OAR Changes. Presented by APD Medicaid LTC Policy

Transcription

1 OAR Changes 1 Presented by APD Medicaid LTC Policy

2 Table of Contents 2 Service Priority OAR Project Overview Why Are We Making These Changes Overarching Changes Changes to ADLS (each ADL will be covered)

3 OAR Project Overview 3 Review of current SPL OAR began in 2015 with local CMs and Supervisors In 2016 APD received Legislative direction to bend the cost curve Created multiple internal workgroups and Rule Advisory Committees Central Office reviewed service case CMs completed 1,100 side-by-side assessments OARs finalized

4 Reasoning Behind Changes 4 More clearly define what is meant by a nursing facility level of care Bend the cost curve by approx. 4% APD Budget is reliant on meeting the reduction target NF LOC is the criteria that allows someone to receive Medicaid funded long term services and supports. It does not mean that is where people receive services.

5 Reasoning Behind Changes 5 Address areas of concern including: Aligning rule language with intent Updating rules to match existing policy Using consistent language throughout all ADLs and IADLS Address areas raised through hearings and QA reviews Make it easier for CMs to assess individuals Make it easier for consumers/families to understand the rules Improve consistency in assessments

6 Overarching Changes 6 Increased minimum frequency in ADLs to at least one day each week totaling FOUR DAYS during a month; This means at least 1 time each week, not 4 times in 1 day Removed the term phases All ADLs and IADLs are now comprised of: Components Tasks All ADLs now have defined and specific assist types Critical Point: During assessments only use the specified assist types Components Example Mobility has Ambulation and Transfers components

7 Reminder Documenting ADL Needs 7 Why is there a need? This is not diagnosis driven. Clearly describe the symptoms of the diagnosis, which are the cause of the need for assistance. How frequent is the need? Words like occasionally, at times, or on bad days are not specific enough. How is the assistance being received? Describe what the provider is doing instead of stating the assist type.

8 Reminder: Documenting Cognition 8 Provide an example of the need that ties to health and safety. Explain how the provider is assisting the individual with the above example. Describe the frequency.

9 Mobility Changes 9 Ambulation Transfer

10 Definition Changes to Ambulation 10 Ambulation still includes all of the former language and now also includes: Going to or from the toileting area. Minimum threshold is now one day per week. This means at least 1 time each week, not 4 times in 1 day.

11 Ambulation: Assistance Levels 11 Minimal Assist Requires HANDS-ON assistance OUTSIDE their home or care setting at least one day each week. May require HANDS-ON assistance from another person to ambulate INSIDE their home or care setting less than one day each week. Substantial Assist Requires HANDS-ON assistance to get around INSIDE their home or care setting at least one day each week.

12 Mobility: Assistance Levels 12 Full Assist ALWAYS needs HANDS-ON assistance inside their home or care setting every time the individual is required to ambulate. Individuals who are confined to their bed are Full Assist in Ambulation.

13 Example of Someone no Longer Meeting Ambulation Definition 13 The consumer experiences seizures 1-2 times a month. After a seizure occurs, the consumer needs the provider to hold him by the arm and assist him to his bedroom to rest. This example does not meet rule requirement as the need for assistance is less than 1x a week.

14 Definition Changes to Transfer 14 Transfer still includes all of the former language and now also includes: Getting on or off the toileting area. As a reminder, Transfer does NOT include: Getting in and out of a motor vehicle; or Getting in or out of a bathtub or shower. Minimum threshold is now one day per week (previously it was 4 days a month).

15 Transfer Assist Levels 15 Independent When an individual is able to complete the activity of transferring in their home or care setting, but require assistance at another location that is not ADA compliant, they are considered to be Independent with Transfers. Assist Needs assistance to transfer at least one day each week. Full Assist ALWAYS requires HANDS-ON assistance to Transfer every time the activity is attempted. When assistance is required with repositioning it should be captured as a task of repositioning in CA/PS and on exception requests.

16 Example of Someone no Longer Meeting Transfer Definition 16 The consumer experiences Multiple Sclerosis. Most days, the consumer experiences no symptoms. However, on average, about 3-4 days in a row per month, she is unable to transfer out of her bed or recliner due to numbness and pain, requiring a provider to physically help her out of the chair. This example does not meet rule requirement as the need for assistance is less than 1x a week.

