Intellectual Disabilities

Our mission is to provide supports that enable individuals with Developmental Disabilities and their families to participate fully in the community.

Developmental/Intellectual Disabilities Services & Supports

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Supports for Community Living Waiver (SCL)

Michelle P. Waiver (MPW)

General Services

 

SERVICE AREA: Cumberland Valley Area Development District – Harlan, Bell, Knox, Jackson, Clay, Laurel, Rockcastle, & Whitley Counties

ARRAY OF SUPPORTS/SERVICES: Cumberland River Behavioral Health (CRBH) provides a broad spectrum of supports/services aimed to support participants with developmental and/or intellectual disabilities to remain and become a vital part of their communities.  Funding sources include but not limited to Medicaid Waivers (SCL, MPW), State General Funds (SGF), various grants, self-pay, donations, etc.

 

  1. Supports for Community Living Waiver (SCL) provide an array of community supports to eligible individuals who meet Intermediate Care Facility criteria but choose to remain in or return to their community in the least restrictive environment as an alternative to institutional care. These supports are provided to a limited number of individuals determined by and reimbursed through the Kentucky Department for Medicaid Services (DMS). Participant Directed Services (PDS) gives SCL waiver recipients more choices in the way Medicaid Services are provided. The recipient and/or their designated representative manage the approved service units for needed services and hire their own staff.
  2. Michelle P. Waiver (MPW) provides an array of community supports to eligible individuals who meet Intermediate Care Facility or Nursing Home criteria but choose to remain in the community with supports (excluding residential supports). These supports are provided to a limited number of individuals determined and reimbursed through Kentucky Department for Medicaid Services (DMS).  Consumer Directed Option (CDO) gives MPW waiver recipients more choices in the way Medicaid Services are provided.  The recipient and/or their designated representative manage the approved budget for needed services and hire their own staff.
  3. General services which includes: Psychological; Misc. Goods and Services; Respite Care; Case Management; Outreach and Education; Transition; AFCHP; Personal Assistance; Day Training; Positive Behavior Support; Supported Employment; Community; PASRR; Staffed Residence. These services are provided on a sliding scale including self-pay, state general funding, and special grants.  Supported Employment is funded by a special grant from the Division of Developmental and Intellectual Disabilities (DDID) and funding for successful placements through the Department for Vocational Rehabilitation.  Hart-Supported Living, Crisis; Response/Prevention, and Individualized Supports are funded by a special allocation through the DDID at no cost to the recipient.  The PASRR Program is a state funded program.

 

 

SUPPORTS FOR COMMUNITY LIVING (SCL)

 

SUPPORTS FOR COMMUNITY LIVING:

 

Supports for Community Living is a community-based Kentucky Medicaid Waiver Program for individuals with developmental/intellectual disabilities which allows an individual to remain in or return to the community in the least restrictive environment as an alternative to institutional care.

 

TARGET POPULATION/ELIGIBILITY:

 

-Kentucky resident with developmental/intellectual disabilities

-Must be a Medicaid recipient.

-Must meet patient status criteria for placement in an Intermediate Care Facility for the

Intellectual disabilities (ICF-MR).

-Is authorized for the ASupports@ services by the Department of Medicaid Services (DMS) and

Department of Developmental and Intellectual Disabilities (DDID).

-Choose a case management agency such as CRBH from the Provider’s List obtained from DMR.

-The chosen case management agency indicates that they can meet the individual’s support needs.

 

WAITING LIST:

 

A person who meets the criteria for ICF-MR placement can submit an application through a case management agency such as CRBH to the DMR.  DMR will confirm receiving the application and place the individual’s name on a statewide waiting list.  An individual will be allocated potential funding based upon: (1) regional of origin, (2) category of need (emergency, urgent, or future planning) (3) and chronological date of placement on the state waiting list.

 

ADMISSION CRITERIA:

 

Admission into the SCL Waiver Program begins when an participant meets SCL eligibility criteria, has received notification of potential SCL funding from the Department of Behavioral Health, Developmental, and Intellectual Disabilities (DBHDID) and chooses CRBH to become the SCL Provider.  The participant’s support team will strive to gather the information required to complete and submit to DBHDID the application packet.  The participant will not be enrolled in the CRBH SCL Program in the event that it is determined that the program cannot meet the participant’s support needs.  The SCL Program will assist (within reason) the participant in identifying a SCL Provider that can provide the needed supports.

