Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 35 - Medical Assistance for Adults and Children-Eligibility › Subchapter 17 - Advantage Waiver Services › Section 317:35-17-14 - Case management services

Current through Vol. 41, No. 20, July 1, 2024
(a)
				Case management services involve ongoing assessment, service planning and
				implementation, service monitoring and evaluation, member advocacy, and
				discharge planning.
(1) Within one-business
				(1-business) day of receipt of an ADvantage referral from the ADvantage
				Administration (AA), the case management supervisor assigns a case manager to
				the member. The case manager makes a home visit to review the ADvantage
				program; its purpose, philosophy, and the roles and responsibilities of the
				member, service provider, case manager, and the Oklahoma Department of Human
				Services (DHS). The case manager will reviewand/or update the Uniform
				Comprehensive Assessment Tool (UCAT) Part III and discuss service needs and
				ADvantage service providers. The case manager notifies the member'sprimary
				physician, identified in the UCAT Part I, in writing that the member was
				determined eligible to receive ADvantage services. The notification is a
				preprint form that contains the member's signed permission to release this
				health information and requests physician's office verification of primary and
				secondary diagnoses and diagnoses code obtained from the UCAT Part
				III.
(2) Within fourteen-calendar
				(14-calendar) days of the receipt of an ADvantage referral, the case manager
				completes and submits a person-centered service plan for the member, signed by
				the member and the case manager, to the case manager supervisor for approval
				and submission to the AA. The case manager completes and submits the annual
				reassessment person-centered service plan documents no sooner than sixty
				-calendar (60-calendar) days before the existing service plan end-date but
				sufficiently in advance of the end-date to be received by the AA at least
				thirty (30) days before the end-date of the existing person-centered service
				plan. The case manager submits revisions for denied services to be resubmitted
				for approval within five-business (5-business) days to the AA. Within
				fourteen-calendar (14-calendar) days of receipt of a Service Plan Review (SPR)
				for short-term authorizations from the AA, the case manager submits corrected
				person-centered service plan documentation. Within five-business (5-business)
				days of assessed need, the case manager completes and submits a service plan
				addendum to the AA to amend current services on the person-centered service
				plan. The person-centered service plan is based on the member's service needs
				identified by the UCAT Part III, and includes only those ADvantage services
				required to sustain and/or promote the health and safety of the member. The
				case manager uses an interdisciplinary team (IDT) planning approach for
				person-centered service plan development. Except for extraordinary
				circumstances, the IDT meetings are held in the member's home. When home care
				is the primary service, the IDT includes, at a minimum, the member, a nurse
				from the ADvantage home care or assisted living provider chosen by the member,
				and the case manager. Otherwise, the member and case manager constitute a
				minimum IDT.
(3) The case manager
				identifies long-term goals, strengths and challenges for meeting goals, and
				service goals including plan objectives, actions steps and expected outcomes.
				The ADvantage case manager documents on the person-centered service plan the
				presence of two (2) or more ADvantage members residing in the same household
				and/or when the member and personal care provider reside together. The case
				manager documents on the Electronic Visit Verification (EVV) system in the
				member record any instance in which a member's health or safety would be at
				risk when even one (1) personal care visit is missed. The case manager
				identifies services, service provider, funding source units and frequency of
				service and service cost, cost by funding source and total cost for ADvantage
				services. The member signs and indicates review/agreement with the
				person-centered service plan by indicating acceptance or non-acceptance of the
				plans. The member, the member's legal guardian or legally authorized
				representative signs the person-centered service plan in the presence of the
				case manager. The signatures of two (2) witnesses are required when the member
				signs with a mark. When the member refuses to cooperate in development of the
				person-centered service plan or when the member refuses to sign the
				person-centered service plan, the case management agency refers the case to the
				AA for resolution. Based on the UCAT Part III and/or case progress notes that
				document chronic uncooperative or disruptive behaviors, the DHS nurse or AA may
				identify members that require AA intervention through referral to the AA's
				Escalated Issues unit.
(A) For members that
				are uncooperative or disruptive, the case manager supports the member to
				develop an individualized person-centered service plan to overcome challenges
				to receiving services. This plan focuses on behaviors, both favorable and those
				that jeopardize the member's well-being and includes a design approach of
				incremental plans and addenda that allows the member to achieve stepwise
				successes in behavior modification.
(B) The AA may implement a person-centered
				service plan without the member's signature when the presence of a document
				that requires their signature may itself trigger a conflict. In these
				circumstances, mental health/behavioral issues may prevent the member from
				controlling his or her behavior to act in his or her own interest. When the
				member, by virtue of level of care and the IDT assessment, needs ADvantage
				services to ensure his or her health and safety, the AA may authorize the
				person-centered service plan when the case manager demonstrates effort to work
				with and obtain the member's agreement. Should negotiations not result in
				agreement with the person-centered service plan, the member may withdraw his or
				her request for services or request a fair hearing.
