1. Health and Wellness Unit Acuity Level 4, 5 & 6 Determination Training February 23, 2016 Presented by: Shirley Quarles-Owens, RN MSN

2. Contact Phone number for the Person submitting Acuity Packet : _______________________________ Email: _______________________________________

3. *_______Documentation reviewed supports Provider’s recommendation for Acuity Level______________ *_______Documentation reviewed does not support recommendation. Documentation supports recommendation for Acuity Level_____________ DDA Staff Signature/Title__________________________________________________________________ Date______________

4. General Requirements All packets must be completed in accordance to the guidelines as outlined in the DCMR 4101.3(a) standards. These documents must be current and legible as this can delay the packet from being forwarded to DHCF. All packets should be completed and in hand of SC at the ISP meeting. SC should sign for the packet and date receipt. LON scores must support requested rate in order to be approved for the acuity level.

5. All acuity packets are logged-in by the staff assistant for Service Planning and Coordination Division for receipt time/date. Acuity packets for levels 4, 5 and 6 are transported to the Health and Wellness Unit Administrative Assistant to be logged-in for receipt time/date. Immediately is given to the H&W supervisor (review/assign). A nurse reviews the packet for completeness, meeting the standard requirements and justification purposes. After the reviewing process (2-3 days or sooner), the reviewer will write and highlight the total number of hours and duration being requested for the acuity level on the front of the packet. All completed packets needing no revisions will be scanned and emailed to DHCF. Providers with packet(s) needing revisions will receive an email from the nurse describing what is needed (e.g., SC, Exec staff, DON, QIDP/RN). General Processes

6. Top Concerning Factors Regarding Acuity Packets Acuity Packets that don’t meet the standards as required for the level being requested (e.g., incomplete physician or APRN order, etc.). Acuity Packets are unorganized with missing documents Acuity Packets are too bulky and thick Acuity Packets with another person’s information Acuity Packets with documents needing to be revised or outdated. No contact information provided. At times there is a repeated need to contact providers for the corrected information over the 72-hour time period. This delays the packet to being submitted to DHCF.****

7. Top Concerning Factors Regarding Acuity Packets Writing the Physician’s or APRN verbal or telephone order on an already transcribed Physician Order Sheet (POS). Sending the Health Passport, Medical Administrative Records (MAR), Lab Work and HCMP with your packets for supporting data. The information must be relevant to the acuity level request.

8. Acuity Level Determination Checklist Review the DCMR 4101.3(a) standards for the requested level. Take the time to assure that all supported information is included in the acuity packet The checklist should be used EVERYTIME you are putting your acuity packets together. Follow the checklist to ensure that you have all items needed for the requested level. Don’t wait until the last minute to get your items together. Don’t check-off any items until your final review of the acuity packet to be submitted to your service coordinator.

9. The Four Basic Documents Among all of the acuity level determination categories, the following four documents are required: LON Medical Assessment Psychological Assessment ISP When organizing your acuity packets, make sure these four documents are at the top of your list.

10. Common Mistakes (LON) The Level of Need (LON) describes the health care needs of the person to optimize their plan of care and to provide a score for the rate of services. LON submitted with the packet is still in progress status. If not completed in MCIS, then DHCF will not accept it. LON is marked incorrectly LON isn’t legible (printing issues) LON is missing from the packet LON is Blank

11. Acuity Level-4 Determination

12. Acuity Level – 4 Extensive-Medical  A beneficiary shall qualify for Acuity Level 4 (Extensive – Medical) when he or she requires skilled nursing and extensive health and habilitation supports on a daily basis. Skilled nursing and extensive health and habilitation supports shall be prescribed by the person’s primary care physician or advanced practice registered nurse.  Does the person require services and intervention that can address conditions associated with a significant intellectual and developmental disability and significant medical and support challenges?

13. What’s Important About Acuity Level-4? The Physician or Advanced Practice Nurse Order Is Always Required!! The prescription for the skilled nursing must include the Type, Frequency, Scope and Duration.

14. Physician/APRN Order Type: Acuity Level 4 Skilled Nursing/Extensive Medical Frequency: Total number of hours (just writing daily is not acceptable and daily doesn’t mean 24 hours). The number hours needed could be (e.g., 12 hours). You must be able to justify the number of hours being requested. Scope: Why is skilled nursing being requested? (e.g., Is the skilled nursing for wound care, suctioning, etc.)? Duration: How long do you need the skilled nursing? (e.g., Mon, Wed, and Fri) or 7-days per week.

15. Acuity Level – 4 Packet Contents  The four common most recent documents are: 1) Level of Need Assessment 2) ISP 3) medical and 4) psychological assessments  Physician or APRN order (Type, Frequency, Scope and Duration)  Supporting documents (clinician team assessments, incident reports, hospital recommendations, etc.)

