Presented by:West Central Florida Area

Agency on Aging (WCFAAA)

January 31, 2012January 31, 2012

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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

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Martha Caron is the ARC Enrollment Manager

ARC Enrollment Management

This is her office -

NOT!

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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

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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.

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Risk Score Range --- Annual Est. Care Plan

Cost:

> 0 to 7 = Risk Level 1 --- $3,493.92>8 to 15 = Risk Level 2 --- $5,646.30>16 to 26 = Risk Level 3 --- $7,246.17>27 to 52 = Risk Level 4 --- $9,673.18>53 to 100 = Risk Level 5 --- $14,270.86

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Services implemented must be offered in the program for which the client is released.

EXAMPLE:1. Client is waitlisted for: CCE & HCE2. AAA releases client for CCE only3. CCE services can be started but not HCE

subsidy4. HCE can only be started when released

by AAA

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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.

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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.

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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.

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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

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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 603

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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

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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

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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.

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Working Together with Case Managers

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Kristen ‘Dani’ Gray - serves Hillsborough and Manatee Counties

Carol Keen – serves Polk, Highlands and Hardee Counties

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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

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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.

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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.

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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).

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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).

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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.

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Receive referral from ARC fax line ◦ #888-401-4606

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.

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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.

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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.

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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.

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Kristen ‘Dani’ Gray 813-676-5601 or

1-866-827-6095 Option 1Referral Fax888-401-4606

Fax verification to:813-600-1997

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Carol Keen863-413-3473 or

1-866-827-6095 Option 2Referral Fax

1-888-401-4606Fax verification to

863-413-3475

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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.

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The ARTT Web site is pictured to the left.

The ARTT website address is:https://199.250.26.79/reports/artt/artt.html

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Services routinely provided within 72 hours !

Improved Documentation with better detail

No findings by DOEA monitors on APS files!

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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!

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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.

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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

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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

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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.

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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)

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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.

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Made sometime before 14th 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 14th day.

Calls should be documented and include date that services started.

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Continue or terminate services?

“Need” vs.

“Abuse, Neglect, Exploitation”

? ? ? ?

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Before or on 31st 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 31st day, an explanation as to why must be included in the notes.

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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?

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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.

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◦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

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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?

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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?

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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

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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.

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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.

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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

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REQUIRED ALW CONTACTS CASE MANAGER CONCERNS DOEA MONITORING FINDINGS DOEA SUGGESTIONS FOR IMPROVEMENT WCFAAA MONITORING FINDINGS WCFAAA SUGGESTIONS FOR

IMPROVEMENT BEST PRACTICES

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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

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

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Eligibility: Gaps in Level of Care Gaps in AssessmentsCare Plan not documented timelyNarrative:

◦No documentation of client’s condition at face-to-face visits

◦No documentation of service receipt

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Ensure refresher training sessions for case managers include:◦billable or non-billable activities and documentation

◦proper documentation of monthly client contact

◦case narratives requirements

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Reimbursable Activities 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 care4) Arranging for service delivery5) Following up and monitoring service provision

and quality of services6) Recording case management activities in the

recipient’s record7) Recipient visitation8) Telephone, travel time and recording of progress

notes associated with billable activities9) 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)

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•MW cannot bill after date of death or after nursing home/hospital entry.

Monitor client changes

Monitor receipt of, and satisfaction with, services

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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.

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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.

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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

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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

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Case Narratives:◦Service Receipt: Document review results

◦Medical Care Episodes: Missing documentation of changes

upon client’s return

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

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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

hospitalization67

Complaints/Grievances: Document client complaints and how resolved

Case Narratives◦Case Management Billing: Sign the case narratives Document billable activities Include case narratives

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

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Eligibility: ◦Contact MBC’s for assistance◦Encourage facility involvement

◦Communicate with the facility

◦Use documentation receipts

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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

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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!

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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

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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

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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.

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WHEN TYPE ACTIVITY PROGRAM

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

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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.

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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

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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

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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

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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 …

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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

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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

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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

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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?

◦Cross out the error with one line

◦Correct the error

◦Date the correction

◦Initial the correction

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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

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Quieres Taco Bell?

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APS Imminent Risk Caregiver Likely to continue

providing care Caregiver Ability to provide

care

Statewide Focus

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Currently achieving 8 of 9 goals!

CONGRATULATIONS!Which one is not being achieved?

Hint

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• Furniture needed repairs• No phone• Insects visible throughout the house• Unsanitary conditions due to odor (client incontinent)

Negative aspects included:

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MAYBE- MAYBE MAYBE- MAYBE NOT 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?

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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.”

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Mailed March 2011

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Mailed Returned Return Rate

551 Case Managed 210 38%

279 Homemaker 120 43%

51 Home Del. Meals

233 Frozen Del. Meals

272 Personal Care

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88

93

37%

37%

35%

1386 530 39%Totals:

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Case Management Survey Case Management Survey

It’s all about YOU!It’s all about YOU!

• 94% know how to contact 94% know how to contact YOUYOU..

• 90% believe 90% believe YOUYOU listen to what they say. listen to what they say.

• 94% believe 94% believe YOUYOU are polite and treat them are polite and treat them with respect. with respect.

• 94% believe 94% believe YOUYOU are knowledgeable are knowledgeable about the available services.about the available services.

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www.agingflorida.com

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The end

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