(4) Consumer-Directed Personal Assistance
				Services and Supports (CD-PASS) planning and supports coordination.
(A) CD-PASS offers ADvantage members personal
				choice and control over the delivery of their in-home support service,
				including who provides the services and how services are provided. Members or
				their legal representatives have singular "employer authority" in
				decision-making and are responsible to recruit, hire, train, supervise and when
				necessary, terminate the individuals who furnish their services. They also have
				"budget authority" to determine how expenditures of their expense accounts are
				managed.
(B) Members who elect the
				CD-PASS service option receive support from Consumer-Directed Agent/Case
				Manager (CDA/CM) in directing their services. The CDA/CM liaison between the
				member and the program assists members, identifying potential requirements and
				supports as they direct their services and supports. ADvantage case management
				providers deliver required support and assign the CD-PASS members a case
				manager trained on the ADvantage CD-PASS service option, independent living
				philosophy, person centered service planning, the role of the member as
				employer of record, the individual budgeting process and service plan
				development guidelines. A case manager, who has completed specialized CD-PASS
				training, is referred to as a CDA/CM with respect to the service planning and
				support role when working with CD-PASS members. The CDA/CM educates the member
				about his or her rights and responsibilities as well as community resources,
				service choices and options available to the member to meet CD-PASS service
				goals and objectives.
(C) The
				ADvantage case management provider is responsible for ensuring that case
				managers serving members who elect to receive or are receiving the CD-PASS
				service option have successfully completed CD-PASS certification training in
				its entirety and have a valid CDA/CM certification issued by the AA.
(D) Consumer-directed, SoonerCare
				(Medicaid)-funded programs are regulated by federal laws and regulations
				setting forth various legal requirements with which states must comply. The
				ADvantage case management provider is responsible for ensuring that CDA/CMs in
				their employment provide services to CD-PASS members consistent with
				certification guidelines so as to be in keeping with federal, state, and Waiver
				requirements. Non-adherence may result in remediation for the case management
				provider, the case manager, or both, up to and including decertification.
(E) Members may designate a family
				member or friend as an authorized representative to assist in the service
				planning process and in executing member employer responsibilities. When the
				member chooses to designate an authorized representative, the designation and
				agreement, identifying the willing adult to assume this role and
				responsibility, is documented with dated signatures of the member, the
				designee, and the member's case manager, or AA staff.
(i) A person having guardianship or power of
				attorney or other court-sanctioned authorization to make decisions on behalf of
				the member has legal standing to be the member's designated authorized
				representative.
(ii) An individual
				hired to provide CD-PASS services to a member may not be designated the
				authorized representative for the member.
(iii) The case manager reviews the
				designation of authorized representative, power of attorney, and legal guardian
				status on an annual basis and includes this in the reassessment packet to AA.
(F) The CDA/CM provides
				support to the member in the person-centered CD-PASS planning process.
				Principles of person-centered planning are listed in (i) through (v) of the
				subparagraph.
(i) The person is the center of
				all planning activities.
(ii) The
				member and his or her representative, or support team are given the requisite
				information to assume a controlling role in the development, implementation,
				and management of the member's services.
(iii) The individual and those who know and
				care about him or her are the fundamental sources of information and
				decision-making.
(iv) The
				individual directs and manages a planning process that identifies his or her
				strengths, capacities, preferences, desires, goals, and support needs.
(v) Person-centered planning
				results in personally-defined outcomes.
(G) The CDA/CM encourages and supports the
				member, or as applicable his or her designated authorized representative, to
				lead, to the extent feasible, the CD-PASS service planning process for personal
				services assistance. The CDA/CM helps the member define support needs, service
				goals, and service preferences including access to and use of generic community
				resources. Consistent with member-direction and preferences, the CDA/CM
				provides information and helps the member locate and access community
				resources. Operating within the constraints of the Individual Budget Allocation
				(IBA) units, the CDA/CM assists the member translate the assessment of member
				needs and preferences into an individually tailored, person-centered service
				plan.
(H) To the extent the member
				prefers, the CDA/CM develops assistance to meet member needs using a
				combination of traditional personal care and CD-PASS PSA services. However, the
				CD-PASS IBA and the PSA unit authorization is reduced proportional to agency
				personal care service utilization.
(I) The member determines with the PSA to be
				hired, a start date for PSA services. The member coordinates with the CDA/CM to
				finalize the person-centered service plan. The start date must be after:
(i) authorization of services;
(ii) completion and approval of the
				background checks; and
(iii)
				completion of the member employee packets.
(J) Based on outcomes of the planning
				process, the CDA/CM prepares an ADvantage person-centered service plan or plan
				amendment to authorize CD-PASS personal service assistance units consistent
				with this individual plan and notifies existing duplicative personal care
				service providers of the end-date for those services.
