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1 SA/IH Case Management: An In-Depth Look Presented By NC Division of Aging and Adult Services Adult Services Section Adult Programs Representatives Slide 2 2 Objectives for This Workshop Understand the SA/IH Case management process Understand the importance of good communication between Eligibility and Services Review the Adult Services Functional Assessment Review the SA/IH Economic Assessment Worksheet Create a Service plan Complete a Transmittal Slide 3 3 Objectives for This Workshop Review budgeting and uses of the SA/IH payment Discuss reassessments/continued need for SA/IH and services What to do when the client is no longer eligible for SA/IH Notices and Hearings Discuss Wait Lists Review SA/IH Payment Tracking Tool Slide 4 4 What is the SA In Home Program? The State/County Special Assistance In-Home Program for Adults (SA/IH) provides a cash supplement to help low-income individuals, who are at risk of entering an Adult Care Home, to remain at home safely The payments are intended to help maintain the individuals health and safety while remaining in the community Slide 5 5 History September 2000 Demonstration project with 400 slots 22 participating DSSs In 2003 The General Assembly approved 800 slots total through June 2005 61 participating DSSs 2005 1000 slots were authorized Payment amount increased from 50% to 75% of payment for ACH Slide 6 6 History Legislation in 2007: Established SA/IH as a permanent program under General Statutes Allowed the caseload to expand up to 15% of the total statewide SA caseload 108A- 47.1. 108A- 47.1. DSSs continue to participate voluntarily Ninety-one counties had slots assigned Slide 7 7 History 2012 Legislation SL 2012-142 The monthly payment to individuals enrolled in the SA/IH program was increased to 100% of the monthly payment an individual would receive if they resided in an ACH. SA/IH Program requires all DSSs to participate Participating DSS must maintain at a minimum, average number of cases from SFY 2011-2012. slotsDSS with assigned slots and no active cases must begin participating effective February 15, 2013, by filling all their assigned slots Slide 8 8 History 2012 Legislation SL 2012-142 A DSS with no established slots must begin participating, effective February 15, 2013. DAAS has recommended the slot numbers for these counties. Allows the Department of Health and Human Services to waive the 15% cap on slots on or after February 15, 2013 Changes are implemented within the current authorized budget for 2012-2013 (same as 2011- 2012) Slide 9 9 Developing the SA/IH Program Outreach Educate Community Partners Expand the program - If all of a countys allotted slots are filled, and the county has decided not to request additional slots, this should be discussed with the Adult Programs Representative prior to initiating a waiting list Slide 10 10 US Department of Justice (DOJ) Compliant The complaint cited an institutional bias where People who enter an ACH or other type of facility can obtain certain financial assistance, services, and supports that are not equally available to people with similar levels of disability and financial need who choose to remain in their own homes. The States failure to redirect resources and its failure to prioritize community-based setting over institutional care has confined thousands of people with mental illness unnecessarily and indefinitely in adult care homes and puts many others at risk of unnecessary institutionalization. Slide 11 11 US DOJ Specifically regarding Special Assistance Instead of allocating resources to community- based settings, the State has opted to fund a substantial portion of the cost of providing care in adult care homes. Through its State-County Special Assistance Program, NC subsidizes the cost for individuals with disabilities to live in adult care homes...Aside from limited circumstances, the State has not made this supplement available to person[s] with disabilities living in the community. Slide 12 12 Transitions to Community Living Initiative (formerly US DOJ) The US DOJ Settlement Agreement between NC and the US DOJ is now referred to as the Transitions to Community Living Initiative Eligible individuals will receive Supported Housing Slots which provide rental subsidies for community-based supported housing and transition and tenancy support The SA-IH Program has been identified as a valuable resource for these individuals if they are determined to be eligible for the program Slide 13 13 Transitions to Community Living Initiative (formally DOJ), cont A DAAS staff member will notify the DSS Adult Services Supervisor in the county of SA/Medicaid eligibility and in the county which the individual is interested in moving to verify that a Supported Housing Slot has been assigned by DHHS DSS is responsible for SA eligibility determination and