CIL-NET Presents…

1. CIL-NET Presents… Personal Assistance Services A National Onsite Training August 16-18, 2011 St. Louis, Missouri Presenters: Gwen Dean Phil Pangrazio

2. Arizona Health Care Cost Containment System (AHCCCS) “AHCCCS” is Arizona’s Medicaid Program AHCCCS is a Managed Care Model

3. AHCCCS Role AHCCCS is responsible for - • Financial Eligibility • Medical Eligibility • Selecting and monitoring the performance of Arizona Long Term Care (ALTCS) Managed Care Program Contractors • There are four ALTCS Program Contractors • Mercy Care, Bridgeway, SCAN & Evercare Health Plans

4. Financial and Medical Eligibility • Our waiver combines, Acute Care Medical services, Institutional Services and a comprehensive Home and Community Based Service managed through Arizona Long Term Care Service (ALTCS) Program Contractors • Serving people with Developmental or Physical Disabilities, and the Elderly • Native Americans may choose to receive services through AHCCCS or Indian Health Service • 65 years of age or older, disabled and requiring nursing facility level of care • Income limit 300% of SSI maximum $1,656 per month for an individual

5. Financial and Medical Eligibility, cont’d. • Resource limit is $2,000 for an individual • A home, vehicle and irrevocable burial plan are not counted toward resource limits • AHCCCS eligibility takes up to 90 days • Family members, friends and a spouse can be paid to provide service • Parents with children under the age of 18 are not allowed to be paid

6. Arizona Long Term Care Services (ALTCS) • Personal Care • Homemaking • Attendant Care • Respite Care • Self-directed Attendant Care • Assisted Living • Nursing Homes 6

7. Managed Care Program Contractor ALTCS Program Contractors are responsible for – • Selecting and monitoring the performance of provider agencies • Monitoring Self-Directed Care Services • Assigning the Consumer an ALTCS Case Manager • The coordination and authorization of services • Ensure that new consumers have services provided within 30 days • Semi-annual consumer re-assessment of services 7

8. Philosophical Benefits and Value of Being a Managed Care Sub-Contract Provider of PAS • Increase the Center’s consumer base • Discretionary dollars

9. Provider Agencies Services • Personal Care • Homemaking • Attendant Care • Respite Care • Prescriptions • Transportation to medical appointments • Home modifications • Visiting nurse services • Durable medical equipment • Doctors and hospitals

10. Personal Care Assistant Services • Personal Care – 2 to 3 hours, 2 to 3 times per week • Showering • Dressing • Shopping • Meal preparation • Homemaking – 2 to 3 hours, 1 to 2 times per week • Housekeeping • Change linens & make bed • Laundry • Shopping • Meal preparation

11. Personal Care Assistant Services, cont’d. • Attendant Care – 15 to 40 hours, 5 to 7 days per week • Personal Care • Homemaking • Supervision • Respite Care – 720 hours annually • Personal Care • Homemaking • Supervision

12. Self-directed Attendant Care The consumer can access all HCBS Services through their ALTCS Case Manager. In addition their PCA is allowed to do the following tasks - • Bowel care • Bladder catheterization (non-indwelling) • Wound care (non-sterile) • Glucose monitoring • Permanent tube feeding • Insulin injections

13. Self-directed Attendant Care, cont’d. Consumer is responsible for - • Recruiting • Interviewing/hiring/terminating • PCA Training • Acquiring CPR and First Aid training before employment • Directing their care • Developing a Service Plan • Developing a Service Agreement between a consumer and the PCA

14. Self-directed Attendant Carecont’d 2 • Ensuring that all applicant documents are accurately completed and submitted to the Fiscal and Employer Agent (FEA) • References and Criminal Clearance card is optional • Scheduling and monitoring their services hours • Submitting the PCA/consumer signed timesheets • Monitor their quality of care and potential Medicaid fraud • Notify the ALTCS Case Manager of any changes, i.e. service hours, health changes, hospitalization etc.

