Overview of Expectations of CCSNL

Overview of Expectations of CCSNL Sharon Lambton, R.N., M.S.N Nurse Consultant Children’s Medical Services

Basic Requirements • Be a registered nurse (RN) case manager in the CCS Program with at least 6 months experience in that role • Have completed the Pediatric Nursing End-of-Life Education Consortium (ELNEC) training • Complete the Partners for Children (PFC) palliative care training provided by the CMS Branch • Be responsible for no more than 50 waiver participants In addition, each county needs to identify a second CCS RN with ELNEC and PFC training to serve as a back-up for the primary liaison in the county.

Roles and Responsibilities(refer to CCS Numbered Letter 07-1109) • Receive and process all referrals for enrollment in the waiver • Case finding – identify potentially eligible children by searching the current CCS caseload in the county • Provide training and consultation about the waiver to providers in the community • Be knowledgeable of community resources in the county that may be needed for the waiver participants

Collaboration and Communication A. With the Care Coordinator • Serve as liaison with the CCS program in the county and provide ongoing technical assistance • Review the completed Family-Centered Action Plan and discuss with Care Coordinator at least every 60 days • Authorize state plan and waiver services identified on F-CAP • Participate in care conferences related to participant’s needs and goal achievement

Collaboration and Communication(continued) B. With Participant and Family • Discuss waiver services and benefits • Confirm that applicant is not already enrolled in another home and community based waiver • Review the PFC Freedom of Choice form • Review the Client Agreement form

Collaboration and Communication with Participant and Family(Continued) • Educate the applicant/family on health and safety issues and how to report events or incidents • Provide a copy of the Participant Enrollment Packet to family • Contact family at least monthly to ensure that the services authorized were provided and obtain feedback about satisfaction

Collaboration and Communication(continued) C. With the CMS Branch • Summarize all communications with the participant/family and PFC Care Coordinator in CMSNet case notes • Discuss issues related to health and welfare, remediation and disenrollment with Branch staff and document findings, plan and actions in case notes • Participate in all trainings related to PFC as directed by the CMS Branch

Collaboration and Communication(continued) D. With Special Care Centers (SCC) • Ensure SCC staff are aware of your role with client • Provide ongoing technical assistance to SCC related to waiver participation and services

Collaboration and Communication(continued) E. With Home Health and Hospice Agencies • Discuss timely completion of F-CAP • Work to identify resources for intermittent or shift nursing as noted in F-CAP

Collaboration and Communication(continued) F. With Physicians • Discuss referrals, use of PFC Referral form, and medical documentation needed • Provide consultation to local providers as needed regarding PFC

QUESTIONS???

Transition From PFC • Reasons for transition: • Move from active waiver county to county not participating in waiver • Participant and family may choose to enroll in hospice • When the participant becomes 21 years old • The participant/family no longer wants to participate in the waiver

Transition off PFC(continued) B. Role of CCSNL in Transition process • Assist the participant and family in the dis-enrollment process. • Work with the Care Coordinator in facilitating the transfer of client to a new county and connecting them with resources/services available there; or • Work with the Care Coordinator and hospice agency to ensure a smooth transition to that service; or • For PFC participants at age 20, prepare/update the Adolescent Transition Health Care Plan. Meet with participant, family, and Care Coordinator to discuss planning; or • Work with the Care Coordinator in identifying ongoing non-waiver resources in the community.

Transition off PFC(continued) B. Role of CCSNL in Transition process (continued) • Document activities related to transition planning and coordination into the PFC database (under transition tab)

Required Logs for CCS NL • Current “logs” –PFC data base and case notes • County specific “logs” -several different formats noted; client specific files, pending referrals log, and spread sheet. • Branch in process of reviewing data requirements for federal assurances and evaluation

Overview of Expectations of CCSNL