Live-in Rule Changes and Service Planning for High Care Needs 1 Effective July 1, 2016 Presented by APD Medicaid Long Term Care
2 Topics to be covered: Live-in Rule Changes Service Planning Options Independent Choices Program Adult Day Services Program Program of All-Inclusive Care for the Elderly (PACE) Service Planning For High Care Needs Hourly Cap Safe Service Planning Scenarios
3 Live-in Services Rule Changes U.S. Department of Labor regulations required changes to who can access live-in service plans (due to the high costs involved). These changes were made in late August, 2015 with the goal of restricting those who can participate in the program. Thanks to your hard work, live-in service plans are decreasing at a rate of approximately 12% a month statewide. Unfortunately, additional changes are still necessary in order to maintain program sustainability.
4 Live-in Services Rule Changes Effective July 1 st, 2016, the In-Home Live-in program will be closed to new individuals. There will be no exceptions to this rule change. If the individual is not currently receiving live-in services prior to July 1 st, they will not have the option to select the program. Assessments completed in June 2016 with a new service plan starting on July 1 st may still qualify and receive live-in services when approved by Central Office.
5 Live-in Services Rule Changes These changes also include receiving live-in service hours under the Independent Choices Program. Individuals currently receiving live-in services as of July 1 st may remain on the program. However, this will most likely change in the near future. Multiple options are currently being considered on the best way to wind-down live-in services for current individuals. A decision and announcement is coming after field and stakeholder input is received.
Service Planning 6 Since individuals will no longer have the option to select live-in services, the first approach may be to develop a 24 hour service plan. Service planning, however, involves much more than authorizing and assigning hours.
Service Planning 7 OAR 411-015-0008 (2) SERVICE PLAN. (a) An individual being assessed, others identified by the individual, and a case manager must consider the service options as well as assistive devices, architectural modifications, and other alternative service resources as defined in OAR 411-015-0005 to meet an individual's service needs identified in the assessment process. (b) A case manager is responsible for: (A) Determining eligibility for specific services; (B) Presenting service options, resources, and alternatives to an individual to assist the individual in making informed choices and decisions; (C) Identifying goals, preferences, and risks; and (D) Assessing the cost effectiveness of an individual's service plan. (d) An eligible individual, or the individual's representative, is responsible for choosing and assisting in developing less costly service alternatives.
8 Community Resources: Service Planning Options to Consider Engage and discuss Natural Supports with family, friends, neighbors. Volunteer services that may be available in the area Volunteer Connections for example. Other community resources find out about the resources available in the area that may be utilized to assist with some care needs of the consumer. ADRC is a great tool to find specific resources.
9 Service Planning Options to Consider continued Outside Agency Supports: Hospice providers: If an individual is enrolled into hospice, work with the agency to determine what kind of assistance they can provide so hours are not duplicated. VA Aid and Attendance: Some veterans may qualify for assistance. Mental Health referrals Contract Agency In-Home Services (Hourly cap and overtime does not apply) Home Delivered Meals
10 Service Planning Options to Consider continued Alternative Program Options: Independent Choices Program Adult Day Services Program Program of All-Inclusive Care for the Elderly (PACE)
11 Service Planning Options to Consider continued Other Options: Emergency Response System Durable Medical Equipment Supplemental K State Plan Services Discuss with the individual/representative regarding other Medicaid LTC service placements Adult Foster Home, Assisted Living, Residential Care Facility, etc.
Service Planning 12 What about individual choice and preferences? An individual may still choose how they want their services delivered. They may accept or reject any offered options. However, individuals must understand that there is a need to develop plans that are cost effective. This is especially important for continued sustainability of the In-Home program.
Independent Choices Program 13 The Independent Choices Program is cost effective because overtime is not applicable. The program is also beneficial to the individual as it provides a monthly flexible cash benefit based on the service plan. The individual decides on the rate of pay and the actual number of hours providers work. Directing care: Individual managed; or Elect a representative Managing Cash Benefit: Individual managed; or Elect a representative; or Pay a bookkeeper/accountant Questions? Find info here or contact the analyst: Contact: Kelsey Weigel Independent Choices Program Coordinator 503-779-6849 Kelsey.C.Weigel@state.or.us
14 Adult Day Services Program The Adult Day Services Program is cost effective as it reduces the number of provider hours on the service plan. It also relieves providers if the individual has high care needs. The program is beneficial to the individual as it provides many activities and community interaction the individual may not otherwise receive. The program may supplement or replace in-home services. Half or full day authorizations are allowed up to 5 days a week.
