MFP and Transition Coordination Refresher Training

Department of MedicalAssistance Services

Webinar

MFP and Transition Coordination Refresher Training Agenda

MFP – National Initiative New MFP Eligibility Criteria New Waiver Supports as a Result of MFP Outreach Efforts Keys to a Successful Transition Planning and Risk Assessment Transition Process, MFP Enrollment and Required Forms Consumer Direction Transition Services Administration and Reimbursement

for Rendering Waiver Services Additional Resources

An award from the Centers for Medicare and Medicaid Services Gives individuals of all ages and all disabilities who live in

Virginia LTC institutions options for community living

This Project has three Objectives:

Goal 1 - To give individuals who live in inpatient institutions more informed choices and options about where they can live and receive services;

Goal 2 - To transition individuals from institutions if they choose to live in the community; and

Goal 3 - To promote quality care through services that are person-centered, appropriate, and based on the individual’s needs.

MFP - National Initiative

MFP - National Initiative

MFP is the single largest investment in Medicaid Long Term Care 46 States have been awarded $4 Billion with a projected

number of over 70,000 individuals to be transitioned through calendar year 2016

Federal opportunity to further develop community integration strategies, systems, and infrastructure for individuals with long-term support needs

Emphasizes community living vs. institutional placement to help “rebalance” the system

A program that identifies individuals in institutions who wish to move back into the community and assists them with the transition process

MFP Eligibility

o New Eligibility Requirements – Effective June 1, 2011

o Have resided for at least 90 consecutive days in a hospital, nursing facility (any days spent in short-term skilled rehabilitation services do not count towards the 90 days), intermediate care facility for individuals with developmental disabilities (ICF-DD), long-stay hospital, institute for mental disorders (IMD), psychiatric residential treatment facility (PRTF), or a combination thereof;

o Be a resident of the Commonwealth of Virginia;

o Have received Medicaid benefits for inpatient services for at least one day prior to MFP enrollment;

MFP Eligibilityo Qualify for, and enroll into upon discharge, a Program for All-

inclusive Care for the Elderly (PACE) or one of the five following waiver programs:

o Elderly or Disabled with Consumer-Direction Waiver (EDCD) o Individual and Family Developmental Disabilities Support

Waiver (DD) o HIV/Aids Waiver (AIDS) o Intellectual Disabilities Waiver (ID) o Technology Assisted Wavier (TECH); and

o Move to a “qualified residence.”  A qualified residence is: 1) a home that the individual or the individual’s family member owns or leases; 2) an apartment with an individual lease, with lockable access and egress, that includes living, sleeping, bathing and cooking areas over which the individual or the individual’s family has domain and control; or 3) a residence in a community-based residential setting in which no more than four (4) unrelated individuals reside.

MFP Eligibility

MFP Qualified InstitutionsHospital Nursing FacilityIntermediate Care Facility for Individuals

with Developmental Disabilities (ICF-DD) Long-stay Hospital Institute for Mental Disorders (IMD)Psychiatric Residential Treatment Facility

(PRTF)

MFP Eligibility

Certain days during a nursing facility stay must be excluded from the 90 day countAny days spent in short-term skilled

rehabilitation services are excludedConfirm with billing office

Have received Medicaid benefits for inpatient services for at least one day prior to MFP enrollment;

Waiver Services Added

Transition Services is a one-time, life-time benefit assisting with one-time, up-front household expenses. Added to EDCD, AIDS, TECH, ID and DD waivers. $5,000 maximum Time limited to 9 months Not available to individuals moving into provider-

operated living arrangements

Transition Coordination supports individuals who elect services through the EDCD waiver both before and after transitioning to the community. Time limited to 12 months from date of discharge

MFP Demonstration Services

Transition Services – Available to individuals participating in MFP up to 2 months prior to discharge

Transition Coordination – Available to individuals participating in MFP up to 2 months prior to discharge for a total 14 consecutive months in the EDCD waiver

Assistive Technology – Available to individuals participating in MFP who are in either the EDCD or HIV/AIDS waiver upon entry to the waiver

Environmental Modifications - Available to individuals participating in MFP who are in either the EDCD or HIV/AIDS waiver upon entry to the waiver

MFP Demonstration Services Supplemental Home Modifications

Supplemental Home Modifications through partnership with Department of Housing and Community Development Provides funds for “barrier” home modifications prior to

discharge for individuals participating in MFP Provides funds for home modifications that exceed $5000

post-discharge for individuals participating in MFP Administered by DHCD and five regionally-based Centers for

