Transition Coordination: “The Real Nuts & Bolts” June 26, July 2, 10, and 16, 2008

1. Transition Coordination: “The Real Nuts & Bolts” June 26, July 2, 10, and 16, 2008 Department of Medical Assistance Services

2. MFP Nuts & Bolts Training Overview MFP - National Initiative • What is Successful Transition • Transition Process • Services • Outreach • Enrollment • Planning and Assessments • Consumer Direction • Service Authorization • Reimbursements • QMR • Additional Resources

3. MFP - National Initiative • An award from the Centers for Medicare and Medicaid Services • Gives participants of all ages and all disabilities who live in Virginia LTC institutions options for community living This Project has three Objectives: • Goal 1 - To give participants who live in nursing facilities, Intermediate Care Facilities for Individuals with Intellectual Disabilities/Mental Retardation and Related Conditions, and long-stay hospitals more informed choices and options about where they can live and receive services; • Goal 2 - To transition participants from these institutions if they choose to live in the community; and • Goal 3 - To promote quality care through services that are person-centered, appropriate, and based on participant needs.

4. MFP - National InitiativeVirginia’s Numbers • Anticipated numbers of transitions by waiver by year (MFP slots)

5. MFP Nuts & Bolts Training Overview  MFP - National Initiative What is Successful Transition • Transition Process • Services • Outreach • Enrollment • Planning and Assessments • Consumer Direction • Service Authorization • Reimbursements • QMR • Additional Resources

6. What is Successful Transition? • More than someone changing residence • Increasing a sense of self-direction • Increasing decision-making • Becoming a full participant in community activities • Developing informal and formal supports

7. What is Successful Transition?Who are Transition Coordinators / Case Managers? • A DMAS enrolled provider who is responsible for supporting the individual and family/caregiver, as appropriate, with activities associated with transitioning from an institution to the community • Transition Coordinators / Case Managers work closely with participants • Assist individuals to take a proactive role in the transition process • Recognizes that a successful transition is dependent on the participant themselves and their willingness to change

8. What is Successful Transition? Characteristics of theTransition Coordinator/Case Manager • Transition Coordinators / Case Managers will have multiple roles including • Being an effective peer mentor • Understanding circumstances of placement in institution • Being mindful of the individual’s potential • Being knowledgeable of all community resources • Being an active listener

9. What is Successful Transition? Characteristics of theTransition Coordinator/Case Manager • Recognizing that the participant’s emotions of fear, anger, and anxiety are real • Openly acknowledge and discuss emotions with participant • Providing accurate information in a timely manner • Exploring all options with the participant • Acknowledging and balancing risk

10. What is Successful Transition? Critical Components of Transition that Contribute to Success • Developing a trusting relationship • Having a comprehensive assessment that clearly reflects • needs • concerns • priorities • Developing and implementing a Transition Plan that addresses • the participant’s needs • critical follow-up with post-transition activities

11. What is Successful Transition?Guiding Principles • There are two important principles to keep in mind throughout the transition process • self-determination • dignity of risk

12. What is Successful Transition? Self-Determination • Is the ability or right to make one’s own decisions without interference from others Dignity of Risk • Making choices about new experiences and possibilities • Participants grow by making choices even if those choices are viewed as poor choices • Participants learn by both successes and failures • Taking risks is part of living

13. What is Successful Transition? Balancing Risk • Prudent risks vs. undue risks • Participants should not be expected to face challenges that will cause failure

14. MFP Nuts & Bolts Training Overview  MFP - National Initiative What is Successful Transition Transition Process • Services • Outreach • Enrollment • Planning and Assessments • Consumer Direction • Service Authorization • Reimbursements • QMR • Additional Resources

15. Transition ProcessThe key of the transition process • The ability to coordinate pre- and post- reentry day planning and service delivery • The ability to submit/ obtain waiver enrollment & PA authorization on the day of discharge from facility

16. Discharge Date Implementation Phase Completed after transition and individual is living in community Transition Process3 Stages Stage 1Stage 2Stage 3 Planning Phase Completed while in facility

17. Transition ProcessStage 1 “Planning Phase” Pre-Discharge activity for Transition Coordinator/Case Manager • Recruit participant • Educate participant • Coordinate with discharge planner at facility • Complete MFP enrollment: • MFP Enrollment form • MFP Informed Consent • Administer Quality of Life survey Develop Transition Plan which includes a risk assessment • Provide Transition Coordination/Case Manager and Transition Service /Funding services • Locate and secure qualified housing • Schedule discharge date • Schedule transportation • Confirm and insure all is ready for D/C

