Care Coordination

E-VISORY The Care Coordination E-VISORY is an electronic publication which provides information on policies, guidance, available programs and services, and training opportunities related to Care Coordination services. In order to receive an email notification when a new Care Coordination E-Visory is posted, or to view past issues, visit the following link: Care Coordination E-Visory ISSUE # 8-2019 March 8, 2019 CORRECTION TO E-VISORY 07-2019: Level of Care Eligibility Determination Process This E-Visory is being issued to correct a typo in E-Visory 07-2019 – Below please find the correct information on the Level of Care Eligibility Determination Process. Please disregard the information on Level of Care that was previously provided. OPWDD would like to clarify the processes for completion of the initial Level of Care Determination (LCED) for individuals seeking services as of July 1, 2018, forward: Once an individual’s OPWDD Eligibility is determined by the DDRO, the required pre-admission evaluation documents to support the initial LCED (physical/medical evaluation, social evaluation, and psychological evaluation) are reviewed to make a level of care eligibility determination. This revision to the process allows for completion of the initial LCED to occur earlier in the sequence than it previously did. Depending on the availability of a state physician, the process of obtaining a physician signature on the initial LCED will vary. State physicians are available to OPWDD Regional Office Front Door staff in parts of Region 3 (Hudson Valley and Taconic districts only) and Region 4 (NYC). Contact information for Front Door staff can be found at the following link: https://opwdd.ny.gov/welcome-front-door/Front_Door_Contact_Numbers. If the services of a state physician are used to sign the initial LCED, the Front Door staff will upload the completed initial LCED with the physician’s signature to the individual’s record in CHOICES. If no state physician is involved, the DDRO will fill out all relevant sections of the initial LCED form and forward the form to the CCO care management staff who will then need to work with the individual and his/her physician to have the initial LCED form reviewed and signed by the physician. The CCO care management staff will then upload the initial LCED form that has been signed by the physician into CHOICES and notify the Front Door staff that the document is waiting for review and finalization by the DDRO. Once level of care eligibility is determined the DDRO, Front Door staff will complete the Level of Care Date Transmittal Form in CHOICES. By completing this form, the individuals LCED effective date is recorded in the OPWDD CHOICES/TABS system and will then allow for the information to be generated and relayed on the monthly CCO roster. For all LCED redeterminations (regardless of the physician who signed the initial LCED), the CCO is required to complete the LCED Transmittal Form in CHOICES. OPWDD has developed an LCED Transmittal form user guide that is available on the OPWDD CHOICES website at the following link: https://opwdd.ny.gov/opwdd_login/choices

Materials for March 13, 2019 Quarterly Care Manager’s Conference The Quarterly Care Manger’s Conference is being held on March 13, 2019 via WebEx from 9:30am-12:30pm. The conference agenda is as follows: • Self-Direction • NYSTART • Front Door Process, LCED and LCED Redeterminations • Care Manager’s Role and Health Home Core Services NOTE: The materials that will be referenced during this conference are attached to this EVisory. There will not be any materials distributed on the day of the conference. Registration can be accessed at: http://www.opwdd.ny.gov/opwdd_careers_training/training_opportunities/slms.Existing users can log into SLMS from the page listed above. You can search OPWDD-QCMC in SLMS. The WebEx link will be available in SLMS day of. If you have any issues with registration or logging in on the day of the conference please contact Talent and Development by email at talentdevelopment@opwdd.ny.gov or by phone at 518-473- 1190. If you need assistance on how to access the OPWDD SLMS or how to create an account information can be found at the following links: SLMS Account Creation (First time users) https://opwdd.ny.gov/opwdd_careers_training/training_opportunities/slms-account-creation SLMS Login (Existing users) https://nyslearn.ny.gov/ Using SLMS https://opwdd.ny.gov/opwdd_careers_training/training_opportunities/slms-user-guide

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Welcome to the Quarterly Care Manager’s Conference

March 13, 2019

Amanda HarperAssistant Statewide Care Manager

Coordinator Amanda.m.harper@opwdd.ny.gov

Welcome!

InformationMaterials can be found in the Care

Coordination E-Visory at: https://opwdd.ny.gov/opwdd_services_supports/service_coordination/medicaid_service_coordination/msc_e-visories

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AgendaWelcome

Hot Topics

Self‐Direction

NYSTART

Front Door Process, LCED and LCED Redeterminations

Care Manager’s Role and Health Home Core Services

Closing

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Hot Topics• CCO Policy Manual• Care Coordination Support Liaison (CCSL)• CCO CHOICES forms• Navigating CCO information on the

website• Verifying Active Medicaid• Transition from NYSoH to the LDSS

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Health Home Provider Policy Guidance and Manual update

• Health Home Provider Policy Guidance and Manual is available at:https://opwdd.ny.gov/providers_staff/care_coordination_organizations/providers/cco-manual

• As Health Home policies are updated or created, guidance documents will be posted to OPWDD’s website in the "Health Home Policy and Updates" at the above link.