Independent Living• Blue Ridge Independent Living Center, Roanoke, 540-342-1231 • Endependence Center, Norfolk, 757-351-1595• Independence Empowerment Center, Manassas, 703-257-5400• Junction Center for Independent Living, Wise, 276-679-5988• Resources for Independent Living, Richmond, 804-353-6503

Outreach

Outreach is The first activity Critical to the success of a transition Varied in its forms Provided by many people

Levels of Outreach Agency Individual Regional

OutreachState Agency Led Outreach

The Department of Medical Assistance Services, the Virginia Health Care Association, the Virginia Association of Non-Profit Homes for the Aging, and Long-Term Care Ombudsman Office will

• Send information about MFP to all nursing facilities and long-stay hospitals

• Hold Informational Sessions• Incorporate educational and awareness information about the MFP

program into the annual resident review process

The Department of Medical Assistance Services, the Department of

Behavioral Health and Developmental Services, and the Virginia Association of Community Services Boards will

• Send information about MFP to all Intermediate Care Facilities for Individuals with Developmental Disabilities

Outreach Individual Led Outreach

Case Managers, Transition Coordinators, Health Care Coordinators, Human Rights Advocates, Long Term Care Ombudsman's will:• Contact facilities to:

• hold one-on-one meetings

• hold open informational sessions

Sources of Information

Information can be obtained through: DMAS DBHDS Local DSS Local Dept of Health Community Service Boards Area Agencies on Aging Centers for Independent Living On the Web

• http://www.DMAS.virginia.gov• http://www.DBHDS.virginia.gov• Virginia Easy Access www.easyaccess.virginia.gov• Olmstead http://www.olmsteadva.com/mfp

Referral Sources & Contacts

Professional Staff at Hospital Nursing Facility Intermediate Care Facility for Individuals with Developmental

Disabilities (ICF-DD) Long-stay Hospital Institute for Mental Disorders (IMD) Psychiatric Residential Treatment Facility (PRTF)

People in the community Family members Friends

Referral Sources & Contacts

Specific to Nursing Facilities MDS 3.0 Section Q Referrals

• Individuals who wish to seek additional information on community living and a list of Transition Coordination Agencies will be provided information from the local Area Agency on Aging

• Individuals will choose a Transition Coordination Agency• The Area Agency on Aging will contact the chosen

Transition Coordination Agency to arrange referral

Keys to a Successful Transition

More than someone changing residence Increasing self-direction Increasing decision-making Participating fully in community activities Developing informal and formal supports

Keys to a Successful TransitionTransition Coordinators

A DMAS-enrolled provider who is responsible for supporting the individual and family/caregiver, as appropriate, with activities associated with transitioning from an institution to the community

Transition Coordinators / Case Managers:

Work closely with individuals

Assist individuals to take a proactive role in the transition process

Recognize that a successful transition is dependent on the individuals themselves and their willingness to change

Keys to a Successful Transition Characteristics of the Transition Coordinator

Transition Coordinators / Case Managers will have multiple roles including Being an effective mentor Understanding circumstances of placement in

institutionBeing mindful of the individual’s potentialBeing knowledgeable of all community

resourcesBeing an active listener

Keys to a Successful Transition Characteristics of the Transition Coordinator

Recognizing that the individual’s emotions of fear, anger, and anxiety are real

Openly acknowledge and discuss emotions with the individual

Providing accurate information in a timely manner

Exploring all options with the individualAcknowledging and balancing risk

Keys to a Successful Transition Critical Components

Developing a trusting relationship Having a comprehensive assessment that clearly

reflects preferences and strengthsneeds concernspriorities

Developing and implementing a Transition Plan that addressesthe individual’s preferences and needscritical follow-up with post-transition activities

Keys to a Successful TransitionGuiding Principles

There are two important principles to keep in mind throughout the transition process

o self-determination

o the right to take risks

Keys to a Successful TransitionGuiding Principles

Self-Determinationo Is the right to make one’s own decisions without

interference from others

Right to Take Riskso Making choices about new experiences and

possibilitieso Individuals grow by making choices even if those

choices are viewed as poor choices o Individuals learn by both successes and failures o Taking risks is part of living for everyone

Keys to a Successful Transition Balancing Risk

Prudent risks vs. undue risks

Individuals should not be expected to face challenges that will result in failure

