Transcript Slide 1
MFP and Transition Coordination
Refresher Training
Department of Medical
Assistance Services
Webinar
MFP and Transition Coordination
Refresher Training Agenda
MFP – National Initiative
New MFP Eligibility Criteria
New Waiver Supports as a Result of MFP
Outreach Efforts
Keys to a Successful Transition
Planning and Risk Assessment
Transition Process, MFP Enrollment and Required Forms
Consumer Direction
Transition Services Administration and Reimbursement
for Rendering Waiver Services
Additional Resources
MFP - National Initiative
An award from the Centers for Medicare and Medicaid Services
Gives individuals 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 individuals who live in inpatient institutions
more informed choices and options about where they can live
and receive services;
Goal 2 - To transition individuals from 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 the individual’s
needs.
MFP - National Initiative
MFP is the single largest investment in Medicaid Long Term
Care
46 States have been awarded $4 Billion with a projected
number of over 70,000 individuals to be transitioned
through calendar year 2016
Federal opportunity to further develop community integration
strategies, systems, and infrastructure for individuals with
long-term support needs
Emphasizes community living vs. institutional placement to
help “rebalance” the system
A program that identifies individuals in institutions who wish
to move back into the community and assists them with the
transition process
MFP Eligibility
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New Eligibility Requirements – Effective June 1, 2011
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Have resided for at least 90 consecutive days in a hospital,
nursing facility (any days spent in short-term skilled
rehabilitation services do not count towards the 90 days),
intermediate care facility for individuals with developmental
disabilities (ICF-DD), long-stay hospital, institute for mental
disorders (IMD), psychiatric residential treatment facility
(PRTF), or a combination thereof;
o
Be a resident of the Commonwealth of Virginia;
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Have received Medicaid benefits for inpatient services for at
least one day prior to MFP enrollment;
MFP Eligibility
o Qualify for, and enroll into upon discharge, a Program for Allinclusive Care for the Elderly (PACE) or one of the five
following waiver programs:
o Elderly or Disabled with Consumer-Direction Waiver (EDCD)
o Individual and Family Developmental Disabilities Support
Waiver (DD)
o HIV/Aids Waiver (AIDS)
o Intellectual Disabilities Waiver (ID)
o Technology Assisted Wavier (TECH); and
o Move to a “qualified residence.” A qualified residence is: 1) a
home that the individual or the individual’s family member
owns or leases; 2) an apartment with an individual lease, with
lockable access and egress, that includes living, sleeping,
bathing and cooking areas over which the individual or the
individual’s family has domain and control; or 3) a residence
in a community-based residential setting in which no more
than four (4) unrelated individuals reside.
MFP Eligibility
MFP Qualified Institutions
Hospital
Nursing Facility
Intermediate Care Facility for Individuals
with Developmental Disabilities (ICF-DD)
Long-stay Hospital
Institute for Mental Disorders (IMD)
Psychiatric Residential Treatment Facility
(PRTF)
MFP Eligibility
Certain days during a nursing facility stay
must be excluded from the 90 day count
Any days spent in short-term skilled
rehabilitation services are excluded
Confirm with billing office
Have received Medicaid benefits for
inpatient services for at least one day prior
to MFP enrollment;
Waiver Services Added
Transition Services is a one-time, life-time benefit
assisting with one-time, up-front household
expenses. Added to EDCD, AIDS, TECH, ID and
DD waivers.
$5,000 maximum
Time limited to 9 months
Not available to individuals moving into provideroperated living arrangements
Transition Coordination supports individuals who
elect services through the EDCD waiver both
before and after transitioning to the community.
