1. Overview of Expectations of CCSNL Sharon Lambton, R.N., M.S.N Nurse Consultant Children’s Medical Services

2. Basic Requirements  Be a registered nurse (RN) case manager in the CCS Program with at least 6 months experience in that role  Have completed the Pediatric Nursing End-of-Life Education Consortium (ELNEC) training  Complete the Partners for Children (PFC) palliative care training provided by the CMS Branch  Be responsible for no more than 50 waiver participants In addition, each county needs to identify a second CCS RN with ELNEC and PFC training to serve as a back-up for the primary liaison in the county.

3. Roles and Responsibilities (refer to CCS Numbered Letter 07-1109)  Receive and process all referrals for enrollment in the waiver  Case finding – identify potentially eligible children by searching the current CCS caseload in the county  Provide training and consultation about the waiver to providers in the community  Be knowledgeable of community resources in the county that may be needed for the waiver participants

4. Collaboration and Communication A. With the Care Coordinator 1.Serve as liaison with the CCS program in the county and provide ongoing technical assistance 2.Review the completed Family-Centered Action Plan and discuss with Care Coordinator at least every 60 days 3.Authorize state plan and waiver services identified on F-CAP 4.Participate in care conferences related to participant’s needs and goal achievement

5. Collaboration and Communication (continued) B. With Participant and Family 1.Discuss waiver services and benefits 2.Confirm that applicant is not already enrolled in another home and community based waiver 3.Review the PFC Freedom of Choice form 4.Review the Client Agreement form

6. Collaboration and Communication with Participant and Family (Continued) 5.Educate the applicant/family on health and safety issues and how to report events or incidents 6.Provide a copy of the Participant Enrollment Packet to family 7.Contact family at least monthly to ensure that the services authorized were provided and obtain feedback about satisfaction

7. Collaboration and Communication (continued) C. With the CMS Branch 1.Summarize all communications with the participant/family and PFC Care Coordinator in CMSNet case notes 2.Discuss issues related to health and welfare, remediation and disenrollment with Branch staff and document findings, plan and actions in case notes 3.Participate in all trainings related to PFC as directed by the CMS Branch

8. Collaboration and Communication (continued) D. With Special Care Centers (SCC) 1. Ensure SCC staff are aware of your role with client 2. Provide ongoing technical assistance to SCC related to waiver participation and services

9. Collaboration and Communication (continued) E. With Home Health and Hospice Agencies 1. Discuss timely completion of F-CAP 2. Work to identify resources for intermittent or shift nursing as noted in F-CAP

10. Collaboration and Communication (continued) F. With Physicians 1. Discuss referrals, use of PFC Referral form, and medical documentation needed 2. Provide consultation to local providers as needed regarding PFC

11. QUESTIONS???

12. Transition From PFC A.Reasons for transition: 1.Move from active waiver county to county not participating in waiver 2.Participant and family may choose to enroll in hospice 3.When the participant becomes 21 years old 4.The participant/family no longer wants to participate in the waiver

13. Transition off PFC (continued) B. Role of CCSNL in Transition process 1.Assist the participant and family in the dis-enrollment process. a.Work with the Care Coordinator in facilitating the transfer of client to a new county and connecting them with resources/services available there; or b.Work with the Care Coordinator and hospice agency to ensure a smooth transition to that service; or c.For PFC participants at age 20, prepare/update the Adolescent Transition Health Care Plan. Meet with participant, family, and Care Coordinator to discuss planning; or d.Work with the Care Coordinator in identifying ongoing non- waiver resources in the community.

14. Transition off PFC (continued) B. Role of CCSNL in Transition process (continued) 2.Document activities related to transition planning and coordination into the PFC database (under transition tab)

15. Required Logs for CCS NL Current “logs” –PFC data base and case notes Current “logs” –PFC data base and case notes County specific “logs” -several different formats noted; client specific files, pending referrals log, and spread sheet. County specific “logs” -several different formats noted; client specific files, pending referrals log, and spread sheet. Branch in process of reviewing data requirements for federal assurances and evaluation Branch in process of reviewing data requirements for federal assurances and evaluation