Specific Need Contract Review

Specific Need Contract Webinar

November 7, 2013

Alternatives to nursing facility long term care

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Field SupportSpecific Need Contract Team

Contract Administrators Melissa Taber: Operations and Policy Analyst (ECS)

Sarah Hansen: Operations and Policy Analyst (LTC Contract Nursing)

Roberta Lilly: Operations and Policy Analyst (Diversion and Transition)

Linda Woelke: Operations and Policy Analyst (Behavioral Support Services)

Nathan Singer: Field Support Manager

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Contact Information

apd.admissions@state.or.us To be used by TC/CM to get central office approval for admission to Specific Need contract facility and for renewal of specific need service payments.

Specific-Needs.Contract-Team@state.or.us Providers can be instructed to email this address if they have questions about their contract and need to reach the contract team.

Contract administrators can be contacted directly for specific contract questions or concerns.

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Contract Terminology

Contract - any written agreement between the Department of Human Services (DHS) and another party describing rights, obligations and work or services to be performed.

Contract Administrator - the person designated in the contract who has responsibility for specific contract administration actions i.e., authorizing the performance of work, evaluating the contractor’s performance, approval of invoices for payment and requesting contract amendments, etc.

Request for Proposal (RFP) - a written competitive solicitation process where price and specification are considerations in determining award criteria. This solicitation process is intended to result in a contract.

Statement of Work (SOW) - a written statement that specifically describes the phases of work or services, major tasks, or areas of responsibility the contractor is to perform. The SOW typically identifies specific objectives that the contractor is to attain or describes in detail the deliverables that the contractor is to provide and when they are to be provided.

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Specific Need Contract Services

A contract between an APD Medicaid provider and DHS to provide a set number of “slots” (beds) for a targeted population, as defined in the Statement of Work (SOW) for an agreed upon service payment. There are a total of 5 SOWs which we will discuss in detail in this presentation.

Existing Specific Need AFHs will choose 1 of 5 SOWs

The updated list of facilities and the type of contract they choose, will be provided to the field in the near future

The 5 SOWs can be viewed on-line by going to Case Management Tools, Program and Services. Under Program, see “Transition/Diversion”

Enhanced Care Facilities (ECF) and Enhanced Care Outreach Services (ECOS) are outside of today’s discussion and will not experience any changes to their admission processes

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What type of facility could have a Specific Need Contract?

Assisted Living Facility

Resident Care Facility

Adult Foster Home

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How does a facility get aSpecific Need contract?

New Specific Need contracts are being developed state-wide through the RFP process

Providers will need to submit a proposal when an RFP is posted in their region

Proposals will include AFHs, ALFs, and RCFs

Existing Specific Need AFH providers will start a new contract with a new SOW

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New RFP Specific Need Contracts

State-wide development is rolling out in three regions of the state at a staggered pace

The contract team will develop 90 slots statewide.

The first roll out is finishing up and the 2nd roll out is in progress

The 3rd roll out will begin in late spring or early summer

New RFP development includes AFH, RCF and ALF facilities for contracts

Local offices in regions involved in the roll out will be included during development

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New Statements of Workfor Existing Specific Need AFH

Basic Dementia

Advanced Dementia

Basic Neurological

Advanced Neurological

Bariatric

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New Dementia Statements of Work (Existing AFH)

Basic Dementia1. Dementia diagnosis

2. Cannot access local memory endorsed units, or CBC

3. In NF or diverted from NF

4. CAPS SPL 3- cognition

5. Either 1-1 staffing for one of these four: mobility, transfers, eating, toileting OR has unpredictable ADL or behavioral needs

Advanced Dementia1. Dementia diagnosis, neuro disease

or disorder

2. Failed CBC, including Basic Dementia home

3. In NF or diverted from NF

4. CAPS SPL 3- cognition

5. 2nd staff needed, on-site for ADL, health or behavior

6. Have 1 of 7 behavioral service needs as described in SOW Target

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Advanced Dementia Target Requirements

At least one of the following are required:

1. Dangerous behavior which has resulted in hospitalization, criminal charges or caused injuries to self or others

2. Physical or sexual aggression to staff or individuals

3. Disruptive or agitated behaviors which occur on a weekly basis

4. Verbally abusive behaviors to staff or others which occur on daily or weekly basis

5. Refuses meds or health care services creating legal or healthcare risks to themselves or other individuals

6. Addictions to cigs, food, RX narcotics, alcohol, medical marijuana or illegal substances requiring special care planning or staff training

7. Complex medical or psycho pharmaceutical regime requiring on-site RN service more than once per week

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New Neurological Statements of Work (Existing AFH)

Basic Neurological

1. Neurological disease, brain or spinal cord injury dx.

2. Cannot access CBC in local area

3. In NF or diverting from NF

4. Full assist in at least one: mobility, toileting, eating or cognition (as reflected CAPS assessment), AND

5. Needs either 1-1 staffing for mobility, transfer, eating or toileting ORunpredictable ADL or behavioral needs

Advanced Neurological

1. Neurological disease, brain or spinal cord injury dx.

2. Hx. of failed placement in Basic Neurological home

3. In NF or diverting from NF

4. Full assist in at least one: mobility, toileting, eating or cognition (as reflected CAPS assessment)

5. ADL, health or behavioral need requiring available, on-site 2nd staff, 24/7.

6. Have 1 of 7 behavioral service needs as described in the SOW Target

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Advanced NeurologicalTarget Requirements

At least one of the following are required:

1. Dangerous behavior which has resulted in hospitalization, criminal charges or caused injuries to self or others

2. Physical or sexual aggression to staff or individuals

3. Verbally abusive behaviors to staff or others which occur on daily/weekly basis

4. Refuses medications or health care services creating legal or healthcare risks to themselves or other individuals

5. Addictions to cigs, food, RX narcotics, alcohol, medical marijuana or illegal substances requiring special care planning or staff training

6. Has a rehabilitation plan developed and reviewed on a twice-a-year basis by licensed therapists and which requires daily interventions by trained caregivers

7. Has complex medical, rehab or psycho pharmacy regime requiring on-site RN services more than once weekly

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New Bariatric Statement of Work(Existing AFH)

1. In a NF or being diverted from NF

2. Medicaid service eligible at admission

3. Requires full assist in one of mobility, toileting, eating or cognition

4. Has ADL, medical or behavioral needs requiring available and on-site second staff 24/7

5. Cannot be served in another I/H or CBF

6. Has at least one of the following:

a. MD diagnosis of obesity with body mass index calculation of 38 or greater on admission

b. Deteriorating medical condition needing weekly MD; example Hospice

c. Complex health condition requiring complex care coordination, DME, on-site RN (more than weekly) and support by interdisciplinary health team

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Admission to Specific Need Contract Facility

The admission process for the Specific Need contract facility will direct field staff (CM/TC) to electronically complete the new admission form: SDS 494. The SDS 494 form will replace the old 490 form.

The new process is electronic therefore, the admission email mailbox was created. Traditionally, some of the providers have completed the 490 independently from the field staff and submitted it to central office. In the new process, the SDS 494 form will only be accepted by field staff.

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Processing the SDS 494 Admission Form

Email the completed SDS 494 to the Admission mailbox, apd.admissions@state.or.us, at least 5 days prior to admission

An approval (or denial) will be electronically returned to the sender within 2 business days

Once the CM/TC receives the approved SDS 494 back: narrate the approval in OA, print and save copy for the case file

An SDS 494 submitted by providers will not be approved, but will be directed back and instructions will be given to work directly with the assigned staff

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CM/TC Pre-Admission Process

The pre-admission process is designed to strengthen the communication between resident, provider, admitting CM/TC and the receiving CM/TC (if transferring out of the office to a new office).

The SDS 494 is to be completed and submitted to central office as a tool to verify that the field staff have considered all requirements for admission to the facility.

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SDS 494 (partial)CM/TC to Verify

Placement Information Proposed facility name: ______________ facility type: _________provider #__________

Current Location: ____________ facility type: ________

___ Specific Need Slot Available

___ Statement of Work Summary reviewed and consumer meets admission criteria

___ Provider has completed the screening process and has approved this admission

___ Receiving local office notified of admission

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Service Payments

Specific Need service payments must be entered individually for each case, once the 512 is set up. The SDS 494 instructs the CM/TC to email back to the APD.admissions@state.or.us once the 512 is set up. The process summary is as follows:

1.Email the SDS 494 to the admission mailbox for approval

2.Receive an approval reply and proceed with admission

3.Complete the 512

4.Email to the mailbox and include provider name and #, consumer’s name and prime #, date of admission

5.You will receive an email back , instructing you to “touch” the 512 to pick up the Specific Need contract service payment

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Renewal Service Payments

The Specific Needs service payment is set to end on the last day of the current CAPS. In order to renew the Specific Need service payment, a new CAPS will need to be completed timely and a communication from the field staff will need to be made to central office following these steps:

1. Consider a tickler to remind yourself of the requirement to notify central office of the need to renew the service payment

2. Once the CAPS is updated, email the Apd.admissions@state.or.us to notify central office regarding the need to add the service payment on the 512

3. Subject of email should be “Renewal”. Include name of consumer, prime billing #, name of facility, facility provider # and date of renewal

A reply email will be sent instructing the 512 to be “touched” to pick up the service payment

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Thank You!