Time limited to 12 months from date of discharge
MFP Demonstration Services
Transition Services – Available to individuals participating in
MFP up to 2 months prior to discharge
Transition Coordination – Available to individuals participating
in MFP up to 2 months prior to discharge for a total 14
consecutive months in the EDCD waiver
Assistive Technology – Available to individuals participating in
MFP who are in either the EDCD or HIV/AIDS waiver upon entry
to the waiver
Environmental Modifications - Available to individuals
participating in MFP who are in either the EDCD or HIV/AIDS
waiver upon entry to the waiver
MFP Demonstration Services
Supplemental Home Modifications
Supplemental Home Modifications through partnership with
Department of Housing and Community Development
Provides funds for “barrier” home modifications prior to
discharge for individuals participating in MFP
Provides funds for home modifications that exceed $5000
post-discharge for individuals participating in MFP
Administered by DHCD and five regionally-based Centers for
Independent Living
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Blue Ridge Independent Living Center, Roanoke, 540-342-1231
Endependence Center, Norfolk, 757-351-1595
Independence Empowerment Center, Manassas, 703-257-5400
Junction Center for Independent Living, Wise, 276-679-5988
Resources for Independent Living, Richmond, 804-353-6503
Outreach
Outreach is
The first activity
Critical to the success of a transition
Varied in its forms
Provided by many people
Levels of Outreach
Agency
Individual
Regional
Outreach
State Agency Led Outreach
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
program into the annual resident review process
The Department of Medical Assistance Services, the Department of
Behavioral Health and Developmental Services, and the Virginia
Association of Community Services Boards will
• Send information about MFP to all Intermediate Care Facilities for
Individuals with Developmental Disabilities
Outreach
Individual 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
• hold open informational sessions
Sources of Information
Information can be obtained through:
DMAS
DBHDS
Local DSS
Local Dept of Health
Community Service Boards
Area Agencies on Aging
Centers for Independent Living
On the Web
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http://www.DMAS.virginia.gov
http://www.DBHDS.virginia.gov
Virginia Easy Access www.easyaccess.virginia.gov
Olmstead http://www.olmsteadva.com/mfp
Referral Sources & Contacts
Professional Staff at
Hospital
Nursing Facility
Intermediate Care Facility for Individuals with Developmental
Disabilities (ICF-DD)
Long-stay Hospital
Institute for Mental Disorders (IMD)
Psychiatric Residential Treatment Facility (PRTF)
People in the community
Family members
Friends
Referral Sources & Contacts
Specific to Nursing Facilities
MDS 3.0 Section Q Referrals
• Individuals who wish to seek additional information on
community living and a list of Transition Coordination
Agencies will be provided information from the local Area
Agency on Aging
• Individuals will choose a Transition Coordination Agency
• The Area Agency on Aging will contact the chosen
Transition Coordination Agency to arrange referral
Keys to a Successful Transition
More than someone changing residence
Increasing self-direction
Increasing decision-making
Participating fully in community activities
Developing informal and formal supports
Keys to a Successful Transition
Transition Coordinators
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 individuals
Assist individuals to take a proactive role in the transition process
Recognize that a successful transition is dependent on the
individuals themselves and their willingness to change
Keys to a Successful Transition
Characteristics of the Transition
Coordinator
Transition Coordinators / Case Managers will
have multiple roles including
Being an effective mentor
Understanding circumstances of placement in
institution
Being mindful of the individual’s potential
Being knowledgeable of all community
resources
Being an active listener
Keys to a Successful Transition
Characteristics of the Transition
Coordinator
Recognizing that the individual’s emotions of
fear, anger, and anxiety are real
Openly acknowledge and discuss emotions with
the individual
Providing accurate information in a timely
manner
Exploring all options with the individual
Acknowledging and balancing risk
Keys to a Successful Transition
Critical Components
Developing a trusting relationship
Having a comprehensive assessment that clearly
reflects
preferences and strengths
needs
concerns
priorities
Developing and implementing a Transition Plan that
addresses
the individual’s preferences and needs
critical follow-up with post-transition activities
Keys to a Successful Transition
Guiding Principles
There are two important principles to keep in
mind throughout the transition process
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self-determination
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the right to take risks
Keys to a Successful Transition
Guiding Principles
Self-Determination
o Is the right to make one’s own decisions without
interference from others
Right to Take Risks
o Making choices about new experiences and
possibilities
o Individuals grow by making choices even if those
choices are viewed as poor choices
o Individuals learn by both successes and failures
o Taking risks is part of living for everyone
Keys to a Successful Transition
Balancing Risk
Prudent risks vs. undue risks
Individuals should not be expected to
face challenges that will result in failure
Planning & Risk Assessment
Risk Assessment
Assessment elements for Person Centered
Planning
Assessment is not a single meeting
Assessment is a series of meetings
establishing
• Trust