Planning & Risk Assessment Risk Assessment

Assessment elements for Person Centered PlanningAssessment is not a single meeting Assessment is a series of meetings

establishing• Trust • Individuals’ ability to manage risk• Determination of preferences and needs

Planning & Risk Assessment Risk Assessment (continued)

7 key componentsHealth ServicesSocial SupportsHousingTransportationVolunteering/ EmploymentAdvocacyFinancial Resources

Planning & Risk Assessment Risk Assessment (continued)

Risk assessments are integrated with the development of the support plan It determines the level of support needed for

• Health Services• Daily Living Activities• Housing• Transportation• Social Supports

It determines the plan’s ability to meet the personal goal of the individual

It determines the type of back-up plan

Planning & Risk Assessment Description of Required Tiers

Tier 1: Service Plan Backup Providers Required to have backup provider for each service

Tier 2:  Informal Network Reaches out to the individual, family, friends, and

neighbors to provide interim supportsTier 3: 24-hour Response System

Call the toll-free call center, 2-1-1 Virginia Tier 4: Extreme Emergency

An immediate crisis involving a threat to the individual’s health, safety, or life, call 911

Planning & Risk Assessment Risk Assessment (continued)

Transition Coordinators are Mandated reporters for CPS & APS

Professional judgment is used to determine risk factors

Accessible and proper housing is critical to a individual’s success

Key elements to consider in helping the individual select the new home are: Location Affordability Access to transportation Personal security Opportunity for social activities Opportunity for employment

Planning & Risk Assessment Housing

Planning & Risk Assessment Housing and MFP Qualifying Criteria

Residences must meet one of the following requirements:

A home that the individual or the individual’s family member owns or leases

An apartment with an individual lease, lockable entry and exit and includes living, sleeping, bathing and cooking areas, over which either individual or the individual’s family has domain and control

A residence, in a community-based residential setting, in which no more than four unrelated individuals reside

Transition Process The key of the transition process

The ability to coordinate pre- and post- facility discharge transition planning and supports delivery

The ability to submit/ obtain waiver enrollment & prior authorization on the day of discharge from facility

3 Stages of the Transition Process

Planning Phase

Completed while in facility

Implementation Phase

Completed after transition and while individual is living in community

Discharge

Date

Stage 1 Stage 2 Stage 3

Pre-Discharge activity for Transition Coordinator/Case Manager

Educate and recruit individual Coordinate with discharge planner at facility to confirm individual

still meets nursing home level of care Ensure a copy of current UAI is available Complete MFP enrollment:

MFP Enrollment form (DMAS-222) MFP Informed Consent (DMAS-221)

Complete Prior Authorization Requests (DMAS-98) to enroll individual into MFP

Complete Prior Authorization Request (DMAS-98) for Transition Coordination prior to discharge as MFP demonstration services

Transition Coordination

Transition Process Stage 1 “Planning Phase”

Pre-Discharge activity for Transition Coordinator/ Case Manager (continued):

Complete MFP enrollment: Administer Quality of Life survey (DMAS-416) Develop Transition Plan which includes a risk assessment (DMAS-220)

Locate and secure qualified housing Schedule discharge date Complete Prior Authorization Requests (DMAS-98) for Transition

Services if needed prior to discharge as MFP demonstration services• Transition Services• Special Note: BE SURE HOUSING IS SECURED PRIOR TO

REQUESTING TRANSITION SERVICES Schedule transportation Confirm and ensure all is ready for discharge Plan for needed waiver supports upon discharge from facility

• Assistive Technology • Environmental Modifications • Transition Coordination • Personal assistance

Transition ProcessStage 1 “Planning Phase”

MFP Enrollment

Transition Coordinator/Case Manager must request MFP enrollment

MFP enrollment is available for as long as needed prior to discharge and 12 months from the date of discharge

Services available during the period of residence in an institution include Transition Coordination/Case Management Transition Services Environmental Modifications through DHCD

MFP Enrollment

The Transition Coordinator requesting the enrollment must:

Certify that the individual meets all MFP criteria

Determine with the individual if the individual can live safely in community

Complete needed forms• MFP Enrollment (DMAS-222) • Informed Consent (DMAS-221)• Administer Quality of Life Survey (DMAS-416)

