Informed Choice 525-05-12

(NEW 1/1/21 ML #3624)

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Purpose

The purpose of informed choice is for the department to ensure the target population member (TPM); individuals, over age twenty-one (21) who are eligible for, or likely will become eligible for Medicaid in the next 90 days, and who are screened for nursing facility level of care (NF LOC), have the opportunity to make an informed decision about how and where to receive long-term services and supports (LTSS).

The intent of informed choice is to work directly with the TPM to provide information on LTSS. This allows the TPM to make a decision about their care and support and have their voice heard.

The TPM’s wishes is the primary focus of the discussion.

Service Eligibility Criteria for The Target Population Member (TPM) for informed choice must meet the following criteria:

1. Individual has physical disability; and are at serious risk of entering a nursing facility.

• The NF LOC is approved and indicates functional impairment.
• Individuals may have a co-occurring mental or behavioral health need indicated on the screening.

2. Individuals twenty-one or over meet the TPM definition.

• If an individual is 18-20 years old and is referred through the informed choice process, the referral will be sent to the MFP Program Administrator to provide information and referral on options for LTSS.

3. The TPM may be eligible or likely to become eligible for Medicaid LTSS.

• Including individuals who have $25,000 or less in assets or have applied or are planning on applying for Medicaid funded LTSS.

4. LTSS are likely to be required for at least 90 days

• TPM will require either formal or natural supports.
• 90 days includes services in the hospital/nursing facility and in the community.
• Individuals screened with a short-term screening who indicate a high preference for returning to the community, may receive either written.

Examples:

Mary was in the hospital and diagnosed with terminal cancer. Mary’s life expectancy is less than 3 months and she is wanting to receive hospice care in the nursing home. Informed choice would not be completed as Mary does not meet the target population due the LTSS need is expected to last less than 90 days.

Kevin was hospitalized due to a motor vehicle accident that left impaired in toileting/transferring and locomotion. Kevin is expected to spend 60 days in the nursing facility then will return to his apartment. Kevin anticipates he will be able to manage his own care needs after a 60 day stay in the nursing facility. Kevin does not meet the target population criteria due to short term stay and he is anticipated to not need LTSS. An SFN 892 is completed indicating that Kevin does not meet the target population. On day 45 Kevin is rescreened for NF LOC as his rehab is taking longer as he developed an infection. Kevin is on the informed choice referral list and now meets the criteria for the TPM. Informed choice would be completed and a referral would be made to HCBS and MFP as Kevin would like to return home and he agrees that he would like to learn about assistance with transitioning back into the community.

In-reach

The assigned case manager must complete the informed choice process with the TPM using a person-centered planning process, Informed Choice Questionnaire, SFN 892.

1. The case manager must make contact with the TPM unless TPM level of cognitive impairment, mental illness or end-stage life conditions is such that they do not understand the questions, a family member, significant other, guardian and/ or legal representative should be asked the informed choice questions.

• Legal representative of the TPM may include a guardian, Durable Power of Attorney (DPOA), Power of Attorney (POA), or representative identified on the TPM Living Will.
• Documentation of authority is required and must be verified prior to allowing legal representative to make any decisions on behalf of the TPM.
• Informed Consent - In some cases, TPM may not understand the question or the questions may result in the TPM being agitated or saddened by being asked the informed choice questions. Or if the TPM level of cognitive impairment is such that they do not understand, a family member, significant other, guardian and/ or legal representative should be asked the informed choice questions.
• In instances where there is no legal representative, family or informal support and the TPM cannot participate due to cognitive impairment, the informed choice worker will recommend to the nursing facility social worker to refer for guardianship.

2. Case manager must provide written (Community Living Brochure, DN 1864) and verbal communication with the TPM and/or their legal representative on LTSS in the most integrated setting.
   
   
3. The case manager must contact the TPM as soon as possible, but no later than 5 business days from the date of referral.

• If the visit cannot be completed within the designated timeframe the case manager must document why the visit did not take place within the designated timeframe on the SFN 892.

4. Priority should be given to individuals discharging from the hospital.

• Best practice is to follow up with the hospital daily and no later than two working days of the informed choice referral.
• Case management must provide face-to-face person-centered planning with the TPM whenever possible.

5. A virtual or visit by telephone may be completed in circumstances where a face-to-face visit cannot be completed. Such circumstances may include visitation restrictions due to COVID-19.

• Connection Carts should be used when available.
• The case manager must document on the SFN 892 why the visit was not completed face-to-face.

6. If the TPM could not be located (ie. they discharged or do not answer their phone), the case manager must mail the DN 1864 and the community living handout to the TPM’s address on the NF LOC screening.

• Contact attempts including mailing of information need to be documented on the SFN 892.
• At least two attempted contacts must be made to contact the TPM before the informed choice information is mailed out.