assignment of the SA/IH slot number Slide 14 14 Transitions to Community Living Initiative (formally DOJ), cont These individuals cannot be placed on the SA-IH waiting list If these individuals apply and are determined eligible for SA/IH, the LME is responsible for the ongoing case management Refer to DAAS Administrative Letter 13-07 Slide 15 15 Open Lines of Communication Are KEY to a successful SA/In-Home Program Slide 16 16 Communication between Eligibility and Services must include: Determination that the client meets all eligibility criteria Determination that the clients needs can be met safely at home after completing the functional assessment Amount of the SA/IH payment Redeterminations and changes in situation Status of SA/IH slot availability Slide 17 17 Communication, continued. Status of the waiting list Income Maintenance Caseworker (IMC) will communicate the maximum SA/IH payment Case Manager will communicate the SA/IH payment authorized based on the needs of the client The SA/IH Program Interagency Transmittal form will be used by social workers as the communication tool Slide 18 18 Tools to guide the Case Manager through the process SA/IH Flow Chartoutlines the referral process SA/IH Case Managers Checklistexcellent tool for organization and to assure critical time limits are met Slide 19 19 Slide 20 20 Referral and Screening Referrals may come either through Eligibility or Services. One should communicate to the other that a referral has been received If the IMC determines a client is potentially eligible, communicate with the case manager so the Adult Services Functional Assessment can begin Complete the SA/IH Pre-Screening Form Slide 21 21 Referral and Screening Referral to the case manager must include the Slot authorization number and EIS ID number A staff member must be designated to maintain and distribute slot authorization numbers (can be eligibility or services) The designated staff member must communicate the ongoing status of available slots to both services and IMC staff Slide 22 22 Referral and Screening Case manager initiates the Adult Services Functional Assessment within 10 workdays of the referral from the IMC IMC continues to process SA application Slide 23 23 SA/IH Eligibility Criteria Client is at least 18 years old. Client is eligible for Medicaid as a categorically needy aged, blind, or disabled individual Needs ACH level of care and lives in, or desires to live in a private living arrangement Requests SA/IH payments and services at home in order to remain there safely With appropriate services and the SA/IH payment he/she can have his/her health, safety and well-being maintained at home Slide 24 24 Eligibility Process IMC determines SA benefits eligibility and communicates that decision to the case manager Case manager determines the need for the program using the Adult Services Functional Assessment and the SA/IH Economic Assessment Worksheet Final determination of the payment is made by the case manager and communicated to the IMC All communication between the SA IMC & the adult services case manager should be documented on the SA/IH Program Interagency Transmittal Form Slide 25 25 SA In-Home and SA Program Eligibility Comparisons Slide 26 26 SA In-Home & SA Program Eligibility and Budgeting Comparisons Slide 27 27 Eligibility for Other Benefits SA-5400 SA/IH is a non-countable benefit for the following programs: Supplemental Security Income (SSI) Medicaid Subsidized housing (HUD Section 8) and other federal housing programs Slide 28 28 Eligibility for Other Benefits SA/IH is a countable benefit for the following programs: Food Stamps LIEAP Slide 29 29 Case Managers Role Advocate For the clients For the Program Gatekeeper Communicate Educate Prioritize Slide 30 30 IMC Role Source of referrals for potential recipients Determination of SA/IH financial eligibility Communicate approvals/denials/changes/ redetermination of eligibility to the Adult Services case manager Communicate changes in payment to the client Slide 31 31 How Do Counties Pay for the Case Management Related to SA/IH? Social Services Block Grant Some activities related to medical and mental health services may be reimbursed using Medicaid Administrative Claiming Slide 32 32 Case Management Process Assessing Service Planning Monitoring/follow up Ongoing contacts Reassessing (quarterly, annually) Slide 33 33 Assessment Must begin within 10 workdays of SA/IH IMC referral 30 days to complete assessment Adult Services Functional Assessment (DAAS- 6220) is used Must include the Economic Assessment Worksheet to determine financial need and SA/IH payment Slide 34 34 Assessment Needs to indicate how the client meets the target population and is eligible for the service The assessment and economic worksheet will identify needs that will be included in the service plan Slide 35 35 What is the purpose of the Economic