• Individuals’ ability to manage risk
• Determination of preferences and needs
Planning & Risk Assessment
Risk Assessment (continued)
7 key components
Health Services
Social Supports
Housing
Transportation
Volunteering/ Employment
Advocacy
Financial Resources
Planning & Risk Assessment
Risk Assessment (continued)
Risk assessments are integrated with the
development of the support plan
It determines the level of support needed for
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Health Services
Daily Living Activities
Housing
Transportation
Social Supports
It determines the plan’s ability to meet the personal
goal of the individual
It determines the type of back-up plan
Planning & Risk Assessment
Description of Required Tiers
Tier 1: Service Plan Backup Providers
Required to have backup provider for each service
Tier 2: Informal Network
Reaches out to the individual, family, friends, and
neighbors to provide interim supports
Tier 3: 24-hour Response System
Call the toll-free call center, 2-1-1 Virginia
Tier 4: Extreme Emergency
An immediate crisis involving a threat to the
individual’s health, safety, or life, call 911
Planning & Risk Assessment
Risk Assessment (continued)
Transition Coordinators are Mandated
reporters for CPS & APS
Professional judgment is used to determine
risk factors
Planning & Risk Assessment
Housing
Accessible and proper housing is critical to a
individual’s success
Key elements to consider in helping the individual
select the new home are:
Location
Affordability
Access to transportation
Personal security
Opportunity for social activities
Opportunity for employment
Planning & Risk Assessment
Housing and MFP Qualifying
Criteria
Residences must meet one of the following requirements:
A home that the individual or the individual’s family member owns
or leases
An apartment with an individual lease, lockable entry and exit and
includes living, sleeping, bathing and cooking areas, over which
either individual or the individual’s family has domain and control
A residence, in a community-based residential setting, in which no
more than four unrelated individuals reside
Transition Process
The key of the transition process
The ability to coordinate pre- and postfacility discharge transition planning and
supports delivery
The ability to submit/ obtain waiver
enrollment & prior authorization on the
day of discharge from facility
3 Stages of the Transition
Process
Stage 1 Stage 2
Stage 3
Planning Phase
Discharge
Completed
while in facility
Date
Implementation Phase
Completed after
transition and while
individual is living in
community
Transition Process
Stage 1 “Planning Phase”
Pre-Discharge activity for Transition Coordinator/Case Manager
Educate and recruit individual
Coordinate with discharge planner at facility to confirm individual
still meets nursing home level of care
Ensure a copy of current UAI is available
Complete MFP enrollment:
MFP Enrollment form (DMAS-222)
MFP Informed Consent (DMAS-221)
Complete Prior Authorization Requests (DMAS-98) to enroll
individual into MFP
Complete Prior Authorization Request (DMAS-98) for Transition
Coordination prior to discharge as MFP demonstration services
Transition Coordination
Transition Process
Stage 1 “Planning Phase”
Pre-Discharge activity for Transition Coordinator/ Case Manager
(continued):
Complete MFP enrollment:
Administer Quality of Life survey (DMAS-416)
Develop Transition Plan which includes a risk assessment (DMAS-220)
Locate and secure qualified housing
Schedule discharge date
Complete Prior Authorization Requests (DMAS-98) for Transition
Services if needed prior to discharge as MFP demonstration services
• Transition Services
• Special Note: BE SURE HOUSING IS SECURED PRIOR TO
REQUESTING TRANSITION SERVICES
Schedule transportation
Confirm and ensure all is ready for discharge
Plan for needed waiver supports upon discharge from facility
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Assistive Technology
Environmental Modifications
Transition Coordination
Personal assistance
MFP Enrollment
Transition Coordinator/Case Manager must request
MFP enrollment
MFP enrollment is available for as long as needed
prior to discharge and 12 months from the date of
discharge
Services available during the period of residence in an
institution include
Transition Coordination/Case Management
Transition Services
Environmental Modifications through DHCD
MFP Enrollment
The Transition Coordinator requesting the enrollment
must:
Certify that the individual meets all MFP criteria
Determine with the individual if the individual can live safely in
community
Complete needed forms
• MFP Enrollment (DMAS-222)
• Informed Consent (DMAS-221)
• Administer Quality of Life Survey (DMAS-416)
Submit for MFP enrollment (DMAS-98) to KePRO
MFP Enrollment
Prior Authorization Process
KePro Service Authorization Activities
•Confirms if individual meets MFP criteria
•Grants Prior Authorization / support plan approval
•Forwards letter of approval to provider & individual
•Enters individual in MMIS as participating in MFP
Transition Process
Stage 2 “Day of Reentry”
Insure waiver enrollment & PA’s are in place by Service Provider
Conduct home visit to ensure
Coordinate submission of DMAS-225 by both the institution and the accepting
services provider to the local Department of Social Services
Service provider submits PA for services
Service provider submits waiver enrollment
Enroll for CD fiscal agent supports if appropriate (caution: a delay in CD services
may occur due to enrollment activities to become an employer)
Monitor / coordinate delivery of goods for day of reentry
Supports are in place and meeting needs
Verify the back-up plan
Verify delivery of Transition Services purchases
Verify/schedule/completion of environmental modifications and/or assistive
technology
A Critical Point
IMPORTANT!
