ALLOWED VS. AUTHORIZED HOURS CASE MANAGEMENT IN-SERVICE POWER HOUR JULY 14, 2016 MEDICAID APD LTC SYSTEMS 1
AGENDA PURPOSE PLANS BELOW PLANS ABOVE - EXCEPTIONS EXCEPTIONS FOR STATE PLAN PERSONAL CARE 2
Purpose FOR IN-HOME SERVICE PLANS, CA/PS PROVIDES A MAXIMUM NUMBER OF HOURS BASED UPON THE TYPICAL NEEDS OF A CONSUMER. HOWEVER, SERVICE PLANNING MAY INVOLVE ALLOWING A LOWER OR HIGHER NUMBER OF HOURS BASED UPON THEIR ACTUAL NEEDS. THE PURPOSE OF THIS TRAINING IS TO DISCUSS WHEN IS IT APPROPRIATE TO CHANGE THE NUMBER OF HOURS ALLOWED. 3
WHEN MIGHT IT BE APPROPRIATE TO DECREASE HOURS? OPTIONS TO SELECT IN OREGON ACCESS: # OF PEOPLE IN THE HOUSEHOLD CM DETERMINATION CONSUMER DECLINED DECLINED DUE TO PAY-IN NATURAL SUPPORT NOT AVAILABLE PROVIDED BY ANOTHER AGENCY 4
2 CONSUMER HOUSEHOLD OAR: 411-030-0070(3)(C) LOWER CASE C WHEN 2 OR MORE INDIVIDUALS ELIGIBLE FOR IADL TASK HOURS LIVE IN THE SAME HOUSEHOLD, THE ASSESSED IADL NEED OF EACH INDIVIDUAL MUST BE CALCULATED. PAYMENT IS MADE FOR THE HIGHEST OF THE ALLOTMENTS AND A TOTAL OF 4 ADDITIONAL IADL HOURS PER MONTH FOR EACH ADDITIONAL INDIVIDUAL TO ALLOW FOR THE SPECIFIC IADL NEEDS OF THE OTHER INDIVIDUALS. 5
CM DETERMINATION WHEN THE HOURS ARE REDUCED BASED UPON THE ACTUAL HOURS NEEDED FOR THE SERVICE PLAN. 6
ADL/IADL EXAMPLES TO REDUCE HOURS AMBULATION/TRANSFER: THE CONSUMER STAYS IN BED MOST OF THE TIME, NOT REQUIRING ASSISTANCE VERY OFTEN. ELIMINATION: THE CONSUMER IS ON DIALYSIS/SPECIFIC MEDICATIONS THAT DECREASE THE FREQUENCY TO USE THE TOILET. BATHING: THE CONSUMER CHOOSES TO HAVE THEIR BATHING NEEDS MET INFREQUENTLY (I.E. 1-3 TIMES PER WEEK VS DAILY). DRESSING: THE CONSUMER USUALLY WEARS CLOTHING THAT TAKES MINIMAL TIME TO MANAGE. HOUSEKEEPING: THE CONSUMER LIVES IN A HOME THAT REQUIRES MINIMAL CLEANING. MEAL PREP: THE CONSUMER MAY EITHER SKIP OR ONLY EAT A MINIMAL AMOUNT IN ONE OR MORE MEAL PREP CATEGORY. 7
DECLINED WHEN THE CONSUMER DOES NOT WISH TO HAVE THE NEED MET AT ALL OR IS DECLINING THE NUMBER OF. Example: The consumer does not eat breakfast. The consumer has bathing needs but declines assistance for personal reasons. 8
DECLINED DUE TO PAY-IN WHEN THE CONSUMER WANTS THEIR HOURS REDUCED DUE TO PAY-IN. 9
