New Jersey Balancing Incentive Program
Application for the State of New Jersey
New Jersey Department of Human Services
December 2012
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State of New Jersey Balancing Incentive Program
Table of Contents
Cover Letter ... 2
Project Abstract and Profile ... 4
Preliminary Work Plan ... 5
Application Narrative ... 9
A. Understanding of Balancing Incentive Program Objectives ... 9
B. Current System’s Strengths and Challenges ... 12
C. No Wrong Door/Single Entry Point Agency Partners and Roles ... 16
D. No Wrong Door/Single Entry Point Person Flow ... 18
E. No Wrong Door/Single Entry Point Data Flow ... 22
F. Potential Automation of Initial Assessment ... 24
G. Potential Automation of Core Standardized Assessment (CSA) ... 25
H. Incorporation of CSA in Eligibility Determination Process ... 26
I. Staff Qualifications and Training ... 27
J. Locations of Single Entry Point Agencies ... 28
K. Outreach and Advertising ... 28
L. Funding Plan ... 30
M. Challenges ... 31
N. No Wrong Door/Single Entry Point’s Effect on Rebalancing ... 35
O. Other Balancing Incentives ... 41
P. Technical Assistance ... 45
Proposed Budget ... 46
Acronyms/Abbreviations ... 47
4 Project Abstract and Profile
In early October 2012, New Jersey received approval from the Centers of Medicare & Medicaid Services (CMS) for a new Medicaid Section 1115 (a) five-year demonstration: the
Comprehensive Medicaid Waiver (CMW). New Jersey now has begun a statewide health reform effort that will increase existing managed care programs to include managed long term services and supports (MLTSS) and expand home and community based services (HCBS) to certain populations.
It is within the framework of the CMW that the Department of Human Services (DHS) proposes to leverage the Balancing Incentive Program (BIP) to expand access to non-institutionally based long term services and supports (LTSS) in a managed care environment. The DHS’ Division of Aging Services, Disability Services, Developmental Disabilities, Medical Assistance and Health Services (Medicaid) and Mental Health and Addiction Services will work collaboratively on providing services to individuals in the most appropriate, least restrictive settings.
New Jersey has a 20-plus year commitment to creating a LTSS system that emphasizes HCBS and relies less on institutionalization. The approval of the CMW elevates this obligation—creating the opportunity for a coordinated, departmental mission.
The State proposes to harness the collective strength of the DHS, as the single state Medicaid agency, with its community partners to meet the structural requirements mandated under the BIP and CMW demonstration:
Expand New Jersey’s Aging and Disability Resource Connection (ADRC) network
beyond its current target population of older adults and people with disabilities to serve as the No Wrong Door/Single Entry Point (NWD/SEP) for the full array of Medicaid and non-Medicaid LTSS, including individuals under the auspices of the Divisions of
Developmental Disabilities and Mental Health and Addiction Services. Access will be broadened through the website, the toll-free number and in a variety of physical locations.
Develop and implement core standardized assessment tools to determine HCBS eligibility for populations included and excluded from managed LTSS. This would be similar to the NJ Choice tool used for older adults and people with disabilities – and required under the CMW. The methods may differ across populations, but they all will have the capacity to determine a beneficiary’s LTSS needs and develop an appropriate service plan.
Ensure that conflict-free care management is employed uniformly to assist residents in gaining access to LTSS regardless of the funding source. Under the CMW, the state will establish a process for conflict free coordination by maintaining responsibility for the level of care determination. Care coordination will be provided by the respective managed care networks and the Program of All-Inclusive Care for the Elderly organizations and is responsible for monitoring the Plan of Care and assuring a beneficiary’s health and safety. Behavioral Health Administrators will be assigned to integrate behavioral health care, physical health care and managed LTSS with the care coordinators.
As a result of CMS’ approval of the CMW, New Jersey can continue to move forward with reforms to deliver smarter, more effective services with a focus on transitioning from
institutionalized settings to HCBS. New Jersey’s BIP application, with its proposed budget of about $108 million over a 2 ½ year period, further enhances the State’s commitment to balancing services towards the home and in the community.
5 Preliminary Work Plan
Issues in the application are included in this preliminary work plan. A more detailed work plan will be forthcoming upon the application’s approval.
Category Major Objective / Interim Tasks Due Date (from time of Work Plan submission)* Lead Person Status of Task Deliverables G en er a l NWD /S EP S tr u ctu
re All individuals receive standardized information and experience the same eligibility determination and enrollment processes.
Establish interdivisional Public Awareness and Education workgroup
2 months Establish major activities, time frames, and budget for Awareness Campaign Develop standardized informational
materials that ADRCs and partners provide to individuals
5 months Informational materials
Present draft materials to DHS MLTSS Steering Committee and Consumers for feedback and input.
6 months Consumer and provider input to ensure materials are informative and consumer friendly Train and certify personnel to conduct
screenings and assessments for MLTSS
18 months A statewide network of ADRC, State and MCO personnel trained and certified to conduct level 1 and 2 screenings & assessments for MLTSS
A single eligibility coordinator, “case management system,” or otherwise coordinated process guides the individual through the entire functional and financial eligibility determination process. Functional and financial assessment data or results are accessible to NWD/SEP staff so that eligibility determination and access to services can occur in a timely fashion. (The timing below corresponds to a system with an automated
Level I screen, an automated Level II assessment and an automated case management system. NWD/SEP systems based on paper processes should require less time.)
Design an integrated MLTSS client flow system (initial overview) that includes: older adults, and persons with physical, developmental, and mental
health;/additions.
0 months (submit with Work Plan)
Description of the system
Design system (final detailed design) 6 months Detailed technical specifications of system Develop Level 1 screenings and Level 2
assessments and options counseling
DoAS/DDS –
o Modify electronic Level 1 Screening Tool to include screening questions for DDD and DMHAS
DDD
o Develop a Level 1 Screening Tool or modify ADRC Level 1 Screening tool for DD population
o Identify State database for automating Level 1 Screen
DMHAS
o Develop Level 1 Screening Tool or modify ADRC Level 1 Screening tool for DD
5 months
8 months 10 months 8 months 10 months
Level 1 screening tools for each of the target populations will share common domains. Level 2 Core Standardized Assessment Tools will also include the core domains.
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Category Major Objective / Interim Tasks Due Date (from time of Work Plan submission)* Lead Person Status of Task Deliverables population
o Identify State database for automating Level 1 Screen
Implement and test system
o DOAS/DDS – test and implement modified Level 1 screen o DDD – – test and
implement modified Level 1 screen o DMHAS– test and
implement modified Level 1 screen
8 months 18 months 18 months
Validation of the Level 1 screening tools
System goes live
o DOAS/DDS o DDD o DMHAS 18 months 24 months 24 months
ADRCs will serve as the NWD/SEP for the expanded target populations. – DD/MHA System updates Semiannual
Review Description of successes and challenges NWD /S EP
State has a network of NWD/SEPs and an Operating Agency; the Medicaid Agency is the Oversight Agency.
DoAS serves as the Operating Agency for the ADRC network
0 months (submit with Work Plan)
Division of Aging Services
The Area Agencies on Aging (AAA) serve as the lead county agency for the ADRC/NWD/SEPs
0 months (submit with Work Plan)
Attached are the names and contact information for the 21 AAAs /ADRCs Develop and implement a Memorandum
of Understanding (MOU) across agencies including those agencies that serve the DD/MHA populations.
6 months All 21 AAA/ADRC
Signed MOUs
Train all ADRC partners on the eligibility determination and enrollment processes for MLTSS, including eligibility process for MHAS and DD services.
15 months A training module will be developed to educate the current ADRC partners on the eligibility processes for the expanded target
populations – DD/MHAS. The training curriculum will be available through classroom and webinar formats
NWD/SEPs have access points where individuals can inquire about community LTSS and receive comprehensive information, eligibility determinations, community LTSS program options counseling, and enrollment assistance.
Identify service shed coverage of all NWD/SEPs
0 months NJ’s ADRC are
statewide, effective 5/12. Ensure NWD/SEPs are accessible to
older adults and individuals with disabilities
0 months NJ’s AAAs/ADRCs must
have a physical location that is handicapped accessible or staff that can travel to the persons residential setting. Develop Options Counseling
Curriculum for ADRC screeners and assessors. Curriculum will include sections for expanded target populations served by the divisions of Mental Health
4 months Training and certification curriculum for Level 1 and Level 2
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Category Major Objective / Interim Tasks Due Date (from time of Work Plan submission)* Lead Person Status of Task Deliverables
& Addiction Services and Developmental Disabilities
Conduct Options Counseling training and certification for ADRC partners, MCOs, PACE, OCCO, and other designated agencies.
8 months All ADRC Level 1
screeners and Level 2 Assessors will have successfully completed training and certified as meeting the State’s performance standards.
We
b
site
The NWD/SEP system includes an informative community LTSS website; Website lists 1-800 number for NWD/SEP system.
Expand the ADRC On-Line Resource Center to include services and programs for DDD and DMHAS in the resource directory and learning library
8 months NJ ADRC Website will serve as the comprehensive database for MLTSS 1 -8 0 0 Nu m b
er Single 1-800 number where individuals can receive information about community LTSS options in the State, request additional information, and schedule appointments at local NWD/SEPs for assessments.
DDS statewide toll-free number for individuals/caregivers seeking information for all disability
populations will be expanded to include older adults.
Reconfigure all Senior numbers, including the direct links to the 21 county AAAs to connect to DDS toll-free number
4 months
8 months
Single toll-free number for all populations seeking MLTSS.
Train State and county ADRC staff members on the broad array of MLTSS (including public & private) options, conducting the Level I screen for MLTSS and linking the caller to appropriate point of entry across all target populations.
9 months Training curriculum developed, core of trained State/local individuals certified to conduct training sessions for
Adv
er
tisin
g
State advertises the NWD/SEP system to help establish it as the “go to system” for community LTSS
Develop advertising plan 8 months Advertising plan Implement advertising plan 12 months Materials associated with
advertising plan will be distributed through the ADRC NWD/SEP network
CSA/CDS
A CSA, which supports the purposes of determining eligibility, identifying support needs and informing service planning, is used across the State and across a given population. The assessment is completed in person, with the assistance of a qualified professional. The CSA must capture the CDS (required domains and topics).
Develop questions for the Level I screen o DOAS/DDS o DDD o MHAS 0 months 18 months 18 months
Level I screening for Aging and physically disabled is completed Level 1 screenings for expanded populations are developed and automated or the ADRC Level 1 Screen is modified for the expanded target
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Category Major Objective / Interim Tasks Due Date (from time of Work Plan submission)* Lead Person Status of Task Deliverables
Fill out CDS crosswalk (see Appendix H) to determine if your State’s current
assessments include required domains and topics
o DOAS/DDS o DDD o DMHAS
0 months (submit with Work Plan) 0 months 12 months 12 months
Completed crosswalk(s)
NJ Choice includes all of the required domains DDD has a single CSA tool for determining LOC DMHAS has a single CSA tool for determining LOC
Incorporate additional domains and topics if necessary (stakeholder
involvement is highly recommended)
DoAS/DDS included stakeholder input in the development of NJ Choice
DDD/DMAS
0 months
6 monts Final Level II
assessment(s); notes from meetings involving stakeholder input Train staff members at NWD/SEPs to
coordinate the CSA
o DOAS/DDS – for MCOs, PACE, AAAs, OCCO o DDD o DMHAS 6 months 18 months 12 months
Training materials and certification process for Level 2 assessment process is completed
Identify qualified personnel to conduct the CSA
12 months List of entities contracted to conduct the various components of the CSA Continual updates Semiannual after
12 months Description of success and challenges Co n fli ct -Fre e Ca se Ma n a g em en
t States must establish conflict of interest standards for the Level I screen the Level II assessment and plan of care processes. An individual’s plan of care must be created independently from the availability of funding to provide services.
Describe current case management system, including conflict-free policies and areas of potential conflict
6 months (submit with Work Plan)
Under the Comprehensive Medicaid Waiver, the State will establish policies and protocols to ensure conflict-free care management.
Establish protocol for removing conflict of interest
9 months Protocol; if conflict cannot be removed entirely, explain why and describe mitigation strategies
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Application Narrative
A. Understanding of Balancing Incentive Program Objectives
Overview
New Jersey is significantly reforming its long-term care system with the transformation of the state Medicaid program through the federal government’s approval of a five-year Medicaid Section 1115 (a) research and demonstration waiver known as the New Jersey Comprehensive Medicaid Waiver (CMW). Among other key components, this historic step includes the move to managed care for long-term services and supports; increased flexibility so that seniors and individuals with physical disabilities at risk of nursing home placement can choose the home and community-based services (HCBS) they need and live where they prefer; expanded support services for people with intellectual and
developmental disabilities; and enhanced access to community-based mental health and addiction services. It is within the context of the move to a managed care system under the CMW – with its integrated primary, acute, behavioral health and long-term services – that New Jersey reiterates its commitment to making structural reforms and ensuring consumers and their caregivers have access to a no wrong door/single point of entry (NWD/SPE) to non-institutional long-term services and supports (LTSS), a core standardized assessment (CSA), and conflict-free care/case management.
On July 1, 2012, the Governor realigned senior services from the Department of Health and Senior Services (DHSS) to the Department of Human Services (DHS), the single state agency for Medicaid. The realignment established a single point of access – no wrong door for seniors, people with disabilities and their caregivers, regardless of
Medicaid eligibility – in the framework of state government. Within the DHS structure, the state’s long-term services and supports systems are managed by the Divisions of Aging Services (DoAS), Developmental Disabilities (DDD), Disability Services (DDS) and Mental Health and Addiction Services (DMHAS). Administrative and fiscal oversight is delegated by DHS to its Division of Medical Assistance and Health Services (DMAHS). Over the past 25 years, New Jersey has created a LTSS system to enable people of all ages with disabilities and illnesses to have alternatives to institutions with (HCBS). In the past 10 years, New Jersey has used legislation, executive orders and budget initiatives to advance balancing of long-term care expenditures away from a historical reliance on institutions.
In 1996, the consolidation of senior services in the DHSS by a Governor’s
Reorganization Plan was the state’s first step to consolidating services for older adults and allowing for the expansion of HCBS for this population. Through Medicaid HCBS waivers, the implementation of Aging and Disability Resource Centers, and nursing home transitions/Money Follows the Person (MFP), the DoAS served as a catalyst for promoting home and community-based services that resulted in the percentage of funding spent on nursing homes dropping from 92.7 percent in 1997 to 74 percent in 2010 and the number of people served in nursing homes decreasing from almost 32,000 in 1997 to 27,000 in 2010.
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ADRC and Balancing Long-Term Care
A strong partnership formed among the DHS divisions dating back to 2003 when New Jersey was awarded the original Aging and Disability Resource Center (ADRC) grant from the U.S. Administration on Aging. New Jersey’s ADRC was the first joint venture partnering the two state agencies responsible for aging and disabilities to create a NWD/SEP system.
The ADRC, which began as a pilot project in two counties, now operates statewide with the 21 Area Agencies on Aging (AAA) serving as the county lead agencies in partnership with the county welfare agencies (CWA), County Offices for Disabilities, Centers for Independent Living, hospitals, and other nonprofit agencies in the aging and disability services networks. Other federal grants supporting New Jersey’s balancing efforts included two Nursing Home Diversion Modernization Grants, a Real Choice Systems Change Grant for Community Living, a Systems Transformation Grant and the Veterans Directed HCBS Program.
In 2004-2005, building upon a successful nursing home transition program and the creation of a NWD/SEP system for seniors and younger adults with physical disabilities, a series of Governor’s Executive Orders called for the implementation of a global
budgeting process and a fast track Medicaid eligibility option for LTSS. Supported by AARP, the SFY 2006 budget included a provision to reallocate funds from its nursing home budget to HCBS. In 2006, New Jersey enacted the “Independence, Dignity and Choice in Long-Term Care Act.” The Act directed balancing of the long-term care budget to support expanded HCBS options for older adults and persons with physical disabilities who meet nursing facility level of care.
Since 2007, additional opportunities for balancing were realized through New Jersey's participation in the MFP demonstration initiative. The MFP partnership which includes DoAS, DMAHS, DDD and DDS is based on a common vision: (1) consumer friendly access to information and assistance; (2) streamlined eligibility processes for state and federal programs; (3) person-centered planning/self-directed control over service plans; (4) continued expansion of affordable and cost-effective options for receiving HCBS, and (5) continuous quality improvement.
Division of Developmental Disabilities (DDD)
Since 1990, the DDD decreased the number of people served in its seven (ICF-MR) Developmental Centers by 53 percent or 2,721 people from 5,110 to 2,389 (Sept. 30, 2012). Beginning in 1999, DDD increased the number of people served in the community by 89 percent from 23,174 to 43,841; and home and community based waiver
participants increased by 56 percent from 6,635 to 10,375.
DDD’s blueprint for these efforts is showcased in its strategic plan—New and Expanded
Options for Individuals with Developmental Disabilities and their Families. While adopting
a philosophy of person-centered planning, DDD provided more options for self-direction through a series of budget initiatives that increased state resources for HCBS.
Administrative practice changes were accompanied by the creation of a more efficient, automated infrastructure for claiming federal match for state-funded services. The
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Governor and the Legislature supported these efforts, facilitating the reinvestment of new revenues to further expand home and community based services. Balancing will be furthered by the upcoming closures of two developmental centers. In addition to transitioning over 500 consumers to community residences, the closures will generate state savings that will be reinvested in community services and supports.
Division of Mental Health and Addiction Services (DMHAS)
In 2006, the DMHAS initiated its recovery-oriented community service model. This initiative resulted in an additional $80 million in state funding and a dramatic expansion of community services that will continue through at least SFY2014. Between SFY2006 and 2009, these state funds were responsible for 938 new community placements. Since the Olmstead Settlement Agreement was signed in 2009, the DMHAS developed 734 housing options for individuals diagnosed with a mental illness, expanding such options for its consumers in all 21 counties. While the DMHAS has created a vast array of evidence-based practices to support individuals in the community, it still is exploring and piloting innovative programs.
The regional state psychiatric hospitalshave been redesigned within this community-based context. All such hospitals now have admission units that provide active treatment and return individuals to the community without requiring longer-term hospitalization. Each hospital now features a treatment mall, thereby increasing the availability of active treatment for individuals in the state psychiatric hospitals. They offer an array of
programming choices whereby individuals in conjunction with their treatment team can select areas of interest based on their treatment goals, strengths and areas for
improvement.
Olmstead efforts, in conjunction with increased active treatment in the state psychiatric hospitals, have resulted in a census reduction in the state psychiatric
hospitals. Specifically, the hospital census on July 1, 2006 was 2,111 and on August 31, 2012 it was 1,450 – excluding the state forensic hospital. This decrease marks a 32 percent reduction (661 less individuals) in the state hospital census. It enabled the closure of a state psychiatric hospital in June 2012 and the reinvestment of some of the savings from the hospital closure in the expansion of community-based services.
Included are outpatient treatment, supportive housing, supported employment and the development of diversion programs. A diversion program offers treatment, stabilization, referral and linkage services for individuals with behavioral health needs who are high utilizers of the emergency department and emergency psychiatric screening service. While there is still a need in New Jersey for long-term care provided in the state
psychiatric system, the decline in hospital census (both current and anticipated) allows for a redistribution of resources. This reallocation will advance community integration for mental health consumers while generating budgetary cost savings.
Commitment to Balancing Incentive Program Goals
The CMW is designed to advance the state's balancing efforts away from institutionally-based expenditures to less costly HCBS. The Balancing Incentive Program (BIP) will further support this goal. Indeed, the CMW is committed to the goals of the BIP and its requirements of a NWD/SEP system, conflict-free case management services and core
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standardized assessment instruments. A number of elements are already in place, starting with the recent state realignment of consolidating all divisions responsible for LTSS into the DHS.
With the exception of the DDD, New Jersey is moving away from fee-for-service toward managed LTSS. The move to managed LTSS will integrate acute, primary, behavioral and long-term care. It is driven by the state's desire to see improved health outcomes, appropriate care in the appropriate setting, coordination of services and the ability to create increased opportunities for individuals in need of LTSS to remain at home.
Managed LTSS will provide an opportunity to benefit from the financial incentives offered in the BIP to the advantage of the citizens of New Jersey. The DDD currently operates a cost-reimbursement model, which will shortly begin transition to a fee-for-service system, thus standardizing services across the State and resulting in greater consumer flexibility when choosing service providers.
B. Current System’s Strength and Challenges
In 2010, New Jersey spent more than $3.5 billion on long-term care services for seniors and individuals with physical disabilities under existing long-term services and supports (LTSS) – 74 percent for institutional care while only 26 percent was for home and community based services (HCBS). The goal of the state’s current Medicaid reform proposal is to move into a managed long-term services and supports (LTSS) delivery system —to assist beneficiaries with nursing level of care needs to navigate a complex network of health and social support providers, reduce duplication and cost-shifting in the LTSS system and assist the state in better controlling and predicting long-term care expenditures.
New Jersey’s biggest strength in advancing the structural changes required under the BIP application is found in the approval of its 1115(a) demonstration—the New Jersey Comprehensive Medicaid Waiver (CMW). Yet the state’s greatest challenge in moving to a managed LTSS system under the CMW is to measure improved health outcomes. New Jersey will move to managed LTSS by amending its existing managed care organization (MCO) contracts to require management of all long-term care services, including HCBS and nursing home care for seniors and individuals with physical
disabilities who meet NF level of care. Under the 1115(a) demonstration, New Jersey will terminate its 1915(j) SPA and its 1915(c) waivers for the Traumatic Brain Injury (TBI), Aids Community Care Alternatives Program (ACCAP), Community Resources for Persons with Disabilities (CRPD) and the Global Options for Long-Term Care (GO) programs. Although these separate waivers will end, the same service options will continue but will no longer be restricted to a specific target population. Once the state determines that the MCOs are ready, these entities will assume full risk for all LTSS, including NF placements. In addition, New Jersey will continue the Program of All-Inclusive Care for the Elderly (PACE). PACE is outside of managed LTSS, but it is still an option for seniors and others in designated zip code areas.
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The current systems’ strengths and challenges with regard to the state’s LTSS
information and referral, eligibility determination and case management processes are as follows:
LTSS Information and Referral Processes
New Jersey’s ADRC serves as the No Wrong Door/Single Entry Point (NWD/SEP) for older adults, younger persons with physical disabilities and long-term chronic illnesses and their caregivers in need of LTSS, providing access to information and a full range of public (federal/state/county) and non-profit community-based alternatives. With its ADRC fully operational and statewide, New Jersey has a pathway by which individuals enter the LTSS system and have access to programs and services through a statewide toll-free number, a website, and county-based locations. Through these entry points, consumers and their caregivers may receive a level 1 screening to determine if they are at risk of NF placement and may be referred for a Level 2 comprehensive clinical assessment and financial eligibility determination for Medicaid and other federally or state funded programs.
A challenge for New Jersey’s ADRC will be to expand its knowledge and customer base to assist the populations served by the Divisions of Developmental Disabilities (DDD) and Mental Health and Addiction Services (DMHAS). Under the CMW, New Jersey plans to use the ADRC partnership as the NWD/SEP for consumers to access managed LTSS regardless of age, disability or income.
In concert with New Jersey’s move to managed LTSS under the Comprehensive Medicaid Waiver, the BIP will enable the DHS to build upon its current ADRC model. Specifically, the Division of Disability Services (DDS) will assume responsibility at the DHS for managing the community LTSS 1-800 number to provide the widest access to the NWD/SEP system. This 1-800 number will connect individuals directly to the county-based ADRCs where they can receive information about community LTSS options. LTSS Eligibility Determination Processes
Since 1996, New Jersey’s eligibility system has been administered by two separate departments. The Department of Human Services (DHS), as the single state agency for Medicaid, was responsible for financial eligibility, while the Department of Health and Senior Services (DHSS) managed the clinical eligibility side. In July 2012, under legislative authority, aging services under DHSS were transferred to the DHS, thereby creating a single department responsible for both Medicaid clinical and financial eligibility determinations. This transition allows DHS to effectively coordinate these processes at the state and county levels, resulting in the streamlining and implementing of policies and regulations to more efficiently expand long term services and supports across the lifespan.
Currently the 21 county welfare agencies (CWAs) are designated as the state’s agent for determining financial eligibility for Medicaid programs. Within the context of state
policies and regulations, each CWA operates under its own county governance, which results in inconsistencies for consumers when applying for Medicaid programs.
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Disability Services'(DDS) 1915 (c) HCBS Waivers are referred to the state (DoAS’ Office of Community Choice Options) or to its designated agents for a comprehensive clinical assessment and eligibility determination.
Unnecessary delays result because financial and clinical eligibility systems are separate. Traditionally, individuals first go to the CWA office to apply for Medicaid programs, which starts the financial eligibility process. If approved for LTSS, individuals are then referred to the DoAS’ Office of Community Choice Options (OCCO) for a comprehensive
functional assessment and clinical eligibility determination. Between the two processes, consumers could wait weeks before final eligibility is determined.
With its new tools and processes, the ADRC client pathway was designed to streamline and coordinate financial and clinical eligibility. A computerized Level 1 screen enables ADRC specialists to identify individuals who are potentially clinically and financially eligible for LTSS; conduct an initial options counseling session on the full range of HCBS; and, if interested in LTSS, refer individuals simultaneously to the CWA for
financial eligibility and to the OCCO for a Level 2 comprehensive functional assessment and clinical eligibility determination.
The ADRC model also created a second process for financial eligibility: Fast Track. It is an expedited eligibility process that allows consumers, who appear eligible for Medicaid, to be authorized to receive State Plan Services for up to 90 days while they complete the full Medicaid application and determination process. Because Federal Financial
Participation (FFP) is not available for services delivered to applicants deemed ineligible for Medicaid, the state assumes the cost of services if the applicant is not approved. At the basis of the ADRC client pathway and included to be used under the
Comprehensive Medicaid Waiver (CMW) is the NJ Choice Suite. It contains a level 1 screening tool to evaluate a person’s care needs for HCBS and potential financial eligibility for state and federally funded programs and a level 2 core standardized assessment tool. Together they provide New Jersey with a validated instrument to ensure that consumers’ needs for HCBS are addressed in a consistent manner, regardless of their income and point of entry.
LTSS Conflict Free Case Management Processes
Under the current 1915 (c) waivers, the Department of Human Services (DHS)
subscribes to a conflict-free case management strategy. The department has established clear delineations between determining clinical eligibility; developing and authorizing plans of care; establishing service caps; and overseeing quality assurance management. The MCOs and PACE organizations will have the authority and flexibility to manage their members health and social LTSS needs, yet must ensure that they have established clear separation between:
Case management from direct service provision;
Eligibility determination from direct service provision; and
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o Related by blood or marriage to the individual or any of the individual’s paid caregivers;
o Financially responsible for the individual, and
o Empowered to make financial or health-related decisions on behalf of the individual.
For those individuals enrolled at the time of the managed LTSS implementation, the state will establish timelines for the initial contact, care assessment, plan of care, individual service agreement, and authorization and implementation of services. The state will ensure that the MCO and PACE case managers have successfully completed the training and certification required by the state before these entities will be considered "ready" for managing LTSS members.
For individuals already enrolled in an MCO or PACE and who may benefit from LTSS, the MCO or PACE will be responsible for conducting the Level 2 comprehensive
functional assessments and forwarding the completed assessment to OCCO for review and clinical eligibility determination. It is the state that retains sole authority for
approving/denying clinical eligibility. The MCOs and PACE organizations are responsible for automating their assessment tool. However, the tool must contain all the data
elements and algorithm found in the NJ Choice assessment tool.
Preadmission Screening and Resident Review (PASRR) regulation requires states to screen all individuals entering a Medicaid certified nursing facility regardless of payer source for the presence of serious mental Illness or intellectual disablities and/or a
related condition. A Medicaid-certified Nursing Facility (NF) may include facilities that are certified by both Medicaid and Medicare, or the Medicaid-certified distinct part of a larger institution.
The level I PASRR screening tool must be completed for all NF applicants prior to NF admission in accordance with Federal Regulations 42 CFR 483.106. The minimum credentials for a professional completing the level I PASRR screening tool is a Registered Nurse or Certified Social Worker.
To ensure preadmission screening is done prior to NF admission, it will be necessary for hospitals to initiate completion of the PASRR screening in their discharge planning process. Hospital discharge planners must complete a level I screening tool (LTC – 26) for all individuals regardless of payment source who are being referred to a NF from the hospital. NF staff will complete the level I screening tool for NF admissions from the community.
If the Level I PASRR screening tool indicates that the NF applicant screened positive for mental illness, a PASRR Level II Psychiatric Evaluation must be done and sent to the Division of Mental Health and Addiction Services (DMHAS) for a determination on whether the individuals’ mental health care needs can be meet in a NF.
If the Level I PASRR screening tool indicates that the NF applicant screened positive for intellectual/developmental disability and/or related condition, a referral is made to the
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Division of Developmental Disabilities (DDD) to conduct a PASRR level II ID/DD and/or related condition determination on whether the individuals’ ID/DD and/or related
condition needs can be meet in a NF.
MCOs and PACE providers must develop and implement a person-centered written plan of care and individual service agreement in compliance with Medicaid regulations. The MCOs and PACE providers are expected to promote HCBS in order to prevent or delay institutionalization whenever possible. An update to the plan of care must occur at least annually.
Each MCO and PACE organization will be required to develop and provide to the state an annual case management plan—how it will implement and monitor the case
management contract and policy requirements established by the state. The state’s oversight process will be more intensive during the first one to two years of managed LTSS operations so that steps can be taken to resolve issues and program improvement can be rapidly carried out.
C. NWD/SEP Agency Partners and Roles
In 2003, the NWD/SEP concept for New Jersey was developed and implemented as the centerpiece of its ADRC model through federal grant funding. Today, the ADRC serves as the single point of access in all 21 counties for older adults 60 years and older, adults 18 years and older with physical disabilities, and their caregivers, regardless of income. The ADRC is a partnership between the Department of Human Services (DHS) as the single state Medicaid agency and the State Unit on Aging, the 21 county-based Area Agencies on Aging (AAAs), the 21 county welfare agencies (CWAs), the 16 county offices on disability services, the 12 non-profit Centers for Independent Living (CILs) and other nonprofit agencies in the aging and disability services networks. The ADRC
provides consumers with improved access to community programs such as meals-on-wheels, personal care, housekeeping, specialized transportation, assisted living and nursing home care. It also connects seniors and adults with disabilities with work and volunteer opportunities, insurance programs, health promotion and disease prevention programs, housing, crisis intervention, and other home and community programs.
The Division of Disability Services (DDS) Office of Information and Assistance serves as the statewide entry point for individuals with disabilities and their caregivers to educate them about disability issues, community resources, and link them to either state or private service providers. In concert with New Jersey’s move to managed LTSS under the Comprehensive Medicaid Waiver, the BIPP will enable the DHS to build upon its current ADRC model. Specifically, DDS will assume responsibility at the DHS for managing the community LTSS 1-800 number to provide the widest access to the NWD/SEP system. This 1-800 number will connect individuals directly to the county-based ADRCs where they can receive information about community LTSS options. Through the ADRC physical locations and virtual portals, consumers have easy access to information on the full array of home and community-based services (HCBS). The ADRC provides the consumer with a level 1 screen whereby he or she can be evaluated
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for long term services and supports (LTSS) and, if appropriate, can be referred for a Level 2 comprehensive functional assessment. The ADRC enables the consumer to begin applying for state and federal programs and services and can link the consumer to programs based on their care needs and financial situation. Consumers and their
caregivers can access information through a toll-free statewide number, the ADRC website or a visit to county-based offices.
The ADRC website – www.adrcnj.org – contains thousands of national, state and local
resources, several new search options, and other consumer-friendly tools including Google translation and mapping features. The site is Section 508 compliant for improved access to individuals with vision impairments.
The state ADRC team focused largely on seven goals in the development of its
NWD/SEP: (1) Access; (2) Assessment and Options Counseling; (3) Money Follows the Person; (4) Transition Care Models; (5) IT Support; (6) Financing Opportunities, and (7) Quality Management. The ADRC as the NWD/SEP serves as the focal point for
continued LTSS infrastructure, process and delivery development.
The ADRC’s statewide presence is the foundation for New Jersey’s plan to use and expand this NWD/SEP network for consumers, including individuals served by the Divisions of Developmental Disabilities and Mental Health and Addiction Services, to access LTSS under the Comprehensive Medicaid Waiver. With collaborative
partnerships comprised of the aging and disability entities at the state and county levels, New Jersey will ensure that AAAs as fully functioning ADRCs.
In 2006, the ADRC was included in the legislation known as the “Independence, Dignity and Choice in Long-Term Care Act.” The Act charged the state with expanding the Medicaid long-term care system by offering a larger array of HCBS. It fostered greater consumer choice that would facilitate maximum flexibility between HCBS and nursing home care (in line with the goals of the BIP).
Traditionally, services for older adults have been administered separately from those for persons with disabilities although these groups share many of the same needs and face many similar barriers to care. While the ADRC has already changed access to LTSS, the shift to managed LTSS under the Comprehensive Medicaid Waiver (CMW) will further expand the populations served through this NWD/SEP. Under managed LTSS, the ADRCs will work closely with the managed care organizations (MCOs) and Program of All-Intensive Care for the Elderly (PACE) organizations, and serve as the NWD/SEP for all consumers to learn about their long-term care options.
Under the CMW, the ADRC role will be expanded to focus on outreach and educational activities to individuals potentially Medicaid eligible; assist individuals to gather the required documents for the Medicaid application process; track status of an application; and arrange short-term services until LTSS can be put in place. At this time, the ADRCs are performing certain functions that may be transitioned to other partners. The following examples are representative of such potential changes:
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The DDS also creates and uses a resource guide that is updated regularly. Meanwhile the ADRCs use a separate guide that identifies county resources. The BIP will designate the DDS as the lead to assume on-going responsibility for integrating all available DHS resource directories and guides into a single database.
The Comprehensive Medicaid Waiver enables the Division of Mental Health and Addiction Services (DMHAS) to contract with an Administrative Services Organization (ASO) to manage behavioral health services (inclusive of Medicaid, state and block grant funded services) across the continuum of inpatient to ambulatory treatment and services. One of the ASO’s functions will be to provide information concerning services available, assess an individual’s need for treatment and refer individuals to the least restrictive, most integrated services. In instances where an individual is seeking
managed LTSS services for his or her primary care needs, the individual will be referred to the MCO for primary care services. Through the data exchange between the ASO and MCOs and by examining utilization patterns, it may be possible to identify consumers at risk of LTSS earlier and provide targeted interventions to lessen nursing home placement.
D.NWD/SEP Person Flow
ADRC Person Flow
Built upon an algorithm, the ADRC client pathway is designed to assist professionals with the decision-making process for accessing information; determining clinical and financial eligibility for state, Medicaid, and Older Americans Act funded programs; counseling individuals on home and community-based services (HCBS) regardless of their income and linking them to appropriate public/private community services and programs.
New Jersey’s unique ADRC client pathway was a collaborative effort between the Divisions of Aging Services (DoAS), Disability Services (DDS) and Medical Assistance and Health Services (DMAHS) to serve as the NWD/SEP for older adults, younger adults with physical disabilities and their caregivers. Currently in each county, the AAA serves as the lead agency for the ADRC partnership as detailed in Section C of this document. Under the BIP initiative, the DDD and Division of Mental Health and Addiction Services (DMHAS) in partnership with the DoAS will expand the client pathway to include their populations in the ADRC model. DHS will establish an interdivisional work group to:
Identify key access points where the new target populations can receive Level 1 screenings, Level 2 functional assessments, options counseling, and
referrals to public and community-based LTSS;
Based on the person flow identified above, integrate the screening and referral process into the ADRC client pathway;
Identify and develop additional screening criteria to be added to the ADRC Level 1 screening tool for the new target populations;
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Expand the ADRCNJ Online Resource website to include state and community-resources for these populations;
Develop and implement training curriculum for the ADRC partners on the special needs and community resources for these populations, and Transfer the DoAS’ toll-free number to the DDS that now serves as the
statewide toll-free number for families and persons with disabilities across the lifespan.
Level 1 Screen and Level 2 Core Standardized Assessment
At the basis of the ADRC client pathway and included to be used under the
Comprehensive Medicaid Waiver (CMW) is the NJ Choice Suite. It contains a level 1 screening tool to evaluate a person’s care needs for HCBS and potential financial eligibility for state and federally funded programs and a level 2 core standardized assessment tool. Together they provide New Jersey with a validated instrument to ensure that consumers’ needs for HCBS are addressed in a consistent manner, regardless of their income and point of entry.
The suite includes the minimum data elements for intake; a level 1 “screen for
community services” designed as a telephone survey and used by the ADRC Specialists to assess a caller’s’ potential LTSS needs; and the level 2 core standardized
assessment tool to determine the person’s functional needs and clinical eligibility for LTSS. The Level 1 screen and Level 2 tools identify these five level of care needs: (1) information and Assistance; (2) homemaker; (3) intermittent personal care; (4) home care, and (5) nursing home level of care.
Based upon the outcome of the level 1 screen, consumers may be referred to the state, ADRC or Program for All Inclusive Care for the Elderly (PACE) assessors who are responsible for conducting home visits and the NJ Choice assessment. The assessors review the outcomes; counsel consumers and their caregivers on appropriate home and community-based services; and connect them to their locally-based care management agencies or other appropriate service providers.
Medicaid Financial Fast Track Eligibility Determination
The ADRC’s client pathway also includes an expedited financial eligibility determination as part of its NWD/SEP system called Fast Track Eligibility. It is a process that allows consumers, who appear to have a high probability of being eligible for Medicaid, to be authorized to receive State Plan Services for up to 90 days while they complete the full Medicaid application and undergo the determination process. Because Federal Financial Participation (FFP) is not available for services delivered to applicants deemed ineligible for Medicaid, the state assumes the cost of services if the applicant is not approved. Under the NJ-Choice Core Standardized Assessment tool mentioned above, the Level 1 Screen for Community Services triggers the Fast Track: if a consumer’s screening results indicate a high probability of being eligible for Medicaid long-term care benefits, the outcome is forwarded to the ADRC or the DoAS assessor for a comprehensive functional assessment. Once the assessment is scored, the results are uploaded to a central database whereby the DoAS reviews the assessment and approves or denies
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nursing facility level of care. Names of individuals who meet clinical eligibility are checked against two internal databases -- the Medicare Part D Low Income Subsidy (LIS) and Pharmaceutical Assistance to the Aged and Disabled (PAAD) databases. Within two business days, the state is able to forward the financial information to the ADRC to review and approve or deny Medicaid benefits under Fast Track. If the person is approved for Fast Track, a temporary Medicaid number is assigned and State Plan services and care management are authorized for up to 90 days. Within 30 days, the person must schedule an appointment with the County Welfare Agency (CWA) to
complete the full Medicaid application process or risk being terminated from Fast Track. The DHS is monitoring progress and working with the CWA directors and eligibility supervisors to address the issues and concerns. Feedback indicates that a major contributor to the low number of participants being approved is because the databases must show that the federal financial requirements are met, ensuring that there is
adequate documentation for the five-year look back period. Fast Track can’t proceed without proof that the person’s current income/assets fall within the financial guidelines at the time of the application.
The ADRC current person flow is based upon the schematic detailed on the following page and will be modified to include the expanded target populations and reflect the move to managed care under the CMW.
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The ADRC Eligibility Process Schematic
ASSISTANCE SOUGHT
Contact is made by or on behalf of a person seeking Medicaid eligibility. Contact can be made by the individual or family, the local hospital, the local nursing facility or the local assisted living facility.
ELIGIBILITY
2 part eligibility for Medicaid Waivers, clinical and financial. Eligibility Process begins with the financial eligibility or the clinical eligibility or both concurrently.
Financial Eligibility
Determined by the local County Welfare Agency/Board of Social Services (CWA/BSS) Clinical Eligibility Determined by the Regional Office of Community Choice Options (OCCO) Offices located in Newark, Edison
and Hammonton State staff determines Nursing Facility Level of Care (NFLOC) eligibility for NF, hospital or AL or community consumers
In Atlantic, Gloucester and Warren Counties, clinical eligibility is determined by the
County Assessor located in the County Office on Aging. The PAS is reviewed by state staff in OCCO who authorizes the determination of Nursing
Facility Level of Care (NFLOC) eligibility for community only in these counties, OCCO for all others. Consumer is
determined eligible for Community Medicaid/NJCARE
but is not seeking NF care, not referred for clinical eligibility or waiver services.
PROCESS ENDS
Clinical review or Pre-Admission Screen (PAS) is performed, using the
NJCHOICE tool for clinical eligibility
determination
Clinical eligibility for NF LOC is not met; consumer is referred
to local county agencies for other,
non-Medicaid services. PROCESS ENDS Clinical eligibility for NF
LOC is met; consumer is provided information on
program options pending financial eligibility determination
Financial and clinical eligibility is established. If consumer is wants and is willing to accept two waiver services they are referred to a local care management site for enrollment into the GO waiver or approved for NF placement.
Consumer is determined eligible for
Community Medicaid/NJCARE and is seeking NF care
or waiver enrollment. CP-2 form is issued to
OCCO indicating the consumer has met the financial eligibility for
institutional care.
Consumer indicates they are SSI eligible, no referral
to the CWA is needed, the clinical eligibility can be done since financial eligibility is established by being
on SSI.