18. Transition ProcessStage 1 “Planning Phase” Pre-Discharge activity for Transition Coordinator/ Case Manager (continued): • Complete Prior Authorization Requests • Complete Assessment & Waiver application • UAI, LOF (from facility) • Choice Form • Person-centered Service Plan with risk assessment • Schedule waiver service providers for goods and services needed for successful transition • Assistive Technology • Environmental Modifications • Setting up household items • Personal care

19. Transition ProcessStage 2 “Day of Reentry” • Insure waiver enrollment & PA’s are in place by Service Provider • Conduct home visit to ensure • Service provider submits PA for services • Service provider submit waiver enrollment • Enroll for CD fiscal agent supports if appropriate (caution a delay in CD services may occur due to enrollment activities to be an employer) • Monitor / coordinate delivery of goods for day of reentry • Supportive Services are in place and meeting needs • Verify the back up plan • Verify delivery of Transition Service/funding purchases • Verify/schedule/completion of environmental modifications and or assistive technology

20. Transition ProcessStage 3“Implementation Phase” Activities • Service provider provides waiver services and submit for payments • Environmental Modifications • Transition Services/funding • Assistive Technology • Ensure providers submit the annual DMAS 122 • Conduct and submit the annual reassessment to DMAS (97a/b, 99c MR/ID 437) • Establish Transition Coordinator/ Case manager visit schedule for up to 12 months • Be sensitive to Participant stress • Check appropriateness of services being delivered • Check participants view of how new life is progressing • Revise Service plan as needed and before Transition Coordination ends

21. Note This process can take up to 6 weeks to process Transition ProcessConsumer Directed Option (CD) • Added activities to coordinate • Pre discharge • Discuss the CD option • Provide a clear picture of the responsibilities of CD • Connect with Service Facilitator for services • Incorporate consumer direction into the service plan • Service Facilitators will confirm • All IRS Employer forms complete (W9) • All employees are “ready to go” • Day Of Discharge • Coordinate with Service Facilitator that are services ready to start • Service plan is understood by attendants • Post Discharge • Check on Service Facilitator services • Monitor Services meeting participants needs as defined in service plan and adjust as needed

22. MFP Nuts & Bolts Training Overview  MFP - National Initiative What is Successful Transition  Transition Process Services • Outreach • Enrollment • Planning and Assessments • Consumer Direction • Service Authorization • Reimbursements • QMR • Additional Resources

23. ServicesNew Waiver Services Transition Services/Funding: a one-time, life-time benefit assisting with one-time, up-front household expenses. Added to EDCD, AIDS, TECH, MR and DD waivers. Time limited to 9 months (Up to 2 months prior to discharge for MFP Participants only) Transition Coordination supports participants who elect services through the Elderly or Disabled with Consumer Direction Waiver both before and after transitioning to the community *Time limited to 14 months (Up to 2 months prior to discharge for MFP Participants only) *Subject to change based on CMS regulatory changes

24. ServicesAdded Existing Waiver Services • Assistive Technology - includes devices that enhance one’s ability to function and communicate, such as specialized toilets, braces, chairs, and computer hardware and software. Added to EDCD and AIDS waivers. • Environmental Modifications - assistance with making modifications to homes and primary vehicles to make them accessible. Added to EDCD, AIDS and TECH waivers. (For MFP Participants, this service can be delivered prior to discharge) • Personal Emergency Response System and Personal Emergency Response System medication monitoring. Added to AIDS and TECH waivers.

25. MFP Nuts & Bolts Training Overview  MFP - National Initiative What is Successful Transition  Transition Process  Services Outreach • Enrollment • Planning and Assessments • Consumer Direction • Service Authorization • Reimbursements • QMR • Additional Resources

26. Outreach • Outreach is • The first activity • Critical to the success of a transition • Varied in it’s forms • Provided by many people • Levels of Outreach • Agency • Individual • Regional