• Currently the following updated information is posted• Policy Update Memorandum-September 2018• Care Manager Checklist-Revised September 2018• Service Authorizations Post July 1, 2018- issued January 7, 2019

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OPWDD Regional Office Care Coordination Support Liaison

(CCSL) • The CCSLs can provide information and

assist with understanding Care Coordination Organization (CCO) Care Management program requirements

• https://opwdd.ny.gov/opwdd_services_supports/service_coordination/medicaid_service_coordination/contacts

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CHOICES Forms• User guides for enrollment, transfer and

disenrollment forms, document submission and LCED Transmittal forms

https://opwdd.ny.gov/opwdd_login/choices

• Updates to forms in CHOICES

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CHOICES from updates

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Navigating the OPWDD Website CCO Information

• https://opwdd.ny.gov/providers_staff/care_coordination_organizations/msc

• E-Visory 6-2019https://opwdd.ny.gov/providers_staff/care_coordination_organizations/medicaid_service_coordination/care_coordination_e-visories

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Active Medicaid Coverage • Verify that an individual has active

Medicaid coverage for CCO • Medicaid coverage that will support CCO;

https://opwdd.ny.gov/sites/default/files/documents/medicaid_coverage_chart.pdf

• Medicaid expiration dates are reflected on the monthly CCO TABS rosters

• eMedNY Training Calendarhttps://www.emedny.org/training/index.aspx

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Transitions from NYSoH to the LDSS

NYS Department of Health Transition Teamhxfacility@health.ny.gov

• Individual's Name• DOB• CIN• Account or case number• Type of waiver service(s) • HCBS Waiver documentation

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Self-DirectionChad Colarusso

Self-Direction Statewide Coordinator

Topics1. Overview of Self-Direction 2. Relationship between Care Managers and Support

Brokers3. Self-Directed Services in Life Plans4. Self-Direction Resources

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What is Self-Direction?

• Self-Direction is not a service, it is a way in which services are delivered.

• Self-Direction means that the individual with developmental disabilities chooses the mix of supports and services that work best for him/her, how and when they are provided, and the staff and/or organizations that provide them.

• The individual accepts responsibility for helping to manage (co-manage) his/her supports and services.

• Self-Direction is available to people in the HCBS Waiver with a wide range of needs. It can be an option for people who live in certified settings or those who receive traditional day services.

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The Importance of Self-Direction

Self-Direction provides people who receive OPWDD services with:

• The most control of support and service plan development.• The ability to truly drive the person-centered planning

process.• A clear focus on the person as opposed to a service

delivery model.

Participation in Self-Direction has grown rapidly. 11,852 people were self-directing with Budget Authority at the end of 2018.

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Authorities of Self-Direction Participants

People who choose to self-direct their OPWDD services have a range of options for the level of responsibility they accept and the authority they exercise.

There are two types of Self-Direction authority:1. Budget Authority2. Employer AuthorityA person may exercise one or both of these types of responsibilities.

The person self-directing their services, with support:

• Makes choices about the goods and services they need and selects who is paid to provide them.

• Must maintain service costs within an annual funding amount called a Personal Resource Account (PRA), which is determined based on their needs assessment and other variables.

• Can decide how much to pay self-hired staff to deliver Community Habilitation, Respite and Supported Employment.

• Can access unique services, including Individual Directed Goods and Services (IDGS), Other than Personal Services (OTPS) and Family Reimbursed Respite.

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Budget Authority: Fundamentals

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• People who self-direct with Budget Authority must use the OPWDD issued Self-Direction Budget.

• The Self-Direction Budget is developed by the person and their Support Broker. It must be reviewed and approved by the person’s Fiscal Intermediary and by OPWDD.

• The Self-Direction Budget is a tool to aid the person in planning annual service expenses and maintaining those costs within their PRA.

• The Self-Direction Budget does not replace the person’s Life Plan, but it can supplement information contained therein.

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Budget Authority: The Self-Direction Budget

A Fiscal Intermediary (FI) is an OPWDD nonprofit provider agency that supports people who self-direct with Budget Authority in:

• Billing and payment of budgeted goods and services.

• Fiscal accounting and reporting.

• Ensuring Medicaid and corporate compliance.

• Conducting required staff background checks and providing general administrative supports.

“Fiscal Intermediary” is also the name of an HCBS Waiver service. It is a monthly fee billed by the FI to cover the costs associated with administering the services in the person’s Self-Direction Budget.

