Day Activity and Health Services Webinar based upon the July 1,
2015 Stakeholder Meeting
Draft Changes to DADS Program Eligibility Requirements and Streamlining of Required
Assessment Documentation
Agenda Welcome and introductions
Purpose of the proposed DADS DAHS program eligibility and assessment criteria changes
Preliminary Draft changes for stakeholder consideration: DADS is seeking input through July 21, 2015.
• Draft Chapter 48 rule changes • Draft Physician’s Orders changes • Draft Health Assessment and Service Plan changes
Q & A Discussion
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State Plan Requirements
Listed within Rehabilitative Services -- Day Activities and Health Services:
• Program services must be provided under the supervision of a licensed nurse
• Services must be prescribed by a physician • An individual must have a need because of a chronic medical
condition • An individual must be able to benefit therapeutically from
Day Activities and Health Services
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State Plan continued
• Potential for receiving therapeutic benefit from Day Activities and Health Services will be established by an assessment of the recipient’s medical needs.
• A recipient of Day Activities and Health Services must establish and maintain a living arrangement in the community.
• Day Activities and Health Services are limited to no more than 10 hours per day and 230 hours per month.
• Facilities must meet any licensing requirement.
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History of DADS Program Policy Development
A Federal audit of the DAHS program in 2010 identified CMS concerns around state-wide consistency in how eligibility determinations were being made.
DADS began an internal workgroup in 2011 to ascertain what process improvements and supporting policy was needed to address the CMS concern. The project of DAHS policy development was ongoing through the end of 2013.
Final changes to policy regarding the eligibility assessment process and documentation for Forms 3049, 3050 and 3055 were published in 2014.
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FY2014 DAHS Services in Texas
27,966
5,447
Number of Individuals
STAR+PLUS
DADS Title XIX 40%;DADS Title XX 60%
16%
84%
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Development of the Current Policy Project
• On September 1, 2014, the beginning of our current fiscal year FY2015, the remaining Medicaid Rural Service Areas (MRSAs) transitioned to STAR+PLUS.
• The DADS program became much smaller in FY2015
• DADS received stakeholder feedback that the eligibility criteria and assessment process for the DADS program is more burdensome than STAR+PLUS processes through managed care.
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Development of the Current Policy Project
• DADS performed an analysis of the current DADS rule requirements as compared to the State Plan language and explored the current enrollment documentation requirements utilized by the various managed care organizations.
• Findings: • The DADS rules for eligibility determination are more
stringent than is required in the State Plan • The eligibility documentation requirements for the DADS
program were not as streamlined as those utilized by the MCOs.
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Current DADS Chapter 48 Program Eligibility Requirements
Individual must meet Medicaid financial eligibility requirements as stated in 40 TAC Chapter 48.
The individual must have a medical diagnosis, a related functional disability, and physician’s orders requiring care, monitoring, or intervention by a licensed vocational nurse or a registered nurse.
Have one or more of the of the following personal care or restorative needs that can be stabilized, maintained, or improve by participation in DAHS: (nine specific interventions and/or needs are listed in the current rule).
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Purpose of Re-visiting DADS Eligibility Policy
More closely align the DADS program with the eligibility requirements as stated within the State Plan:
• Eliminate the DADS requirement that the individual has a medical need requiring care, monitoring, or intervention by a licensed vocational nurse or a registered nurse.
• Eliminate specific rule requirements regarding assessment of the individual’s functional need to allow the facility nurses to utilize clinical judgement regarding and individual’s functional limitations during the Health Assessment process.
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Purpose of Re-visiting DADS Eligibility Policy
More closely align the documentation requirements for assessment and enrollment to the more streamlined requirements utilized by MCOs.
• Combine the doctor’s order, diagnosis of chronic medical condition, and current medication and treatments into one form, with medications and treatments kept on a single page for ease in updating through time.
• Combine the Health Assessment and DAHS Service Plan into one form and delete the need to repeatedly document current medications and treatments.
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Proposed Chapter 48 Rule Changes
• §48.2907 is amended so that DAHS is exempt from the programs which are listed in which DADS uses a “DADS Needs Assessment Questionnaire and Task/Hour Guide” form to determine an individual’s functional need.
• §48.2907 is amended to clarify that DAHS continues to be authorized only if the individual has an unmet need for the program services, which is a requirement for all Community Care for the Aged and Disabled (CCAD) program services.
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Proposed Chapter 48 Rule Changes
• §48.2915 - to be eligible for day activity and health services (DAHS), an applicant or client must: (1) be Medicaid eligible; (2) have an unmet need as determined by DADS; (3) While receiving DAHS, not receive a mutually
exclusive service; and (4) have a chronic medical diagnosis and a
physician’s order for DAHS on the DADS DAHS Physician’s Orders form.
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Proposed Chapter 48 Rule Changes
• §48.2915 - to be eligible for day activity and health services (DAHS), an applicant or client must:
(5) have one or more functional limitations and the potential for receiving therapeutic benefit from DAHS as determined by DADS review of the Day Activity and Health Assessment/Individual Service Plan form.
