FLORIDA NURSING HOME TRANSITION PLAN 1

Transcription

1 1 FLORIDA NURSING HOME TRANSITION PLAN 1 Sectin A: Backgrund and Overview Intrductin: Building upn the legislative nursing hme transitin language in sectin , Flrida Statutes, this nursing hme transitin plan frmalizes a prcess that will result in the successful transitin f eligible Medicaid nursing hme residents wh desire t transitin back int a cmmunity setting. Definitin f Nursing Hme Transitin: The vluntary transfer f an eligible Medicaid beneficiary residing in a nursing hme fr a minimum f 60 cnsecutive days, t a cmmunity setting such as a family member s hme, individual s apartment r hme, an Assisted Living Facility, r Adult Family Care Hme. Transitin activities include the screening and priritizatin f nursing hme residents fr transfer t a cmmunity setting. The prcess als requires crdinatin and cmmunicatin amng residents, cmmunity service prviders, nursing hme staff, family members r caregivers. State Gals: 1. The state will develp and implement a plan t achieve the successful transitin f eligible Medicaid beneficiaries 18 years f age r lder frm nursing hmes int the least restrictive setting apprpriate t their needs. 2. Increase awareness f, and prvide infrmatin regarding alternatives t, nursing hme care t nursing hme residents, their families and/r authrized representatives, health care prfessinals, and rganizatins that prmte residence in the cmmunity fr individuals with lng-term care needs. 3. Identify individuals wh desire t transitin frm nursing hmes t cmmunity settings by develping, enhancing r adpting assessment tls t successfully identify candidates. 2 Prgram Objectives: Develp a nursing hme transitin prcess that: 1 This Nursing Hme Transitin Plan is intended t be used as a guideline fr all agencies invlved in the nursing hme transitin prcess. It is nt intended t replace successful existing transitin prcesses that agencies already have in place. 2 CARES currently cnducts assessments f all nursing hme residents. This plan is nt intended t impact r change CARES prcesses r assessment instruments already in place. Hwever, supplemental tls and prcesses fr ther agencies will be addressed as needed

2 2 Reflects best practices f ther successful transitin prgrams; Prmtes the integratin f state and cmmunity supprts; Respects all individuals and their need t be treated with dignity; and Utilizes data cllectin t track utcmes and imprve the transitin prcess. Sectin B: Prgram Phases 1. Planning and Develpment: Develp an verall plan t implement a nursing hme transitin prcess fr Flrida Medicaid recipients. This phase includes: Develp specialized materials t educate and infrm residents, stakehlders, and respnsible parties abut cmmunity alternatives t nursing hmes. The materials will include types and frequencies f services that can be prvided t ptential transitin candidates. Develp infrmatin t be used by individuals answering phne calls frm nursing hme residents wh desire t transitin. The individuals answering phne calls may include representatives f the Clearinghuse n Disability Infrmatin, the Department f Elder Affairs, CARES, the Aging Resurce Centers, the Lng-Term Care Ombudsman Prgram, the Elder Helpline, the Department f Children and Families, and the Department f Health s Traumatic Brain and Spinal Crd Injury Prgram. Develp plicies and prcedures t assist in transitining individuals. Draft and execute necessary cntracts r agreements. Cnsult with key stakehlders and define individual rles fr the crdinatin f nursing hme transitin activities. Identify hme and cmmunity based services (HCBS) waiver prgrams and ther Medicaid prgrams that will be impacted by the nursing hme transitin prcess, define the impacts and recmmend amendments t the waiver prgrams which wuld be necessary t meet transitin service needs. Develp r mdify a screening tl that will be used t priritize individuals fr nursing hme transitin. Develp training n the transitin initiative fr Clearinghuse n Disability Infrmatin staff, case managers, mbudsman, and ther stakehlders r adapt existing training materials. 2. Outreach, Identificatin and Intake f Transitin Candidates: Describe the utreach, identificatin and intake prcesses that will be utilized in the transitin prgram. This phase includes: Outreach The state will develp and distribute utreach materials, r make the materials available n the agency s website, t prvide infrmatin abut the Flrida Medicaid Nursing

