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CALIFORNIA DEPARTMENT OF AGING DEPARTMENT OF HEALTH CARE SERVICES MSSP S ITE A SSOCIATION (MSA) MULTIPURPOSE SENIOR SERVICES PROGRAM (MSSP) MODULE THREE.

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Presentation on theme: "CALIFORNIA DEPARTMENT OF AGING DEPARTMENT OF HEALTH CARE SERVICES MSSP S ITE A SSOCIATION (MSA) MULTIPURPOSE SENIOR SERVICES PROGRAM (MSSP) MODULE THREE."— Presentation transcript:

1 CALIFORNIA DEPARTMENT OF AGING DEPARTMENT OF HEALTH CARE SERVICES MSSP S ITE A SSOCIATION (MSA) MULTIPURPOSE SENIOR SERVICES PROGRAM (MSSP) MODULE THREE C ARE P LANNING & C OORDINATION 1 November 5, 2013

2 W EBINAR “H OUSEKEEPING ” “ Raise your hand” button—please hit if you can hear us If calling in (instead of listening through your computer speakers, be advised that there may be charges) If we get disconnected, please follow the link you received after registering to sign back in Type your questions in the question or chat box (typically on the upper right- hand side of your screen) Keep questions brief and clear – it will be helpful if you indicate the subject of your questions first. For example: “Feedback – Where do I send suggestion's for waiver amendments?” Many questions will be answered at the end of the presentation as time permits Questions not answered today will be answered and posted on CDA’s website in the following weeks. 2

3 O BJECTIVES o Understand the MSSP Care Planning Process o Understand the MSSP Care Coordination Process o Understand the MSSP Participant Population o Understand How MSSP Benefits Participants and Reduces Costs o Generate Discussion 3

4 MSSP C ARE C OORDINATION o The care coordination process includes: Knowledge of MSSP Waiver program and other community resources. Conducting timely and comprehensive face-to-face Assessments and Reassessments. Developing and updating a Care Plan and monitoring outcomes. Coordinating services and/or purchases using waiver funds only for approved expenditures after other resources have been exhausted. Monitoring interventions and the impact on the Waiver Participant’s functional abilities and goals. Continuous face-to-face reassessment. Monthly discussion of Care Plan with the waiver participant and/or their family or representative. Terminating participation in MSSP. 4

5 O VERVIEW OF MSSP W AIVER P ARTICIPANT o 75+ Years Old o Female o Minority o Multiple Chronic Conditions o Takes Multiple Medications o Has Cognitive Issues o Needs Assistance with Multiple Activities of Daily Living and Instrumental Activities of Daily Living o Over Half Live Alone 5

6 MSSP W AIVER P ARTICIPANT S CENARIO Jose, who resides alone, is an 89 year old widowed monolingual Spanish-speaking male living in a 4 th floor apartment building. He is originally from Jalisco, Mexico, but has lived in the county for the last 15 years. His niece-in-law, Maria who lives nearby and works long hours split between two jobs, is his primary family support. His reported diagnoses and medical history is as follows: generalized weakness, diabetes type 2 (1983), left eye blindness (2011), hypercholesterolemia (2012), bladder incontinence, arthritis (unknown onset). Medical History: depression (2009), Cerebrovascular Accident (CVA) x3 w/last episode in 2011, pneumonia (2012), bilateral cataracts eyes 2012, hypotension, hypoglycemia, and recent weight loss. He has been awarded 25 IHSS hours per month and his IHSS Care Provider has quit. 6

7 MSSP W AIVER P ARTICIPANT S CENARIO The original referral received from his niece-in-law indicated the following: Lacking a reliable caregiver Lack transportation to doctors appointments Recent repeated trips to the emergency room Lack of medication monitoring and inappropriate administration Unpaid bills, landlord threatening eviction IHSS hours awarded are insufficient to meet his care needs 7

8 MSSP C ARE P LAN E XAMPLE Problem Statement GoalIntervention Client is unable to perform chores and personal care due to limited ability to stand longer than 10 minutes, generalized weakness, chronic arthritic pain and left eye blindness. Client will report during monthly contacts that his homemaker chores and personal care needs are being met daily for the next 12 months. Referred- to IHSS for re-evaluation of hours to Public Authority’s Office for list of potential care providers Meals on Wheels Local Transportation Agency-small van transport services Care Management- Monitor effectiveness of IHSS hours; advocate for increased hours as needed Purchase- Supplemental Homemaker Chore & Personal Care Services up to 20 hours per month 8

9 MSSP C ARE P LAN E XAMPLE Problem StatementGoalIntervention Client is at risk for unmonitored health conditions due to urinary incontinence; poor vision; Type 2 insulin dependent diabetes; generalized weakness; bouts of depression; and recent weight loss Client and family will report during monthly contacts having zero unmonitored health conditions for the next 12 months. Referred and Care Management- Client and family will contact Primary Care Physician (PCP) for assessment of recent weight loss and generalized weakness. Client and family will coordinate with and keep PCP medical appointments regularly Physician prescription for disposable briefs from ___ vendor. Social Work Care Manager (SWCM) will monitor client and family’s follow up with PCP and specialists as needed. 9