(K) When the plan requires an Advanced
				Personal Service Assistant (APSA) to provide assistance with health maintenance
				activities, the CDA/CM works with the member and, as appropriate, arranges for
				training by a skilled nurse for the member or member's family and the APSA to
				ensure that the APSA performs the specific health maintenance tasks safely and
				competently, when the:
(i) member's APSA was
				providing Advanced Supportive Restorative Assistance to the member for the same
				tasks in the period immediately prior to being hired as the APSA, additional
				documentation of competence is not required; and
(ii) member and APSA attest that the APSA was
				performing the specific health maintenance tasks to the member's satisfaction
				on an informal basis as a friend or family member for a minimum of two (2)
				months in the period immediately prior to being hired as the PSA, and no
				evidence contra-indicates the attestation of safe and competent performance by
				the APSA, additional documentation is not required.
(L) The CDA/CM monitors the member's
				well-being and the quality of supports and services and assists the member in
				revising the PSA services plan as needed. When the member's need for services
				changes due to a change in health/disability status and/or a change in the
				level of support available from other sources to meet needs, the CDA/CM, based
				upon an updated assessment, amends the person-centered service plan to modify
				CD-PASS service units appropriate to meet the additional need and submits the
				plan amendment to the AA for authorization and update of the member's IBA.
(M) In the event of a disagreement
				between the member and CD-PASS provider the following process is followed:
(i) either party may contact via a toll free
				number the Member/Provider Relations Resource Center to obtain assistance with
				issue resolution;
(ii) when the
				issue cannot be resolved with assistance from the Member/Provider Relations
				Resource Center or from CD-PASS Program Management, the CD-PASS Program
				Management submits the dispute to the ADvantage Escalated Issues Unit for
				resolution. The Escalated Issues Unit works with the member and provider to
				reach a mutually-agreed upon resolution;
(iii) when the dispute cannot be resolved by
				the ADvantage Escalated Issues Unit it is heard by the Ethics of Care
				Committee. The Ethics of Care Committee makes a final determination with regard
				to settlement of the dispute; or
(iv) at any step of this dispute resolution
				process the member may request a fair hearing to appeal the dispute resolution
				decision.
(N) The CDA/CM
				and the member prepare an emergency backup response capability for CD-PASS
				PSA/APSA services in the event a PSA/APSA services provider essential to the
				individual's health and welfare fails to deliver services. As part of the
				backup planning process, the CDA/CM and member define what failure of service
				or neglect of service tasks constitutes a risk to health and welfare to trigger
				implementation of the emergency backup (i) or (ii) may be used. Identification
				of:
(i) a qualified substitute provider of
				PSA/APSA services and preparation for their quick response to provide backup
				emergency services, including execution of all qualifying background checks,
				training, and employment processes; and/or
(ii) one (1) or more qualified substitute
				ADvantage agency service providers, adult day health, personal care, or nursing
				facility (NF) respite provider, and preparation for quick response to provide
				backup emergency services.
(O) To obtain authorizations for providers
				other than PSA and APSA identified as emergency backups, requests the AA
				authorize and facilitate member access to adult day health, agency personal
				care, or NF respite services.
(5) The case manager submits the
				person-centered service plan to the case management supervisor for review. The
				case management supervisor conducts the review/approval of the plans within
				two-business(2-business) days of receipt from the case manager or returns the
				plans to the case manager with notations of errors, problems, and concerns to
				be addressed. The case manager re-submits the corrected person-centered service
				plan to the case management supervisor within two-business (2-business) days.
				The case management supervisor returns the approved person-centered service
				plan to the case manager. Within one-business (1-business) day of receiving
				supervisory approval, the case managersubmits, the person-centered service plan
				to the AA. Only priority service needs and supporting documentation may be
				submitted to the AA as a "Priority" case with justification attached.
				"Priority" service needs are defined as services needing immediate
				authorization to protect the health and welfare of the member and/or avoid
				premature admission to the NF. Corrections to service conditions set by the AA
				are not considered a priority unless the health and welfare of the member would
				otherwise be immediately jeopardized and/or the member would otherwise require
				premature admission to a NF.
(6)
				Within one-business (1-business) day of notification of care plan and
				person-centered service plan authorization, the case manager communicates with
				the service plan providers and member to facilitate service plan
				implementation. Within five-business (5-business) days of notification of an
				initial person-centered service plan or a new reassessment service plan
				authorization, the case manager visits the member, gives the member a copy of
				the person-centered service plan and evaluates the service plan implementation
				progress. The case manager evaluates service plan implementation on the
				following minimum schedule:
(A) within
				thirty-calendar (30-calendar) days of the authorized effective date of the
				person-centered service plan or service plan addendum amendment; and
(B) monthly after the initial thirty-calendar
				(30-calendar) follow-up evaluation date.