27. OutreachAgency Led Outreach • Nursing Facilities and Long-Stay Hospitals • The Department of Medical Assistance Services, the Virginia Health Care Association, the Virginia Association of Non-Profit Homes for the Aging, and Long-Term Care Ombudsman Office will • Send information about MFP to all nursing facilities and long-stay hospitals • Hold Informational Sessions • Incorporate educational and awareness information about the MFP into the annual resident review process • ICF/MR • The Department of Medical Assistance Services, the Department of Mental Health, Mental Retardation and Substance Abuse Services, and the Virginia Association of Community Services Boards will • Send information about MFP to all Intermediate Care Facilities for Individuals with Intellectual Disabilities/Mental Retardation and Related Conditions

28. OutreachIndividual Led Outreach • Case Managers, Transition Coordinators, Health Care Coordinators, Human Rights Advocates, Long Term Care Ombudsman's will: • Contact facilities to: • hold one-on-one meetings • open informational session

29. OutreachRegionally Led Outreach • REGIONAL EMPOWERMENT TEAMS (RET) • Assist in identifying and mentoring participants who want to transition • The Teams are coordinated by the Centers for Independent Living and will address • specific issues • encourage broad stakeholder participation • evaluate the process, and create recommendations • annually survey stakeholders to obtain their input and assess their concerns • RET meetings are for participants, family members, caregivers and other interested citizens to address team members and meet with the Virginia Money Follows the Person Project Director • Provide a forum for discussion and consensus building among members; • Support the state’s planning to accurately project participants’ needs and resources; • Identify systemic issues and provide guidance for change to the long-term support system; • Review training, marketing, and other materials to ensure that competencies and diversity are addressed; and • Report to the Transformation Leadership Team any necessary changes to legislation and regulations.

30. Outreachto Individuals • Key Elements of Outreach to Participants • Source of information • Who should be identified for MFP? • What qualifies a MFP candidate? • Referral sources and contacts • Key decisions you must protect • Choice • Informed consent • What are the participant’s responsibilities?

31. Outreach Sources of Information • Sources of information can be obtained through: • DMAS • DMHMRSAS • Local DSS • Local Dept of Health • Community Service Boards • Area Agencies on Aging • Centers for Independent Living • On the Web • http://www.DMAS.virginia.gov • http://www.DMHMRSAS.virginia.gov • Virginia Easy Access www.easyaccessvirginia.gov • Olmstead http://www.olmsteadva.com/mfp

32. OutreachWho should be indentified for MFP? • Residents of the Commonwealth of Virginia • Living in a long-term care institutional setting defined as • Nursing Facility • Long-Stay Hospital • Intermediate Care Facility for Individuals with Intellectual Disabilities/Mental Retardation and Related Conditions

33. OutreachWhat qualifies a MFP candidate? They must Have : • Lived in a long-term care institutional setting for atleast six successive months, including periods of hospitalization; and • Be Medicaid eligible for at least one month at the time of discharge • Qualify for a waiver program • EDCD • IFDDS • HIV/Aids • Intellectual Disability / MR • Technology

34. OutreachReferral Sources & Contacts • Professional Staff at • Nursing Facilities and Long-Stay Hospitals • Intermediate Care Facility • People in the community can recommend • Family members • Friends

35. OutreachInsuring Choice • –Participants MUST choose for themselves – • The option of choice is a vital • component of the recruitment process • Family members or caregivers, as appropriate, may seek transition information, the final choice is the participants. but

36. Outreach Insuring Choice • Choice is insured by the : • Professional through person-centered planning • Participant through participation in all aspects of their planning and care • This is documented on: • The Informed Consent form • The service plan or • individual support plan • MFP PROVIDER DO’S • As a provider you need to assure the participant has free choice • Insure forms are correctly and completely filled out. • Maintain the document in their records • 3. Insure the a participant has a copy

37. OutreachWhat is informed consent? • Informed consent means • a voluntary, written agreement • required for participation in the Money Follows • no one can force or trick you into giving your consent to participate.

