Appendix G: Self-Direction Appendix

Registered nurse, licensed to practice in the State

0

Licensed practical or vocational nurse, acting within the scope of practice under State law

0

Licensed physician (M.D. or D.O)

X

Case Manager. Specify qualifications:

For nursing facility waivers: The DADS case manager must have:

• Knowledge of special problems of long term care service clients;
• Knowledge of interviewing techniques to obtain personal information, make inquiries, and resolve conflicting statements;
• Ability to listen to clients, exploring and reflecting feelings, and present relevant alternatives describing the feasibility and consequences of choices;
• Ability to appraise living conditions including physical and emotional environments;
• Professional experience working in social services;
• Computer experience; and
• Education which demonstrates possession of knowledge, skills, and abilities related to working with the elderly and individuals of all ages with physical disabilities.

For ICF/MR waivers: Case Managers/Service coordinators have the following requirements:

• Licensed social worker; or
• A Bachelor’s degree in a health and human services related field plus two year of experience in the delivery of human services to persons with disabilities; or
• An Associates degree in a health and human services related field plus four years of experience in the delivery of human services to persons with disabilities; or
• (only for DBMD) A High School degree with eight years of experience in the delivery of services to persons who are deaf blind with disabilities, and fluency in all communication systems used by their clients; and
• (only for DBMD) Be fluent in the communication system used by their clients.

For HCS and Texas Home Living:

• Have a bachelor’s degree with major specialization in social, behavioral or human services or related fields; or
• Have a high school diploma or Certificate of High School Equivalency (GED credentials) with related volunteer experience comparable to two years full-time work in social, behavioral, or human services or related fields; or
• Have a high school diploma or Certificate of High School Equivalency (GED credentials) with a minimum of two years full-time work experience in social, behavioral, human services or related work; or
• Be licensed in the State of Texas as a Registered Nurse or Licensed Vocational Nurse with one year of experience in human services.

For CLASS: Case Managers must be licensed by the Texas State Board of Social Work Examiners at the time of employment or no later than nine months after employment as a Licensed Master Social Worker or a Licensed Baccalaureate Social Worker; or the case manager must have the formal educational equivalent of a bachelor’s degree in a health and human services field plus two years of experience in the delivery of human services to persons with disabilities.

0

Social Worker. Specify qualifications:

0

Other (specify the individuals and their qualifications):

Entities and/or individuals that have responsibility for service plan development may not provide other services to the participant.

0

Entities and/or individuals that have responsibility for service plan development may provide other direct services to the participant. The State has established the following safeguards to ensure that service plan development is conducted in the best interests of the participant. Specify:

The IDT supports the applicant or participant in setting goals that address the needs identified during assessment and educates the applicant or participant about all service options available. The applicant or participant and the IDT then work together to develop a Plan of Care that addresses the applicant or participant’s goals and identifies providers, caregivers, and other third party resources that will contribute to goal achievement.

The applicant or participant participates in the IDT, and may choose to include other appropriate individuals. The applicant or participant and other IDT members, including any designated representative, sign the Plan of Care before implementation.

For Nursing Facility Waivers:

(a) The applicant/participant, the case manager/service coordinator, and individuals chosen by the applicant/participant, develop the Individual Plan of Care (IPC). A re-evaluation is conducted annually and an IPC is developed for services for the next year. The participant, DR, LAR, or provider on behalf of the participant can request changes in the IPC. The case manger/service coordinator discusses the requested IPC changes with the participant/participant representative and approves or denies the changes.

(b) The medical assessment form is utilized in developing the IPC.

The case manager/service coordinator works with the applicant and representative to set goals to address caregiver relief, health care, social, and other support needs identified for and by the applicant during the initial assessment. They develop a plan to achieve each goal, including those goals requiring non-waiver/non/Medicaid State Plan services that are otherwise important to the applicant/participant’s health and well being. The IPC must reflect the most integrated setting possible and desired by the applicant.