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Budget Authority: Fiscal Intermediary

Budget Authority: Support Brokerage

An HCBS Waiver service provided to a person who self-directs with Budget Authority, which assists the person to:

• Develop his/her Self-Direction Budget.• Develop and facilitate Circle of Support (COS) meetings.• Write Staff Action Plans for self-hired services.• Other support tasks (e.g., educate the person on Medicaid and NYS

regulations, help him/her identify and develop community connections, attend Life Plan meetings, etc.).

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The person self-directing their services, with support:

• Makes decisions about who works for them.

• Recruits people to work for them.

• Decides what they need staff to do to help them, how many hours of help they need, and when they need that help.

• Supervises their staff and can change staff if they aren’t satisfied.

A person may exercise Employer Authority for Community Habilitation, Respite and Supported Employment services within a Self-Direction Budget, or may exercise employer authority independent of having Budget Authority.

Employer Authority

Relationship between Care Managers and Support Brokers

• The Care Manager uses person-centered planning processes to develop the Life Plan.

• The Broker uses person-centered planning processes to help the person develop his/her Self-Direction Budget and the Staff Action Plans for any self-hired staff.

• The Care Manager is a principle partner to the Broker in developing the Self-Direction Budget and Staff Action Plans for self-hired staff; the Broker is a principle partner to the Care Manager in developing the Life Plan.

• They are both required critical members of the person’s Circle of Support. It is expected that Circle of Support Meetings overlap with Life Plan meetings.

Self-Directed Services in Life Plans

• Where Self-Direction is not itself a service, those services that are self-directed must each be listed in the Life Plan in accordance with the requirements detailed in the service’s Administrative Memorandum.

• When a person exercises only Employer Authority (there is no Self-Direction Budget), Life Plan listing will follow the same instructions as if the services were not self-directed. The details of the Employer Authority will be captured in a Memorandum of Understanding between the person and the provider agency.

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Self-Directed Services in Life Plans

• For people with Budget Authority, the Fiscal Intermediary will be listed as the provider agency in the Life Plan for Fiscal Intermediary, Support Broker, Live-in Caregiver, OTPS, Family Reimbursed Respite and self-hired services.

• A person with a Self-Direction Budget may have other services in their budget (e.g., Day Habilitation, Supported Employment and Family Support Services) provided by other agencies apart from the FI.

• A person with a Self-Direction Budget can receive additional services that are not included in their Self-Direction Budget. See the Self-Direction Guidance for Providers, Attachments A and B for details.

Self-Directed Services in Life Plans

• Self-directed HCBS Waiver services (such as Respite, Live-in Caregiver and IDGS) are listed in Section IV of the Life Plan.

• Self-directed State Paid services (such as OTPS, Housing Subsidy and Family Reimbursed Respite) are listed in Section V of the Life Plan.

• For services included in a Self-Direction Budget that are not Agency Supported or Direct Provider Purchased (including Broker, IDGS, and FI), a zero “0” should be entered for in the total units column and the following should be entered in the comments section “per approved Self-Direction budget.”

Self-Directed Services in Life Plans

• Each habilitation service in the Self-Direction budget (e.g., Community Habilitation) must have a provider assigned “My Goal/Valued Outcome” in Section II or III of the Life Plan.

• For non-habilitation services (e.g., IDGS), an assigned “My Goal/Valued Outcome” is not mandated. Justification in the Life Plan for non-habilitative services included in a Self-Direction budget can be provided through “My Goal/Valued Outcomes in either section II or III, or by needs described in the narrative section (section 1).

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Resources• OPWDD Self-Direction Websitewww.opwdd.ny.gov/selfdirection

• Self-Direction Guidance for Providershttps://opwdd.ny.gov/node/6198

• Service Administrative Directive Memoranda (ADMs)https://opwdd.ny.gov/opwdd_regulations_guidance/adm_memoranda

• Regional Self-Direction Liaisonshttps://opwdd.ny.gov/opwdd_services_supports/opwdd_services_supports/self-direction-liaisons_list

• Self Direction Mailboxself.direction.redesign@opwdd.ny.gov

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NYSTART Systemic, Therapeutic, Assessment,

Resources, and Treatment

Angie FrancisCare Management and NYSTART Statewide Coordinator

What is START?Systemic, Therapeutic Assessment, Resources and Treatment

• The START Model provides prevention and intervention services to individuals with developmental disabilities (DD) and complex behavioral health needs through crisis response, training, consultation, and therapeutic supports.

• The goal is to create a support network that is able to respond to crisis needs at the community level. Providing supports that enable an individual to remain in their home or community placement is the first priority.

