ࡱ> ~`  bjbj ; %jjj|X>>>R@@@82AlH4 RĨSIn"!&l$hpϣ>!ϣ>>yd$>>a>>kS *p`@sf`]}L&<ĨfHkk>l( 7<ϣϣepĨRRR$vRRRvRRR>>>>>>  Improving Emergency Backup and Critical Incident Management for Consumer Direction Funding Provided by Centers for Medicare & Medicaid Services Independence Plus Grant #18-P-92019/8-01 Authored by Diane M. King, Grant Administrator Edited by Casey China, Policy Specialist Colorado Department of Health Care Policy and Financing April 2005 This document was prepared under Grant No. #18-P-92019/8-01 for the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services. However, these contents do not necessarily represent the policy of the U. S. Department of Health and Human Services, and you should not assume endorsement by the Federal government. Please include this disclaimer whenever copying or using all or any of this document in dissemination activities.  TOC \o "1-5" \h \z \u   HYPERLINK \l "_Toc102798927" Executive Summary  PAGEREF _Toc102798927 \h 3  HYPERLINK \l "_Toc102798928" Background  PAGEREF _Toc102798928 \h 3  HYPERLINK \l "_Toc102798929" Emergency Backup  PAGEREF _Toc102798929 \h 3  HYPERLINK \l "_Toc102798930" Critical Incident Management  PAGEREF _Toc102798930 \h 4  HYPERLINK \l "_Toc102798931" Conclusion  PAGEREF _Toc102798931 \h 5  HYPERLINK \l "_Toc102798932" Introduction  PAGEREF _Toc102798932 \h 6  HYPERLINK \l "_Toc102798933" Background  PAGEREF _Toc102798933 \h 6  HYPERLINK \l "_Toc102798934" Methodology  PAGEREF _Toc102798934 \h 6  HYPERLINK \l "_Toc102798935" Emergency Backup  PAGEREF _Toc102798935 \h 7  HYPERLINK \l "_Toc102798936" What is emergency backup?  PAGEREF _Toc102798936 \h 7  HYPERLINK \l "_Toc102798937" Current Definition  PAGEREF _Toc102798937 \h 7  HYPERLINK \l "_Toc102798938" Examples of Emergency Situations  PAGEREF _Toc102798938 \h 7  HYPERLINK \l "_Toc102798939" Current Approaches to Emergency Backup  PAGEREF _Toc102798939 \h 8  HYPERLINK \l "_Toc102798940" Informal Backup  PAGEREF _Toc102798940 \h 10  HYPERLINK \l "_Toc102798941" CDAS Emergency Backup  PAGEREF _Toc102798941 \h 10  HYPERLINK \l "_Toc102798942" Critical Incident Management  PAGEREF _Toc102798942 \h 10  HYPERLINK \l "_Toc102798943" What is a critical incident?  PAGEREF _Toc102798943 \h 11  HYPERLINK \l "_Toc102798944" Current Definition  PAGEREF _Toc102798944 \h 11  HYPERLINK \l "_Toc102798945" Definition of Critical Incident in a Consumer Directed Program  PAGEREF _Toc102798945 \h 11  HYPERLINK \l "_Toc102798946" Examples of Critical Incidents  PAGEREF _Toc102798946 \h 12  HYPERLINK \l "_Toc102798947" Current Approaches to Critical Incident Management  PAGEREF _Toc102798947 \h 12  HYPERLINK \l "_Toc102798948" Sanctions for Agency Providers  PAGEREF _Toc102798948 \h 14  HYPERLINK \l "_Toc102798949" CDAS Critical Incident Management  PAGEREF _Toc102798949 \h 15  HYPERLINK \l "_Toc102798950" System Disconnects  PAGEREF _Toc102798950 \h 15  HYPERLINK \l "_Toc102798951" Other States Approaches  PAGEREF _Toc102798951 \h 17  HYPERLINK \l "_Toc102798952" Recommendations  PAGEREF _Toc102798952 \h 17  HYPERLINK \l "_Toc102798953" Consumer Direction Basic Tenets and Philosophical Ideas  PAGEREF _Toc102798953 \h 17  HYPERLINK \l "_Toc102798954" Systems Currently in Place for Consumer Direction  PAGEREF _Toc102798954 \h 18  HYPERLINK \l "_Toc102798955" Immediate Implementation  PAGEREF _Toc102798955 \h 18  HYPERLINK \l "_Toc102798956" Possible Implementation  PAGEREF _Toc102798956 \h 19  HYPERLINK \l "_Toc102798957" Beyond Scope of Grant  PAGEREF _Toc102798957 \h 19  HYPERLINK \l "_Toc102798960" Conclusion  PAGEREF _Toc102798960 \h 20  HYPERLINK \l "_Toc102798961" Appendices  PAGEREF _Toc102798961 \h 22  HYPERLINK \l "_Toc102798962" Appendix A: Key Informant Questionnaires  PAGEREF _Toc102798962 \h 23  HYPERLINK \l "_Toc102798963" Appendix B: Rules and Regulations Followed  PAGEREF _Toc102798963 \h 27  HYPERLINK \l "_Toc102798964" Appendix C: Stakeholders Interviewed & their Job Descriptions  PAGEREF _Toc102798964 \h 29  HYPERLINK \l "_Toc102798965" Appendix D: Focus Group Topics, Guidelines, Questions, Forms  PAGEREF _Toc102798965 \h 42  HYPERLINK \l "_Toc102798966" Appendix E: ULTC 100.2 Assessment Tool  PAGEREF _Toc102798966 \h 47  HYPERLINK \l "_Toc102798967" Appendix F: Other States Approaches  PAGEREF _Toc102798967 \h 76  Executive Summary Background The Colorado Department of Health Care Policy and Financing (the Department) has two consumer direction programs which enable consumers to direct their own attendant services. While these initiatives were instrumental in bringing consumer direction to Colorado, the quick push to provide this choice has resulted in a system with little infrastructure. The implications of the current administrative and service systems in place for consumer direction are more evident with anticipated legislation and changes to the Home and Community Based Services (HCBS) waiver application template. If passed by the Colorado General Assembly, House Bill 05-1243 will create consumer direction opportunities in all Colorado HCBS Medicaid waivers. At the same time, through the Centers for Medicare and Medicaid Services (CMS), the federal government has established expectations for critical incident management and emergency backup systems in HCBS. These expectations apply to both traditional agency services and consumer-directed services. Colorados current systems for emergency backup and critical incident management for provider agencies are not compatible with consumer direction programs. Furthermore, consumer direction programs already adequately address emergency backup and critical incident management. The Independence Plus grant has allowed the Department to research improving Colorados emergency backup and critical incident management systems to better support consumer direction in Medicaid. This report summarizes information gathered from key informant interviews, consumer focus groups and research on initiatives in other states. It also includes definitions for critical incident and emergency back up, provides recommendations for the Department and outlines an implementation plan for the recommendations. Emergency Backup CMS does not provide a definition for emergency backup, nor is it defined in Medicaid regulations found at 10 C.C.R. 2505-10, 8.000 et seq. Consumers and key informants provided examples which fit into the broad definition of care provided when the scheduled attendant cannot provide care or in the event of an emergency when no care is scheduled. According to the draft HCBS waiver application, states must ensure that emergency back-up services and/or emergency response are furnished promptly to participants whose health and welfare would be seriously jeopardized when their primary support staff or other caregivers are not available or who are at high risk. The only statewide emergency backup systems currently in place are traditional agency or institutional models. Under the traditional agency-based system, consumers must call the agency to request emergency backup care. Advocates often criticize agencies for having restricted hours of operation and worker shortages and for failing to provide backup care. As a result, consumers often rely on informal backup care, in which family, friends or neighbors provide the care or the consumer calls 911. If consumers find agency-based routine and emergency care to be unreliable, it is doubtful that they would depend on it in an emergency. Imposing such agency-based systems on consumer direction would take responsibility and control away from the consumer. By definition, consumers in consumer direction programs have personal choice and control over waiver services based on the participants needs and preferences, including who provides services and how they are delivered. This choice and control should encompass plans for emergency backup and critical incident management services. For example, the Consumer Directed Attendant Support (CDAS) 1115 waiver program addresses emergency backup by enabling consumers to have choice and control over attendant services. Consumers develop individualized backup plans with assistance from the Single Entry Point (SEP) agency case manager, if necessary. For many CDAS consumers, the informal but reliable method of backup care becomes formalized in the individual backup plan. Critical Incident Management In the HCBS waiver application template, states must also address management of critical events or incidents (e.g., abuse, neglect and exploitation) that bring harm, or create potential harm, to a waiver participant. There are numerous critical incident management systems currently in place in Colorado, including those administered by the Colorado Department of Human Services (DHS) Adult Protective Services (APS), Division of Child Welfare and Developmental Disabilities Division. These systems were designed for services provided by agencies or institutions. They do not meet the needs of consumers in consumer direction programs for several reasons. First, they focus on extreme situations such as abuse, neglect and exploitation which, although critical, are not always what consumers would define as critical events. Consumers include a wider variety of situations, such as being threatened by an attendant, left in an uncomfortable or unsafe situation or cared for by an attendant who behaves inappropriately. Second, professionals such as case managers and state staff utilize these systems. Consumers do not have an active role in these systems, they have not been trained or required to identify and report incidents and they do not control the outcome of critical incident reports. For these reasons, the current critical incident management systems are not compatible with consumer direction. Stakeholders have stated that state agencies do not have regulatory authority over attendants in consumer direction programs because the attendants are not agency employees, nor are they required to be certified or licensed. As a result, it would be difficult to impose penalties or sanctions against attendants who cause critical incidents. In a consumer direction program such as CDAS, the consumer defines critical incidents and takes an active role in managing them. The consumer takes responsibility for managing critical incidents because the consumer has choice and control over who provides care and how care is provided. Through a rigorous training program and a peer trainer network, the CDAS program ensures that consumers have adequate training, support and resources to address critical incidents. Conclusion Many states have developed successful consumer direction programs with emergency backup and critical incident management systems that are similar to those for CDAS. In addition, consumer direction programs, including Cash and Counseling, have been subject to numerous program evaluations. Studies of consumer direction indicate positive outcomes in terms of consumer satisfaction, quality of life, and perceived empowerment. There is no evidence that consumer direction compromises safetyin fact, the opposite appears to be true. Individuals who have participated in consumer directed systems express strong preference for consumer direction and satisfaction with their care. The individualized approach to emergency backup and critical incident management in CDAS is most appropriate for consumer direction programs. Federal expectations for emergency backup and critical incident management systems are not compatible with the philosophy of consumer direction, in which consumers have choice, control and responsibility for managing attendant services. Consumers do not rely on the traditional agency-based systems for emergency backup or state systems for critical incident management, because these systems cannot guarantee adequate care and have not been designed for consumer direction programs. Additionally, stakeholders, including state staff, stressed that state agencies do not have regulatory authority over the attendants hired by consumers. Mechanisms for emergency backup and critical incident management already exist in consumer direction programs which have shown a high level of satisfaction and quality care for consumers. Some improvements can be made to better support consumers in directing care and addressing emergency backup and critical incidents. For example, stakeholders and consumers suggested augmenting consumer training materials with educational brochures, emergency backup decision trees, methods to prevent critical incidents and information on advance directives. They suggested creating a registry of attendants available for backup care and conducting outreach to government staff, police officers and firefighters on supporting people with disabilities during emergencies. Consumers also recommended establishing a support person who is available to review and address critical incidents. These efforts would significantly improve support for consumers in consumer directed programs and contribute to the sustainability of consumer direction initiatives, while maintaining consumer independence, choice and control. Introduction Consumers, stakeholders and state and federal agencies generally agree that consumer directed programs in Medicaid need emergency backup and critical incident management systems. These groups also agree that the health, safety and well being of consumers are top priorities. Opinions diverge when addressing how to provide these systems. Some prefer infrastructure that requires a high level of control over consumers who direct their own care. Others recognize that consumers understand skilled medical procedures as the result of living with a disability or long term illness and are very capable of directing their own care. Consumers prefer having freedom and independence to manage attendant services and their own lives. The Independence Plus grant has allowed the Department to research how to improve Colorados emergency backup and critical incident management systems to support consumer direction. This report summarizes information gathered from key informant interviews, consumer focus groups and research on initiatives in other states. It also includes possible definitions for critical incident and emergency back up, provides recommendations for the Department and outlines an implementation plan for the recommendations. Background The Department has two consumer direction programs designed to enable participants to direct their own attendant services. The programs currently offered are the 1115 CDAS waiver and In-Home Support Services (IHSS) offered through the HCBS waivers. While these initiatives were instrumental in bringing consumer direction to Colorado, the quick push to provide this choice resulted in a system with little infrastructure. The implications of the current administrative and service systems in place for consumer direction become more evident with anticipated legislation and changes to the Home and Community Based Services (HCBS) waiver application template. If passed by the Colorado General Assembly, House Bill 05-1243 will create consumer direction opportunities in all Colorado HCBS Medicaid waivers. At the same time, CMS established expectations for critical incident management and emergency backup systems in HCBS. These expectations apply to both traditional agency services and consumer-directed services. Colorados current systems for emergency backup and critical incident management for provider agencies are not compatible with consumer direction programs. Furthermore, consumer direction programs already adequately address emergency backup and critical incident management. Methodology To determine Colorados current capacity for these systems, the grant administrator designed two questionnaires and conducted 42 key informant interviews with stakeholders.  HYPERLINK \l "Appendix_A" (See Appendix A for questionnaires.) Stakeholder participants included current and former staff at the Department, the Colorado Department of Public Health and Environment (DPHE), the Board of Nursing, urban and rural SEP agencies, care provider agencies, urban and rural Adult Protective Services (APS), advocates, the Department of Human Services Division of Developmental Disabilities and Division of Child Welfare and Community Centered Boards (CCB).  HYPERLINK \l "Appendix_B" (See Appendix B for Rules and Regulations stakeholders follow)  HYPERLINK \l "Appendix_C" (See Appendix C for stakeholders interviewed.)  Concurrently, an independent consultant conducted focus groups with consumers and family members of consumers who use attendant services.  HYPERLINK \l "Appendix_D" (See Appendix D for the outline of topics, guidelines and questions, consent form and demographic form used in the focus groups.) The consultant asked focus group participants questions about emergency backup and critical incident reporting infrastructure. For the consultants full report please refer to  HYPERLINK "http://www.chcpf.state.co.us/HCPF/Syschange/Focus%20Groups%20Final%20Report.doc" http://www.chcpf.state.co.us/HCPF/Syschange/Focus%20Groups%20Final%20Report.doc. The report also reviews approaches in other states regarding emergency back up and critical incident management systems,  HYPERLINK \l "_Appendix_F:__Other States Approach" found in Appendix F. Emergency Backup What is emergency backup? The definition that CMS uses for an emergency backup system is, [a statewide] formal arrangement the state uses to respond to emergency situations. This system includes assuring emergency backup and/or emergency response capability in the event those providers of services and supports essential to the individuals health and welfare are not available.  