3 3 Hme Transitin Prgram. The Agency fr Health Care Administratin (AHCA) will be respnsible fr develping, printing, and distributing materials t partner agencies and ther stakehlders. Outreach effrts will fcus n: Educating and increasing awareness amng nursing hme residents and stakehlders abut cmmunity alternatives t nursing hme care. Prviding persns interested in returning t the cmmunity with the apprpriate cntacts fr btaining additinal infrmatin n what resurces are available. Prviding state agencies, advcacy grups, prviders, and prvider assciatins with prgram infrmatin via the Agency s website r training sessins/wrkshps. Outreach Materials (published in English and ther languages as apprpriate): Brchures: Prvided t nursing hme residents by Lng-Term Care Ombudsman and available fr dwnlad n the Agency s website. Psters: Placement n bulletin bards in nursing hmes, Centers fr Independent Living, and senir centers. Psters will als be available fr dwnlad n the Agency s website Letters: An infrmatinal letter will be sent t nursing hme administratrs Website: Develp a website at the Agency fr Health Care Administratin. All waiver partner agencies will prvide a link t the AHCA website. The website will include a descriptin f the nursing hme transitin prgram, frequently asked questins, links t partner agencies, cntact infrmatin, prgram brchures and ther infrmatinal materials. Stakehlder Publicatins: Transitin articles published in newsletters r n web pages f stakehlder grups. AHCA will make utreach materials available in an electrnic printable frmat via the nursing hme transitin link: Entities such as thse listed belw may print and distribute the materials as necessary: Lng-Term Care Ombudsman (distributin f transitin prgram materials t nursing hme residents) Aging Resurce Centers (ARC) Lead Agencies Nursing Hmes Centers fr Independent Living Medicaid Field Offices CARES The fllwing entities are the primary cntacts fr infrmatin, referral and enrllment:

4 4 Adults with disabilities, age Department f Children and Families, Adult Prtective Services Centers fr Independent Living Individuals with Brain r Spinal Crd Injury, age 18 r lder Department f Health, Brain and Spinal Crd Injury Prgram Elders, age 60 r lder Department f Elder Affairs Aging Resurce Centers Elder Helpline CARES Identificatin Surces Candidates fr transitin may be identified thrugh referrals frm any surce, including: Self, friend r family Advcacy grups/cmmunity rganizatins Lng-Term Care Ombudsman Centers fr Independent Living (CIL) Aging Resurce Centers Elder Helpline Lead Agencies Nursing hme discharge planners CARES Clearinghuse n Disability Infrmatin Candidates may als be identified thrugh analysis f databases cntaining infrmatin abut nursing hme residents. Intake Prcess The intake segment describes wh, what, hw and when regarding the steps in handling the infrmatin gathered fllwing the identificatin f persns fr transitin. The intake prcess is presented in tw categries: intake frm referrals and intake frm data analysis. Intake frm Referrals When transitin referrals are received, the fllwing intake/dcumentatin prcess will ensue: a) The entry will be lgged, capturing infrmatin such as the persn s name, date f birth (DOB), Medicaid ID, facility name and cunty and the date cntact was made. Nte: The lgging system will be an individualized database maintained by each agency with further discussin regarding the apprpriateness f a centralized database accessible t all agencies invlved. Each agency will have t reprt

