1. Presentation of the Hospital At-Risk Criteria Preadmission Screening Pilot October 2006

2. Project Goals Streamline eligibility and access to long-term care services. Provide consumers more choice and flexibility with long-term care services. Reduce hospital and nursing facility length of stay Target individuals for nursing facility transitions. Encourage more collaborate and cooperative working relationships between hospital and nursing facility providers and the aging and disabled provider network.

3. Regulatory Authority Under NJAC 8:85, DHSS has the authority to determine nursing facility level of care and authorize services for any Medicaid eligible individual seeking long-term care services. Traditionally DHSS staff has performed the Pre Admission Screening. Performing a PAS involves both a screening and in- depth assessment.

4. Overview The Office of Community Choice Options (OCCO) has been working with both the Atlantic and Warren County Aging and Disability Resource Connection (ADRC) to pilot the At-Risk Criteria Preadmission Screening Pilot (ARC-PAS) beginning February of 2006. To date, Warren, Hackettstown, Shore Memorial, and Atlanticare (Mainland and City Divisions) hospitals have been participating in the pilot.

5. Who is Appropriate for ARC-PAS Pilot? Meets clinical eligibility for NF level of care and meets at-risk criteria. Financially eligible for Medicaid (or potentially Medicaid eligible in 180 days) and Medicare. Has both Medicare A & B insurance.

6. Who is Inappropriate for ARC PAS Pilot? Individuals with a history of Mental Illness or Mental Retardation Patients going to a nursing facility (sub-acute) for 20 days or less are considered PAS Exempt. Straight Medicaid or on Medicaid Managed Care. Patients seeking admission to a Special Care Nursing Facility (Vent, TBI, Behavioral, Huntington’s, etc.)

7. What is the ARCST? (At-Risk Criteria Screening Tool) Primarily a screening tool instrument with checkboxes. Elements are drawn from DHSS’ At-Risk Criteria for Nursing Facility Placement guidelines (Form LTC-D1) – OCCO review box – Identifying information – Insurance information – MI and MR/Developmental Disability screen – Preliminary clinical screen – Medical, Social and Financial screen – Attestation – Initial Plan of Care

8. OCCO Review Box Authorized – Transfer to NF or Referral to ADRC Not Authorized – OCCO in-depth assessment must be completed onsite at the hospital OCCO reviewer signature and date fields

9. Identifying and Insurance Information Patient demographic information Name, address, DOB, SSN, Medicare/Medicaid numbers, gender, etc. Questions about Medicaid, Medicare, other insurance Would patient’s funds last less than 6 months if placed in NF?

10. MI, MR/Developmental Disability Section Requires Yes or No response to screening question about history and diagnosis of serious MI and/or MR/Developmental Disability If response is Yes, OCCO must be contacted regarding OCCO PAS in hospital

11. Preliminary Clinical Screen Cognitive deficits Skilled or rehab needs ADL functional status Bed mobility Transfer Ambulation Bathing Dressing Eating Toilet Use

12. Medical Section Catastrophic illness Debilitation and/or chronic illness Multiple hospital admissions Previous NF admissions Major health needs

13. Financial Section Check box for either of 2 categories: Income at/below current Medicaid institutional cap of $1809 Individual resources no greater than $2K or resources below $39K Combined couple resources at/below $99,540 Income at/below NJ Care Special Medicaid Programs cap of $817 Individual resources no greater than $4K or resources below $39K Combined couple resources at/below $99,540

14. Social Section Living arrangements are uncertain Lives alone and/or has no immediate support system Caregiver not able to provide adequate care

15. Attestation Section Discharge Planner attests to information on tool and that the patient was screened

16. Initial Plan of Care Section Patient/family/authorized representative acknowledges that he/she was prescreened and received counseling. Following hospital discharge, the discharge planner indicates patient transfer destination and date/time of transfer.

17. Hospital ARC-PAS Pilot Process Discharge Planner completes all sections of the At Risk Criteria Screening Tool (ARCST). ARCST is faxed to OCCO’s Regional Field Office. A Community Choice Counselor reviews the ARCST, then faxes a disposition back to the Hospital Discharge Planner.

