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10/16/2002 M{}~roo County Oerk's Office OrigU;.." AREA AGENCY ON AGING DEPARTMENT OF ELDER AFFAIRS - CARES COMMUNITY CARE FOR THE ELDERLY LEAD AGENCIES MEMORANDUM OF AGREEMENT FOR CARES REFERRALS This Memorandum of Agreement, made this 30th day of June, 2002, shall be in effect July I, 2002, through June 30, 2003, between the Alliance for Aging, the Area Agency on Aging for Planning and Service - Area 11, United Home Care Services, Inc., Douglas Gardens Community Care, First Quality Home Care, the Community Care for the Elderly Lead Agencies for Miami- Dade County, Monroe County Social Services, the Community Care for the Elderly Lead Agency for Monroe County, and the Department of Elder Affairs - CARES. The purpose of this agreement is to promote the development of a coordinated service delivery system to meet the needs of consumers who are referred by CARES. This document was used to formulate the following prerequisites: I. Objectives - A. To maintain a climate of cooperation between agencies in order to achieve equitable delivery of services to frail and vulnerable elder Floridians. B. To promote services and activities designed to serve clients in imminent risk of nursing home placement and clients leaving the hospital or nursing home to remain in the community. C. To participate together by means of shared information in the development and expansion of services. D. To provide technical assistance and consultation to each other on matters pertaining to actual service delivery and to share appropriate assessment information and care plans. II. Definitions- A. Imminent Risk: Persons in the following categories, when identified or referred by CARES, will be designated Imminent Risk: existing Medicaid residents in nursing homes who can return to a community setting with services; elderly individuals in nursing homes whose Medicare coverage is expiring who can return to the community with services; elderly in nursing homes that are closing and can be discharged to the community with services; elderly whose mental or physical health condition has deteriorated to the degree that self care is not possible, there is no capable caregiver and institutional placement will occur within 72 hours; elderly assessed as appropriate and pending enrollment in the Long Tern Care Community Diversion Project. B. Upstreaming: A statewide program which outposts CARES staff in hospitals to assess and identify elderly patients who are at risk on nursing home admission. The purpose of the program is to successfully divert elderly patients from nursing home care by linking them with home and community-based services, whether they are publicly or privately funded. 1 C. Nursing Home Transition: Identifying and moving existing Medicaid nursing home residents who's needs can be met safely in an Assisted Living facility that participates in the Medicaid Waiver program. III. Under this Agreement, the Service Provider Agency, the Department of Elder Affairs and Area Agency on Aging agree to the following: A. Referral Process: 1. CARES will provide choice counseling to the consumers explaining the different programs. 2. If a consumer chooses a program other than Community Care for the Elderly, Home and Community-Based Services/Aged and Disabled Adult Medicaid Waiver, the Assisted Living Medicaid Waiver or the Consumer Directed Care Waiver (e.g.: Channeling, PACE, Eldercare), CARES will have the consumer sign a form indicating their choice and will make the necessary referrals. 3. If a consumer chooses Community Care for the Elderly, Home and Community-Based Services/Aged and Disabled Adult Medicaid Waiver, the Assisted Living Medicaid Waiver or the Consumer Directed Care Waiver, CARES will have the consumer sign a form indicating their choice and will refer the consumer to the Elder Helpline. a) CARES will send the completed fax cover sheet that includes the name and Social Security number of the client, Medicaid number, the reason for the referral and service recommend- ations to the Elder Helpline. b) CARES will send the following documents along with the fax cover sheet to the Elder Helpline: the Comprehensive Assessment, the physician Form 3008, the informed consent sheet, Form 603 indicating the client's level of care with a note in the comment section that the client also meets the Medicaid Waiver eligibility requirements, and Form 608, indicating the consumer's choice of programs. 