home Help services. Saying this, we would then enter a Y for yes that CLS help will be needed in this area. John requires verbal assistance in this area, so we would enter a Y for verbal assistance and leave the rest of the assistance areas as an N. Continuing down this assessment, we would ask if John is able to plan his own menu for weekly meals. John said that he would like to learn how to manage his diabetes better by choosing the right foods, and that he needs verbal assistance with this; so we would mark this a Yes. After asking, John is able to shop on his own as long as he has a grocery list developed, and does not need assistance in this area; because this is a No, you would skip the following question around whether he has N/S, C/S/ or AHH helping him. Continuing on, after questioning, John is unable to prepare food independently and would like to learn how to cook his own meals. Again, John does not have any other supports, so an N would be entered. John requires verbal guidance to assist him with lunch and dinner preparation, John does know how to cook breakfast as he has a limited repertoire of dishes that he can eat with his diabetes. Since he needs help with lunch and dinner, we would enter 2, for the meals/day needing assistance. John is able to operate all of his appliances, and does not need assistance in this area. John has a difficult time handling hot pans, and sometimes forgets to put on oven mitts and burns himself. He is asking for help in learning how to be safe around hot items. Because this skill would occur during meal preparation, it is not an area that will add any additional time into the calculations. And finally, John is independent and able to eat on his own so no supports are needed. Finally, you will see our note that a clinical consideration of note is that staff should be focused on John s medical diagnosis of diabetes when meal planning. You will continue to do this for each section that the consumer has needs in. You may have one section filled out for someone who only is going to have limited CLS services, or you may have all 9 assessment areas completed; it just depends on the consumer. 26

27 Example Here is what the final assessment area would look like based on our example. For John, if you were to click over to the detail tab, you would see that without any additional time added, John would need assistance for 5.75 hours per week for helping him learn skills around food prep and kitchen safety. Again, if we have a consumer who we know is going to need more time based on their individual case, we can add in additional time for these areas. For John, he has difficult in organization and in planning meals on a weekly basis due to his diabetes. Because of this, we are going to request an additional 30 minutes per week. Please enter this in next to this area. You will notice that the total hours/week at the bottom of this tab will go from 5.75 hours to This is due to the time we have added, and it will calculate automatically. 27

28 Here is what the detail tab would look like for John with our additional time added. Finally, here is what the summary tab would look like with the total amount of hours/week needed for Food Prep/Kitchen Safety. 28

29 Process and Protocol of the CLS Committee CLS Committee Composition The composition of this committee is as follows: Lisa Martinson (Mecosta/Osceola) Beth Zawadil (Midland) ShaVonne Brubaker (Clare/Gladwin) Mary Diepstra (Isabella) Kathie Swan (ad hoc member) Barb Mund (Administration) Kara Kime (Administration) 29

30 Process Steps (Also on Pages 24 and 25 of Handbook) Step 1: Consumer/Guardian makes a new request to obtain CLS, or would like to continue CLS services Step 2: Complete the CLS Assessment Tool (with the consumer/guardian and supports) in conjunction with the consumer s Psychosocial Assessment The CLS assessment will be completed during the psychosocial assessment process. Ideally, this assessment will be completed 1-2 weeks in advance to ensure that the CLS and psychosocial assessment inform the goals, objectives, and interventions that are discussed during the PCP meeting. The PCP (including the CLS goals/objectives/interventions) should be drafted. Authorizations should be requested and will remain pending by the supervisor until the Committee decision is made. Step 3: If the request for CLS services is 40 hours or more of CLS services per week, please sign up for a 15 minute slot within Kara Kime s CIGMMO calendar for a review date and time with the Committee. If the request is under 40 hours a week, the process will not change, and your supervisor will perform the review for the authorizations in place **Please note that if we believe the discussion will take more than 15 minutes due to complicating factors with the Committee s documentation review, we will ask that you sign up for 2 slots, making the total review time 30 minutes. Step 4: Upload the CLS assessment (excel file), CLS documentation (scanned into a PDF) from the past two months to the CLS Documents Tab within the consumer s chart. The AHH Time and Task approval or denial, should be scanned within the Consumer s chart under the DHS tab. Please the Review Committee listserv the Monday prior to when your scheduled time takes place once this is completed (CLSreviewcommittee@cmhcm.org) 30