Waiver enrollment MUST be
coordinated with facility discharge
date
Transition Process
Stage 3 “Implementation Phase”
Activities
Coordinate with service provider who provide needed waiver supports
Environmental Modifications
Assistive Technology
Personal Assistance
Adult Day Health
Establish Transition Coordinator/ Case manager visit schedule for up to
12 months
Be sensitive to individual’s stress
Check appropriateness of supports being delivered
Check individual’s view of how new life is progressing
Revise support plan as needed and before Transition Coordination ends
Waiver Enrollment
HIV/Aids
On the day of discharge, the individual
participating in MFP is enrolled into the
appropriate waiver
Receive Authorization and begin
delivery of identified, needed waiver
supports
IFDDS
EDCD
ID
Tech
MFP Enrollment
Completion of enrollment period
Individuals participating in MFP are
permanently transferred to regular
waiver status after MFP enrollment
period ends
All waiver supports continue as long as
waiver criteria is met
MFP Enrollment
Disenrollment from MFP
Disenrollment from MFP due to hospitalization or
institutionalization
Individual is hospitalized for more than 30 days
• If re-admitted to a facility or hospital and stays
there for more than 30 days, the individual will be
automatically dis-enrolled from MFP
MFP Enrollment
Reenrollment Criteria
Individual does not have to meet the
requirement for 90 consecutive days of
institutional residency again
Reenrollment does not entitle the individual to
Transition Services a second time
Remaining Transition Services funding is
available for use if within the original 9-month
period
MFP Enrollment
Disenrollment – Returning to a
facility
This will be a difficult decision to make because of the
strong commitment to maintaining the individual in the
community
Decision should always be made with the individual
Factors to use in determining
• How does the individual feel about the current situation?
• Is the risk too great?
• Are the basic living needs being met (food, shelter, clothing,
daily needs)?
• Are supports meeting the individual’s needs?
• Are the family and informal supports adequate to sustain the
individual?
• Can the financial obligations be managed?
Can participation in MFP be
withdrawn?
Yes
Withdrawal Steps:
1.
Individual will contact the Transition Coordinator
2.
Individual (with the Transition Coordinator) will
complete the MFP Withdrawal form
3.
Transition Coordinator will make sure the form is
signed and dated by both the individual and
themselves.
4.
Be sure the effective date of the withdrawal is
clear
5.
Send the withdrawal form to KePRO agent
6.
Maintain copy for individual’s record and provide a
copy to the individual
MFP Enrollment Forms
All forms are on DMAS website: Search Services
MFP enrollment forms:
MFP Enrollment (DMAS-222)
• Provider Checklist to ensure individual meets MFP
eligibility criteria
• Maintained in individual’s record
MFP Informed Consent (DMAS-221)
• Ensures individuals are fully aware of their decision to
participate in MFP
• Maintained in individual’s record
MFP Enrollment Forms
KePRO CBC Request for Services Form
(DMAS-98)
Enrolls individual into MFP
Must be faxed to KePRO
• Box 12 - MFP Enrollment (PA Service Type 0909)
• Box 13 – Individual Meets All MFP Eligibility
Criteria
MFP Demonstration Service
Prior Authorization
KePRO CBC Request Services Form (DMAS-98) to
request prior authorization for Transition
Coordination (H2015) and/or Transition Services
(T2038)
Must be faxed to KePRO
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Box 12 - MFP Enrollment (PA Service Type 0909)
Box 15 – H2015 and/or T2038
Box 18 – 1 unit
Box 19 – H2015 = month T2038 = year
Box 22 – H2015 = up to 2 month prior and 12 months post
discharge T2038 = 9 months
Service Authorization Cycle
Follow-up w/
individual
and document
in
support plan
Coordinate
purchase,
service
delivery, etc.