Consumer indicates they are not on SSI and is
receiving Social Security and/or other retirement payments (pension, IRA, etc. Referral is made to the local CWA for financial eligibility and to the
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Behavioral Health Standardized Assessment
The MCO, in collaboration with the Administrative Service Organization/Managed Behavioral Health Organization (ASO/MBHO), under the Comprehensive Medicaid Waiver (CMW), will establish a level 1 screening process for identification and management of the top five percent (in terms of medical costs and medical or
psychosocial risk factors) of individuals with co-morbid medical and behavioral health (BH) conditions. The MCO will participate in the necessary co-management of these cases, which may be done through MCO care management staff or through provider initiatives. The MCO will establish a process for dissemination and implementation of Evidence-Based Practices (EBP) for BH conditions commonly treated in primary care settings, protocols to monitor primary care provider adherence to these EBPs and
financial incentives for BH-physical health (PH) coordination activities in the primary care setting (i.e., submitting the BH screening tool to the MCO, developing care coordination capacity within a primary care practice for enrollees with chronic diseases and BH co-morbidities, or co-location of BH and PH specialists).
The adult MBHO will be required to develop and/or implement a level 2 uniform clinical and medical necessity criteria. Combining screening and assessment results with claims and other utilization data, the adult MBHO will develop a predictive model and a
systematic approach to risk stratification to identify high risk BH consumers for participation in intensive care management services, which may include behavioral health home services. The adult MBHO must have the ability to meet the care
coordination needs of individuals across a number of specialized programs targeted to specific consumers, including the welfare to work substance abuse initiative (SAI) and behavioral health initiative (BHI).The SAI and BHI are specialty care management programs that go beyond traditional utilization and care management by incorporating return to work goals into consumer treatment plans.
Each MCO will be required to implement a standardized protocol to identify common BH risks in primary care settings, provide necessary education and brief intervention in order to facilitate referrals of individuals who screen positive to an appropriately credentialed and qualified BH provider. This includes but is not limited to selecting appropriate screening tools and establishing provider requirements to follow the established
screening and referral protocols, including the Screening, Brief Intervention and Referral to Treatment (SBIRT) protocol. The MCO will collaborate with the ASO/MBHO and DMAHS to create a list of approved screening tools that are efficient to use and meet generally accepted standards for reliability (consistency of results) and two measures of validity: sensitivity (accuracy in identifying a problem) and specificity (accuracy in
identifying individuals without a problem).
E. NWD/SEP Data Flow
New Jersey has embarked on a major redesign of its Medicaid management information system (MMIS). Once the MMIS is fully implemented, it will dramatically streamline the Medicaid eligibility business process, eliminate redundancies for both state and county
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personnel, and provide real-time access to client data, status, and service utilization. The two major initiatives are the procurement for a new MMIS and a client eligibility system – known as the Consolidated Assistance Support System (CASS).
Medicaid Financial Eligibility System
CASS will be the foundation for the NWD/SEP financial data flow. CASS will replace multiple obsolete applications within the Divisions of Family Development and Medical Assistance and Health Services. It will provide a full integrated system to: standardize financial eligibility and benefit calculations; provide real-time access to information and services; enable case management access to the applicant’s information across multiple programs (including waiver programs for aging, disability, developmental, and mental health and addiction services); and data sharing. The “GO Live” target date for
implementation is October 2013. Prior to CASS, DHS has created a “work-around” for eligibility for managed LTSS.
ADRCNJ Website for LTSS
In May 2012, the state announced it had established an ADRC in all 21 New Jersey counties. A new ADRC website – www.adrcnj.org – was launched that includes an
interface with the SAMS provider database (soon to include 4,000 aging and disability network providers); a library with thousands of national, state and local resources; multiple search options; and other consumer-friendly tools including Google translation and mapping features. The site is also Section 508 compliant for improved access to individuals with vision impairments.
A workgroup comprised of representatives from the NJ Divisions of Aging Services (DoAS), Disability Services (DDS) and Developmental Disabilities (DD), and the Area Agencies on Aging (AAAs) worked for several months to develop the site along with Harmony and their website development partner, AGIS.
The ADRC site offers a number of unique features as follows for consumers and aging and disability services workers that are not available on the other websites:
Gives access to a database of national resources created and maintained by the AGIS Network;
Provides read-only access to the SAMS database information posted on the ADRC website for agencies without SAMS;
Has its information refreshed on a schedule set the by DoAS, and
Ability to electronically request regular content updates and verification from providers.
Intake, Level 1 Screen, and Level 2 Core Standardized Assessment
In 2008, the DoAS bought an integrated client-tracking system from Harmony
Information Systems, Inc. known as the Social Assistance Management System (SAMS). As of January 2012, over 1,000associate users of the 21 AAAs and over 600 additional users of their contracted agencies were trained. As a web-based, client-tracking system, SAMS can support multiple departments, divisions and programs. The SAMS integrated
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data system provides intake, consumer profiles, screen for home and community-based services (HCBS), functional assessment, case management, service planning and authorization, service utilization, and the federal reports required by New Jersey under the Older Americans Act.
Data Flow for Behavioral Health Management Organizations
The Administrative Service Organization/Managed Behavioral Health Organization (ASO/MBHO) will establish and maintain an MIS that allows the MBHO and its
subcontractors to collect, analyze, integrate and report data on service utilization, service costs, claim disputes, appeals and clinical and financial outcomes. As relevant, the MIS must also meet Federal block grant reporting requirements. The ASO/MBHO also will establish and maintain electronic interfaces to:
Send and receive information to and from the Divisions of Medical Assistance and Health Services (DMAHS), Mental Health and Addiction Services
(DMHAS) including but not limited to eligibility data and timely, accurate encounter data submissions that meet all state and Federal requirements; Receive encounter data and information from subcontractors and providers
after assumption of responsibility for claims administration;
Send behavioral (BH) claims (as relevant) and physical health (PH) risk screening results to the appropriate MCO;
Receive pharmacy claims, medical claims and BH risk screening results from the MCOs;
Send and receive data and information to and from other agencies, as required (i.e., other child serving agencies to administer cross system
collaboration and measure outcomes under the Children’s System of Care); Adopt electronic health records (EHR) in use by the Children’s System of
Care, and
Adhere to state and federal guidelines regarding the privacy and security of protected health information and confidentiality of client records.
F. Automation of Initial Level 1 Screen Assessment
Under the ADRC initiative, a work group researched, evaluated and selected an assessment suite developed by the University of Michigan (Michigan). The suite was tested in the two ADRC pilot counties, modified to meet New Jersey’s regulations for nursing facility (NF) level of care and implemented statewide as the NJ Choice
assessment suite. The suite, which was based upon the InterRAI MDS-HC assessment, is a nationally and internationally validated assessment tool.