Worksheet? Identifies sources of income Indicates how income is being used Reveals a surplus or deficit Helps identify unmet needs Slide 36 36 Completing the Economic Assessment The SA/IH payment benefit is to be used for those health, safety, and basic needs that will allow an individual to remain safely in their home as opposed to residing in a residential care facility Slide 37 37 Calculating the Budget Observe the following principles: Explore regular monthly expenses & expenditures Do not arbitrarily divide monthly household bills by the number of adults living in the household Explore unusual expenses reported by the client Example: a client reports $150.00 allowance for clothing. Consider if this is a one-time need Note: As of 7/1/15 FNS benefits cannot be counted as income or a resource Slide 38 38 Calculating the Budget, cont Remember the client is entitled to a personal needs allowance of $66.00 to purchase items outside of basic needs, i.e. cigarettes, cable, pet food (if it is a therapeutic animal, that can be calculated as part of a need) etc. If the expenses reported by the client exceed his/her income when combined with the maximum allowable SA/IH payment, the client may not be able to remain safely at home Reasonable expenses should be viewed in terms of the clients particular circumstances Slide 39 39 Uses of the SA/IH Payment The SA/IH Payment should be used to help the individual remain in the community by focusing on the following: Health/Medical Safety Basic Needs Slide 40 40 Uses of the SA/IH Payment (Medical/Health) Payments for health needs include items that are not covered by Medicaid or other health insurance or funding source but are recommended by the health care provider(s). These are services or items that the client needs to maintain or improve his/her health and mental health functioning Slide 41 41 Uses of the SA/IH Payment (Medical/Health) Medications including OTC recommended by the physician Co-payments for prescriptions & physician visits Nutritional Supplements Incontinence supplies Durable medical equipment Additional PCS hours and/or IHAS Slide 42 42 Uses of the SA/IH Payment Transportation to medical appointments Mental Health Treatment and Services Dental and Eye Care Adult Day Services Slide 43 43 Uses of the SA/IH Payment (Safety) Safety needs are related to those items and services that will enable the client to be safe in his/her environment. Please note that the client does not have to own his/her home for these items or services to be purchased. Please check the rental agreement to see what the landlord is legally responsible for providing. The client should also obtain permission for any adaptations for items not covered by the lease. Slide 44 44 Uses of the SA/IH Payment (Safety) Safety items may include the following: Home Repairs or modifications necessary to maintain safety Essential technology for communications (lifeline, telephone systems) Smoke Detectors Extermination Services for rodents and insects Home alarms Slide 45 45 Uses of the SA/IH Payment (Safety) Annual inspections related to air and heating or other safety inspections Cleaning services Repair or replace damaged appliances Environmental factors related to safety i.e. scatter rugs, outlets Slide 46 46 Uses of the SA/IH Payment (Basic Needs) Basic needs are those items or services that help ensure the overall well-being of the client is maintained Slide 47 47 Uses of the SA/IH Payment (Basic Needs) Rental or mortgage payments Essential furnishing Appliances Utilities Food Essential clothing Slide 48 48 Uses of the SAIH Payment (Basic Needs, cont.) Cleaning supplies Personal care items Property Taxes Pre-Need burial Slide 49 49 Priority of SA/IH Payment Ensuring that the Health and Safety needs of the client are met is the first priority of the SA/IH payment The SW should always try to link the client to community resources that the adult is eligible to receive but may not be knowledgeable about (Medicaid transportation, volunteer services, discounted telephone services, HUD etc.) The SA/IH payment is not intended to replace or duplicate services and resources already available to the client Slide 50 50 Things to Consider What are the health/safety issues that are not currently being addressed? How will the SA/IH payment be used to help address these concerns/issues? Are there services that the client is eligible for but they have not been linked to? How were needs being met prior to the SA/IH payment? Slide 51 51 Slide 52 Slide 53 Slide 54 Slide 55 55 Slide 56 56 Completion of the Assessment Process SW and client identify priorities from the Functional Assessment and the Economic Assessment Worksheet SW and client develop a service plan together Slide 57 57 Service Plan (DSS-6221) The service plan should identify problems/needs from the assessment Goals should be developed to address identified needs List