Submit for MFP enrollment (DMAS-98) to KePRO

MFP Enrollment Prior Authorization Process

KePro Service Authorization Activities

•Confirms if individual meets MFP criteria

•Grants Prior Authorization / support plan approval

•Forwards letter of approval to provider & individual

•Enters individual in MMIS as participating in MFP

Insure waiver enrollment & PA’s are in place by Service Provider

Conduct home visit to ensure

Coordinate submission of DMAS-225 by both the institution and the accepting services provider to the local Department of Social Services

Service provider submits PA for services Service provider submits waiver enrollment Enroll for CD fiscal agent supports if appropriate (caution: a delay in CD services

may occur due to enrollment activities to become an employer) Monitor / coordinate delivery of goods for day of reentry Supports are in place and meeting needs Verify the back-up plan Verify delivery of Transition Services purchases Verify/schedule/completion of environmental modifications and/or assistive

technology

Transition Process Stage 2 “Day of Reentry”

A Critical Point

IMPORTANT!

Waiver enrollment MUST be coordinated with facility discharge

date

Activities Coordinate with service provider who provide needed waiver supports

Environmental Modifications Assistive Technology Personal Assistance Adult Day Health

Establish Transition Coordinator/ Case manager visit schedule for up to 12 months Be sensitive to individual’s stress Check appropriateness of supports being delivered Check individual’s view of how new life is progressing

Revise support plan as needed and before Transition Coordination ends

Transition Process Stage 3 “Implementation Phase”

Waiver Enrollment

On the day of discharge, the individual participating in MFP is enrolled into the appropriate waiver

Receive Authorization and begin delivery of identified, needed waiver supports

HIV/Aids

IFDDS

EDCD

ID

Tech

MFP Enrollment Completion of enrollment period

Individuals participating in MFP are permanently transferred to regular waiver status after MFP enrollment period ends

All waiver supports continue as long as waiver criteria is met

MFP Enrollment Disenrollment from MFP

Disenrollment from MFP due to hospitalization or institutionalization

Individual is hospitalized for more than 30 days• If re-admitted to a facility or hospital and stays

there for more than 30 days, the individual will be automatically dis-enrolled from MFP

MFP Enrollment Reenrollment Criteria

Individual does not have to meet the requirement for 90 consecutive days of institutional residency again

Reenrollment does not entitle the individual to Transition Services a second time Remaining Transition Services funding is

available for use if within the original 9-month period

MFP Enrollment Disenrollment – Returning to a facility

This will be a difficult decision to make because of the strong commitment to maintaining the individual in the community Decision should always be made with the individual Factors to use in determining

• How does the individual feel about the current situation?• Is the risk too great?• Are the basic living needs being met (food, shelter, clothing,

daily needs)?• Are supports meeting the individual’s needs?• Are the family and informal supports adequate to sustain the

individual?• Can the financial obligations be managed?

Can participation in MFP be withdrawn?

Yes Withdrawal Steps:

1. Individual will contact the Transition Coordinator2. Individual (with the Transition Coordinator) will

complete the MFP Withdrawal form 3. Transition Coordinator will make sure the form is

signed and dated by both the individual and themselves.

4. Be sure the effective date of the withdrawal is clear

5. Send the withdrawal form to KePRO agent6. Maintain copy for individual’s record and provide a

copy to the individual

MFP Enrollment Forms

All forms are on DMAS website: Search Services MFP enrollment forms:

MFP Enrollment (DMAS-222)• Provider Checklist to ensure individual meets MFP

eligibility criteria• Maintained in individual’s record

MFP Informed Consent (DMAS-221)• Ensures individuals are fully aware of their decision to

participate in MFP• Maintained in individual’s record

MFP Enrollment Forms

KePRO CBC Request for Services Form (DMAS-98) Enrolls individual into MFPMust be faxed to KePRO

• Box 12 - MFP Enrollment (PA Service Type 0909)• Box 13 – Individual Meets All MFP Eligibility

Criteria

MFP Demonstration Service Prior Authorization

KePRO CBC Request Services Form (DMAS-98) to request prior authorization for Transition Coordination (H2015) and/or Transition Services (T2038) Must be faxed to KePRO

• Box 12 - MFP Enrollment (PA Service Type 0909)• Box 15 – H2015 and/or T2038• Box 18 – 1 unit• Box 19 – H2015 = month T2038 = year• Box 22 – H2015 = up to 2 month prior and 12 months post

discharge T2038 = 9 months

Service Authorization Cycle

MFP Enrollment Forms

Transition Coordination Services Plan for EDCD (DMAS-220) Used to develop individual’s transition plan including

assessing risk, developing back-up plan, listing of needed supports, and other aspects of community living

Maintained in individual’s record MFP Quality of Life Survey (DMAS-416)

Required of all individuals participating in MFP To be administered prior to individual’s discharge Omit questions preceded by “After Transition Only” Complete Supplemental Questions on page 18 Maintain copy in individual’s record and send original to

DMAS (see page 19 for address)

Consumer Direction “Consumer Direction” and “self direction” are terms used interchangeably.