• START does not replace existing services in the community. START provides training and technical assistance to enhance the ability of the community to support individuals with DD and co-occurring mental illness/complex behavioral needs.

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Role of START• Provide support and technical assistance to community Mental

Health crisis and intervention supports• Create and maintain linkages and relationships with community

partners, including Care Coordination Organizations• Coordinate support meetings, with the care planning team –

including the Care Manager, to build cross-system capacity• Discuss behavioral health cross systems crisis plans for individuals • Provide on-going consultation to providers and/or families• Provide training and technical assistance to community partners• Provide short-term therapeutic crisis supports – both emergency and

planned

Each NYSTART Team ProvidesAs each of the NYSTART teams is established and becomes fully operational, services provided will include:

• Community partnerships and systems linkages• Systemic and clinical consultation and training• Community training and education• Clinical Education Team training meetings• Cross Systems Crisis Prevention and Intervention Planning• Mobile crisis support and response for individuals enrolled in

NYSTART services• Outreach and follow up• Comprehensive Service Evaluations

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Additional Elements of the Model will Include

The NYSTART team will clinically assess individuals enrolled in NYSTART services to determine the need for the provision of:

• Therapeutic coaching support services in the home for NYSTART-enrolled individuals age 6 and over

• Therapeutic emergency or planned Resource Center services for NYSTART- enrolled individuals age 21 and over

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NYSTART In-Home Therapeutic Coaching Services & Utilization

In-Home Coaching Services are:• recommended by the START coordinator who determines the need

for supports in collaboration with the center director/in-home team leader and the individual and his or her team;

• designed to assess and stabilize an individual in his or her natural setting;

• to assist the person’s current support provider or family in implementing successful strategies to prevent the exacerbation of a problem, implement crisis intervention strategies, and provide observational assessment of the person and his/her circumstances.

• to support the individual with eventually accessing the START center (if needed)

• to provide direct support and training to family and support staff members

• to transition interventions successful at the center to the person’s home

• part of the mobile crisis capacity of START.34

NYSTART Resource Center Services & Utilization

Resource Center Services are:• For both planned and emergency therapeutic

support • To provide assessment, systemic supports, and

services so that the individual can return successfully to and/or remain in his/her home

• Closely linked with the START Clinical team and includes evaluations by the START medical and clinical directors in addition to ongoing collaboration with START coordinators

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NYSTART Eligibility CriteriaTo receive START services the individual:Has been determined to be eligible for OPWDD services • Is age 6 or above• Presents with a history of or current acute behavioral health

needs (mental health and/or challenging behaviors)• Has a team with whom to work with (i.e., family, residential

staff, Care Manager, school, Community habilitation) and• Must be interested in START services AND/OR• Is currently using or has a history of psychiatric ED/Inpatient

utilization• Is at risk of losing a significant resource/support due to unmet

behavioral health needs36

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Current Operational START Teams in New York

At this time OPWDD has five NYSTART teams that are in

various stages of development

1. Western Finger Lakes NYSTART Team (Region 1)– 1-844-567-8278

2. Capital District, Taconic and Hudson Valley NYSTART Team (Region 3) – 1-

844-782-7880

3. Richmond Kings NYSTART Team (Region 4) –646-565-5890

4. Tri-Borough NYSTART Team (Region 4) – 212-273-6300

5. Long Island NYSTART Team (Region 5) – 516-870-1647

Broome, Central NY, & Sunmount (Region 2) – There is not yet a START

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Role of the Care Manager and START Coordinator

Care Manager• Collect information to inform

Person-Centered planning tools and identify individual needs

• Gather/record information• Service Plan development• Implementation of Life Plan• Monitoring of goals, health and

safety• Referral to services• Follow-up to support informed

choice• Advocacy for the individual• Documentation and record

keeping

START Coordinator• Crisis Assessment• Use of Standardized assessments to

inform short term clinical needs• Assessment of system needs• Gathering historical information• Development of Cross System Crisis Plan

(CSCP)• Training system on CSCP and modifying

as needed• Linkages with community partners• Comprehensive Service Evaluations• Discharge planning from acute settings

for short term therapeutic supports• Training and consultation to community

partners • Documentation and data collection

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How to Document START in the Life Plan

• Anyone receiving NYSTART services will need to have NYSTART listed in his/her Life Plan

• The expectation is that state-paid services are listed in Section V of the Life Plan

• START services, most often, will not have a provider assigned goal– However, the Life Plan must indicate the need/justification for

services, therefore justification for START services, within the Life Plan can be identified in:

• “My Goals/Valued Outcomes” in either Section II or III, or • described in the narrative section (Section I)

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START Therapeutic Resource Center Services in the Life Plan

