(a) Case management services involve ongoing assessment, service planning and implementation, service monitoring and evaluation, member advocacy, and discharge planning.

• (1) Within one working day of receipt of an ADvantage referral from the ADvantage Administration (AA), the case management supervisor assigns a case manager to the member.  Within three working days of being assigned an ADvantage member, the case manager makes a home visit to review the ADvantage program (its purpose, philosophy, and the roles and responsibilities of the member, service provider, case manager, AA and OKDHS in the program), and review, update and complete the UCAT assessment, and to discuss service needs and ADvantage service providers.  The Case Manager notifies in writing the member's UCAT identified primary physician that the member has been determined eligible to receive ADvantage services.  The notification is via a preprint form that contains the member's signed permission to release this health information and requests physician's office verification of primary and secondary diagnoses and diagnoses code obtained from the UCAT.
• (2) Within 14 calendar days of the receipt of an ADvantage referral, the case manager completes and submits to the AA an individualized care plan and service plan for the member, signed by the member and the case management supervisor. The case manager completes and submits to the AA the annual reassessment service plan documents no sooner than 60 days before the existing service plan end date but sufficiently in advance of the end date to be received by the AA at least 30 calendar days before the end date of the existing service plan.  Within 14 calendar days of receipt of a Service Plan Review Request (SPR) from the AA, the Case Manager provides corrected care plan and service plan documentation.  Within five calendar days of assessed need, the case manager completes and submits a service plan addendum to the AA to amend current services on the care plan and service plan.  The care plan and service plan are based on the member's service needs identified by the UCAT, Part III, and includes only those ADvantage services required to sustain and/or promote the health and safety of the member.  The case manager uses an interdisciplinary team (IDT) planning approach for care plan and service plan development.  If in-home care is the primary service, the IDT includes, at a minimum, the member, a nurse from the ADvantage in-home care provider chosen by the member, and the case manager.  Otherwise, the member and case manager constitute a minimum IDT.
• (3) The case manager identifies long-term goals, challenges to meeting goals, and service goals including plan objectives, actions steps and expected outcomes.  The case manager identifies services, service provider, funding source, units and frequency of service and service cost, cost by funding source and total cost for ADvantage services.  The member signs and indicates review/agreement with the care plan and service plan by indicating acceptance or non-acceptance of the plans.  The member, the member's legal guardian or legally authorized representative shall sign the service plan in the presence of the case manager.  The signatures of two witnesses are required when the member signs with a mark.  If the member refuses to cooperate in development of the service plan, or, if the member refuses to sign the service plan, the case management agency refers the case to the AA for resolution.  In addition, based on the UCAT and/or case progress notes that document chronic uncooperative or disruptive behaviors, the LTC nurse or AA may identify members that require AA intervention.
  • (A) For members that are uncooperative or disruptive, the AA develops an individualized Addendum to the Rights and Responsibilities Agreement to try to modify the member's uncooperative/disruptive behavior.  The Rights and Responsibilities addendum focuses on behaviors, both favorable and those that jeopardize the member's well-being and includes a design approach of incremental plans and addenda that allow the member to achieve stepwise successes in the modification of their behavior.
  • (B) The AA may implement a service plan without the member's signature if the AA has developed an Addendum to the Rights and Responsibilities Agreement for the member.  For these members the presence of a document that "requires" their signature may itself trigger a "conflict".  In these circumstances, mental health/behavioral issues may prevent the member from controlling their behavior to act in their own interest.  Since the person by virtue of level of care and the IDT assessment, needs ADvantage services to assure their health and safety, the AA may implement the service plan if the AA demonstrates effort to work with and obtain the member's agreement through an individualized Addendum to the Rights and Responsibilities Agreement.  Should negotiations not result in agreement with the care plan and service plan, the member may withdraw their request for services or request a fair hearing.
• (4) CD-PASS Planning and Supports Coordination.
  • (A) The ADvantage Case Management provider assigns to the CD-PASS member a Case Manager that has successfully completed training on CD-PASS, Independent Living Philosophy and Person-Centered Planning.  Case Managers that have completed this specialized CD-PASS training are referred to as Consumer-Directed Agent/Case Managers (CDA/CM) with respect to their CD-PASS service planning and support role in working with CD-PASS members.  The CDA/CM educates the member about their rights and responsibilities as well as about community resources, service choices and options available to the member to meet CD-PASS service goals and objectives.
  • (B) The member may designate a family member or friend as an "authorized representative" to assist in the service planning process and in executing member employer responsibilities.  If the member chooses to designate an "authorized representative", the designation and agreement identifying the "willing adult" to assume this role and responsibility is documented with dated signatures of the member, the designee and the member's Case Manager or the AA staff.
    • (i) A person having guardianship or power of attorney or other court sanctioned authorization to make decisions on behalf of the member has legal standing to be the member's designated "authorized representative".
    • (ii) An individual hired to provide Personal Services Assistance to a member may not be designated the "authorized representative" for the member.
  • (C) The CDA/CM provides support to the member in the Person-Centered CD-PASS Planning process.  Person-Centered Planning is a process directed by the participant, with assistance as needed from an "authorized representative" or support team.  The process supports the member to exercise choice and control and to assume a responsible role in developing, implementing and managing their services and supports.  The process is intended to identify the strengths, capacities, preferences, needs and desired outcomes of the participant and it may enlist assistance from individuals freely chosen by the participant to serve as important contributors.  The Person-Centered Planning process enables the participant to identify and access a personalized mix of paid and non-paid services and supports to help him/her achieve personally-defined outcomes in the most inclusive community setting.  The focus of Person-Centered Planning is on the individual's development of personal relationships, positive roles in community activities, and self-empowerment skills.  Decisions are made and outcomes controlled by the participant.  Strengths, preferences and an individualized system of support are identified to assist the individual to achieve functional and meaningful goals and objectives.  Principles of Person-Centered Planning are as follows:
    • (i) The person is the center of all planning activities.
