SA/IH Case Management: An In-Depth Look

1. SA/IH Case Management: An In-Depth Look Presented By NC Division of Aging and Adult Services Adult Services Section Adult Programs Representatives

2. Objectives for This Workshop Understand the SA/IH Case management process Understand the importance of good communication between Eligibility and Services Review the Adult Services Functional Assessment Review the SA/IH Economic Assessment Worksheet Create a Service plan Complete a Transmittal

3. Objectives for This Workshop • Review budgeting and uses of the SA/IH payment • Discuss reassessments/continued need for SA/IH and services • What to do when the client is no longer eligible for SA/IH – Notices and Hearings • Discuss Wait Lists • Review SA/IH Payment Tracking Tool

4. What is the SA In Home Program? • The State/County Special Assistance In-Home Program for Adults (SA/IH) provides a cash supplement to help low-income individuals, who are at risk of entering an Adult Care Home, to remain at home safely • The payments are intended to help maintain the individuals health and safety while remaining in the community

5. History • September 2000 • Demonstration project with 400 slots • 22 participating DSSs • In 2003 • The General Assembly approved 800 slots total through June 2005 • 61 participating DSSs • 2005 • 1000 slots were authorized • Payment amount increased from 50% to 75% of payment for ACH

6. History • Legislation in 2007: • Established SA/IH as a permanent program under General Statutes • Allowed the caseload to expand up to 15% of the total statewide SA caseload § 108A-47.1. • DSSs continue to participate voluntarily • Ninety-one counties had slots assigned

7. History • 2012 Legislation SL 2012-142 • The monthly payment to individuals enrolled in the SA/IH program was increased to 100% of the monthly payment an individual would receive if they resided in an ACH. • SA/IH Program requires all DSSs to participate • Participating DSS must maintain at a minimum, average number of cases from SFY 2011-2012. • DSS with assigned slots and no active cases must begin participating effective February 15, 2013, by filling all their assigned slots

8. History • 2012 Legislation SL 2012-142 • A DSS with no established slots must begin participating, effective February 15, 2013. DAAS has recommended the slot numbers for these counties. • Allows the Department of Health and Human Services to waive the 15% cap on slots on or after February 15, 2013 • Changes are implemented within the current authorized budget for 2012-2013 (same as 2011-2012)

9. Developing the SA/IH Program • Outreach • Educate Community Partners • Expand the program - If all of a county’s allotted slots are filled, and the county has decided not to request additional slots, this should be discussed with the Adult Programs Representative prior to initiating a waiting list

10. US Department of Justice (DOJ) Compliant • The complaint cited an “institutional” bias where “People who enter an ACH or other type of facility can obtain certain financial assistance, services, and supports that are not equally available to people with similar levels of disability and financial need who choose to remain in their own homes.” • “The State’s failure to redirect resources and its failure to prioritize community-based setting over institutional care has confined thousands of people with mental illness unnecessarily and indefinitely in adult care homes and puts many others at risk of unnecessary institutionalization.”

11. US DOJ Specifically regarding Special Assistance • “Instead of allocating resources to community-based settings, the State has opted to fund a substantial portion of the cost of providing care in adult care homes. Through its State-County Special Assistance Program, NC subsidizes the cost for individuals with disabilities to live in adult care homes.…..Aside from limited circumstances, the State has not made this supplement available to person[s] with disabilities living in the community.“

12. Transitions to Community Living Initiative (formerly US DOJ) • The US DOJ Settlement Agreement between NC and the US DOJ is now referred to as the Transitions to Community Living Initiative • Eligible individuals will receive Supported Housing Slots which provide rental subsidies for community-based supported housing and transition and tenancy support • The SA-IH Program has been identified as a valuable resource for these individuals if they are determined to be eligible for the program

13. Transitions to Community Living Initiative (formally DOJ), cont… • A DAAS staff member will notify the DSS Adult Services Supervisor in the county of SA/Medicaid eligibility and in the county which the individual is interested in moving to verify that a Supported Housing Slot has been assigned by DHHS • DSS is responsible for SA eligibility determination and assignment of the SA/IH slot number

