(NEW 02-01-2025 ML #3899)
Purpose
The purpose of HCBS Care Coordination is to improve access to HCBS services and promote health equity, health literacy, and cultural humility in person-centered planning through collaboration with North Dakota’s Tribal partners and cultural and community-based entities in North Dakota. This change is a step to strengthen individualized support, assistance, and advocacy in person-centered planning.
Definition
The HCBS Care Coordination tasks defined in the service of Case Management provide additional support to waiver eligible individuals by promoting health equity, health literacy and cultural humility in person-centered planning. HCBS Care Coordination includes assisting waiver eligible individuals to explore and understand options, make informed choices, solve problems, provide a link between the eligible individual and community resources. Additionally, HCBS Care Coordination provides support and coordination of services to meet the needs of eligible waiver participants through collaboration with Tribal organizations, and culturally based or community-based organizations.
HCBS Care Coordination services are necessary to establish or stabilize waiver eligible participants living in their individual or family home or a community-based setting.
Waiver participants are eligible for HCBS Care Coordination services when a participant is at risk due to health, unstable living situation, or the participant is at risk of institutionalization, such as the following:
Frequent institutional contacts (ER visits, SNF stays, hospital admits, etc.).
Frequent turnover of caregivers and/or services resulting in an inability to maintain continuity of care.
Risk of eviction or loss of current living arrangement.
HCBS Care Coordination services are provided in a manner that protects and supports the participant's health and welfare and is appropriate to the participant's physical and cognitive needs by improving access to services or advancing health equity and health literacy.
HCBS Care Coordination services includes:
Identifying needs and locating necessary resources to establish or maintain a stable and safe living arrangement.
Coordinating, educating, and linking the participant to resources which will establish or stabilize community supports, including arrangements with pharmacies, primary care physicians, financial institutions, utility companies, housing providers, social networks, local transportation options, household budgeting, and other needs identified in care plan.
Providing and establishing networks of relevant participant partners: nursing or institutional facility staff, case managers, community providers (including QSP’s), medical personnel, legal representatives, paid caregivers, family members, housing agencies and landlords, informal supports, and other involved parties.
Ensuring all necessary paperwork and documentation is completed to establish or maintain a stable and safe living arrangement.
Assisting with the development of a plan for, and when necessary, providing emergency assistance to sustain a safe and healthy community setting.
Assisting the participant in arranging for transportation to effectively connect the participant with the community.
HCBS Care Coordination Service Delivered Remotely
A visit by virtual means can be conducted when individual cannot have an in-person face to face due to extenuating circumstances. The individual may be afforded the option to use the phone or other telehealth technology to engage in the development and/or monitoring of person-centered plans when there are extenuating circumstances impeding the ability to conduct the visit in person. Extenuating circumstances may include instances where the in-person visit poses a health or safety risk to the individual or case manager; public emergency as determined by local, state and federal government.
Virtual Support Guidance
The participant’s services may not be delivered via virtual support 100% of the time. The participant must always have the option to request in-person services. Instances of visit by virtual means must be approved by the HCBS CM Supervisor or HCBS Program Administration as a safeguard to ensure virtual supports can help meet the needs of the participant in a way that protects the right to privacy, dignity, respect, and freedom from coercion. Any issues will be addressed prior to the implementation of virtual supports and documented in the individual’s case record.
In virtual supports, the use of cameras in bathrooms or bedrooms impacting the participant’s dignity and privacy is not permitted. Provider must use a HIPAA compliant service delivery method (e.g. Microsoft Teams, Zoom for Healthcare). HIPAA rules apply to all covered entities regarding HIPAA Privacy and Security. Participant will be given education and support on the use of virtual supports by their chosen provider. Virtual supports are not a system to provide surveillance or for staff convenience.
HCBS Care Coordination Limitations
The provision of HCBS Care Coordination is limited to agency providers.
Provider qualifications allow cultural or community-based organizations, including non-profit, LLCs, and Tribal entities to provide the service.
Waiver case management that includes the task of HCBS care coordination may not claim for the service provided to individuals working towards transition until the individual enters the waiver program.
The state will administratively claim for case management services for individuals working towards transition when the individual enters the waiver program. Both HCBS Case Management and HCBS care coordination can be delivered simultaneously.
State employed case managers will be responsible for ongoing monitoring of the provision of services in the services plan.
Provider Qualifications
Community-based, non-profit organizations in North Dakota which provide services by and for people with disabilities or entities such as Centers for Independent Living, Community Health Representatives, Community Health Worker, Older Americans Act, Older Americans Act Title VI service providers, Tribal organizations, or other cultural based organizations.
Enrolled Qualified Service Provider N.D.A.C. 75-03-23-07
Initial/re-enrollment every 60 months for agency providers, and/or upon notification of provider change.
Other Standards
Agency employed HCBS Care Coordinators must have:
An associate degree or higher in Psychology, Social Work, Social Services, Human Services, Behavioral Sciences, or other closely related field including a medical field,
and a minimum of one years' experience in the coordination of community services and supports, e.g., housing, personal assistance services recruitment or management, independent living skills training, etc.
Qualifying education and experience will be considered in lieu of degree requirement. Qualifying education and experience means;
Two years of experience in the coordination or provision of community services and supports in a social service setting under qualified supervision.
Four years of personal experience with a disability and has documented experience in the coordination of community services and supports in a social service setting.
Provider Training Requirements
Completion of Person-Centered Planning training
Initial and annual HCBS Training on Home and Community Based Services
HCBS Settings Regulation