Current Definition Colorado Medicaid regulations have no formal definition for emergency backup. However, they do reference emergency backup in two sections. The first section lists provider certification standards for emergency procedures. The second section addresses supervision of emergency backup. Stakeholders and consumers agreed that emergency backup is necessary and gave examples of emergency situations, but did not have any formal definitions to offer. Since the focus in consumer directed programs is on the individual, emergency backup would be different for each consumer. Emergency backup is care provided in the event of an emergency when no care is scheduled or the scheduled attendant cannot provide care. In a consumer directed program, individuals define what an emergency is and design prevention plans according to their specific needs. Examples of Emergency Situations Stakeholders and consumers gave numerous examples of situations that required emergency backup. An emergency exists any time an attendant does not show up to provide care. Consumers reported having to sleep all night in their wheelchairs or stay in bed all day when attendants did not show up. An emergency occurs when something happens outside of the normal care and needs immediate attention, such as a catheter falling out, an involuntary bowel movement or the consumer falls and hospital or clinic care is needed. Current Approaches to Emergency Backup One type of emergency backup is to have a substitute caregiver replace a missing or absent caregiver. An example occurred during a blizzard in 2002, when home health care providers activated emergency preparedness plans. Providers identified most vulnerable consumers at intake and provided these consumers with first priority in staffing for basic care. One agency had attendants at the Halcyon House, which has a large disabled population. These attendants worked the whole building and slept on the consumers couch until snow removal and movement was possible and regular attendants could return. For other consumers who were not in a large community and were more difficult to reach, the police took attendants to the consumers location. Police generally respond to this kind of request during weather-induced emergencies. Another option available through the HCBS waiver for emergency response is the electronic Lifeline monitor. When the consumer activates the Lifeline device, the response is immediate. The consumer wears the device as a bracelet or necklace and activates it by pushing the call button. The Lifeline monitoring agency accesses calls. If the consumer can respond, the monitoring agency assesses the consumers needs and uses an individual call down list to find someone to provide care for the consumer. If the monitor hears silence, an ambulance is dispatched. The home health program is a federally mandated Medicare and Medicaid program that provides skilled care services in homes or alternative community settings. One of the federal requirements is 24/7 availability of a registered nurse for medical emergencies. DPHE monitors, evaluates and enforces Medicare and Medicaid standards and quality of health care services provided by home health providers. Home health agencies must be certified. Before DPHE recommends a home health agency for certification, the agency must have policies and procedures in place that follow federal requirements and DPHE conditions of participation. DPHE instructs the agency to include procedures outside of calling 911 in the event of an emergency. Policies and procedures must address how the agency will triage disasters, power outages, rural forest fires, etc. All home health provider agencies interviewed reported having similar 24/7 backup systems. During business hours, scheduling staff are available to take consumer calls if an attendant does not arrive when expected. The scheduling staff calls replacement workers. For after-hours issues, the agencies provide the consumers an on-call number staffed by a registered nurse. The registered nurse completes a phone assessment of the situation and can respond in person if necessary. If the agency has no one to send, the agency should use a sub-contractor or a temp agency. If the agency does not respond, the agency would document why the visit was missed, call the consumers physician, explain the circumstances and discuss the consumers care. Emergency backup usually involves only the consumer and the agency. It does not always involve the SEP, which provides all case management functions. Administrators, regulators, case managers, protectors and advocates may not be aware of emergency backup situations until after the fact. Their involvement may only occur when the consumer is hospitalized or dies. Another emergency backup approach available to the consumer is to call the case manager to report that the care provider did not arrive as scheduled during regular business hours. The case manager calls the agency to assess the situation and request that the agency send a new care provider to the consumer. If the provider does not have anyone available to respond, the case manager calls a new provider. Consumers report to the case manager when a provider is habitually unavailable at scheduled designated times and the case manager may replace the provider permanently. The case manager has no involvement in the actual emergency. If a personal care provider (PCP) does not arrive, it is not considered an emergency by providers and administrators because the PCP does not provide skilled care. Colorado does not have any emergency backup rules or regulations for PCPs. Colorado does have a statewide emergency telephone system available 24/7 called the telephone triage program (TTP). Medicaid consumers call the TTP and speak to a registered nurse. The intended users of this system are Medicaid consumers who receive fee for service care and are not in an HMO. The Department instructs consumers to call the TTP before going to an emergency room. Medicaid waiver consumers may also use this system, because they are Medicaid recipients. The list below provides practices that stakeholders and consumers found to be most effective for emergency backup in an agency model. It is evident that these practices are not feasible in the consumer directed care model because there is no agency involvement in consumer directed care. Home health provider agencies are mandated to have 24/7 backup available, the provider agencies plan for emergencies in advance and consumers know they can call anytime during the day or night. Emergency backup is planned for and available any time that the consumer requests it. The case manager can stop referring consumers to a provider agency with a history of being unreliable. Consumers receive care from dependable attendants and do not have to rely on emergency backup. The provider agency must follow regulations to notify the case manager before discharging a consumer so no interruption in care occurs. Consumers do not experience emergency situations when the agency stops providing care. The list below provides stakeholder and consumer comments about barriers and when the agency model system is least effective. Consumers report that the provider agency does not always respond with backup during emergency situations, especially if the agency thinks a family member or friend is available. Provider agencies may not hold their employees accountable for problems with reliability. There are no consequences for frequent cancellations or no-shows by attendants, which leads to a greater need for emergency backup. The SEP cannot remove unreliable provider agencies from the referral list. If the consumer removes the Lifeline device and an emergency occurs, the consumer cannot activate the device and receive emergency care. In remote geographical areas, it is difficult to maintain a pool of attendants. When emergencies occur, there are few attendants available to provide backup care. Consumers and advocates report that agencies fail to consistently provide routine and backup care and they often rely on informal backup for care. It is unlikely that those in a consumer direction program would rely on agencies for backup care. It is the consumers responsibility to plan emergency backup to maintain independence and control. Informal Backup The informal backup system is fundamental to how emergency backup works in consumer direction. When the agency model fails, the informal backup system is where consumers turn for help. Informal backup support evolved from experiences within the community. The most successful people using consumer direction have strong informal backup systems in addition to the individualized backup plan. For example, one administrator suggested the consumer call everyone he/she knows to get a response when needed. The neighborhood watch system is also helpful. Neighbors are aware of what would be normal activity and respond when that has changed. Postal carriers and meal delivery people often notice changes in behavior of a consumer or if it appears something is wrong. If the consumer attends a church, friends from the church may be called for backup. CDAS Emergency Backup No formal statewide emergency backup system exists in the current CDAS program. The Departments training protocol and manual include emergency planning. Each applicant is required to complete an Attendant Support Management Plan which explains his or her attendant support needs, methods for monitoring his or her health needs, a budget and an emergency backup plan. The applicants case manager, from one of the states Single Entry Point agencies is available to assist with attendant support planning as needed. It is the responsibility of the consumer to develop an effective emergency backup plan. The CDAS training coordinator and program administrator review each plan to ensure that it is comprehensive and includes a viable system for emergencies. Family, friends, neighbors and attendants may be part of the backup plan. If the emergency plan is not adequate, the training coordinator will work with the applicant to develop an effective plan before the applicant enrolls in CDAS. The Department contracts with an Intermediary Service Organization (ISO) to provide financial and personnel services to CDAS participants. The ISO serves as the employer of record for CDAS attendants and must ensure that backup attendants are in place before an emergency occurs, so that those attendants are able to receive reimbursement. Critical Incident Management What is a critical incident? The definition for a critical incident management system from CMS is, a formal plan, developed and implemented by the state, to define, identify, investigate, and resolve incidents, events or occurrences which jeopardize the health and welfare of a consumer. Current Definition Colorado Medicaid regulations do not define a critical incident. All references to critical incidents are administrative in nature and focus on reporting and investigating critical incidents. The informal definitions from stakeholders involve personal judgment of the situation. Most of the stakeholders interviewed agreed that a critical incident is anything that affects the health and welfare of the consumer. No formal definition was suggested by stakeholders. Consumers were not familiar with the term critical incident. The focus group consultant asked consumers to describe a situation when they had been hurt or threatened by an attendant or left in an uncomfortable or dangerous situation or victimized in any way. Described in this context, all consumers had experienced some type of critical incident. They had not found reporting resources that produced a satisfactory outcome, and none of the consumers suggested establishing a statewide critical incident management system. The consumers did suggest establishing a resource person who is available to discuss critical incident episodes, issues and strategies. The resource person would also evaluate trends and historical data and establish ways to improve training for consumers. Definition of Critical Incident in a Consumer Directed Program Many of the stakeholders interviewed did not think the definition for critical incident in a consumer directed program would be different from the agency model definition. They agreed it is something that causes injury, abuse, neglect or exploitation. Stakeholders noted that if a consumer hired his/her own attendant who does not work for an agency and is not licensed or regulated by the state, no regulatory authority would exist to monitor the attendant. Stakeholders had no suggestions for how a critical incident management system could be implemented in a consumer directed program. Some felt that a critical incident in a consumer directed model would be whatever the consumer has determined is not satisfactory, suggesting that if the consumer is responsible for making decisions, it is up to the consumer to identify and address critical incidents. The consumers and stakeholders suggested that an individual decentralized consumer directed system would support consumer autonomy and independence in the community. Examples of Critical Incidents Stakeholders and consumers provided examples of a wide range of situations considered to be critical incidents, especially those involving criminal activity, psychological abuse and extremely poor care. Examples of critical incidents included consumers feeling unsafe with a lift, falling with bruise or injury and receiving a debilitating injury. Consumers also mentioned neglect, exploitation and verbal, physical or sexual abuse. Other examples included the attendant not arriving as scheduled, coming to work drunk or late, taking financial advantage, behaving inappropriately, not caring for the consumer, making errors that result in hospitalization and threatening, intimidating or manipulating the consumer. The most common examples were theft of money, medications or other items. Current Approaches to Critical Incident Management The critical incident management system for traditional agency care is extensive and complex. The focus is on professionals and agencies and how they report problems and track critical incidents. Professionals expect consumers to report critical incidents to provider agencies, DPHE, Ombudsmen or APS. If a consumer calls the provider agency to report a critical incident or if an attendant reports a critical incident, the agency files a report with DPHE, completes the agency internal complaint log and documents the critical incident in the consumers file. DPHE expects the agency to resolve the incident internally. Through site visits and reviews, DPHE ensures that agencies track critical incidents and record the information in the complaint log and consumer file. Agencies give consumers the home health hotline (HHH) which is a toll-free telephone number managed by DPHE. Consumers are instructed to use this number when any questions or concerns arise regarding health care providers. The HHH is available 24/7, although it is not staffed 24/7. When staff is unavailable, an answering machine records messages. The HHH receives approximately 5-10 calls per week. DPHE investigates all calls in which it has regulatory authority over the agency in question. When a call is received, DPHE completes a complaint intake form determining the allegation, what the provider agency failed to do, the degree of the alleged harm and the speed at which response must be made. DPHE determines if the incident has placed the consumer in immediate jeopardy, actual harm or potential harm. DPHE enters this information into the computer system and assigns the complaint to a surveyor for investigation. If the consumer is in immediate jeopardy, DPHE calls the provider and responds within 2 hours. The less serious complaints receive a response within 2 days. The least serious receive a response within 10 days. A DPHE surveyor will go to the agency unannounced to investigate the complaint. If DPHE cannot substantiate a complaint, no action is taken against the provider agency. DPHE determines if the agency did not follow the policies and procedures it wrote to participate as a care provider. If the allegation is substantiated, the provider receives a deficiency and must submit a plan of correction and DPHE later revisits the agency. DPHE believes that many complaints are not reported. If an attendant employed by a home health agency caused a critical incident, most consumers reported the incident to the agency. The home health agency may require more training for the attendant, may remove the attendant from that particular consumer's home, may take disciplinary action against the attendant or may terminate the attendant. Even in instances where the agency fires the attendant, the attendant may find another job that places other disabled persons at risk. Consumers experienced some retaliation from attendants when reporting behavior problems to the agency. Examples include rough treatment, intimidation, threatening behavior and, in extreme cases, stalking and causing property damage. Consumers also reported retaliation from the agency if the consumers were persistent with complaints. Examples usually took the form of services being stopped or suspended. In Denver, if a caregiver is taken from the home of a consumer by police, the police will dispatch a victims advocate who will activate an emergency adult protective order. The victims advocate works with the Visiting Nurse Association to provide attendant care for up to three days. The SEPs maintain records of complaints received about an agency or case manager. Information is followed up internally by the SEP for their case managers. The SEPs contact the organization most appropriate to follow-up and investigate other allegations and may include APS, Ombudsman, the Department or DPHE. The board of nursing regulates licensing and responds to complaints filed against licensees. If an organization wants to hire a registered nurse (RN), licensed practical nurse (LPN) or certified nurse aid (CNA), the board of nursing provides the Automated Licensure Information System Online (ALISON) for on-line licensee verification which lists information including disciplinary actions. If the licensee has disciplinary actions listed on ALISON, Registrations Online Disciplinary Documents (RODD)  HYPERLINK "http://www.dora.state.co.us/doraimages/" http://www.dora.state.co.us/doraimages/ lists what happened, problems that were identified and supervisory plans to monitor the licensee. APS works with at-risk adults regarding abuse, neglect and exploitation. APS goal is to help people stay in the community in the least restrictive environment. APS stakeholders agreed that a critical incident could be classified into one of their categories of abuse, neglect or exploitation. For example, if the home health agency does not provide care as expected, this would be neglect. If someone is supposed to pay bills for a consumer and does not, this is exploitation. APS intake caseworkers receive calls, provide information and referrals, investigate cases and may assist with finding resources. If exploitation is suspected, the police become involved and begin a criminal investigation. Some focus group participants were aware of the option of reporting critical incidents to APS, the police, DPHE, the state Board of Nursing or the Department. Several consumers mentioned the option of reporting the incident to their caseworker. Only a few had actually used any of these resources. "It may cause more problems," one consumer said. "You've got to be careful. They might assume you're not able to live on your own. They may put you in a more 'protective' environment." The following list summarizes the current critical incident management protocol and reinforces the point that the agency model does not work in consumer direction because attendants are not monitored through an agency. DPHE believes the Home Health Hotline is effective, acting as a safety net and enabling the consumer to voice a complaint. When a critical incident occurs, DPHE responds appropriately and resolves the situation. Investigations are timely because the information is passed to DPHE surveyors quickly so that they may monitor the agency. DPHE surveyors hold agencies accountable to track and resolve consumer complaints and critical incidents. SEP case managers use networking and creative problem solving to maximize available resources and resolve and prevent critical incidents. They maintain a list of other available agencies in the service area. Provider agencies establish contracts with consumers in which the consumer agrees to meet expectations for appropriate behavior. If the consumer fails to meet these expectations and a critical incident occurs, the provider places the consumer on probation and may choose to terminate services. Provider agencies view such contracts as an effective means of preventing and managing critical incidents. The list below provides stakeholder and consumer comments about barriers and when the system is least effective in an agency model. DPHE does not effectively resolve complaints and critical incident reports because of lack of resources. Consumers do not think that DPHE responds to critical incident reports in a timely manner. When critical incidents occur and the DPHE issues a deficiency to a provider agency, there is no intermediate penalty, such as a financial sanction, to improve provider behavior. A deficiency is not always strong enough to motivate providers to make significant, long-lasting improvements. Communication between DPHE and the SEP is not clear. Critical incident reports from DPHE are not accessible for SEPs and final resolutions are not shared. The case manager is not always informed of the results of a complaint or critical incident report and cannot effectively coordinate the consumers care. Consumers do not have a single care coordinator and there is fragmentation and poor communication between everyone involved in the consumers care. Different entities, such as the SEP, hospitals, provider agencies, attendants and family members may not communicate all that is known regarding the consumers care. When a critical incident occurs, the case manager may be the last to know what is happening with the consumer. Managing and planning for critical incidents in rural communities is more difficult for a variety of reasons. Poor road and weather conditions can become barriers to quality care and there are fewer resources. More sophisticated care may only be available in urban areas and due to greater distances to travel, access to services can be limited. Due to workforce shortages, it is difficult to find qualified and reliable attendants. Critical incidents are more likely to occur with poorly qualified attendants. Sanctions for Agency Providers DPHE receives telephone calls, emails or letters from consumers, family members of consumers, concerned citizens and health professionals reporting critical incidents. Surveyors may also discover deficient practices during scheduled surveys. If DPHE is able to find corroborating evidence that the allegation occurred, DPHE may cite the agency with deficient practice. If DPHE cites deficient practice, the provider has to respond with a Plan of Correction within 10 days to assure that problems are corrected. DPHE may return after 30 days as a follow up to verify that new procedures are being followed. If corrections were not instituted, the provider could lose their certification and possibly go out of business. When a provider receives a deficiency, the provider can expect