Consumer Direction allows the individual to be the employer for their consumer-directed services.

As the employer, individuals are responsible for: advertising hiring training supervising firing their own consumer-directed services employees developing their own support plan

When supports are consumer-directed, individuals or their family or caregiver, as appropriate, decide

what support is needed who will provide it when it will be provided where it will be provided how it will be provided

Service limits for

Consumer Direction Apply

Family members & individuals who reside under the same roof cannot be employees, unless objective documentation is provided.

Pre discharge• Discuss the CD option• Provide a clear picture of the responsibilities of CD• Connect with Service Facilitator for services• Incorporate consumer direction into the support plan• Service Facilitators will confirm

• All IRS Employer forms complete (W9)• All employees are “ready to go”

Day Of Discharge• Coordinate with Service Facilitator that supports are ready to start• Support plan is understood by personal assistants

Post Discharge• Check on Service Facilitator services• Monitor supports meeting individual’s needs as defined in support plan and

adjust as needed

Transition Process Consumer Directed Option (CD)

Let the individual know that this

process can take up to 6 weeks

Transition Services Administration and Reimbursement

Transition Service reimbursement is unique to LTC home and community-based waivers

https://fms.publicpartnerships.com/VirginiaMFP

Step I – Obtain Prior Authorization (PA) from appropriate agent (PA will only be valid for 9 months from the date of authorization)

Step II – Determine with the individual the individual’s household needs essential for community living and generate estimate with Public Partnership, LLC (PPL) website

Step III – Local Agency will approve and purchase essential goods for transition to set-up the individual's household and arrange for delivery of services

Step IV – Local Agency will submit reimbursement requests via PPL website

Step V - Agency will retain documentation sufficient to explain purchase needs

Reimbursement Waiver Service Limits

The unit of service shall be specified by the DMAS fee schedule

To receive payment the services shall be explicitly detailed in the supporting documentation

Transition Coordination Service Transition coordination may not be billed solely for

monitoring purposes In-kind task or expenditure expenses within Transition are

not billable as separate items - examples include• Travel time• Written preparation • Telephone communication

Reimbursement Submission Process

Consult chapter 5 of your waiver manual for the details of submitting claims

Consumer Direction payroll will remain the same

DMAS training unit will be providing training on Transition Coordination, MFP services

Additional MFP Resources

MFP Operational Protocol Housing Waiver Supports Bridge rent Contact lists Quality of Life Survey Adult Foster Care Marketing info/ brochures Assisted Living Consumer Direction Transportation Providers Listings

ABC’s of Nursing Home Transition A publication of the IL Net

National Training & Technical Assistance Program at Independent Living Research Utilization

http://www.ilru.org – Click on “Publications” and Scroll down to “Olmstead Implementation”

On the WEB DMAS at

www.dmas.virginia.gov DBHDS at

www.dbhds.virginia.gov MFP SITE at

www.olmsteadva.com/mfp

MFP Transition Coordination Agency Monthly Conference Calls

Scheduled the last Tuesday of every month from 10:00 am to 11:00 am

Send request to be included on email distribution list to mfp@dmas.virginia.gov

MFP Email DMAS will receive general

inquiries on the MFP project at mfp@dmas.virginia.gov

Please enter “MFP Inquiries” in the subject line.

Contact InformationVirginia Department of Medical Assistance Services

Division of Policy and Research600 East Broad Street, Richmond, VA 23219

Jason Rachel, Ph.D.MFP Project Director

(804) 225-2984jason.rachel@dmas.virginia.gov

Dana HicksMFP Analyst

(804) 225-4218dana.hicks@dmas.virginia.gov

MFP website DMAS websitehttp://www.olmsteadva.com/mfp http://www.dmas.virginia.gov

MFP Emailmfp@dmas.virginia.gov