2017 Statewide Diversion & Transition Training Trans Tools Docs/2… · •Coordinating delivery of services including: medical supplies, transportation, placement options, wrap-around

2017 STATEWIDE DIVERSION

& TRANSITION TRAININGWho we are and what we do.

AGENDA

• 9:00 – 9:55: Diversion/Transition Basics

• 9:55 – 10:10: Break – Local Discussion – Questions

• 10:10 – 10:55: APD focus on safety and internal relationship building

• 10:55 – 11:10: Break – Local Discussion – Questions

• 11:10 – 12:00: Neurocognitive Disorder & Staffing with Mental Health

Q & A

• Please do not ask case specific questions.

• Can be staffed later

• Please type in your questions as they come up and we will pause to answer as we go.

• If you want to talk please send a question indicating that and I will do my best to unmute you.

• Follow up questions and suggestions are encourgaed.

WHO WE ARE

APD: Preadmissions Screening

Specialist - Transition Coordinator

LCOG: Transition and Diversion

Case Manager

MultCo: Senior Case Manager -

Transition Coordinator

NWSDS: Diversion and Transition

Case Manager

OCWCOG: Diversion & Transition

Coordinator

APD JOB DESCRIPTION

• The PREADMISSION SCREENING SPECIALIST assesses an individual's functional, psychosocial, and economic status to determine the most appropriate placement/services for persons who are requesting or being referred for nursing facility (nf) placement. The primary goal of the intervention is to determine the most appropriate and least restrictive setting for service delivery for clients with complex medical, psychosocial, and service needs.

• The Preadmission Screening Specialist coordinates information from a variety of sources to intervene on behalf of the client; provides technical expertise and training to local staff in professional areas of expertise concerning client planning and service delivery for clients with unusual or complex problems; determines care settings and services for clients; and represents the division in related legal actions taken against the division.

LCOG JOB DESCRIPTION

• This position provides two types of services, Transition and Diversion.

• A person residing in a Nursing Facility, with Medicaid funding covering the cost of care, is eligible for Transition services. These services may be provided to enable a client to move from the Nursing Facility.

• Diversion services are provided to prevent a person from becoming a long term resident of a Nursing Facility, prior to Medicaid funding covering the cost of care. Diversion can begin prior to Nursing Facility placement of while a person is receiving skilled Nursing Facility care.

MULTCO JOB DESCRIPTION

• Provide transition and diversion services to clients leaving the nursing facility setting using Home and Community Based Care C and K waivered programs and through the federally awarded Money Follows the person program.

• Diversion services are provided to those clients receiving acute care NF or hospital services before Medicaid payments start to avoid long term institutional stays.

• Transition services are provided to clients receiving Medicaid paid long term care institutional services to return to community based services.

NWSDS JOB DESCRIPTION

• Meets agency mission by helping consumers and or families to prevent unnecessary placement in nursing facilities and facilitate transitions for those who can better be served in the community based setting

OCWCOG JOB DESCRIPTION

• This position will provide two types of services for Medicaid and potential Medicaid clients: Diversion and Transition. Provides diversion case management services to prevent long term nursing facility residency. Assesses Medicaid clients residing in a nursing facility for possible transition to a lower level of care.

WHAT WE ALL DO:

• Provide two types of services to APD LTSS eligible consumers: Diversion and Transition from Nursing Facilities or other institutional settings.

• Assess consumer’s functional abilities to manage their own ADL/IADL needs.

• Determine the most appropriate placement and services based on the consumer’s functional, psychosocial and economic status.

• Assist consumers in relocation to the least restrictive & most independent community based setting.

• Coordinating delivery of services including: medical supplies, transportation, placement options, wrap-around services, and more.

• Provide technical assistance to other staff regarding diversion/transition resources and services.

• Build lasting relationships with community partners including Nursing Facilities, CBC providers, hospitals, CCO Intensive Case Managers and more.

