SMMC Long-term Care Provider Webinar: Home-like Environment


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SMMC Long-term Care Provider Webinar: Home-like Environment

  1. 1. Follow the link below tothe SMMC Website2. Select the “News andEvents” tab under theheader image.Note: You can also use thered button to sign up forSMMC Program updates viae-mail.
  2. 2. 3. Select “Event Materials”to download today’spresentation.Note: You may also viewdetails regarding futureSMMC events using the“Upcoming Events” tab.
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  4. 4. • Wendy Smith– Government Analyst– Agency for Health Care Administration• Cheryl Young– Bureau Chief of Long-Term Care & SupportServices– Department of Elder Affairs
  5. 5. • Requires providers that serve Medicaid recipients in thecommunity maintain home and community-basedcharacteristics, which includes person-centered services anda home-like environment• Proposed rule [CMS-2249-P2] published in Federal Register5/3/2012• Online at and
  6. 6. • All Medicaid waiver programs providing services inALFs/AFCHs are expected to provide a home-likeenvironment and community integration to the fullest extentpossible:– Nursing Home Diversion Waiver– Assisted Living Waiver– Channeling Waiver (Facility-based Respite)– Aged/Disabled Adult Waiver (Facility-based Respite)– Long-term Care Statewide Medicaid Managed Care Waiver– Any other Medicaid waiver program that offers services inassisted living facilities
  7. 7. • Provide funding for services for Medicaid eligible people withqualifying disabilities who want to live at home or in thecommunity• Purpose: Allow state Medicaid programs to cover servicestraditionally viewed as “long-term care” and provide them in acommunity setting to individuals instead of nursing home orinstitutions
  8. 8. • Recipients must:– Meet institutional level of care– Meet Medicaid Institutional Care Program (ICP) incomeand asset limits– Satisfy any additional impairment criteria– Accept waiver services in lieu of institutional placement
  9. 9. • Each resident must be assured privacy in sleeping andpersonal living areas:– Entrance doors must have locks, with appropriate staffhaving keys to the doors– Freedom to furnish and/or decorate sleeping or personalliving areas– Choice of private or semi-private rooms– Choice of roommate for semi-private rooms– Access to telephone service as well as length of use– Freedom to engage in private communications at any time
  10. 10. • Freedom to control daily schedule and activities (physical andmental conditions permitting)• Visitation options of the resident’s choosing• Access to food and preparation areas in the facility at anytime (physical and mental conditions permitting)• Personal sleeping schedule• Participation in facility and community activities of theresident’s choice• Ensuring that residents are allowed to participate inunscheduled activities of their choosing
  11. 11. • Access to the greater community is facilitated by the ALF orAFCH based on the resident’s abilities, needs andpreferences• The ALF or AFCH setting must offer meaningful communityparticipation opportunities for their residents at times,frequencies and with persons of their choosing• Example: The resident wishes to visit the senior center toparticipate in social activities• Barrier: The resident does not have access totransportation• Intervention: The case manager works with the ALF orAFCH to ensure that transportation, such as Dial-a-Ride, isavailable to transport the resident to and from the seniorcenter and to ensure that the resident is dressed andready to depart
  12. 12. • The basis of a successful home and community-based settingis the creation of a individualized and inclusive person-centered plan of care that addresses services, supports, andgoals based on the resident’s preferences• The person-centered plan of care is based on acomprehensive assessment that includes the resident andparticipation by any other individuals chosen by the resident• The plan of care must support the resident’s needs in themost integrated community setting possible• The waiver recipient’s plan of care must include personalpreferences, choices, and goals to achieve personaloutcomes
  13. 13. • Examples of personal goals a resident may choose:• Deciding where and with whom to live• Making decisions regarding supports and services• Choosing which activities are important• Maintaining relationships with family and friends• Deciding how to spend each day
  14. 14. • The state will ensure the promotion of home and community-based settings and community integration through:• Individualized person-centered care planning• Goal planning activities• Promotion of a home-like environment in assisted livingfacilities and adult family care homes
  15. 15. • To ensure that ALFs/AFCHs serving Medicaid recipients maintain ahome-like environment and provide community integration, the statewill implement the following new processes:• DOEA modified contracts with all Diversion Plans (ManagedCare Organizations and Other Qualified Providers) to require:• amended subcontracts with ALFs by early May 2013• MCO/OQP review for these characteristics during credentialingand re-credentialing of ALF providers• All assisted living facilities participating in the Assisted Living, orother waivers utilizing ALFs, must sign amended referralagreements and comply with the characteristics of a home-likeenvironment and community integration by June 2013• State staff are currently conducting on-site reviews of ALFs toensure a home-like environment.
