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Support planning for long-term services and supports (LTSS)

Page posted: 9/28/18

Page reviewed:

Page updated:

Legal authority

Federally approved BI, CAC, CADI, DD and EW waiver plans, Minn. Stat. §256B.0911, Minn. Stat. §256B.092, Minn. Stat. §256B.0915, Minn. Stat §256B.0913

Definitions

Support planning: A person-centered process that helps people identify and access social, health, educational, vocational and other community and natural supports and services based on the person’s values, strengths, goals and needs. The process encourages the use of formal and informal supports.

Support planner: The professional who helps the person with his/her long-term services and supports (LTSS) support planning process. Professionals who can provide this support include case managers, care coordinators and certified assessors.

Overview

The support planning process might involve:

  • • Person who receives services and/or his/her legal representative
  • • Case manager
  • • Managed care organization (MCO) care coordinator (when applicable)
  • • Certified assessor
  • • Providers
  • • Other people as designated by the person (e.g., relatives, friends).
  • Summary of the process for counties and tribal nations

    Counties and tribal nations summarize the decisions made during the person-centered planning process using MnCHOICES Support Plan Application with the community support plan (CSP) and coordinated services and supports plan (CSSP).

    Community support plan (CSP)

    The CSP is a written summary completed for everyone who has an assessment, regardless of whether the person is eligible for Minnesota Health Care Programs (MHCP) or chooses to receive publicly funded home and community-based or state plan services. This document provides a summary of what the assessor discovered through the assessment process and identifies next steps based on the person’s needs.

    For more information, see the CSP section.

    Coordinated services and supports plan (CSSP)

    The CSSP is a summary of the person’s choice of supports and/or services if the person chooses to receive publicly funded home and community-based services and/or state plan services.

    For more information, see the CSSP section.

    Summary of the process for MCOs

    MCO care coordinators use the MCO comprehensive care plan, which includes all required support plan components.

    Provider standards and qualifications

    Lead agencies must ensure the support planner who helps people develop support plans meets the qualifications for that role.

    Case managers

    For qualifications, see CBSM – Waiver/AC case management and CBSM – Rule 185 case management.

    Care coordinators

    Qualifications for MCO care coordinators are outlined in the contracts between DHS and MCOs. See DHS – Managed care contracts.

    Certified assessors

    For qualifications, see CBSM – MnCHOICES certified assessors.

    Secondary information

    People 65 years or older

    When assessing people 65 years or older who are currently fee-for-service and will be transitioning to an MCO, the county or tribal nation may choose to use either the MnCHOICES Support Plan Application or the MCO comprehensive care plan.

    Initial/annual assessment process and procedure

    Throughout the initial/annual assessment, both the certified assessor and the case manager are responsible to:

  • • Follow planning and referral responsibilities as warranted by the person’s needs (as described below)
  • • Promote informed decision-making by the person
  • • Apply person-centered practices to address what is important to and important for the person (see DHS – Person-centered practices)
  • • Work with the person to develop outcomes based on his/her strengths, needs and preferences.
  • Certified assessor responsibilities

    The certified assessor is responsible for the initial/annual assessment. The certified assessor:

  • • Schedules the assessment with the person and his/her legal representative
  • • Conducts the assessment using person-centered practices
  • • Completes the Community Support Plan Worksheet, DHS-6791A (PDF) during the assessment and gives a copy to the person
  • • Reviews what is working and not working for the person in his/her current CSP
  • • Reviews input from the person’s caregivers (either using Caregiver Questionnaire, DHS-6914 [PDF] or entering it informally during the assessment)
  • • Reviews input from the person’s provider(s)
  • • Completes the Long-Term Services and Supports Assessment and Program Information and Signature Sheet, DHS-2727 (PDF) during the assessment and sends it to the person
  • • Develops the person’s CSP in the MnCHOICES Support Plan Application or DHS-6791B (PDF)
  • • Sends the completed CSP to the person and his/her case manager within 40 calendar days of the assessment
  • • Completes the CSSP if the person is going to use a program or service that does not offer case management or if the service will start before a case manager is assigned
  • • Provides the person with a Notice of Action, DHS-2828A (PDF) to help him/her understand the programs for which he/she is both eligible and not eligible.
  • Case manager responsibilities

