Division of Medical Assistance
Annual Family Support Plan
(July 2003 - June 2004)
Overview of Family Support
• What is your agency's definition of family support?
Given the nature ofMedicaid business as a health insurer, our members receive family support in a wide variety of ways from state plan services such as personal care attendant and hospice care to Home and Community-Based waiver services such as respite for targeted populations. However, there is no specific state plan family support service.
DMA will no longer exist due to EOHHS reorganization. Our 950,000 members, particularly children, are served by many other human service agencies and most of those agencies are covered by Chapter 171 mandates. Consequently, it is difficult to apply all the principles of this bill, but we have provided answers to the following questions.
• What types of family support services are currently available?
This year the Division has focused on implementing a new pilot for children with complex medical needs who need private duty nursing. Please see attached document for a more detailed description.
• What is your network for providing family support services?
The network consists of a wide range of providers who support families in many diverse ways with state plan services; however, Medicaid dollars for this specific type of support come through the Home and Community-Based services waiver with DMR.
• How you got substantial consultation and input from families in the development of this plan?
DMA has participated in forums with DMR for. Chapter 171 planning. In addition, concerns about Medicaid accessibility were heard during Olmstead hearings in 2001-2002. However, we did have specific consultation with families whose children receive continuous skilled nursing. They were invited to attend five focus groups across the state.
I. Family Empowerment
What is the agency currently doing to promote or enhance family input or direction in the development of agency policies and procedures, program development, and evaluation of services?
All DMA changes in rules have public notice and comment periods. We also frequently have member, provider and advocate meetings on a host of issues.
How will your agency change how they are currently doing business to make their agency and services more family-friendly and provide opportunities for families and individuals to have greater input and influence.
Given reorganization, DMA will not exist as the agency it is today and while there will be a central coordinating Office ofMedicaid, most of your work in this area will be done through the mission agencies such as DMR, DMH, MCB, etc.
II. Family Leadership
What training opportunities doss the agency currently offer to families/individuals that would enhance their repertoire of skills?
Given the nature of our business, DMA has no specific initiatives in this area.
What new ideas or proposals would the agency initiate to give families/individuals more opportunities to develop and/or exercise their leadership skills?
This type of activity will be supported through the mission agencies.
III. Family Support Resources and Funding
What are the current resources/funding that the agency allocates to family support? What are ways that the agency provides flexible funding to families that allow them to customize their services?
As a purchaser of health insurance, DMA has no specific resources or services allocated to family support on the state plan.
Are their new initiatives proposed to help families design individualized services and supports?
Through a new Independence Plus grant from the Centers for Medicare and Medicaid Services, DMA and other EOHHS agencies will explore the concept of cashing out service plans, including Medicaid services, to allow families a budget to purchase services in non-traditional ways.
IV. Accessing Services and Supports
What are current examples of ways the agency is educating families on how to access services in a timely and effective manner? What are some illustrations of different services and resources, which promote good access to information and referral?
DMA has a customer service line and outreach workers in the field that are available to answer questions. In addition, case workers from all EOHHS agencies provide information about MassHealth/ Medicaid benefits.
What new initiative(s) will the agency undertake to promote good local access to information and resources?
The case management pilot described in the attachment will allow families a new resource to help their medically involved children understand their benefits and access them in a more timely fashion.
V. Culturally Competent Outreach & Support
What are the current activities or services that the agency offers that ensure culturally appropriate access and supports to ethnically, culturally, and linguistically diverse families and individuals?
DMA, in conjunction with UMass Medical School has sponsored many activities in recent years to enhance our providers' ability to be culturally competent. The majority of the focus has been in the area of acute and ambulatory providers such as physicians.
What new ideas/initiatives will the agency propose to outreach and meet the needs of culturally diverse families and individuals?
There are no new initiatives underway at this time that are directed by DMA.
VI. Interagency Collaboration
What are the current activities that the agency is collaborating with other EOHHS agencies to promote more effective service delivery and maximization of resources?
DMA participates in extensive collaborations with the other mission agencies that serve our children and adults with disabilities. This principle of collaboration applies across all the other EOHHS agencies; however, the agency or agencies collaborating with DMA depends on the service and the target population.
An example of this is the recent series of Durable Medical Equipment (DME) trainings conducted by Masshealth specifically for DMR area staff. These DMR staff are directly involved in assisting their members access Masshealth funded medical equipment and supplies. Masshealth is also participating in multi agency
discussions reviewing opportunities to maximize the utilization of assistive technology for all of its populations.
What new activities or initiatives does the agency propose to demonstrate the above goals?