38. OutreachWhat are the procedures for Informed Consent? • Requirements • Must give informed consent before participation in MFP. • Consent will be documented on the Informed Consent form • Consent is for the following items: • Participation in the MFP • Choice of waiver versus institutional services; • Choice of a place to live (called a “qualified residence”); • Choice of waiver service(s) and the opportunity to self direct; • Choice of service provider(s); and • Continuation of services after transition. Transition Coordinator/Case Managers are responsible to: 1. Ensure forms are correctly and completely filled out 2. Maintain the document in their records 3. Ensure that the participant has a copy

39. OutreachCan anyone but the participant give Informed Consent? • Surrogate decision makers are allowed If: • If a surrogate decision maker is designated to make decisions for the participant, that person must provide informed consent for to participate in MFP. • If a child, the person who has legal custody is the surrogate decision-maker. • If an adult, in most cases the surrogate decision maker is a guardian or Power of Attorney. Transition Coordinator/Case Managers are responsible to: 1. Ensure the surrogate decision maker is “valid” with legal documentation to support decision (copy of Power of Attorney) 2. Ensure forms are correctly and completely filled out 3. Maintain the document in their records 4. Ensure that the participant has a copy

40. OutreachCan participation in MFP be withdrawn? • Yes • Withdrawal Steps: • Individual will contact the Transition Coordinator/ Case Manager • Individual with the Transition Coordinator/Case Manager will complete the MFP Withdrawal form • Transition Coordinator / Case Manager will make sure the form is signed and dated by both the participant and themselves. • Be sure the effective date of the withdrawal is clear • Send the withdrawal form to Prior Authorizing agent • Maintain copy for individual’s record and provide a copy to the individual

41. OutreachWhat are participant responsibilities? • These responsibilities include: • Choosing service providers (Agency or Consumer Directed); • Ensuring that the back-up plan is adequate and can be implemented it when needed; • Working with a case manager or transition coordinator to assure a smooth transition with ongoing supports; • Expressing satisfaction or dissatisfaction with services and supports; • Reporting changes in the their needs; and • Paying bills.

42. MFP Nuts & Bolts Training Overview  MFP - National Initiative What is Successful Transition  Transition Process Services Outreach  Enrollment • Planning and Assessments • Consumer Direction • Service Authorization • Reimbursements • QMR • Additional Resources

43. MFP Enrollment • Transition Coordinator or Case Manager must request MFP enrollment • The MFP enrollment is up to 14 consecutive months • Up to 2 months before discharge and 12 months after discharge • Waiver services available during the period of residence in a NF, ICF/MR or Long-Stay Hospital are; • Transition Coordination / Case Management • Transition Service/funding • Environmental Modifications

44. MFP Enrollment Activities • The Transition Coordinator or Case Manager requesting the enrollment must: • Certify that the recipient meets all MFP criteria • Determine if participant can live safely in community • Complete needed forms • Informed Consent • MFP Enrollment • Administer Quality of Life Survey • Submit for MFP enrollment for Prior Authorization to the appropriate agency (DMHMRSAS, KePro or DMAS)

45. MFP EnrollmentPrior Authorization • Submit MFP enrollment information based on waiver • KePRO • EDCD • AIDS • DMAS • Tech Waivers • DD • DMHMRSAS • MR/ID Waiver • Enrolling PA Agency activities : • Confirms if meets MFP criteria • Grant Prior Authorization / service plan approval • Forwards letter of approval to provider & participant • Enters participant in MMIS as MFP participant

46. MFP EnrollmentDisenrollment – Returning to a facility • This will be a difficult decision to make because of the strong commitment to maintaining the participant in the community • Factors to use in determining • What does the participant feel about current situation? • Is the risk too great? • Are the basic living needs being met (food, shelter, clothing, daily care needs)? • Are services meeting the participants needs? • Are the family and informal supports adequate to sustain the participant? • Can the financial obligations be managed?

47. MFP EnrollmentDisenrollment from MFP • Possible reasons for disenrollment from MFP • Participant is hospitalized for more that 30 days • If re-admitted to a facility or hospital and stay there for more than 30 days, individual will be automatically disenrolled from MFP • Participant decides to return to the facility • Participant completes MFP enrollment period • 12 months after discharge, the individual is automatically disenrolled from MFP

48. MFP EnrollmentCompletion of enrollment period • MFP participants are permanently transferred to regular waiver category after MFP enrollment period ends • All Waiver services continue as long as waiver criteria is met

49. MFP EnrollmentReenrollment Criteria • Individual does not have to meet the requirement for six (6) consecutive months of institutional residency again • Reenrollment does not entitle the participant to Transition Service/funding a second time • Remaining Transition Services funding is available for use if within the original 9 month period

50. Waiver Enrollment HIV/Aids IFDDS EDCD MR/ID Tech • Enrollment process is the same as any waiver • Submit the required forms to the correct Authorizing Agent • Receive Authorization • Begin delivering services The 10 day retroactive billing window is in effect except for MR/ID waiver