5 5 certain infrmatin frm their database t AHCA fr purpses f reprting transitin activities, transfer f funds, mnitring and quality cntrl. b) Frm the lgged entry, a reprt will be generated with infrmatin n hw t cntact the ptential transitin candidate. c) The reprt will be used t cntact the ptential transitin candidates t screen and determine apprpriateness fr transitin. Given that different agencies (e.g., DOEA, ARC, DCF, & DOH) are statutrily and prgrammatically respnsible fr serving the varius Medicaid ppulatins impacted by this transitin initiative, any referral received shuld be directed t the agencies respnsible fr that ppulatin: Individuals age 60 and lder, r their representatives wh desire t transitin frm nursing hmes t a cmmunity setting shuld cntact the lcal CARES r the Aging Resurce Center (ARC). Individuals age r their representatives wh desire t transitin frm nursing hmes t a cmmunity setting shuld cntact the lcal Department f Children and Families (DCF) Adult Prtective Services ffice. Individuals age 18 and lder with a traumatic brain r spinal crd injury (TBSCI) shuld cntact the Department f Health s Brain and Spinal Crd Injury Prgram. Individuals age 18 r lder wh desire t transitin but need Medicaid financial eligibility determinatin shuld cntact the Department f Children and Families Autmated Cmmunity Cnnectin t Ecnmic Self Sufficiency (ACCESS). Cntacts made t entities ther than thse listed abve will be referred t the apprpriate agency. Intake frm Data Analysis When individuals are identified fr transitin thrugh the data surces listed belw, the entity husing the data will initiate and fllw the fllwing intake/dcumentatin steps: a) The entry will be lgged, capturing infrmatin such as the individual s name, date f birth (DOB), Medicaid ID, facility name and cunty and the date the individual was identified. b) Frm the lgged entry, a reprt will be generated with infrmatin n the ptential transitin candidate and hw t cntact him r her. c) The reprt generated will be used fr the screening f the ptential transitin candidates. Nte: Sme intake infrmatin will need t be frwarded t AHCA fr purpses f reprting, mnitring and quality cntrl.

6 6 Other avenues (including data surces) fr transitin identificatin will include: Individuals currently n HCBS waiver waiting lists wh reside in a nursing hme. Each waiver perating agency will be respnsible fr lgging these candidates. Prir transitining effrts may be utilized t identify factrs t cnsider during intake prcesses. Minimum Data Set (MDS): AHCA has secured a data use agreement with the Centers fr Medicare and Medicaid Services and will be cllabrating with the Flrida State University in analyzing certain elements f the MDS t be able t identify and gather pertinent infrmatin abut nursing hme residents t facilitate the transitin f the residents t a cmmunity setting. AHCA will cntinue t wrk with transitin partner agencies regarding access t and utilizatin f the MDS fr their target ppulatins. Client Infrmatin and Referral Tracking System (CIRTS): The Department f Elder Affairs (DOEA) may add additinal fields t the CIRTS database t identify and gather pertinent infrmatin n nursing hme residents wh wish t transitin t a cmmunity placement setting and will lg ptential candidates identified in this way. Adult Prtective Services Infrmatin System (ASIS): The Flrida Department f Children and Families (DCF) Adult Prtective Services will make mdificatins and enhancements t the ASIS t facilitate the identificatin and infrmatin gathering n nursing hme residents fr transitin t cmmunity setting and will perfrm the intake prcess. Department f Health, Brain & Spinal Crd Injury Prgram (BSCIP) surveys: Candidates will be identified thrugh annual surveys cnducted by the BSCIP. These surveys will be a part f the BSCIP s regular utreach t individuals in nursing hmes wh have brain and spinal crd injuries, t determine their desire t return t the cmmunity. BSCIP will perfrm the intake prcess. Cmprehensive Assessment and Optins Cunseling CARES is federally mandated t determine medical necessity f Medicaid funded lng term care, including nursing hme services and hme and cmmunity-based services prgrams. CARES will perfrm the level f care assessment fr all f the ppulatins listed abve.