• If individuals are also receiving NY START Therapeutic Resource Center Services the Care Manager will need to review Administrative Memorandum (ADM) 2017-01 on Home and Community-Based Services (HCBS) Waiver and Non-Waiver Enrolled Respite Services

• The ADM provides information on required documentation to apply for Intensive Respite as well as how it must be documented within the Life Plan

• That ADM can be found on the OPWDD webpage at the following link: https://opwdd.ny.gov/sites/default/files/documents/ADM-2017-01.pdf

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Resources and Additional Information

• Additional Information on the Center for START Services and NYSTART can be found on the OPWDD website at the following link:

http://www.opwdd.ny.gov/ny-start/home

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Front Door Process, LCED and LCED Redeterminations

Sally BerryDirector of Service Access, Regional Offices

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Front Door Topics

• Level of Care Eligibility Determination (LCED)

• Service Authorization Process

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Front Door Key Process Steps• Initial Contact• OPWDD Eligibility and Level of Care Eligibility

Determinations• DDP2 Assessment/Information Gathering• CCO Development of IAM, Life Plan, Requests

for Services• Service Authorization Requests, Waiver

Application• Review, Waiver Enrollment, Service Authorization• Enrollment into Services

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Level of Care Eligibility Determination

LCED• LCED occurs early in the Front Door process,

immediately after OPWDD eligibility is determined

• Once OPWDD eligibility is determined, the eligibility evaluation documents are reviewed to determine Level of Care Eligibility

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LCED – Physician Signature• The process to obtain the physician signature on LCED

may vary, depending on availability of a state physician. • If DDRO uses the services of a state physician to sign the

LCED, Front Door uploads completed LCED with physician’s signature to individual’s record in CHOICES.

• If no state physician is involved, the DDRO fills out the LCED form and forwards the form to CCO staff, who help the individual secure the physician signature on LCED form.

• State physicians are available in Region 4 and parts of Region 3 (Taconic and Hudson Valley)

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LCED• CCO staff uploads the signed LCED form into

CHOICES and notifies Front Door staff that the document is waiting for review

• Once LCED is determined:– DDRO staff completes the Level of Care Date

Transmittal Form in CHOICES (This includes the effective LCED date)

– The effective LCED date that is entered on the LCED Transmittal Form is transmitted to TABS

– For LCED redeterminations, CCO completes the LCED Transmittal Form in CHOICES

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Waiver Documents• If the individual is pursuing HCBS waiver, the

evaluation documents collected for OPWDD eligibility and LCED are used

• Also needed: – Application for Participation – Documentation of Choice – Front Door staff request Letter of Introduction from

RSFO – based on LCED• LCED documents and waiver forms:

– Are uploaded into CHOICES using the Documentation Submission Form if individual is likely to apply for waiver services

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LCED Redeterminations• The purpose of the annual redetermination is to

ascertain if the individual continues to meet ICF/MR level of care eligibility criteria

• The LCED redetermination must be completed and signed annually– not to exceed one year (i.e., 365 days) from the

effective date of the initial Eligibility Determination or from the signature date of the previous year’s redetermination review date.

• The CCO is responsible for LCED redeterminations, regardless of what physician signed the initial LCED

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LCED RedeterminationsLCED redeterminations are completed by the CCO, based on: • Direct knowledge of the individual through

observations and discussions with them• A review of the most recent psychological

evaluation, social history, physical/medical history, and other applicable information

• A review of the criteria outlined in the initial LCED form (i.e., diagnosis, disability manifested before the age of 22; behavioral problems; health care needs; adaptive behavior deficits)

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LCED Redeterminations• If additional information is needed to make a

determination, updates to the physical/medical examination, social evaluation, and/or psychological evaluation should be requested and reviewed

• Updates may consist of notations and signatures on evaluations verifying that the current status of the individual remains unchanged or may include newly completed evaluations

• CCO submits the LCED Transmittal Form in CHOICES

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Developmental Disabilities Regional Office (DDRO) Service Authorization

Process52

TOPICSReview Service Authorization Process Flow

• New to Waiver services - Request for Service Authorization

• Existing Individuals Service Amendment Request Form

• Review of documentation expectations for Service Authorization

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Individuals New to Waiver Services

• Front Door staff will be reviewing:– DDP2 – Front Door conversation/information gathering– Information from an in-process Life Plan– Request for Service Authorization (RSA) form– Supporting Documents

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Individuals New to Waiver Service

In Process Life Plan• Care managers will submit in process Life Plan to the Front

Door– Sections I is a primary focus– Other sections also reviewed and used

• Section I – “Assessment Narrative Summary” of the Life Plan– Contains information about the individual’s needs and goals– CM should provide details that will support the need for

services being requested– Information about the individual’s current situation, goals,

assistance needed and in what way

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Individuals New to Waiver Service

