1. Managed Care Organization Overview WELCOME

2. AGENDA Introductions and Opening Comments History Eligibility Transition Coordination Waiver Interaction Question & Answer / Closing Comments

3. HISTORY Karen Peed Project Director

4. WHAT IS MOVING HOME MN? Federal Demonstration project Know by its Federal name as “Money Follows the Person” Assists in the transition from institutional care to care and support in the community Allows states to develop, implement and evaluate services not otherwise covered by traditional waivers

5. MHM MISSION STATEMENT Creating choice and opportunity for Minnesotans to move from institutions to homes and communities, live more independently, and enhance the quality of their own lives

6. WHY MHM MATTERS TO THE CLIENT Focus on community integration Person-Centered Planning Planning for safety (risk mitigation) Additional services, alternatives and choices Expanded benefit set in transitioning and supporting the client for the first 365 days

7. WHY MHM MATTERS TO THE LEAD AGENCY Provides more tools and resources to assist in transitioning client to community of choice Can allow for an additional 180 days Transition Service Coordination if the client is unable to successfully transition using Relocation Service Coordination Provides compliance to Olmstead Act and Jensen Settlement

8. ELIGIBILITY OVERVIEW Nancy Schultz Eligibility Specialist

9. WHO IS ELIGIBLE? Residents of Minnesota Any age or disability group Those who have 90 consecutive days in one (1) or a combination of Qualified Institution(s) Those qualified to receive Medical Assistance (MA) prior to discharge, and who maintain MA eligibility post discharge Those whose MA has paid for at least one (1) day of institutional care prior to discharge

10. QUALIFYING INSTITUTIONS Nursing Facilities Hospitals Intermediate Care Facilities for Developmentally Disabled (ICF/DD) Institutions for Mental Disease (IMD) Under 21 or over 65 years of age only

11. QUALIFIED INSTITUTIONS

14. INST FOR MENTAL DISEASE (IMD) Hospital, nursing facility or other institution with 17 or more beds Primary focus is providing diagnosis, treatment and/or care of mental health disorders References: Code of Federal Regulations, Title 42, Chapter IV MN Health Care Programs Manual, 03.45.25

15. MENTAL HEALTH IMD PROGRAMS Anoka Metro Regional Treatment Center Andrew Board & Care (Minneapolis) Prairie Saint Johns (Fargo) Richard P Stadter Psychiatric Center (Grand Forks)

16. CHEM DEP IMD PROGRAMS

17. WHO CAN APPLY Intake Form can be completed by: client family member social worker case manager care coordinator any other invested party acting with permission of the client

18. METHODS TO APPLY Online via DHS eDocs (easiest/fastest) Enter 5032 in the search field Mail: PO Box 64250, St Paul MN 55164 Fax: (651) 431-7745

19. METHODS TO APPLY By Phone: Disability Linkage Line (800) 333-2466 Senior Linkage Line (800) 333-2433 MHM Intake (651) 431-3951

20. WHO ACTS AS LEAD AGENCY? Health Care ProductActing Lead Agency Enrolled in MSHO or MSC+ (age 65 and over) Managed Care Organization Enrolled in SNBC (under or over age 65) County or Tribe PMAPCounty or Tribe Fee-for-Service MA (not enrolled in Managed Care) County or Tribe

21. APPROVAL PROCESS: INTAKE Applicant Identified Completed Intake Form Submitted

22. APPROVAL PROCESS: VERIFICATION DHS determines eligibility DHS notifies client/Lead Agency of result If eligible, Lead Agency assigns a Transition Coordinator Care Coordinator MHM Transition Coordinator (delegated) Other qualified provider

23. APPROVAL PROCESS: COMPLETION ● Transition Coordinator meets with client ● Informed Consent is signed/returned ● Client/Lead Agency informed and services can now begin and be billed

24. TRANSITION COORDINATION OVERVIEW Nancy Schultz Eligibility Specialist

25. TC RESPONSIBILITIES Meets with client face-to-face to complete the following: Informed Consent (DHS-6795I) Housing Transitions Worksheet (DHS-6759G)