10 MSSP C ARE P LAN E XAMPLE Problem StatementGoal Intervention Problem StatementGoalIntervention Client is at risk for unmonitored health conditions due to urinary incontinence; poor vision; Type 2 insulin dependent diabetes; generalized weakness; bouts of depression; and recent weight loss Client and family will report during monthly contacts having zero unmonitored health conditions for the next 12 months. SWCM will refer client/family to Community Based Adult Services (CBAS) and “Friendly Visitor” Program to increase socialization. Consult with PCP for possible referral for therapeutic counseling. Monitor skin integrity and educate client and family on signs of infection Purchase Supplemental transportation-up to 4 taxi vouchers per month for medical appointments. Gloves, wipes, wash, creams, towels, sheets, mattress from _____vendors. 10

11 MSSP C ARE P LAN E XAMPLE Problem StatementGoal Intervention Problem StatementGoalIntervention Client is at risk for medication mismanagement. Client and family will report during monthly contacts having zero episodes of medication mismanagement for the next 12 months. Referred and Care Management Client and family will discuss all medications with PCP for proper medication administration and management. SWCM will provide local sites for waste disposal for SHARPS containers. SWCM will monitor as needed. Purchase One medication reminder pill box/container from ____ vendor. One SHARPS container for safe disposal of used lancets and insulin syringes. 11

12 MSSP C ARE P LAN E XAMPLE Problem StatementGoal Intervention Problem StatementGoal Intervention Client is at risk for financial mismanagement due to limited income. Client and family will report during monthly contacts having zero episodes of financial mismanagement for the next 12 months. Referred and Care Management Refer to Utility Discount Programs. Discuss with client & family to assist with money management. Monitor and coordinate with client and family as needed. 12

13 MSSP C OLLABORATION WITH H EALTH P LAN o The MSSP provider will coordinate and work collaboratively with the Plan on care coordination activities surrounding the MSSP Wavier Participant including, but not limited to: Coordination of MSSP benefits and Plan benefits to avoid duplication. Care coordination is especially important at the point of discharge from the MSSP. 13

14 MSSP C ARE P LAN E XAMPLE Problem Statement GoalIntervention Client is unable to perform chores and personal care due to limited ability to stand longer than 10 minutes, generalized weakness, chronic arthritic pain and left eye blindness. Client will report during monthly contacts that his homemaker chores and personal care needs are being met daily for the next 12 months. Referred- to IHSS for re-evaluation of hours to Public Authority’s Office for list of potential care providers Care Management- Monitor effectiveness of IHSS hours; advocate for increased hours as needed Purchase Supplemental Homemaker Chore & Personal Care Services to 20 hours per month Refer Meals on Wheels Local Transportation Agency – small van transport services 14

15 MSSP C ARE P LAN P ROCESS o The MSSP interdisciplinary care management team must develop a comprehensive care plan for each Waiver Participant. o The MSSP interdisciplinary care management team, at a minimum includes: o Supervising Care Manager (SCM) o Social Work Care Manager (SWCM) o Nurse Care Manager (NCM) 15

16 MSSP C ARE P LAN P ROCESS o MSSP care planning is the process of developing an agreement between the Waiver Participant and care manager regarding identified problems, resources, outcomes and services arranged in support of goal achievement. o The Waiver Participant actively participates in the Care Plan process. Approval of the Care Plan is indicated with the Waiver Participants (or representative’s) signature. o It is envisioned that the MSSP Care Plan will be integrated into the Health Plan Care Plan. 16

17 MSSP C ARE P LAN P ROCESS o The care plan is: Waiver Participant-centered and approved when the Waiver Participant (or representative) signs the care plan. Based on Waiver Participant information and needs identified in the health and psychosocial assessment or reassessment. Encompasses both formal and informal services. Completed timely. 17

18 MSSP C ARE M ANAGEMENT C YCLE 18 Comprehensive Initial Psychosocial and Health Assessment Reassessment Process Problems identified in assessment process discussed in Interdisciplinary Team conference Care Plan created based on assessment and team conference input Primary Care Manager reviews the Care Plan with the client and both sign the Care Plan to activate it. Monthly calls, quarterly home visits and additional care management provided as needed.

