Reserved Capacity 2013 Update PD Part-2 073013 2€¦ · Renewal of the Intellectual Disabilities...

Welcome to Part 2 of the training on Reserved Capacity.

Course Number 009-05-02 1

Reserved Capacity 2013 Update - Part 2

This webcast includes spoken narration.

To adjust the volume, use the controls at the bottom of the screen. While viewing this webcast, there is a pause and reverse button that can be used throughout the presentation.

The written version of the narration appears to the right of the screen.



Certificates of Achievement will be available to Administrative Entity and Provider staff as well as Supports Coordinators and SC Supervisors after completing all course requirements.

Please view and then save or print your certificate in order to receive credit for this course.

For SCs and SC Supervisors, course requirements include successful completion of a pre‐test and post‐test.



Hello. My name is Patty McCool. I am the Director of the Bureau of Supports for People with Intellectual Disabilities for the Office of Developmental Programs. I will be introducing this webcast and setting the stage for this training on ODP’s Reserved Capacity process.



If you have not yet reviewed Part 1 of this webcast, I encourage you to view it first as it provided definitions and information that will help provide context for this webcast.

As we begin Part 2, I want to review the concept of Reserved Capacity. To state it simply: Reserved Capacity is the Office of Developmental Programs’ method to provide continuity when people receiving Waiver services are admitted to a hospital or rehabilitation care–and while in the setting, the Waiver services they had been receiving have not been delivered for 30 days.

Because this process seeks to provide continuity through cooperative efforts of the team –and because it increases the likelihood that people will get the supports they need when they need them ‐ it demonstrates the commitment of the Office of Developmental Programs’ (ODP) to the Everyday Lives Principles of stability, collaboration, and accountability.

Although ODP, Administrative Entities, Supports Coordinators and providers have collaborated to provide continuity and stability for individuals receiving Waiver services for many years, Reserved Capacity defines responsibilities in a more specific way. In this sense, the expectation to provide continuity is not new, but is defined in more detail in the Renewal of the Intellectual Disabilities Waivers effective July 1, 2012. This webcast is part of ODP’s effort to communicate clarifications and changes resulting from the Renewal of the Waivers.



The information in this presentation is primarily written to shed light on the role of Supports Coordinators within Reserved Capacity. However, we’ll also be talking about how responsibilities of Administrative Entity staff fit with what Supports Coordinators do when an individual’s Waiver Capacity is reserved – the information in this webcast coordinates with Administrative Entity responsibilities outlined by the Office of Developmental Programs. Providers watching this webcast will gain insight into how Reserved Capacity affects individuals they support and the services they provide.

Most importantly – individuals who find themselves in the challenging circumstances of needing longer‐term hospital or rehabilitation care and families will be better‐informed on the protections Reserved Capacity provides.



In the first webcast, Reserved Capacity – Part 1, I spoke directly to individuals, family members, relatives, and others whose loved ones receive Waiver services and supports.

This second webcast outlines detailed steps for Administrative Entity staff, Supports Coordinators, and other professionals in regard to timelines and actions of the team that are necessary to complete responsibilities for Reserved Capacity correctly and on time.

As you watch Part 2, keep in mind that Reserved Capacity is designed to offer protection to you during an extended period of time away from home in a hospital or rehabilitation setting. We recognize that this can be an extremely stressful time. Anyone in this situation thinks about who will help after returning home. Reserved Capacity – because it “holds a spot” in the Waiver for a certain period of time until a person can return home ‐ can help to ease that worry. Reserved Capacity provides protections until the person is well enough to go home and return to living the life he or she wants with the support needed.

I encourage you to talk with your Supports Coordinator if you have questions about the information in either of these webcasts.

I will now turn this presentation over to Robin Levine from ODP Consulting System and she will guide you through the rest of this presentation.



Thanks Patty!