17 Eating Changes 17

18 Definition Changes to Eating 18 Assistance with nutritional IV or tube feeding is being moved to the definition of Eating. This means consumers who require assistance in nutritional IV or tube feeding may now be assessed as Independent, Assist or Full Assist. Previously, CMs were not able to assess at the assist level for this task. Minimum threshold is now one day per week. Clarified the intent of the phrase, within sight and immediately available. This means that the consumer must have someone able to actively provide HANDS ON assistance either to feed them or to step in when they are unable to clear their airway.

19 Definition Changes to Eating 19 Previously, the Monitoring assist type was used to address a choking need. The assist type has changed to Hands On. To qualify as an Assist, this means that a provider must be required to physically assist an individual that is choking. The rule has been previously trained to this standard, however the rule itself has been modified to clarify the intent. The tasks that are now allowed in Eating are: IV feeding Hands On feeding or hydration Cueing to help the individual complete all of the tasks of eating (getting food to the mouth, chewing, and swallowing) Hands On assistance to address choking

20 Assist Levels in Eating 20 Assist: When eating, the individual requires another person to be within sight and immediately available to: Actively provide Hands On assistance with feeding; Assist with the use of special utensils; Immediate Hands-On assistance to address choking; or Cueing during the act of eating. Full Assist: When eating, the individual always requires one-on-one assistance through all tasks of the activity for direct feeding, constant Cueing to prevent choking or aspiration every time the activity is attempted. Please note that Cueing may be considered a Full Assist only if it is to prevent choking or aspiration.

21 Example of Someone no Longer Meeting Eating Definition 21 The consumer has a history of choking on his food while eating. The provider monitors the consumer while he eats, however the provider has not needed to assist as he has been able clear his airway on his own. The Monitoring assist type is no longer enough. It must be Hands-On. Please note that training has indicated the need for Hands-On assist, but it was not clearly indicated in rule.

22 Elimination Changes 22 Bladder Bowel Toileting

23 Changes to Elimination 23 Elimination has changed significantly: Some tasks that were previously assessed in Bladder and Bowel are now in Toileting. Some tasks are no longer considered in Elimination Some have moved to other ADLs/IADLs; Others are no longer in the assessment.

24 Elimination: Changes to Bladder 24 Bladder now only includes the following tasks: Catheter care; and Ostomy care. It does NOT include the tasks of: Toileting schedule (replaced with new language in toileting); Monitoring for infection (no longer assessed); or Changing incontinence supplies (moved to toileting). Minimum threshold is now one day per week.

25 Bladder Assist Types and Levels 25 Assist Type includes HANDS ON only. Assist Levels: Assist - Requires HANDS ON assistance to complete a task of bladder care at least one day each week totaling four days per month. Full Assist - ALWAYS requires HANDS ON assistance to manage all tasks of bladder care every time the activity is attempted.

26 Example of Someone no Longer Meeting Bladder Definition 26 The consumer has incontinence issues on a daily basis as he does realize the need to urinate at least once per day. The consumer wears incontinence supplies, but is unable to physically change it due to his limited range of motion. His provider must assist with this task. The task described no longer meets the definition of Bladder as no Catheter or Ostomy care is needed. However, it will meet the new definition of Toileting.

27 Elimination: Changes to Bowel Care 27 Bowel Care now only includes the following tasks: Digital stimulation; Suppository insertion; Ostomy care; or Enemas. It does NOT include the tasks of: Toileting schedule; or Changing incontinence supplies. Minimum threshold is now one day per week.

28 Bowel Assist Types and Levels 28 Assist Type includes HANDS-ON only Assist Levels Assist - Requires HANDS-ON assistance to complete a task of bowel care at least one day each week totaling four days per month. Full Assist - ALWAYS requires HANDS-ON assistance to manage all tasks of bowel care every time the activity is attempted.

