Ad lt D Adult Day Care and C d Community Based Adult Services - - PDF document

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Ad lt D Adult Day Care and C d Community Based Adult Services - - PDF document

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4/25/2013 Ad lt D Adult Day Care and C d Community Based Adult Services (Adult Day Health Care) ) Snack & Learn April 30, 2013 1 Supported by the California Department of Health and Human Services Agency and U.S. Department of Health

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4/25/2013 1

Ad lt D C d Adult Day Care and Community Based Adult Services (Adult Day Health Care)

1

)

Snack & Learn April 30, 2013

2

Supported by the California Department of Health and Human Services Agency and U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services under Grant CFDA 93.779

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4/25/2013 2

Agenda

  • Welcome
  • Speaker Introductions
  • Presentations

Presentations

  • QA & Closing Remarks
  • Return Evaluations

3

Presenters

  • Jim Banks, Director of Health Services at CalOptima
  • Gio Corzo, Vice President Home and Care Services at

Senior Serv Senior Serv

  • Pam Jacobs, Administrator at Mount of Olives Adult Day

Care

  • Mallory Vega, Executive Director at Acacia Adult Day

Services

4

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1

Day Services

The Third Option in Long Term Care

Our Mission

“T i th lit f d lt d i “To improve the quality of adult day services for consumers and to position adult day services as an integral component of the emerging health care system through advocacy, education and training.”

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Profile of Adult Day Services

 18 Day Services Member Centers

y Adult Day Programs (ADC) – Social Model Adult Day Health Care (ADHC) – Private pay Community Based Adult Day Services (CBAS) – Medi‐Cal

 Licensed to serve 18 years old +  Locations throughout the county  Specialties – cultural, linguistic, diagnoses, models of care etc.

Who do we serve

 Adults with cognitive

and/or physical impairments p

 Average age 78  64% Women  Diverse ethnic population  63% require medication

management

 73% need assistance with

ADLs

 50% suffer cognitive

limitations

 40% functionally dependent  Caregiver respite

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When Families Ask for Help?

 Change in Health  Change in Health  Falls and Accidents  Memory Loss  A Loved One Gets Lost

 Restore or maintain optimal capacity for self‐care and

Goals of Adult Day Services?

p p y independence to frail elderly persons or adults with disabilities; and

 Delay or prevent inappropriate or personally undesirable

institutionalization.

 Day Services create partnerships with the participant the  Day Services create partnerships with the participant, the

family and/or caregiver, the primary care physician, and the community in working toward maintaining personal independence.

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Why Day Services?

 We Keep Families Together  Relief from 24 Hour Care

Responsibility

 Social Interaction and

Mental Stimulation

 Assistance with ADLs,

, Done with Dignity

 Daily Medical Care

(Health Model) and Protective Supervision

Day Services: The Third Option in Long Term Care

 Community Based  Secure  Cost Effective  Compassionate

Care

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5

Meet Our Participants

 Average age 78  64% women  64% women  Majority Caucasian  73% need assistance

with ADLs

 63% require medication

management % ff

 50% suffer cognitive

limitations

 40% functionally

dependent

Medical Necessity Criteria

Welfare and Institutions Code, Section 14526.1

  • 1. One or more chronic or post acute medical, cognitive, or mental health

conditions identified by their person health care provider that requires

Monitoring

  • Treatment or
  • Intervention
  • 2. The participant has a condition or conditions resulting in both of the

following:

Limitations in the performance of two or more activities of daily living or

Limitations in the performance of two or more activities of daily living or instrumental activities of daily living, as those terms are defined in W&I Code, Section 14522.3, or one or more from each category.

A need for assistance or supervision in performing the activities identified in (2) (first paragraph) as related to the condition or conditions specified in paragraph (1) above. That assistance or supervision shall be in addition to any other non‐CBAS support the participant is currently receiving in his or her place of residence.

