2015 Annual Level of Care Reviews Department of Medical Assistance Services Division of Long-Term Care A Closer Look Web-Ex Session 1 .

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2015 Annual Level of Care Reviews

Department of Medical Assistance ServicesDivision of Long-Term CareA Closer LookWeb-Ex Session

http://dmasva.dmas.virginia.gov 1

Department of Medical Assistance Services

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Today Conversation

• Why annual LOC• Overview of the LOC process • Common submission errors• Recap of LOC criteria • Digging deeper into criteria• Helpful hints• Training supports

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Why Annual Level of Care Review

• Annual Level of Care review(LOC) is a federal mandate- 42 §441.302 (c) (2)

• “Periodic reevaluations, at least annually, to

determine if the beneficiary continues to need the level of care provided and would, but for the provision of waiver services, otherwise be institutionalized”.

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Overview LOCERI Process DMAS sends

electronic notification

(e-mail) monthly notice to

Providers with LOC list to complete

Provider completes scheduled LOC in portal and updates DMAS on

admissions and discharges

DMAS reviews LOC’s submitted for obvious

errors and contacts providers for correction

to avoid system “not meets”.

DMAS processes portal submissions

through LOCERI

Individuals who “do not meet” in first

review receive secondary

review

Process concludes with letter being sent to

individuals who “did not meet” in secondary review. (Appeal rights

are provided)

If the providers do not receive an e-mail they will not have any LOC’s to complete that month.

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Common Submission Errors

1. Attempting to submit by paper-i.e. fax, e-mail, U.S. mail

2. Incorrect scoring • Forgetting to include the Medical or Nursing needs• Not observing /seeing individual perform the ADL, i.e.

simply taking their word for it; therefore inaccurately listing as independent

3. Understanding types of EDCD service groups

regular EDCD

CCC EDCD

from

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Level of Care Criteria Recap

There are three criteria:

Note: See PAS Provider Manual, Appendix B, for specific instructions regarding determining LOC.

functional capacity,

medical or nursing needs

risk of nursing facility placement

All three criteria must be met to meet criteria

Critical area’s of UAI that impact Eligibility

• Activities of Daily Living and Mobility• Joint Motion and Medication Administration • Behavior and Orientation• Medical nursing needs

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1 Dependent in 2-4 ADLs, plus semi-dependent or dependent in behavior and orientation, plus semi-dependent in joint motion or dependent in medication administration, OR

2 Dependent in 5-7 ADLs plus dependent in Mobility, OR

3 Semi-Dependent in 2-7 ADLs, plus dependent in mobility, plus dependent in behavior and orientation.

Functional CapacityThere are three different ways to meet the criteria for

ADL dependencies ….

functional capacity, the ability of the

individual to perform activities of daily living (ADLs);

An individual must meet one of the ADL descriptions

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Activities of Daily living

• Although Mobility is not considered an activity of daily living, it is an area where screeners have questions. The definition of mobility is – the extent of the individual’s movement outside his/her usual living quarters.– Mobility can be significant in determining if ADL criteria

listed as independent

• Joint Motion is not considered an activity of daily living; however, Joint motion is considered a part of the criteria for nursing facility placement. The definition of joint motion dependency is if an individual requires assistance due to:

• Limited motion;• Instability uncorrected• Immobility

• Medication Administration is not considered an activity of daily living, but is considered as part of the criteria for nursing facility placement. The definition of medication administration dependency is if an individual requires assistance with medications of the following:

• By licensed/professional nurse and/or monitored weekly or more;• Some or all by professional nurse

Joint motion and Medication Administration

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Behavior and Orientation

• Behavior and Orientation are considered one item for the purposes of criteria determination.

• Semi-dependency and dependency are based on the combination of both behavior and orientation.

• Remember: In order to meet this criteria, the individual must be semi-dependent or dependent in both areas.

Behavior can be significant in determining if ADL criteria listed as independent

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Medical or Nursing Needs

• In addition to meeting functional criteria, in order to receive Medicaid reimbursement, the individual must have medical or nursing supervision or care needs that are not primarily for the care and treatment of mental disease.