WHAT IS A DIVERSION OR

TRANSITION?• Diversion- The process of developing a service plan that offers an alternative to an

institution setting (long term care placement). The HCBC service plan is implemented prior to long term care placement. Mitigating the barriers to put an individual at high risk for losing their community based plan is required. Diversion cases should be entered in to the Diversion/Transition Data Base and be monitored for at least 90 days. A person may be a patient in an acute care setting (inpatient in a hospital or first 20 days of skilled care in a skilled nursing facility).

• Transition- The process of developing a HCBC service plan designed to assist a Medicaid client who is currently receiving services in an institutional setting (long term care). The transition process includes completing an updated assessment; interviewing the individual and determining where they would like to receive their services; meeting with the interdisciplinary team as needed (this may include individual, their rep or family, discharge planner, RN, new providers, mental health), touring potential facilities, a home visit to see what home modifications are needed; gathering bids for modifications, arranging for household items and DME products. The TC would verify that the transition day itself goes smoothly and is typically present for the actual move. All transitional cases should be entered in to the D/T Database and monitored for at least 90 days.

IDENTIFYING INSTITUTIONS

• While institutions offer different services – sometimes they consider other institutions as a step-down in care and therefor a more independent setting.

• The Center for Medicaid and Medicare Services identifies the following facilities as institutions:

• Long Term Hospitals

• Nursing Facilities (NF – Title 19)

• Skilled Nursing Facilities (SNF – Title 18/19)

• Psychiatric Hospitals & Units

• Rehabilitation Hospitals & Units

• Swing Bed Hospitals

• Intermediate Care Facilities/Mentally Retarded (ICF/MR)

CMS – Institutional Types

DATABASE?!?!

• Sorry – it is down – no ETA

• Track all consumers on it using your own form or the one I sent out

• Send it to me at the end of the month via email

• Don’t worry if it will be “counted” or not• The work you do is valuable and should be recorded even if it does not meet the

definition of a diversion or transition.

• Not submitting information runs the risk that data is missed.

• The new database will be created in such a way where the outcome of your work is sorted into appropriate categories depending on the information provided.

• Final product will be developed by Best Practices Committee

• Any input is welcomed

DEFINITIONS FROM 411-070 OAR

• Pre-Admission Screening (PAS)means:

• the assessment and determination of a potential Medicaid-eligible individual’s need for nursing facility services, including the identification of individuals who can transition to community-based service settings and the provision of information about community-based alternatives. This assessment and determination is required when potentially Medicaid-eligible individuals are at risk for admission to nursing facility services. PAS may include the completion of the federal PASRR Level I requirement (42 CFR, Part 483, (C)-(E)), to identify individuals with mental illness or intellectual or developmental disabilities.

PAS: OAR

• NF Rule: 411-070-0040 Screening, Assessment and Resident Review:

• INTRODUCTION. All individuals who are candidates for admission to a Medicaid-certified nursing facility must be assessed to evaluate their service needs and preferences and must receive information about community-based, alternative services, and resources that can meet the individual’s service needs and are safe, least restrictive, and potentially less costly than comparable nursing facility services.

• PRE-ADMISSION SCREENING. A pre-admission screening (PAS) as defined in OAR 411-070-0005 is required for potentially Medicaid eligible individuals who are at risk for nursing facility services.

PAS INCLUDES:

• An assessment;

• The determination of an individual’s service eligibility for Medicaid-paid long term care or post-hospital extended care services in a nursing facility;

• The identification of individuals who can transition to community-based service settings;

• The provision of information about community-based services and resources to meet the individual’s needs; and

• Transition planning assistance as needed.

PAA DEFINITION:

• Private Admission Assessment (PAA) means the assessment that is conducted for non-Medicaid residents as established by ORS 410.505 to 410.545 and OAR chapter 411, division 071, who are potential admissions to a Medicaid-certified nursing facility. Service needs are evaluated and information is provided about long-term service choices. A component of private admission assessment is the federal PASRR Level I requirement, (42 CFR, Part 483.128(a)), to identify individuals with mental illness or developmental disabilities.