15. Self-directed Attendant Carecont’d 3 Program Contractor is responsible for - • Authorizing Consumer training services: • Recruitment tips • Interviewing techniques • Developing a Job Description • Developing a Service Agreement • How to manage your PCA • How to monitor the performance of their PCA • Authorizing agency to provide back up PAS services • Monitoring the quality of all services

16. Self-directed Care Model and Provider Agency Model • The Consumer’s role is to - • DIRECT their Care • Make CHOICES • Make DECISIONS • Live INDEPENDENTLY

17. Provider Agencies Agencies are responsible for - • Recruitment – Local newspapers, flyers, brochures, word of mouth • Employing PCAs – Character, stability and ability • PCA Training – Fundamentals and disability related competencies • Identifying consumer needs – Intake Assessment • Referring PCAs – Character, PCA skills, location, availability • Quality of service – Joint responsibility with consumer • Contract Compliance – Adhere to agency & contract requirements

18. Five Components to Agency Model • Case Management • Hiring PCAs • Payroll • Claims • Policies and Procedures

19. Case Management -Provider Agency Service Intake Independent Living Overview Intake Assessment Summary Consumer Training Overview Consumer Needs Assessment Consumer/PCA Service Agreement After Hours Service PAS Policies and Procedures

20. Case Management -Independent Living Overview Independent Living Philosophy Consumer Rights Independent Living Center Programs & Services Identify interest in developing an Independent Living Plan Encourage consumer to get involved in Advocacy Assist with voter registration

21. Case Management -Intake Assessment Summary • Living arrangements • Language spoken • Cognitive abilities • Vision, hearing, literate • Consumer’s healthcondition • Accessibility & condition of home • Safety issues • Lifestyle (i.e., pets, smoking, etc.) • Identify days & hours of service • Consumer’s contingency plan Getting to know your Consumer

22. Case Management -Consumer Training Overview PCA referral process Interviewing your PCA Selecting a PCA / replacement Process Contingency plan Monitoring your PCA performance Reportng Requirements

23. Case Management -Consumer Needs Assessment • Identify the consumer’s Personal Care and Homemaking tasks, be specific • Identify who will provide medical tasks that the PCA is not allowed to perform, be specific • Identify days and hours of services preferred • Ensure the ALTCS Case Manager has allowed enough hours to complete the task

24. Case Management -Consumer Needs Assessment cont’d. • The consumer can use the Needs Assessment as an interview tool for potential PCAs • The agency will use the Consumer Needs Assessment to identify PCAs who have the skills, knowledge, ability and availability to provide the service

25. Case Management -Consumer/PCA Service Agreement • Avoid problems by including all tasks that the consumer and PCA have agreed upon, be specific • Include hours and days of service that have been agreed upon by the consumer and the PCA. • Ensure both parties have a clear understanding and agree on how service will be provided

26. Case Management -Consumer/PCA Service Agreement cont’d. • The agency will use this agreement to complete Consumer Service Evaluations and PCA performance evaluations • If issues arise, refer back to the agreement • The consumer will contact the agency if the agreement requires revision

27. Case Management -After Hours Service Provided after normal business hours • Monday through Friday, 5pm to 8am • Week-ends and ABIL holidays 24 hours • Consumer contingency plan

28. Case Management -After Hours Service cont’d Provided after normal business hours • List of available PCAs • Ensure the consumer and the PCA have the contact information • Ensure the consumer and PCA know to only contact the service after hours

29. Case Management -Provider Agency Consumer Monitoring • On-site Service Evaluation is conducted 5 days after the initial service date for new consumers only. This is to ensure the PCA has the skills, knowledge and ability to meet the consumer needs. • 30 day, (60 day if necessary), and 90 days from the initial service date an on-site service evaluation is completed to ensure the consumer needs are being met and the PCA continues to have the skills and is satisfied with his/her position.

30. Case Management -Provider Agency Consumer Monitoring cont’d • Onsite service evaluations are then completed every 90 days thereafter. • Unannounced onsite visits are conducted when necessary.

31. Program pitfalls • Lack of communication between Case Managers, Agency Supervisors, Consumers, Payroll and claims • Liability Insurance • Workers comp Insurance • Unemployment Insurance • Overtime • Turnover

32. Program pitfalls cont’d • Family members taking advantage of the consumer’s service • Designate one spokesperson when family has oversight of service

33. Paid Family Member Pros and Cons • Majority of paid family members provide excellent care. • Difficult to know who is providing the care when several people live in the home. • Failure to report consumer’s change in health condition, hospitalization. • Submitting hours for payment when the consumer is in the hospital, out of town or has been disenrolled from Medicaid benefits.

34. Paid Family Member Pros and Cons cont’d • Some family members will only provide care if they are being paid. • Some only want the consumer Social Security check. • Some family members threaten the consumer with nursing home placement if they admit the care is not being provided.

