H05-026 --Policy/Procedure

April 5, 2005

TO: / Home and Community Services Regional Administrators
Area Agency on Aging Directors
FROM: / Penny Black, Director,Home and Community Services Division
SUBJECT: /
New Steps and Information Related to Adult Day Health (ADH) Assessment, Referral and Authorization for newly referred clients
Purpose: / To maximize efficiency in the assessment and referral process and to ensure appropriate referrals of eligible clients into ADH.
Background: / Based on analysis of the WAC implementation process and progress and discussion with case management offices and stakeholders, the need to clarify definitions and adjust procedures was identified.
What’s new, changed, or
Clarified /
  1. Timelines for holding cases prior to transfer are shortened.
  2. Requirements for preliminary negotiated care plan are clarified.
  3. Points at which Planned Action Notices are to be sent are clarified.
  4. Sources of information to be used in eligibility determinations are clarified.
  5. Profiles to help identify eligible clients in need of ADH are provided.
  6. General eligibility clarification is provided.

ACTION: / Assess, refer and authorize clients for ADH according to the changes, clarifications and information outlined below, effective immediately upon release.
  1. Requirements for preliminary negotiated care plan:
  • An ADH center’s communication stating that the client can be served in ADH may serve as the preliminary negotiated care plan if the clients needs identified in the CARE assessment/service plan can be met sufficiently,and the communication identifies how those needs will be met, as required by WAC 388-71-0722(3).
  • This communication can be as simple as a faxed/e-mailed statement and does not need to be a preliminary version of the final, formalized care plan. It can be used by the case manager as the basis for an initial authorization.
  1. Timelines for holding cases:
  • ADH providers can be expected to respond with the preliminary negotiated care plan within 3 service days. In unusual cases, the maximum of 10 daysmay be necessary as allowed by WAC 388-71-0722 (3).
  • Where the three-day target is not met, the case manager may work with the client to find alternative means to meet the client‘s needs. Case Managers should communicate to providers when more rapid timelines are needed for start of services and for determination of ability to serve clients.
  • HCS can transfer cases to the AAA after the center provides an acceptable preliminary negotiated service planinstead of holding the case until the final negotiated care plan is completed.
  1. Points at which Planned Action Notices are sent:
  • For clients new to ADH, the initial Planned Action Notice authorizing Intake and Evaluation should be sent to the ADH provider at the point of referral into ADH, along with the CARE service plan.
  • The Planned Action Notice authorizing on-going services will be sent at the point of case transfer by department staff (after 3 service days when the center communicates it can serve the client).
Additional note: On the HCS/AAA Planned Action Notice, a space in front of the word “nursing” was inadvertently omitted for authorizing ongoing ADH services. Until the forms are reprinted, please place a circle around “nursing” if the client is referred for nursing, and/or a check in front of the word “rehabilitative” as applicable.
  1. Sources of information to be used in eligibility determinations:
WAC 388-71-0722 requires:
4) Upon approval by the case manager of the adult day health preliminary or negotiated care plan, the day health center multidisciplinary team must obtain and provide to the case manager any required practitioner's orders for skilled nursing and rehabilitative therapy along with a copy of the negotiated plan of care, according to department documentation requirements. Orders must indicate how often the client is to be seen by the authorized practitioner. The case manager or nursing services staff may follow up with the practitioner or other pertinent collateral contacts concerning the client's need for skilled services. Services may not be authorized for payment without current practitioner orders and the client's consent to follow up with the practitioner.
  • Basic sources of information for client eligibility are the CARE assessment; any required practitioners orders for skilled nursing or therapy; and the provider’s assessment/service plan (which should be readily available for clients already receiving Adult Day Health).
  • In the interest of avoiding additional work for prescribing practitioners, a first source for required orders should be the ADH center’s required practitioner’s orders for the client. However, additional information and/or sources of information may be solicited as necessary to clarify gaps in information in these documents.
  1. Case profiles:
Examples of “profiles” of clients to consider for ADH if eligible are:
  • Clients with diabetes that is poorly managed and who require skilled nursing intervention for better control;
  • Clients with other unstable, poorly managed diagnoses (such as CHF, COPD)—as evidenced by exacerbations, hospitalizations or ER visits—where skilled nursing intervention could bring stabilization;
  • Clients who are experiencing falls and require skilled rehabilitative intervention to decrease/prevent future falls;
  • Clients with progressive disabling conditions (such as Parkinson’s, MS, ALS) who require skilled rehabilitative intervention to slow decline, maintain functioning or ease related pain;
  • Clients with recent events (such as a stroke or head injury) where need for skilled rehabilitative intervention is needed to maintain or improve functioning or to learn how to use adaptive equipment;
  • Clients who are being discharged from a hospital, SNF or home health services and require continuing skilled nursing and/or rehabilitative intervention to progress, maintain, prevent/slow decline or ease related pain.
  1. General eligibility clarification:
Clients with a diagnosis of dementia or other cognitive/mental health diagnoses are eligible for ADH if they have an unmet need for skilled nursing and/or rehabilitative therapy and meet all other eligibility criteria.As in all cases,it is important to review the negotiated care plan from the ADH program for time-limited, client specific, measurable goals for accomplishing the objectives of the adult day health skilled services (WAC 388-71-0722 (5)(e)).
Clients who live in AFH’s and BH’s are eligible for ADH if they have an unmet need for skilled nursing and/or rehabilitative therapy and meet all other eligibility criteria.
Related
REFERENCES: / WAC 388-71-0702 through 0776; HCS MB H03-73; DDD MB D04-004
ATTACHMENT (S): / None
CONTACT (S): / Candace (Candy) Goehring, Program Manager
360-725-2562;