NATURAL SUPPORT / HOURLY OR LIVE-IN WHEN THE CONSUMER USES AN UNPAID PROVIDER FOR SOME OF THEIR HOURS. Providers that are currently unpaid should have a reason why they should be paid. ADL/IADL needs are considered individually. Some may be paid, while others may remain unpaid. 10
NATURAL SUPPORT CONSIDERATIONS WHY IS THE PROVIDER NO LONGER ABLE TO VOLUNTARILY PROVIDE THE CARE? ADL/IADL NEEDS ARE CONSIDERED INDIVIDUALLY. SOME MAY BE PAID, WHILE OTHERS MAY REMAIN UNPAID. SOME PROVIDERS (ESPECIALLY FAMILY MEMBERS THAT ALREADY PROVIDE THIS CARE), MAY BE WILLING TO CONTINUE ASSISTING WITH SOME OF THE IADL TASKS WITHOUT BEING PAID. CONSUMERS AND PROVIDERS THAT LIVE TOGETHER MAY HAVE SHARED TASKS. FOR EXAMPLE, IF THE PROVIDER IS ALREADY PREPARING A MEAL FOR THEMSELVES OR GOING ON A SHOPPING TRIP, CAN THEY ALSO PROVIDE THE ASSISTANCE AS A NATURAL SUPPORT TO THE CONSUMER? WE CAN T REQUIRE OR ASSUME PROVIDERS WILL CONTINUE AS A NATURAL SUPPORT. HOWEVER, WILLING AND ABLE NATURAL SUPPORTS SHOULD NOT BE OFFERED THE ABILITY TO BE PAID UNLESS CIRCUMSTANCES CHANGE. 11
PROVIDED BY ANOTHER AGENCY WHEN ANOTHER PROVIDER IS PROVIDING SERVICES WHICH WOULD OTHERWISE BE INCLUDED IN THEIR SERVICE PLAN. Example: Home Delivered Meals is providing lunch for the consumer. 12
THE BIG QUESTION: HOW MANY HOURS SHOULD I REDUCE THE ADL/IADL BY? OAR 411-030-0070 STATES THAT HOURS ARE BASED UPON THE NEEDS OF THE INDIVIDUAL. HERE ARE SOME TIPS TO CONSIDER: CALCULATE THE ACTUAL TIME NEEDED TO PROVIDE THE CARE. CUT THE HOURS BASED UPON A PERCENTAGE (DETERMINE WHAT IS REASONABLE). FOR ONGOING ASSESSMENTS, IF IT IS CLEAR THAT CARE NEEDS ARE BEING MET ADEQUATELY, THERE IS NO REASON TO INCREASE THE HOURS EVEN IF THE SERVICE PLAN ALLOWS YOU TO (CM DETERMINATION). FOR NEW (AND ONGOING) ASSESSMENTS, DISCUSS WITH THE CONSUMER WHAT THEY WOULD LIKE TO USE THEIR HOURS FOR. AVOID AUTOMATICALLY ASSIGNING ALL OF THE HOURS THAT HAVE BEEN ASSESSED. 13
EXCEPTIONS WHEN MIGHT IT BE APPROPRIATE TO INCREASE HOURS? TWO PERSON TASKS LONG DURATION MEET SPECIFIC MEDICAL NEEDS HIGH FREQUENCY MEET SPECIFIC MEDICAL NEEDS COGNITION/BEHAVIOR SUPPORT 14
ALLOWED HOURS EXCEPTIONS TIP 1: EXCEPTION HOURS ARE NEED BASED ONLY (MONITORING, BEING AVAILABLE JUST IN CASE OR FOR COMPANIONSHIP ARE NOT ALLOWED. TIP 2: EXCEPTION HOURS SHOULD BE CONSIDERED ONLY WHEN THE INDIVIDUAL HAS NEEDS THAT GO BEYOND WHAT IS CONSIDERED TYPICAL. TIP 3: BE SURE TO NOT DUPLICATE HOURS. FOR EXAMPLE: MAY REPORT THAT BATHING TAKES AN HOUR TO COMPLETE, HOWEVER PART OF THAT ESTIMATE INCLUDED DRESSING. 15