• (Alzheimer’s and dementia are not considered mental diseases.)

medical or nursing needs

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Medical and or Nursing Need• In determining the medical nursing need

consider every aspect of the individual's care– Key facts to consider

• Is the need ongoing or temporary?• Does the need require professional staff to provide the

care?• If the need is temporary, is it likely to reoccur?• Is current condition stable because of services received,

i.e. prevent destabilization• Does the diagnosis or age effect the individual’s ability

to self observe and/or report symptoms or illnesses?

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• Digging inAssessing criteria

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Medical Nursing NeedsThere are three ways to qualify

• The individual requires at least one ongoing medical or nursing need (examples to follow)

• The individual’s medical condition requires observation and assessment to assure evaluation of the individual’s needs due to the inability for self observation or evaluation; OR

• The individual has complex medical conditions which may be unstable or have the potential for instability

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• An individual requires at least one of the following shown below listed on the DMAS 99LOC Form:

• Delivery of specific services:• Routine care of colostomy or ileostomy or management of neurogenic bowel and

bladder;• Use of physical (e.g., side rails, poseys) or chemical restraints; • Routine skin care to prevent pressure ulcers for individuals who are immobile;• Care of small uncomplicated pressure ulcers and local skin rashes;• Management of those with sensory, metabolic, or circulatory impairment with

demonstrated clinical evidence of medical instability;• Infusion therapy;• Administration of oxygen;

Medical or Nursing Needs continued

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Medical or Nursing Needs continued

• Application of aseptic dressings;• Routine catheter care;• Respiratory therapy;• Therapeutic exercise and positioning;• Chemotherapy and/or radiation;• Dialysis;• Suctioning;• Supervision for adequate nutrition and hydration for individuals who show clinical

evidence of malnourishment or dehydration or have a recent history of weight loss or inadequate hydration which, if not supervised, would be expected to result in malnourishment or dehydration-

– The following individuals may be at risk:• An individual on chemotherapy (poor or no appetite), Stroke, Depression, Dementia, Muscular Dystrophy, ALS,

CP, TBI

Note: The 15 above listed medical nursing needs are NOT an exclusive list; the DMAS 99-LOC form allows for the provider to add an additional condition of need.

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Meeting criteriaObservation

• Examples– Chemotherapy, s/p Transplant, s/p Cardiac surgery or

other complex surgeries. Consider the age of the individual,(a 90 year old may not heal as quickly as a 50 or 65 year old), Depression, Cognitive ability or Dementia

• The individual’s medical condition requires observation and assessment to assure evaluation of the individual’s need for modification of treatment or additional medical procedures to prevent destabilization, and the individual has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals -

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Meeting CriteriaComplexity

Examples– This is an individual who has multiple diagnosis,

co-morbid- one disease impacts the other(s)– i.e. CAD, Diabetes, Hypertension, Cancer, again

look at their Cognitive ability

• Due to the complexity created by the individual’s multiple, interrelated medical conditions, the potential for the individual’s medical instability is high or exists

• Due to the complexity created by the Individual’s multiple, interrelated medical conditions, the potential for the individual’s medical instability is high or exists

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III. At Risk of Nursing Facility PlacementContinuing eligibility for home and community based services waivers requires that:

• The individual would, but for the provision of home or community-based services, otherwise be institutionalized.

• It demonstrates there is a reasonable indication the beneficiary might need in near future (30 days) the need for nursing facility supports/services

• {42CRF 441.302(c)(2)}

risk of nursing facility placement in the absence of

home and community based services.

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• Digging inAssessing criteria

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Activities of Daily Living

• Required Activities of Daily Living (for purposes of Medicaid eligibility must be dependent in 5 of the ADL’s plus mobility) see slide 8

• Bathing• Dressing• Toileting• Transferring• Eating/Feeding• Bowel and Bladder control (continence)• Mobility-Although not considered an activity of daily living, it is

an area where screeners have questions. The definition of mobility is – the extent of the individual’s movement outside his/her usual living quarters.