Request for Service Authorization

• Care manager submits the Request for Service Authorization (RSA) form that identifies specific waiver service(s) and service units

• RSA must include a short explanation of the need for each service requested

• Refer in the explanation section to specific parts of the Life Plan and/or specific sections of other submitted documents (e.g. psycho-social, medical etc.) that will justify the service request

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Individuals New to Waiver Service

Request for Service Authorization

• Documents referenced should have been uploaded into CHOICES

• Care Manager (CM) Sends an alert to the DDRO district-specific “CCO Alert” mailbox informing district there are documents awaiting review

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Individuals New to Waiver Service

Front Door Actions:• Review of RSA, DDP2, Life Plan and any other

documentation submitted for service authorization• Authorize services and/or request additional information• Ensure completed waiver documents have been

submitted• Distribute Service Authorization Letter (SAL), Waiver

Notice Of Decision (NOD) and next step guidance document to individual and CM

• Upload SAL and Waiver NOD into CHOICES

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Care Manager’s Role and Health Home Core Services

Angie FrancisCare Management and START State wide Coordinator

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Health Homes Provide Six Core Care Management Functions

Individual & HH Care

Manager

Comprehensive Care

Management

Care Coordination &

Health Promotion

Health Information Technology

Individual & Family Support

Referral to Community & Social Support

Services

Comprehensive Transitional

Care

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1. Comprehensive Care Management

Includes all aspects of:• Comprehensive assessments• Developing a Plan that integrates the continuum of

services and promotes continuity of care• Developing a Plan that clearly identifies all paid and

non-paid services/supports and clearly identifies goals and timeframes to achieve outcomes

• Including the Individual and care planning team as they play central and active role

• Ensuring the Plan is assessed as needed or as prescribed and clearly identifies progress and planning to achieve needs

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Comprehensive Care

Management

Comprehensive Care Management

Includes:• Development of an understandable and useable

Life Plan that is informed by a person’s functional needs assessment as well as comprehensive person-centered planning tools that are completed with the person and his/her care planning team

• A plan cannot be successfully developed without all of the providers included and actively engaged

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How are Provider Assigned Goals, Frequency, Quantity, and Timeframe Determined in the Life Plan?

• The Life Plan is developed using a person-centered planning process and all members of the care planning team, including the person, should be working together to identify;– the person’s goals/valued outcomes– the provider assigned goals and the frequency,

quantity and timeframe in which the provider assigned goals/supports will be delivered

• Coming to agreement on the provider assigned goals/action steps is important during the Life Planning meeting so that all parties leave the meeting with the same understanding

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What do I (Care Manager) do when there are a lot of goals and supports generated from the comprehensive

assessment process?

• The goals and supports in Section II and III of the Life Plan are derived through the comprehensive assessment(s) as a starting point and refined and prioritized through the person-centered planning process driven by the person, to the maximum extent possible, and his/her care planning team during the Life Plan meeting

• Care Managers, providers, the person and his/her care plan team must collaborate to prioritize the goals, generated from the comprehensive assessment, that are most important to the person to be worked on as well as safeguard needs

• If there are too many goals assigned, the care planning team will not be able to effectively monitor goal achievement and service delivery strategies or make adjustments when needed for optimum goal achievement

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What do I (Care Manager) do when there are a lot of goals and supports generated from the comprehensive

assessment process? (cont.)

• The care planning team, through this prioritization, can decide to defer some goals for later inclusion in the Life Plan and Staff Action Plan by documenting the deferred potential goals in the;– Narrative section of the Life Plan– Care Manager’s notes from the Life Plan meeting– Comments section that aligns with the specific goal

• Through this process and prioritization, goals remaining for the Life Plan period should be manageable and included in the Staff Action Plan

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Comprehensive Care Management

The individual’s Life Plan:• Integrates the continuum of medical,

behavioral health services, rehabilitative, long term care, developmental disabilities and social service needs

• Clearly identifies the primary care physician/nurse practitioner, specialist(s), behavioral health care provider(s) developmental disability providers, Care Manager and other providers directly involved in the individual’s care

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How are goals and/or supports that are not captured in the comprehensive assessment process or

documented in the Life Plan addressed?• The Life Plan development is a team effort driven by the

person in collaboration with the entire planning team to ensure that the Life Plan captures the person’s comprehensive needs and meaningful goals so that services and supports are tailored to help the person achieve what is most important to him/her

• The Life Plan is the starting point for the development of supports and services

• If the Life Plan does not address a major goal area or support that the person wants or needs, it should be revised to do so

• In addition, review and updates of the Life Plan must also occur when;– The individual or their family/representative requests that

information be changed or added– When the need for supports and services or goals change

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How should services be listed in the Life Plan?