    • (ii) The member and their representative, or support team, are given the requisite information to assume a controlling role in the development, implementation and management of the member's services.
    • (iii) The individual and those who know and care about him or her are the fundamental sources of information and decision-making.
    • (iv) The individual directs and manages a planning process that identifies his or her strengths, capacities, preferences, desires, goals and support needs.
    • (v) Person-Centered Planning results in personally-defined outcomes.
  • (D) The CDA/CM encourages and supports the member, or as applicable their designated "authorized representative", to lead, to the extent feasible, the CD-PASS service planning process for Personal Services Assistance.  The CDA/CM helps the member define support needs, service goals and service preferences including access to and use of generic community resources.  Consistent with member-direction and preferences, the CDA/CM provides information and helps the member locate and access community resources.  Operating within the constraints of the Individual Budget Allocation (IBA) units, the CDA/CM assists the member in translating the assessment of member needs and preferences into an individually tailored, personalized service plan.
  • (E) To the extent the member prefers, the CDA/CM develops assistance to meet member needs using a combination of traditional Personal Care and CD-PASS PSA services.  However, the CD-PASS IBA and the PSA unit authorization will be reduced proportional to agency Personal Care service utilization.
  • (F) The member determines with the PSA to be hired, a start date for PSA services.  The member coordinates with the CDA/CM to finalize the service plan.
  • (G) Based on outcomes of the planning process, the CDA/CM prepares an ADvantage service plan or plan amendment to authorize CD-PASS Personal Service Assistance units consistent with this individual plan and notifies existing duplicative Personal Care service providers of the end date for those services.
  • (H) If the plan requires an APSA to provide assistance with Health Maintenance activities, the CDA/CM works with the member and, as appropriate, arranges for training by a skilled nurse for the member or member's family and the APSA to ensure that the APSA performs the specific Health Maintenance tasks safely and competently;
    • (i) If the member's APSA has been providing Advanced Supportive Restorative Assistance to the member for the same tasks in the period immediately prior to being hired as the PSA, additional documentation of competence is not required;
    • (ii) If the member and APSA attest that the APSA has been performing the specific Health Maintenance tasks to the member's satisfaction on an informal basis as a friend or family member for a minimum of two months in the period immediately prior to being hired as the PSA, and no evidence contra-indicates the attestation of safe and competent performance by the APSA, additional documentation is not required.
  • (I) The CDA/CM monitors the member's well being and the quality of supports and services and assists the member in revising the PSA services plan as needed.  If the member's need for services changes due to a change in health/disability status and/or a change in the level of support available from other sources to meet needs, the CDA/CM, based upon an updated assessment, amends the service plan to increase CD-PASS service units appropriate to meet additional member's need and forwards the plan amendment to the AA for authorization and update of the member's IBA.
  • (J) The CDA/CM uses the ADvantage Risk Management process the results of which are binding on all parties to resolve service planning or service delivery disagreements between members and ADvantage service providers under the following circumstances:
    • (i) A claim is formally registered with the CDA/CM by the member (or the member's family or "authorized representative"), the AA, or a provider that the disagreement poses a significant risk to the member's health or safety; and
    • (ii) The disagreement is about a service, or about the appropriate frequency, duration or other aspect of the service; or
    • (iii) The disagreement is about a behavior/action of the member, or about a behavior/action of the provider.
  • (K) The CDA/CM and the member prepare an emergency backup/emergency response capability for CD-PASS PSA services in the event a PSA provider of services essential to the individual's health and welfare fails to deliver services.  As part of the planning process, the CDA/CM and member define what failure of service or neglect of service tasks would constitute a risk to health and welfare to trigger implementation of the emergency backup.  Any of the following may be used in planning for the backup:
    • (i) Identification of a qualified substitute provider of PSA services and preparation for their quick response to provide backup services when called upon in emergency circumstances (including execution of all qualifying background checks, training and employment processes); and/or,
    • (ii) Identification of one or more qualified substitute ADvantage agency service providers (Adult Day Care, Personal Care or Nursing Facility Respite provider) and preparation for their quick response to provide backup services when called upon in emergency circumstances.
  • (L) If the emergency backup fails, the CDA/CM is to request the AA to authorize and facilitate member access to Adult Day Care, Agency Personal Care or Nursing Facility Respite services.
• (5) The case manager submits the care plan and service plan to the case management supervisor for review.  The case management supervisor documents the review/approval of the plans within two working days of receipt from the case manager or returns the plans to the case manager with notations of errors, problems, and concerns to be addressed.  The case manager re-submits the corrected care plan and service plan to the case management supervisor within two working days.  The case management supervisor returns the approved care plan and service plan to the case manager.  Within one working day of receiving supervisory approval, the case manager forwards, via postal mail, a legible copy of the care plan and service plan to the AA.  Case managers are responsible for retaining all original documents for the member's file at the agency.  Only priority service needs and supporting documentation may be faxed to the AA with the word, "PRIORITY" being clearly indicated and the justification attached.  "Priority" service needs are defined as services needing immediate authorization to protect the health and welfare of the member and/or avoid premature admission to the nursing facility.  Corrections to service conditions set by the AA are not considered to be a priority unless the health and welfare of the member would otherwise be immediately jeopardized and/or the member would otherwise require premature admission to a nursing facility.
• (6) Within one working day of notification of care plan and service plan authorization, the case manager communicates with the service plan providers and with the member to facilitate  service plan implementation.  Within one working day of receipt of a copy or the computer-generated authorized service plan from the AA, the case manager sends (by mail or fax) copies of the authorized service plan or computer-generated copies to providers.  Within five working days of notification of an initial or new service plan authorization, the case manager visits the member, gives the member a copy of the service plan or computer-generated copy of the service plan and evaluates the progress of the service plan implementation.  The case manager evaluates service plan implementation on the following minimum schedule:
  • (A) within 30 calendar days of the authorized effective date of the service plan or service plan addendum amendment; and
  • (B) monthly after the initial 30 day follow-up evaluation date.