One of the major thrusts of the EOHHS reorganization is to better align policies for populations agencies share. We fully expect that this reorganization will support all of the above principles.
COMMUNITY LONG TERM CARE
The Division of Medical Assistance, Office of Long Term Care, in conjunction with UMass Medical School, Commonwealth Medicine, is planning to implement a pilot Complex Care Management Program effective August 1,2003. This pilot is limited to pediatric members, defined as those children and young people under age twenty-two (22) who qualify for continuous nursing in the community. This is the pediatric population that qualifies for what is now known as the Private Duty Nursing Program.
October 15,2003; This program is now well underway with forty nine children fully enrolled and many others in various stages of enrollment. It is anticipated all children requiring continuous nursing services in the home (currently approx. 480 statewide) will be enrolled by Sept 2004.
The Pilot Consists of Two Major Initiatives:
1. Case Management:
UMass will develop and implement Case Management, that includes service authorization, as applicable, for certain Community Long Term Care services currently overseen in the Office of Long Term Care. Beginning Aug. 1, 2003, the Home Health benefit will require prior authorization for complex care members only. Services that require prior authorization include all Nursing, Home Health Aide services. Therapies provided by Home Health agencies and Independent Therapists, Durable Medical Equipment, Oxygen/Respiratory services and Personal Care Attendant services.
Nurse Case Managers will perform the initial comprehensive assessment for the child for whom services are sought. This face-to-face assessment will be done and a service plan developed in conjunction with the family and existing care providers. It is anticipated that many of these assessments will be done in the hospital as the child is discharged home for the first time. The Nurse Case Manager will follow the case, authorizing all of the services identified above, that are medically necessary, for as long a period of time as is clinically indicated. Families will be provided information on all available MassHealth providers and will choose which providers they will access. Families will have the name and contact information for their assigned Nurse Case Manager who will assist the family to access identified services.
A central file will be established and maintained by the UMass Nurse Case Manager for each of the children. Nurse Case Managers will work closely with other members of the UMass multidisciplinary team. Other members of the team planned at the present time include, but are not limited to, Physical Therapists, Occupational Therapists, and Respiratory Therapists. There will also be non-clinical administrative support staff. All members of the team will operate from the central file so as to avoid duplication and simplify the processing of requests for medically necessary products and services reimbursed by MassHealth. Nurse Case Managers will also support these members and their families with any other necessary DMA or EOHHS needs, working in concert with other departments and with other state agencies.
• October 15, 2003: UMass has added the services of a part time pediatrician to complement and support the case management staff
2. Personal Care Worker:
The pilot contemplates the establishment and authorization of a new service for complex care members only, the Personal Care Worker. The Personal Care Worker (PCW) is similar to a Personal Care Attendant but will be employed by the participating Home Health Agency, not by the member. Personal Care Workers will be employed by Home Health agencies that choose to participate in this model. Only those agencies providing continuous Nursing will be eligible to provide PCW services. These Home Health agencies will incorporate the PCWs into the multidisciplinary teams of professionals assigned to these pediatric cases, as clinically appropriate. Families will make the ultimate determination as to who that worker will be. Families will have the opportunity to review resumes and interview the PCW before they will be assigned. The function of PCWs will be to support the primary caregiver and / or clinical professional with the care needs of the member. PCWs are not a substitute for Nursing. They are an additional support that the family may choose to access if the member qualifies. Only those complex care members who qualify for continuous Nursing will be able to access the Personal Care Worker service at this time.
If families are currently using the Personal Care Attendant (PCA) Program, or choose to access that program at any time, they may continue to do so. The Nurse Case Manager will authorize all medically necessary PCA services based on the comprehensive clinical assessment done at intake and updated as necessary.
October 15, 2003: Response to this program by families has been positive. All children enrolled have been visited by the nurse case manager either at the hospital or home or school as appropriate. Families have been directly involved in the assessments and have been actively communicating their clinical needs to the UMass case managers. Families have been able to receive answers to their questions and information about MassHealth funded services directly from the case managers. Administrative staff is on duty during business hours to support the program and to triage any calls from families or providers to appropriate clinical staff.
A series of five family focus groups was conducted across the Commonwealth immediately prior to the inception of this program. Families and their advocates were able to provide input and to help shape the initial roll-out of the program. The focus groups will begin again in the near future, now that there are several months of experience to review. As well as collaboration with families, there has been outreach to the other involved state agencies, MCB, DPH, DMR in particular. The professional relationships are being enhanced as we work together to better serve the needs of children with special health care needs in the Commonwealth.
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