 

TYPE OF SERVICES:

 

  1. CASE MANAGEMENT:

 

Case Management is the provision of services to, or on behalf of, the participant/family with developmental/intellectual disabilities to assist him/her in accessing social, medical, educational and other services needs identified through a person-centered process.  Case Management includes:

  • Initiation, coordination, implementation, and monitoring of the assessment, reassessment, evaluation, intake, and eligibility process;
  • Assisting in the identification, coordination, and arrangement of the person centered team and person centered team meetings;
  • Facilitation of person centered team meetings that assist a participant to develop, update, and monitor the plan of care;
  • Assisting a participant to gain access to and maintain employment, membership in community clubs, groups, activities, and opportunities at the times, frequencies, and with the people the participant chooses;
  • Coordination and monitoring of all waiver and non-waiver services;
  • Assisting a participant in planning resource use and assuring protection of resources;
  • Monitoring to ensure that services continue if a participant has been terminated from any service until an alternative provider has been chosen and services approved;
  • Provide twenty four hour telephone access to case management staff;
  • Making monthly face-to-face visits with the participant.

 

SCL Case Management shall be “conflict free” unless the department grants an exemption to the conflict free requirement.

 

  1. COMMUNITY ACCESS:

 

Community Access is a service designed to support a waiver participant to become involved in clubs and organizations including recreational, educational, religious, civic, and volunteer opportunities with an outcome of less reliance on formal supports and more on natural supports such as neighbors, friends, and church members.

 

  1. COMMUNITY TRANSITION:

 

Community Transition offers funds for a participant moving from an institution or provider operated residential service to their own home.  This service provides reimbursement for certain one-time set-up expenses such a security deposits, essential household items such as furniture, window coverings, kitchen items, bath and bed linens, set-up fees for utility access such as electricity, telephone service, water or pest eradication, cleaning, and possibly minor accessibility adaptations.  The reimbursement is not to exceed $2000.00 per qualified move.

 

  1. CONSULTATIVE CLINICAL AND THERAPUETIC SERVICES:

 

Consultative Clinical and Therapeutic Services include professional consultation, evaluation and assessment of the person in the environment and the system of support for the person and their team.  The service may be provided by the following: certified nutritionist, licensed dietician, licensed marriage and family therapist, licensed professional clinical counselor, licensed psychological associate, licensed psychologist, licensed psychological practitioner, licensed clinical social worker, positive behavior support specialist.

 

  1. COMMUNITY LIVING SUPPORTS:

 

Community Living Supports are provided on a one-on-one basis to facilitate independence and promote integration into the community for individuals residing in their own home.  The supports include assistance, support (including reminding, observing, and guiding) and training in activities such as meal preparation, laundry, routine household care and maintenance, activities of daily living such as bathing, eating, dressing, personal hygiene, shopping and use of money, reminding, observing, and monitoring of medications, and non-medical care (not requiring nurse or physician intervention).

 

These supports also include socialization, relationship building, leisure choice and participation in community activities. These supports are based upon therapeutic goals and are not diversional in nature.

 

  1. DAY TRAINING SUPPORTS:

 

The Day Training programs are designed for adults 18 years and over with developmental/intellectual disabilities to provide:

  • meaningful activities that are designed to foster the acquisition of skills, build positive social behavior and interpersonal competence, foster greater independence and personal choice; and/or
  • career planning or pre-vocational activities to develop experiential learning opportunities and career options consistent with the participants skills and interests; or
  • supported retirement activities and supports to maintain skills and functioning and to prevent or slow regression of skills.

 

Day training services are documented with a note for each service rendered including date, location, times, and entry date of services and with a detailed monthly summary note for the month and year of the time period the note covers.  Day training services are limited to five days per week excluding weekends and 160 fifteen minute units per week alone or in combination with any hours of paid community employment or on-site supported employment service.

 

  1. RESPITE:

 

Respite services are services provided to individuals unable to care for themselves; furnished on a short-term basis because of the absence or need for relief of those persons normally providing the care.

 

Respite can be provided in a variety of settings including but not limited to:  individual’s home or place of residence; Medicaid certified ICF-MR; certified family-care homes or the home of an approved respite provider.