    The case manager supports the initial/annual assessment and ensures the person continues to receive necessary services and supports throughout the process. The case manager:

  • • Uses his/her knowledge to inform the certified assessor about the person’s accomplishments and/or needs during the previous year
  • • Informs the person about the benefits of the assessment
  • • Provides information to the person about what he/she can expect during the assessment process
  • • Encourages the person and his/her formal and/or informal supports to engage with and participate fully in the assessment process
  • • Reviews what is working and not working for the person in his/her current CSSP
  • • Develops the person’s new CSSP in the MnCHOICES Support Plan Application or DHS-6791B (PDF) within 10 business days of receiving the person’s CSP from the certified assessor
  • • Reviews and documents the need for assistive technology and provides potential referrals as needed
  • • Sends the completed CSSP to the person, his/her legal representative, designated providers and care coordinator (if applicable)
  • • Secures provider signatures on new or updated CSSPs (see CBSM – Provider signature requirements for HCBS support plans)
  • • Provides the person with Notice of Action, DHS-2828B (PDF) to help him/her understand any denials, reductions or terminations to services
  • • Completes the Long-Term Services and Supports (LTSS) Improvement Tool with the person (see DHS – Frequently asked questions about the new LTSS Improvement Tool).
  • A case manager, certain service provider(s) and the person or his/her legal representative signs the MnCHOICES Coordinated Services and Supports Plan Signature Sheet, DHS-6791D (PDF). This is to indicate agreement with the services and supports in the support plan.

    Managed care organization (MCO) responsibilities

    If the person is age 65 or older and enrolled in an MCO, the care coordinator should follow the MCO’s protocols for assessments and support plans. If a person is either on or returning to BI, CAC, CADI or DD waivers, the county/tribal nation maintains the responsibility to complete the assessment.

    Community support plan (CSP)

    The CSP must include:

  • • Information that is important to and important for the person
  • • The person’s strengths, preferences, needs and desired outcomes
  • • A summary of the person's assessed needs as identified by the certified assessor
  • • Options and choices available to the person to meet the identified needs (including all options for providers)
  • • Health and safety risks, and how those risks will be addressed
  • • Referral information identified through the assessment process
  • • Informal caregiver supports, if applicable (e.g., relatives, friends).
  • • A notice about the person's right to request a conciliation conference or appeal hearing (see CBSM – Appeals).
  • Coordinated services and supports plan (CSSP)

    The CSSP must:

  • • Identify the person's long-term and short-term goals
  • • Identify the person's preferences for services, including his/her choices for self-directed options and goals
  • • Document that the person made an informed choice from all available options for providers
  • • Include a notice about the person's right to request a conciliation conference or appeal hearing (see CBSM – Appeals)
  • • Describe the person's need for services (including needs met by relatives, friends and others, as well as community services used by the general public)
  • • List specific services to be provided for the person, including the amount and frequency of the services, and relate the service to an assessed need, the person's preferences and available resources
  • • Reasonably ensure the person's health and welfare, including personal risk strategies (see CBSM – Guide to encouraging informed choice and discussing risk)
  • • Contain the authorized annual and monthly amounts for the services
  • • Describe the provider's responsibility to implement and make recommendations about modifying the CSSP
  • • Provide information that assists the provider with developing an individual service delivery plan, as required by the provider’s license
  • • Address the person's assessed needs, his/her choices for long-term services and supports (including formal and informal services) and risk management strategies
  • • Be reviewed by a health professional if the person has overriding medical needs that impact the delivery of services
  • • Be agreed to and signed by the person, his/her legal representative (if applicable), authorized lead agency representative and providers of HCBS services.
  • Comprehensive care plan

    Care coordinators use the comprehensive care plan instead of the state’s CSP and CSSP. The comprehensive care plan includes all required components.

    Additional resources

    CBSM – Assessment and support planning overview
    CBSM – Guide to encouraging informed choice and discussing risk

    CBSM – MnCHOICES

    CBSM – Notice of action

    CBSM – Provider signature requirements for HCBS support plans

    DHS – Person-centered practices

    HCBS Rights Modification Support Plan Attachment, DHS-7176H (PDF)

    MnCHOICES Community Support Plan (CSP) worksheet, DHS-6791A (PDF)

    MnCHOICES Community Support Plan with Coordinated Services and Supports (CSSP), DHS-6791B (PDF)

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