7 7 Optins cunseling n available hme and cmmunity-based services prgrams may be prvided by CARES, the Aging Resurce Centers, Brain and Spinal Crd Injury case managers, r a designated transitin case manager. 3. Screening and Priritizatin Prcess: This sectin describes the screening and priritizatin prcess fr individuals interested in transitining frm a nursing hme. This assumes that there may be mre individuals wh wish t transitin than there are case managers t assist them and/r waiver funds t serve them. In that scenari, the state will priritize fr transitin assistance thse candidates wh have the greatest ptential t successfully transitin. 3 Each agency will use its wn screening instrument t cllect basic infrmatin pertaining t the individual s functinal abilities, health, need fr services and existing supprt system. Upn the cmpletin f the screening, each individual s transitin ptential will be determined. Individuals in nursing hmes wh have strng cmmunity supprt and individuals wh have the greatest ptential t remain in the cmmunity after transitin will receive the highest pririty. The priritizatin prcess will assess individuals transitin ptential using factrs such as: Infrmal cmmunity resurces available t assist the individual t live in the cmmunity; Whether r nt the individual has a caregiver wh is able and willing t prvide sme f the necessary care; The individual s present health and hw it cmpares t a year ag; Hw much the individual s health affects them ding what they want t d; and Hw much assistance the individual will need with activities f daily living and instrumental activities f daily living 4. Transitin: This sectin describes the manner in which transitin will ccur, This phase includes: Transitin Case Management Transitin Case Manager Qualificatins and Skills: Experience helping individuals adjust t cmmunity living; 3 See ftnte n page ne regarding CARES screening prcess.

8 8 A bachelrs degree in health care r human services is preferred, hwever related experience can substitute fr the preferred educatin; Demnstrated expertise wrking with individuals with disabilities and their families; Familiarity with 1915 (c) waivers and cmmunity-based services; Knwledge, skills and abilities t assess, identify, netwrk, and address gaps in cmmunity services; Excellent cmmunicatin, interviewing and presentatin skills; Ability t develp and maintain cllabrative relatinships with partner agencies such as the Centers fr Independent Living, Flrida Department f Health, Flrida Department f Children and Families, and Flrida Department f Elder Affairs; Wrking knwledge f cmmunity-based resurces fr senirs and individuals with disabilities; Ability t identify, rganize, dcument, crdinate, mnitr, and mdify services needed by each individual; Prven prblem-slving and investigatin skills; and Skill in crdinating activities, evaluating utcmes and establishing pririties. Transitin Case Manager Duties and Respnsibilities: After CARES cmpletes the cmprehensive assessment and ptins cunseling, the transitin case manager is expected t: Meet with prspective transitin candidates t explain available hme and cmmunity-based services and determine whether the individual meets the criteria fr a specific waiver prgram r fr ther cmmunity services; Wrk with the individual and the individual s family t develp a service plan t meet the individual s needs and facilitate a successful transitin t the cmmunity; Assist individuals in lcating cmmunity r family supprt; Wrk with the waiver case manager t enrll the individuals with the greatest transitin ptential int the apprpriate waiver (dependent n availability f funds); Assist the individual with explring cmmunity husing ptins; Refer individuals t lcal wrkfrce bards t identify skills training pprtunities and emplyment pprtunities (as apprpriate and applicable t the individual); Prvide resurce infrmatin and educatin regarding cmmunity-based services; Track participants frm identificatin phase t hand-ff t waiver case manager; Maintain a detailed case recrd which dcuments all activities and interactins with the individual; and Reprt transitin activities accrding t data cllectin schedule.