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Medical Necessity Criteria (Cont’d)

Welfare and Institutions Code, Section 14526.1

3 Participant’s network of non‐CBAS center supports is

  • 3. Participant s network of non CBAS center supports is

insufficient to maintain the individual in the community

  • 4. A high potential exists for the deterioration of the

participant’s medical, cognitive, or mental health condition(s) likely to result in ER visits, hospitalizations, or

  • ther institutionalizations
  • 5. The participant’s condition(s) require CBAS services on

each day of attendance that are designed to maintain the ability of the participant to remain in the community

CBAS Eligibility Criteria – 5 Categories

Category 1

NF-A LOC AND Medical Necessity

Category 2

C t 3 CBAS Eligibility

Category 4

Mild C iti Assistance or Supervision with 2 ADL / IADL’s OR 1 + 1 ADL / IADL’s Organic, Acquired, Traumatic Brain Injury or CMI AND Medical Necessity

Category 3

Dementia or Alzheimer’s Stage 5,6,7 AND Medical Necessity Mild Cognitive Impairment or Alzheimer’s Stage 4 AND Medical Necessity

Assistance or Supervision with 2 ADL / IADL’s Category 5

Developmental Disability AND Medical Necessity

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CalOptima & CBAS

 Community Based Adult Services (CBAS) benefit transitioned

to CalOptima in July 2012. p y

 CalOptima administers, authorizes, and manages the CBAS

benefit for Orange County

 Approximately 1,900 CalOptima members are enrolled in

CBAS

 New enrollment process includes a Face to Face assessment

by a CalOptima representative.

How to make a referral

 Fill out the CalOptima Benefit Inquiry form for CBAS  Fill out the CalOptima Benefit Inquiry form for CBAS  OR provide the client with a list of Centers  OR contact a Center directly to make the referral  Encourage your clients about the benefits  Thank you! We look forward to working with you!

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Day Services: The Best Kept Secret for Preventative Care

 Health Models  Health Models

 CBAS – Medi-Cal Only  ADHC – Private Pay,

LTC Insurance, Veteran’s Benefits

Social Model

 Social Model

 Private Pay,

LTC Insurance

Social Model of Care

 For Seniors and Persons

with Disabilities

 Can serve 18 or older  Some providers specialize in

serving seniors or persons with developmental disabilities

 Can vary, check with individual

providers for level of care and assistance options offered

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Social Model of Care

 Services Offered

 S

i li ti d

 Socialization and

Recreational Activities

 Meals  Physical and Cognitive

Exercise

 Individualized

Assessment

 Relief from 24/7

Caregiving Responsibilities

Social Model Requirements

 Licensed through Health and  Licensed through Health and

Human Services, Community Care Licensing Division

 Employees and Volunteers

are Live Scanned through the Department of Justice

 Permitted through OC Public

Health Services

 Audited Quarterly by the

Office on Aging

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Social Model Enrollment Process

 Immediate Enrollment  Immediate Enrollment

Possible

 No Home Visit required  Most Centers Require Two

Day Evaluation

 Physician Report (LIC602)

with TB Test Clearance

 Appraisals – Needs and

Services Plan (LIC625)

  • ABC Westminster ADHC
  • Acacia Adult Day Services
  • A Day Away ADHC
  • Age Well Adult Day Services
  • Alzheimer’s Family Services Center

y

  • Commonwealth Adult Day Health Care Center
  • Easter Seals Senior Adult Day Services
  • Irvine Adult Day Health Services
  • Mount of Olives Senior Day Care Center
  • Regent West ADHC
  • Rehabilitation Institute of Southern California (RIO)

 Adult Day Health Care Center, Orange  Adult Day Health Care Center, Fullerton  Leo Fessenden Adult Day Health Care Center, San Clemente

  • Sarang ADHC
  • Sarang ADHC
  • SeniorServ:

 Adult Day Health Care Center, Anaheim  Adult Day Center, Buena Park  Adult Day Heath Care Center, Santa Ana/Tustin

  • Sultan Adult Day Health Care
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4/25/2013 1

Community-Based Adult Services

Snack & Learn on Adult Day Care Program/CBAS Program/CBAS

April 30, 2013 Jim Banks, RN, Director Health Services

Agenda

  • History
  • What is CBAS?
  • Eligibility
  • Prior Authorization Process

2

  • On-going Operations
  • Q&A and Closing Remarks
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4/25/2013 2

History

  • California state budget no longer supports the continuation of

the ADHC

  • CalOptima implemented CBAS effective July 1, 2012.
  • CBAS Centers provide services similar to those provided by the

ADHC.

