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Presented by: West Central Florida Area Agency on Aging (WCFAAA) January 31, 2012 1.

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Presentation on theme: "Presented by: West Central Florida Area Agency on Aging (WCFAAA) January 31, 2012 1."— Presentation transcript:

1 Presented by: West Central Florida Area Agency on Aging (WCFAAA) January 31,

2  Introductions  Program Updates  Enrollment Management  Medicaid Benefit Counselor Role in your community  Adult Protective Service Referrals  SGR Case Narratives  Medicaid Waiver Concerns and Great CM Documentation  Performance Outcome Measure Overview  Client Satisfaction  Q & A  Kudos 2

3  Martha Caron is the ARC Enrollment Manager ARC Enrollment Management This is her office - NOT! 3

4  Martha’s responsibilities : ◦ Evaluates the availability of State funds ◦ Determines how many clients to serve ◦ Releases highest priority clients for service ◦ Tracks start date of service delivery ◦ Reviews Care Plans submitted for approval 4

5  Case Managers can start services for released clients up to Risk Level/Cost Threshold.  Does NOT apply to MedWaiver clients; advance approval is still required. 5

6 Risk Score Range --- Annual Est. Care Plan Cost: > 0 to 7 = Risk Level $3, >8 to 15 = Risk Level $5, >16 to 26 = Risk Level $7, >27 to 52 = Risk Level $9, >53 to 100 = Risk Level $14,

7  Services implemented must be offered in the program for which the client is released. EXAMPLE: 1. Client is waitlisted for: CCE & HCE 2. AAA releases client for CCE only 3. CCE services can be started but not HCE subsidy 4. HCE can only be started when released by AAA 7

8  Once a level of care planned services has been approved by WCFAAA, further approvals are not required unless the units of service are to be increased. 8

9  Complete the 701B Assessment  If the 701B Priority Score is 1 or 2: ◦ return to ARC ◦ terminate APPL line in CIRTS ◦ restore APCL status  If the client is not to be served for any other reason, terminate APPL and notify ARC. 9

10  If priority score is 5, 4 or 3, submit Care Plan for services needed by the authorized program(s).  Make client ACTV in CIRTS upon approval of care plan services.  If client is on waiting list for multiple programs and their needs are already being met, close out the other program lines. 10

11  Risk and/or Priority Score not provided  Program that services are requested under not indicated  Services requested that are not available under the authorized program  Inadequate justification provided for services requested  Justification states declining condition but no indication of updated assessment  Incorrect/Illegible completion of form 11

12  Transition Case Manager will conduct face to face visit within 10 business days of receiving referral from the ARC  TCM will update CARES 701B and complete nursing home transition plan  TCM will notify CARES via the NHT plan of client’s estimated discharge date and submit updated 701B with request for LOC via the DOEA-CARES form

13  NHT plan must be signed by TCM and client or designated representative when determination has been made that client is able to safely return to community  Once Notice of Case Action is obtained from DCF, TCM must submit NOA to the ARC  Upon receipt of the LOC, the TCM must submit Form 2515 to DCF and request ex parte  Within 14 days of the waiver start date, the TCM must follow up with face to face visit 13

14 In order to bill, the following requirements must be met per the waiver handbooks:  Client resided in nursing home 60 consecutive days by the time they discharged  No more than 20 hrs of TCM can be billed within 6 months of waiver start date  Client has completed and signed NHT plan  Upon nursing home discharge, client is enrolled into ADA or ALW waiver 14

15  If client is unable to transition after TCM services, the TCM will finalize the NHT plan and forward it to CARES for due process notification. Both the TCM and client or designated representative must sign the NHT plan.  In the case that a client cannot transition out of the nursing home and into ADA or ALE waiver, transition case management cannot be billed. 15

16 Working Together with Case Managers 16

17  Kristen ‘Dani’ Gray - serves Hillsborough and Manatee Counties  Carol Keen – serves Polk, Highlands and Hardee Counties 17

18  The MBC takes care of the Medicaid eligibility portion and can save you time.  The MBC expedites these applications- process time after submitting the application is 3-7 days (depending on county) as opposed to 45 days.  MBC’s follow up with DCF for Notices of Case Action (NOCA’s)  MBC’s are able to research clients in DCF’s FLORIDA system as well as FLMMIS 18