26. LEAD AGENCY RESPONSIBILITIES Pre-transition: Screenings (MnChoices/LTCC/DD) Assessments Determination/Approval of Services including waiver Assignment of Transition Coordinator MMIS maintenance (RLVA, RELG etc)

27. TRANSITION COORDINATION Includes two (2) categories in which participants will be eligible for 180 days from the date Informed Consent is signed Transition Planning Transition Services

28. TRANSITION PLANNING Activities required for development and completion of a Person Centered Plan DHS-6759G Transition Worksheet DHS-6759J Planning Tool Part 1 DHS-6759K Planning Tool Part 2

29. TRANSITION SERVICES (T2038) Transportation to research/locate housing or opportunities (MHM) Funds for furnishings, deposits, moving expenses (EW) Purchase of items related to establishing and setting up a household (EW)

30. WHAT IS A QUALIFIED RESIDENCE? Home, owned or leased by the individual or individual’s family Apartment with an individual lease Assisted Living for those aged 55+ Community-based residential setting in which no more than four (4) unrelated persons reside Adult Foster Care

31. ADULT FOSTER CARE EXCEPTION If the residence is licensed for a fifth crisis bed, the residence becomes non- qualified for any MHM clients when/if the fifth bed is occupied.

32. WHAT IS A QUALIFIED RESIDENCE? Any residence must have lockable access and egress Must include separate living, sleeping, bathing and cooking areas

33. TC REPORTING RESPONSIBILITIES Request for assistance with housing, employment or mental health services Estimated transition date as soon as possible Actual transition date with housing type and client information as requested Use encrypted methods when communicating any identifiable/protected information

34. TC REPORTING RESPONSIBILITIES Warm hand off to Waiver Case Manager Client status or condition changes

35. WAIVER INTERACTION Patrick Alford Eligibility Specialist

36. REFERRAL FROM TC TO CM Client estimated move date identified Transition Coordinator notifies DHS of move plans via Communication Form

37. REFERRAL FROM TC TO CM TC and CM arrange to make transfer of Person Centered Plan and case details TC informs client of case transfer details

38. WARM TRANSFER TO CM All MHM Transition Planning Documents Status of application for public assistance benefits (i.e. SNAP, cash, Social Security) Status of any outstanding equipment orders

39. MHM EXPECTATIONS Active engagement with clients Assessment of client priorities, strengths and challenges Development/refinement of Person- Centered Plan based on current need and potentially changing circumstances

40. MHM EXPECTATIONS Monitoring of service delivery Evaluation of outcomes Closure, including participation termination and/or transactional follow-through

41. POST TRANSITION SERVICES Participants of all populations can be eligible for 365 days of post-transition services once transitioning to the community (with or without a waiver)

42. POST TRANSITION SERVICES Case Management EW waiver requirement to participate Home Care Training family and non-family Comprehensive Community Support Services Overnight Assistance Certified Peer Specialist

43. NEEDS ASSESSMENT At initial meeting and interview with client, review all Transition Planning Documents Identify and prioritize specific, attainable, measurable objectives and steps/parties to attain those objectives

44. NEEDS ASSESSMENT Revise the PCP to the client’s current needs and strengths to best foster self- sufficiency Delineate responsibilities of CM, client, and other involved parties integral to service planning and successful implementation

45. EVALUATIONS AND FOLLOW UP MHM clients are followed by two different methods during transition: Quality of Life Survey (Vital Research) Senior Linkage Line

46. QUALITY OF LIFE SURVEY Required by Centers for Medicare and Medicaid (CMS) 15-20 minute face-to-face survey, can be refused ay any time Seven (7) domains covered: Living situation Choice and control Access to personal care Respect/dignity Community integration/inclusion Health status Overall life satisfaction

47. QUALITY OF LIFE SURVEY To procure timely interview scheduling, 2 week notice of move is requested Conducted at 3 points in time: Prior to discharge At 11 months after discharge At 24 months after discharge

48. Questions?

49. CONTACT US MHM Intake (651) 431-3951 voice (651) 431-7745 fax movinghomemn.mfp@state.mn.us

50. Thank you for all do you on behalf of MHM clients! FINAL WORD