7. Collateral contact may be made with the screening agency or facility in which the TPM is residing to provide information about the individual’s admission/discharge.

• The public or private agency cannot prevent or impede the informed choice process.
• The collateral contact should not influence the decision of the TPM or their legal representative.
• Information can be exchanged on a need to know basis under the continuum of care between the facility and the informed choice worker without a release of information.
• The TPM and/or their legal representative should be made aware that information is exchanged between entities.

8. Informed Choice must be completed once over a three-month period of time if there are multiple referrals on the TPM.

• For each informed choice referral a new SFN 892 must be submitted to Aging Services.

• The case manager will complete the first section of the SFN 892 and enter in the narrative section the date the individual received informed choice in the past 3 months.
• If the informed choice visit was completed more than 3 months from the new referral, the informed choice visit must be completed and documented on the SFN 892.

Examples:

Henry was referred for informed choice on January 12th, and informed choice visit was completed and the SFN 892 was submitted to Aging Services. On April 29th, Henry was on the informed choice referral list again. Informed choice must be completed as it has been more than 3 months since the last informed choice visit was completed.

Iris was referred for informed choice on February 12th. Several attempts to contact Iris were unsuccessful. The informed choice worker mailed the informed choice brochure and handout to Iris’s home residence and submitted the SFN 892 indicating the informed choice information was mailed, the list of unsuccessful attempts to contact Iris. On March 1st, Iris was again referred for informed choice due to needing to continue in the nursing facility for longer than 30 days. The informed choice worker was able locate Iris and complete the visit. On May 20th, Iris was referred a third time for informed choice due to an additional diagnosis being added to her conditions. Since the worker had just completed the visit on March 1st (within the last 3 months) they would complete the first section of the SNF 892 and indicate in the narrative that the informed choice visit was already completed on March 1st. They would not be required to complete another informed choice visit at this time.

Referrals

Case manager (informed choice worker) must complete referrals made to other programs/services as requested by the TPM and document the date that the referral was made on the SFN 892.

1. Referrals to MFP must be made to the MFP Program Administrator, HCBS Territory Supervisor and the HCBS Program Administrator at the same time.

• The case manager must coordinate with MFP for transition coordinator throughout the transition process.

• The informed choice worker may include the most recent History and Physical and the face sheet, medication list and care plan for the referred individual.
• The informed choice worker must also include the SFN 892 with the referral.

• If the individual has been residing in BC and has CM there would not need refer to MFP if the individual plans on returning to BC.

2. Referrals to ND DHS, Developmentally Disability Division

Informed choice will be completed by the DD Division when the referral is also submitted by the NF LOC contractor for Level II review.

• The DD Division will provide documentation indicating informed choice was completed upon the request of HCBS Program Administrator.
• Individuals meeting the TPM criteria and receiving DD services must be referred to the DDPM to complete the Informed Choice referral.

• Documentation of completed informed choice visit must be submitted by the DDPM/DDPA to Aging Services within 5 business days of the visit.

Documentation

Documentation of the informed choice exchange must be documented on the SFN 892.

1. Documentation of any referrals must entered on the SFN 892.

• A signed copy of the SFN 892 must submitted to Aging Services within 5 working days of the informed choice visit.
• The individual or legal representative must sign the SFN 892 or give verbal permission for the case manager to sign on their behalf.

2. The case manager must document that the individual gave verbal permission for signature in the narrative section of the SFN 892.

• Additional notes can be added to the narrative section of the 892.

Continuum of Services

1. Refusal of Informed Choice

• The individual has the right to refuse informed choice. Please document the refusal and obtain a signature indicating the refusal.

2. The TPM must be asked if they would like a follow up with an informed choice visit at a later date.

• A copy of the SFN 892 must be sent to the department for filing noting the future request for an informed choice visit.

• The date for future informed choice must be entered on the SFN 892.
• The in-reach worker and supervisor will determine what territory will follow up with the individual at the requested time.

• The determination of who will complete the follow up informed choice visit will depend on the location of the individual.
• The SFN 892 will be complete again at the follow -up informed choice visit.

• Indicate on the SFN 892 the date the follow up visit is in relation to.

3. HCBS Services are requested by individual

• The informed choice worker must staff the referral with the HCBS Supervisor who will determine who will be assigned as the HCBS Case Manager.
• The Supervisor may need to coordinate with other HCBS Supervisors and forward the completed SFN 892 and provide a soft hand off to the HCBS Case Manager assigned. (In-reach worker and the CM must work together.)
• Example: The individual was in a Fargo hospital and is wishing to have HCBS services in their home in Gackle, ND. The Fargo Area in-reach worker and supervisor would coordinate with the territory servicing Gackle and complete a referral. • Consult with the MFP Program Administrator to explore MFP eligibility or other transition service eligibility.