29 Example of Someone no Longer Meeting Bowel Definition 29 The consumer does not know when he needs to have a bowel movement. He is on a daily toileting schedule and must be cued to follow this schedule due to his cognitive needs. Without assistance, he will have an accident and require cleansing afterward. The toileting schedule task itself no longer meets the definition in any category of Elimination. Cueing to prevent incontinence is now considered in Toileting.

30 Elimination: Changes to Toileting 30 Toileting now only includes the following tasks: Cleansing after elimination; Adjusting clothing in order to eliminate; Changing soiled incontinence supplies or clothing; or Cueing to prevent incontinence.

31 Elimination: Changes to Toileting 31 It does NOT include the tasks of: Getting to/from or on/off the toileting area; These tasks are now assessed in Ambulation and Transfers, respectively. Cleaning and maintaining the toileting area or assistive devices. This is now considered Housekeeping regardless of the magnitude or frequency of the need. Minimum threshold is now one day per week.

32 Assist Types and Levels for Toileting 32 Assist Types Hands On assistance; and Cueing to prevent incontinence. Cueing may only be used for preventing incontinence.

33 Assist Types and Levels for Toileting 33 Assist Levels Assist: Even with assistive devices, the individual requires Hands-On assistance from another person with a task of toileting or cueing to prevent incontinence at least one day each week totaling four days per month during the assessment timeframe. Full Assist: The individual is unable to accomplish all tasks of toileting without the assistance of another person. This means the individual needs assistance of another person through all tasks of the activity, every time the activity is attempted.

34 Example of Someone no Longer Meeting Toileting Definition 34 The consumer does not have the sensation of when he needs to urinate. On a daily basis, he will not make it to the toilet on time, resulting in urine getting on the floor. The provider must clean the floor each time this occurs. Cleansing the floor due to urine incontinence is no longer considered a task of Toileting. The task of cleansing the floor is now addressed in Housekeeping.

35 Cognition Changes 35 4 New Components Self-Preservation Decision-Making Ability To Make Self Understood Challenging Behaviors

36 Changes to Cognition 36 The former components have been replaced with 4 new components: Self-Preservation; Decision-Making; Ability To Make Self Understood; and Challenging Behaviors

37 Changes to Cognition 37 For each assist level, individuals must have a documented history of actions or behaviors showing they need help ensuring their health and safety. Individuals are assessed based upon their functioning on prescribed medications. CMs must assess the consumer's understanding of the risks and consequences of refusing to take their medication. APD still cannot serve individuals for whom mental illness is the primary driver of need if they are under the age of 65. Refer to MED.

38 Overarching Assist Levels 38 Each component is different but all include the following: Minimal Assist: The individual requires assistance at least one day each month or is event specific. Substantial Assist: The individual requires assistance at least daily. Full Assist: The individual needs constant assistance to the level that the individual may not be left alone. Please note that the Assist need level is now assessed as either Minimal or Substantial Assist.

39 Self-Preservation Definition 39 Self-Preservation means the individual s actions or behaviors that reflect the individual s understanding of their health and safety needs, and how to meet those needs. Self-Preservation refers to the individual s ability to recognize and take action in a changing environment or a potentially harmful situation. This does not include engaging in risk or life threatening acts when the individual understands the potential consequences of their actions.

40 Self-Preservation Tasks 40 Self-Preservation tasks includes, but is not limited to: Being oriented to their community and surroundings; Understanding how to safely use appliances; Understanding how to take their medications; Understanding how to protect themselves from abuse, neglect or exploitation; or Understanding how to meet their basic health and safety needs.

41 Self-Preservation Assist Types 41 Self-Preservation includes the following assistance types unless otherwise indicated in the assist level: Cueing; Hands-on; Monitoring; Reassurance; Redirection; or Support.

42 Self Preservation Assist Level and Example 42 Minimal Assist: The individual needs assistance to ensure they are able to meet their basic health and safety needs. Minimal Assist Example: The consumer goes to the doctor once per month. When this occurs, the consumer is lost and confused. The caregiver must ensure that he gets to the car, to the doctor s office and back again. Without assistance the consumer has gotten lost and had to be brought back home by law enforcement.

