1915(c) Children's Waiver

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WY2021-2022 Case Review Combined Meeting

January 2023

Agenda

Introduction

  • For WY21-22 HH/C-YES reviews, 376 cases were reviewed by the case review team.
    • 341 eligible participants and 35 ineligible applicants.
  • Performance measures were calculated from case review evaluation items in the case review tool. The tool contained a total of 143 evaluation items.
  • For WY21-22 QA reviews, CAPs were issued for outcomes below 85% in alignment with the Children's Waiver guidelines for measure outcomes.
  • A total of 564 HCBS Provider cases were reviewed by the QA case review team.
  • 44 of the eligible cases were also selected for Interrater Reliability (IRR) Reviews by the NYS State Partners of OPWDD, OMH, and OCFS.
  • For an evaluation item to be considered passing, an overall percentage of 65% had to have been met.
    • Due to this being the first review for HCBS providers the 85% requirement for the Children's Waiver was not required but noted for HCBS providers to be aware for the next year's review.
Crossover Cases - Data Highlights
  • Records from both HHCM and HCBS providers were reviewed in a total of 125 cases.
  • The tables contain a sample of evaluation items identified from each tool that relate to a participant's holistic experience, specifically related to the themes of communication and POC/Service Planning.
Care Manager Reviews Provider Reviews
Question % of Compliance % of Compliance Question
Are valid information sharing consents present in the record? 79.2% 44.1% Is the care management provider indicated on information sharing consents?
Is there documentation of participation by key providers of the care team in the development and updating of the POC? 87.0% 46.3% Did the provider solicit feedback from the HHCM/C-YES on the development and maintenance of the service plan?
Does the record contain documentation of ongoing communication/collaboration, and monitoring of services between the providers and the CM at least quarterly? 77.9% 23.9% Did the HCBS Provider communicate the approval/denial of F/S/D with the HHCM?
Does the record contain documentation of ongoing communication/collaboration, and monitoring of services between the MCO and the CM at least quarterly? 20.2% 52.5% If applicable, did the Provider communicate with the managed care plan to obtain approval of F/S/D?
Are the HCB service goals/objectives identified in the POC adequate and appropriate to their needs? 87.6% 92.1% Does the service plan define appropriate interventions and strategies that enable achievement of the desired needs and goals?
Comm Hab: If this service was obtained during the waiver year (WY 2021-2022) is there an "HCBS Referral to HCBS Provider" form in the record? 92.3% 100.0% Comm Hab: Is there evidence in the record that the child was referred for this service?
Did the care manager monitor progress on the HCBS goals/objectives identified in the POC through interactions with the participant and family? 69.6% 93.8% Does the record demonstrate discussion with the participant/family to monitor progress towards goals and objectives in the service plan?
Was the service received as specified in the POC for F/S/D? 33.3% 46.2% Was the service received as specified in the service plan for frequency, scope, and duration?
General Findings
  • CM documentation generally contained more pertinent information, including consents (and other necessary documentation), appropriate POCs inclusive of safety plans, and documentation of communication with provider.
  • Provider agencies tended to lack these things specifically.
Communication between HHCM and HCBS Provider
  • Records consistently lacked documentation of the same communication. There were multiple instances where reviewers noted that no documented communication between the CM and Provider was found in either record.
  • Based on information received in CAP responses, this communication is likely occurring, but not being documented in the record.

✤ For the next case review, NYS DOH will be providing more detail instructions for HCBS providers and a FAQ to support the review. Additionally, policies and the HCBS manual will be updated to clearly address problem areas and/or questions from providers.

Crossover Cases: Reviewer-Noted Trends

POC/Service Planning/Referral/Discharge
  • CM documentation included more detailed safety planning compared to provider plans, which, if included, tended to be generic and not specific to the participant's needs.
  • Both CM and Provider POC/Service Plans highlighted member/family collaboration to develop goals and objectives.
  • CM POCs and provider Service Plans lacked appropriate member/caregiver signatures. In multiple instances, there was a verbal consent present with no follow-up wet signature within 60 days.
  • CM documentation more effectively captured rationale for member discharge and discussion with member/family regarding discharge. In general, Provider discharge documentation was very limited and generic.
Service Delivery
  • Overall, service referrals were more often found in provider records than HH records.
  • CM notes and provider notes were often incongruent regarding delivery/receipt of services, especially if there was a lack of service delivery during WY.
  • CM agencies tended to document the reasons why services were not delivered according to F/S/D. Provider agencies failed to document these reasons more often than CM agencies.
  • A lack of consistency was found in F/S/D between the provider Service Plan and CM POC.