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EXCEPTIONS TWO PERSON TASKS: TWO PROVIDERS MAY BE NEEDED IN ORDER TO PROVIDE AN ADEQUATE LEVEL OF CARE FOR CERTAIN TASKS. FOR EXAMPLE: TRANSFERS, TOILETING, BATHING 17
EXCEPTIONS HIGH FREQUENCY NEEDS: IF THE CONSUMER HAS A HIGH LEVEL OF FREQUENCY TO MEET THEIR SERVICE NEEDS. FOR EXAMPLE: THE CONSUMER MAY TAKE A PRESCRIPTION THAT REQUIRES THEM TO USE THE TOILET SEVERAL TIMES THROUGHOUT THE DAY. 18
EXCEPTIONS LONG DURATION: IF THE CONSUMER TAKES A LONG PERIOD OF TIME TO MEET THEIR SERVICE NEED. FOR EXAMPLE: THE CONSUMER MAY REQUIRE A BED BATH THAT TAKES LONGER TO COMPLETE DUE TO CONTINUED REPOSITIONING THROUGHOUT THE PROCESS. 19
EXCEPTIONS MEET SPECIFIC MEDICAL NEEDS: ADDITIONAL HOURS MAY BE APPROPRIATE WHEN TASKS SUCH AS MANAGING OXYGEN, DIABETIC MONITORING, OR VENTILATOR EQUIPMENT IS PERFORMED. 20
EXCEPTIONS COGNITION/BEHAVIOR SUPPORT: IF TASKS TAKE LONGER DUE TO COGNITIVE IMPAIRMENT OR BEHAVIORS. THESE HOURS SHOULD BE ASSIGNED TO THE SPECIFIC ADL/IADL AS NEEDED. BEHAVIORS NOT TIED TO AN ADL/IADL SHOULD BE ASSIGNED UNDER COGNITION. 21
The green and yellow circles on the service plan and the exceptions calculator should match. 22
EXCEPTION HOURS FOR STATE PLAN PERSONAL CARE ADDITIONAL HOURS MAY BE REQUESTED WHEN 20 HOURS PER MONTH DOES NOT MEET THE CONSUMER S NEEDS. ONE TIME INTENSIVE HOUSECLEANING MAY ALSO BE APPROVED. 2 HOURS: BASIC PERSONAL HYGIENE 2 HOURS: TOILETING, BOWEL & BLADDER 2 HOURS: MOBILITY, TRANSFERS & REPOSITIONING 2 HOURS: NUTRITION 2 HOURS: MEDICATION/O2 MANAGEMENT 2 HOURS: DELEGATED NURSING TASKS 5 HOURS: COGNITIVE & EMOTIONAL ASSISTANCE 23
TOOLS EXCEPTIONS WEBPAGE: HTTP://WWW.DHS.STATE.OR.US/SPD/TOOL S/CM/EXCEPTIONS/INDEX.HTM EXCEPTIONS REQUEST EMAIL: SPD.EXCEPTIONS@DHSOHA.STATE.OR.US STATE PLAN PERSONAL CARE WEBPAGE: HTTP://WWW.DHS.STATE.OR.US/SPD/TOOL S/CM/SPPC/INDEX.HTM ASSESSMENT, SERVICE PLANNING & CAPS WEBPAGE: HTTP://WWW.DHS.STATE.OR.US/SPD/TOOLS/C M/CAPSTOOLS/INDEX.HTM NATURAL SUPPORTS WEBPAGE: HTTP://WWW.DHS.STATE.OR.US/SPD/TOOLS/C M/CAPSTOOLS/NATURAL_SUPPORTS.PDF APD MEDICAID ANALYST & CASE MANAGEMENT ANALYST CONTACT LIST: HTTP://WWW.DHS.STATE.OR.US/SPD/TOOLS/ MEDICAID%20ANALYST%20CONTACT.HTM 24