15 Adult Day Services Program The program provides the following services: Rehabilitative services Assist in arranging transportation to and from the program Social activity and access to the broader community Nutritional meal and snacks Some programs provide nursing services such as medication administration, and health assessments Personal care Questions? Find info here or contact the analyst: Contact: Darwin Frankenhoff, Adult Day Services Program Coordinator 503-947-5162 Darwin.J.Frankenhoff@state.or.us
16 Program of All-Inclusive Care for the Elderly (PACE) PACE is cost effective as APD pays a flat rate to Providence Elder Place to meet the needs of the individual. The program is also beneficial to the individual as Providence provides comprehensive and coordinated care. The individual must be at least the age of 55 and live in a PACE service area. The following counties are served: Clackamas, Clatsop, Multnomah, Tillamook, Washington
17 Program of All-Inclusive Care for the Elderly (PACE) Some of the services include: Home and Community Based Services Nursing Home Care Medical Services Hospice/Palliative Care Therapeutic Services Medical Equipment Transportation Dental Services Mental Health Social Services Medications Medical Supplies Questions? Find info here or contact the analyst: Contact: Cindy Susee PACE Coordinator 503-945-6448 Cynthia.Susee@state.or.us
18 Pop Quiz! 1. Which of the following is not a true statement? a. The live-in service program is ending for new individuals on July 1. b. Service planning includes evaluating cost effectiveness. c. Exceptions to the live-in rule will be granted. d. Adult Day Services may supplement or replace in-home services. 2. True or False: Supplemental State Plan K Services may only be approved if it reduces the individual s need for assistance.
19 Pop Quiz Answer 1. Which of the following is not a true statement? C. Exceptions to the live-in rule will not be granted. 2. True or False: Supplemental State Plan K Services may only be approved if it reduces the individual s need for assistance. True
20 Service Planning for High Care Needs After reviewing with the individual all of the available cost effective ways to meet the individual s needs, and an hourly plan is still needed, here are some things to consider for individuals with high care needs: Hourly service planning is based upon the times when a provider needs to be present to complete ADL/IADL tasks. It is not based upon whether or not a provider lives with the individual. An individual may choose to have a provider live with them. However, an hourly service plan means the provider is free to leave after care is provided.
21 Service Planning for High Care Needs Hours associated with unusually high frequency, duration, or two person tasks (exceptional hours) are still calculated based upon the length of time it takes to manage the need (calculated throughout a 31 day month). Hours can not be calculated solely based upon a schedule or a number of hours per day that is desired by the individual. Schedules are typically necessary for individuals, especially those that have high care needs. However, for paid support time, it must be properly justified. If the calculated hours do not quite equal a set number of hours per day, slight modifications may be approved (i.e. a calculation of 8.2 hours a day may be rounded to 8 or 8.5 hours a day. Just make sure this is clear in the exception request). Hours can not also be calculated by the fact that a paid provider lives with the individual.
22 Service Planning for High Care Needs Hours can t be authorized for the following circumstances: During the individual s sleep hours unless care is actually needed Just in case/preventative type care Times where the individual can most likely be situated and left alone with minimal risk/unlikely to need care Natural supports are providing care To replace external resources (i.e. Adult Day Services or Home Delivered Meals) Non ADL/IADL supports Anxiety, comfort, or companionship hours
23 Service Planning for High Care Needs Service planning for unpredictable, nighttime, and high frequency needs can be more challenging. However, hours are still calculated only by the time spent doing the task. Some examples: Elimination ADL Provider may need to stop by 1-2 times during the nighttime when there is most likely a need, however all night time hours can t be authorized. If it only takes 15 minutes to complete each task (for example), then only 15-30 minutes per night may be authorized. Medical equipment or incontinence supplies may be needed to reduce need. Repositioning Verify if repositioning is frequently and medically required every 2 hours per night (don t assume)
24 Service Planning for High Care Needs Another example: Cognition/Behavior ADLs Unless active assistance is actually needed 24 hours a day, the hours are based only upon how often assistance is required (redirection, cueing, etc.). If a reliable provider lives with the individual and feels that they can t leave the home, they may need to be willing and able to consider themselves a natural support for the times that no care is required, but allows themselves to be available just in case.
25 The Hourly Cap The hourly cap, currently at 220 hours a month or 50 hours per workweek, still applies to all individuals (unless an exception is granted). This also applies to individuals that live with their HCW. Individuals that have more than 220 hours of care per month and wish to receive in-home services have the following options: Hire an additional HCW for the remaining hours The HCW agrees (and is able) to be a natural support for care above 220 hours The individual chooses to have some of their care needs unmet (this could potentially be an unsafe service plan that can t be supported) Under no circumstance may an individual ask the homecare worker to provide more than the hours authorized.
26 Service Planning for High Care Needs Any service plan coming to Central Office for an exception must meet the requirements described in APD-PT-16-020 (described below). Individuals must be able to fulfill the duties of an employer or appoint a representative (that is an unpaid provider) on their behalf. Remember, a paid provider can t be appointed or act as their representative. Note that individuals with exceptional hours more than likely will have a greater responsibility in managing schedules, multiple providers, back up plans, etc. Central Office will not approve exceptions if the above criteria is not met. However, short term exceptions, on a case by case basis, may be approved for transition purposes. Click here for additional information on the employer responsibilities, warning signs, and when the CM must intervene.