19  What is an ex parte? An ex parte is a switch from one Medicaid type to another.  Who can ex parte? Anyone with a “full Medicaid” (Waiver, ICP, Hospice, MMS).  What forms are needed for ex parte? ARC Referral Form, LOC, both pages of the 2515 and sometimes bank statements. 19

20  Who can ex parte? Anyone that has Share of Cost, MMS, ICP, Hospice (Community or ICP) or any type of Waiver.  What forms are needed for ex parte? ARC Referral Form, LOC, both pages of the 2515, and sometimes bank statements. 20

21  New ARC Referral Form-faxed to I&S Fax (see form in appendix)  Please complete all sections on this form, including the date 3008 was received.  The MBC Documentation List can be given directly to the client or care giver (This form is in appendix). 21

22  Level of Care (LOC) and 2515 indicating Case Manager start date and include the Room and Board rate;  Send any income and asset based information that is available; ◦ Any monthly income that is direct deposited can be excluded from the balance of their bank account for the application month. ◦ Subtract income to get the value of the bank account. ◦ Assets can be excluded as burial contract up to $2,500 (see form in appendix). 22

23  What is a QIT? An account that helps you become eligible when you are over the income limit ($2,094).  How do I set up a QIT? Please see Irrevocable Income Cap Trust form in appendix. An elder law attorney can also assist.  How does it work? Basically, any amount over the gross income limit gets deposited into this account each month. 23

24  Receive referral from ARC fax line ◦ #  Research client on DCF Florida, CIRTS and FLMMIS databases;  Call client/caregiver, or facility to discuss income, assets and expenses;  Mail out checklist of verification needed to submit application ◦ checklist includes contact info & instructions to call MBC once all verification is together. 24

25  Client can mail or fax verification if they are able and have a current DCF Medicaid case in process. ◦ If not, MBC will conduct a home visit to gather all verification.  Application is submitted and all verification is faxed to DCF. 25

26  Direct enroll clients-SSI is active, need LOC and verification that the client receives SSI. DCF does not process these clients and you WILL NOT get a NOCA.  Income must be verified from the source. Bank statements may not be used.  When whole life policies have face values that exceed $2500, the cash value must be verified from the source. 26

27  Provider Log: CM’s can use this tool to check the current status of referrals made to MBC’s.  APPL Report: A tool used to track clients that have been released for waiver, but have not yet had eligibility established. 27

28 Kristen ‘Dani’ Gray or Option 1 Referral Fax Fax verification to:

29 Carol Keen or Option 2 Referral Fax Fax verification to

30 Adult Protective Service Referrals 30

31 31

32  Required of all Case Managers  Online on the ARTT System  If you are a new Case Manager and have not taken this training module, please arrange to do so with your supervisor. 32

33 The ARTT Web site is pictured to the left. The ARTT website address is: https:// /reports/artt/artt.html 33

34  Services routinely provided within 72 hours !  Improved Documentation with better detail  No findings by DOEA monitors on APS files! 34

35  Care Plan ALL services for 31 days, then revise for remaining 11 months if CM & API agree to continue services.  Problem continues: Many instances of only CM care planned for 1 month and all other services care planned for 12 months! 35

36  Update ARTT within 72 hours and include actual dates of services.  Include Assessment Summary page with all assessments and updates.  Call API within 24 hours if client refused or delayed services.  Call API if all recommended services were not ordered. 36

37  Specific dates individual was contacted by CM during the 31 days following referral.  Specific dates the individual was assessed  Individual’s abilities, needs and deficiencies observed during all assessments 37

38  specific services and service dates for services provided during 72 hours following referral (include NDP– non-DOEA )  services provided and frequency at which they were provided during 31 days following referral  all contact and discussions with APS staff 38

39  If services could not be provided for reasons beyond control of provider, document all actions taken in an attempt to provide services and/or contact the referred individual  If services were delayed, document why, when services began, and which services were provided.  CM must staff service delay issues with API immediately.  If the API and CM disagree on need for services requested by API, the CM Sup and API Sup jointly review and resolve. 39

40  all contacts and discussions with Nursing Home Diversion providers (if applicable)  when follow-ups are performed ◦ AT A MINIMUM:  before 14 calendar days to ensure services started ( call to client)  By 31st day to determine if services are still needed (call to API) 40