(c) The case manager/service coordinator must educate the applicant/participant and representative about all waiver and Medicaid State Plan services as part of the IPC development.

(d) The IPC or service plan must reflect the goals desired by the applicant/participant. The applicant/participant or representative must sign the plan to indicate understanding of the IPC. If the applicant/participant does not agree with the IPC, the applicant/participant or representative may file an appeal.

(f) The IPC shall include services (e.g., units, frequency, etc), and the roles of the applicant/participant, case manager, providers, family, and informal caregivers in achieving the goals and meeting the applicant/ participant’s needs, including health care needs. The case manager is responsible for monitoring and overseeing the implementation of the IPC. Monitoring and implementing the IPC requires that the case manager maintain contact with the participant and their representative to ensure appropriate service delivery.

(g) The IPC can be updated at the request of the participant, the representative or the provider when the participant’s condition changes.

For ICF-MR Waivers and Medicaid State Plan Services, generally the process is similar. The service coordinator initiates, coordinates and facilitates the planning process to assure that an individual’s service plan addresses the desires and need as identified by an individual and the DR or LAR. The initial service plan must be developed with 45 days of the date the applicant, DR or LAR chooses the waiver/Medicaid State Plan service and self-direction. The service plan must be reevaluated at least annually and can be changed before that. The participant may include others, such as family, friends or service providers for his or her service planning team.

During the service planning process, the case manager/service coordinator, with support from appropriate professionals, uses assessment information along with the applicant’s/participant’s/representative’s input to determine any risks that might exist to health and safety as a result of living in the community. The development of back-up plans is an integral part of the service planning process. Key backup planning activities include use of informal supports, third party resources, and other community resources identified by the participant. The case manager incorporates back-up plans into the IPC or service plan.

The DADS website provides service coordinators/case managers and other service planning team members, access to a “Person-directed Plan Discovery Tool,” which assists in considering a variety of risks such as risks related to health factors; abuse, neglect, or exploitation; and safety risks.

For the nursing facility waivers, the case manger/service coordinator provides a list of service providers at the initial home visit and during the IPC/service planning process. The list includes the providers available in the area and is maintained by local DADS staff. Participants indicate that they were given choice on the Service planning form.

For the ICF/MR waivers the service coordinator provides a current list of service providers once the individual has indicated a choice of waiver services over ICF/MR services. The list includes the name of providers contracted to serve the local service area, name of a local contact person for the provider and numbers of people served by the provider sorted by county.

DADS has also posted on its website an “interview tool” that individuals and the families may tailor for their own use during the process of provider selection.

Participants indicate that they were given a choice of providers on the “Documentation of Provider Choice” form.

HHSC Medicaid LTSS staff has discretion to participate with DADS in on-site visits to provider agencies and will participate in at least one review per waiver per year. HHSC staff reviews multiple plans of care and verify compliance of the MOU between HHSC and DADS which is the operating agency.

During the waiver development and waiver renewal processes, HHSC reviews and approves/disapproves standards and practices related to the development of plans of care. HHSC approves/disapproves:

• the method for determining individual cost ceilings which provide a limit on the amount of services available in the plan (Form 3652 TILE determination);
• the method for assessing the need for specific services based on consumer need and level of functioning (Form 2060 Assessment);
• requirements for consumer and other participation in the development of the plan of care; and
• requirements related to the annual and as needed re-evaluations of the plan of care.

Additionally, through automation, 100 percent of plans of care are assessed for cost-effectiveness through electronic edits in the Service Authorization System. Authority to approve assessment-based plans of care is delegated to the operating agency case managers.

Additionally, while on-site, HHSC staff review 100 percent of the samples that DADS pulls and monitors the process used by the operating agency to collect and aggregate annual waiver performance information reported to HHSC annually as provided for in 2.2.2 Individual Service Plan, Assurance 1, Indicator 1 of the Evidentiary Information as it relates to plan of care requirements.

DADS’ staff reviews each plan of care to verify that medical necessity determination has been met and that the cost of the plan of care is within range for the individual’s cost ceiling.