14. Transitions to Community Living Initiative (formally DOJ), cont… • These individuals cannot be placed on the SA-IH waiting list • If these individuals apply and are determined eligible for SA/IH, the LME is responsible for the ongoing case management • Refer to DAAS Administrative Letter 13-07

15. Open Lines of Communication Are KEY to a successful SA/In-Home Program

16. Communication between Eligibility and Services must include: • Determination that the client meets all eligibility criteria • Determination that the client’s needs can be met safely at home after completing the functional assessment • Amount of the SA/IH payment • Redeterminations and changes in situation • Status of SA/IH slot availability

17. Communication, continued…. • Status of the waiting list • Income Maintenance Caseworker (IMC) will communicate the maximum SA/IH payment • Case Manager will communicate the SA/IH payment authorized based on the needs of the client • The SA/IH Program Interagency Transmittal form will be used by social workers as the communication tool

18. Tools to guide the Case Manager through the process • SA/IH Flow Chart—outlines the referral process • SA/IH Case Managers Checklist—excellent tool for organization and to assure critical time limits are met

20. Referral and Screening • Referrals may come either through Eligibility or Services. One should communicate to the other that a referral has been received • If the IMC determines a client is potentially eligible, communicate with the case manager so the Adult Services Functional Assessment can begin • Complete the SA/IH Pre-Screening Form

21. Referral and Screening • Referral to the case manager must include the Slot authorization number and EIS ID number • A staff member must be designated to maintain and distribute slot authorization numbers (can be eligibility or services) • The designated staff member must communicate the ongoing status of available slots to both services and IMC staff

22. Referral and Screening • Case manager initiates the Adult Services Functional Assessment within 10 workdays of the referral from the IMC • IMC continues to process SA application

23. SA/IH Eligibility Criteria Client is at least 18 years old. Client is eligible for Medicaid as a categorically needy aged, blind, or disabled individual Needs ACH level of care and lives in, or desires to live in a private living arrangement Requests SA/IH payments and services at home in order to remain there safely With appropriate services and the SA/IH payment he/she can have his/her health, safety and well-being maintained at home

24. Eligibility Process • IMC determines SA benefits eligibility and communicates that decision to the case manager • Case manager determines the need for the program using the Adult Services Functional Assessment and the SA/IH Economic Assessment Worksheet • Final determination of the payment is made by the case manager and communicated to the IMC • All communication between the SA IMC & the adult services case manager should be documented on the SA/IH Program Interagency Transmittal Form

25. SA In-Home and SA Program Eligibility Comparisons

26. SA In-Home & SA Program Eligibility and Budgeting Comparisons

27. Eligibility for OtherBenefits SA-5400 • SA/IH is a non-countable benefit for the following programs: • Supplemental Security Income (SSI) • Medicaid • Subsidized housing (HUD Section 8) and other federal housing programs

28. Eligibility for Other Benefits • SA/IH is a countable benefit for the following programs: • Food Stamps • LIEAP

29. Case Manager’s Role Advocate For the clients For the Program Gatekeeper Communicate Educate Prioritize

30. IMC Role • Source of referrals for potential recipients • Determination of SA/IH financial eligibility • Communicate approvals/denials/changes/ redetermination of eligibility to the Adult Services case manager • Communicate changes in payment to the client

31. How Do Counties Pay for the Case Management Related to SA/IH? • Social Services Block Grant • Some activities related to medical and mental health services may be reimbursed using Medicaid Administrative Claiming

32. Case Management Process Assessing Service Planning Monitoring/follow up Ongoing contacts Reassessing (quarterly, annually)

33. Assessment Must begin within 10 workdays of SA/IH IMC referral 30 days to complete assessment Adult Services Functional Assessment (DAAS-6220) is used Must include the Economic Assessment Worksheet to determine financial need and SA/IH payment