31 Process Steps Step 5: Present to Committee at Designated Date/Time For the Committee meeting, you will not need to bring anything other than the documents you sent to the Committee about your consumer. If we have significant questions that require chart review, these will be sent in advance of the committee meeting. The 15 minutes of Committee review time allows for questions around the assessment as well as feedback and discussion around the proposed times for CLS services. Step 6: The Committee will discuss the consumer s services with the case holder and will fill out the authorization approval form which will state the amount of services the CLS committee approves Step 7: The Committee will the supervisor the authorization approval form with the Committee s recommendations Step 8: The supervisor will then approve, approve a modified amount, reduce, add, or deny the CLS service authorizations based on the Committee s recommendations Step 9: The case holder will send the Action Notice of approval/reduction/denial (please ensure that 12 days effective notice is provided to allow for Appeal if this is necessary) Step 10: Case holder continuously reviews/monitors medical necessity of CLS services 31

32 Flowchart CLS Committee Review Meetings Upload the requested documentation the Monday before the Wednesday Committee meeting. You can send any questions/concerns to: Presentation at designated date/time In-person or through video/phone conference Question and answer Based on: CLS Assessment Consumer s background/psychosocial assessment PCP Recommendations Follow-Up 32

33 CLS Committee Review Documentation Is extremely important! If you do not send your documentation before the end of the day on Monday, we will be unable to review your case, and your review time will be rescheduled. Committee Record Review Extensive review is done in advance of the Committee meeting each week We are a team and as such, we value your opinion and feedback during our meetings Continuous Review and Monitoring of CLS Services 33

34 Monitoring Function of Case Management/Supports Coordination One of the key functions of case management/ supports coordination is monitoring of Specialty Services and Supports as well as other community services/supports. Documentation of CLS Services Providers are required to document CLS services provided. Requirements include: Date of Service Start Time Stop Time Description of the service provided. The description must be sufficiently detailed to allow reconstruction of what transpired. Signed/dated by person providing service. 34

35 On July 1 st, there was an updated CLS progress note that all providers and individuals being served under Self-Determination Arrangements receiving CLS services are required to begin filling out. This form is not something that CMHCM caseholders will be filling out; rather, this is the documentation that you will be required to monitor on a monthly basis for your consumers that have CLS services. All CLS staff should be filling out progress notes such as this one; if their forms do not look identical to this, that s okay. There are some providers who have been approved to use their previous forms, since it includes all necessary Medicaid components such as date of service, start and stop times, a narrative, and the staff signatures. Again, you are not required to fill out any of this information, this is for the CLS staff providing the service. You will note that it has staff signature and credentials at the end; this is for the CLS staff, not CMHCM staff. If we do not have documentation of the service provided, then it essentially did not happen. The Medicaid Provider Manual does specifically outline these requirements, and documentation requirements are also outlined in CMHCM Provider contracts. Here is an example of the CLS progress note template that Providers were given on July 1 st. 35

36 Monthly Monitoring As a caseholder, you need to be monitoring the CLS services being provided. Here are some of the items to be checking on a monthly basis: Are required elements documented? (Date, Start/Stop Times, Description of service provision, signature/date of provider) Do the services provided match the interventions/supports identified in the PCP? Have the providers of service been trained on the PCP? Is the training documented? (Need scanned into CIGMMO as attachment to PCP) Another piece of documentation that you should be receiving (if you have consumers under Self-Determination arrangements) are the monthly self-determination budget summaries. This is an important piece to be monitoring as you can see whether consumers are going over or under their allocated budgeted CLS hours. This could potentially help you see any issues that are occurring with the case, and could prompt a conversation with the consumer and/or guardian to ask what services are occurring that are different from the initial budgeted service amounts. 36

37 In Conclusion Reminder If you have additional questions, first reference the CLS Handbook which was provided to you. This is a great tool and resource for questions that may come up. Also, you can always ask your supervisor if you need additional guidance around CLS services, or the CLS Utilization Management and Review Committee. Beginning on December 1 st, 2015, you will be completing the CLS assessment for any consumer receiving CLS services. If your consumer receives over 40 hours of CLS services per week, you will also be signing up for a 15 minute Committee review slot (which takes place on Wednesdays from 12-2pm). This review can be done via video or audio conference for those of you outside the Isabella office. The CLS assessment and CLS staff documentation (from providers or Self-determination arrangements) should be uploaded to the CLS Documents tab within CIGMMO. The Adult Home Help Time and Task, or denial letter should be uploaded to the DHS tab within CIGMMO. 37

38 Please Contact Us!! Please do not hesitate to contact us if you have any questions, concerns, or comments. Our Committee now has a listserv where you can reach all of us: CLSreviewcommittee@cmhcm.org 38