activities necessary to meet the goals Identify persons responsible for carrying out goals/activities Plan must include specific target dates Slide 58 58 Slide 59 59 Service Plan Must include case management services provided Must include the amount of the payment and how the payment is being used Must be signed by the CM, client or their representative within 7 days after authorization of SA/IH payment by CM Needs to be reviewed at least quarterly Must be revised and updated as the clients needs change New service plan must be completed at least annually or as needed and signed by the client and CM Slide 60 60 Goal Planning GOALS SHOULD BE GOALS SHOULD BE SMART Specific Specific Measurable Measurable Achievable Achievable Realistic Realistic Time limited Time limited Slide 61 Slide 62 62 Case Management Activities Regularly review the service plan with the client Communicate to the client how the SA/IH payment is to be used Monitor to assure that the SA/IH payment is being used appropriately For large projects or items encourage client/family to obtain estimates Link client to available services in the community Slide 63 63 Case Management Activities Help the client establish payment plans, if needed Regularly discuss with the client progress in meeting goals Continue to assess and document how the SA/IH program is helping the client remain safely at home Ask for receipts, when necessary, if there is concern regarding how the money is being spent Slide 64 64 Case Management Activities Monitor to assure that all service needs are being met, not just financial needs Monitor to assure that the services and payment that are put in place are adequate in meeting the clients health, safety and basic needs Slide 65 65 Case Management Activities Follow up with all persons identified in the service plan to assure that clients needs are being met Document and address any concerns related to service delivery Document how you, as the case manager, and the client will address the concerns/issues related to clients resistance or non-compliance with the service plan Slide 66 66 How has SA/IH helped people remain in the community? A 62 year old woman with a diagnosis of formal thought disorder; diabetes, COPD, osteoarthritis and with limited ability to make decisions She lives in a rent-subsidized apartment She has some support from sister Receives Medicaid PCS during week SA/IH pays privately for weekend help provided by same aide who assists during the week Also pays for monthly Lifeline service and household furnishings Slide 67 67 How has SA/IH helped people remain in the community? This gentleman is 58 years old and has mild mental retardation and traumatic brain injury He came to the attention of the Program as an APS report. His previous rep. payees were exploiting him. He did not have heat or food and was living in substandard housing. He was determined to be eligible for the SA/IH Program The SA/IH funds helped to pay moving expenses into an improved trailer, helped pay to demolish/haul off the old trailer and assisted with providing furniture and appliances for the new trailer Slide 68 68 Case Continued With the help of SA/IH, he was able to pay back property tax bills and install a telephone for safety reasons. He also needed clothes and household items that SA/IH funds have helped him afford He now lives in safe and adequate housing This is a successful example of a person who benefited from SA/IH funds and was able to maintain an independent living status as a result of the SA/IH program Slide 69 69 Ongoing Case Management Monitoring Monthly contacts At least monthly, contact the client, appropriate family members and service providers to review the provision of payments and services Quarterly Reviews - Must be done in person to review the provision of service and utilization of the payment Annual Reassessment must also be done in person. Slide 70 70 Annual Reassessment Process Complete the Adult Services Annual Assessment (DAAS-6224) and Economic Worksheet IMC will inform the client of what is needed for eligibility redetermination FL-2 form which reflects domiciliary level of care must be current (within 90 days) Social Worker should be prepared to assist the client to obtain necessary information Slide 71 71 Annual Reassessment Process Advise IMC of continued eligibility decision on the Interagency Transmittal Form IMC should send any required notices to the client as appropriate or needed Social Worker should complete a new service plan before the anniversary date Slide 72 72 Changes in Situation Changes in Situation After a hospital or Nursing Home stay, the recipients needs may have changed - make sure that the FL-2 is still appropriate for SA/IH If not, SA/IH must be terminated If still appropriate, make any changes to the assessment and service plan as needed SA/IH must be terminated when an absence is over 30 