MFP Demonstration: California Community Transitions Transition Process & Services

1. MFP Demonstration:California Community TransitionsTransition Process & Services August 2008 [G://staff/m/presentation/NE/NEIITraining/South/2008-CCTTransitionProcess&Services.ppt]

2. Agenda • Waivers, programs, and state plan services • Waiver/Service Application • Target Population • Transition Process • Comprehensive Service Plan • Demonstration & Supplemental Services • Questions & Answers

3. HCBS Waivers NF/AH MSSP ALWPP DD AIDS Capitated Care Plan Services: PACE SCAN Medi-Cal State Plan Services IHSS Waivers, Programs, & State Plan Services

4. Waiver/Service Application Copy of all Demonstration Participant Waiver/Service Applications will be sent to Mary Sayles, Project Nurse. Why ?? To assist with simultaneous enrollment of Participants into Waiver/Service and CCT by date of discharge from Nursing Facility as required by CCT Operational Protocol.

5. Waiver/Service Application (continued) NF/AH Application: 1. Request “Demonstration Participant” inserted on upper portion of HCBS waiver application. 2. Project Nurse will work with HCBS Intake team to get all information needed for enrollment.

6. Transitioning to the Community How will available services be presented to residents who are potential Waiver beneficiaries?

7. Target Populations ― 2,000 Total • Elders • Persons who have: • Physical disability • Mental illness • Developmental disability • Dual diagnoses of chronic medical and mental illness

8. Transition ProcessLead Organization will confer with area Nursing Facilities (NFs) to identify persons who have expressed an interest in livingin the community.The CCT Project Team will access Medi-Cal computer for potential participants.

9. Transition Coordinator (TC) will conduct California Pathways Preference Interview with facility residents (or their surrogate decision-maker), who are Medi-Cal eligible for at least 30 days, and have resided in a NF for at least 6 months. • TC will present information to resident and/or representative, and discuss options & considerations related to transitioning.

10. A second Preference Interview will be conducted approximately 2-3 weeks after initial Interview. • If a “stable preference” is found, with resident’s permission, the TC will meet with NF Staff to gather information (data & service) and coordinate transition plans. • Eligibility in the Demonstration will be determined, and Participant Information Form completed and signed by resident.

11. TC meets with Transition Team, Healthcare Personnel, and Service Providers and the Demonstration Participant, to discuss resident’s skilled needs and service options. How will available services be presented to residents who are potential Waiver beneficiaries?

12. TC develops a Comprehensive Service Plan using Resident’s requests. • NF Staff Members work with TC to set a Discharge Date, so community services can be set up at the Participant’s new “home.”

13. Prior to DC date, the Transition Coordinator ensures all preparation for services is completed, including waiver/service applications, delivery of all equipment, home set-up, financial arrangements, health care services, supportive and other services. • All services will be in place on day of discharge, prior to Participant leaving the facility.

14. In addition, the Quality of Life Survey will be conducted by a Regional Transition Team member prior to discharge, per CMS requirement. • Provision of Waiver/Service Program will begin the day of discharge. Service Manager will take over lead for all ongoing services at that time, including any needed changes to the CSP. • TC will follow Participant for two months to ensure services are being received.

15. At the end of 365 days (12 months), participation in the Demonstration ends. • Whatever waiver and/or services in which the Participant is enrolled may continue as long as s/he meets waiver and Medi-Cal requirements. • A Quality of Life survey will be repeated at about 12 months and 24 months per CMS requirements.

16. Billing for Services • Providers will bill for services using the Medi-Cal TAR system, with payment through EDS. • Project Nurse will adjudicate TARs submitted for services prior to discharge. • Once the resident transitions home, adjudication of TARs for Waiver, Demonstration, and Supplemental Services will be coordinated by the Project Nurse and Waiver Case Manager.

17. Health Care Services Plan of Treatment (POT) Nursing Care Services Nutrition Services Allied Health/Other Therapies Durable Medical Equipment and Supplies Supportive Services Personal Attendants PERS (personal emergency response system) Housing Transportation Social Services Peer Support/Mentoring Recreation/Cultural Connections Environmental Services Home & Vehicle Adaptation Assistive Technology Household Set-up Education/Training Services Independent Living Skills Caregiver Training Financial Services Medi-Cal Codes SSI/SSP payments Other Services Demonstration Services Supplemental Services Comprehensive Service Plan(Putting the pieces together)

18. Demonstration & Supplemental Services

19. Demonstration Services Current services include the following: • Transition Coordination Services • 24/7 Personal Emergency Response Services (PERS) • Waiver Personal Care Services (WPCS)

20. Demonstration Services(subject to change) Suggested new services include: • Independent Living Coach Services. • Expanded/Updates Assistive Technology • Attendant/Accompaniment during Medical appointments. • Individualized Information Caregiver Training. • Peer Mentoring.

21. Supplemental Services Current services include: • Home set-up Suggested new services include: • Orientation to mobility adaptations (for blindness, deafness, amputation, etc.) • Pet attendant set-up and owner training. • Modifications to a vehicle.

22. Supplemental Services Suggested new services(continued) • Adaptable clothing set-up. • Disaster preparedness supplies/accommodated first aid kits. • Fall prevention-modified environment (e.g., furniture moving, floor covering modification, etc.) • Social network reconnect (social worker and/or peer mentor.)

23. Questions & Answers