 

Respite shall be limited to 833 hours per calendar year.  Respite is available only to individuals living in family homes or their own homes.

 

  1. RESIDENTIAL SUPPORTS:

 

Residential Supports Services facilitate independence and promote integration into the community for an individual residing in an alternative living arrangement.  The supports include 24 hour supervision and assistance, support (including reminding, observing, or guiding) and training in activities such as meal preparation, laundry, routine household care and maintenance, activities of daily living such as bathing, eating, dressing, personal hygiene, shopping and money management, reminding, observing, and monitoring of medications, and non-medical care (not requiring nurse or physician intervention).  Money management includes such skills as coin recognition, making change, budgeting, etc.

 

These supports also include socialization, relationship building, leisure choices and participation in community activities.  CRBH provides the following residential options:

 

  • Residential Level I:  Residential Level I Supports are provided in an agency owned or leased staffed residence or group home which consists of a typical house or apartment in the local communities.

 

  • Residential Level II: Residential Level II Supports are provided in the family home of a contracted adult foster care provider.  This support is provided across the region in foster homes that meet the standards outlined in the SCL Medicaid Waiver regulations.

 

  1. SUPPORTED EMPLOYMENT:

 

Supported employment one-to-one supports are paid employment for individuals whom competitive employment at or above the minimum wage is unlikely, and who, because of their disabilities, need intensive ongoing support to perform in a work setting.  Vocational Rehabilitation funding must be exhausted prior to SCL funding supports.

 

  1. PERSONAL ASSISTANCE:

 

Personal Assistance services shall enable a person to accomplish tasks that the person normally would do for themselves if the person did not have a disability.  The supports include assistance, support (including reminding, observing, and guiding) and training in activities such as meal preparation, laundry, routine household care and maintenance, activities of daily living such as bathing, eating, dressing, personal hygiene, shopping and use of money, reminding, observing, and monitoring of medications, and non-medical care (not requiring nurse or physician intervention).

 

These supports also include socialization, relationship building, leisure choice and participation in community activities. These supports are based upon therapeutic goals and are not diversional in nature.

 

This is available only to a person who lives in their own residence.

 

  1. POSITIVE BEHAVIOR SUPPORTS:

 

Behavior support is the use of a planned systematic application of techniques and methods to influence or change behavior in a desired way.  It is based on the belief that behaviors are learned and are maintained because of their consequence.  The techniques are used to increase positive behavior and decrease undesirable behaviors.  The maladaptive or problem behavior is to be replaced with behaviors that are adaptive and appropriate.  Behavior support activities include evaluation of the individual’s environment and behavior including a functional assessment, development of a behavioral support plan, training staff regarding implementing the behavior plan and monitoring the individual’s progress for needed plan revisions.  Monitoring shall be accomplished through the reports of all staff involved in the individual’s supports.  One-to-one monitoring time by the behaviorist shall be minimal.

 

Problem behaviors necessitating the use of behavior support are those behaviors which:

 

(a)  are a danger to the person or others;

(b)  result in damage to property; or

(c)  interfere with educational or developmental programs or interfere with the

acceptance and integration into community activities.

All programming and activities shall be designed to equip the individual to communicate his/her needs and to participate in age appropriate activities.  Behavior support programs developed by the behavior specialist shall be implemented by provider staff of other program areas in all relevant environments and activities. For example, an day training provider may implement planned interventions during an individual’s day training program.

 

PARTICIPANT DIRECTED SERVICES:

 

Participant Directed Services (PDS) is an option provided by the Supports for Community Living waiver (SCL) that provides members more choices in the way some Medicaid services are provided.  With PDS, one can choose who will provide services needed as well as how, when and where services will be provided.  PDS allows participants to hire their own employees to provide services for them.  Services included in this Medicaid funded option are Community Access, Community guide services, Day Training, Personal assistance services, Respite, Shared Living, Goods and Services, and Supportive Employment.

There is also the option of blended services (PDS & traditional) or the member may return to traditional service delivery at any time with no loss of services.  A Case Manager will assist the participant with the process of developing and monitoring a plan of care, request and monitor a budget, submit criminal background checks of PDS employees, train PDS employees and conduct a monthly face-to-face home visit.   Anyone that chooses PDS must be capable of managing their own budget, hire staff, etc. or identify a representative to do so.  Residential and medical services are not covered under the PDS.

