Disease and Case Management Work Aid

Title:	Person’s Evaluation of FC, CL, AD (Foster Care, Customized Living, or Adult Day Service)
Program(s):	Disease and Case Management- MSHO/MSC+ Program	Effective Date:	8/1/2018
Frequency:	At time of Assessment	System(s):	MMIS
Process Owner:	Lisa Ellis	Back-up Owner:	All supervisors
Revised by:	NA	Last Revision:	8/1/2018
Preparation/Materials:	Person’s Evaluation of Foster Care, Customized Living, or Adult Day Service (DHS 3428Q LTC Screening Document – ( DHS-3427)

Purpose:

To collect feedback about the person's perception of a provider from whom he or she receives customized living, foster care, or adult day service as part of meeting requirements under the federal HCBS rule.

• Adult day services (S5100/S5100 w/U7)

• Customized living (T2031 w/TG/T2031)

• Foster care (S5140/S5140 w/U9)

When to use:

Complete this evaluation at reassessment. This evaluation form must be completed at least once per year.

This evaluation is only done when a member is already open to EW at the time of re-assessment. The LTCC and plan of care is also being completed at this time.

Completed evaluation information will be added to the LTCSD after the CC populates the LTCSD with the LTCC results. Both the LTCC document result and this evaluation results are reflected in the LTCSD. (DHS – 3427)

Summary of the Survey Process:

(The evaluation document has detailed instructions, so please review the form itself along with this Work Aid)

Steps:

Find the Evaluation form (DHS 3428Q) by going to the MSHO/MSC+ Care Coordination Portal and accessing this specific document.

If a member does not receive Adult day or Residential services, the evaluation form is not completed, but the CC will need to enter (NA) into the LTCSD- Field 108 Services

If the member has one of the 3 services, then the CC continues with the evaluation. If a member has both ADC and Residential service- CLS or FC, choose the CLS or FC to evaluate.

If a member is not able to participate in the evaluation and they do not have a guardian, the evaluation form is not completed, but the CC will need to enter 3 in Field 110 and the NPI number for the FC, CL, AD provider into the LTCSD).

If there is a Guardian involved and willing to participate, CC will do the evaluation with the Guardian and will enter 2 in Field 110 and the NPI number and all the other fields of the evaluation results.

If the member is able to participate, CC will do the evaluation with the member and will enter 1 in Field 110 and the NPI number and all the other fields of the evaluation results.

Evaluation questions 1-11 are for all 3 services. Question 12 is only asked if they have ADC. Questions 13-23 are only asked if the member is a CLS or Foster Care setting.

For all the questions, there is an option of Choose not to answer for each question. If you have a member who does not want to participate in the survey at all, you must still complete the survey using the - choose not to answer- for each question.

When questions are complete, manually enter all the required codes into MMIS.

Considerations for Care Planning based on the results of this evaluation

DHS states the following:

While quality assessment of residential and adult day service is a primary purpose of this evaluation, it is important that case manager/care coordinators also use enrollee responses to improve services and enrollee experiences. If the person's responses indicate they are not satisfied, the case manager/care coordinator may need to take follow-up action for remediation or improvement. Follow-up action may include a discussion with the provider to resolve the identified issue, updating the person's Collaborative/Comprehensive Care Plan (CCP), or documenting in a case note why no action was needed or taken by the case manager/care coordinator. There are reminders for follow-up imbedded in the question response sets.