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Activities of Daily Livingselect appropriate level

• Bathing, Dressing, Toileting, Transferring & Eating/Feeding

Needs no helpMechanical helpHuman help-superviseHuman help-physical assistMH & HH-SuperviseMH & HH-Physical AssistAlways performed by othersSpoon fedSyringe/Tube FedFed by IV

Independent

Semi-dependent

Dependent

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Activities of Daily Livingselect appropriate level

• Continence (Bowel)– Continent – External Device/Indwelling/Ostomy (self care)– Incontinent (less than weekly)– Incontinent (weekly or more)– Ostomy (not self care)

Independent Semi Dependent Dependent

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Activities of Daily Livingselect appropriate level

• Continence-Bladder– Continent– External Device (not self care)– External device/indwelling/ostomy (self care)– Incontinent (less than weekly)– Incontinent (weekly or more)– Indwelling catheter (not self care)– Ostomy (not self care)

Independent

Semi-dependent

Dependent

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Select appropriate level

Joint Motion: • Within normal limits or instability corrected • Limited motion • Instability uncorrected or immobile

Independent

Semi-dependent Dependent

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Select appropriate level

• Medication Administration– Without assistance– Administered by lay person– Administered/monitored by professional

nursing staff

DependentIndependent Semi-dependent

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Behavior and OrientationPlease refer to the preadmission screening for scoring this section

• Behavior and Orientation are considered one item for the purposes of criteria determination.

• Semi-dependency and dependency are based on the combination of both behavior and orientation.

• Remember: In order to meet this criteria, the individual must be semi-dependent or dependent in both areas.

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Mobilityselect appropriate level

• Needs No Help • Mechanical Help (MH) Only • Human Help - Supervise • Human Help – Physical Assistance • MH & Human Help - Supervise • MH & Human Help – Physical Assistance • Confined Moves About • Confined Does Not Move About

Independent semi-dependent Dependent

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Functional criteria

ADL’s

Continence

Physical Health

assessment

Mobility

Bathing-Mechanical Help- Human Help Physical assistDressing-HH superviseToileting-MH-HH physical assistTransferring- MH- HH Physical assistEating/Feeding-HH supervise

Joint Motion-Limited MotionMedicine Administration-Administered by lay personOrientation-Disoriented some spheres/sometimesBehavior-Wandering/Passive less than weekly

MH-HH physical assist

Bowel, Bladder

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Assessment Hints

• Many of our older citizens are proud and independent

• Remember to “paint a picture” of the individual so we know what the individual looks like clinically

• Include clinical information – recent falls, hospitalizations, change in status

• Include all of the pertinent diagnosis i.e. COPD, diabetes, cancer, autism, ADHD, etc.

• List the most pertinent medications first

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Assessment Hints• Consider the following when doing the assessment

– Many individuals are embarrassed to discuss some issues– Observe the individual when asking the questions (observation)– Ask the attendant or primary care giver– Many individuals feel that if they say they are doing well or okay

it will actually keep them in the waiver as opposed to being truthful (they want things to remain the same)

– If they state they need help they are admitting defeat or view themselves in a different light because they are dependent

– You may want to ask- “If you had no attendant in your home (to assist with your ADL’s) for 24 hours for 7 days how would you manage?’

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Functional Elements

• Digging in

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Functional Capacity Tips

Remember the purpose of the waiver is to assist the individual i.e. prevent the individual from destabilizing- by preventing• A worsening condition• Frequent hospitalizations including emergency room visits• Nursing Facility placement

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Key points to remember when assessing Functional status

• Functional status is a measure of the individual’s impairment level and need for personal assistance.

• Interpret the ADLs in terms of what is usually needed to safely perform the entire activity.

• Functional status is based on what the individual is able to do not what they prefer to do

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Assessing Functional Status

When assessing the individual remember to consider

– Physical health– Mental health– Cognitive impairment – Functional disability challenges may manifest themselves

as the inability to perform ADL’S, ambulation, and IADL activities

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Assessing Functional Status

• Self-reporting on ADLs and other functional activities should be verified by observation or reports of others.