34. Assessment • Needs to indicate how the client meets the target population and is eligible for the service • The assessment and economic worksheet will identify needs that will be included in the service plan

35. What is the purpose of the Economic Worksheet? • Identifies sources of income • Indicates how income is being used • Reveals a surplus or deficit • Helps identify unmet needs

36. Completing the Economic Assessment • The SA/IH payment benefit is to be used for those health, safety, and basic needs that will allow an individual to remain safely in their home as opposed to residing in a residential care facility

37. Calculating the Budget • Observe the following principles: • Explore regular monthly expenses & expenditures • Do not arbitrarily divide monthly household bills by the number of adults living in the household • Explore unusual expenses reported by the client • Example: a client reports $150.00 allowance for clothing. Consider if this is a one-time need • Note: As of 7/1/15 FNS benefits cannot be counted as income or a resource

38. Calculating the Budget, cont… • Remember the client is entitled to a personal needs allowance of $66.00 to purchase items outside of basic needs, i.e. cigarettes, cable, pet food (if it is a therapeutic animal, that can be calculated as part of a need) etc. • If the expenses reported by the client exceed his/her income when combined with the maximum allowable SA/IH payment, the client may not be able to remain safely at home • Reasonable expenses should be viewed in terms of the client’s particular circumstances

39. Uses of the SA/IH Payment • The SA/IH Payment should be used to help the individual remain in the community by focusing on the following: • Health/Medical • Safety • Basic Needs

40. Uses of the SA/IH Payment (Medical/Health) • Payments for health needs include items that are not covered by Medicaid or other health insurance or funding source but are recommended by the health care provider(s). These are services or items that the client needs to maintain or improve his/her health and mental health functioning

41. Uses of the SA/IH Payment (Medical/Health) • Medications including OTC recommended by the physician • Co-payments for prescriptions & physician visits • Nutritional Supplements • Incontinence supplies • Durable medical equipment • Additional PCS hours and/or IHAS

42. Uses of the SA/IH Payment • Transportation to medical appointments • Mental Health Treatment and Services • Dental and Eye Care • Adult Day Services

43. Uses of the SA/IH Payment (Safety) • Safety needs are related to those items and services that will enable the client to be safe in his/her environment. Please note that the client does not have to own his/her home for these items or services to be purchased. Please check the rental agreement to see what the landlord is legally responsible for providing. The client should also obtain permission for any adaptations for items not covered by the lease.

44. Uses of the SA/IH Payment (Safety) Safety items may include the following: • Home Repairs or modifications necessary to maintain safety • Essential technology for communications (lifeline, telephone systems) • Smoke Detectors • Extermination Services for rodents and insects • Home alarms

45. Uses of the SA/IH Payment (Safety) • Annual inspections related to air and heating or other safety inspections • Cleaning services • Repair or replace damaged appliances • Environmental factors related to safety i.e. scatter rugs, outlets

46. Uses of the SA/IH Payment(Basic Needs) • Basic needs are those items or services that help ensure the overall well-being of the client is maintained

47. Uses of the SA/IH Payment (Basic Needs) • Rental or mortgage payments • Essential furnishing • Appliances • Utilities • Food • Essential clothing

48. Uses of the SAIH Payment (Basic Needs, cont.) • Cleaning supplies • Personal care items • Property Taxes • Pre-Need burial

49. Priority of SA/IH Payment • Ensuring that the Health and Safety needs of the client are met is the first priority of the SA/IH payment • The SW should always try to link the client to community resources that the adult is eligible to receive but may not be knowledgeable about (Medicaid transportation, volunteer services, discounted telephone services, HUD etc.) • The SA/IH payment is not intended to replace or duplicate services and resources already available to the client

50. Things to Consider • What are the health/safety issues that are not currently being addressed? • How will the SA/IH payment be used to help address these concerns/issues? • Are there services that the client is eligible for but they have not been linked to? • How were needs being met prior to the SA/IH payment?