more frequent unannounced surveys by DPHE. All deficiency reports are public information and are posted on the DPHE website where the public can see the number and types of deficiency reports received. The information about the provider found on the web may discourage use of a provider by consumers. There is no financial component to the sanction. The Board of Nursing ensures rules are followed. Most complaints filed against licensees are potential violations. The Colorado Nurse Practice Act lists grounds for discipline. Complaint calls usually focus on care given by an RN, LPN or CNA. The Nursing Board can dismiss or recommend further action, the licensee can agree to have a letter of admonition placed in the licensees file and placed into public record or the incident can be sent to a hearing. The agency model system for critical incident management uses DPHE, the nursing board, SEPs and the providers. Consumers are not part of this system. This critical incident management system cannot work in a consumer directed model because none of the regulatory agencies have authority or control over the consumer or attendants. CDAS Critical Incident Management Stakeholders and consumers agreed that in a consumer directed program responsibility for care and protection resides with the consumer. Critical incident management is incorporated in the training process. DPHE has no regulatory authority. Colorado statute waived the Nurse Practice Act for implementation of consumer directed services. The current critical incident management system agency model is not designed for consumer direction. The CDAS program uses an individualized system of critical incident management. The consumer defines critical incidents and takes an active role in managing them. Currently, critical incident management is not developed or implemented as a statewide system. The CDAS program is a coordinated effort between the consumer, case manager, ISO and program administrator with many checks and balances. If the case manager notices the consumers health is declining, the administrator is contacted to increase services if needed. If the ISO notices budgeting problems, the administrator is contacted and additional training is provided to the consumer. The consumer is given tools and support to help make the program work for them. System Disconnects The items below point to places where the current agency model systems fail to work as designed. CMS administers and regulates the HCBS and consumer directed waivers using social security policy that was originally created for the agency model. Even though changes have been made to adapt to consumer direction, the result remains difficult to implement when consumers are in charge of their own care. CMS most recent statewide emergency backup and critical incident management system requirements do not exist in established consumer directed programs such as CDAS. The new CMS requirements compromise the design and intent of these consumer directed programs. Research suggests consumer directed care is better quality than agency care and consumers are healthier, happier and generally experience a higher quality of life. Currently, providers are expected to monitor their own consumer complaints without being held accountable for them. The focus is on documentation and administration rather than function. If the consumer complains too often or too much, the agency may terminate care for the consumer because the provider does not want numerous complaints listed against the agency. There is no mechanism in the current system to guarantee that the agency will self-regulate. The home health hotline implies, by its name, that immediate action will result from a telephone call to that line. DPHE named this telephone service hotline because it is a dedicated line that is always available to receive calls and is not used for outgoing calls. Because immediate action does not result from calls on this line, consumers feel that their voice is not heard or that it is a waste of time to call. The federal Medicare and Medicaid standards require home health providers to have 24/7 emergency backup availability. However, consumers report numerous incidents of neglect. One provider admitted that 1% of the time, the agency cannot provide backup. There are no penalties for the provider in these instances. Because there is a shortage of workers and the cost to hire temporary workers is high, the provider does not respond on occasion. There appears to be inconsistency between the written requirements for backup and what actually happens. APS tries to help consumers remain in their homes for as long as possible. Consumers often do not trust APS and other organizations in authority because of past experiences where penalties for asking for help were seen as proof the consumer could not take care of him/herself. Nurses report some care can only be provided by licensed professionals and that without a licensed care provider, the consumer is in jeopardy and cannot manage critical incidents. This is not always true. If a consumer requires regular care originally considered medical in nature, after a period of time that care becomes routine and a function of the consumers life. There are many consumers who can train unlicensed attendants to provide this kind of functional care. The current critical incident management system is based on the agency model and may not work as originally intended. The consumer was not included in its design and operation. Even when the consumer has provided input, consumers report they do not feel supported. By its nature the consumer direction model requires that the consumer be responsible for his/her critical incident management system. The consumer must be included in the system design in order for the resulting system to fit the consumer needs. Other States Approaches Many states are re-directing Medicaid funds to consumer directed programs that enable people to live in their own communities and homes, with approaches to emergency backup and critical incident management that are similar to those in CDAS. For example, New Jersey, Arkansas and Florida provide Cash and Counseling programs as 1115 demonstration waivers. Cash and Counseling is an expanded model of consumer-directed supportive services. It provides a flexible monthly allowance (based on the consumers assessed needs) that consumers can use to hire their choice of workers, including family members, and to purchase other goods and services. Cash and Counseling requires that consumers develop spending plans showing how they would use the allowance to meet their needs for supportive services. It also provides counseling and fiscal assistance to help consumers manage their allowance and their responsibilities.  Alabama, Iowa, Kentucky, Michigan, Minnesota, New Mexico, Pennsylvania, Rhode Island, Vermont, Washington and West Virginia are in the process of developing Cash and Counseling programs. The Cash and Counseling programs successfully serve thousands of consumers using approaches similar to those in CDAS. As in CDAS, the New Jersey and Arkansas Cash and Counseling program participants complete individualized emergency backup plans. The critical incident management system in Arkansas has training mechanisms that are similar to CDAS individualized and decentralized training. No adverse affects to consumers have been reported in these programs. There is growing evidence that by removing barriers to consumer directed attendant support, consumer quality of life and health is improving and Medicaid costs are reduced. States have developed many different approaches to emergency backup and critical incident management in consumer directed programs.  HYPERLINK \l "_Appendix_F:__Other States Best Prac" (See Appendix F: Other States Approaches) Recommendations Stakeholders, the focus group consultant and consumers shared their ideas, suggestions and recommendations for future consumer directed programs. Several of the recommendations focus on the basic tenets and philosophical approaches to consumer direction, some already exist as CDAS program requirements and some are beyond the scope of the grant. Consumer Direction Basic Tenets and Philosophical Ideas In order to establish true consumer direction, a philosophical change must occur in the framework of governmental regulations created when disabled people were required to be institutionalized in order to receive care. Within the consumer directed model, ideally the basic framework needs to include the following recommendations. Design a collaborative approach with all people who would have a stake in the outcome, with the awareness that every case is different and requires individualized solutions. Make sure the resources the consumer needs to succeed are provided through training. Educate people in the community who are not familiar with the consumer direction model who may hold old prejudices regarding disabled people. Systems Currently in Place for Consumer Direction The following recommendations emphasize the importance and necessity of maintaining currently used practices. Many of these requirements would be useful standards for future consumer directed programs. Provide a detailed explanation of consumer responsibility and liability to a consumer participating in a consumer directed program. Provide extensive training to the consumer detailing consumer direction, managing attendants and planning emergency backup. Have the consumer use a contract with each attendant that shows the attendant knows and will follow the established rules. Make assistive technology such as voice activated telephones more readily available to consumers as part of emergency backup support if requested by the consumer. Require background checks and verify credentials for all care providers. Maintain case management and monitoring. Immediate Implementation All of the input provided by stakeholders and consumers were reviewed, focusing on their suggestions and ideas for improving infrastructure. The recommendations below summarize the input and the themes that emerged, in addition to suggestions for implementation. Recommendation: Include a decision tree in CDAS and other consumer directed trainings to assist consumers with emergency backup decisions and the steps to take in order to insure health, safety and quality care. Implementation: Collaborate with the CDAS training coordinator to enhance current and future training manuals for consumer directed programs. Disseminate information to consumers who have already completed training. Recommendation: Develop a training module on preventing identity theft and preventing the attendant from obtaining the power of attorney, becoming a beneficiary or adding names to accounts or property. Implementation: Collaborate with the CDAS training coordinator to enhance current and future training manuals for consumer directed programs. Disseminate information to consumers who have already completed training. Recommendation: In CDAS and other consumer direction training, include detail on advance directives that consumers may give to attendants. Address specific conditions such as acute illness, stroke and suicidal behavior. Create a list of whom to contact and how to proceed in these types of situations. Implementation: Collaborate with the CDAS training coordinator to enhance current and future training manuals for consumer directed programs. Disseminate information to consumers who have already completed training. Recommendation: Set up a registry of attendants who are available 24/7 for short-term backup care. Implementation: Work with Policy Studies Inc. (PSI), the consultant hired to provide marketing, outreach and training materials, to include this component on the web-based registry of attendants. Work with the ISO on registry transition and maintenance for sustainability. Recommendation: Provide training and outreach to government agency staff, police officers and fire fighters to increase awareness of disabled people using attendant services and living independently in the community. Include the situations people with disabilities can experience, such as attendant abuse, exploitation, neglect, theft of prescription medications, etc. and what support would be helpful in emergency situations. Implementation: Research and develop training materials for use in the PSI community outreach campaign. Recommendation: Create and distribute educational brochures on critical incident management for people with disabilities. Brochures will focus on causes, consequences and prevention and offer suggestions, strategies and resources available. Implementation: Develop content for brochures and collaborate with PSI to produce the brochures. Include brochures in CDAS and other consumer direction training. Disseminate information to consumers who have already completed training. Recommendation: Define the role of the case manager and consumer more clearly. Train the case manager in consumer directed programs. Implementation: Collaborate with consumers, the CDAS administrator and training coordinator, the Community Based Long Term Care Section, SEPs, the ISO and the advisory committee to develop viable changes. Possible Implementation The recommendation below may provide additional support to consumers but it is not clear how the Department would implement. Department and state staff, stakeholders and the advisory committee will provide ideas and input on feasibility and implementation. Staff will conduct additional research to determine who this would be, how the system would work, who would fund the position and what resources already exist, such as peer trainers, ombudsman, etc. Recommendation: Establish a support person outside the home, who is available to review critical incidents with the consumer and develop strategies to address the incidents. Any information gathered would help to improve training for consumers. Beyond Scope of Grant Because the Independence Plus grant is exploring ways to create or improve infrastructure for consumer direction that are specific to emergency backup and critical incident management systems, the recommendations listed below are beyond the scope of the grant. While the grant is unable to implement these recommendations, organizations outside of the Department may find them useful. Create a brochure explaining the consumer's rights with regard to social services, adult protective services and other governmental services and promote the right to live independently. Create a participant newsletter that provides information on ways to avoid unwanted situations, safety alerts and successful strategies for emergency backup and critical incident management. Provide support for a community of people participating in consumer direction. For example, develop a chat room, offer grassroots networking or create local support groups where people with disabilities meet on a regular basis and share their knowledge, strategies and resources. Create a tracking system and/or database of attendants who provide poor quality work and are not ethical, but who pass the CBI. Track 911 calls to see if they increase as more people participate in consumer direction. Conclusion The challenge for consumer-directed programs is to devise a system of quality that balances consumers needs and abilities with policy-based mandates for accountability. The new CMS requirements focus on risk management and protection and impose rules used in the agency model. Federal expectations for emergency backup and critical incident management in consumer directed programs are not compatible with the philosophy of consumer direction. In addition, stakeholders, including Department and state staff, stressed that state agencies have no regulatory authority over the attendants hired by consumers. Colorados approach to emergency backup and critical incident management in CDAS is most appropriate for consumer direction programs for many reasons. It is individualized and decentralized and the consumer has choice and control in developing emergency backup plans and managing critical incidents. CDAS and other consumer direction programs have shown a high level of satisfaction and quality care for consumers. Studies of consumer direction indicate positive outcomes in terms of consumer satisfaction, quality of life, and perceived empowerment. There is no evidence that consumer direction compromises safetyin fact, the opposite appears to be true. Individuals who have participated in consumer directed systems express strong preference for consumer direction and satisfaction with their care. The independence resulting from consumer direction comes with responsibilities, including the responsibility to plan for and address emergency backup and critical incident management situations. The recommendations in this report would significantly improve support for consumers in consumer directed programs and contribute to the sustainability of consumer direction initiatives, while maintaining consumer independence, choice and control. Appendices Key Informant Questionnaires Rules and Regulations Followed Stakeholders Interviewed Focus Group Outline of Topics, Guidelines and Questions Consent Form Demographic Form Assessment Tool: ULTC100.2 Other States Approaches Appendix A: Key Informant Questionnaires Used with all stakeholders except APS. Name__________________________________ Date______________________ Organization________________________________________________________ Title: Basic Info about organization: Do you have any copies of written rules, policies, agency letters, memos, reports, etc pertaining to critical incident management or emergency backup that I might take with me? Definition from CMS: An incident management system is a formal plan, developed and implemented by the state, to define, identify, investigate, and resolve incidents, events or occurrences which jeopardize the health and welfare of participants. Within the current system, what exists with regard to critical incident management? How do you define critical incident within the current system? Whats the process once a critical incident occurs? What do you perceive other players do? What does your organization do? What is most effective within the current system? What is least effective within the current system? Is there any tracking mechanism or reporting required? Are there sanctions? If yes, how are they implemented? Have consumers given feedback on this system? If yes, what have they said? Regarding critical incident management systems, what kinds of changes would have to occur to accommodate a consumer-directed program? In a consumer directed model, how would you define a critical incident? Regarding critical incident management systems, what challenges do you perceive would arise from changing the system to accommodate consumer direction? In the arena of consumer-directed care, what do you perceive to be most important in critical incident management reporting or tracking? Definition from CMS: A statewide emergency backup system is a formal arrangement the state uses to respond to emergency situations. This system includes assuring emergency backup and/or emergency response capability in the event those providers of services and supports essential to the individuals health and welfare are not available. Within the current system, what formal arrangement exists with regard to a home care emergency backup? Whats the process when a home care emergency occurs? What do consumers do? What does your organization do? What do you perceive other players do? What is most effective within the current formal emergency backup system? What is least effective within the current formal emergency backup system? Have consumers given feedback on this system? If yes, what have they said? How do you think this system would work in a consumer directed program? Do you have an informal emergency backup system that evolved from your past experiences? In the arena of consumer-directed care, what do you perceive to be most important in emergency back up? Regarding emergency backup systems, what kinds of changes would have to occur to accommodate a consumer-directed program? Regarding emergency backup systems, what challenges do you perceive would arise from changing the system to accommodate consumer direction? Who else do you suggest I contact? If I have other questions, may I contact you again? Used with APS Name__________________________________ Date______________________ Organization________________________________________________________ Title: Basic Info about organization: How does APS receive referrals? What process do you use to follow up on referrals? Do