• This is especially critical when individual’s report that they do activities by themselves, but the performance level or safety of the individual is in question. Or – You have observed some physical limitations that are incongruent with

individuals statements. Or– A diagnosis indicates there may be ADL limitation(s)

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Medical Elements

• Digging in

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Medical Nursing Needs Tips

• In determining the medical or nursing need consider every aspect of the individual's care

• Key facts to consider– Is the need ongoing or temporary?– Is the need one that requires professional staff to

provide the care?– Is the need (if temporary) likely to reoccur?– Is current condition stable because of services received?– Is the diagnosis or age effecting the individuals ability to

self observe and/or report symptoms or illnesses?

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At Risk Elements

• Digging in

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Clarification

• Imminent risk: – Without waiver

services, is the individual at risk of nursing facility placement within 30 days?

• At risk of placementThe individual does not need

to be placed:It demonstrates there is a

reasonable indication the individual might need in near future (30 days) the Need for Supports/Services

42CFR 441.302(c,1i,ii) State Assurances

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The following “paints a picture”- assists in seeing the individual clinically

• Please review the assessments prior to submission to be sure they are correct• Please be sure to check the medical/nursing

needs section (YES) this will auto-populate the list to select the medical and or nursing needs• If you do not select yes- you are essentially

dis-enrolling the individual from the waiver

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Helpful Hints

Some things that may be helpful to review and look for while in the home doing the assessment are mentioned on the next few pages under Helpful Hints. They include

– Diagnosis– Medications– Support Systems in place– Home Supports

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Helpful Hints- Diagnosis

• If the individual has the following diagnosis– Cancer – are they on Chemotherapy – Endstage renal disease, are they receiving dialysis– COPD (Emphysema & Bronchitis)– Individuals with an amputation– Individuals with Quadriplegia or Paraplegia– Many Mental health diagnosis– Painting the picture-tell us about this individual- clinically

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Helpful Hints MedicationsThis is to continue to “paint a picture of the individual clinically.

• Medications– Cardiac medications– Diabetic medications– Hypertensive medications– Seizure medications– Pain medications– Psychiatric medications– Medications for Autism, ADHD

• List the most pertinent meds. first- i.e., diabetes, seizures, cardiac-

• Some providers list over the counter medications first and then do not have enough characters for the most pertinent meds.

• DO NOT simply state on X amount of medications

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Current Health Statuscontinue to “paint a picture”

• It is helpful to have additional informationi.e. stroke, when was the stroke– Last month, 6 months ago, last year, 10 years agoWhen was the accidentRecent falls (when)Recent hospitalizations (when) When were they dx. With the disease-What type of cancer- are they on chemotherapy or Radiation therapy- how long?

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Helpful Hints Support Systems in place

• What other community or medical supports are in place for this individual– Home health– PERS– Do they have a case manager for behavioral health– Are they receiving any therapies (P.T.,O.T., S.T. or

other therapies)– Are they receiving any other services in the home-

counseling, etc.

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Helpful Hints Home Supports

• What are the supports within the home– Who is the primary care giver– Who cares for the individual when the attendant

(or provider) is not in the home– Who does the shopping or takes the individual to

appointments

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• Review guidance document on Children from UAI• Examples-

– Bathing/Dressing- based on Child Development criteria, a child 5-21 years of age should be able to physically and/or cognitively perform all essential components of the task, safely, and without assistance

– Toileting-based on Child Development criteria, a child should be able to physically and cognitively perform all essential components of the task safely, without assistance if 6 years of age or older.

– Eating/Feeding- Considerations for children birth through 4 include: a child younger than 12 months should be totally dependent on another for feeding. Children 2-4 years should physically participate in eating, and may need constant supervision and/or assistance in setting up meals.

– Mobility-considerations for children birth through 4 include: a child younger than 5 years may require supervision for safety of the child. Children birth through 2 years may need intermittent physical assistance

Assessing Children

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Scenario- 89 year old• Diagnosis-Breast cancer, status post mastectomy last March,

Rheumatoid arthritis, Glaucoma, Hypothyroidism, recent Fracture of the right ring finger, Peripheral Edema and Acid Reflux disease

• Medications include: Prevacid, Tamoxifen, Lantaprost eye drops, Levothyroxine, Alleve, Lasix

• Mrs. Smith lives in a single story home, with her 92 year old husband who has difficulty hearing. Mrs. Smith was recently seen at the dentist due to improperly fitting dentures and noted that she rarely wears her dentures due to them not fitting correctly.

