DCH Updates – SOURCE July 1 st Release

1. DCH Updates – SOURCE July 1st Release August 6, 2010 Presented by Jean Carpenter, RN Director of Quality Assurance and Education - SCM

2. Welcome • Roll Call • Webinar/Conference Call Format • Housekeeping

3. Objectives • At the end of this presentation, participants will be able to: • Identify updates to DCH regulations for SOURCE. • Understand how revisions impact the role of the Medical Director within SOURCE Care Management.

4. Chapter 600 – SOURCE Overview • 601. Introduction to SOURCE • SOURCE • Operates under Elderly and Disabled 1915-c Home and Community Based Services Medicaid Waiver • Eligible members receive Supplemental Security Income (SSI) • Members meet Intermediate Level of Care for Nursing Home placement

5. Chapter 600 – SOURCE Overview (cont’d) • 601. Introduction to Source • SOURCE • Individuals must be • physically, functionally impaired • in need of services to assist with the performance of ADLs • Targets individuals who are elderly and physically disabled • Incorporates PCPs to address medical needs and need for community based long-term care services

6. Chapter 600 – SOURCE Overview (cont’d) • 601. Introduction to SOURCE • SOURCE Case Management Provider is contracted with DCH to provide Enhanced Primary Care Case Management services for eligible older and physically disabled Medicaid recipients.

7. Chapter 700 – Eligibility • 701. Eligible Members (New) • SOURCE • Provides Home and Community Based Services to elderly and physically disabled members who are functionally impaired and require assistance to perform the ADLs and who meet the Intermediate Nursing Home Level of care for placement in a nursing facility.

8. Chapter 800 – Scope of Services • 801.2 Level of Care Criteria • a) The SOURCE RN/LPN, through the use of the MDS-HC(v-9), Level of Care justification criteria (Appendix I), and professional judgment, determines the Level of Care (LOC) for members during the assessment process.

9. Chapter 800 – Scope of Services (cont’d) • 801.3 Procedures • Terminology changed • #3 Placement form (new) vs. Appendix F • #5 SOURCE Level of Care Placement Form vs. Appendix F

10. Chapter 800 – Scope of Services (cont’d) • 804 Case Management (Added) • SOURCE case managers • Consist of nurses, RN and LPN, currently licensed in Georgia and social services workers

11. Chapter 800 – Scope of Services (cont’d) • Section 804 (cont’d) • Program policy does not mandate specific education and experience requirements for CM staff; however, best practice suggests the following guidelines: • Bachelor’s degree in a healthcare or human service field such as nursing, social work, sociology, psychology, etc. • Two years experience in the field of case management

12. Chapter 800 – Scope of Services (cont’d) • 807 Community Services (Added) • Triggers for referral to SOURCE • Cognitive loss • Physical impairment • Acute illness • Exacerbation of a chronic illness • An unmet need for assistance with ADLs and IADLs due to the lack of an adequate and/or reliable informal support network.

13. Chapter 900 – SOURCE Member Enrollment (cont’d) • 903 Program Admission • Step#2. Approval of the nursing home level of care as determined by the assessment nurse using the information gathered from the MDS-HC (v9) and compared to the Level of Care Justification

14. Chapter 900- SOURCE Member Enrollment (cont’d) • Section 903 (cont’d) • Procedures • b) Following discussion of information presented, the multidisciplinary team reviews the Level of Care, MDS-HC and other SOURCE approved assessment tools, with the RN/LPN presenting justification as needed. • c) The team recommends confirmation of the Level of Care

15. Chapter 900 – SOURCE Member Enrollment (cont’d) • Section 903 (cont’d) • Procedures • f) Following team meeting, the SOURCE level of Care Placement form should be faxed to DCH at: 404-463-2889 for enrollment

16. Chapter 900- SOURCE Member Enrollment (cont’d) • Section 903 (cont’d) • Procedures • k) The supervising RN reviews the MDS-HC, completes and signs the MDS-HC Participants Form…RN reviews the findings of the MDS-HC and determines level of care based on the clinical assessment.

17. Chapter 1000 – SOURCE Carepaths(cont’d) • 1002 Carepath Development and Completion (new) • Note: When a new service is required as the result of a change in member support or functional capacity; the physician signature and date on the Carepath will confirm his or her review and approval of the new plan of care. • Example: • 7/30/10 PSS initiated Dr. Doctor 8/4/10 (team meeting date)

18. Chapter 1000 – SOURCE Carepaths (cont’d) • 1003 Completed Carepaths (Added) • During the initial review of the individualized member carepath with the PCP or designee (PA, NP or RN), the following exchange of information will occur: • PCP role in patient education and treatment • monitoring of chronic conditions at home • Self care and informal support • Reimbursed services ordered

19. Chapter 1400 - Provider Performance Monitoring (cont’d) • 1406. Right to Appeal • B. Failure to Meet Nursing Home Level of Care • Members who fail to meet the Nursing Home Level of Care Criteria will be: • Reviewed by the Interdisciplinary team • Receive review of the team prior to issuance of the Appendix Z • The assessment nurse will present, or, at a minimum, be available to answer questions about the member’s MDS-HC assessment, additional assessments and any other documents used in the LOC determination…

20. REVISION TO FORMS

21. April 2010 updates PCP Conference PCP signature Date Case Manager Signature Date July 2010 updates PCP Conference PA Signature Date PCP signature Date Case Manager Signature Date Appendix U – SOURCE Contact Sheet

22. QUESTIONS

23. References • www.dch.georgia.gov • Policies and Procedures for Service Options Using Resources in Community Environments (SOURCE), July 1, 2010