43 Self Preservation Assist Level and Example 43 Substantial Assist: The individual requires assistance because they are unable to act on the need for selfpreservation nor understand the need for self-preservation. Substantial Assist Example: The consumer tries to cook on the gas stove but forgets to light the burner. She has been hospitalized because of Carbon Monoxide poisoning. She has also burned herself on the heating element. She tries to cook daily. Her caregiver must monitor her at meal times every day. Additionally, if the consumer goes just a few homes away from her yard, she cannot find her way home. She does not try to go out often but at least one time per day she must be redirected.

44 Self Preservation Assist Level and Example 44 Full Assist: The individual requires assistance to ensure that they meet their basic health and safety needs throughout each day. FA only includes Cueing, Hands On, Reassurance, and Redirection. Full Assist Example: The consumer has advanced Dementia and is living in a memory care facility. The consumer must be supported all day, every day because of the level of dementia. The consumer no longer understands basic life sustaining activities such as eating, drinking, bathing and elimination. The caregiver must provide Hands On and Cueing assistance throughout the day. The consumer cannot be left alone for even short time periods each day.

45 Decision Making Definition 45 Decision Making means the individual s ability to make decisions about activities of daily living, instrumental activities of daily living, and the tasks that comprise those activities.

46 Decision Making Tasks 46 An individual needing assistance demonstrates: They are unable to make decisions, Needing assistance in understanding how to accomplish the tasks necessary to complete a decision, or They do not understand the risks or consequences of their decisions. This is different than self-preservation. In this component, a consumer may know that they need to eat but they cannot think through the steps to get food.

47 Decision Making Assist Types 47 Decision-Making includes the following assistance types, unless otherwise indicated in the assist definitions: Cueing; Hands-on; Monitoring; Redirection; or Support.

48 Decision Making Assist Levels 48 Minimal Assist: The individual requires assistance at least one day each month with decision-making. The need may be event specific. Example: Mr. Smith cannot follow through on making decisions. He knows that he needs to go to the doctor but he cannot remember the steps it takes to call the doctor and schedule the appointment. His caregiver has to schedule the appointment, keep the appointment reminder visible, cue him to get ready for the appointment and help him to get to there. Mr. Smith has CVD and sees his doctor monthly. Without support, Mr. Smith misses his critical appointments.

49 Decision Making Assist Levels 49 Substantial Assist: The individual requires assistance in decision-making and completion of ADL and IADL tasks at least daily. Example: The consumer cannot make decisions independently. She must be cued through each decision. As an example, she knows that she is hungry but cannot remember how to go to the kitchen, take out food or prep it. She also forgets the steps necessary to take her medications. Her caregiver must cue, monitor and provide support throughout common ADL and IADL tasks. She has been hospitalized because she did not eat.

50 Decision Making Assist Levels 50 Full Assist: The individual requires assistance throughout each day in decision making. The individual may not be left alone without risk of harm to themselves or others. FA only includes Cueing, Hands-on Reassurance, Redirection Example: The consumer has advance dementia and makes no decisions independently. The caregiver must cue, support and provide hands-on assistance throughout the entire day. The consumer cannot be left alone. The consumer was found in stupor previous to being on services.

51 Ability to Make Self-Understood Definition 51 Ability to Make Self-Understood means the individual s cognitive ability to communicate or express needs, opinions, or urgent problems, whether in speech, writing, sign language, body language, symbols, pictures, or a combination of these including use of assistive technology. An individual with a cognitive impairment in this component demonstrates an inability to express themselves clearly to the point their needs cannot be met independently. Ability to make self-understood does not include the need for assistance due to language barriers or physical limitations to communicate.

52 Ability to Make Self-Understood Assist Types 52 Ability to make self-understood includes the following assistance types, unless otherwise indicated in the assist definitions: Cueing, Monitoring, Reassurance, Redirection or Support.

53 Ability to Make Self Understood Definition and Example 53 Minimal Assist: The individual requires assistance in finding the right words or in finishing their thoughts to ensure their health and safety needs. Minimal Assist Example: The consumer, dx with dementia, is unable to tell her caregiver when she is hungry or when she needs her pain medications. CM observed consumer struggling to find the words to explain to her caregiver that she was thirsty. The caregiver must try to interpret what the consumer needs or cue the consumer with appropriate words of expressions.