(b) Authorization of service plans and amendments to service plans.  The ADvantage Administration (AA) certifies the individual service plan and all service plan amendments for each ADvantage member.  When the AA verifies member ADvantage eligibility, plan cost effectiveness, that service providers are ADvantage authorized and SoonerCare contracted, and that the delivery of ADvantage services are consistent with the member's level of care need, the service plan is authorized.  Except as provided by the process described in OAC 317:30-5-761(6), family members may not receive payment for providing ADvantage waiver services.  A family member is defined as an individual who is legally responsible for the member (spouse or parent of a minor child).

• (1) If the service plan authorization or amendment request packet received from case management is complete and the service plan is within cost effectiveness guidelines, the AA authorizes or denies authorization within five working days of receipt of the request.  If the service plan authorization or amendment request packet received from case management is complete and the service plan is not within cost-effectiveness guidelines, the plan is referred for administrative review to develop an alternative cost-effective plan or assist the member to access services in an alternate setting or program.  If the request packet is not complete, the AA notifies the case manager immediately and puts a "hold" on authorization until the required additional documents are received from case management.
• (2) The AA authorizes the service plan by entering the authorization date and signing the submitted service plan.  Notice of authorization and a copy of the authorized plan or a computer-generated copy of the authorized plan are provided to case management.  AA authorization determinations are provided to case management within one working day of the certification date.  A service plan may be authorized and implemented with specific services temporarily denied.  The AA communicates to case management the conditions for approval of temporarily denied services.  The case manager submits revisions for denied services to AA for approval.
• (3) For audit purposes (including SURS reviews), the computer-generated copy of the authorized service plan is documentation of service authorization for ADvantage waiver and State Plan Personal Care services.  State or Federal quality review and audit officials may obtain a copy of specific service plans with original signatures by submitting a request to the AA.

(c) Change in service plan.  The process for initiating a change in the service plan is described in this subsection.

• (1) The service provider initiates the process for an increase or decrease in service to the member's service plan.  The requested changes and justification for them are documented by the service provider and, if initiated by a direct care provider, submitted to the member's case manager.  If in agreement, the case manager requests the service changes on a care plan and service plan amendment submitted to the AA within five calendar days of assessed need.  The AA approves or denies the care plan and service plan changes within five calendar days of receipt of the plan.
• (2) The member initiates the process for replacing Personal Care services with Consumer-Directed Personal Services and Supports (CD-PASS) in geographic areas in which CD-PASS services are available.  The member may contact the AA using a CD-PASS services request form provided by the Case Manager or by calling the toll-free number established to process requests for CD-PASS services.
• (3) A significant change in the member's physical condition or caregiver support, one that requires additional goals, deletion of goals or goal changes, or requires a four-hour or more adjustment in services per week, requires a UCAT reassessment by the case manager.  The case manager, in consultation with AA, makes the determination of need for reassessment.  Based on the reassessment and consultation with the AA, the member may, as appropriate, be authorized for a new service plan or be eligible for a different service program.  If the member is significantly improved from the previous assessment and does not require ADvantage services, the case manager obtains the member's dated signature indicating voluntary withdrawal for ADvantage program services.  If unable to obtain the member's consent for voluntary closure, the case manager requests assistance from the AA.  The AA requests that the OKDHS area nurse initiate a reconsideration of level of care.  If the member's service needs are different or have significantly increased, the case manager develops an amended or new service plan and care plan, as appropriate, and submits the new/amended plans for authorization.