41  Update the current 701B by making hand-written changes on the actual 701B hard copy.  Update Assessment Date (#4d) to current date. (this does not change the initial referral date)  Update Assessment Type (#4f) to ‘U’ for update.  Update Referral Source (#11) to ‘A’ for APS  Update CIRTS with changes noted during re-assessment.  Print out new turnaround report and put into file. 41

42  Made sometime before 14 th day to ensure that services have started.  If CM has already received confirmation of service delivery prior to day 14, no need to make additional call on the 14 th day.  Calls should be documented and include date that services started. 42

43  Continue or terminate services? “Need” vs. “Abuse, Neglect, Exploitation” ? ? 43

44  Before or on 31 st day, CM must speak to API to determine service continuance. Remember to document call attempts and messages left.  If the call is delayed after the 31 st day, an explanation as to why must be included in the notes. 44

45  Is the client likely to be a victim of Abuse, Neglect or Exploitation if services ended ?  Risk score –likelihood of nursing home placement without services  Caregiver in the home?  Income/assets – could they privately pay for services? 45

46  Termination letters do NOT need to be sent to client if it is determined that services should not continue after the 31 day period.  CM should speak with Supervisor, then API, then advise client of termination. ◦ Document case notes regarding decisions and all discussions ◦ Update assessment ◦ Re-write care plan  Put client on APCL list if they would like future services. 46

47 ◦ Similar to MW requirements. ◦ DOEA is closely examining files for:  Client eligibility  Use of current forms  Excessive billing  Repetitive or duplicative documentation  Billable vs. non-billable actions  Reasons for Face to face contact 47

48 OBSERVATIONS! ◦ Case narratives must contain the case manager’s observations of the client:  What did you see in and around the home?  What did the client or caregiver say?  How did the client appear? 48

49 Note review : At the end of your note, ask yourself the following: Does the note justify the time billed?  If not, why not?  What should be included or left out?  Did you record the appropriate time spent and units of services? 49

50 Tips to keep in mind… ◦ Case notes should not be repetitive or contradict previously stated documentation. They should provide a fresh picture of the client’s current condition. ◦ Keep in mind that what your write down can potentially be seen by the client, caregiver or other providers. ◦ Case Narratives must justify units billed 50

51 AVOID “EXCESSIVE” BILLING! ◦ One line case narratives are not sufficient to justify units claimed. Example 1: ◦ “Received Client’s new LOC.” Example 2: “The client received no PECA service as there was no worker available to provide service” Problems with service providers must be addressed in the narrative with a planed course of action noted. 51

52 The purpose of the Assisted Living Waiver program is to promote, maintain, and restore the health of eligible recipients, and to minimize the effects of illness and disability in order to delay or prevent institutionalization. 52

53  At the conclusion of this training, case managers should know the following: ◦ When to contact ALW recipients ◦ What documents to maintain in case records ◦ How to maintain case narratives 53

54  REQUIRED ALW CONTACTS  CASE MANAGER CONCERNS  DOEA MONITORING FINDINGS  DOEA SUGGESTIONS FOR IMPROVEMENT  WCFAAA MONITORING FINDINGS  WCFAAA SUGGESTIONS FOR IMPROVEMENT  BEST PRACTICES 54

55 WHEN TYPE ACTIVITYPROGRAM ALW Monthly Face-to-Face Assess Client Status ALW ALW Quarterly Face-to-Face Care Plan Review ALW ALW Annual Face-to-Face Assessment/Reassessment ALW 55

56  Which tool(s) are now used to monitor your work? 56

57  Eligibility: Gaps in Level of Care  Gaps in Assessments  Care Plan not documented timely  Narrative: ◦ No documentation of client’s condition at face-to-face visits ◦ No documentation of service receipt 57

58  Ensure refresher training sessions for case managers include: ◦ billable or non-billable activities and documentation ◦ proper documentation of monthly client contact ◦ case narratives requirements 58

59 Reimbursable Activities (not specifically addressed) 1)Assisting applicants with enrollment and the Medicaid eligibility application process (if applicable) 2)Conducting and reviewing client assessment and reassessment for service needs 3)Developing and reviewing plans of care 4)Arranging for service delivery 5)Following up and monitoring service provision and quality of services 6)Recording case management activities in the recipient’s record 7)Recipient visitation 8)Telephone, travel time and recording of progress notes associated with billable activities 9)Case closure and termination*  Prior authorization documents, warranty information on equipment purchases, price quotes, assistance with grievance process.  Client specific inter-agency consulting/staffing/communicating (examples: medical professionals, provider agencies, other case management agencies/their case managers, other external entities) 59 MW cannot bill after date of death or after nursing home/hospital entry.

60  Monitor client changes  Monitor receipt of, and satisfaction with, services 60

61  At the end of your note, ask the following: Does the note justify the time billed?  If not, why not?  What should be included or left out?  Did you record the actual times spent and units of service in the case note? Note: Travel time and time spent documenting the case note are included in the note entry. 61

62  Case notes should not be repetitive or contradict previously stated documentation. They should provide a fresh picture of the client’s current condition.  Keep in mind that what you write down can potentially be seen by a client, caregiver or other provider. 62

63  Case Records: ◦ Eligibility: LOC’s and Medicaid printouts ◦ Administrative: Fair Hearing, POA/Legal Guardianship documentation missing ◦ Assessments: Missing assessments or pages, untimely assessments, assessments not updated or completed correctly ◦ Care Plan: missing original care plans, not legible and maintained in detail, not properly signed, quarterly reviews not initialed or dated 63

64  Case Narratives: ◦ Client’s Condition at Face-to-Face Visits:  Client and/or staff observations and reports  ASK: In light of services received, are there discrepancies? ◦ Service Provision:  Document changes to care plan, and why  Document informal supports participation 64

65  Case Narratives: ◦ Service Receipt:  Document review results ◦ Medical Care Episodes:  Missing documentation of changes upon client’s return 65

66  Case Narratives: ◦ Client Satisfaction:  A statement from the client they are satisfied with services, or a similar statement 66

67  Case Narratives: ◦ A narrative is comprehensive when you:  Document purpose of visit  Document care plan reviews  Document eligibility activity  Document reason for untimely assessment  Address unmet client needs  Contact the facility after hospitalization 67

68  Complaints/Grievances:  Document client complaints and how resolved  Case Narratives ◦ Case Management Billing:  Sign the case narratives  Document billable activities  Include case narratives 68

69  Case Management Billing ◦ The Date of Service (DOS) is always the last day of the month for which reimbursement is requested. 69

70  Eligibility: ◦ Contact MBC’s for assistance ◦ Encourage facility involvement ◦ Communicate with the facility ◦ Use documentation receipts 70

71  Administrative/Procedural: ◦ Send 2515’s to MWS for transfers and terminations ◦ Update CIRTS when client info. changes ◦ Notify WCFAAA of adverse incidents ◦ Maintain well-organized case files 71

72  Care Plan: ◦ Thoroughly document problems or gaps ◦ Review care plan service descriptions ◦ Review care plans prior to signing  Case Narratives: ◦ Use narrative templates! It helps! 72

73  Case Narratives: ◦ When A Case Manager Changes:  Spot check case files to ensure duties were completed  Ensure proper training is given  Utilize model case files and case managers 73

74  Great case management included: ◦ Eligibility:  Constant contact with provider facility ◦ Administrative  Well-organized case files ◦ Case Narratives:  Use of narrative templates  Great problem/complaint follow-up 74

75 75

76  The purpose of the A/DA Waiver Program is to promote, maintain, and restore the health of eligible elders and adults with disabilities and to minimize the effects of illness and disabilities in order to delay or prevent institutionalization. 76

77 WHEN TYPE ACTIVITYPROGRAM MW Monthly Telephone Assess Client ADA MW Quarterly Face-to-Face Care Plan Review ADA MW Annual Face-to-Face Assessment or ADA Reassessment Required ADA MW Contacts 77

78  The assessment, care plan and narrative dates should be congruent; that means all of the dates match !  Narratives must describe the client’s current situation, support the need for the case management services provided and the units billed  Changes to care plan services must be documented and include agreement by client/representative. 78

79  Document in the case narrative for all Face- to-face contacts:  Brief description of the Case Manager’s professional observations of the client’s behavior, affect, appearance, dress, grooming, and environment; NOT just a medical diagnosis  Include the Client’s self-reported health, functional, mental, emotional states  Financial or other issues of client concern 79

80  Significant Changes or Medical Care Episodes require follow-up and documentation, to determine the following: ◦ If the consumer is safe ◦ If the 701B and care plan need updating ◦ If additional services are needed  Examples of significant changes include: ◦ Consumer returns from hospital, nursing home, rehab ◦ Caregiver moves or has significant health change ◦ An APS report has been made for an active consumer ◦ The consumer moved to a new home 80

81  CM must maintain Monthly Contact to monitor client changes, receipt of and satisfaction with services; MUST be documented in the case narrative  Typically a phone call  Should not exceed 15 minutes total (1 unit) to complete and document  Attempt to contact recipient at least twice and document in narrative 81

82  In all client contacts, you must make every effort to speak directly with the client, not just the caregiver  If the client is unable to communicate for him or herself, the reason why must be documented in the case narrative at minimum on the annual review and be supported by the 701B assessment Keep in mind … 82

83  When a recipient’s participation in the A/DA waiver is terminated, the case manager must: ◦ If appropriate, Notify the recipient of his right to due process, ( minimum of ten days advance written notice of any termination, suspension, or reduction of services) ◦ Notify all service providers to cancel A/DA waiver services ◦ Notify the local Department of Children and Families ◦ END the Care Plan and, ◦ Document all final contacts in the case narrative and WHY the case is being closed or terminated 83

84  Care Plans must document ◦ Formal and Informal services ◦ Begin and End dates, Revisions, Duration of services, Funding sources ◦ Document all current services and updates ◦ Care Plan is dated and signed by the case manager and the consumer (or the consumer’s caregiver/authorized representative) ◦ Quarterly Reviews are noted with date and CM initials 84

85  The case note for the annual review, quarterly review and monthly contacts should not be repetitive with only a word or two changed from one to the next. It should provide a fresh picture of the client’s current condition.  The case note should not be an essay repeating verbatim everything covered on the 701b. ◦ It should be a summary of the interview with the client and any observations of facts not captured in the assessment 85

86  Legally correct any errors in the case file ◦ NO “WITE OUT,” SCRIBBLES or WRITE OVERS, and over, and over, and over ……  What is a legal correction? ◦ C ross out the error with one line ◦ C orrect the error ◦ D ate the correction ◦ I nitial the correction 86

87  Great case management documentation  Narratives justify units claimed  Avoid “excessive billing” issues  No billing logs in the case narrative documentation  Focus on QUALITY not Quantity; narratives should be relevant, clear and concise 87

88 Quieres Taco Bell? 88

89 89

90 * ADL score * IADL score * APS w/in 72 hrs * Imminent risk * Average time in CCE for MW probable clients * Caregiver likely to continue * Caregiver able to continue * Nutrition * Environment 90

91  APS  Imminent Risk  Caregiver Likely to continue providing care  Caregiver Ability to provide care Statewide Focus 91

92  Currently achieving 8 of 9 goals! CONGRATULATIONS!  Which one is not being achieved? Hint 92

93 Furniture needed repairs No phone Insects visible throughout the house Unsanitary conditions due to odor (client incontinent) Negative aspects included: 93

94 MAYBE- MAYBE NOT MAYBE- MAYBE NOT Ask yourself these questions : Can the client safely stay in the house? Are you imposing your standard of living on the client? Can any of these issues be easily rectified by providing services? 94

95  MAKE IT SHORT & SWEET  Describe the changes from the last assessment. EXAMPLE: Client’s ADL score went from a 5 to a 9. “Client had a mild stroke and now needs bathing and dressing assistance.” 95

96 Mailed March

97 Mailed ReturnedReturn Rate 551 Case Managed 21038% 279 Homemaker 12043% 51 Home Del. Meals 233 Frozen Del. Meals 272 Personal Care % 35% % Totals : 97

98 Case Management Survey It’s all about YOU! 94% know how to contact YOU. 90% believe YOU listen to what they say. 90% believe YOU listen to what they say. 94% believe YOU are polite and treat them with respect. 94% believe YOU are polite and treat them with respect. 94% believe YOU are knowledgeable about the available services. 94% believe YOU are knowledgeable about the available services. 98

99 99

100 ? ? ? ? 100

101 101

102 The end 102


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