you know when clients who are referred are Medicaid clients? If yes, is there any process that you use to make the Department or a case manager aware that you have received a referral? How does APS differentiate between a critical incident and abuse, neglect or exploitation? CMS uses the following definitions regarding consumer direction: Consumer Directed Model (CDM) - A public program where consumers have an employer/employee relationship with personal assistance or personal care workers. Consumer direction - Describes programs and services where people are given maximum choice and control. Consumer direction may also be called "self-determination" or "independent living." When people say they want to be "independent" or they want "autonomy" or "self-direction," they are talking about consumer direction too. In consumer-directed programs, consumers can choose to select, manage and dismiss their workers. What role would APS have in a consumer directed program? How would APS receive referrals in a consumer-directed program? Who would make the referral? Consider a situation in which a Medicaid client with a disability is supervising employees who provide home health or personal care in the clients home. What would be your concerns regarding exploitation, abuse, or neglect? How would you suggest that the Department address these concerns? Appendix B: Rules and Regulations Followed Regulations and Rules Followed The administrators follow Colorado Regulations, Federal Medicaid law in Title XIX of Social Security Act relating to their program, Terms and conditions set forth in CMS approval of the 1115 waiver, and CDAS Protocol. The regulators also follow Colorado Regulations as stipulated in the Memorandum of Understanding (MOU) with the Department, Colorado Nurse Practice Act 12-38-101 C.R.S., Colorado Nurse Aide Practice Act 12-38.1-101 C.R.S., Statutes and Rules Chapter XVIII-Rules and Regulations Concerning Reporting Requirements and Title 18 & 19 of social Security Act federal standards. The Occurrence Manual gives a listing of types of incidences that need to be reported and the forms to be used. The case managers follow Colorado Regulations and CDAS rules. The care providers follow Medicare rules and Colorado Regulations. Providers are governed under rules of participation for providers from DPHE and the Joint Commission on Accreditation of Health Care Organizations set of standards, local County and State Legislature for grants. The protectors follow Title 26-3.1-101 and also additional state statutes that focus on the at-risk adult population C.R.S. 26-3.1-201-206, Protection Against Financial Exploitation of At-Risk Adults Act and C.R.S. 18-6.5-101-106, Wrongs to At-risk Adults. Appendix C: Stakeholders Interviewed & their Job Descriptions Stakeholders Interviewed NAMEAGENCYHCPF (Administrators)Janet DaumanCBLTC-HHA/PDN/Hospice AdministratorTodd CoffeyCBLTC-HCBS AdministratorPeggy SpauldingCBLTC-SEP AdministratorLois JacobsCBLTC-Childrens HCBS WaiverVirginia BedfordNursing FacilitiesMargaret Mohan/P KurthQuality ImprovementDonna Kellow Sec MgrQuality ImprovementMaureen WallnerQI/QAAggie BerensCDAS Program AdministratorCheryl WilliamsCOmPASS Training CoordinatorCDPHE/Nursing Board (Regulators)Linda PeroFacilities Complaint InvestigatorLesa BoomHF&EMS-Complaint SurveyorSusan CseresnyesHF Generalist SurveyorChris SmithHF&EMS Complaint Program MgrTerrie MillerBoard of NursingSEPs (Case Managers)Gretah DussartLTC Options/HCPF SEP MonitorLori WoodsLTC Options-Asst MgrJennifer BrodisLTC Options-SEP supervisorSarah GrimLTC Options-Case ManagerRoosevelt GloverLTC Options-Case ManagerDeborah ClarkJeffco Options for LTCMargaret WoockMontezuma County SEP (rural)Laurie RingoLas Animas County*Providers (Caregivers)Carol BouchardAccent on IndependenceBarry RosenbergPASCOBarbara CampbellVisiting Nurse AssociationJudy RagonVisiting Nurse AssociationPamela CahalMaxim Healthcare ServicesAdult Protection (Protectors)Patricia StanisDHS-APSCarol MooreDenver County-APSRuth SpinaleAdams County-APSRena KuberskiJefferson County-APSLaurie RingoLas Animas County-APS*AdvocatesPat TunnellOmbudsmanEvelyn TilestonILC-CraigBeth DanielsonILC-GreeleyCarol ReynoldsILC-DenverRuralMargaret WoockMontezuma County SEP (rural)Laurie RingoLas Animas County-SEP*Laurie RingoLas Animas County-APS*DD/CCB/Child Welfare Shari RepinskiDD-Program Quality MgrJay KauffmanDD-HCBS Waivers Program AdministratorKent DysonDevelopmental Pathways (CCB)Roger JensenStarpoint (CCB-rural)Judy RodriguezDHS-Child Welfare*Rural-does APS & SEP Health Care Policy and Financing (HCPF) The Administrators Home Health Agency, Private Duty Nursing & Hospice Program Administrator The primary responsibilities of the HCPF program administrator for Home Health Agency (HHA), Private Duty Nursing and Hospice are rule interpretation, authoring rules, and utilization and analysis of policy. HHAs are required to have an advisory committee consisting of medical professionals for quality assurance, a governing board who write policies and procedures, and a self-audit mechanism that reports to the board. The advisory committee oversees all. The administrator also serves as clinical advisor because of her extensive nursing experience. Policy Analyst Nursing Facility Section The policy analyst manages the interagency contract with Colorado Department of Public Health and Environment (DPHE) to provide survey and certification of Medicaid Home Health Agencies, Hospice, Home and Community-Based Services (HCBS- Elderly Blind and Disabled (EBD)/ People Living With Aids (PLWA)/Mentally Ill (MI)/ Brain Injury (BI) Providers of Personal Care/ Homemaker Services; HCBS-EBD/MI/BI Providers of Adult Day Services; In Home Support Service (IHSS) HCBS-EBD/MI Providers of Alternative Care Facility Services and IHSS Providers and Brain Injury Supported Living Providers (BI-SLP). Monthly meetings are held alternately between the Department and DPHE to discuss problem facilities, the contract and any issues that require joint involvement. Home and Community-Based Services (HCBS) Waiver Administrator The HCBS waiver administrator is responsible for Elderly Blind and Disabled (EBD) and People Living with Aids (PLWA) waivers and waiver renewals. The administrator provides information for CMS waiver audits. Case managers call for technical assistance. The administrator interprets regulations for the case managers and verifies what can and cannot be done. The administrator also makes home modification approvals and provides follow up when problems develop with a home modification. For home care allowance and adult foster care the administrator provides technical assistance and manages the budget. If a client was denied benefits, the administrator reviews administrative law decisions on appeals. Single Entry Point (SEP) Administrator The SEP administrator monitors contracts and contract renewals between the Department and SEP. The administrator writes reports and gathers information such as the average case manager fee for caseload, which agencies have nurses and the number on staff, education of staff, number of Prior Authorization Request (PARs) completed, client satisfaction survey, and anything out of the ordinary noticed during visits. SEP Monitor The SEP monitor performs on site monitoring of SEPs once per year, technical assistance, and training. The monitoring has a two-program approach that includes reviewing the administration of the agency and reviewing of case records. The SEP monitor sees clients and receives opinions from clients. Program Integrity Unit The program integrity unit is responsible for reviewing all Medicaid providers, which includes pharmacies, HCBS agencies, transportation, hospitals, doctors, etc. The review focuses on verifying that claims match what was paid, documentation reflected by providers for services match case files and regulations were followed in billing and filing claims. They also review if a new claim is being filed for a previously denied claim. They also monitor for abuse and services by the provider. The Department has the authority to terminate a provider for good cause. Examples of good cause events are egregious abuse, abuse of the Medicaid system or harm to a consumer. If a provider is terminated from Medicare, the provider will automatically be terminated from Medicaid. When the Department becomes involved in a critical incident in this part of the system, the focus is on finances and documentation. If the incident appears to be part of a bigger problem, the Department may use its regulatory authority to remedy a situation. Quality Improvement & Behavioral Health Benefits Quality Improvement and Behavioral Health Benefits monitors managed care organizations, PCP programs, and mental health assessment agencies (MHASA) also known as behavioral health organizations; administers the consumer assessment survey asking clients about care and if access is good; reviews on site Managed Care Organizations and Administrative Service Organizations; provides documentation standards and review and compliance reporting standards; manages acute care utilization contract and McKesson triage line contract; and manages managed care benefits, contracts and quality. Utilization Contract Manager - Quality Improvement The primary focus for the quality improvement section is utilization at acute care and long term benefits providers. This group has no critical incident management system. The only statewide system with 24/7 capabilities that manages emergencies is the Telephone Triage Program (TTP). This program is subcontracted to McKesson. Nurses answer questions for Medicaid clients 24/7 to reduce the use of emergency room visits. This is the only statewide system. TTP is not in rules or statute. It is a value added program. Consumer Directed Attendant Support Administrator The program administrator for Consumer Directed Attendant Support (CDAS) manages the 1115 demonstration waiver. CDAS Training Coordinator The CDAS training coordinator provides training to CDAS participants before they enter the CDAS program. Trainings are in groups held at various locations and individualized in participants homes. Colorado Department of Public Health and Environment/ Nursing Board The Regulators Complaint Program Manager Health Facilities & Emergency Medical Services (HF&EMD) The complaint program manager receives complaints for hospitals, nursing facilities, skilled nursing facilities, home health care, ambulatory surgical centers, rural health clinics and other types of facilities DPHE licenses or certifies. Complaint calls are received through the home health hotline (HHH) or directly. When a call is received, the first consideration is to determine if DPHE has jurisdiction over the complaint. DPHE is always involved regarding any calls related to care issues. If jurisdiction is established, the calls are triaged based on the level of harm to the client. The degree of alleged harm determines the speed in which DPHE investigates calls. Their function is regulatory and not enforcement. DPHE is the watchdog regulator. Enforcement is federal. The home health program is a federally mandated Medicare and Medicaid program that provides skilled care services in homes or alternative community settings. The Health Facilities Division enforces Medicare and Medicaid standards in the home health program, and is also responsible for monitoring and evaluating the quality of health care services provided by home health providers. While home health agencies are not licensed, they must be certified. The division makes recommendations to the Centers for Medicare and Medicaid Services and to the Colorado Department of Health Care Policy and Financing regarding the certification of home health providers.There are approximately 130 certified home health agencies currently providing service in Colorado. (11/03) Home health agencies provide a wide range of health and social services to persons recovering from an illness or injury, or persons who are disabled and/or chronically ill. They provide skilled services such as nursing, social services, and therapeutic treatments (physical, speech, occupational therapy). They also provide non-skilled services like help with bathing, dressing and eating. Medical equipment such as wheelchairs, walkers and oxygen may also be provided. Complaint Surveyor HF& EMS Division The Home Health Hotline (HHH) rings at the surveyors desk. This hotline covers complaints regarding agencies that provide home health care, long-term care and care for individuals with developmental disabilities. The phone number is 800-842-8826.The HHH telephone is answered during the day when the surveyor is at the desk. An answering machine picks up calls the rest of the time. The surveyor uses a complaint intake sheet when speaking to the caller. As the caller talks about concerns and problems, the surveyor begins filling in part of the form. The surveyor asks any other questions to complete the form. The HHH receives approximately 5-10 calls per week. Half the calls are about benefits questions and employee relations. These calls are referred to the Department and DOL. The calls received by DPHE on the HHH and subsequent investigations, are investigated only if DPHE has regulatory authority over the agency in question. The HHH handles complaints about agencies that are licensed by DPHE. The phone number is given to clients who receive care from the agencies, as a requirement of the agencys licensing. The most common complaints are from a consumer who is not receiving staffing as needed or if monitoring of medications is not being handled. Worse case scenario would be if a consumer calls the home health agency for care, the agency does not provide the care, the symptoms progress, and the consumer calls 911 and is subsequently hospitalized. Complaint Investigator HFD Complaints about facilities come to the Health Facilities Division by calls or letters from family members, concerned citizens and health professionals. If the complaint falls under the divisions jurisdiction, division staff will investigate the complaint. Complaint investigations comprise of interviewing residents, patients, family members and staff and reviewing facility records. Following the investigation, the results are summarized in a public report. The division encourages solving any concerns or complaints at the facility level through communication between residents, family, staff and ombudsmen. However, if concerns are not being satisfactorily resolved at the facility level, a formal complaint can be filed with the division by calling (303) 692-2800, toll free at 800 886-7689, sending an email to  HYPERLINK "mailto:health.facilities@state.co.us" health.facilities@state.co.us or faxing a statement to (303) 753-0139. Anyone with knowledge or concerns about a health facility can file a complaint, and complainants may file the complaint anonymously. It is important that the complainant be able to provide as much specific information as possible about the situation, including who is involved, what happened, when it happened, how it happened and where it happened. The division can investigate complaints relating to quality of life and quality of care at a facility, including residents rights, abuse, dietary concerns, staffing and environmental concerns. The division cannot investigate complaints related to billing or insurance concerns. Complaints are prioritized based on level of actual harm to resident health and safety. A complaint that alleges immediate jeopardy, a crisis situation in which individuals are in imminent danger or harm that may result in death or serious injury, will be investigated within two working days. A complaint that alleges a higher-level actual harm, such as abuse, neglect, assault, or inappropriate use of restraints, will be investigated within 2 to 10 working days. Most complaints will be investigated within 60 working days. When a complaint is received at the division, staff review it, prioritize it, and initiate the investigation process by sending the complainant a letter confirming the divisions receipt of the complaint. A complaint investigator may then call the complainant back to ask further questions and clarify the situation. Most complaints are investigated on-site at the facility, and the complaint investigator will make an unannounced visit to the facility. To protect confidentiality, complaint investigators do not share the complainants name with the facility. However, in some cases, the facility may be able to detect the complainant's identity because of the nature of the complaint itself. While on-site at the facility, the complaint investigator will review records, conduct interviews with staff and residents, and observe facility practices. An investigator may also make calls to others, such as family members, who may be involved in the complaint or situation. Following the on-site investigation, the investigator may substantiate the complaint allegations or find the allegations are unsubstantiated. The investigator may also cite the facility for deficient practice. The complaint investigator will notify the complainant of the investigation outcome, and will write a summary of the investigation. The complainant will receive a letter explaining the finding(s) of the investigation as well as the summary of the investigation results. These summaries are also subsequently posted on the divisions web site. If the division is able to prove that the allegations in the complaint exist, and if they represent a violation of state or federal regulations, the division may cite deficient practice, which shows that the facility violated state or federal laws. If the division cites deficient practice, the facility has to respond with a Plan of Correction to assure that problems are corrected. If the facility does not correct the problems, the facility may be subject to sanctions. The division investigators may not be able to cite deficient practice if the facility has corrected the problem prior to the investigation, if the facility has been recently cited for the same/similar deficient practice during an annual survey/complaint investigation, if the deficient practice occurred a long time ago, or if there is no violation of state or federal regulations. Generalist Surveyor-Health Facilities The primary duty for the health facilities compliance surveyor is to survey HCBS certified agencies that are personal care providers and homemakers to verify that they are following regulations and meeting quality care. The survey process has five components: client records, personnel, policies and procedures, complaint log, and home visits. During a survey a 10% sample of client records is requested and reviewed. Personnel records that correlate with the 10% sample of clients records are reviewed to see if the information was recorded accurately. Policies and procedures are reviewed to verify that the provider is following the guidelines they set up. The complaint log is reviewed for complaint, action and resolution information. Five of the clients in the sample are visited (clients permission to visit is requested by the surveyor before visiting). Clients are asked about their care and provider. The survey window is 9-15 months. If a provider receives a complaint, the survey window will be shorter. If a provider does not receive any complaints, the survey window is longer. Nurse Practice Consultant-Board of Nursing The Division of Registrations focuses on individual licensure required by the Board of Nursing. The Board of Nursing insures rules are followed. Most complaints filed against licensees are potential violations. The ultimate goal is to remove unsafe practitioners. The nurse practice consultant handles clinical issues to determine if it rises to the level of something that is considered an emergency. The Colorado Nurse Practice Act is the authority that is followed. The Colorado Nurse Practice Act lists grounds for discipline. Complaint calls usually focus on care given by registered nurses, licensed practical nurses and nurse aids. The majority of the complaints fall into three groups: Has willfully or negligently acted in a manner inconsistent with the health or safety of persons under his care; Has negligently or willfully practiced nursing in a manner which fails to meet generally accepted standards for such nursing practice; orHas falsified or in a negligent manner made incorrect entries or failed to make essential entries on patient records. The nurse practice consultant looks for clinical aspects of what is needed in given situations. The licensee is considered innocent until proven guilty. This division also works with other agencies to implement and determine practical applications of bills passed in the legislature that relate to nursing. Single Entry Point (SEP) The Case Managers Assistant Director for Urban SEP A large urban Single Entry Point (SEP) operates as the metro county case manager for HCBS waivers. The SEPs perform functional assessments for people leaving hospitals who want to enter HCBS waivers. The ULTC100.2 is used to complete the assessment.  