18. ARC-PAS Authorized Discharge Planner counsels the patient and family on Medicaid long-term care options If transfer to NF is authorized by OCCO Patient can transfer to NF Discharge Planner faxes the ARCST to NF and the OCCO Regional Office If referral for HCBS waiver is authorized by OCCO Patient is discharged to community Discharge Planner faxes the ARCST to Regional Field Office and OCCO coordinates in-home assessment.

19. ARC-PAS Authorized – Transfer to NF An OCCO Community Choice Counselor will be assigned to perform an in-depth assessment at the NF within 10 business days. Emphasis will be placed on transitioning the resident out of the NF and back into the community as soon as possible.

20. ARC-PAS Authorized – Referral for HCBS An OCCO assessor will conduct an in-depth assessment within 3 business days of client’s discharge from the hospital to determine clinical eligibility for Medicaid waiver participation. If the client doesn’t meet clinical eligibility criteria for a Medicaid waiver, the individual will be referred to the county AAA for alternative services.

21. ARC-PAS Not Authorized If the ARC-PAS transfer to the NF or ADRC is not authorized by OCCO staff, then the case will be assigned for PAS in the hospital. OCCO staff will complete the PAS in the hospital within 72 business hours from the date and time of the initial ARC-PAS referral.

22. OCCO Roles and Responsibilities Review At-risk Screen within 72 hours and return to hospital provider. Return outcome of screen: authorized or not authorized. Perform PAS in hospital for not authorized clients. Receive LTC-2 from community provider to enter for payment. Schedule OCCO Staff for complete assessment n NF within 10 business days of admission. Complete QA follow-up with Hospital and NH for 90 days to address issues and concerns.

23. Hospital Roles and Responsibilities Effectively and timely screening of appropriate clients. Counseling client concerning discharge options in the community and Medicaid application process. Transfer to community care provider. Effective communication with providers and OCCO. Participate in QA evaluation activities.

24. Nursing Facility Roles and Responsibility Receive client from hospital with packet of discharge information and authorized At-risk screen. Fax LTC-2 to OCCO to initiate billing. Notify OCCO of client transfer and request OCCO staff to schedule full assessment within 10 days. Participate in QA evaluation activities. Include OCCO and HCBS Cs Mgt. On IDT for GO and Transition Grant client.

25. ARC-PAS Tracking Discharge planner completes a Client Tracking Form for the purpose of monitoring the flow and outcome of client activity Discharge planner forwards form to OCCO at end of each reporting month OCCO uses tool to cross reference referral and discharge outcomes

26. Quality Assurance OCCO monitors and measures several areas for QA. Accuracy of level of care Timeliness of OCCO in-depth assessments Thoroughness in completing the ARCST

27. QA Accuracy of Level of Care OCCO compares ARC-PAS screenings completed by hospital staff with outcomes of in depth assessments completed by OCCO staff.

28. QA Timeliness of In-Depth Assessment OCCO review of ARCST is completed within 24 business hours from initial receipt of tool. OCCO in-depth assessment (PAS) at NF is completed within 10 business days of NF admission. If ARCST is NOT AUTHORIZED, OCCO conducts in-depth assessment at hospital within 72 hours of initial ARC-PAS referral.

29. QA Thoroughness in completing ARCST ARCST is completed fully and properly

30. Warren County Statistics February through September 2006 98 total referrals – 79 authorized – 0 not authorized – 19 other outcomes 37 NF PAS approved 0 NF PAS denied

31. Atlantic County Statistics August through September 2006 31 total referrals – 24 authorized – 3 not authorized 2 OCCO PAS in hospital approved 1 patient discharged from hospital AMA with subsequent OCCO PAS in community approved – 4 other outcomes 7 NF PAS approved 0 NF PAS denied

32. ADRC Statistics for Referrals Authorized Transfer to ADRC Warren County – 1 referral – 4/17/06 case referred to ADRC by hospital discharge planner – 5/5/06 daughter declined all ADRC services stating assets >$60K Atlantic County – 1 referral – 8/25/06 case referred to ADRC by hospital discharge planner – 9/5/06 caregiver not interested in any LTC program just wants to stay with hospice