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Proposed Changes for Physician’s Orders
The physician will provide:
• Prescription for the DAHS service; • Verification of the individual’s diagnosis to
establish the presence of a chronic medical condition; and
• Validate functional limitations, dietary orders, medications and treatments for purposes of the health assessment.
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Proposed Changes for Physician’s Orders
Individual Name (Last, First, Middle) D.O.B (month/day/year) Individual No.
DAHS Facility Name DAHS Nurse DAHS Area Code and Telephone No.
DAHS Facility Address
Section I. Individual Information
Section II. List Chronic Medical Diagnoses From The Last 24 Months
Section III. Functional Limitations Related To Medical Diagnoses
Behavior/Emotional Problems Falls Easily Cognitive Impairment Contractures Dizziness Difficulty Swallowing Limited Range of Motion Incontinence Hearing Impairment Limited Dexterity Uses Ambulation Device Spasticity Nausea Hearing Impairment Paralysis Pain Shortness of Breath Tremors Numbness Blackouts Vision Impairment Unable to Stand for Long General Weakness Other: ______________________________________________
Section IV. Special Diet: Instruction/Notes/Comments:____________________________________________________________________________________
Proposed Changes for Physician’s Orders
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Medications taken at the DAHS Facility
Medication Dosage Route Frequency Instructions Initial and Date
Section V. Medications and Treatments
Medications taken at home
Medication Dosage Route Frequency Instructions Initial and Date
Medications taken at home Medication Dosage Route Frequency Instructions Initial and Date
Proposed Changes for Physician’s Orders
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I certify this individual has a chronic medical diagnosis other than an intellectual and developmental disability or mental health condition and a functional limitation and hereby order the above care, monitoring or intervention by a licensed nurse to be performed at the DAHS facility.
I also certify that I am not a significant owner, partner or member of the service provider requesting this order for DAHS.
Signature – Physician Today's Date Date of Verbal Order (if app.) End Date (if order is time limited)
Physician’s Name (please type or print) MD DO
License No./NPI State Military or VA
Yes No
Physician's Address (Street, City, State, ZIP code) Area Code and Telephone No.
Section VI. Physician's Certification
Proposed Changes for Physician’s Orders
• Telephone orders received for new or discontinued medications/treatments to be given at the DAHS program are documented in accordance with licensure rules in providers form utilized for recording that information.
• As the individual’s medications and treatments change, only section V of the Physician’s Orders form will need to be updated, and the updated information is used to inform any needed changes to the Health Assessment/Service Plan.
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Proposed Change for Health Assessment/Service Plan
The DAHS Facility Nurse will conduct the Health Assessment. The “Assessment of Functional/Physical Status” section of the health assessment will identify the individual’s functional need(s).
The DADS nurse will review the Physician’s Orders and the Health Assessment to determine the individual’s potential for receiving therapeutic benefit from DAHS.
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Proposed Change for Health Assessment/Service Plan
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1. Individual Name - Last First M.I 2. Current Date of Eligibility
3. Medicaid No. 4. D.O.B (month/day/year)
5. Sex
Male Female
6. Lives Alone
Yes No
7. Reason for Assessment
Initial Change Ongoing
8. DAHS Facility Name 9. DAHS Nurse 10. DAHS Telephone No.
11. DAHS Facility Address
Section I – Identification and Background Information
Section II - Assessment of Functional/Physical Status (Indicate Problems/Conditions/Symptoms experienced within the last 30 days. Check all that are present. Enter a comment as needed for boxes checked (i.e., frequency, location, etc.). Additional space for comments is available at the end of Section II.
A. Alteration in Nutrition/Metabolism B. Alteration in Elimination C. Alteration in Cardiac/Respiratory Status D. Alteration in Skin E. Alteration/Deficit in Body Control F. Alteration in Neurological Status G. Altered Sensory/Perceptual Awareness H. Communication Deficits I. Behavior Challenges
J. Vital Signs/Height/Weight/Blood Sugar
Proposed Change for Health Assessment/Service Plan
Section III – Therapies and Treatments Section IV – Plan of Care: Personal Care at the DAHS Facility
A. Transfer B. Ambulation C. Eating D. Toileting E. Bathing F. Dressing and Grooming G. Assistance with Self Administered Medication
Section V – Participation in Assessment
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Proposed Change for Health Assessment/Service Plan
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I certify this individual has a chronic medical condition and will benefit therapeutically from DAHS service. I certify that the medical diagnosis listed on the DAHS Physician’s Orders substantiate medical need.
Signature – Nurse Completing Form Date Assessment Completed
Printed Name – Nurse Completing Form Area Code and Telephone Number
Proposed Change for Health Assessment/Service Plan
• The DAHS Facility Nurse will develop the DAHS Service Plan.
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Questions & Answers
• Stakeholder question and feedback can be
submitted through the DAHS email box: [email protected]
Stakeholder questions regarding DAHS in the STAR+PLUS program can be submitted to: [email protected]
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Online Resources
For more information, please visit: • Provider Resources page
http://www.dads.state.tx.us/providers/ADC/index.cfm • DADS Policy mailbox
[email protected] • DAHS Provider Manual
http://www.dads.state.tx.us/handbooks/dahs/
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Thank you!
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DAHS Stakeholder Meeting