In the first webcast we set the stage and defined terms and parameters for Reserved Capacity. As you’ll recall from Part 1, three criteria to determine if Reserved Capacity applies to the person’s situation are:

1. The setting must be applicable: the person is admitted to a medical or psychiatric hospital (excluding state‐operated mental health hospitals), rehabilitation care, or nursing home.

2. The length of admission more than 30 consecutive days, during which the home and community‐based Waiver services the person would have received in the community have not been received while the person has been admitted.

3. The person is expected to return to the community within 180 days after reserved capacity begins.

Now we’ll get into more detail about how Reserved Capacity unfolds. I’ll start by describing what the SC, team, and AE are doing when it becomes clear that the person won’t be able to return home before 30 days have passed and will need to have Waiver capacity reserved



by the AE. I’m going to be outlining steps that the SC takes with the team, but please pay particular attention when I refer to who is responsible for each step.



Let’s pull the concepts we’ve been talking about together into an example.

A person is admitted to a rehabilitation facility on September 1st. Everyone is hoping that this will be a stay of a few days or maybe weeks before the person returns home. However, after a couple weeks of care in the facility, the doctor orders that the person remain in the rehabilitation facility for longer‐term care. It’s now clear that the person will probably not be returning home within 30 days. The SC knows that this means that the person’s Waiver Capacity can be reserved. But, rather than wait until the 31st day, the SC contacts the AE right away so AE staff have time to ensure things are in place to reserve Waiver capacity for the person.

Notice that we’re talking about is giving the AE a “heads up” in advance of the 30 day mark to allow everyone as much time as possible to prepare for Reserved Capacity. The SC can’t wait to notify the AE on the 30th day of an admission to a hospital or rehabilitation care – that doesn’t allow any time for the AE to act. It’s important that the SC or SCO keep the AE informed of the potential need for reserved capacity as soon as he or she is aware it MAY be needed, since capacity in most AEs is usually running close to the maximum and notification in advance will help the AE plan and manage its Waiver Capacity Commitment.

As we’re talking about how the SC communicates this information to the AE, keep in mind that you need to follow local established protocol. Depending on what happens in your SCO, it may be the SC who contacts the AE; in others, it may be the supervisor or SCO administrator.

So, it’s important that the SC is aware of the admission and whether the admission will last more than 30 days, as early as possible. That means that providers of service should contact the SC when someone is admitted. It also means that the SC develops a rapport and understanding with families that they should also contact the SC at the time of admission, especially when the person is living at home.

Once the SC/SCO has given the AE notice that reserved capacity MAY be needed, AE staff will monitor the situation to ensure they will be ready to reserve capacity for the person, if in fact his or her stay extends beyond 30 days.



The SC stays in contact with facility staff to determine whether or not discharge will occur before the 31st day. If the stay will extend to 31 days or longer, the SC or SCO confirms this with the AE, and AE staff begin to take action to reserve capacity. If on the other hand, the person’s discharge is scheduled to occur before the 31st day, the SC or SCO lets the AE know.

The AE staff can then put aside actions to reserve capacity for the person. Frequent, clear dialog between the SCO and AE staff is crucial in making sure that if reserved capacity is needed all the pieces are in place at the 30 day mark.



We’re assuming in this presentation that the SC will know early on when an individual is admitted to a hospital or rehabilitation care in order to take action to ensure Waiver Capacity is reserved.

However, there may be times when the SC is made aware of an admission weeks after it occurred. When this happens, the SC needs to inform his or her supervisor and the AE as soon as possible to determine next steps. The AE may also need to review the unique circumstances with the ODP Regional Waiver Capacity Manager in order to determine the most appropriate actions.



At the same time that a potential need for reserved capacity is first identified, the SC explains how the process will unfold to the team. This is a particularly difficult time for the individual and for the family – who are experiencing the stress of being in a hospital or rehabilitation care and concern about the future.

The SC should be prepared to clearly explain the distinction that reserving Waiver Capacity for up to 180 days means that the AE cannot assign the person’s waiver capacity to someone else until after 180 days from the first day that Reserved Capacity begins – but this protection does not extend to the specific Waiver services that the person was receiving before admission. Providers need to be involved in these discussions so that they can inform the individual and team how long they are able to hold the person’s specific services.



Although it may reassure individuals and families that Waiver Capacity is being reserved by the AE for up to 180 days – the uncertainty about whether specific services will be available after discharge may understandably cause anxiety. The SC should prepare for this discussion with the individual and family by anticipating questions the individual and family may ask in the context of the person’s unique circumstances. It’s a time for the SC to be clear yet compassionate and supportive. The SC should reassure the family that he or she will continue to remain involved and advocate for the person’s needs.



The SC also needs to inform the individual and family that they will receive notice from the CAO that the individual’s Waiver will be terminated and the reasons for the action. Remind the individual and family that the notice from the CAO will include the right to appeal the action and specific timeframes for the individual to exercise the right to appeal. At the same time, make sure they understand that even though the individual’s Waiver enrollment is being terminated, Waiver Capacity within the AE is preserved on the individual’s behalf.

This explanation of how Reserved Capacity will unfold for the individual also includes how and when the team will communicate, as well as roles, responsibilities, and timelines for Reserved Capacity. Providers will also need to be fully engaged in the discussion and understand the implications for their support of the individual and the impact on the services they provide.

This is a time to continue discussion about discharge planning, even though that may be weeks away. The planning may take on a longer‐term perspective, but the team will need that time if new services and supports will be necessary upon discharge.



So far, we’ve talked about actions that occur during the first 30 days of admission to a hospital or rehabilitation care – informing the team about what Reserved Capacity is and how it will play out, giving the AE notice in advance that the person may need Reserved Capacity. At the point the admission reaches the 31st consecutive day after admission –during which the person’s Waiver services have not been received ‐ Reserved Capacity begins.



When Reserved Capacity for hospital or rehabilitation care is needed, the AE completes several actions.

The AE must inform the individual in writing of the action being taken. At the same time, the AE sends the Home and Community‐Based (HCBS) Eligibility/Ineligibility/ Change Form, or PA 1768 Form, to the CAO to request that the individual’s waiver enrollment be ended.



At this point, it’s important to review how reserved capacity happens, especially because it can cause concern when a person’s waiver enrollment is ended. Remember, the approved waivers stipulate that waiver must be ended if the person has not received the waiver services in his or her ISP for 30 days. The AE is obligated to take action to disenroll the person from waiver and does so by removing the Waiver funding designation in HCSIS and end‐dating Waiver‐funded services on the ISP.

Immediately after disenrolling the person from waiver, the AE add the person’s name is added to the intent to enroll screen in HCSIS. So, while the person is no longer enrolled in waiver, the AE’s action of adding the person’s name to the intent to enroll in HCSIS reserves waiver capacity on the person’s behalf. This allows the person to be re‐enrolled in the waiver if he or she is able to return to the community within 180 days. Reserving waiver capacity is seen as continuing eligibility for waiver services.



The CAO reviews the PA 1768 Form and issues notice to the individual that action is being taken to end waiver enrollment. Included with this notice is an explanation of the individual’s right to appeal the action.

The SC’s support at this time is crucial: the individual needs to understand the importance of the right to appeal. Remember that, even though the person’s waiver enrollment has been terminated, the individual’s waiver eligibility is seen as continuing due to the fact that the AE has reserved capacity for the individual. It’s important for the SC to explain, however, that, even if the individual does not appeal the action to end Waiver enrollment, the AE is still obligated to reserve Waiver Capacity on the individual’s behalf for up to 180 days.

The AE will receive notice of the confirmed date that the person’s Waiver enrollment has been terminated when the CAO sends the PA 162 Form. The AE also notifies the Regional Waiver Capacity Manager.



During reserved capacity, ODP stipulates that the AE review information provided by the ISP team to determine if the person will be returning to the community. In order to manage its Waiver Capacity ‐ including reserving Capacity for the individual, it’s important for the AE to stay current on the person’s progress and needs.

You’ll see that much of the information the AE reviews is similar to the information we discussed earlier in the context of discharge planning:

• What progress has the person made, according to the hospital or rehabilitation facility staff, including medical providers?

• Is it possible for the person to return to the community? If so, will there need to be changes in level of support or adaptations at home?

• What role will family and community supports play in assisting the person in returning to the community?



The SC should work with the team to determine the best way to gather the information that the AE needs to review. This could happen in a number of ways and may not always require a meeting of the team. However, it may be advisable that the team plan to meet regularly at the facility where the person is so that the person, family, providers, and facility staff can have a thorough discussion.

The SC’s record of the team’s discussion in a service note is sufficient for the purpose of providing the AE with the information it needs.



The note should contain the basic elements of every service note.

In the “what” section of the service note, the SC includes all of the information the AE needs to review: progress, possibility of returning to the community, changes in support needs and adaptations, and whether family, natural and community supports can assist the person in returning to the community.

More information on Service Notes Basics for Supports Coordinators is available on the Supports Coordinator Curriculum website under Professional Development.



This is an example of a service note that provides the AE with the information it needs to meet its obligation to review progress on at least a monthly basis. Keep in mind that this is intended as a basic illustration of the note and does not contain all of the detail that may need to be included in an actual note.

The note also includes what was discussed in terms of progress, including changes in support needs after discharge, and an indication of when discharge might occur. You can see from the note that the team is anticipating Simon will be discharged before Reserved Capacity ends and be able to return to Waiver services. The note includes the role of Simon’s family. Finally, the note includes one of many follow up actions: the date of the next team meeting.

A copy of this example service note is in the Resources section where you found this webcast.



At this point, we’ve talked about how Reserved Capacity unfolds. Next, we’ll talk about what happens at the end of Reserved Capacity – but before doing that, let’s review the points we’ve covered so far with an example:

Let’s say that the SC receives a call that someone he or she supports was admitted to a rehabilitation facility the evening before. The SC contacts the facility staff assigned to the person and coordinates discussion among the team. At the meeting, the team learns that the person is doing well and will probably be discharged within a week. The team decides on the discharge plan that’s needed to bring the person home.

However, a few days after the meeting, the SC receives a call from the facility contact: the person’s doctor has determined that the situation will require longer‐term care and the person will not be discharged as soon as anticipated. It’s not known if the person will remain in the rehabilitation facility for 30 days or more. The SC asks to be kept aware of changes.

The SC or SCO immediately contacts the AE to give them a “heads up” that the situation has changed. The person’s Waiver capacity will not “officially” be reserved at this point, but the SCO has done due diligence in letting the AE know in advance that it MAY need to be. The AE staff prepares by looking at the AE’s current capacity and the person’s ISP.

A few days later, the SC hears from the rehabilitation facility social worker: the doctor has ordered 6 weeks of care at the facility. The SC or SCO contacts her counterpart at the AE and confirms the change. In turn, the AE prepares the PA 1768 to request the CAO terminate Waiver enrollment,places the person in queue in HCSIS, and notifies the Regional Waiver Capacity Manager.

The SC gathers the team to discuss the implications of Reserved Capacity for the individual and family and to continue discharge planning.

There are other issues that need to be considered during Reserved Capacity – we’ll talk about those next.



While the SC continues to facilitate the team meetings and discussion and report to the AE on a monthly basis while capacity is reserved, he or she may also need to update the ISP to reflect the person’s current circumstances. At other times, a service note is sufficient to record changing circumstances. But when does an SC need to open the ISP and complete a general update – versus simply recording changes in a service note?



To answer this question, the SC should think about the nature of the changes he or she wishes to record. Are the changes considered permanent or long‐term – in other words, will the person’s services in the current ISP need to be changed? Permanent or longer‐term changes in the person’s abilities and needs should be added to the ISP through a general update when they imply that services and supports will need to change. When changes to the ISP are necessary, a general update will in many cases change the medical and functional abilities section of the ISP. Changes in the person’s life resulting from extended stays in hospitals or rehabilitation care may also have an impact on individual preferences and outcomes.

On the other hand: are the changes the SC sees in abilities or needs expected to improve or further change throughout the course of treatment but they are not expected to result in longer‐term changes to supports or services? Or, perhaps is it just not clear yet if the changes will result in new or different services and supports. When changes are not permanent or longer‐term – or when it’s not yet clear if they are – the SC should record these in a service note to avoid frequent revision of the ISP as the situation changes and then changes again and again.

SCs need to use best judgment and support from supervisors to determine when a general update to the ISP is warranted.

Remember that at this point, the person is in a facility and not receiving Waiver‐funded services. Therefore, a critical revision to the ISP to change waiver services would wait until the plan for community support post‐discharge becomes clear. The SC would complete a critical revision ISP then.



In addition to ISP updates and monthly reports to the AE, the SC and the Supports Coordination Organization also need to modify billing for SC services.

Remember that, when reserved capacity begins, the AE is responsible to notify the County Assistance Office that the person’s Waiver enrollment should be ended, end‐date authorizations for ISP services, and end the person’s waiver‐funding designation in HCSIS.

Consequently, the Supports Coordinator will no longer bill Waiver funding for his or her services, but must bill other funding sources from the 31st day until discharge or until the person is re‐enrolled in the Waiver.

The procedures for verifying the correct and most appropriate funding source for SC services and managing this change vary within each SCO. Work with your supervisor and or agency fiscal staff to determine the correct funding source for billing SC activities. This change in billing coincides with the date the person’s Waiver enrollment is terminated.



So, the SC remains involved while capacity is reserved, but must bill non‐waiver funding sources rather than Waiver when recording activities of locating, coordinating and monitoring. Billing non‐waiver funding sources for SC services continues until the person is re‐enrolled in the Waiver after discharge. If the person remains in the facility or is discharged but not re‐enrolled in the Waiver, the SC would continue to bill non‐Waiver funding sources.

The facility in which the person is receiving care is responsible to ensure the appropriate insurance(s) are in place to pay for care, but the SC should ask the facility about this, since it may impact the funding sources available for SC billing.



During an extended stay in a hospital or rehabilitation care facility, the SC needs to act on important dates. First, even though the person’s Waiver has been terminated while Waiver capacity is being reserved at the AE, if the person’s Annual ISP Review date occurs during the stay in the facility, the SC still needs to assemble the team and update the ISP. Even though the person is not receiving Waiver services while in the facility, there is still a need to complete an ISP review, especially in light of changing circumstances. SCs should conduct this ISP Annual update as they would for any other individual not enrolled in Waiver services.

This meeting should occur within the facility when possible, so the person can be present. It includes team mem

rs who are still involved and the facility staff. The SC should follow procedures that he or she would for a non‐Waiver ISP including coordination, completion timelines, and submission for review.



Is it necessary for the Waiver recertification process to be completed if the recertification date occurs during Reserved Capacity?

The answer is no. At the beginning of Reserved Capacity, the CAO discharged the person from the Waiver, at the AE’s request. Therefore, a request for recertification during Reserved Capacity – while the person remains in the hospital or rehabilitation care – is unnecessary.

If, however, a discharge date is known – and if the plan is to resume Waiver services upon discharge – the AE would start the waiver enrollment process using the DP 251 Annual Recertification form to initiate a redetermination of need of ICF/MR level of care. A new level of care determination using the DP 250 form is not required.



If someone has been in a hospital or rehabilitation care for more than 30 days – or perhaps several months ‐ it’s likely he or she is dealing with a serious situation. What we’re talking about during these extended stays are often life‐altering and sometimes permanent changes in the person’s abilities and needs.

Discussions about a person’s changing needs and how they will be supported after discharge are sometimes difficult – but it is vital that these discussions are open and honest and that they start at the beginning of the admission in order to be able to plan for services and supports needed when the person returns home, since it may take time to find and put services in place.

For example, a person who sustained physical injuries that necessitated two months of inpatient rehabilitation may not be able to return to the same level of independence he or she enjoyed before the admission. The first consideration is always for the person’s health and welfare – both while in the facility and in planning ahead for discharge. Perhaps a person will not be able to negotiate stairs after discharge and will need support in a one‐story home. Someone who was independent in public transportation before admission may need support and training to continue to go into the community after discharge. There may be a need for additional staff support to be healthy and safe, even though the person was quite independent in everyday life before admission to the facility.



Changing needs may result in discussion of enhanced or even new services that may be needed as the person continues to recover – or even permanently. It’s the role of the SC to facilitate these discussions. The facility staff may also be invaluable in accessing services, especially medical supports and special services.

Providers that were involved before the person was admitted will need to assess their ability to provide support after discharge and be forthcoming with the person, family, and team. Sometimes, providers know from the first day of admission, given the person’s circumstances, whether or not they will be able to offer services that meet health and safety needs upon discharge. Providers may request the ability to provide enhanced services in order to ensure the person’s health and welfare after discharge.

When new or enhanced services are needed through the ODP system of supports, the method the SC uses to identify and advocate for those services is a familiar one: the Prioritization of Urgency of Needs, or PUNS.

Even when service providers may be able to provide appropriate services upon discharge, extended periods when the person is absent from the service can cause providers hardship.

Remember that Reserved Capacity provides protection of Waiver Capacity for the person up to 180 days. However, Reserved Capacity does not mean that the person’s Waiver services are held for them indefinitely. The services that the person was receiving before being admitted to the facility may – or may not be – still available after an extended stay in a facility.



On the screen is a quotation from the Chapter 51 Home and Community‐Based Services Regulations, disseminated by ODP on June 9, 2012. Note that, although Reserved Capacity applies to all waiver participants receiving any Consolidated or P/FDS service, this quote refers to residential services such as group homes and Lifesharing through Family Living.

ODP expects providers to cooperate with the Office during Reserved Capacity. When it becomes clear that a provider determines it cannot provide the service the person will need upon discharge – or can no longer continue to participate in the team – the provider is responsible to explain its reasons to the individual and family. This is a sensitive topic that can be a source of anxiety for individuals and families. SCs should always be prepared for these conversations by having open and honest communication with providers in advance, when possible, and rely on the support of the Administrative Entity in situations like these. In turn, the AE should seek the support of the Waiver Capacity Manager and other ODP Regional staff.



Earlier I mentioned that when a person is admitted to a hospital or rehabilitation care, the team expands to include facility staff. Because of the reasons we just discussed, the team may also experience changes in composition if there are changes in providers. New potential providers may join the team while others no longer participate.

The SC is responsible to manage the changing team, facilitate discussions and planning, and advocate for services to meet the person’s changing needs, regardless of the composition of the team.



There are two possible scenarios to end Waiver Reserved Capacity. Either the person is discharged to return home and to the community before Reserved Capacity ends or the person continues to need care in a hospital or rehabilitation care past the maximum time Capacity can be reserved – 6 consecutive months or 180 days.



When the SC is made aware that discharge is being planned – and the AE has reserved Waiver capacity for the person – the most important issue for the SC and team is to determine what services will be necessary and how they will be provided.

We’ve already discussed the need for the providers to determine as early as possible if they will be able and willing to provide services upon discharge – given the person’s changing needs – and if enhanced services will be needed. The SC and team need to determine if referrals for new services and providers will be necessary, and what role family and community support will provide. During these discussions, the SC is gathering information that can be used to revise the ISP that will need to be in place upon discharge and return to Waiver services.



