Adult Day Health Eligibility Determination Wac Implementation (Ddd Supplemental Bulletin

D04-004 – Policy /Procedure March 17, 2004 TO: Regional Administrators Field Services Administrators FROM: Linda Rolfe, Director, Division of Developmental Disabilities Penny Black, Director, Home and Community Services Division SUBJECT: ADULT DAY HEALTH ELIGIBILITY DETERMINATION WAC IMPLEMENTATION (DDD SUPPLEMENTAL BULLETIN TO HCS MB 03-73) PURPOSE: This supplemental bulletin: 1) formalizes the implementation date of this WAC for clients within DDD; 2) summarizes implementation steps for field staff, including a description of steps and issues unique to DDD; and 3) responds to common questions and comments that have arisen during training. BACKGROUND: Under former Washington Administrative Code (WAC), staff at Adult Day Centers performed client assessment and eligibility determination for Adult Day Health (ADH) services. WHAT’S NEW, The new Adult Day Services (ADS) WAC (388-71-0702 through 388-71- CHANGED, OR 0776) transfers responsibility for client assessment and eligibility CLARIFIED determination for ADH to department case managers. The new WAC also clarifies ADH eligibility criteria and delineates new steps for referring clients to ADH and Adult Day Care (ADC). ACTION: Effective immediately, DDD case resource managers must include ADH eligibility determination in the routine assessments of clients on their caseload; this process occurs for clients currently enrolled in the service as well as those who are not, but may be eligible and need the service. A list of clients who are currently enrolled in ADH will be sent to the DDD Field Services Offices under separate cover. If a client has a current Comprehensive Assessment (CA) or CARE assessment, eligibility for ADH services can be determined at the time of the client’s next re- assessment. If the client does not have a current CA or CARE assessment, a CARE assessment must be completed by June 30, 2004. Training has been provided for those case managers responsible for completing the reassessments and determining ADH eligibility in CARE.

Eligibility requirements and procedures are outlined in WAC 388-71-0710, 0720, and 0722, and the materials that were provided to staff during

D04-004 Page 1 of 4 5/17/2018 training. See Attachment 1 for an electronic version of the flip chart used in training. The relevant chapters of the Long Term Care Manual will be amended shortly. The implementation process is summarized below.

Authorization Process for Clients Currently Enrolled in Adult Day Health: Medicaid-funded ADH for DDD clients can be provided now only through authorization by a DDD case manager.

If a current ADH client is being assessed for eligibility for the first time by a case manager and the client is eligible for continued service, the case manager documents in CARE that a referral is occurring for a specific number of days per week and also records the specific services the ADH center is to provide (skilled nursing and/or rehabilitative therapy and any core services (WAC 388-71-0704 (2)) that may be appropriate. The case manager then completes a Planned Action Notice (Attachment 2) and sends a copy to the client and/or representative, the ADH center, ADH Program Manager Kathleen Moisio, and DDD Program Manager John Gaskell. No SSPS authorizations are required for payment for ADH services at this time; only the Planned Action Notice is required.

If a current ADH client is not eligible for continued ADH services, that too is documented on the Planned Action Notice and copies are sent to the client and/or representative, the ADH center, ADH Program Manager Kathleen Moisio, and DDD Program Manager John Gaskell. For Terminations, the case manager provides 15 days’ notice from the date of mailing the Planned Action Notice to the effective date. The Planned Action Notice includes information about clients’ appeal rights on the bottom of the form.

Important: This MB does not apply to certain DDD clients. In 1997 HCS transferred funds to DDD for clients who were receiving ADH services and were determined not to be eligible for this service. The division contracted these funds through individual counties to be used for the most appropriate day program service for these clients. While many counties chose to buy employment services, some counties also contracted for ADC services for some individuals. Since they are not receiving COPES-funded ADC or Medicaid-funded ADH services, this process does not apply for these persons. A list of these clients will be sent to the DDD Field Services Offices under separate cover.

Referral/Authorization Process for Clients Not Currently Enrolled in Adult Day Health: For those clients assessed as eligible for ADH and not currently enrolled, an initial authorization can be made via Planned Action Notice (Attachment 2) to allow the ADH center to complete an Intake Evaluation for the client to determine if a specific plan can be developed to meet the client’s needs at the center. If the center confirms that enrollment will occur, an additional authorization needs to be completed via Planned Action Notice for ongoing services for up to one year (as long as quarterly reviews of the ADH care plan continue to indicate ongoing service is warranted). Again, copies of the Planned Action Notice go to the client and/or representative, the ADH center, ADH Program Manager Kathleen Moisio, and DDD Program Manager John Gaskell. If a client becomes ineligible for continued services or does not/cannot attend ADH, services must be terminated via a Planned Action Notice.