 

MICHELLE P. WAIVER (MPW)

 

MICHELLE P. WAIVER:

 

The Michelle P. Waiver program is a community-based Kentucky Medicaid Waiver Program designed to serve individuals who are Medicaid eligible and meet the criteria for an Intermediate Care Facility (ICF/MR) or a Nursing Home Facility.

 

TARGET POPULATION/ELIGIBILITY:

 

-Kentucky resident with developmental/intellectual disabilities

-Must be a Medicaid-eligible recipient.

-Must meet patient status criteria for placement in an Intermediate Care Facility (ICF-MR) or

Nursing Home.

-Is authorized for the “Supports” services by the Department of Medicaid Services (DMS) and

Department of Developmental and Intellectual Disabilities (DDID).

-Choose a participating Michelle P. provider such as CRBH.

-The chosen case management agency indicates that they can meet the individual’s support

needs.

 

TYPE OF SERVICES:

 

  1. Case Management:

 

If CRBH is the chosen MPW Provider, then CRBH provides the point of entry to coordinate the delivery of MPW services.  The case manager works with the individual and others identified by the individual, such as family, to develop an Individual Plan of Care utilizing a person-centered process, including planning to identify and implement strategies which include but are not limited to:

 

(a) Principles of empowerment;

(b) Community inclusion;

(c) Health and Safety assurances; and

(d) Use of informal supports.

 

Case Managers will work closely with the individual to assure his or her ongoing satisfaction with the process and outcomes of the supports, services, and available resources.

 

  1. Day Training Supports:

 

Day Training Services are provided on-site and off-site and are designed to support daily meaningful activities/routines in the community for individuals with developmental/intellectual disabilities 16 years of age and older..  Services include support training and intervention in the areas of self-care, sensory motor development, daily living skills, communication, behavior support, community living, and special skills development.  Often these services allow a person to transition from school to work (age 16-22), supported employment or competitive employment.

 

  1. Supported Employment:

 

Supported employment one-to-one supports are paid employment for individuals whom competitive employment at or above the minimum wage is unlikely, and who, because of their disabilities, need intensive ongoing support to perform in a work setting.  Paid employment must be in an environment in which an individual without disability is employed. Vocational Rehabilitation funding must be exhausted prior to MPW funding supports.

 

  1. Community Living Supports

 

Community Living Supports are provided on a one-on-one basis to facilitate independence and promote integration into the community for individuals residing in their own home or in his/her family’s home.  The supports may include assistance, support (including reminding, observing, and guiding) and training in activities such as meal preparation, laundry, routine household care and maintenance, activities of daily living such as bathing, eating, dressing, personal hygiene, shopping, money management, medications management, relationship building, leisure choices, and participation in community activities.  These supports are based upon therapeutic goals, are not diversional in nature and considered to be non-medical care (not requiring nurse or physician intervention).

 

  1. Behavior Support:

 

Behavior support is the use of a planned systematic application of techniques and methods to influence or change behavior in a desired way.  It is based on the belief that behaviors are learned and are maintained because of their consequence.  The techniques are used to increase positive behavior and decrease undesirable behaviors.  The maladaptive or problem behavior is to be replaced with behaviors that are adaptive and appropriate.  Behavior support activities include evaluation of the individual’s environment and behavior including a functional assessment, development of a behavioral support plan, training staff regarding implementing the behavior plan and monitoring the individual’s progress for needed plan revisions.  Monitoring shall be accomplished through the reports of all staff involved in the individual’s supports.  One-to-one monitoring time by the behavioral specialist shall be minimal.

Challenging behaviors necessitating the use of behavior supports are those behaviors which:

  1. are a danger to the person or others;
  2. result in damage to property; or
  3. interfere with educational or developmental programs or interfere with the acceptance
  4. and integration into community activities.

 

All programming and activities shall be designed to equip the individual to communicate his/her needs and to participate in age appropriate activities.  Behavior support programs developed by the behavior specialist shall be implemented by provider staff of other program areas in all relevant environments and activities. For example, a Day Training provider may implement planned interventions during an individual’s Day Training program.

 

  1. Respite:

 

Respite services are considered short-term care provided to an individual due to the absence or need for relief of the primary caretaker.  Direct-care staff provides services at a level which appropriately and safely meet the needs of the individual.