HYPERLINK \l "Appendix_E" (See appendix E for ULTC100.2 assessment tool). To be eligible for the waiver programs or to be placed in a nursing facility, clients must meet nursing facility level of care based on the score from the ULTC100.2. Collateral contacts such as family, caregivers, landlords or doctors are used along with the assessment tool. Each case manager maintains a caseload of approximately 90-95 clients. Case managers contact each client quarterly and visit two times per year. Once a year, the ULTC100.2 is repeated to see if eligibility needs have changed. If the client is hospitalized, visits are more frequent. Clients may also call the case manager for additional help or services. SEP Supervisor for Urban SEP The SEP supervisor supervises 9 case managers in metro counties. Case managers have a degree in social work, psychology or sociology. Each case managers caseload is approximately 90-95 clients. Case managers visit clients twice a year and call clients or authorized representatives quarterly. The SEP supervisor receives complaint phone calls, brainstorms with staff to problem solve, performs case audits, and trains staff. Case Managers The case manager is generally the first line of resource for clients. Case managers contact clients in person every six months and may contact clients more often if needed. The ULTC100.2 is administered annually to update information about the clients condition and verify the client still meets eligibility requirements. Case managers make telephone contact with clients each quarter. Clients and authorized representatives are requested to notify the case manager if changes in the clients condition exist. Case managers may or may not receive notification. If the client is hospitalized, the case manager usually visits in person when the client returns home. Some clients need more attention than others. The case managers assist clients with coordination of needed services, communication with service providers regarding service delivery and concerns, review and revise services as necessary, and notify clients regarding any change in services. Case managers ask a client if a care provider is preferred. CDAS clients receive 2 telephone contacts in the first quarter and coordinate their own services and providers. Case Manager Supervisor for urban county The Department contracts with the county to provide SEP services to the residents living in the county. The office operates as an arm of human services. There are 21 case managers with a caseload of approximately 90 clients each. The SEP provides information and referrals to county residents who need long term care services and also case management for Medicaid clients who live in their jurisdiction. Rural Case Manager The SEP case manager for two rural counties primarily had an Elderly, Blind, and Disabled caseload and an occasional Brain Injury or People Living with Aids client. The case manager completed intakes with ULTC100, visited clients two times a year, contacted the client quarterly by phone, and monitored providers regarding any issues clients had with care being received. The client caseload was 63. Rural Case Manager A rural county case manager is part of the Department of Social Services and employs 45 people in 6 units. The units include child welfare, SEP, Child Support, Adult Protective Services, financial eligibility and administration. The department serves 300-400 clients in the district. APS has 5 employees. Three people work in one county and two are subcontracted in another nearby county. The three staff wear two hats, SEP and APS. The time is charged separately. The organization differentiates between SEP and APS and the client often does not. The majority of the SEPs have 16 years experience in the department that includes child welfare background. The depth of the experience makes three-day holiday weekends more manageable. The staff knows what resources exist in the county and can find providers when needed. Good working rapport is established with other agencies. The Providers - Caregivers Small Privately Owned Home Health Agency One small caregiver is a proprietary owned home health care agency that provides nursing care, physical therapy, occupational therapy, speech pathology, medical social and home health aide. The agency provides service for125 clients, 98% are Medicaid/Medicare and most are quadriplegics that require at least 2 visits/day. The client to staff ratio is close to 1:1 with 121 staff. During the intake, an effort is made to match client with aid to make sure both are happy with working together. An aid on-call system is in place 5 a.m. to 12 midnight. No aids are working from midnight to 5 a.m. If an emergency happens, there is a 24-hour on-call nurse. A 15-day notice is given to a client to find another agency unless agency staff is in danger i.e. Client with weapon, drugs. No notice is given in these cases. Elderly receive different care from disabled because their needs are not usually as great. The elderly clients can usually get themselves up and may need help bathing or doing household chores. The times that service is delivered is not viewed as critical. New clients are only taken when the agency can provide 85% of visits/week. The agency philosophy is, Employees have the same rights as clients. Rural and Urban Home Health Agency One agency has provided home health services in urban and rural areas to persons with severe disabilities since January 1, 1992. While all persons with disabilities have different needs and abilities, the common thread of clients receiving home health aide services is that they need assistance with such activities of daily living as transferring in/out of wheelchairs or bed, dressing, bathing, bowel/bladder/skin care, range of motion, assistance with medication, etc. A registered nurse assesses clients needs. Based upon their need and orders received from the clients physician, a plan of care is established. The client and the agency staff negotiate times in which the aide comes for visits. Clients and aides are given a copy of the schedule and are routinely informed of changes that may occur. The agency requires that aides work at least every other weekend and most holidays. Aides receive differential pay for working before 7:00 AM or after 7:00 PM and on weekends. Aides are paid time and a half for holidays. Home Health Agency with Skilled Staff An agency that specializes in skilled staff, the primary duties include clinical services such as therapy, nursing, psyche, and extended home registered nurse and private duty nursing. A client who requires 24-hour vent coverage would generally have staffing in 8-12 hour shifts depending on client needs. Duties also include intermittent skilled visits that may require 1-2 hours at a time and would include nursing, therapy, blood transfusions, in home special programs and long term care needs from a disease process a client has. The agency provides quality, safe, clinical care in the home. Quality assurances include home staffing, accepting proper cases, financial and budgetary responsibility. Home Health Agency with Paraprofessionals A large agency with paraprofessionals has 200 caregivers in the Denver metro area. The staff works with Medicaid, Veterans Administration and skilled services that augment Registered Nurse (RN) services. The agency has 15 in house staff that work as schedulers, team leaders, and nurse assessors. Paraprofessionals include CNAs, personal care providers and homemakers. CNAs are CPR certified. All caregivers call the telephony system to record time worked for each client. Ideas about quality of life are not part of the medical model. Large National Home Healthcare Agency A very large home healthcare agency that started in 1992, serves Medicaid clients and a very small percentage of Medicare clients from coast to coast with 300 locations nationally. The services provided include nursing, physical therapy, occupational therapy, speech therapy and home health aids. The regional director is responsible for problem solving in AZ, NM, CO, UT, NV, ID, WA and OR. The agency has an agreement with DPHE to service clients within a 60-mile radius. They have determined that a larger service area would be difficult to supervise, difficult to meet client needs if a no show occurs, and the time required to reach an outlying client would be too long. People like getting care in their homes. Some believe if they go to a nursing facility, it is a death sentence. Adult Protection Services The Protectors State APS Adult Protection Services provides counties with training and technical assistance. APS created a guardianship manual, brochures with available services written at the consumer level, and protocols for the counties. The information provides ways to respond and how to work best with clients. The CAPS tracking system was part of the COIN system and was developed by APS to help counties to track clients and to collect statistics. The CAPS system was replaced by CBMS 9/1/2004. Large Urban County APS A large urban county APS works with at risk adults regarding abuse, neglect and exploitation. The definition of an at-risk adult from the statute is, at risk adult means an individual 18 years of age or older who is susceptible to mistreatment because the individual is unable to perform or obtain services necessary for the individual's health, safety or welfare or lacks sufficient understanding or capacity to make or communicate responsible decisions concerning the individual's person or affairs. At risk usually includes elderly, developmentally disabled, mentally ill or physically disabled persons who are easily preyed upon. The goal is to help people stay in the community and be in the least restrictive environment. This county receives approximately 70-90 referrals monthly. The county has two APS units. In one unit there are 8 intake workers and 2 ongoing caseworkers and in the second unit there are 10 ongoing caseworkers. The intake caseworkers receive calls, provide information and referrals, investigate cases to assess the situation, and may assist with resources if needed and wanted. This county has a six-month period to assess a client. Usually 90% of the cases open and close at intake. The ongoing caseworkers are involved with long-term care cases such as guardianship and representative payee. Fourteen years ago, this urban county APS started a money management plan to help clients pay bills. There are now 300 clients in the money management program. After hours calls concerning APS issues are forwarded to the agency Crisis Hotline. The individuals that work in that area make the determination as to whether to contact the on call APS caseworker, supervisor or administrator. Caseworkers rotate providing 24/7 backup responsibilities by taking a pager for two weeks each year. In-service trainings are provided in the community to the police department, elderly, hospitals, etc. to educate each group regarding what APS can and cannot do. There is a Victim's Protocol in place in this county to assist victims whose caregiver is arrested or otherwise unavailable. Services can be put in place to provide care for this individual until a more long-term plan can be established. The funds for this care can come from General Assistance Funds. A determination to use these funds would only be made if no other resources were available. Small Urban APS The purpose of this small urban county adult protection services office is to protect adults aged 18 years and older. They cannot just remove an adult from the home. Adults have a right to make good and bad decisions. APS becomes involved when an adult is physically, emotionally, or sexually abused; neglected by self or caregiver; or exploited by companies, families, friends, neighbors or other people. A multi-disciplinary team meets monthly to discuss APS cases. The team includes APS, doctors, realtors, county attorneys, district attorney, police and case managers. Cases discussed may not need intervention. The meeting makes the community aware of what is happening within the county and what support they might be able to give vulnerable adults. The caseload includes all income levels, all ages and ethnicities. A triad meets monthly at the senior citizens center. The triad includes seniors, police, APS, and county sheriff. Discussion includes problems the seniors are experiencing in the community, situations where seniors feel they are being taken advantage of and things seniors would like to see happen. Example: a group of seniors requested a meeting away from their apartment building to talk about the building managers comments that the seniors could lose their apartments (this is considered undue influence from the manager). AARP gives trainings in the community and updates participants and others such as law enforcement about anything relating to seniors. APS developed a bank program to give trainings at financial institutions to help banks recognize financial exploitation. Trainings have been developed for hospitals, doctors and postal workers also. The goal of APS is to keep people in their home, help correct any situation that brought APS to the home, and close the case. People are removed from the home as a last resort or if there is immanent danger. The client may be placed in a senior apartment, assisted living facility or nursing home, depending on level of competency. APS can request a guardianship or county conservator from the court when clients are determined not to be competent. APS may become a representative payee for the client. The representative payee receives all income checks for the client, pays all bills for the client and gives the balance as a stipend to the client to spend. Another program used by APS, doctors, community centers, and senior citizen centers is a card placed on the front door that reads, Im a member of medical alert. This informs emergency response workers that all medical information for the participant is located in a pouch on the participants refrigerator. The pouch will include a list of medications, what chronic conditions may exist and do not resuscitate orders. Grief counseling is also available for clients who have worked with APS previously and have lost a family member. Families are encouraged to become group decision makers. APS tells the family how APS became involved with a family member, explains what is going on and what needs to happen to get APS out of their life, and the family is given choices on how to proceed. Small Urban APS An urban adult protection services county in the foothills receives 30-60 referrals monthly. There is no mandatory reporting statewide. People are encouraged to report incidences if abuse, neglect, and exploitation of at risk adults aged 18 years or older is suspected. Five caseworkers and one supervisor receive calls and manage 70 guardianships. Caseworkers are assigned calls to be assessed by zip code areas and are assigned boarding homes and nursing facilities in the community. The philosophy of APS is to intervene in the least restrictive manner possible. Competent adults may choose to live in squalor and stay in their homes. If a person becomes demented, APS steps in. APS first choice is to include the family in decisions. If the family is unwilling or unable to care for a family member, APS will request guardianship. Guardianship remains in effect until the client passes away. The best tool APS has is good public relations because of the many ways the caseworkers interact with different agencies and organizations within the community. APS works with police, fire department, zoning, attorneys, home health agencies, doctors and nursing facilities. The public administrator manages conservatorships. Most calls come from the community. Child protection takes after-hours calls for guardianship cases and adult emergencies. The supervisor responds to these calls. APS contracts with a nursing facility to take people sight unseen for up to 72 hours in an emergency. This allows APS to work with the SEP to process paperwork and set up support for the client in the community. The caseworkers may do many activities with the client because there is no one else to help, such as going to a Medicaid appointment and driving the client to the doctor. Rural APS A rural APS office is part of the Dept. of Social Services and employs 45 people in 6 units. The units include child welfare, SEP, Child Support, APS, financial eligibility and administration. The department serves 300-400 clients in the district. APS has 5 employees. Three people work in one county office and two are subcontracted in another county office. The three member staff wear two hats, SEP and APS. The time is charged separately. The organization differentiates between SEP and APS and the client often does not. The depth of the experience of case managers makes three-day holiday weekends more manageable. The staff knows what resources exist in the county and can find providers when needed. Good working rapport is established with other agencies. Advocates Ombudsman The ombudsman provide advocacy for residents in nursing facilities, personal care boarding homes and long term care facilities. If a person has the capacity to make decisions, they have the right to make good and bad decisions. The relationship the ombudsman has with the client is confidential. This program is federally mandated and financed from the Older Americans Act. This organization also offers technical assistance, training and certificates to ombudsman in Colorado. Rural Mountain Independent Living Center A certified center for independent living serves three mountain counties located in a rural community with a population of approximately 10,000. There are 10 independent living centers in Colorado and some are also home health agencies. The consumer applies for services and information and the ILC provides training on how to live independently in the community. The ILC gives referrals and acts as an advocate. The ILC gives instruction for individual activities of daily living (IADLs), peer trainers, socialization skills and plan development. Rural Independent Living Center A certified independent living center works with seven counties in NE Colorado. Rural areas can experience problems with getting proper care from agencies. This ILC provides four required core services that include information and referrals, system and individual advocacy, peer support, independent living skills and training, and one selected service of housing. A fifth core service may be added for de-institutionalization. The center serves people with sensory disabilities with a focus on deaf and sign language. Urban Independent Living Center An urban independent living center works as an advocate for individuals who have recently transitioned from a nursing facility or people who need to develop independent living skills. Examples of skills training offered include how to ride and use the RTD bus system, how to grocery shop, how to cook or use a toaster, and how to develop social skills by attending ILC parties and meeting neighbors. If a person has been living in an institution, these skills may have been known at one time and may have been forgotten The ILC telephones and visits the client for 6 months to help the client with the transition to the community until the client is ready to be on their own. The ILC also advocates for clients to receive timely evaluations from the SEP. If the client is receiving home health care from an agency, the ILC unofficially oversees the home health agency to assure the client is receiving proper care. If a client has questions about a better way to handle a difficult situation, the ILC helps brainstorm alternative ways to respond in the future. Appendix D: Focus Group Topics, Guidelines, Questions, Forms Introduction -Systems change grant overview -Purpose of focus group -Definitions: attendant services, emergency backup, critical incidents -All participants' opinions are valid and valuable -Confidentiality -Ground rules -Answering questions is entirely voluntary -Group introductions; name and how long used attendant services Icebreaker: If you could