D04-004 Page 2 of 4 5/17/2018 Alternative Options for DDD Clients Found Ineligible for ADH Services: If an individual is found ineligible for ADH, case managers will need to explore with the client options for alternative day program services as needed:

(1) If the client requests Adult Day Care Services, the following options may be available: (a) Available respite funds at adult day centers that have appropriate respite contracts; (b) Senior Citizens Services Act (SCSA) funds for eligible clients over age 60. Consult with the adult day center to access this fund source; (c) Unique grant or other fund sources an adult day center may have available. Consult with the adult day center to access these often limited fund sources; or (d) Private pay funds.

(2) If the client requests DDD county funded day program services, and is not currently receiving a county day program service, case managers will want to work with counties to determine if funding is available for a day program within the current county resources.

(3) For persons on the waiver, case managers will need to review the ISP and identify any unmet need for day program services. They should then follow regional procedures for addressing unmet waiver needs.

RESPONSE TO ISSUE DISCUSSED DURING TRAINING

Quarterly ADH Care Plan Reviews as Collateral Contacts: After initial eligibility determination and care planning processes occurs, WAC 388-71- 0720 states that ADH centers must complete quarterly reviews of each Medicaid client’s care plan, and case managers must review them to determine each client’s continued eligibility. Quarterly ADH care plan reviews and related communication with the ADH center are considered collateral contacts.

Current/Pending Status with CARE: As part of completing assessments, case managers will be determining whether referral to Adult Day Health services is appropriate. If it is, case managers will use the adult day services drop-down boxes on the treatment screen to indicate a service need and that a referral will occur and for how many days per week. The adult day center would be assigned as the provider type. Comment boxes can be used to list services requested at the adult day center (skilled nursing, rehabilitative therapy, supervision, personal care, etc.) so providers will know what client needs to target. The case manager can then put the client into “current” status and refer the client to the adult day center using the Referral and Authorization processes described earlier.

Clients Continue in ADH while DDD Case Managers Complete Assessments: Clients currently enrolled in ADH will continue to attend ADH until completion of their next annual re-assessment or their initial CARE assessment is completed and eligibility determination for ADH services is made by the case manager. Decisions about whether services will be continued, suspended, changed, or terminated must be reflected

D04-004 Page 3 of 4 5/17/2018 via the Planned Action Notice as described earlier. Adult Day Health Conversion to SSPS: Eventually, case managers will be using SSPS to authorize ADH; this conversion is not expected to take place before the end of 2004. Currently, the Planned Action Notice is the mechanism for authorizing ADH services.

Reassessment guidelines specific to Adult Day Health Services: Case managers will follow normal re-assessment guidelines for clients in Adult Day Health Services; however, it may be helpful to clarify situations specific to Adult Day Health Services, especially with regards to CARE:

A. If the number of days per week that the service is needed changes, does this require a full re-assessment? Not always. If the client’s needs have already been identified in the assessment and only the number of days needs to change, the change can be documented on the care plan and on a new authorization form without a new assessment. However, if the assessment/service plan no longer meets the client’s needs, then a new assessment would need to occur.

B. If a client wants to change adult day centers, does this require a full re-assessment? No, a change in provider can be done without a new assessment; the change would need to be documented on the service plan and with a new Planned Action Notice.

C. If a client’s annual re-assessment is complete with no Adult Day Health Services included and sometime during the year the client wants/needs the service, is a full re-assessment required? Not always. If the need that qualifies the client for service is already identified in the assessment, a new assessment would not be required; instead, a re-assignment of the need on the care plan would be adequate along with an updated Planned Action Notice. However, if the client has a new need, not identified in the assessment, then a full re-assessment would be necessary.

D. Do case managers need to do full re-assessments each quarter for ADH clients? No, what is expected quarterly is a review of the ADH care plan to determine if any changes need to be made. If a client has a status change, however, case managers would re-assess per normal guidelines, but not simply because a client is in ADH.

RELATED WAC 388-71-0702 through 388-71-0776 REFERENCES: HCS MB 03-73 ATTACHMENT(S): MB-03-73 WAC Flip Chart Attachment 1 Final Copy.doc MB-03-73 Planned Action Notice Attachment 2.doc CONTACT(S): John Gaskell, DDD MPC/AFH/ARC Program Manager, 360-902-8482, [email protected] Mike Ahern, DDD County Services Program Manager, 360-902-0259, [email protected] Kathleen Moisio, ADH Program Manager, 360-752-2562, [email protected]

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