PASRR DEFINITION:

• Pre-Admission Screening and Resident Review (PASRR)" means the federal requirement, (42 CFR, Part 483, (C)-(E)), to identify individuals who have mental illness or developmental disabilities and determine if nursing facility service is required and if specialized services are required. PASRR includes Level I and Level II functions.

• Level 1: is a screening process that is conducted prior to nursing facility admission for all individuals applying as new admissions to a Medicaid certified nursing facility regardless of the individual's source of payment. The purpose of the screening is to identify indicators of mental illness or intellectual or developmental disabilities that may require further evaluation {42 CFR 483.128} or if categorical determinations, as described in section (2) of this rule, which verify that the nursing facility service is required.

• Level 2: is an evaluation and determination of whether nursing facility service and specialized services are needed for an individual who has been identified through the PASRR Level I screening process with indicators of mental illness or intellectual or developmental disabilities who does not meet categorical determination criteria (42 CFR 483.128).

WHAT DOES IT ALL MEAN?

• The language to describe our body of work can be confusing.

• Our titles and work load may be organized differently – but we all do the same body of work.

• We prevent institutionalization of Oregonians.

• We provide access to resources which enable people to live independent lives.

• We develop placements with wrap around supports that meet the consumers care needs and personal goals.

• We build short-term relations that provide long-term benefits for people.

• We are good stewards of the state.

WHERE TO FIND INFO ON OUR

BODY OF WORK

• Nursing Facility OAR 411-070-0000: http://www.dhs.state.or.us/policy/spd/rules/411_070.pdf

• Community Transition Services OAR 461-155-0526: https://apps.state.or.us/cf1/caf/arm/B/461-155-0526.htm

• Diversion and Transition Service OAR 461-155-0710: https://apps.state.or.us/cf1/caf/arm/B/461-155-0710.htm

• Diversion/Transition Webpage: http://www.dhs.state.or.us/spd/tools/cm/transition/index.htm

• Kplan 411-035-0000: http://www.dhs.state.or.us/policy/spd/rules/411_035.pdf

• OSIPM Special Needs Manual: http://www.dhs.state.or.us/spd/tools/program/osip/h.htm

• DME/POS 410-122-0010: http://arcweb.sos.state.or.us/pages/rules/oars_400/oar_410/410_122.html

BARRIERS RESULTING IN THE

INSTITUTIONALIZATION OF OUR CONSUMERS

• State-wide barriers:• Housing• CBC capacity• Institutionalization of consumers• Payment processes not keeping up with technology• Wait times on CO deliverables• Changing Medicaid service eligible population• Facilities resistant to our body of work • Perceived safety-net at NF

• Internal barriers:• Being pulled into other bodies of work.• Lack of training• Changes in program and management

WHAT THE FUTURE HOLDS

• New Database

• Alternative purchasing resources

• Rescheduled Statewide F2F Training

• Diversion/Transition Worker Guide

• Introduction letter on D/T work for NF and consumer

• Ongoing District Meetings

• Data on changes MAGI created in our NF caseload numbers

• Monthly calls with guest speakers

• Statewide Resource Guide

• Collaboration with OHA – working with CCOs

WHAT DO YOU WANT?

• What resources would help you grow as a D/T worker?

• What is your biggest barrier, that occurs most often, to slow the success of your work?

• What training topics would you like to see?

• What guest speakers would be most helpful?

• What policy or rule would you like to see explained more fully?

• What barriers do you come across when

• working with CCOs?

• doing cross county transitions?

• Utilizing specific need contracted facilities?

THANK YOU FOR YOUR TIME TODAY

Amy Gordin, Transition Services Analyst

[email protected]

503-945-5659 or 503-983-8934