procedures evaluation. Sub-assurance c. - CC conducts reevaluation Document any Change # and % of Ongoing Quarterly Transition Service plans of plan prior to day 365 of unmet needs. Request service plan Process updated/revised at MFP Demonstration for form change requests Post least annually or all participants. Develop plan to Transition # and % when warranted by address unmet Health & increases, waiver participant Additionally, the CC needs. Welfare reductions, needs reviews the ITP, at least Case terminations due quarterly, and updates All requests for Review to change in the plan as needed, change in ITP go form needs based on a change in the through TM participant's needs. Reasons for termination from MFP Sub-assurance d. - TC follows up with TM verifies Discharge Total number of QoL and Quarterly Transition Services are participant on a monthly discharge plan Plan participants Health & Process delivered in basis for first year to with all services within given Welfare = Post QoL accordance with the determine if all needs are in place time frame Ongoing Transition survey service plan, being met and transition Compare QoL analysis Health & including the type, plan is working. Claims authorized plan Welfare Claims analysis scope, amount, =Quarterly TM follows-up with to services Case duration and participant by phone at delivered. frequency specified Review least quarterly. in the service plan. form OADS tracks claims data for MFP participants Sub-assurance e. - TM or TC will describe TM and TC offer Choice # and % by Ongoing Quarterly Preliminary Participants are MFP process and receive choice as letters choice at each Assessment afforded choice: Process informed consent at each indicated in step in process Between waiver step in MFP process; at process steps. Transition services and initial meeting; at time of Choice of Planning institutional care; transition planning TC documents provider Process and between process; and at time of participant’s documented on /among waiver transition process. choice of ITP Transition services and provider. Process TC will receive choice
procedures evaluation. Sub-assurance c. - Service plans updated/revised at least annually or when warranted by waiver participant needs Transition Process Post Transition CC conducts reevaluation of plan prior to day 365 of MFP Demonstration for all participants. Additionally, the CC reviews the ITP, at least quarterly, and updates the plan as needed, based on a change in the participant's needs. Document any unmet needs. Develop plan to address unmet needs. All requests for change in ITP go through TM Change Request form Health & Welfare Case Review form # and % of service plan change requests # and % increases, reductions, terminations due to change in needs Reasons for termination from MFP Ongoing Quarterly Sub-assurance d. - Services are delivered in accordance with the service plan, including the type, scope, amount, duration and frequency specified in the service plan. Transition Process Post Transition TC follows up with participant on a monthly basis for first year to determine if all needs are being met and transition plan is working. TM follows-up with participant by phone at least quarterly. OADS tracks claims data for MFP participants TM verifies discharge plan with all services in place Compare authorized plan to services delivered. Discharge Plan QoL survey Health & Welfare Case Review form Total number of participants within given time frame QoL analysis Claims analysis QoL and Health & Welfare = Ongoing Claims =Quarterly Quarterly Sub-assurance e. - Participants are afforded choice: Between waiver services and institutional care; and between /among waiver services and Preliminary Assessment Process Transition Planning Process Transition Process TM or TC will describe MFP process and receive informed consent at each step in MFP process; at initial meeting; at time of transition planning process; and at time of transition process. TC will receive choice TM and TC offer choice as indicated in process steps. TC documents participant’s choice of provider. Choice letters # and % by choice at each step in process Choice of provider documented on ITP Ongoing Quarterly