days Slide 73 73 Changes in Situations The Case Manager and IMC must communicate with each other if it is determined that the client has been incarcerated If it is determined that the client has been incarcerated, the termination process for SA/IH payments should begin (SA-3310, III.B.5) Slide 74 74 Denials and Terminations Financially ineligible/not eligible for Medicaid No Need for SA/IH Payment or Services Failure to meet programmatic qualifications: Death Absence of over 30 days Move out of county or state Client voluntarily withdraws Clients safety, health and well-being cannot be maintained at home Incarceration Slide 75 75 Waiting Lists for SA/IH When all SA/IH slots are filled and the county has decided not to request additional slots, a client has the option of making an application (which will be denied) or have their name placed on a waiting list (inquiry list is not an option for SA/IH) In either case, refer client for other services The exception is Transitions to Community Living Initiative clients - TCLI clients cannot be placed on a waiting list (If all slots are filled a county must request a slot) Slide 76 76 Waiting Lists for SA/IH Each county DSS must designate a staff person to be responsible for maintaining the waiting list. The purpose of the waiting list is to make the SA/IH slots available on a first come, first serve basis Waiting list policy requires that the individuals placed on a waiting list be contacted at least every 90 days regarding their status. If no slots are available they must be given the option to remain on the list or be removed Slide 77 77 Waiting Lists for SA/IH, cont. Be sure the individual understands that this contact does not constitute an application, and that they or their representative must make an application Document on the waiting list if an applicant on the waiting list chooses not to wait for a slot and/or enters an ACH Slide 78 78 Establishing a Waiting List Counties that wish to increase their current number of slots should request additional slots prior to filling all assigned slots in order to avoid having to use a waiting list If it is decided that a waiting list is appropriate, individuals may request to be placed on a waiting list. Appendix C in the SA/IH Case Management 5600 Manual is the waiting list form for SA/IH and instructions for completing the waiting list form. Use of this SA/IH Waiting List form will ensure that consistent information is obtained Slide 79 79 Maintaining the Waiting List Please use and maintain this waiting list in accordance with the Requirements for Provision of Services Manual, Section VI Prompt Provision of Services Slide 80 80 Required SA/IH Reporting Reports are now completed via a web-based SA/IH Payment Tracking Tool Reports are now completed via a web-based SA/IH Payment Tracking Tool Case managers are required to complete the tool monthly Case managers are required to complete the tool monthly Completion of the tool is required by the 5 th day following the payment month Completion of the tool is required by the 5 th day following the payment month SA/IH Payment Tracking Tool Site: httphttps://saihpay.dhhs.state.nc.us Slide 81 SAIH Tracking Tool Client List 81 Slide 82 82 SA/IH Payment Tracking Tool The Payment Tracking Tool provides categories under which to report to DAAS how the SA/IH payment is spent This web-based tool allows your agency to document and gather information about uses and amounts of the SA/IH payment and to generate statistical reports based on the data entered Slide 83 SAIH Tracking Tool Expense Services 83 Slide 84 Client Expense Service Detail Report 84 Slide 85 85 Programmatic Monitoring for SA/IH SA/IH monitoring will follow the 4-year monitoring cycle that is currently in place The SA/IH Monitoring tools will be used in conjunction with other current monitoring tools Scoring on the tools is by element just like on the SSBG Tool A score of 70% or lower will require a Corrective Action Plan to be developed A final monitoring report will be sent to each county once monitoring is completed Slide 86 86 Monitoring Sample-SA/IH Program For a Level I County, 5 cases For a Level II County, 7 cases For a Level III County, 10 cases Cases identified for this sample may also be cases identified in other programmatic monitoring samples. If so, multiple monitoring tools will be used on the same case A list of Sample Cases will be sent to the agency 10 work days prior to the monitoring visit Slide 87 87 APR Listserv - DAAS Dear County Director Letter AFS 09-2012 The APRs now have a listserv for questions: DAAS.AdultServices@dhhs.nc.gov DAAS.AdultServices@dhhs.nc.gov Expect a response within 2 business days for questions that are not time-sensitive Time-sensitive questions, such as APS, or requests for technical assistance will be handled accordingly Slide 88 88 Questions???? Slide 89 89 Thanks for coming!!