19 MSSP C ARE P LAN E XAMPLE Problem Statement GoalIntervention Client is unable to perform chores and personal care due to limited ability to stand longer than 10 minutes, generalized weakness, chronic arthritic pain and left eye blindness. Client will report during monthly contacts that his homemaker chores and personal care needs are being met daily for the next 12 months. Referred- to IHSS for re-evaluation of hours to Public Authority’s Office for list of potential care providers Care Management- Monitor effectiveness of IHSS hours; advocate for increased hours as needed Purchase Supplemental Homemaker Chore & Personal Care Services to 20 hours per month Refer Meals on Wheels Local Transportation Agency – small van transport services 19

20 MSSP C ARE P LAN C OMPONENTS o The MSSP Care Plan process requires use of the MSSP Care Plan form which includes the following components: Date Problem Statement Client Goal/Outcome Service Provider & Type Plan/Intervention Date Resolved/Outcome/Comments 20

21 MSSP C ARE P LAN C OMPONENTS o Date The form should contain the following date information:  Care plan conference date  Duration of care plan  Date the problem was originally identified or confirmed  Timely signatures o Problem Statement  Waiver Participant centered  Derived from problem list created in the assessment or reassessment process  Explains the Waiver Participant’s functional status and how an issue is a problem for the Waiver Participant 21

22 MSSP C ARE P LAN C OMPONENTS o Goals Must be measurable Relate to the issues identified in the problem statement Should reflect Waiver Participant input and preferences Should be realistic 22

23 MSSP C ARE P LAN S ERVICES o Service Provider and Type Informal Services A service provided without cost to the MSSP through the Waiver Participant’s network of family, friends or informal support. Referred Services (A service provided without cost to the MSSP through referral to a formal organized program/agency). In-Home Supportive Services Community Based-Adult Services (CBAS) Home Delivered Meals Incontinence Supplies NOTE: Medi-Cal and Medicare services may not be purchased with MSSP funds. 23

24 MSSP C ARE P LAN S ERVICES o Purchased Waiver Services - A service or item purchased with wavier service funds after all other resources have been exhausted. o Purchased Waiver Services Include: Adult Day Care Minor Home Repair and Maintenance Non-medical home equipment Emergency move assistance Restoration of utility service Temporary lodging Supplemental Chore Supplemental Personal Care 24

25 MSSP C ARE P LAN S ERVICES o Purchased Waiver Services – (continued) Supplemental Protective Supervision Respite Supplemental Transportation Meals Food Social Reassurance Therapeutic Counseling Money Management Communication-translation Communication Devices 25

26 MSSP C ARE P LAN E XAMPLE Problem StatementGoal Intervention Problem StatementGoalIntervention Client is at risk for medication mismanagement. Client and family will report during monthly contacts having zero episodes of medication mismanagement for the next 12 months. Referred and Care Management Client and family will discuss all medications with PCP for proper medication administration and management. SWCM will provide local sites for waste disposal for SHARPS containers. SWCM will monitor as needed. Purchase One medication reminder pill box/container from ____ vendor. One SHARPS container for safe disposal of used lancets and insulin syringes. 26

27 MSSP C ARE P LAN I NTERVENTIONS /O UTCOMES o Intervention Addresses the problem statement Outlines possible actions, plans or solutions to reach the goal Consider the waiver participant preferences o All interventions must be listed on the care plan. 27

28 MSSP C ARE P LAN R ESOLUTIONS o Date Resolved/Outcome/Comments This section can be used to make notations regarding the name of the service provider, the date a service/item was provided, the outcome and/or general comments. 28

29 MSSP C ARE M ANAGEMENT C YCLE 29 Comprehensive Initial Psychosocial and Health Assessment Reassessment Process Problems identified in assessment process discussed in Interdisciplinary Team conference Care Plan created based on assessment and team conference input Primary Care Manager reviews the Care Plan with the client and both sign the Care Plan to activate it. Monthly calls, quarterly home visits and additional care management provided as needed.

30 MSSP C ARE P LAN A PPROVAL P ROCESS o Care Plan Approval & Activation A Care Plan Conference must be conducted. Care Manager and Supervising Care Manager (SCM) must sign and date the Care Plan. Services cannot be purchased until the Care Plan is activated with the SCM signature. Pending receipt of the Waiver Participant’s signature on the care plan, documentation must demonstrate that the care plan has been reviewed with the Waiver Participant signature within 90 days. 30

31 MSSP C ARE P LAN P ROCESS o Care Plan Documentation Timeline The Initial Psychosocial Assessment (IPSA) and the Initial Health Assessment (IHA) must be completed within two weeks of each other. Care Plan developed within two weeks of last assessment. Signed and dated by the Care Manager and SCM within two weeks. Signed and dated by the Waiver Participant within 90 days of SCM signature. 31

32 MSSP C ARE P LAN P ROCESS - CONTINUED o Care Plan Monitoring Sites must review, verify, and document the following information in the progress notes each month: All care management activity, The status of each care plan problem statement, The effectiveness of interventions implemented during the month. 32

33 MSSP C ARE P LAN S UMMARY o The Care Plan is a living document which is updated in response to changes in the Waiver Participant’s health, support system or environment. o The Care Plan must be rewritten annually. o A notice of action (NOA) to the Waiver Participant is required when a waiver service is reduced or denied. 33

34 Q UESTIONS Contact Person: Mary Sibbett, Operations Manager California Department of Aging, MSSP Branch Thank you for your participation 34


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