have dinner with any person, living or dead, who would it be and why? Describe one time when you needed, and suddenly didn't have, attendant services. -unexpected need arose between visits -attendant didn't show up or called in sick -other What did you do? How did that work? What, if anything, would you do differently now? When you have an unexpected and/or emergency need for attendant services, what emergency backup resources are available to you? (Generate list of resources.) Of these emergency backup resources, which ones are most effective, i.e. which ones work the best? Of these emergency backup resources, which ones are most readily available? Of these emergency backup resources, which ones do you wish were more readily available? What other emergency backup resources can you think of or imagine which would help you in a situation of an emergency need for attendant services? What would you do in the event of a community wide emergency, such as a natural disaster, blizzard, power outage, security alert, or other situation which could prevent attendants from coming to your home? How would you get your personal care needs met? Describe one time when you had a very serious problem with an attendant or caregiver. -they hurt you or threatened to hurt you -they refused to do care that you needed -they left you in a dangerous or uncomfortable situation What did you do? Who did you tell? What was the outcome? What, if anything, would you do differently now? When a serious problem arises with an attendant or caregiver, involving abuse or neglect or abandonment, what resources are available to protect you, or to report the situation? (Generate list of resources.) Of these resources, which ones do you trust? Of these resources, which ones are most effective in resolving the problem and giving protection? What other resources would you like to see become available for people in your situation (i.e. living independently, directing own care) to report serious problems to and seek protection? What new thoughts, ideas, or feelings do you have after today's discussion? CONSENT FORM for FOCUS GROUP PARTICIPANTS If you cannot read this alone, or have trouble understanding this, someone else can read it out loud and explain parts of it. Just ask us for assistance. At the end of this form is a place for you to sign if you want to participate. If you have any questions or concerns, please discuss them either with Laura Hershey, an independent consultant; or with Diane M. King at the Colorado Department of Health Care Policy and Financing. Both can be reached at 303-866-5473 in the Denver metro area, or 1-800-221-3943. (TDD users can call 303-866-2504.) INTRODUCTION You are being invited to participate in a focus group meeting and to discuss your experiences, thoughts and ideas about attendant services. Topics will include covering cancellations, emergency backup resources, and reporting critical incidents such as neglected and abuse. We want your input, because you are a consumer of attendant services. We are gathering this information as part of a federal "systems change" grant to develop a better infrastructure for attendant services users in Colorado. During the focus group meeting, which will last approximately two hours, you will be with a group of between 6 and 16 other consumers, and will participate in a structured discussion, led by Laura Hershey. BENEFITS AND RISKS We want your participation in this focus group to be a positive experience for you. Because the group will be discussing issues and problems involved with attendant services, including neglect and abuse, there is a possibility that you could be reminded of unpleasant or upsetting experiences, and that you might feel distress. We also think you might benefit from listening to other people who might share your experiences. Having your opinions heard, and knowing that your input might help to make improvements in the infrastructure available to attendant services users in Colorado, may give you a feeling of empowerment. CONFIDENTIALITY- How we will protect your privacy In the focus group you are going to be asked questions about your experiences with attendant services. You do not have to answer. If you do answer, your answers will be written down and tape recorded. However, no one except the researchers will know who made each comment. When we analyze the comments we will not put your name or anyone else's name with the comments. Each participant will be assigned a number and no names will be used. We will have your name and address on file if you agree to participate. If you do sign this consent form we will keep the form in a separate locked location so that the page with your signature and the comments are not together. Only a few people will know which code members belong to which participants. These people include the focus group organizer/facilitator, the note-taker; and Diane M. King These individuals promise to keep this information strictly confidential. Other people who are present during the focus group, such as sign language interpreters, attendants, or other helpers, will be asked to sign a confidentiality agreement. Participants in the group will be asked not to disclose the names or experiences of the others in the group. We will not tell other people who was in the groups. INFORMED CONSENT You are a voluntary participant in this research. This means that you may refuse to participate if you wish. If you decide to participate, but change your mind, you may withdraw at any time. You will not lose anything by refusing to participate. You will not be asked to compensate the organizers for any benefits you have already received, such as transportation, reasonable accommodations, or refreshments. We do not want you to do anything that you do not want to do. We feel it is very important for you to feel safe and give your honest opinions. If at any time during or after the focus group, you have concerns and want to stop your participation you have that right. If you decide to withdraw from participation, call Laura Hershey or Diane M. King at the telephone numbers shown at the top of this page. If you withdraw, we will not use your comments. If you do want to participate and understand all these details you can sign below. Before you sign you can ask any questions about this evaluation project. If you do sign the form you can call and ask about the project after you have participated. The project researchers will help you deal with any negative results of participating in the focus group. I hereby give my informed and free consent to be a participant in this focus group. Signature________________________________________________________________ Printed Name___________________________________________________________________ Date____________________________________________________________________ I certify that I have explained to the above individual the nature and purpose, potential benefits and possible risks associated with participation in this research and have answered any questions that have been raised. I witnessed the above signature. Researcher_______________________________________________________________ Date____________________________________________________________________ FOCUS GROUP PARTICIPANT Demographic Information FOCUS GROUP DATE: ___________________ LOCATION: _________________ NAME: ________________________________________________________________________ ADDRESS:______________________________________________________________ CITY/STATE:_______________________________________ ZIP CODE:___________ PHONE NUMBER: _____________________________ EMAIL:_______________________________  ATTENDANT SERVICE SITUATION (Mark all that apply.) _____I have a disability and live in the community. _____I use attendant services at least once a day. _____I use attendant services at least once a week. _____My attendant services are provided by paid workers. _____My attendant services are provided by unpaid volunteers (family members or others). _____I am a family member of someone who uses attendant services. FUNDING SOURCE(S) If your services are provided by paid workers, what is the funding source? (Mark all that apply.) _____Out-of-pocket; your own money. _____Medicaid Waiver: Home and Community-Based Services (HCBS). _____Medicaid Consumer-Directed Attendant Services (CDAS). _____Medicaid: straight Medicaid. _____Home Care Allowance. _____In-Home Support Services (IHSS). _____Medicare. _____Private insurance. _____Other (please describe):_________________________________________________________  OPTIONAL INFORMATION (Answer only those questions you feel comfortable answering.) RACE/ETHNICITY: _______White/Caucasian _______Native American _______Latino/Hispanic _______Asian/Pacific Islander _______African-American _______Other:_________________ AGE RANGE: _______Under 18 _______66-75 _______18-35_______36-65 _______Over 75  SPECIAL NEEDS: Do have need any special arrangements or accommodations in order to participate in the focus group? (Examples: transportation, interpreting, personal assistance, etc.) Please describe in detail. ________________________________________________________________________ ________________________________________________________________________ Appendix E: ULTC 100.2 Assessment Tool Link to ULTC 100.2 on THE DEPARTMENT web site:  HYPERLINK "http://www.chcpf.state.co.us/HCPF/LTC/sepindex.asp" http://www.chcpf.state.co.us/HCPF/LTC/sepindex.asp Date Referral Completed:  FORMTEXT      Screening Agency:  FORMTEXT      Screener Name:  FORMTEXT      Month/Day/YearAssessing Agency: FORMTEXT       Provider #:  FORMTEXT       Worker #   FORMTEXT      Assessor Name: FORMTEXT       ULTC 100.2  INITIAL SCREENING AND INTAKE Current Living Situation FORMCHECKBOX  Alone  FORMCHECKBOX With Spouse/ Others  FORMCHECKBOX With Non-Spouse Relatives  FORMCHECKBOX With Parents FORMCHECKBOX With Non-Relatives  FORMCHECKBOX Alternative Care Facility  FORMCHECKBOX Adult Foster Care  FORMCHECKBOX Nursing Facility FORMCHECKBOX Pending Nursing Facility Discharge or Admission  FORMCHECKBOX Hospital Discharge, Date:  FORMTEXT        FORMCHECKBOX  DD Residential Program  FORMCHECKBOX  ICF/MR FORMCHECKBOX  URGENT Applicant Information State ID:  FORMTEXT       Primary Language  FORMTEXT       County ID:  FORMTEXT       Last Name:  FORMTEXT       First Name:  FORMTEXT       Middle Initial:  FORMTEXT       SSN:  FORMTEXT       Address:  FORMTEXT       DOB:  FORMTEXT       Marital Status: S FORMCHECKBOX M FORMCHECKBOX D FORMCHECKBOX W FORMCHECKBOX  Month/Day/Year City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       Phone:  FORMTEXT       Presenting Problems and DiagnosesComments: FORMTEXT      Areas of Concern FORMCHECKBOX  Bathing  FORMCHECKBOX  Toileting  FORMCHECKBOX  Dressing  FORMCHECKBOX  Transferring  FORMCHECKBOX  Eating  FORMCHECKBOX  Mobility FORMCHECKBOX  Behaviors  FORMCHECKBOX  Memory/Cognition  FORMCHECKBOX  Possible Mental Illness  FORMCHECKBOX  Possible Developmental Disability  FORMCHECKBOX  Brain Injury Potential Community Based Long Term Care Programs FORMCHECKBOX  HCBS-Elderly, Blind and Disabled (EBD)  FORMCHECKBOX  HCBS-Persons Living with HIV/AIDS (PLWA)  FORMCHECKBOX  Home Care Allowance (HCA)  FORMCHECKBOX  HCBS-Brain Injury (BI)  FORMCHECKBOX  Private Case Management  FORMCHECKBOX  HCBS-Mentally Ill (MI)  FORMCHECKBOX  Long Term Skilled Home Health  FORMCHECKBOX  HCBS- DD (Comprehensive Services )  FORMCHECKBOX  PACE  FORMCHECKBOX  Consumer Directed Attendant Support(CDAS)  FORMCHECKBOX  HCBS-Childrens Extensive Support (CES)  FORMCHECKBOX  Childrens HCBS  FORMCHECKBOX  HCBS-Supported Living Services (SLS)  FORMCHECKBOX  Other Program (specify):  FORMTEXT       FORMCHECKBOX  Medical information page sent to provider. Provider Name: FORMTEXT      Date: FORMTEXT       Residential Alternatives FORMCHECKBOX  Adult Foster Care  FORMCHECKBOX  Alternative Care Facility  FORMCHECKBOX  DD Residential Program FORMCHECKBOX  Nursing Facility FORMCHECKBOX  Other:  FORMCHECKBOX  ICF/MR FORMTEXT      Information and Referral Provided  FORMCHECKBOX  Home Health  FORMCHECKBOX  Vocational Rehabilitation  FORMCHECKBOX  Community Centered Board  FORMCHECKBOX  Homeless Shelter  FORMCHECKBOX  Area Agency on Aging  FORMCHECKBOX  Child Protection  FORMCHECKBOX  Hospice  FORMCHECKBOX  Mental Health Services  FORMCHECKBOX  Veterans Affairs  FORMCHECKBOX  Adult Protective Services  FORMCHECKBOX  County Eligibility  FORMCHECKBOX  Community Food Bank FORMCHECKBOX  Other: Contact InformationReferral InformationName:  FORMTEXT      Relationship:  FORMTEXT      Name:  FORMTEXT       Phone #1: Address:   FORMTEXT       Phone #2:   FORMTEXT       Phone #: Address:  FORMTEXT        FORMTEXT        FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT      Organization/ Relationship:  FORMTEXT      Financial InformationClient Income Source(s)Spouse Income Source(s)SourceAmountSource Amount  FORMCHECKBOX  SSA/SSDI  FORMCHECKBOX  SSI  FORMCHECKBOX  Pension  FORMCHECKBOX  Employment  FORMCHECKBOX  OAP  FORMCHECKBOX  AND/AB  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       $ FORMTEXT       $ FORMTEXT        FORMCHECKBOX  SSA/SSDI  FORMCHECKBOX  SSI  FORMCHECKBOX  Pension  FORMCHECKBOX  Employment  FORMCHECKBOX  OAP  FORMCHECKBOX  AND/AB  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       $ FORMTEXT       $ FORMTEXT       FORMCHECKBOX  Other: FORMTEXT       FORMCHECKBOX  Other:  FORMTEXT       Gross Monthly Income Gross Monthly Income Assets:  FORMTEXT      Assets: FORMTEXT      Insurance InformationMedical Provider InformationClient s Insurance InformationProvider Name FORMTEXT       FORMCHECKBOX  VA Benefits  FORMCHECKBOX  Medicare Part A  FORMCHECKBOX  Medicare Part B  FORMCHECKBOX  Private Health Insurance: FORMTEXT        FORMCHECKBOX  Medicaid  FORMCHECKBOX  LTC Medicaid  FORMCHECKBOX  Medicaid Pending  FORMCHECKBOX  Application in Process  FORMCHECKBOX  Application Needed  FORMCHECKBOX  Application Mailed Date:  FORMTEXT      Address: FORMTEXT      City:State: FORMTEXT      Zip: FORMTEXT      Phone: FORMTEXT      Type of Provider FORMTEXT      Contact Person: FORMTEXT      Comments: FORMTEXT       Comments: FORMTEXT       Case Assigned to: (worker name or number):   FORMTEXT       Date:   FORMTEXT       Long Term Care Professional Medical Information Dear Medical Provider: We are conducting a functional assessment of this person for long-term care services. The services will be provided in a skilled nursing facility, alternative care facility or in their own home in the community. Please complete the information below to help with the care planning for this person. Client: Last Name: FORMTEXT      First Name: FORMTEXT      Middle Initial: FORMTEXT       Street Address  FORMTEXT      City FORMTEXT      State  FORMTEXT      Zip FORMTEXT       Date of Birth   FORMTEXT       Telephone   FORMTEXT       Male  FORMCHECKBOX  Female  FORMCHECKBOX Medical Information Section: ICD 9 CodeICD 9 DescriptionOnsetMedication NameDosageFrequencyRoute FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Other Services Required for Medical Problems: (oxygen therapy, patient education, monitoring, follow-up care): Is there a Mental Health Diagnosis? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Is there a Developmental Disability Diagnosis? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Is there a Traumatic Brain Injury Diagnosis? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Diagnosis of dementia must be validated by a neurological exam with documentation by the attending physician. Neurological Exam Date:  FORMTEXT       If Hospitalized, Reason: FORMTEXT      Admit Date:  FORMTEXT       Diet Order:  FORMTEXT      Allergies: FORMTEXT      Prognosis: FORMTEXT       Medical Provider Name:  FORMTEXT      Address:  FORMTEXT       City:  FORMTEXT      State: FORMTEXT      Zip: FORMTEXT       Name of Person Completing this Information FORMTEXT      Title: FORMTEXT       Medical Provider Comments: FORMTEXT       Facility/Case Manager InformationFacility/Case Management Agency:  FORMTEXT      Administrator/Case Manager Name (print): Administrator/Case Manager Signature:  FORMTEXT      Phone Number:  FORMTEXT       FORMTEXT      LONG TERM CARE ELIGIBILITY ASSESSMENT General Instructions: To qualify for Medicaid long-term care services, the recipient/applicant must have deficits in 2 of 6 Activities of Daily Living, ADLs, (2+ score) or require at least moderate (2+ score) in Behaviors or Memory/Cognition under Supervision. ACTIVITIES OF DAILY LIVING I. BATHING Definition: The ability to shower, bathe or take sponge baths for the purpose of maintaining adequate hygiene. ADL SCORING CRITERIA  FORMCHECKBOX 0=The client is independent in completing the activity safely.  FORMCHECKBOX 1=The client requires oversight help or reminding; can bathe safely without assistance or supervision, but may not be able to get into and out of the tub alone.  FORMCHECKBOX 2=The client requires hands on help or standby assistance throughout bathing activities in order to maintain safety, adequate hygiene and skin integrity.  FORMCHECKBOX 3=The client is dependent on others to provide a complete bath. Due To: (Score must be justified through one or more of the following conditions) Physical Impairments:  FORMCHECKBOX Pain  FORMCHECKBOX Visually Impaired  FORMCHECKBOX Limited Range of Motion  FORMCHECKBOX Weakness  FORMCHECKBOX Balance Problems  FORMCHECKBOX Shortness of Breath  FORMCHECKBOX Decreased Endurance  FORMCHECKBOX Falls  FORMCHECKBOX Paralysis  FORMCHECKBOX Neurological Impairment  FORMCHECKBOX Oxygen Use  FORMCHECKBOX Muscle Tone  FORMCHECKBOX Amputation  FORMCHECKBOX Open Wound  FORMCHECKBOX Stoma Site Supervision:  FORMCHECKBOX Cognitive Impairment  FORMCHECKBOX Memory Impairment  FORMCHECKBOX Behavior Issues  FORMCHECKBOX Lack of Awareness  FORMCHECKBOX Difficulty Learning  FORMCHECKBOX Seizures Mental Health:  FORMCHECKBOX Lack of Motivation/Apathy  FORMCHECKBOX Delusional  FORMCHECKBOX Hallucinations  FORMCHECKBOX Paranoia Comments: FORMTEXT      II. DRESSING Definition: The ability to dress and undress as necessary. This includes the ability to put on prostheses, braces, anti-embolism hose or other assistive devices and includes fine motor coordination for buttons and zippers. Includes choice of appropriate clothing for the weather. Difficulties with a zipper or buttons at the back of a dress or blouse do not constitute a functional deficit. ADL SCORE CRITERIA  FORMCHECKBOX 0= The client is independent in completing activity safely.  FORMCHECKBOX 1=The client can dress and undress, with or without assistive devices, but may need to be reminded or supervised to do so on some days.  FORMCHECKBOX 2= The client needs significant verbal or physical assistance to complete dressing or undressing, within a reasonable amount of time.  FORMCHECKBOX 3= The client is totally dependent on others for dressing and undressing Due To: (Score must be justified through one or more of the following conditions) Physical Impairments:  FORMCHECKBOX Pain  FORMCHECKBOX Sensory Impairment  FORMCHECKBOX Limited Range of Motion  FORMCHECKBOX Weakness  FORMCHECKBOX Balance Problems  FORMCHECKBOX Shortness of Breath  FORMCHECKBOX Decreased Endurance  FORMCHECKBOX Fine Motor Impairment  FORMCHECKBOX Paralysis  FORMCHECKBOX Neurological Impairment  FORMCHECKBOX Bladder Incontinence  FORMCHECKBOX Bowel Incontinence  FORMCHECKBOX Amputation  FORMCHECKBOX Oxygen Use  FORMCHECKBOX Muscle Tone  FORMCHECKBOX Open Wound Supervision:  FORMCHECKBOX Cognitive Impairment  FORMCHECKBOX Memory Impairment  FORMCHECKBOX Behavior Issues  FORMCHECKBOX Lack of Awareness  FORMCHECKBOX Difficulty Learning  FORMCHECKBOX Seizures Mental Health:  FORMCHECKBOX Lack of Motivation/Apathy  FORMCHECKBOX Delusional  FORMCHECKBOX Hallucinations  FORMCHECKBOX Paranoia Comments: FORMTEXT      III. TOILETING Definition: The ability to use the toilet, commode, bedpan or urinal. This includes transferring on/off the toilet, cleansing of self, changing of apparel, managing an ostomy or catheter and adjusting clothing. ADL SCORE CRITERIA  FORMCHECKBOX 0=The client is independent in completing activity safely.  FORMCHECKBOX 1=The client may need minimal assistance, assistive device, or cueing with parts of the task for safety, such as clothing adjustment, changing protective garment, washing hands, wiping and cleansing.  FORMCHECKBOX 2=The client needs physical assistance or standby with toileting, including bowel/bladder training, a bowel/bladder program, catheter, ostomy care for safety or is unable to keep self and environment clean.  