 

Respite can be provided in a variety of settings including but not limited to the individual’s home or place of residence.

 

  1. Environmental and Minor Home Adaptation:

 

This service may be a physical adaptation to a home that is necessary to ensure the health, welfare, and safety of a MPW recipient.  The adaptation must meet all applicable safety and local building codes and relate strictly to the recipient’s disability and needs.

 

  1. Homemaker:

 

Homemaker Services are  provided by direct-care staff and consist of general household activities to a MPW recipient who is functionally unable, but would normally perform age-appropriate homemaker tasks and if the caregiver regularly responsible for homemaker activities is temporarily absent or functionally unable to manage the homemaking activities.

 

  1. Personal Care:

 

Personal Care services are provided by direct-care staff and consist of assisting an individual with eating, bathing, dressing, personal hygiene, or other activities of daily living and be age appropriate.

 

  1. Attendant Care:

 

An attendant care service is provided by direct-care staff and consist of hands-on care to a MPW recipient that is medically stable but functionally dependent and requires care or supervision twenty-four (24) hours per day and has a family member or other primary caretaker who is employed and not able to provide care during working hours.  It is not of a general housekeeping nature and cannot be provided if the MPW recipient receives any of the following MPW services:  personal care, homemaker, Day Training, community living support or supported employment.

 

 

GENERAL SERVICES (GEN)

 

State General Funds

 

 

STATE GENERAL FUNDS:

State General Funds provide community-based services for individuals with I/DD that are provided in a manner that promotes dignity and respect, utilizes person-centered thinking and planning, emphasizes integrated community settings, builds natural supports in communities, and focuses on employment first.

 

TARGET POPULATION/ELIGIBILITY:

-Kentucky resident with developmental/intellectual disabilities

-The CMHC shall provide direct services to individuals with I/DD only if supports are not available to the individual through the school system, Medicaid waiver program, EPSDT, other Medicaid state plan services, or private insurance. Services may be provided for a limited period of time (sixty (60) days) while assisting an individual to become eligible for other funding sources.

 

TYPE OF SERVICES:

 

  1. Case Management: May include the initiation, coordination, implementation, and monitoring of the assessment, reassessment, evaluation, intake, and eligibility processes; assisting a person in the identification, coordination, and arrangement of the person-centered team; facilitating person-centered team meetings that assist a person to develop, update, and monitor the Plan of Care (POC) which shall be designed to meet the needs of the participant; and promotes choice, community experiences, employment, and personal satisfaction. Person-Centered Planning involves assisting the recipient in creating an individualized plan for services, paid and unpaid, needed for maximum independence and integration into the community. The plan is directed by the recipient and must include practitioners of the recipient’s choosing.

 

  1. Respite: Shall be provided to a person who resides in their own home or family’s home and is unable to independently administer self-care. Respite is provided on a short-term basis due to the absence or need for relief of an individual providing care to a participant.

 

  1. Supported Employment: Support and assistance provided in accessing and maintaining employment in an integrated community setting and includes person-centered job selection, job development and analysis, job acquisition with support and stabilization, and Long-term Employment Services. Long Term Employment Services are covered for any participant for whom a Long-Term Employment Support Plan has been developed and the plan has been incorporated into the participant’s plan of care. All other employment services are covered for participants who have exhausted services funded through the Rehabilitation Act of 1973 unless there has been an additional disability or the progression of the individual’s disability has far exceeded the original expectation. In which case, additional funding through the Rehabilitation Act may be available and shall be pursued.

 

Supported Employment is provided by certified provider that is also a vendor of supported employment services for the Office of Vocational Rehabilitation; delivered on a one (1) to one (1) basis with a participant or indirectly on behalf of a participant; and excludes work performed directly for the supported employment provider or in a group setting where the program participant is secluded from the population of coworkers not identified as program participants.

 

  1. Residential Services: Shall be provided in a provider owned or leased residence, in the home of an Adult Foster Care Provider or Family Home Provider, or in a person’s own home. Activities covered are necessary to promote increased independence; and be based on the needs of the person as reflected in the person-centered plan. Activities are intended to assure successful community living through utilization of skill training which may include adaptive skill development, assistance with activities of daily living, community inclusion, social and leisure development, protective oversight or supervision, transportation, personal assistance, and the provision of medical or health care services that are integral to meeting the participant’s daily needs.