• Regardless of whether or not they are self-directed, habilitative and non-habilitative waiver services must be listed in the Life Plan

• The expectation is that Section IV of the Life Plan captures all HCBS Waiver Services and State Plan services that are or will be authorized by OPWDDs Front Door Authorization process

• The expectation is that Section V of the Life Plan captures state-paid services, natural supports, community resources, services a person can access with his/her Medicaid card, services provided by Article 16, 28 or 31, and Federal, State, or County funded resources which are government services funded by agencies other than OPWDD

• Justification for services where a provider assigned goal is not required (i.e. non-habilitation services) can be provided through “My Goals/Valued Outcomes” in either Section II or III, or by needs described in the narrative section (Section I)

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2. Care Coordination and Health Promotion

Includes:• Engaging the person and care planning team in coordinating and arranging for

the provision of services and treatment recommendations• Having a dedicated Care Manager responsible for coordinating all aspects of

care and overall Plan management• Establishing processes dedicated to timely and effective communication

between the Care Manager and the care planning team• Having defined practices that support effective collaboration and how care

decisions will be documented and how those decisions are communicated with the care planning team

• Actively developing a relationship with care planning team• Supporting coordination through regular review meetings that include all

members of the care planning team• Providing all individuals with 24/7 availability to a Care Manager to provide

information and emergency consultation services• Developing a provider network within the CCO for individuals to access• Having a system for individuals’ care needs to be tracked and monitored for

outcomes

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Care Coordination &

Health Promotion

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Coordinate all Aspects • ADVOCATE, ADVOCATE, ADVOCATE!• To ensure that all needs are communicated and

discussed regularly and ongoing with all members of the Care Planning team

• Must include all aspects of the individual’s life and may require more than the minimal required visits, when needs change

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How should supervision be listed in the Life Plan and Staff Action Plan?

• Supervision levels in the Life Plan may be generated from the comprehensive assessment process and are considered a starting point for review and discussion during the person-centered planning process

• Through the Life Plan meeting, a person’s supervision needs are discussed with the individual and his/her planning team and this includes discussion of essential supports and oversight documents that contain important information that outlines supervision and safeguard needs (i.e., Behavior Support Plans, Plans of Nursing Services, Risk Management and Safeguarding Plans)

• Through this review and discussion, the appropriate overarching level of supervision is identified and documented in the Life Plan

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How should supervision be listed in the Life Plan and Staff Action Plan? (cont.)

• The Staff Action Plan will then further define/outline the person’s safeguard needs and how they will be implemented by the provider, including any additional detail needed on the supervision levels identified in the Life Plan

• For example: The Life Plan may say, “Frequent Checks less than every 30 minutes” and the Staff Action Plan would provide further detail as, “checks every 15 minutes” or “checks every 5 minutes”

• The level of supervision defined in the Staff Action Plan cannot be less than the overarching level of supervision outlined in the Life Plan

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Care Coordination and Health Promotion

• Care Managers must be aware of the day-to-day status of the individual especially during a hospitalization

• Ongoing and consistent communication with the care team is extremely important– When hospitalized, this may include the hospital

Social Worker, RN, Physician, Physical and/or Occupational Therapist

• Specifically for individuals of the Willowbrook class, if the individual is on an extended hospitalization (7 days), Care Manager must send out a letter notifying all parties including a status update and expected discharge, if known

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3. Comprehensive Transitional Care

• This includes having processes in place to;– Facilitate services for individuals when

transitioning between levels of care (such as hospitals, ICFs, rehabilitation facility, residential school, etc.)

– Support a person if they choose a new Health Home provider

– Foster interdisciplinary collaboration

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Comprehensive Transitional

Care

Comprehensive Transitional Care

• Continuity of care is supported and there’s a relationship with the care planning team

• The Plan identifies supports and coverage needed in the event the person is hospitalized

• Care Manager must ensure that the appropriate supervision level is incorporated into the plan– Needs may require further assessment based on clinical

recommendations– Care Managers must actively advocate and ensure that the

individuals needs are being met – Care Mangers must communicate with providers to ensure the

appropriate staff coverage is provided when a person is in the hospital

• Care Managers and Residential staff must communicate regularly to ensure that the individual’s needs will be appropriately met prior to their discharge home

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Updating the Life Plan if a goal, support or safeguard changes

• The Life Plan is the active document defining the person-centered habilitative goals/valued outcomes and required individual safeguards/IPOP needs

• The Care Manager and all members of the person’s care planning team must have agreed upon methods in place to communicate all aspects of a persons needs