• Mrs. Smith ambulates with a cane and at times uses a walker, states that she is continent of bowel and bladder and uses depends because at times she does not make it to the bathroom in time.

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Scenario- 89 year old continued

• States she enjoys cooking; however, it has become more difficult due to her glaucoma and difficulty standing for even short periods of time.

• States she has a pill box and needs assistance (due to her broken finger and arthritis) opening the medication containers and placing them in her pill box

• She has a niece who assists with grocery shopping, M.D. & dental appointments.

• During the visit it was noted that Mr. Smith also has osteoarthritis and now uses a cane to ambulate.

• During the visit you note that Mrs. Smith appears to be in pain when ambulating and moving extremely slow with her walker for fear of falling.

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Scenario- 89 year old• Diagnosis-Breast cancer, status post mastectomy

last March, Rheumatoid arthritis, Glaucoma, Hypothyroidism, recent Fracture of the right ring finger, Peripheral Edema and Acid Reflux disease

• Medications include: Prevacid, Tamoxifen, Lantaprost eye drops, Levothyroxine, Aleve, Lasix

• Mrs. Smith lives in a single story home, with her 92 year old husband who has difficulty hearing. Mrs. Smith was recently seen at the dentist due to improperly fitting dentures and noted that she rarely wears her dentures due to them not fitting correctly.

• Mrs. Smith ambulates with a cane and at times uses a walker, states that she is continent of bowel and bladder and uses depends because at times she does not make it to the bathroom in time.

Eating/Feeding Can she chew her food properly, does she have mouth sores due to improperly fitting dentures, Is she at risk of choking or aspiration, is she at risk of malnutrition

Status of her cancer (depression)Difficulty seeing Debilitating arthritis, Fractured finger, Dependent edema, Reflux disease

No pain meds noted- for her arthritis and fx. finger is she compliant with her meds. Including eye gtts

Keys to toileting & continent- does she need more than a walker-i.e. supervision- remember her peripheral edema-Hope you did not miss this one!- one cannot be continent if they wear depends

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Scenario- 89 year old continued• States she enjoys cooking; however, it has

become more difficult due to her glaucoma and difficulty standing for even short periods of time.

• States she has a pill box and needs assistance (due to her broken finger and arthritis) opening the medication containers and placing them in her pill box

• She has a niece who assists with grocery shopping, M.D. & dental appointments.

• During the visit it was noted that Mr. Smith also has osteoarthritis and now uses a cane to ambulate.

• During the visit you note that Mrs. Smith appears to be in pain when ambulating and moving extremely slow with her walker for fear of falling.

Fall risk- Difficulty seeing- also risk of burning herself, remember the peripheral edema & fractured finger, is it safe for her to stand with the walker-for a period of time – Dependent-(Transferring-MH HH supervise, Eating/Feeding- HH supervise)

Assistance with opening containers, does she take her medications as prescribed, her broken finger will also impact her writing and perhaps feeding herself. Dependent-Dressing- HH physical assist, Bathing-MH- HH physical assist, Eating/Feeding-HH supervise

Her primary care giver also needs assistance with his ADL’s-she is at risk of nursing home placement without her spouse (PCG)

Dependent-Mobility-MH-HH physical assist

Look at the transferring, and all ADL’s that involve mobility- Transferring-MH HH supervise, Mobility-MH- HH physical assist

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Scenario 8 year old• Juan is an 8 year old with the diagnosis of Autism, Downs

Syndrome, Asthma and seasonal Allergies• He is on the following medications:• Concerta, Singular, Albuterol prn, Flovent QHS, Zyrtex• Juan lives in a tri-level home with his father who works long

hours and his grandparents who assist with his care. You noted during the most recent assessment the grandmother's hearing appears to be getting worse and she has difficulty understanding; in addition, his shirt is not buttoned correctly and his shoes are untied.