16. Acuity Level 5 Determination

17. Acuity Level – 5 Pervasive  Acuity Level 5 (Pervasive) shall represent the health, habilitation, and support needs of a beneficiary who meets the requirements of Section II.C.1. and requires services and interventions that can address conditions associated with a pervasive intellectual and developmental disability and who exhibits dangerous behaviors and/or conditions that require one-to-one (1:1) supervision for twenty-four (24) hours per day or less, as described in Section II.J.; and

18. Acuity Level – 5 A beneficiary shall qualify for Acuity Level 5 (Pervasive) when he or she requires one-to-one (1:1) staffing and exhibits one (1) or more of the following characteristics:  A history of, or is at high risk for, elopement resulting in risk to beneficiary or others;  Exhibits behavior that is life-threatening to the beneficiary or others;  Exhibits destructive behavior that poses serious property damage, including fire-setting;  Is a sexual predator; and  A history of, or is at high risk for, falls with injury, and a primary care physician or advanced practice registered nurse order for one-to-one (1:1) supervision.

19. What’s Unique About Acuity Level 5? Concise Statement (Content) Behavior Support Plan (BSP) 1-to-1 Job Description (Content) 30-days of target behavioral data Physician or APRN Order (Fall Risk)

20. Acuity Level 5 Concise Statement The Concise Statement is your introduction describing the behavioral and or fall risk history and how the 1:1 staff will be utilized. The Concise Statement must include the number of hours and durations being requested for the 1-to-1. REMEMBER: The number of hours and duration must match with what is written in the BSP, Psychological Assessment, 1:1 job description and physician/APRN order (if addressing for fall prevention).

21. Acuity Level 5 BSP & 1:1 Job Description BSP: Needs to be current and the requested number of hours and duration for the 1:1 supervision/arm length, must be written in the concise statement and the 1:1 job description. 1:1 Job Description: Must be PERSON CENTERED regarding the person’s needs and the number of hours and duration for the 1:1 staff must be clearly written.

22. Acuity Level 5 Target Behavioral Data Target Behavioral Data:  30 days worth of descriptive data is required prior to the date the packet is being submitted (Example: If submitting a packet for approval in November, 30-days worth of October’s data is needed. If submitting a packet in February, 30 days worth of January’s data is required, etc.)  30 days mean being able to see the 1:1’s documentation of the behaviors on a daily basis (e.g. ABC Data). A monthly summary is unacceptable.  PLEASE DON’T SEND MORE THAN THE REQUIRED 30 DAYS…

23. Acuity Level 5 (Fall Risk) The acuity level-5 also can be requested for a person who has high risk for falls. The concise statement must provide a description of who, what, where, why and how regarding the fall risk (i.e., what change has happened. The number of hours and duration still applies. Need supporting documentation pertaining to the fall risk [e.g. PT & OT assessments, incident reports, recent hospitalization discharge recommendations (don’t send the entire record…just send enough to justify your case), new diagnosis or worsening factors, etc.]. Requires a physician or APRN order prescribing the 1:1 need for the fall risk (see example under acuity level 4).

24. Acuity Level – 5 Packet Content  The four common most recent documents are: 1) Level of Need Assessment 2) ISP 3) medical and 4) psychological assessments  Concise Statement that sets forth the presenting problem  BSP (pervasive due to behavioral management of the targeted behaviors)  30 days of target data prior to the date the packet is being submitted  1:1 Job Description specific to the needs of the person  Physician or APRN order (if related to fall risk only) ** Any Supporting Data**

25. Acuity Level – 6 Pervasive & Skilled Nursing  Acuity Level 6 (Pervasive & Skilled Nursing) shall represent the health, habilitation, and support needs of a beneficiary who meets the requirements of Section II.C.1. and requires services and interventions that can address conditions associated with a pervasive level of care to accommodate people with dangerous behaviors or medical conditions that require one-to-one (1:1) supervision twenty-four (24) hours per day and those people who are in need of extensive skilled nursing service as described in Section II.K.

26. Acuity Level – 6  A beneficiary shall qualify for Level 6 (Pervasive & Skilled Nursing) if the beneficiary requires at least one (1) type of skilled nursing that shall be ordered by a primary care physician or advanced practice registered nurse and provided, at minimum, on an hourly basis.

27. Acuity Level – 6 Packet Content  The four common most recent documents are: 1) Level of Need Assessment 2) ISP 3) medical and 4) psychological assessments  A Concise Statement that sets forth the presenting problem that requires that 1:1 supervision and skilled nursing. This shall include the number of hours and duration as stated in the order and the 1:1 job description.  1:1 Job Description specific to the need of the person. The number of hours and duration must match as written in the concise statement and the physician or APRN order.  Always required….Physician or APRN order (type, frequency, scope and duration). ** Any Supporting Data**

28. Conclusion Make sure you use the acuity level determination checklist when organizing your packets. Ensure that the number of hours and the duration can be justifiable as needed. Double check your acuity packets for accuracy prior to submitting them to your service coordinator. Immediately respond to Health and Wellness when revisions are necessary. We will include the service coordinator and other provider members on all communications.