  16. 16. • All ALFs/AFHCs participating in Long-term Care ManagedCare must meet these requirements before go-live (before thefirst date of enrollment in region).• State staff are currently conducting on-site reviews ofALFs/AFCHs to ensure a home-like environment by Region.
  17. 17. Area 1 is on hold due to ongoing litigation.
  18. 18. • Managed Care Organizations are required to:• Verify during the credentialing and re-credentialing processthat home-like environment and community integrationexist in facilities they intend to contract with as well as inexisting network ALFs/AFCHs
  19. 19. • If at any point a managed care organization discovers that anALF/AFCH is not maintaining a home-like environment orsupporting full community integration, they must:• Report that finding to the state contract managerimmediately• Propose a remediation within three business days ofdiscovery• When the transition to the Long-Term Care MedicaidManaged Care waiver is completed, AHCA and DOEA willprovide oversight of the monitoring process to ensure theMCOs will contract only with ALFs/AFCHs providing andsupporting a home-like environment and communityintegration.
  20. 20. • Waiver providers will insert the following language into eachsubcontract or referral agreement with ALFs/AFCH:– Assisted living facilities will support the enrollee’s communityinclusion and integration by working with the managed careorganization’s case manager and enrollee to facilitate theenrollee’s personal goals and community activities.– Additionally, waiver enrollees residing in assisted livingfacilities must be offered services with the following optionsunless medical, physical, or cognitive impairments restrict orlimit exercise of these options.
  21. 21. • Choice of:– Private or semi-private rooms;– Roommate for semi-private rooms;– Locking door to living unit;– Access to telephone and length of use;– Eating schedule; and– Participation in facility and community activities.• Ability to have:– Unlimited visitation; and– Snacks as desired.• Ability to:– Prepare snacks as desired; and– Maintain personal sleeping schedule.
  22. 22. • Care Plan Development and Goal Planning:– Monitoring of resident case files by Quality Assurance teammembers– Review of Community Integration Goal PlanningDocumentation• Modification of Referral Agreements:– Annual desk review of referral agreements or MCOsubcontracts for inclusion of home-like environment andcommunity integration language• Credentialing and Re-Credentialing:– Review of monthly provider network reports and MCOcredentialing files• On-site review of ALFs and AFCHs
  23. 23. LTC Plan Contact: Provider NetworksAmerican ElderCare Brenda Evans561-496-4440bevans@americaneldercare.comAmerigroup Victoria McMath800-950-7679 ext 77429Victoria.McMath@amerigroup.comCoventry Mariangeli Cataluna305-222-3012mxcataluna@cvty.comHumana Grace Rodriguez888-234-6401grodriguez@ilshealth.comMolina Healthcare Lisa SchwendelPhone: 1-888-562-5442, ext. 223594Email: lisa.schwendel@molinahealthcare.comSunshine State Heath Plan Susan McCurry, Manager, Provider Relations866-769-1158, ext 41344smccurry@centene.comUnited Healthcare George Rodriguez407-659-7029Primary email: Fl_ltc_network@uhc.comSecondary email:
  24. 24. • Questions can be emailed• Updates about the Statewide Medicaid Managed Care program areposted at:• Upcoming events and news can be found on the “News and Events”tab on the SMMC website:• Keep up to date on information by signing up to receive programupdates by visiting the SMMC website through the following link andclicking the red “Sign Up for Program Updates” box on the right handside of the page.