• Juan attends school daily in a classroom with 4 other children who require educational support

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Scenario 8 year old• The parent states recently (on several occasions) when they arrived to

pick up his son from school they note his pants are wet and smelled of urine (the teacher said it appears as though he does not make it to the bathroom in time); however, he taken to the bathroom several times a day.

• The parents state that he needs assistance with eating- although he can feed himself, he puts too much food in his mouth and has difficulty swallowing, he chokes easily and one recent incident of aspiration where he was seen in the emergency room for possible aspiration pneumonia

• The parents state Juan does not respond when you say his name and they have noted recently that he has become more disruptive at home and in the classroom

• Juan’s parents report he walks okay; however, he does have a congenital defect in his Left knee that occasionally causes swelling in the joint.

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Scenario 8 year old• Juan is an 8 year old little boy with the

diagnosis of Autism, Downs Syndrome, Asthma and seasonal Allergies

• He is on the following medications: Concerta, Singular, Albuterol prn, Flovent

QHS, Zyrtex • Juan lives in a tri-level home with his father

who works long hours and his grandparents who assist with his care. You noted during the most recent assessment the grandmother's hearing appears to be getting worse and she has difficulty understanding; in addition, his shirt is not buttoned correctly and his shoes are untied

Is his Autism mild, moderate or severe-i.e. is he verbal or

non-verbal, does he make eye contact- functional re: Downs

syndrome

Is the caregiver compliant with his medications, does he use a spacer for his inhaled

medications

Needs assistance with dressing, at risk of falling- any safety issues with the elderly

grandparents

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Scenario 8 year old

• Juan attends school daily in a classroom with 4 other children who require educational support

• The parents states recently (on several occasions) when they arrived to pick up their son from school they note his pants are wet and smelled of urine (the teacher said it appears as though Juan does not make it to the bathroom in time); however, he is taken to the bathroom several times throughout the day.

Key here- is he incontinent or forgets to ask to go to

the bathroom- risk of infection, psy. effect from

his peers

This may speak to the stage of Autism

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Scenario 8 year old• The parents state that he needs assistance with

eating- although he can feed himself, he puts too much food in his mouth and has difficulty swallowing, he chokes easily and one recent incident of choking where he was seen in the emergency room and dx. with aspiration pneumonia and hospitalized for three days.

• The parents state recently they have noted that Juan does not respond when you say his name and that he has become more disruptive at home and in the classroom.

• Juan’s parents report he walks okay; however, he does have a congenital defect in his Left knee that occasionally causes swelling in the joint.

Red flag- choking can be a life threatening event & aspiration pneumonia is very serious-

This speaks to orientation and behavior is something else going on

Joint motion also issues with mobility

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Final reminders• It is the responsibility of the providers to keep their e-

mails up to date. If your e-mail address changes please inform the LOC unit by sending the most current e-mail address to: [email protected]

• Remember this is how we communicate with the providers regarding the annual LOC. If we do not have your correct e-mail address you will not receive your encrypted e-mail with the list of individuals that are due and therefore your reviews will be considered late. Remember this is your, responsibility.

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References

• UAI Screening Manual http://www.dss.virginia.gov/files/division/dfs/as/as_intro_page/manuals/uai/manual.pdf

• 12VAC30-120-950. Agency-directed personal care service

• 12VAC30-120-980. Consumer-Directed services

• Waiver Services Provider Manual (AAL, EDCD, TW & PACE) https://www.virginiamedicaid.dmas.virginia.gov/ProviderManual

• DMAS learning center (check under recorded sessions)

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Additional Training Supports

• Portal training Video – https://www.virginiamedicaid.d

mas.virginia.gov/wps/portal/LOCERI

• Frequently asked questions– https://www.virginiamedicaid.d

mas.virginia.gov– DMAS Helpdesk– 1-800-552-8627

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Announcing

• Every other month conference calls• Purpose:

– Share and discuss issues– Announce updates

• When – Second Wednesday of month– Starting in April

• Time– 1:30 to 2:30pm

• Reminder E-mails will be provided with call in conference numbers

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Thank You