9 9 Transitin Prcess: After CARES cmpletes the cmprehensive assessment, and DCF determines financial eligibility fr waiver services, the transitin case manager will wrk with the waiver case manager t facilitate enrllment f the individual int the apprpriate waiver prgram. Individuals wh seek cmmunity placement but are determined nt t be eligible fr an HCBS waiver will be prvided ntice f their due prcess rights. The prcess will include an pprtunity fr a Medicaid Fair Hearing and may als include an pprtunity t request recnsideratin. If the individual is eligible fr transitin, the transitin case manager will meet with the transitin candidate and their family and/r legal representative as apprpriate t review the individual s identified needs, identify the supprts necessary fr the individual t live in the cmmunity and t prepare a service plan and a case file. The transitin case manager will assist the individual in lcating services and service prviders bth frmal and infrmal t meet the identified needs, which may include services such as husing, mving, meals, persnal care, training, emplyment, and transprtatin. When the individual mves frm the nursing hme int the cmmunity and enrlled in a waiver, respnsibility fr managing the individual s case will be transferred t the waiver case manager. Billing fr waiver services may begin after the transitin candidate has mved frm the nursing hme t the cmmunity, enrlled in a designated waiver and started receiving waiver services. Transitin Candidate Respnsibilities: T the extent pssible, transitin candidates and their family members r respnsible parties may be expected t: Assist with transitin activities (e.g., husing applicatins); Secure family and cmmunity supprt; Prvide cmplete and accurate medical histry, including all treatments, interventins, prescribed and ver-the-cunter medicatins; Prvide accurate infrmatin regarding Medicaid, Medicare, VA r ther medically-related insurance prgrams t the case manager; Ask questins when he/she des nt understand his/her services; and, Reprt any significant changes in medical cnditin, circumstances, infrmal supprts and frmal supprts t the case manager.

10 10 5. Tracking: Dcumentatin f the transitin activities, including prgress and cmpletin timeframes. This sectin cnsists f three tracking activities: peratins tracking; trend analysis tracking; and pst transitin review. Operatins Tracking Maintenance f a statewide tracking system t dcument transitin activities fr persns transitining frm nursing hmes t cmmunity settings. The system will capture the fllwing infrmatin: Cunty Facility Name Recipient Medicaid ID Scial Security Number Name Date f Birth Transitin Referral Surce Date f Initial Cntact Date f Screening Date f Assessment and Optins Cunseling Barriers t Cmmunity Placement (if transitin cannt be cmpleted at this time) Date f Nursing Hme Discharge Waiver Enrllment Date Waiver Disenrllment Date Waiver r Prgram Entered Type f Cmmunity Dwelling Care Giving Arrangement r Living Situatin Nte: Each agency will send reprts n transitin activities t AHCA nce a mnth. The reprts will be maintained in a tracking database. Trend Analysis Tracking This will enable the state t determine trends r deficiencies and t imprve n the effectiveness and fiscal respnsibility f the transitin prcess. A trend analysis may be perfrmed annually r n an n-ging basis. Sme factrs t capture in this regard may include: Length f time between recipient-initiated cntact with agency and agency s respnse time Estimated csts and resurces used fr transitin Waiver entered Resurce availability (e.g. Medicaid r nn-medicaid, private r cmmunity) Referral surce Recipient transitin destinatin (e.g. Persnal apartment, grup hme, ALF, r with family)

11 11 Number f failed/incmplete transitins and the barriers t thse transitins Medicaid cst per member per mnth f transitined individuals Number f individuals returning t a nursing hme after cmmunity placement The state may cnsider using Medicaid claims data and the Flrida State University data repsitry as resurce tls fr matching queries in the trend analysis and tracking prcess Benchmarks: Measurement f success including what cnstitutes a successful transitin. In additin t recrding and tracking the number f individuals requesting transitin assistance, and the actual number f individuals wh successfully transitin frm nursing hme care t hme and cmmunity-based service prgrams, the state will examine the transitin prcess. Aspects analyzed may include: Administrative prcess flw Interagency crdinatin Systems crdinatin Cmmunicatin Data cllectin Mnitring activities t determine cnsumer satisfactin with: Transitin crdinatin services Access t hme and cmmunity-based services Length f time frm initial cntact t screening Length f time frm screening t waiver enrllment,, r ther clsing f transitin case Waiver funds management Enrllment f transitining persns int transitin-reserved HCBS waiver slts (if applicable) Sufficiency f reserved transitin slts t meet the needs f transitining individuals (if applicable) Cst and utilizatin NHT cst cmparisn: Nursing Hme csts vs. Medicaid csts in the cmmunity Change in Medicaid nursing hme bed utilizatin and ccupancy rates