FORMCHECKBOX 3=The client is unable to use the toilet. The client is dependent on continual observation, total cleansing, and changing of garments and linens. This may include total care of catheter or ostomy. The client may or may not be aware of own needs. Due To: (Score must be justified through one or more of the following conditions) Physical Impairments:  FORMCHECKBOX Pain  FORMCHECKBOX Visual Impairment  FORMCHECKBOX Limited Range of Motion  FORMCHECKBOX Weakness  FORMCHECKBOX Shortness of Breath  FORMCHECKBOX Decreased Endurance  FORMCHECKBOX Fine Motor Impairment  FORMCHECKBOX Paralysis  FORMCHECKBOX Neurological Impairment  FORMCHECKBOX Bladder Incontinence  FORMCHECKBOX Bowel Incontinence  FORMCHECKBOX Amputation  FORMCHECKBOX Oxygen Use  FORMCHECKBOX Physiological defect  FORMCHECKBOX Balance  FORMCHECKBOX Muscle Tone  FORMCHECKBOX Impaction FORMCHECKBOX Ostomy  FORMCHECKBOX Catheter Supervision Need:  FORMCHECKBOX Cognitive Impairment  FORMCHECKBOX Memory Impairment  FORMCHECKBOX Behavior Issues  FORMCHECKBOX Lack of Awareness  FORMCHECKBOX Difficulty Learning  FORMCHECKBOX Seizures Mental Health:  FORMCHECKBOX Lack of Motivation/Apathy  FORMCHECKBOX Delusional  FORMCHECKBOX Hallucinations  FORMCHECKBOX Paranoia Comments:  FORMTEXT       IV. MOBILITY Definition: The ability to move between locations in the individual s living environment inside and outside the home. Note: Score client s mobility without regard to use of equipment. ADL SCORE CRITERIA  FORMCHECKBOX 0=The client is independent in completing activity safely.  FORMCHECKBOX 1=The client is mobile in their own home but may need assistance outside the home.  FORMCHECKBOX 2=The client is not safe to ambulate or move between locations alone; needs regular cueing, stand-by assistance, or hands on assistance for safety both in the home and outside the home.  FORMCHECKBOX 3=The client is dependent on others for all mobility. Due To: (Score must be justified through one or more of the following conditions) Physical Impairments:  FORMCHECKBOX Pain  FORMCHECKBOX Sensory Impairment  FORMCHECKBOX Limited Range of Motion  FORMCHECKBOX Weakness  FORMCHECKBOX Shortness of Breath  FORMCHECKBOX Decreased Endurance  FORMCHECKBOX Fine or Gross Motor Impairment  FORMCHECKBOX Paralysis  FORMCHECKBOX Neurological Impairment  FORMCHECKBOX Amputation  FORMCHECKBOX Oxygen Use  FORMCHECKBOX Balance  FORMCHECKBOX Muscle ToneSupervision Need:  FORMCHECKBOX Cognitive Impairment  FORMCHECKBOX Memory Impairment  FORMCHECKBOX Behavior Issues  FORMCHECKBOX Lack of Awareness  FORMCHECKBOX Difficulty Learning  FORMCHECKBOX Seizures  FORMCHECKBOX History of Falls Mental Health:  FORMCHECKBOX Lack of Motivation/Apathy  FORMCHECKBOX Delusional  FORMCHECKBOX Hallucinations  FORMCHECKBOX Paranoia Comments: FORMTEXT       LONG TERM CARE ELIGIBILITY ASSESSMENT: ADLS (continued) V. TRANSFERRING Definition: The physical ability to move between surfaces: from bed/chair to wheelchair, walker or standing position; the ability to get in and out of bed or usual sleeping place; the ability to use assisted devices for transfers. Note: Score clients mobility without regard to use of equipment. ADL SCORE CRITERIA  FORMCHECKBOX 0=The client is independent in completing activity safely.  FORMCHECKBOX 1=The client transfers safely without assistance most of the time, but may need standby assistance for cueing or balance; occasional hands on assistance needed.  FORMCHECKBOX 2=The client transfer requires standby or hands on assistance for safety; client may bear some weight.  FORMCHECKBOX 3=The client requires total assistance for transfers and/or positioning with or without equipment. Due To: (Score must be justified through one or more of the following conditions) Physical Impairments:  FORMCHECKBOX Pain  FORMCHECKBOX Sensory Impairment  FORMCHECKBOX Limited Range of Motion  FORMCHECKBOX Weakness  FORMCHECKBOX Balance Problems  FORMCHECKBOX Shortness of Breath  FORMCHECKBOX Falls  FORMCHECKBOX Decreased Endurance  FORMCHECKBOX Paralysis  FORMCHECKBOX Neurological Impairment  FORMCHECKBOX Amputation  FORMCHECKBOX Oxygen UseSupervision Need:  FORMCHECKBOX Cognitive Impairment  FORMCHECKBOX Memory Impairment  FORMCHECKBOX Behavior Issues  FORMCHECKBOX Lack of Awareness  FORMCHECKBOX Difficulty Learning  FORMCHECKBOX Seizures Mental Health:  FORMCHECKBOX Lack of Motivation/Apathy  FORMCHECKBOX Delusional  FORMCHECKBOX Hallucinations  FORMCHECKBOX Paranoia Comments: FORMTEXT       VI. EATING Definition: The ability to eat and drink using routine or adaptive utensils. This also includes the ability to cut, chew and swallow food. Note: If a person is fed via tube feedings or intravenously, check box 0 if they can do independently, or box 1, 2, or 3 if they require another person to assist. ADL SCORE CRITERIA  FORMCHECKBOX 0=The client is independent in completing activity safely  FORMCHECKBOX 1=The client can feed self, chew and swallow foods but may need reminding to maintain adequate intake; may need food cut up; can feed self if food brought to them, with or without adaptive feeding equipment.  FORMCHECKBOX 2=The client can feed self but needs standby assistance for frequent gagging, choking, swallowing difficulty; or aspiration resulting in the need for medical intervention. The client needs reminder/assistance with adaptive feeding equipment; or must be fed some or all food by mouth by another person.  FORMCHECKBOX 3=The client must be totally fed by another person; must be fed by another person by stomach tube or venous access. Due To: (Score must be justified through one or more of the following conditions) Physical Impairments:  FORMCHECKBOX Pain  FORMCHECKBOX Visual Impairment  FORMCHECKBOX Limited Range of Motion  FORMCHECKBOX Weakness  FORMCHECKBOX Shortness of Breath  FORMCHECKBOX Decreased Endurance  FORMCHECKBOX Paralysis  FORMCHECKBOX Neurological Impairment  FORMCHECKBOX Amputation  FORMCHECKBOX Oxygen Use  FORMCHECKBOX Fine Motor Impairment  FORMCHECKBOX Poor Dentition  FORMCHECKBOX Tremors  FORMCHECKBOX Swallowing Problems  FORMCHECKBOX Choking  FORMCHECKBOX Aspiration FORMCHECKBOX Tube Feeding  FORMCHECKBOX IV Feeding Supervision Need:  FORMCHECKBOX Cognitive Impairment  FORMCHECKBOX Memory Impairment  FORMCHECKBOX Behavior Issues  FORMCHECKBOX Lack of Awareness  FORMCHECKBOX Difficulty Learning  FORMCHECKBOX Seizures Mental Health:  FORMCHECKBOX Lack of Motivation/Apathy  FORMCHECKBOX Delusional  FORMCHECKBOX Hallucinations  FORMCHECKBOX Paranoia Comments: FORMTEXT      LONG TERM CARE ELIGIBILITY ASSESSMENT: Supervision VII. SUPERVISION Definition: The need for supervision is indicated by a significant impairment in Behavior and/or Cognition/Memory. A. Behaviors (Wandering/Disruptive/Self-Injurious/Resistive to care/Self-neglect) Scoring Criteria:  FORMCHECKBOX 0=The client demonstrates appropriate behavior; there is no concern.  FORMCHECKBOX 1=The client exhibits some inappropriate behaviors but not resulting in injury to self, others and/or property. The client may require redirection. Minimal intervention is needed.  FORMCHECKBOX 2=The client exhibits inappropriate behaviors that put self, others or property at risk. The client requires more than verbal redirection to interrupt inappropriate behaviors. The client needs medication assistance, monitoring, supervision or is unable to make safe decisions.  FORMCHECKBOX 3=The client exhibits behaviors resulting in physical harm for self or others. The client requires extensive supervision to prevent physical harm to self or others. Due To: (Score must be justified through one or more of the following conditions) Physical Impairments:  FORMCHECKBOX Medication Management  FORMCHECKBOX Chronic Medical Condition  FORMCHECKBOX Acute Illness  FORMCHECKBOX Pain  FORMCHECKBOX Neurological Impairment  FORMCHECKBOX Choking  FORMCHECKBOX Sensory Impairment  FORMCHECKBOX Communication Impairment (not inability to speak English) Mental Health:  FORMCHECKBOX Lack of Motivation/Apathy  FORMCHECKBOX Delusional  FORMCHECKBOX Hallucinations  FORMCHECKBOX Paranoia  FORMCHECKBOX Mood Instability Supervision needs:  FORMCHECKBOX Short Term Memory Loss  FORMCHECKBOX Long Term Memory Loss FORMCHECKBOX Agitation  FORMCHECKBOX Aggressive Behavior  FORMCHECKBOX Cognitive Impairment  FORMCHECKBOX Difficulty Learning  FORMCHECKBOX Memory Impairment  FORMCHECKBOX Verbal Abusiveness  FORMCHECKBOX Constant Vocalization  FORMCHECKBOX Sleep Deprivation  FORMCHECKBOX Self-Injurious Behavior  FORMCHECKBOX Impaired Judgment  FORMCHECKBOX Disruptive to Others  FORMCHECKBOX Disassociation  FORMCHECKBOX Wandering  FORMCHECKBOX Seizures  FORMCHECKBOX Self Neglect Comments: FORMTEXT       B. Memory/Cognition Deficit Scoring Criteria:  FORMCHECKBOX 0= Independent no concern  FORMCHECKBOX 1= The client can make safe decisions in familiar/routine situations, but needs some help with decision making support when faced with new tasks, consistent with individuals values and goals.  FORMCHECKBOX 2= The client requires consistent and ongoing reminding and assistance with planning, or requires regular assistance with adjusting to both new and familiar routines, including medication assistance and monitoring or requires ongoing supervision or is unable to make safe decisions, or cannot make his/her basic needs known.  FORMCHECKBOX 3= The client needs help most or all of time. Medications must be administered for the client. Due To: (Score must be justified through one or more of the following conditions) Physical Impairments:  FORMCHECKBOX Metabolic Disorder  FORMCHECKBOX Medication Reaction  FORMCHECKBOX Acute Illness  FORMCHECKBOX Pain  FORMCHECKBOX Neurological Impairment  FORMCHECKBOX Alzheimers/Dementia  FORMCHECKBOX Sensory Impairment  FORMCHECKBOX Chronic Medical Condition  FORMCHECKBOX Communication Impairment (does not include ability to speak English)  FORMCHECKBOX Abnormal Oxygen Saturation  FORMCHECKBOX Fine Motor Impairment Supervision Needs:  FORMCHECKBOX Disorientation  FORMCHECKBOX Cognitive Impairment  FORMCHECKBOX Difficulty Learning  FORMCHECKBOX Memory Impairment FORMCHECKBOX Self-Injurious Behavior  FORMCHECKBOX Impaired Judgment  FORMCHECKBOX Unable to Follow Directions  FORMCHECKBOX Constant Vocalizations  FORMCHECKBOX Perseveration  FORMCHECKBOX Receptive Expressive Aphasia  FORMCHECKBOX Agitation  FORMCHECKBOX Disassociation  FORMCHECKBOX Wandering  FORMCHECKBOX Lack of Awareness  FORMCHECKBOX Seizures Mental Health:  FORMCHECKBOX Lack of Motivation/Apathy  FORMCHECKBOX Delusional  FORMCHECKBOX Hallucinations  FORMCHECKBOX Paranoia  FORMCHECKBOX Mood Instability Comments: FORMTEXT       Assessment Demographics: Location of Assessment:Present at Interview:  FORMCHECKBOX Applicant s private residence/home  FORMCHECKBOX Nursing Home  FORMCHECKBOX  Hospital/other health care facility  FORMCHECKBOX Assisted Living  FORMCHECKBOX Agency Office  FORMCHECKBOX Relative s home  FORMCHECKBOX Other: FORMTEXT        FORMCHECKBOX Applicant Only  FORMCHECKBOX Caregiver(s) only  FORMCHECKBOX Applicant and caregiver(s)  FORMCHECKBOX Other: FORMTEXT        FORMCHECKBOX Applicant and others  Most of the interview information was provided by:  FORMCHECKBOX Applicant  FORMCHECKBOX Medical record  FORMCHECKBOX Caregiver  FORMCHECKBOX Facility Staff  FORMCHECKBOX Applicant and Caregiver equally  FORMCHECKBOX Other: FORMTEXT        Living Environment: Safe FORMCHECKBOX Services cannot be delivered here FORMCHECKBOX Safe with feasible modifications FORMCHECKBOX Client needs to move so services can be delivered FORMCHECKBOX  Services can be delivered here FORMCHECKBOX Client needs to move to a safer environment FORMCHECKBOX Special home assessment needed FORMCHECKBOX  Adult Protective Services Risk: Person is known to be a current client of Adult Protective Services (APS) Yes  FORMCHECKBOX  No  FORMCHECKBOX  Risk Evident During Assessment: (Check any that apply.) FORMCHECKBOX No risk factors or evidence of abuse or neglect apparent at this time.  FORMCHECKBOX The individual is currently failing or is at high risk of failing to obtain nutrition, self-care, or safety adequate to avoid Significant negative health outcomes.  FORMCHECKBOX Risk factors present; however, LTC services may resolve issues. No APS referral being made at this time.  FORMCHECKBOX There are statements of, or evidence of, possible abuse, neglect, self-neglect, or financial exploitation.   FORMCHECKBOX Referring to APS now? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Advance Directives and Legal Documents: FORMCHECKBOX Living Will: FORMTEXT       FORMCHECKBOX Power of Attorney Financial Power of Attorney: General Power of Attorney: Medical Power of Attorney:  FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX Conservator:  FORMTEXT       FORMCHECKBOX Guardian:  FORMTEXT       Comments/Narrative: FORMTEXT       LEVEL l IDENTIFICATION SCREEN FOR MENTAL ILLNESS/MENTAL RETARDATION Instructions for completing this form are on reverse side of this page. WEB Page www.cdhs.ctate.co.us/ohr/mhs/index.html. Client Name: Social Security Number: - - Current Address: Date of Birth: / / Street Current Location: City State ZIP Code Current Telephone Number: Nursing Facility: SECTION IPASRR/MI/Level I Screen (See back of form for definitions)PASRR/MR-DD/Level I Screen (See back of form for definitions)1. Has a Major Mental Illness Diagnosis as on the back of this form? 2. Has a history of mental illness in the last 2 years? 3. Presents with symptoms of major mental illness (excluding primary dementia, substantiated by a neurological exam)? 4. Has been prescribed or routinely taken antipsychotic or antidepressant medication during the past 2 years? List medications and diagnosis/es here: Psychoactive Medications (Yes (No (Yes (No (Yes (No (Yes (No1. MR-DD diagnosis. 2. Any history of mental retardation or developmental disability in the individuals past? 3. Presenting evidence of cognitive or behavioral impairment (before the age of 22) that may indicate that the individual has a developmental disability. 4. Referral by an agency that provides services to persons with mental retardation or developmental disabilities. Diagnosis/es:(Yes (No (Yes (No (Yes (No (Yes (No    Note: If all responses to SECTION I are NO, skip to SECTION III. SECTION IIIndividual Determinations - You must contact State Utilization Review Contractor and obtain clearance.The individual meets:Date Authorized by URCConfirmation Number provided by State URC: (if applicable)Convalescent Criteria Severity of Illness Criteria Terminal Illness Criteria ____/____/_____ ____/____/_____ ____/____/_____Comments: SECTION III To The Client/Legal Guardian: As a result of one or more YES responses on this screen, a more complete assessment may be necessary. This may result in a delay in the processing of your request for a nursing facility placement. Legal Guardian: Yes Date of duration: (If yes, please list the name and address below.) Name: _______________________________________________________________________________________ Address:______________________________________________________________________________________ Client / Legal Guardian has received a copy of this form: Yes No To the Preparer of this form: By Federal Law, your signature is verification that a copy has been given to the client. Printed Name of Preparer: Agency:_______________________________ Date: ______/_________/_______ Signature of Preparer: Telephone Number: _____________________ Note: Any YES response on this Level I Screen requires review by the Statewide Utilization Review Contractor. SECTION I Level I PASRR Screen: Both MI and MR-DD screens are completed if a client is accessing a nursing facility; do not complete for a Continued Stay review or HCBS EBD. All portions must be completed and a signature is required. If the determination by State URC differs from the responses submitted, instructions will be given to indicate the changes. Note that if there are any yes responses, a copy must be provided to the client and to the legal guardian if applicable, and that the required signature verifies that this has been done. Note that the name and address of the client and legal guardian is required if there are any yes responses; by federal law the legal guardian and client must be notified, in writing, the findings of a Level I failure. Legal guardian definition: Court appointed including medical decision-making, not Power of Attorney (POA). Level I / MI Instructions Diagnosis of Mental Illness defined as: a diagnosis of a major mental disorder (as defined in the DSM-IV R) limited to schizophrenia, paranoia, major affective including bipolar, major depression, dysthymia, cyclothymia or schizoaffective disorder or psychosis nos. Recent (2 year) history of mental illness and includes inpatient psychiatric hospitalization, mental health interventions or symptoms possibly related to mental illness. Presenting evidence of mental illness: patient demonstrates symptomatology and/or behaviors characteristic of mental illness. Use of psychotropic medications without an appropriate psychiatric diagnosis will require a yes response. List all psychotropic medications with corresponding diagnoses. Any person who has a primary diagnosis of dementia that is based on a neurological examination is exempt from the PASRR process. This dementia exclusion DOES NOT apply to individuals with a diagnosis of mental retardation or major mental illness. Level I / MR-DD Developmental disability means: A disability that is manifested before the person reaches twenty-two years of age, which constitutes a substantial handicap to the affected individual, and is attributable to mental retardation or related conditions which include cerebral palsy, epilepsy, autism or other neurological conditions when such conditions result in impairment of general intellectual functioning or adaptive behavior similar to that of a person with mental retardation. SECTION II Individual determinations must be authorized by Statewide Utilization Review Contractor. Convalescent Care Criteria refers to discharge from hospital to NF for a prescribed stay of 60 days or less for rehab/convalescence for a medical or surgical condition that required hospitalization. Severity of Illness Criteria refers to a comatose, vent-dependent, vegetative state. Terminal Illness Criteria refers to physician documentation of life expectancy of less than 6 months. SECTION III If the client fails or client requests a copy, the Level I, the client or legal guardian must receive a copy of this form by the referral source (signature verifies that this is done). Name and address must be provided so that a copy can be mailed to them. The above procedures are a requirement per federal regulations. The original copy is sent to the nursing facility. Copies as needed for client, guardian and Statewide Utilization Review Contractor. Level of Care DeterminationClient Meets Level of Care Yes  FORMCHECKBOX  No  FORMCHECKBOX  Activities of Daily Living Scores:Bathing Dressing Toileting Mobility TransfersEatingSupervision Behaviors Supervision Memory/CognitionScores:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Is there documented medical information supporting any of the following programs? MI  FORMCHECKBOX  BI  FORMCHECKBOX  PLWA FORMCHECKBOX Has Developmental Disability eligibility been determined? Yes  FORMCHECKBOX  No  FORMCHECKBOX Comments/Supporting documentation: FORMTEXT       Services RequirementsWaiver Services Needed within 30 Days Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMCHECKBOX Waitlist Waiver: FORMTEXT      If Waiver Services are not required within 30 days document referral to community resources: Comments:  FORMTEXT        Nursing Facility PASARR DeterminationPASARR Level 1 evaluation Completed  FORMCHECKBOX  Client Passed  FORMCHECKBOX  Client Failed  FORMCHECKBOX  FORMCHECKBOX  Depression Diversion Client Passed  FORMCHECKBOX  Client Failed  FORMCHECKBOX  FORMCHECKBOX  Level II Evaluation Needed Referred to MHASA  FORMCHECKBOX  Date  FORMTEXT       Referred to CCB  FORMCHECKBOX  Date:  FORMTEXT      Comments:  FORMTEXT        Long Term Care Certification FORMCHECKBOX  Admission  FORMCHECKBOX  CSRSSN:  FORMTEXT      - FORMTEXT      - FORMTEXT      State ID: FORMTEXT      Last Name: FORMTEXT      First Name: FORMTEXT      MI: FORMTEXT      DOB: FORMTEXT      County of Residence:  FORMTEXT      Date of Medicaid Application: FORMTEXT      Facility Name:  FORMTEXT      Provider #: FORMTEXT      Admit Date: FORMTEXT      DO NOT COMPLETE BELOW IF CLIENT IS APPROVED FOR WAITLISTTarget Group  FORMCHECKBOX  1 Developmental Disability/MR  FORMCHECKBOX  2 Mental Health  FORMCHECKBOX  3 Frail Elderly (65+)  FORMCHECKBOX  4 Physically Disabled (18-64)  FORMCHECKBOX  5 Physically Disabled (13-17)  FORMCHECKBOX  6 Pediatric (<13)  FORMCHECKBOX  7 Brain Injury (16-64)Program Approval  FORMCHECKBOX  HCBS/DD (Comprehensive)  FORMCHECKBOX  HCBS/MI  FORMCHECKBOX  HCBS/EBD  FORMCHECKBOX  HCBS/PLWA  FORMCHECKBOX  Childrens HCBS  FORMCHECKBOX  Nursing Home  FORMCHECKBOX  HCBS/BI  FORMCHECKBOX  HCBS/CES  FORMCHECKBOX  HCBS/BI Supported Living  FORMCHECKBOX  PACE  FORMCHECKBOX  ICF/MR  FORMCHECKBOX  LTC- Skilled Home Health  FORMCHECKBOX  HCBS/SLS  FORMCHECKBOX  HCA  FORMCHECKBOX  AFCCertification InformationConfirmation #: Start Date: End Date: Authorized By: Agency Authorization Date:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Denial InformationDate Denied: FORMTEXT      Date Denial Letter Mailed: FORMTEXT      Case Mgr. Initials FORMTEXT       Client Name: FORMTEXT      _ __________________________________ LONG TERM CARE ASSESSMENT FOR INSTRUMENTAL ACTIVITIES OF DAILY LIVING IADL SCORE CRITERIA 0= The client is independent in completing activity safely. 