• Identified health and safety needs must be met immediately and communicated effectively to the support providers

• Safeguards identified in the Life Plan must be updated based on the individual’s identified or changed needs

• Changes that must be immediately communicated are sentinel events including:– Accidents or events resulting in serious personal injury; major medical

events; a major psychiatric event or decompensation resulting in extended inpatient psychiatric hospitalization; and/or significant changes or improvement in behavior or physical functioning

• Additionally, Staff Action Plans must be updated and revised accordingly and provided to the Care Manager

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Adding a New Service While Transitioning From ISPto Life Plan

• During this time of transition individuals may have either an ISP or a Life Plan in place

• It is recommended and is best practice for the care planning team to convene a Life Plan meeting to transition the ISP to a Life Plan when a new service is authorized for an individual who has an ISP

• During the Life Plan meeting, personal outcome measures, goals, safeguards, and supports would be established by the person in collaboration with the planning team

• The habilitation providers would then follow the Staff Action Plan development process

• Should the care planning team choose not to transition to the Life Plan at this time and instead do an addendum to the ISP, the habilitation provider would follow the habilitation plan development process

• If the person has a Life Plan in place and a new service is approved and added to the Life Plan, this would be reflected in a Life Plan addendum and the habilitation provider would then follow the Staff Action Plan development process.

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4. Individual and Family Support

• The Life Plan;– Reflects preferences, education and support for self-direction– Is accessible and understandable and based on the individual’s

preferences• The Care Manager;

– Coordinates information and services to support individual’s and their families or representatives to maintain and promote quality of life with a focus on community living options

– Assists to increase knowledge through peer supports, support groups, and self-care programs

– Discusses advance directives with individual’s and their families or caregivers

– Communicates and shares information with appropriate consideration for language, literacy and cultural preferences

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Individual & Family Support

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Accessibility and Support• The person is the center of the planning

process• The process must be tailored to his/her

culture, communication style, physical requirements and personal preferences

• The Life Plan, needs to be usable and understandable to the person but also to assist those helping the person provide supports and services with an understanding and sensitivity to what is important to the person

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5. Referral to Community and Social Support Services

Requires that Care Managers:• Help to identify available community-based resources and

actively manages appropriate referrals, access, engagement, follow-up and coordination of services

• Support effective collaborations with community-based resources

• Ensure the Plan includes community-based and other social support services as well as healthcare, long term supports and services and I/DD services that respond to the enrollee’s needs and preferences and contribute to achieving the enrollee’s goals

• Ensure that the community engagement activities that are meaningful to the person are included in the Life Plan

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Referral to Community & Social Support

Services

How do I Address Inappropriate Provider Assigned Goals?

For example, what if someone who lives independently was assigned a support for fire evacuation to a Community Habilitation provider?• All members of the care planning team, including the person,

should be working together to identify the person’s goals/valued outcomes and the provider assigned goals and frequency, quantity and timeframe in which the provider assigned goals/supports will be delivered

• Provider assigned goals can include support needs that will be met by paid supports, natural supports, or the person directly and should be identified through the planning process

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How do I Address Inappropriate Provider Assigned Goals? (cont.)

• Individuals will have support needs that may or may not be delivered by a paid support– In instances where the support need is met by an unpaid support

the person’s needs still need to be planned for and included in the Life Plan (e.g., support for fire evacuation may be needed for a person who lives independently. The planning team works with the person to identify how the need could be met (e.g., special agreement with fire department; a paid neighbor; etc.)

• Coming to agreement on the provider assigned goals/action steps is important during the Life Planning meeting so that all parties leave the meeting with the same understanding

• The Life Plan must identify accurate and appropriate goals and supports – If there are inaccuracies they must be corrected and updated

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6. Use of Health Information Technology to Link Services

Standards and expectations Include:• A system to support and meet the delivery of the

Health Home Core Services • Structured information systems, policies, procedures

and practices to electronically create, document, execute and update Life Plans

• Systemic process to follow up and monitor individual's needs and referrals

• System that allows information to be shared and accessible between the entire care planning team

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Health Information Technology

Established Means of Communication

The Health Information Technology System (HITS) is an electronic information sharing system• HITS ensures consistent, timely, and

comprehensive information sharing between providers and Care Managers, and must be used if available and accessible

• If the CCO HITS is not available or accessible, another mechanism for prompt communication agreed upon by the Care Manager and habilitation provider and rest of the care planning team may be utilized

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Thank you

for attending, the next Conference is scheduled for

June 5, 2019

Registration for these conferences can be done through SLMS for either the WebEx or VC, please check the SLMS website to register.

https://opwdd.ny.gov/opwdd_careers_training/training_opportunities/slms

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