54 Ability to Make Self Understood Definition and Example 54 Substantial Assist: The individual requires assistance to communicate their health and safety needs at least daily. Substantial Assist Example: The consumer is no longer able to express his needs, including asking for food or water. The caregiver interprets sounds and facial expression to determine if the consumer needs something. The CM saw the caregiver provide reassurance while the consumer tried to express himself. He can be left alone for short period of times without endangering his safety.

55 Ability to Make Self Understood Definition and Example 55 Full Assist: The individual requires assistance throughout each day to communicate and is rarely or never understood and cannot be left alone Full assist includes hands on assistance. Full Assist Example: The consumer cannot be left alone because she cannot tell anyone she is in pain or if her limbs are in an uncomfortable position. The CM saw the consumer become agitated and cry out wordlessly when the caregiver left the room. The caregiver must help the consumer through hands-on assistance to help the consumer communicate non-verbally.

56 Challenging Behaviors Definition 56 Challenging Behaviors means the individual exhibits behaviors that negatively impact their own or others health or safety. An individual who requires assistance with challenging behaviors does not understand the impact or outcome of their decisions or actions. Challenging behaviors include, but are not limited to, those behaviors that are verbally or physically aggressive and socially inappropriate or disruptive. Challenging behaviors does not include behaviors when the individual understands the risks and consequences of their actions.

57 Challenging Behaviors Definition 57 Challenging behaviors includes the following assistance types, unless otherwise indicated in the assist definitions: Cueing, Hands-on, Monitoring or Redirection

58 Challenging Behaviors Definition and Example 58 Minimal Assist: The individual requires assistance dealing with a behavior that may negatively impact their own or others health or safety. The individual sometimes displays challenging behaviors, but can be distracted and is able to self-regulate behaviors with reassurance or cueing. MA includes reassurance assistance. Minimal Assist: The consumer has Huntington s Disease. He becomes agitated and disruptive to others. He has a history of shoving other residents in MCC. The caregiver must provider reassurance and monitoring. He can be redirected and is able to get back in control "with reassurance or cueing. This occurs three days per week.

59 Challenging Behaviors Definition and Example 59 Substantial Assist: The individual displays challenging behaviors and assistance is needed because the individual is unable to self-regulate the behaviors and does not understand the consequences of their behaviors. Substantial Assist Example: The consumer has significant challenging behaviors. She strikes out at others at least daily. She has been hospitalized because she hurt herself while in a behavioral outburst. The consumer is unable to self-regulate her behaviors and does not understand the consequences of her actions. The caregiver must provide reassurance, redirection, monitoring, cueing and handson support, when needed.

60 Challenging Behaviors Examples 60 Full Assist: The individual displays challenging behaviors that require additional support to prevent significant harm to themselves or others. Full Assistance does not include monitoring. Full Assist Example: The individual has a significant TBI and is no longer able to manage his behaviors. Every day he must have one to one support. The caregiver provides redirection, reassurance and hands on support. The consumer can never be left alone because of the significant danger to others.

61 Eligibility Based on Cognition 61 To meet Full Assist in cognition (SPL 3) an individual must require: Full assistance in one (1) component; or Substantial assistance in two (2) components. Individuals assessed as minimal assist in multiple components may receive cognition hours but do not meet eligibility criteria

62 Non Eligibility ADLs 62 Bathing & Personal Hygiene Dressing & Grooming

63 Changes to Bathing & Personal Hygiene 63 Minimum threshold is now one day per week. No other changes have been made to this ADL.

64 Changes to Dressing & Grooming 64 Minimum threshold is now one day per week. Assessing the tasks of Dressing have changed. Task 1: Consider the individual s ability to complete the task of putting on clothing, including shoes and socks. Task 2: Consider the individual s ability to complete the task of taking off clothing, including shoes and socks. When an individual requires another person to complete any portion of the task, it is considered the inability to complete the full task (i.e. if they are unable to put on their shirt without assistance, they are considered as unable to complete task 1). No other changes have been made to this ADL.

65 Feedback 65 During the transition of these changes, please send questions to the following s: Medicaid: OPI/Non-Medicaid: