1. Adult Foster Care Lisa Prince and Rosie McKenna March 27, 2014 BIA-MA Conference MCAFC Leadership Knowledge Advocacy

2. Adult Foster Care Also known as “Adult Family Care” or “Enhanced Family Care” In January 2014 there were 73 AFC providers supporting more than 6000 members across the state.

3. Program Basics AFC is a residential model that provides direct care which includes 24-hour supervision and assistance as needed with activities such as bathing, dressing, eating, toileting, transfers and mobility. Further assistance to be provided with laundry, shopping, housekeeping, meals, and other personal care services as needed. Qualified Caregiver—cannot be spouse, parent of minor children or other legally responsible relative Qualified Setting in the state of Massachusetts Nursing Oversight Case Management

4. Member Eligibility MassHealth members with coverage types: StandardCommonHealth Program of All-Inclusive Care for the Elderly (PACE) Senior Care Options (SCO) One Care Program (began October 2013) Age 16 or older, not abusive of drugs/alcohol, not a danger to self or others, continent or manageable incontinence, requires assistance with Activities of Daily Living, and willing to accept the program model of care Not receiving similar services at the same time, regardless of payer source Duplicative: – Personal Care Attendant (PCA) – GAFC – Shared Living – Home Care Services (some limited exceptions for Waiver clients) Not Duplicative: – Day programs (Day Hab, ADH, etc) – Hospice, VNA, Continuous Nursing, etc.

5. Intake Process AFC providers must complete all of the following preadmission procedures and steps: 1.conduct a preadmission meeting with the member to determine their needs and desires; 2.identify appropriate potential AFC caregivers and qualified settings; 3.schedule and conduct meetings with the member and potential AFC caregiver(s) 4.submit and obtain clinical authorization of payment for AFC services.

6. Authorization MassHealth makes determinations based on physician’s summary, request for services, completed assessment, and a provider’s statement of ability to provide care PACE, SCO and One Care have their own separate authorization processes, which may vary in requirements

7. Activities of Daily Living (ADLs) ADLs for determining eligibility : 1.Bathing (full body bath or shower) 2.Dressing, including street clothes and undergarments, but not solely help with shoes, socks, buttons, snaps or zippers 3.Toileting, if the member is incontinent (bladder or bowel) or requires scheduled assistance or routine catheter or colostomy care 4.Transferring, if the member must be assisted or lifted to another position 5.Ambulating, if the member must be physically steadied, assisted, or guided one-to-one in ambulation, or is unable to self-propel a wheelchair appropriately without assistance of another person 6.Eating, if the member requires constant supervision and cueing during the entire meal, or physical assistance with a portion of all of the meal.

8. Level of Care There are two levels of care supported through the AFC program. – Level I AFC: requires that the member have a medical or mental condition that requires daily physical assistance or cueing and supervision to complete one of the following activities: bathing, dressing, toileting, transferring, ambulating or eating. – For Level II or “Enhanced AFC”—member requires physical assistance with 3 ADLs; or 2 ADLs and the management of a behavior that requires caregiver intervention, such as wandering, verbally or physically abusive, socially inappropriate/disruptive or resists care. – Determination of service level is completed by the AFC provider on admission, annually and when there is a significant change in the member’s clinical status. The provider must use the assessment tool designated by MassHealth to document the need for Level I or Level II. – The nursing and case management oversight is determined by the level of care. The caregiver stipend is greater for Level II care.

9. Allowable Leave Days Leave days go to the member, not the caregiver Medical Leave of Absence—up to a total of 40 days per calendar year; member is temporarily admitted to a hospital or nursing facility Non-medical Leave of Absence—up to 15 days per calendar year; a member does not receive AFC from the AFC caregiver because the member is away from the AFC qualified setting for non-medical reasons. Member is not in a qualified setting or has not received care from a qualified caregiver. Alternative Placement—up to 14 days per calendar year; member receives AFC from an alternate caregiver when the AFC caregiver is temporarily unavailable or unable to provide care. Alternate caregiver and setting must meet all applicable requirements. Unused days do not “roll over” to the next year Unused days follow the member when transferring from one AFC provider to another AFC provider.

10. AFC Provider Responsibilities Find and match members and caregivers Assess members for AFC program eligibility Assess Caregivers Assess Qualified Setting Devote at least 3.5 hours per member per week to AFC (10:1 ratio) – Multidisciplinary Professional Team: Program Director Registered Nurse Care Manager/Social Worker

11. AFC Provider Responsibilities All associated with the AFC program must meet the initial and ongoing requirements including: – CORI checks completed before hire – OIG checks (Bulletin 196) – Physicals—expected annually – TB screenings—expected every two years* This includes AFC staff, caregivers and members.(*Members only have to have a TB screening once.) AFC staff and caregivers must complete at least 8 hours of training per year, to include member-specific training as needed. AFC staff assess the home on an ongoing basis to make sure it meets basic requirements re: safety, privacy, accessibility, etc. AFC staff conduct visits in the home with the caregiver and member on a monthly basis for Level II members, and alternating months for Level I members.

12. Qualified Setting A private residence in Massachusetts – Caregiver must live in the same home as the member(s); either caregiver or member’s home – Home cannot be occupied by more than 3 members/clients regardless of payer. If there are 3 people in the home receiving care, no more than 2 may require Level II care – Cannot be a hospital, nursing facility, rest home, group home, intermediate care facility or an assisted living residence. – Must be accessible to meet the needs of the member(s) – Equipped with a fire extinguisher and emergency first aid kit – Meet other AFC-specific requirements (not the same as Shared Living requirements).

13. Scenarios

14. Challenges in AFC Member desires vs. caregiver availability Accessibility of homes in the community Low pay to caregivers, difficulty recruiting Back-up plans for discharge in the event the relationship ends Ability to meet program requirements on an ongoing basis

15. For additional information: Lisa Prince, President Massachusetts Council for Adult Foster Care masscouncilafc@hotmail.com (800) 286-6640, ext. 3060 MCAFC Leadership Knowledge Advocacy