27 411-030-0050 Safe Service Planning We must make sure that service plans protect an individual s health, safety, and welfare. When an informed decision is made that jeopardizes health and safety, we need to work with the individual in determining ways to minimize the risk. We can t authorize the following service plans: The service setting has dangerous conditions that jeopardize the health or safety of the individual or provider if the risks can t be minimized Services cannot be provided safely or adequately by the provider due to: The extent of the individual's service needs; or The choices or preferences of the eligible individual or the individual's representative The individual does not have the ability to make an informed decision and does not have a designated or legal representative
28 Safe Service Planning The extent of care that is needed for some individuals may require someone to be immediately available all or most of the time, or during the individual s sleeping hours. If an individual wishes to remain in their own home, we need to make efforts to offer all available options to make the service plan work. If part of the plan includes having a provider live with the individual, it may mean determining if they are willing and able to be a natural support for any standby type time. However, if the above options do not result in a safe service plan, by rule we should not be authorizing the service plan. Alternatives will need to be considered.
29 Pop Quiz! 1. Which of the following statements are not true? a. The hourly cap still applies to all individuals (unless an exception is granted). b. Exceptional hours for Cognition are only granted for actual care being provided. c. We should not authorize service plans that are unsafe, even if the individual agrees to the plan. d. An individual that is unable to direct their care or act as the employer may have the homecare worker take this responsibility if they are designated as a guardian. 2. True or False: Service hours may be authorized for the entire night when there are about 2 or 3 times a provider must stop by and provide assistance.
30 Pop Quiz Answers 1. Which of the following statements are not true? d. An individual that is unable to direct their care or act as the employer may have the homecare worker take this responsibility if they are designated as a guardian. 2. True or False: Service hours may be authorized for the entire night when there are about 2 or 3 times a provider must stop by and provide assistance. False
31 Scenario 1 The individual is diagnosed with dementia. Although he is usually happy with watching TV, he has behaviors that are unpredictable throughout the day. Sometimes he will suddenly get up and wander out of the home, other times he may feel hungry and microwave food, including some metal utensils. He is generally considered unsafe if left alone for any period of time while he is awake. He is currently living with family that takes care of him (including a daughter that is providing the primary care). Service planning: Hours are based upon need, therefore hours can t be assigned for all waking hours in case something comes up. Natural supports have been and are willing to provide meal prep, housekeeping, and shopping as unpaid tasks. Consumer is a Full Assist all areas. It is reported that there is, on average, 3 hours per day worth of redirecting and assisting the consumer with cognitive related tasks. Hours may be reduced further in the future if he starts going to an Adult Day Service program.
32 This plans adds up to 7.38 hours per day in a 31 day month. A service plan may be developed for 7 hours (217 a month) or 7.5 hours (233 a month) if the individual develops a schedule.
33 Scenario 2 The individual is generally bedbound except for the occasional visit to the doctor. His ADL needs, such as repositioning, Toileting (note that he is not incontinent), and Bathing, are managed in bed. His Toileting needs are especially frequent due to the medications he is on. These tasks take longer than usual to accomplish due to the individual being bariatric. He prefers to have someone around at all times due to the possibility of needing assistance, though admits that his care needs are not as extensive at night. He lives alone and does not have any natural supports. Service Planning Exceptional hours are needed for repositioning, Toileting, and Bathing. Emergency Response System will be provided for times no one is available. A provider will come once during the night for repositioning and toileting assistance.
34 This plan adds up to 9.06 hours per day in a 31 day month. A service plan may be developed for 9 hours (279 a month) if the individual develops a schedule.
35 Scenario 3 An individual is diagnosed with quadriplegia. He currently lives in his own apartment with family taking turns providing care. However, due to work schedules and burnout, they are needing some paid assistance as well. He is a Full Assist in all ADL and IADL areas except Cognition (Independent) and Ambulation (Independent as he can use his electric wheelchair). In order to prevent sores, repositioning every 2 hours is required. His catheter care is extensive throughout the day. A family member is still willing to provide some assistance at this time. Family believe someone should always be available to assist him. Service Planning Care every waking hour may be currently required due to his catheter and repositioning needs.. However, hours can t be assigned for standby time. A discussion with a doctor may be needed to see if there are ways to reduce repositioning or catheter care needs. Exceptional hours needed for repositioning, Transfers, and Bladder. Home delivered meals have been offered and accepted.
36 This plan adds up to 8.51 hours per day in a 31 day month. A service plan may be developed for 8.5 hours (264 a month) with a a schedule. This also means that family may need to assist when a HCW is not scheduled. If natural supports can t meet the need, it may difficult to develop a safe service plan.
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