Notify
individual,
Other agencies
Submit Request
to KePRO
Receive
written
approval
from
authorizing
entity
MFP Enrollment Forms
Transition Coordination Services Plan for EDCD (DMAS-220)
Used to develop individual’s transition plan including
assessing risk, developing back-up plan, listing of needed
supports, and other aspects of community living
Maintained in individual’s record
MFP Quality of Life Survey (DMAS-416)
Required of all individuals participating in MFP
To be administered prior to individual’s discharge
Omit questions preceded by “After Transition Only”
Complete Supplemental Questions on page 18
Maintain copy in individual’s record and send original to
DMAS (see page 19 for address)
Consumer Direction
“Consumer Direction” and “self direction” are terms used interchangeably.
Consumer Direction allows the individual to be the employer for their consumerdirected services.
As the employer, individuals are responsible for:
advertising
hiring
training
supervising
firing their own consumer-directed services employees
developing their own support plan
Family members &
individuals who reside under
the same roof cannot be
employees, unless objective
documentation is provided.
When supports are consumer-directed, individuals or their family or caregiver, as
appropriate, decide
what support is needed
who will provide it
when it will be provided
where it will be provided
how it will be provided
Service limits for
Consumer Direction Apply
Transition Process
Consumer Directed Option (CD)
Pre discharge
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Discuss the CD option
Provide a clear picture of the responsibilities of CD
Connect with Service Facilitator for services
Incorporate consumer direction into the support plan
Service Facilitators will confirm
• All IRS Employer forms complete (W9)
• All employees are “ready to go”
Let the individual know
that this process
can take up to 6
weeks
Day Of Discharge
• Coordinate with Service Facilitator that supports are ready to start
• Support plan is understood by personal assistants
Post Discharge
• Check on Service Facilitator services
• Monitor supports meeting individual’s needs as defined in support plan and
adjust as needed
Transition Services Administration
and Reimbursement
Transition Service reimbursement is unique to
LTC home and community-based waivers
https://fms.publicpartnerships.com/VirginiaMFP
Step I – Obtain Prior Authorization (PA) from appropriate agent (PA will only be valid
for 9 months from the date of authorization)
Step II – Determine with the individual the individual’s household needs essential for
community living and generate estimate with Public Partnership, LLC (PPL)
website
Step III – Local Agency will approve and purchase essential goods for transition to
set-up the individual's household and arrange for delivery of services
Step IV – Local Agency will submit reimbursement requests via PPL website
Step V - Agency will retain documentation sufficient to explain purchase needs
Reimbursement
Waiver Service Limits
The unit of service shall be specified by the DMAS fee schedule
To receive payment the services shall be explicitly detailed in
the supporting documentation
Transition Coordination Service
Transition coordination may not be billed solely for
monitoring purposes
In-kind task or expenditure expenses within Transition are
not billable as separate items - examples include
• Travel time
• Written preparation
• Telephone communication
Reimbursement
Submission Process
Consult chapter 5 of your waiver manual
for the details of submitting claims
Consumer Direction payroll will remain the
same
DMAS training unit will be providing
training on Transition Coordination, MFP
services
Additional MFP Resources
MFP Operational Protocol
Housing
Waiver Supports
Bridge rent
Contact lists
Quality of Life Survey
Adult Foster Care
Marketing info/ brochures
Assisted Living
Consumer Direction
Transportation
Providers Listings
ABC’s of Nursing Home Transition
A publication of the IL Net
National Training & Technical
Assistance Program at
Independent Living Research
Utilization
http://www.ilru.org – Click on
“Publications” and Scroll down
to “Olmstead Implementation”
On the WEB
DMAS at
www.dmas.virginia.gov
DBHDS at
www.dbhds.virginia.gov
MFP SITE at
www.olmsteadva.com/mfp
MFP Transition Coordination Agency
Monthly Conference Calls
Scheduled the last Tuesday of
every month from 10:00 am to
11:00 am
Send request to be included on
email distribution list to
[email protected]
MFP Email
DMAS will receive general
inquiries on the MFP project at
[email protected]
Please enter “MFP Inquiries” in
the subject line.
Contact Information
Virginia Department of Medical Assistance Services
Division of Policy and Research
600 East Broad Street, Richmond, VA 23219
Jason Rachel, Ph.D.
MFP Project Director
(804) 225-2984
[email protected]
Dana Hicks
MFP Analyst
(804) 225-4218
[email protected]
MFP website
http://www.olmsteadva.com/mfp
MFP Email
[email protected]
DMAS website
http://www.dmas.virginia.gov