3

What is CBAS

4

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4/25/2013 3

What is CBAS – Cont.

  • Program offers daytime care and health and social services to

frail seniors and disabled adults.

  • Services enable participants to remain living at home instead of

a nursing facility.

  • Helps the whole person with a range of services that support

participants socially and physically.

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p p y p y y

  • Offers a safe and friendly environment for social interaction,

with supervised activities and nutritious meals.

What is CBAS – Cont.

  • CBAS is an outpatient, facility based program that provides

services and support to eligible Medi-Cal members.

  • CBAS services may include:
  • skilled nursing care
  • social services
  • physical therapy, speech therapy and occupational therapy
  • personal care

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  • family/caregiver training and support
  • meals while at the center
  • medication management and Health Services coordination
  • transportation to and from CBAS center
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4/25/2013 4

Eligibility

  • To be eligible for CBAS a member must:
  • Be a CalOptima Medi-Cal member
  • Be 18 years old or older
  • Have a physical, behavioral or memory problem
  • Q

lif f l t l t if t i i i t CBAS t

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  • Qualify for long-term placement if not receiving services at CBAS center

Member Choice

  • Member’s choice of center is critical and can be based on:
  • Geographic location
  • Cultural sensitivity of center
  • Cultural sensitivity of center
  • Language
  • Family/caregiver preference
  • Member choice influences:
  • Location and timing of face-to-face assessment
  • CBAS center selection

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C S ce te se ect o

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4/25/2013 5

Authorization Work Flow

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Ongoing Operations

  • Currently contracted and have arrangements with CBAS

centers in Orange County and bordering counties

  • 33 centers primarily utilized
  • 33 centers primarily utilized
  • Activity summary:

New Inq. F2F Appt. Sched. F2F Comp. TAT 3 Day IPC Auth. New Auths. Re- Auths. 729 674 645 7 25 593 367 2 449

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729 674 645 7.25 593 367 2,449

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4/25/2013 6

Ongoing Operations – Cont.

  • Authorizations include:
  • 2 – 5 days of service – based on IPC
  • 6 months with instruction to verify eligibility
  • 6 months with instruction to verify eligibility
  • Re-authorization process initiated prior to expiration
  • F2F repeated if request for decrease in days of service
  • Authorization process integrated into Prior Auth with dedicated

team that includes:

  • Medical Assistant and Nurse team

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ed ca ss sta t a d u se tea

  • Social workers to review inquiries and schedule F2F
  • Long Term Care Nurses and contracted Nurse to conduct F2F
  • Medical Director support

CalOptima Medical Department Contacts

  • Jim Banks – Director, Health Services

(714) 246-8530, jbanks@caloptima.org

  • Jim Pijloo – Manager, MSSP

(714) 246 8773 jpijloo@caloptima org (714) 246-8773, jpijloo@caloptima.org

  • Kymberli Vo – Program Specialist – Social Worker

(714) 796 -6114; kvo@caloptima.org

  • John Robertson, Manager, Prior Authorization

(714) 246-8774, jrobertson@caloptima.org

  • Edna McConnell Manager LTC

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Edna McConnell, Manager, LTC (714) 246-8828, emcconnell@caloptima.org CBAS dedicated Fax Lines: CBAS Dedicated line (855) 227-1314 Emergent/Urgent – (714) 481-6422 cbasteam@caloptima.org Routine – (714) 481-6423

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Questions & Answers

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CalOptima’s Mission

To provide members with access to quality health care services delivered in a cost-effective and compassionate manner.

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4/25/2013 3

Questions

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Closing

  • Complete Evaluations
  • Next session

Next session

  • July 30
  • Effect of Immigration Status on Benefits and Gap Services
  • Thank you

T rn in P rple E al ation Forms

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Turn in Purple Evaluation Forms