The suite includes: (1) minimum data elements for information and assistance (I&A) intake; (2) the Level 1 screen - “screen for community services,” a set of 20 clinical and 10 financial questions that ADRC specialists ask consumers over the phone to assess their potential need for long-term care support services, and (3) the Level 2
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Michigan wrote an algorithm for the Level 1 screen that predicts the care needs of persons seeking long term care assistance. The algorithm is imbedded in the telephone screening instrument used by NJ ADRC screening professionals and predicts five "levels of care" that roughly correspond with the following care modalities:
1. Information and referral: the person needs assistance in securing information but does not need any formal (paid) services;
2. Homemaker: In order to help maintain his or her home, the person needs non-personal assistance, such as meals, housecleaning, transportation, etc.;
3. Intermittent personal care: the person can be cared for in a home or community based setting and requires minimal personal care (less than daily care or daily care for a single task, e.g., bathing.):
4. Home care: the person can be cared for in a home or community based setting but requires intensive skilled nursing care or therapy services (three or more times a week), minimal skilled nursing care or therapy services (one to two times a week), or intensive personal care services (daily assistance for multiple tasks.), and
5. Nursing Facility Level of Care: the person has extensive medical and personal care needs that require ongoing 24 hour care.
The algorithm does not consider the informal care available to the individual, the person’s ability to pay for services needed, the person’s preferences for (or refusal of) specific care modalities, the specific formal care options available locally, or concerns about the ability of services to ensure the person’s health and safety.
The Division of Aging Services (DoAS) worked with the Harmony Information Systems, Inc. development team to computerize the intake and Level 1 screening tool into the SAMS application. The tool was tested in the ADRC pilot counties and is now
operational in all 21 ADRCs. The state established a performance standard whereby those consumers who score from level three to five are offered the opportunity to have an assessor come to their home to conduct a clinical assessment and counsel them on the full range of HCBS.
The ADRC computerized screening tool has proven to be an effective indicator of a consumer’s need for home and community based services. When clinically assessed, 94 percent of those individuals who scored at level three or above on the screening tool were clinically determined appropriate for LTSS. Not only is the tool effective in targeting the appropriate individuals for home visits and assessments, but it is also an important means to help allocate state and county resources more efficiently and cost-effectively.
G. Potential Automation of a Core Standardized Assessment
During the past year Harmony Information Systems, Inc. worked with the Division of Aging Services (DoAS) to migrate the NJ Choice clinical assessment tool from a stand-alone database administered by DoAS to the Social Assistance Management System
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(SAMS) database supported by Harmony. At this time, the modification is in the testing phase with a “go live” target date of June 30, 2013.
By including the NJ Choice clinical assessment tool in SAMS, the DoAS and ADRC assessors will be able to use a single database to gain access to client demographic information, outcomes of level 1 screens and Level 2 comprehensive clinical
assessments; and to track referrals to programs such as Medicaid services, Older Americans Act and state funded programs, and other home and community-based services for all expanded target populations.
H. Incorporation of a Core Standardized Assessment (CSA) in the Eligibility Determination Process
As background, the Division of Aging Services (DoAS) contracted with the University of Michigan (Michigan) to support use and interpretation of data from the interRAI Minimum Data Set for Home Care version 2.0, known as the MDS-HC, for policy and program administration purposes. The DoAS asked Michigan to analyze MDS-HC records from persons applying either for home and community based services (HCBS) or nursing facility (NF) services under Medicaid.
The New Jersey version of the MDS-HC is comprised of all the items in the standard interRAI instrument as well as additional items identified by New Jersey. Thus, the New Jersey MDS-HC records are fully capable of producing a variety of standardized
measures on an individual or population basis. These include: clinical assessment protocols (CAPs) to identify persons at risk for a variety of problems; scales to measure the individual’s status in key domains such as cognition, functional capacity, pain, and depression; and measures of acuity/resource use that utilize the RUG-III/HC system. Michigan analyzed the outcomes of NF level of care (NF LOC) determination decisions. Prior to the UM analysis, DoAS staff had developed a “scoring logic”, or an algorithm, to interpret state NF LOC regulations (NJAC8:85-2.1). At that time, the NF LOC decision was a judgment by the individual assessor, informed by DoAS training on the particular MDS-HC items used in the decision logic.
The goal of the analysis was to use the data from 19,093 Pre-Admission Screenings conducted by the DoAS assessors and develop the logic in the software used by OCCO assessors to enable implementation of evidence-based, objective NF LOC determination criteria. UM was asked to profile the characteristics of persons who would be deemed NF LOC eligible using the OCCO algorithm and to compare the outcomes of the
algorithm logic with OCCO assessor judgments to see how accurately the two processes corresponded.
Based on the dialogue with DoAS staff, Michigan then developed a flow chart to illustrate the interplay of the MDS-HC items with the scoring logic used in the NF LOC criteria. Upon approval of the flow chart, Michigan then programmed it as an algorithm and applied it to the MDS-HC records described above.
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Michigan also created a profile of all NF LOC applicants from the New Jersey MDS-HC data. The profile was also applied to two sub-groups of interest: persons who had been judged by DoAS staff as NF LOC eligible and persons who had been judged as not NF LOC eligible. The profile’s purpose was to enable a side-by-side comparison of key characteristics of each sub-group, including Activities of Daily Living (ADL) function, cognitive performance, acuity level, and health/mental health status. Due to the large size of the two sub-groups, almost any difference would be statistically significant. Therefore, the subsequent analysis utilizing data from this profile focused on
“substantial” differences, defined as a +/- 5 percent variation between the two groups.
Lastly, Michigan undertook a special analysis to identify the applicant characteristics that would best explain the underlying logic by which DoAS was deciding whether persons met the NF LOC criteria. In this analysis, Automatic Interactions Detections (AID), a statistical procedure, was used to create a classification system based on characteristics of persons in the sample that were related to their LOC eligibility. Thus, the AID
classification system attempted to mimic the DoAS’ decisions.
Findings
One of the key advantages for New Jersey in adopting the MDS-HC is that it is a standardized assessment instrument with a strong research base. As a result, the research base can and should be used to inform policy. Based on the Michigan
analysis, New Jersey NF LOC algorithm was amended to incorporate established scales with demonstrated reliability and validity without compromising the existing NJ LOC regulations. Finally the NJ Choice database was programmed based on the validated algorithm.
Although discussions continue with Division of Developmental Disabilities, for the near term the Division will continue to use the ID/DD clinical assessment tool developed by the New Jersey Institute of Technology. As part of the transition to fee-for-service, various components of this tool will be merged into a single assessment that will determine both eligibility and the functional limitations relevant to service planning.
I. Staff Qualifications and Training
In preparation for the implementation of the Comprehensive Medicaid Waiver (CMW), the Department of Human Services (DHS) created an interdivisional workgroup on case management to develop guiding principles, staff qualifications and training,
requirements, frequency of outreach, and case weights and caseload. In regards to care management and clinical assessors’ qualifications, the following criteria were
established:
Licensed or Certified Social Worker, NJSA 45:1-15 OR
Licensed, Registered Nurse, NJSA 45: 11-26, OR
Graduate from an accredited college or university with a Bachelor’s degree, or higher, in a health related or behavioral science field, with 1,600 hours (46 weeks working 35 hours per week) of paid work or internship experience (non-volunteer) with the elderly or physically disabled in an institutional or community setting.