 

  1. Day Training: Designed to foster the acquisition of skills, build positive social behavior and interpersonal competence, and foster greater independence and personal choice. Day training shall include informational sessions sponsored by the provider at least annually for the individual regarding community involvement or employment services and arrangement of opportunities for the participant to explore such opportunities in the community. May also include supported retirement activities that support a person in hobbies, clubs, or other senior-related activities in the community; or training and supports designed to maintain skills and functioning and to prevent or slow regression, rather than acquiring new skills or improving existing skills.

 

  1. Career Planning Activities: Designed to develop experiential learning opportunities and career options consistent with the participant’s skills and interests that are person-centered and designed to support employment related goals, provide active training designed to prepare a participant to transition from school to adult responsibilities, community integration, and work; and enable the person to attain the highest level of work in the most integrated setting with the job matched to the participant’s interests, strengths, priorities, abilities, and capabilities.

 

  1. Community Access: Is a service provided in integrated community settings. It is designed to support an individual to participate in meaningful routines, events, and activities through various community organizations and to develop personal social networks, membership opportunities, friendships, and relationships. Services are designed to empower the individual in developing natural supports; and stresses training that empowers the individual in acquiring, practicing, utilizing, and improving skills related to connecting with others: independent functioning, self-advocacy, community participation, personal responsibility, financial responsibility, or other skills related to optimal well-being as defined in the participant’s Plan of Care (POC). Community Access is an impact service and the POC shall define steps to decrease the provision of the service as the individual becomes more independent in accessing and becoming part of the community.

 

  1. Personal Assistance: For a participant residing in his or her own home, this service is designed to assist with independence in the community by providing routine personal care services such as bowel and bladder care, bathing, hygiene and grooming care, dressing, routine household care and maintenance, shopping, laundry, money management, medication management and meal preparation

 

  1. Psychological Testing (for diagnostic purposes to determine eligibility for available programs): Shall be provided by a licensed psychologist, licensed psychological practitioner, licensed psychological associate, certified psychologist with autonomous functioning, or certified school psychologist within their scope of practice.

 

  • Miscellaneous Goods: Equipment or supplies that are individualized and utilized to reduce the need for assistance with personal care or to enhance independence or safety in the home environment and allow an individual to maintain a stable living environment in the community through a decreased need for other services. Any good purchased shall exclude experimental or prohibited treatments and shall be clearly linked to a need.

 

  • Miscellaneous Services: Shall be individualized and used to enhance independence, inclusion in the community or safety in the home environment. Any service purchased shall exclude experimental or prohibited treatments and shall be clearly linked to a need.

 

  • Outreach and Education: Extending information and educational opportunities that may not otherwise be available to underserved populations, in community settings. These services are often mobile and may fill an identified gap in services. Facilitation of educational services can be geared towards entities such as individuals, groups, agencies, public or private, associations, or Boards. Facilitate activities and efforts to raise community awareness of services and supports available to individuals with I/DD. Tools identified for outreach, have included measures such as leaflets, newsletters, advertising, stalls and displays, or dedicated events with common locations such as libraries, community centers, markets, etc.

 

  • Transition: Facilitate outreach, information and assistance for all transition age youth, with I/DD, in the care of DCBS, age 16-20. May involve joint case planning, assistance with completing or arranging needed assessments, linkage with other opportunities such as the Office of Vocational Rehabilitation and natural supports that may facilitate transition into a person-centered, safe and healthy life after high school.

 

PASRR (D/ID)

MISSION:

To eliminate the practice of inappropriately placing persons with intellectual disability/related conditions in Medicaid certified nursing facilities and to ensure services are provided to make a person’s life more meaningful.

TARGET POPULATION:

This program provides supports and services to participants of any age across the region with developmental/intellectual disability residing in a nursing home.  This program takes a person-centered approach to developing a plan to make a person’s life more meaningful while residing at the nursing facility.

ADMISSION CRITERIA:

CRBH PASRR staff will conduct the PASRR Level II Evaluations for persons with serious mental illness and/or intellectual disability/related conditions.  Any individual identified through the PASRR process as being in need of specialized services for mental illness will be offered access to specialized services through the use of existing resources.

