california department of aging department of health care services mssp s ite a ssociation (msa)...
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CALIFORNIA DEPARTMENT OF AGINGDEPARTMENT OF HEALTH CARE
SERVICES MSSP SITE ASSOCIATION (MSA)
MULTIPURPOSE SENIOR SERVICES PROGRAM(MSSP)
MODULE THREE
CARE PLANNING & COORDINATION1
November 5, 2013
WEBINAR “HOUSEKEEPING”
“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)
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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.
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OBJECTIVES
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
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MSSP CARE COORDINATIONo 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.
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OVERVIEW OF MSSP WAIVER PARTICIPANT
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
MSSP WAIVER PARTICIPANT SCENARIO
Jose, who resides alone, is an 89 year old widowed monolingual Spanish-speaking male living in a 4th 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.
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MSSP WAIVER PARTICIPANT SCENARIO
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 needs7
MSSP CARE PLAN EXAMPLE
Problem Statement Goal Intervention
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 hoursto Public Authority’s Office for list of potential care providers Meals on WheelsLocal Transportation Agency-small van transport servicesCare Management-Monitor effectiveness of IHSS hours; advocate for increased hours as neededPurchase-Supplemental Homemaker Chore & Personal Care Services up to 20 hours per month
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MSSP CARE PLAN EXAMPLEProblem Statement Goal Intervention
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.
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MSSP CARE PLAN EXAMPLE
Problem Statement Goal Intervention
Problem Statement Goal Intervention
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 PurchaseSupplemental transportation-up to 4 taxi vouchers per month for medical appointments. Gloves, wipes, wash, creams, towels, sheets, mattress from _____vendors.
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MSSP CARE PLAN EXAMPLE
Problem Statement Goal Intervention
Problem Statement Goal Intervention
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 ManagementClient 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. PurchaseOne medication reminder pill box/container from ____ vendor. One SHARPS container for safe disposal of used lancets and insulin syringes.
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MSSP CARE PLAN EXAMPLE
Problem Statement Goal Intervention
Problem Statement Goal 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 ManagementRefer to Utility Discount Programs. Discuss with client & family to assist with money management. Monitor and coordinate with client and family as needed.
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MSSP COLLABORATION WITH HEALTH PLAN
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.
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MSSP CARE PLAN EXAMPLE
Problem Statement Goal Intervention
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 hoursto Public Authority’s Office for list of potential care providers Care Management-Monitor effectiveness of IHSS hours; advocate for increased hours as neededPurchaseSupplemental Homemaker Chore & Personal Care Services to 20 hours per monthReferMeals on WheelsLocal Transportation Agency – small van transport services
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MSSP CARE PLAN PROCESS
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)
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MSSP CARE PLAN PROCESS
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.
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MSSP CARE PLAN PROCESS
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.
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MSSP CARE MANAGEMENT CYCLE
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MSSP CARE PLAN EXAMPLE
Problem Statement Goal Intervention
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 hoursto Public Authority’s Office for list of potential care providers Care Management-Monitor effectiveness of IHSS hours; advocate for increased hours as neededPurchaseSupplemental Homemaker Chore & Personal Care Services to 20 hours per monthReferMeals on WheelsLocal Transportation Agency – small van transport services
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MSSP CARE PLAN COMPONENTS 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
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MSSP CARE PLAN COMPONENTS
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
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MSSP CARE PLAN COMPONENTS
o Goals• Must be measurable
• Relate to the issues identified in the problem statement
• Should reflect Waiver Participant input and preferences
• Should be realistic
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MSSP CARE PLAN SERVICES
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
MSSP CARE PLAN SERVICES
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
MSSP CARE PLAN SERVICESo Purchased Waiver Services – (continued)
• Supplemental Protective Supervision• Respite• Supplemental Transportation• Meals• Food• Social Reassurance• Therapeutic Counseling• Money Management• Communication-translation• Communication Devices
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MSSP CARE PLAN EXAMPLE
Problem Statement Goal Intervention
Problem Statement Goal Intervention
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 ManagementClient 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. PurchaseOne medication reminder pill box/container from ____ vendor. One SHARPS container for safe disposal of used lancets and insulin syringes.
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MSSP CARE PLAN INTERVENTIONS/OUTCOMES
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.
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MSSP CARE PLAN RESOLUTIONS
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.
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MSSP CARE MANAGEMENT CYCLE
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MSSP CARE PLAN APPROVAL PROCESS
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
MSSP CARE PLAN PROCESSo 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.
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MSSP CARE PLAN PROCESS - 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.
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MSSP CARE PLAN SUMMARY
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.
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QUESTIONS
Contact Person:
Mary Sibbett, Operations Manager
California Department of Aging, MSSP Branch
Email: [email protected]
Thank you for your participation
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