✤ Monthly communication should be occurring minimally between the HCBS provider providing the service and the CM, regarding service delivery, service progress, and any concerns.

Safety Planning

✤ Please be mindful of the need to report Critical Incidents, Grievances, and Complaints within IRAMS

Discharge
  • A lack of documentation was noted surrounding discharge from the waiver, or from specific HCBS.
  • Communication regarding a participant's discharge from the waiver or services needs to occur between the HHCM and HCBS provider.
    • Examples where this communication did not occur:
      • Participants who lost Medicaid eligibility and were discharged from the waiver but continued receiving HCBS. The service provider was unaware of the discharge.
      • Participants who were discharged from a particular service due to a change in provider availability, but the care manager had not been notified.
        Children's HCBS Waiver Disenrollement and Discharge Policy(ny.gov)

✤ Communication with all involved providers, CMs, MCOs, etc. need to occur if the member is being discharged and share what is the discharge plan. Planning for discharged should involved the Care Team. If the discharge/disenrollment cannot be planful, then at minimally notification to all involved professional should be made. If discharge is being considered due to non-compliance, and interdisciplinary team meeting should occur with member/family involved, if possible.

Person-Centered Planning and F/S/D

  • Person-Centered Planning:
    • Is ensuring that the right service is being provided to address a specific need/concern.
    • Is based upon participant and family choice.
    • F/S/D is based upon participant/family's needs, choice, and availability.
    • Regular communication between HH and HCBS Providers is necessary and should be documented. This includes discussion of progress toward HCBS goals.
  • Many Service Plans outlined the maximum allowed for the service F/S/D or even more:
    • HCBS providers must periodically review if the HCBS F/S/D is being met, discuss the changing needs, choice, and availability of the participant/family and may need to change the authorization for F/S/D.
    • Proper documentation of the reasons why F/S/D is not being met is important, both in the HH and Provider records.
  • This evaluation item impacts the case review performance of Health Home/C-YES care managers - Plan of Care items.
  • This evaluation item assists in several performance measures reported to CMS.
  • HCBS providers should make realistic F/S/D determination dependent upon member/family agreement.
    • As the provider builds a rapport and provide the services, initial F/S/D may need to be changed
    • Discussion with the CM and member/family for the change should occur
  • CMs can question if concerns with F/S/D and discuss with the HCBS provider justification of the F/S/D
  • HCBS providers can update/change F/S/D based upon service delivery and member/family responsiveness. As well as when they determine re- authorization/continuation of services

Performance Measure: Annual Physical Exams

  • Participants in the Children's Waiver require an annual physical / well child exam.
    • This is a performance measure that is monitored and reported to CMS.
  • Although Care Managers are responsible for assisting the child/family to secure the wellness examination, it is the expectation that Care Managers and HCBS Providers work together, when possible, to help connect the participant with a physical/wellness exam.
Waiver Year 2021-2022 Metric Waiver Year 2022-2023 Metric (To Date)
56.42% 62.32%
  • HH/C-YES Reviews are scheduled to begin in April.
  • HCBS Provider Reviews are scheduled to begin in July.
  • Case Review Kick-off meetings will be held prior to the start of reviews.
  • Please identify who will be the point-of-contact for your agency for the purposes of communication throughout the case review process. Be prepared to provide NYSTEC with this point-of-contact information.
  • Please be sure that your agency's point of contact's Health Commerce System/Secure File Transfer access is up to date. Secure File Transfer access info: Secure File Transfer 2.0 Quick Reference Guide (ny.gov)
  • During WY21-22 reviews, non-responsive agencies negatively impacted the timeline for completion of reviews, Summary Of Findings, and Corrective Action Plans.
  • The Corrective Action Plan template will be updated for WY22-23 reviews to assist in streamlining the completion process for HHs and HCBS providers.

Questions and Open Discussion