35. Paid Family Member Pros and Cons cont’d 2 • Reduces recruitment cost • Reduced training cost • It would be difficult to fill all positions without family members • Potentially increases workers comp • Increases unemployment insurance

36. Hiring Requirements – Personal Care Assistant • Application • 3 References – 1 should be an employer • Criminal History Self-Disclosure – should be notarized • Federal Criminal Fingerprint Clearance Card • E-Verification qualification • Federal Health Care Exclusion qualification

37. Hiring Requirements – Personal Care Assistant cont’d • Negative TB skin-test or x-ray indicating free from pulmonary tuberculosis • Complete and pass PCA training and CPR/1st Aide • New hire orientation • Appropriate Employment Identification • Completed tax documents, i.e. I9, W4, & A4 • Policy and Procedure signed Acknowledgement

38. Personal Care Assistant Training Family Members-Homemakers • Fundamentals of Caregiving -2 day training • Philosophy and Values when providing care and support • Roles and Responsibilities within an Agency • Ethical and Legal Issues • Observing, Reporting and Documenting • Communication and Cultural Competency • Job Management Skills/Time Management • Infection Control • Safety and Emergencies

39. Personal Care Assistant Trainingcont’d. • Nutrition and Food Preparation • Home Environment Maintenance • Body Mechanics and Techniques for Maintaining Back Safety • Transfer / Positioning – disability specific • Personal Care – disability specific • CPR and First Aide • Students must demonstrate their skill and ability to perform the task • Disability specific training, if necessary

40. Personal Care Assistant Trainingcont’d 2 General Personal Care Assistant • Fundamentals +one module: 4 day training • Elderly/Physical Disabilities or Developmental Disabilities • Chronic Diseases and Physical Disabilities • Physical and Emotional Needs of an Individual • Transfers and Positioning • Personal Care • Activities and Activity Planning • Dementia-Specific Care • Grief and end-of-life Issues • CPR and First Aide • Students must demonstrate their skill and ability to perform the task

41. Payroll Process • Service hours cannot be paid without a timesheet • Service hours paid must have the Case Managers’ and Agency authorization • Timesheets must have both Consumer and Personal Care Assistant signature before payment is issued • Payment can not be paid if the consumer is in the hospital or disenrolled from the Medicaid program

42. Payroll Process cont’d. Agencies should- • Develop a Payroll verification Report • Verify Case Manager authorization before payment is issued • Verify Supervisor’s authorization before payment is issued • Verify hospitalization and services not provided

43. Payroll Process Cont’d 2 • Set a due date for timesheets to be submitted • Clearly inform the PCA when their regular payday is and when payment will be issued when payday falls on a holiday • Not allow early payment to the PCA • Not allow a payroll advance • Always pay on time - Never have insufficient funds

44. Payroll Pitfalls • Issuing payment without a Case Manager’s authorization • Poor communication between Case Managers, Supervisors and payroll • Issuing payment without appropriate PCA employment documents • Forgery • Fraud / falsification

45. Claims Process • Authorization must be received before billing a claim • Submit a clean claim; complete all required information on CMS 1500 • Diagnosis (ICD9 code) • Procedure Code –Service • Modifier code – Service provided • Service dates and hours • Bill rate • Agency name • Provider ID # • National Provider ID number (NPI) • Consumer name • Consumer Medicaid ID number

46. Claims Tips • Claims are billed using the PCA timesheet • Bill only hours submitted on the PCA timesheet • Reject PCA timesheet that are incorrect or missing information • Bill only your agreed upon unit rate

47. Claims Pitfalls • Not receiving payment • Claims are paid 30 to 45 days after received by the Program Contractor • Case Managers authorizing a service, then not informing their claims department • Failure to be notified by the Case Manager that hours have been decreased and continuing to pay the PCA for hours you can’t bill.

48. Claims Pitfalls cont’d • Billing without an authorization • Research on denied claims is very time intensive • Re-submitting denied claims

49. Important Considerations in Developing Policies and Procedures • In-house operations, Consumer and PCA. • Consumer and PCA policies and procedures are the same. You will communicate the same information to both parties • Develop policies/procedures that will reduce the agency’s liability • Inter-connect all components when developing policies/procedures

50. Important Considerations in Developing Policies and Procedures cont’d • Create timelines for each process • Case Management based on the contract requirements, Agency policies and philosophy • Hiring which reflects State & Federal Department of Labor guidelines • Payroll and claims reflects contract requirements and agency policies