1= Minimal Assistance - The client can manage the IADL task but must be reminded or supervised at least some of the time or the client may require stand-by assistance, may require limited hands on assistance. 2= Moderate Assistance - The client regularly requires verbal and/or hands on assistance with IADL task. 3= Maximum Assistance - The client is dependent on others to perform or complete the IADL task. IADL Functional Deficits Due To: Physical Impairments:  FORMCHECKBOX Pain  FORMCHECKBOX Visually Impaired  FORMCHECKBOX Limited Range of Motion  FORMCHECKBOX Weakness  FORMCHECKBOX Balance Problems  FORMCHECKBOX Shortness of Breath FORMCHECKBOX Decreased Endurance  FORMCHECKBOX Falls  FORMCHECKBOX Paralysis  FORMCHECKBOX Neurological Impairment  FORMCHECKBOX Oxygen Use  FORMCHECKBOX Muscle Tone  FORMCHECKBOX Amputation FORMCHECKBOX Open Wound  FORMCHECKBOX Stoma Site Supervision:  FORMCHECKBOX Cognitive Impairment  FORMCHECKBOX Memory Impairment  FORMCHECKBOX Behavior Issues  FORMCHECKBOX Lack of Awareness FORMCHECKBOX Difficulty Learning  FORMCHECKBOX Seizures Mental Health:  FORMCHECKBOX Lack of Motivation/Apathy  FORMCHECKBOX Delusional  FORMCHECKBOX Hallucinations  FORMCHECKBOX Paranoia IADL Task0123CommentsHYGIENE: The ability to perform grooming, shaving, nail care, body care, oral care or hair care for the purpose of maintaining adequate hygiene. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT      MEDICATION MANAGEMENT: The ability to follow prescribed medication regime. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX TRANSPORTATION: The ability to drive and/or access transportation services in the community. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX MONEY MANAGEMENT:The ability to handle money, pay bills, plan, budget, write checks or money orders, exchange currency, handle coins and paper work, i.e. to do financial management for basic necessities (food, clothing, shelter). Do not check if limitation is only cultural (e.g., recent immigrant who has not learned U.S. currency and/or English language). FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX SHOPPING: The ability to run errands and shop; select appropriate items, get around in a store, physically acquire, transport and put away items (money management not considered in this activity). FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX MEAL PREPARATION: The ability to obtain and prepare routine meals. This includes the ability to independently open containers and use kitchen appliances, with assistive devices if person uses them. If the person is fed via tube feedings or intravenously, treat preparation of the tube feeding as meal preparation and indicate level of help needed. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX LAUNDRY: The ability to maintain cleanliness of personal clothing and linens. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX ACCESSING RESOURCES: The ability to identify needs and locate appropriate resources; is able to complete phone calls, setup and follow through with appointments and to complete paperwork necessary to acquire/participate in service/activity offered by the resource. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX HOUSEWORK: The ability to maintain cleanliness of the living environment. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX SCORE TOTALSGRAND TOTAL:  Strengths Assessment and Evaluation Please identify strengths in each domain: SOCIAL SUPPORTSPARTICIPATIION IN ACTIVITIESEXTERNAL RESOURCESHEALTH AND WELLNESSPERSONAL ASSETS FORMCHECKBOX  Supportive family  FORMCHECKBOX  Supportive friends  FORMCHECKBOX  Caring neighbors  FORMCHECKBOX  Community recognition and respect  FORMCHECKBOX  Sense of a place in the world  FORMCHECKBOX Other: FORMTEXT        FORMCHECKBOX Other:  FORMTEXT        FORMCHECKBOX  Creative activities  FORMCHECKBOX Church/spiritual activities  FORMCHECKBOX  Community activities  FORMCHECKBOX  Clubs, groups, planned meetings  FORMCHECKBOX  Volunteer service opportunities  FORMCHECKBOX  Other:  FORMTEXT        FORMCHECKBOX  Other:  FORMTEXT        FORMCHECKBOX  Adequate housing  FORMCHECKBOX  Financial security  FORMCHECKBOX  Adequate transportation  FORMCHECKBOX  Safe environment  FORMCHECKBOX  Access to safety resources  FORMCHECKBOX  Medical equipment  FORMCHECKBOX  Other:  FORMTEXT        FORMCHECKBOX  Other: FORMTEXT        FORMCHECKBOX  Adequate physical health  FORMCHECKBOX  Balanced mental health  FORMCHECKBOX  Self care ability or resources  FORMCHECKBOX  Adequate medical access  FORMCHECKBOX  Commitment to health  FORMCHECKBOX  Knowledge about how choices impact health  FORMCHECKBOX  Other: FORMTEXT        FORMCHECKBOX  Other: FORMTEXT        FORMCHECKBOX  Positive self-image  FORMCHECKBOX  sense of empowerment  FORMCHECKBOX  positive view of others  FORMCHECKBOX  positive view of the future  FORMCHECKBOX  adequate communication skills  FORMCHECKBOX  sense of purpose  FORMCHECKBOX  ability to ask for and accept help  FORMCHECKBOX  ability to accept personal responsibility  FORMCHECKBOX  other: FORMTEXT        FORMCHECKBOX  other: FORMTEXT        LIST STRENGTHS / ASSETS THREATENED OR RECENTLY WEAKENED STRENGTH / ASSETWHY WEAKENED OR THREATENED? FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       LIST STRENGTHS CLIENT WOULD LIKE TO INCREASE OR ADD TO A DOMAINSTRENGTH:HOW COULD THIS BE INCREASED OR ADDED?WHO WILL TAKE THE FIRST STEP? FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Self Reported Physical Health Medical Treatments or Therapy Regimes: Services Needed:SkilledNRFreqD/W/MProvider NameBlood sugar monitoring Bowel/Bladder program Catheter care Dialysis Foot Care Injections IV Therapies Medication monitor Oxygen Occupational therapy Ostomy care Physical therapy regime Range of motion Respiratory treatment Speech therapy regime Suctioning Tube Feeding Ventilator Assistance Wound care/Dressing Other: FORMTEXT       FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   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FORMCHECKBOX  Spouse:  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Friends:  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Family:  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Neighbor:  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Faith Based Name:  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Support Group:  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Agency/ Organization: FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Community Based:  FORMCHECKBOX  FORMCHECKBOX  Psycho/Social Problems: FORMCHECKBOX  Psychological illness presentSignificant Changes FORMCHECKBOX  Psychological illness historyLosses FORMCHECKBOX  Depression FORMCHECKBOX  Death of spouse FORMCHECKBOX  Nervousness FORMCHECKBOX  Death of friend/family member  FORMCHECKBOX  Crying FORMCHECKBOX  Death of pet FORMCHECKBOX  InsomniaChanges FORMCHECKBOX  Nightmares FORMCHECKBOX  Change in residence  FORMCHECKBOX  Divorce/separation  FORMCHECKBOX  Retirement FORMCHECKBOX  Loss of appetite  FORMCHECKBOX  Concerns regarding potential psychosocial situation  FORMCHECKBOX  Poor eye contact  FORMCHECKBOX  Alcohol/Substance AbuseThreat/Victim  FORMCHECKBOX  Financial concern  FORMCHECKBOX  Safety concerns  FORMCHECKBOX  Victim of assault/theft  FORMCHECKBOX  Victim of abuse/neglect LONG TERM CARE PLAN Non-Medicaid Services Available to Address NeedsService ProviderFrequency and DurationAvailability FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Medicaid Services Equipment:HaveNeedEquipment:HaveNeedAdaptive Seating Adaptive Utinsels Assistive Technology Augmentative Communication Device Bath Mat Bath/Shower Chair Bathroom Access Braces Cane Circulation Stockings Cleaning Equipment Cleaning Supplies Commode Crutches Electric Lift Electronic Monitor External Catheter Feeding Pump Feeding Tubes Foley Catheter Gait Belt Grab Bars Hand Held Shower Handrail Hi Riser  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Intermittent Catheter IV Equipment Kitchen Access Lift chair Manual Lift Mechanical Lift Medication Box Medication Dispenser Monitors Orthotics Ostomy Supplies Pivot Board Plate Guard Prostheses Ramp Reacher Roll-In Shower Scooter Sliding Board Sock Aide Standing Frame Transfer Bench Urinal Walker Wheelchair Other: FORMTEXT       FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  N = Needs R = Receiving D/W/M = Daily, Weekly, Monthly Skilled Medicaid ServicesSkilledNRFreqD/W/MProvider NameTask to be completedCNA LPN RN Psych RN Self Family Unpaid Provider Nursing Home PT OT RT ST Ambulance FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Comments: FORMTEXT        Unskilled Medicaid ServicesUnskilledNRFreqD/W/MProvider NameTasks to be completedACF/AFC ADC Counselor EM Family Home Care Provider Home Mod Homemaker ILST Med. Transport. Medication Dispense Non-Med. Transport. PCP Pest Control Self Unpaid Voc. Rehab FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Comments: FORMTEXT        Appendix F: Other States Approaches New Jersey In the cash and counseling program in New Jersey, the consumer develops emergency back up as part of the cash management plan. The consumer determines how many regular workers and backup workers are needed. All care providers listed on the cash management plan are registered with the fiscal intermediary before an emergency occurs. When an emergency occurs, the consumer contacts the designated backup person to provide care. The counseling portion of the program is provided by a consultant/guidance counselor. A consultant/guidance counselor trains the consumer on the program and reviews the cash management plan and emergency backup plan. There is no 24/7 backup in this program. Some counselors do provide their personal cell phone numbers to consumers, although the New Jersey Medicaid office does not encourage this practice. Florida Florida cash and counseling has four levels of emergency backup with costs for emergency backup care set aside in the consumers monthly savings and purchase plan. In level one the consumer designates two emergency backup providers for each critical service in their backup plan. The emergency backup plan identifies specific arrangements necessary to provide critical services and maintain the health and safety of the consumer in the event of a breakdown in the routine plan of care. Level two includes the informal network of friends and family who are contacted in the event the backup providers listed in the purchasing plan are not able to provide backup as planned. Level three includes the enrolled Medicaid providers who are available if backups planned in levels 1 and 2 are not adequate in an emergency. This level of backup involves accessing enrolled Medicaid providers such as home health agencies, nurse registries or other home and community based service providers. Consultants in the Florida cash and counseling program function similarly to those in New Jerseys plan, with the exception that the consultants are considered the consumers first contact for all emergency situations and carry pagers. Level four is activated in the event of an extreme emergency. In level four Adult and Child Protective Services responds if there is a situation of possible abuse, neglect or exploitation. The Division of Emergency Management is activated during natural or manmade disasters. Arkansas Arkansas calls its Cash and Counseling program Independent Choices. Consumers in the Independent Choices program meet with counselors who help develop written plans for care that include a backup plan. Having a backup worker, whether paid or not, is mandatory for enrollment in the program. During the planning process the consumer and counselor identify risks or potential risks as well as a plan to eliminate, reduce or manage them. Program participants may access other waiver or state plan services to address emergency situations. The operating agency for the consumer-directed program administers the wavier program and the Adult Protective Services (APS) Unit, which produces efficient, close communication between the three programs. APS is responsible for maintenance of the incident reporting system for the Division. During enrollment, the participant receives a pamphlet thatdiscusses recognizing and reporting abuse and knowing how and when to report to APS. South Carolina The South Carolina Choice waiver is a pilot program consumers may select to obtain a wide range of consumer directed community-based services. A care advisor trains and works with the consumer to develop an action plan and backup plan. The backup plan is individualized for each consumer and identifies 2-3 people who are available as backup if the regular care provider is unavailable. The training also provides specific information about when to contact APS if a critical incident is suspected or alleged. APS receives critical incident reports and also provides final backup if needed. During the first 6 months after a consumer begins the SC Choice waiver, the care advisor visits monthly. Each care advisor asks if the backup plan was implemented during the month and how effective it was. After 6 months, the care advisor visits quarterly. For day-to-day emergency planning, each consumer in the SC Choice waiver has an individual plan based on needs and generally includes informal supports such as family, friends and neighbors who may or may not receive compensation for emergency backup. No one has chosen to receive agency delivered services for emergency backup, even though hours of service may be purchased from an agency. CMS waived the 24/7 emergency backup requirement in this waiver because of the Care Cost System South Carolina developed to monitor the delivery of services across all of the waiver programs. 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Personal emergency response system (PERS) is an electronic monitoring service also available in the SC Choice waiver. The participants allocation pays for this service. California Each county in California administers an In-Home Supportive Services (IHSS) program. Public authorities (PAs) provide training for attendants and consumers, a registry of home care workers and act as employer of record. Alameda County has a Rapid Response Emergency Service that provides access to home care workers on short-notice and emergency replacement home care workers 24/7. The original program targeted emergency backup and was revised when too few clients called for services and the attendants were waiting to receive calls to work. This service is now available for emergency and planned absences. Workers arrive within 30 minutes of the time requested or within 2 hours, if 2 hours or less notice is given. The number of true emergencies is small.  These expectations were originally laid out in the Independence Plus waiver template, which CMS has incorporated into a draft revised version of the HCBS waiver application template.  Revised Application for a 1915(c) Home and Community-Based Services Waiver: Draft Version 3.0, Centers for Medicare and Medicaid Services, 3/7/05, pg. 55.  Ibid. pg. 74.  Ibid. pg. 91.  Consumer-Directed Health Care: How Well Does It Work? National Council on Disability,  HYPERLINK "http://www.ncd.gov/newsroom/publications/2004/consumerdirected.htm" http://www.ncd.gov/newsroom/publications/2004/consumerdirected.htm 10/26/04.  These expectations were originally laid out in the Independence Plus waiver template, which CMS has incorporated into a draft revised version of the HCBS waiver application template.  It became clear to the author after speaking with the Community Centered Boards, the Division of Developmental Disabilities, the Childrens Waiver Administrator and Child Welfare that addressing the special needs of these groups and the their unique administration of services is beyond the scope of this grant.  CMS Invitation to Apply for Real Choice System Change Grants for Community Living, 5/30/03, p. 36.  10 C.C.R. 2505-10, 8.000 et seq.  10 C.C.R. 2505-10, Section 8.487.14 Provider agencies shall have written policies and procedures regarding emergency procedures.  10 C.C.R. 2505-10, Section 8.489.43C Supervision shall include, but not be limited to, the following activities: C. Informing staff of policies concerning advance directives and emergency procedures.  The TTP phone number is 1-800-283-3221.  CMS Invitation to Apply for Real Choice System Change Grants for Community Living, 5/30/03, p. 36.  10 C.C.R. 2505-10, Section 8.487.15 Provider agencies shall have written policies and procedures regarding the handling and reporting of critical incidents, including accidents, suspicion of abuse, neglect or exploitation, and criminal activity. Provider agencies shall maintain a log of all complaints and critical incidents, which shall include documentation of the resolution of the problem.  10 C.C.R. 2505-10, Section 8.489.40H Investigation of complaints and critical incidents.  The toll free telephone number is (800) 842-8826.  A toll-free number (800-221-3943) is listed on the consumers Medicaid card to report problems or administrative needs to Medicaid customer service. Most of the consumers who called this number with a problem, stated no action had resulted.  Suzanne Crisp, Medstat Senior Research Leader, email 11/19/04.  A Guide to Quality in Consumer Directed Services, Scripps Gerontology Center, August 2004, p. 3.  Consumer-Directed Health Care: How Well Does It Work? Executive Summary, National Council on Disability, 10/26/04.     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F(*X+Y+0000001y22-r-r-r|Jt Jt#J#t c$t= !=t   t ^^t tIGGtI**t It69b9t8D%t@D%@t _Toc102798927 _Toc102798928 _Toc102798929 _Toc102798930 _Toc102798931 _Toc102798932 _Toc102798933 _Toc102798934 _Hlt92095095 _Hlt100374798 _Hlt100374799 _Toc102798935 _Toc102798936 _Toc102798937 _Toc102798938 _Toc102798939 _Toc102798940 _Toc102798941 _Toc102798942 _Toc102798943 _Toc102798944 _Toc102798945 _Toc102798946 _Toc102798947 _Toc102798948 _Toc102798949 _Toc102798950 _Toc102798951 _Hlt98922715 _Hlt101234165 _Toc102798952 _Toc102798953 _Toc102798954 _Toc102798955 _Toc102798956 _Toc102798957 _Toc94601028 _Toc95202997 _Toc95621381 _Toc95789858 _Toc95795346 _Toc95796153 _Toc95796237 _Toc95808326 _Toc98564790 _Toc98566082 _Toc98922353 _Toc98922518 _Toc99160080 _Toc99165220 _Toc99255648 _Toc99440833 _Toc100372363 _Toc100375453 _Toc100378848 _Toc100552275 _Toc100559683 _Toc94601027 _Toc95202996 _Toc95621380 _Toc95789857 _Toc95795345 _Toc95796152 _Toc95796236 _Toc95808325 _Toc98564789 _Toc98566081 _Toc98922352 _Toc98922517 _Toc99160079 _Toc99165219 _Toc99255647 _Toc99440832 _Toc100727152 _Toc100728139 _Toc100727153 _Toc100728140 _Toc100977243 _Toc100983857 _Toc101234071 _Toc101234238 _Toc101335430 _Toc101864780 _Toc101921669 _Toc102188635 _Toc102203544 _Toc102203746 _Toc102208989 _Toc102209207 _Toc102271044 _Toc102798958 _Toc94601029 _Toc95202998 _Toc95621382 _Toc95789859 _Toc95795347 _Toc95796154 _Toc95796238 _Toc95808327 _Toc98564791 _Toc98566083 _Toc98922354 _Toc98922519 _Toc99160081 _Toc99165221 _Toc99255649 _Toc99440834 _Toc100372364 _Toc100375454 _Toc100378849 _Toc100552276 _Toc100559684 _Toc100727154 _Toc100728141 _Toc100977244 _Toc100983858 _Toc101234072 _Toc101234239 _Toc101335431 _Toc101864781 _Toc101921670 _Toc102188636 _Toc102203545 _Toc102203747 _Toc102208990 _Toc102209208 _Toc102271045 _Toc102798959 _Toc102798960 _Toc98922356 _Toc98922521 _Toc99160083 _Toc99165223 _Toc102798961 Appendix_A _Toc102798962 Appendix_B _Toc102798963 Appendix_C _Toc102798964 _Hlt92095402 Appendix_D _Toc102798965 Appendix_E _Toc102798966 _Hlt87156561 _Hlt87156891 _Hlt87156892 _Hlt87156933 _Hlt87156934 _Hlt87156536 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