SC or SCO informs the AE of the date of discharge from the facility

Because the SC has maintained contact with the individual, family, providers, and facility staff during the admission, he or she will know if discharge is being discussed. As soon as the SC becomes aware of discharge planning, the SC or SCO needs to inform the AE promptly so that the AE is prepared to complete its responsibilities, including notifying the County Assistance Office that the person will be returning to the Waiver from reserved capacity.

The AE requests the CAO re‐enroll the person in the Waiver using form PA 1768

Next, the AE requests the CAO to re‐instate waiver enrollment to coincide with the discharge date. The CAO will determine what activities they need to complete in order for the person to be eligible for re‐enrollment into the Waiver. Keep in mind, re‐enrolling the person in the Waiver can be complicated and depends on many factors such as the last recertification, assets and income, and the person’s current circumstances. It’s the CAO’s job to respond to the request for re‐enrollment in the waiver and to inform the AE what needs to occur to accomplish it.

At the same time, the AE informs the Regional Waiver Capacity Manager of the target date for re‐enrollment in the Waiver.



The individual, SC, and team complete a draft critical revision of the ISP

While the AE and SCO are working with the CAO to re‐instate the person’s Waiver enrollment, the SC is coordinating a critical revision of the ISP, a familiar process for the SC that includes identification of services within the ODP system, including existing services or perhaps modifications to existing services, and possibly, referrals for new services. The process and timelines for submitting this ISP for AE review are the same as for any critical revision ISP.

The team’s discussion while revising the ISP includes much of the detail that has been discussed during the entire facility stay, including current status, prognosis, and future course of treatment after discharge. The team discusses if changes to existing supports will be needed and if they will need to be enhanced with additional staff or other supports, how often, and for how long, and the choice of available and willing providers. The ISP includes description of changes in the person’s abilities and whether or not specific adaptations that may be required at home and in other service locations. As it always must, this revision includes the contribution of natural, family, and community supports that may be important after discharge. Specific discharge instructions and follow up should also be included in the ISP critical revision.

The SC or SCO submits the critical revision ISP to the AE for review

The critical revision ISP is submitted to the AE for review and follows normal protocol for review, revision, approval and authorization of services. Authorized waiver services cannot be provided before the Waiver re‐enrollment date.



Upon verification of eligibility from the CAO, the AE re‐enrolls the person in the Waiver

When the AE staff confirms eligibility through EVS/Promise or receives the PA 162 from the CAO confirming Waiver re‐enrollment, they also re‐enroll the person in the Waiver in HCSIS to coincide with resumption of Waiver services and the effective date of the ISP critical revision. The effective date of Waiver re‐enrollment is also the date that the SCO can resume billing Waiver for SC services, provided the service is included in the plan and authorized by the AE.

The person is discharged and returns to Waiver services

After these steps are accomplished, the person is able to be discharged and return home and receive the supports and services in the ISP.

As the AE, CAO, SC and team are completing these actions, keep in mind that they may be happening simultaneously. What’s important to remember is that Waiver services cannot resume until after the effective date of the person’s re‐enrollment in the Waiver, as confirmed by the CAO on the PA 162 Form.

Locally, AEs and SCOs have long‐established agreements on who performs what actions and how they are to occur when someone is entering Waiver services. The process for re‐enrolling a person in Waiver services from Reserved Capacity is similar to what AEs and SCs complete for any new person being enrolled in the Waiver. As you’re aware, making sure dates are lined up and all team members know their responsibilities takes a great deal of coordination, communication and leadership by the Supports Coordinator.



Remember that the AE reserves Waiver Capacity for up to 180 days, but is not obligated to reserve Capacity for more than 180 days. There are circumstances when discharge from a hospital or rehabilitation care setting may not occur within 180 days.

In some situations, the person may need to stay in the hospital or rehabilitation care to receive necessary treatment for more than 180 days. In other situations, it may be determined that the person may not be able to return to the community but will need to remain in the facility.

Note that if the person’s prognosis changes ‐ and the team is in agreement that the person needs long‐term hospital or rehabilitation care ‐ then reserved capacity can end at that point in time and does not need to be continued for the full 180 days.