 

REFERRAL PROCESS:

DBHDID and DMS have designated the following as appropriate to initiate requests for PASRR evaluations and services directly to CRBH:

  • State guardianship officers;
  • CMHC staff;
  • DCBS staff;
  • State operated or contracted psychiatric hospital discharge planners; and
  • Private psychiatric hospital discharge planners with approval of center PASRR coordinator

 

The referral source is expected to be reasonably sure that the individual will meet the nursing facility level of care criteria and is also expected to provide the information needed.  A specific nursing facility should be identified prior to evaluation since PASRR determinations should be based on the scope of services provided by the particular facility.

 

TYPE OF SERVICES:

Services include level II evaluations and specialized services.  Components of specialized services include the following:

  1. Case Management

Specialized services should be initiated by assignment of a Case Manager to develop the Individual Support Plan for each individual with a Specialized Services recommendation.

 

  1. Person centered Planning

This process is central in providing for the needs of those with specialized service recommendations, as it is a plan based on the individual’s preferences and values. The plan reflects the needs, wants, and desires of the individual by assisting in fulfilling his/her goals as related to health issues, families, friendships, community inclusion and human services. This is achieved utilizing a facilitator, who may or may not be the Case Manager, and a team of supportive individuals who have true interest in the individual, are willing to take an active role in maintaining goal direction, and are outcome focused to stay active in participation. This plan should be available to all team members and Specialized Services Providers should encourage that a copy be maintained on the nursing facility record, along with the ISP and staff notes.

 

  1. Habilitative Therapies

Nursing facility staff members are responsible for implementing rehabilitative therapies related to acute or chronic medical condition(s). However, when a person has therapy needs that are related to their intellectual or developmental disability, these needs may be considered habilitative in nature. Each nursing facility should be able to provide an evaluation of the person’s physical, speech and, occupational therapy needs, whether Medicaid certifies implementation of such services or not. Utilizing these needs evaluations, develop a plan to have them implemented either through a contract service or the nursing home’s restorative therapy program. Habilitative therapies enhance quality of life and prevent deceleration in physical and/or psychological conditions.

 

  1. Recreational/Leisure Services

Recreational/Leisure services encompass a wide range of services and are important in promoting community reintegration. Recreational/Leisure services may also be very important for people who may not be able to leave the nursing facility because of the complexity of their medical issues.

 

  1. Behavioral Supports

Behavior is a form of communication; it is a way to express happiness, frustration, pain and the need to stop an activity or interaction. All humans communicate in this manner. When asked, we might say we are fine but our behavior may tell those who know us well that we are frustrated or in pain. Communicative functions include making requests, protests or refusals and comments or declarations. It is essential to understand the reason for behaviors. To do this, a caregiver should develop a relationship with the person and observe them. Most behavioral issues are due to the environment which includes the room, smells, lights, other people, staff and activities. Some behaviors can be predicted, such as a person having more difficulty in the evening or being withdrawn or angry when a preferred caregiver is on vacation.

 

Specialized Services may include positive behavioral supports which establish a plan for caregivers to help the person improve their coping skills and learn how to express themselves in a more acceptable manner. When a particular behavior or set of behaviors interferes with a person’s ability to function as independently as possible or poses a threat to themselves or others, special behavior supports may be indicated.

 

  1. Community Participation

In many cases, individuals are admitted to a nursing facility with an acute medical condition and require only a temporary nursing facility stay. Generally, an improvement in functioning will occur following successful rehabilitation services, or the individual’s general medical condition(s) stabilize and therefore no longer require the level of medical monitoring of a nursing facility environment. These persons should be referred by the nursing facility staff for a significant change in condition Level II evaluation. As a Specialized Services provider, you might often be the first to recognize this change. Please notify the appropriate nursing facility staff and the PASRR Coordinator for your specific region.

 

Some community placements which may be more appropriate for these individuals are provided through various Medicaid Programs, such as Supports for Community Living Waiver, Medicaid Home and Community Based Waiver, Traditional Home Health Services, Michelle P. Waiver, Money Follow the Person, and in cases of developmental disability related to head injuries, Acquired Brain Injury (ABI) and ABI Long Term Care Waiver.

 

In rare instances, the person’s needs might be better met in an ICF/MR setting to help in preparation for an upcoming community placement. ICF/MR placements are considered temporary and appropriate only when all other placements have been determined inappropriate.

 

 

Reviewed 3-6-15