4. If a consumer is an Imminent Risk referral, the Elder Helpline will prioritize this referral. Contingent on funding availability, the Elder Helpline will offer the consumer the choice of three Dade County Community Care for the Elderly Lead Agencies or the Monroe County Lead Agency. Standard operating procedures for processing referrals will be followed. a) After offering consumer choice, the Elder Helpline will send the same fax cover sheet and forward the attachments to the selected Lead Agency. b) The Lead Agency will complete the bottom portion of the fax cover sheet and return it to the Elder Helpline. The Lead Agency will indicate the services started and what services were authorized. c) The Elder Helpline will fax a copy of the returned cover sheet to CARES. This is only to serve as feedback to CARES; this is not to receive CARES approval. Lead Agencies will respond to CARES referrals within one (1) week. 2 5. Ifa consumer is not an Imminent Risk referral and is an Upsteaming or Nursing Home Diversion referral and funding is available, the Elder Helpline will follow the standard operating procedures for processing referrals. a) After offering consumer choice, the Elder Helpline will send the same fax cover sheet and forward the attachments to the selected Lead Agency. b) The Lead Agency will complete the bottom portion of the fax cover sheet and return it to the Elder Helpline. The Lead Agency will indicate the date services started and what services were authorized. c) The Elder Helpline will fax a copy of the returned cover sheet to CARES. This is only to serve as feedback to CARES; this is not to receive CARES approval. Lead Agencies will respond to CARES referrals within one (1) week. 6. If a consumer is not an Imminent Risk referral and is an Upstreaming or Nursing Home Transition referral and funding is not available, the Elder Helpline will place the consumer on the waiting list and make referrals to other agencies and programs. The Elder Helpline will then notify CARES. 7. CARES will send copies of the Imminent Risk referral logs to the Lead Agencies and the Alliance for Aging to review and reconcile any discrepancies prior to forwarding the logs to DOEA. 8. If the Lead Agency conducts an assessment and the client refuses services, the Lead Agency should open the case and close it the next day in CIRTS (termination code is client refused co-payor client placed in nursing home after case management had already started, etc.) CARES will enter the client on the referral log. The Lead Agency will enter the information CARES completed on the 701A form into CIRTS. 9. If a referred client dies before an assessment is conducted by the Lead Agency, CARES will not place the client on the referral log and the Lead Agency will not enter the client in CIRTS. B. Basic Understandings 1. New Consumers: A 3008 form is valid for up to one (1) year, unless there is some medical change, upon which a new 3008 form may be requested. A need for a new 3008 form would be determined by a CARES physician or supervisor and would be done on an exception basis. The case management agency should attach a brief narrative addressing any changes related to the client's health. 2. Reassessments: For currently active consumers, there is no expiration date for 3008 forms, if reassessments by the Lead Agencies are done and submitted to CARES in a timely manner (for example: between the 11th and the 13th month on the Level of CARE expiration date). If later than that, CARES will request a new 3008 form prior to issuing a new Level of Care. 3. In cases where the expiration date of the assessment does not coincide with the expiration date of the Level of Care, the renewal request will be made between the 11th and the 13th month ofthe Level of Care expiration date. The case manager will include a note indicating whether there have 3 been any changes in the consumer's health condition and that the assessment information has been updated. 4. Since consumers must have a Level of Care in order to be on the Assisted Living Medicaid Waiver waiting list, CARES will issue Levels of Care to consumers on the waiting list, regardless if those consumers are active or wait listed for other programs. 5. A Level of Care may be shared among the Lead Agencies as long as the client remains in the same funding program. If the client changes funding programs, a new Level of Care would need to be reissued. 6. CARES is permitted by Medicaid rules to issue Levels of Care retroactive for up to ninety (90) days prior to the date of application for waiver services, providing that the condition of the client is certified and dated by the private physician as qualifying for Medicaid Waiver services. This criteria applies to all provider agencies participating in Medicaid Waiver programs. 7. Copies of the 3008 forms will be accepted by CARES. 8. When a CARES referred consumer becomes active in a program, the Elder Helpline will fax a copy of the referral form to CARES. If a CARES referred consumer changes case management agency, the Elder Helpline will fax a copy of the transfer form to CARES. ALLIANCE FOR AGING, INC. r ~ L-/~ V'S~ature L ) -V r.c.f '4p~ .J- (b ~ Title ( 1 ))... J 6.. ~"- Date c::::::::J OF ELDER AFFAI~ARD ~ Si~ ~ \ :P;A/{ r... ~ Title I 2j ~O / i) 2- Date ES, INe. CeJl) !(rJl Title Date Date TV 4 , j' " ; ',,:: ) ,D,ate (SEAL) ''c.'', ~. ,,' \" 1. 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