In either scenario, the actions are similar.



When discharge from the hospital or rehabilitation care facility will not occur within 180 days, the SC or SCO informs the AE.

Next, the AE sends the person notice of this action and includes form DP 458, outlining the person’s appeal rights. The AE should plan to send this notice at day 165 in order to be sure there’s sufficient time to meet the timeframe for appeal before the 180th day. The SC is copied on this correspondence. It’s important that the SC be prepared to help the person understand the right to Fair Hearing, including the fact that there is a limited amount of time for the individual to exercise Fair Hearing Rights. The AE must wait for the specified period of time for the individual to appeal before taking further action.



If the individual chooses to appeal, the AE cannot remove the person from the intent to enroll queue until after the appeal is resolved. If, however, the individual chooses not to appeal, the AE takes appropriate action to remove the person from the “queue” thereby eliminating the Reserved Capacity for the person, allowing it to be used for another person needing Waiver services.

The SC convenes the team to discuss future involvement of the team and supports coordination. At this point, after a long stay in a hospital or rehabilitation care, the composition of the team may be very different than when the person was admitted. In some cases, the team may be the person, family, facility staff and SC. The SC’s continuing involvement is the same as the support offered to any other individual not receiving Waiver services.

If the person is subsequently to be discharged from the hospital or rehabilitation care after Reserved Capacity ends and wants or needs home and community‐based services – including Waiver home and community‐based services – he or she must re‐apply for Waiver. It’s the SC’s responsibility to advocate for the person’s needs.

In other cases, a discharge from the facility is proposed, but the person no longer needs ‐ or perhaps no longer wants continued Waiver services.



As we conclude this webcast on Reserved Capacity, I’ll summarize the major points that we covered.

When a Waiver participant is admitted to a hospital or rehabilitation care facility for more than 30 consecutive days ‐ during which the Waiver services he or she had been receiving in the community have ceased ‐ the person’s Waiver enrollment must be ended. However, within its agreement with CMS, ODP is permitted to reserve Waiver capacity under certain circumstances. Reserved Capacity allows an Administrative Entity to “hold” Waiver Capacity, providing protection for the person if he or she is able to be discharged to the community before Reserved Capacity ends.

For Reserved Capacity to apply, the person must need care in an applicable setting for at least 31 consecutive days and up to 6 consecutive months or 180 days.

During the time an AE is reserving Waiver capacity on the person’s behalf, the AE reviews information from the ISP team on the person’s progress, changing needs, and the possibility that the person will return to the community.



If the person is able to return to the community before 180 days have passed, the SC and ISP team develop a plan to meet the person’s needs upon discharge. This critical revision ISP includes changes to services and, in some cases, new services. The ISP is subject to review, approval and authorization by the AE.

If the person’s prognosis changes at any time to extend beyond the 180 days, the AE is not obligated to continue to reserve Waiver capacity for the person. The SC and team continue to support the person and advocate for his or her needs the same as any individual who is not enrolled in the Waiver.



Additional resources are available in the place you found this webcast, including ODP’s Letter to Administrative Entities explaining their responsibilities in Reserved Capacity. Also included are the letters that the AE sends to individuals and families during Reserved Capacity.

In addition, links to the Consolidated and P/FDS Waivers are available for those who wish to read more about Reserved Capacity in the context of the entire approved Waivers.



Finally, on the ODP Consulting System website and each of the ODP Information Centers for AEs, Providers, SC Organizations and the SC Curriculum website are links to more information about the Renewal of the Intellectual Disability Waivers effective July 1, 2012. On these pages you’ll find information about other Waiver topics.



This webcast has been developed and produced by the Office of Developmental Programs

Consulting System on behalf of the Pennsylvania Department of Public Welfare, Office of

Developmental Programs.

46


Course Number 009-05-02

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Reserved Capacity 2013 Update PD Part-2 073013 2€¦ · Renewal of the Intellectual Disabilities...

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