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Minnesota Department of Human Services Community-Based Services Manual (CBSM)
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Long-term care consultation

Page posted: 10/1/03

Page reviewed: 11/17/10

Page updated: 4/20/16

Legal authority

Minn. Stat. §256B.0911

Definition

Long-term care consultation (LTCC): A variety of services designed to help people make decisions about long-term care needs and choose services and supports that reflect their needs and preferences.

Purpose

The intention of the LTCC program is the following:

  • • Ensure persons are made aware of available home and community-based options
  • • Prevent long-term placement of persons in nursing facilities, hospital swing beds and certified boarding care facilities
  • • Provide options to persons so they can make informed decisions about where they want to live
  • LTCC eligibility

    Upon request, any person with long-term or chronic care needs is entitled to receive LTCC services regardless of their age or eligibility for Minnesota Health Care Programs. The county where the person is located at the time of request or referral for LTCC service is responsible to provide the LTCC services.

    Individuals, families, human services and health professionals, hospital and nursing facility staff may make referrals for LTCC services.

    Covered components

    LTCC incorporates four main components. The components may be provided in any combination.

    1. Consumer information and education about local long-term care services options.
    2. Face-to-face assessment and support plan to determine program eligibility for people considering home and community-based programs (Alternative Care and CAC, CADI, DD, EW, BI waivers).
    3. Preadmission screening related to nursing home admission. (See OBRA)
    4. Transition assistance to relocate people currently in nursing facilities to community settings.

    Contracted case managers

    Private contracted case management providers cannot complete:

  • • LTCC functions related to home and community-based program eligibility determination
  • • PAS activities
  • Initial and annual LTCC assessments to determine and re-determine program eligibility are always the responsibility of the LTCC staff in the lead agencies. As these are administrative functions, lead agencies cannot delegate them to contracted case managers.

    Contracted case managers may complete case management activities described in the waiver case management covered services section. Contracted case managers must meet the qualifications of each type of case management service. Case management qualifications by type.

    Non-covered services

    LTCC does not include:

  • • Case management services billable under relocation service coordination, Rule 185 case management, targeted case management and waiver case management
  • • Implementation of the LTCC Community Support Plan
  • • Other administrative activities such as development, changing and deletion of service agreements
  • • Private pay case management
  • LTCC teams

    County teams

    The county boards of commissioners establish LTCC teams. Two or more counties may collaborate to establish a joint local consultation team or teams. The board(s) may designate either the social services or public health departments as the lead agency for LTCC services. County LTCC Contact information

    Each local LTCC team must include at least one social worker and one public health nurse from their respective county agencies. The county may use a team of either the social worker or public health nurse or both to conduct LTCC assessments. When one-person assessments are completed, consultation needs to be available between the social worker and the public health nurse to determine the most appropriate care for each person assessed.

    If a county does not have sufficient public health nurse staff available, the county may request approval from the Commissioner of Human Services to assign a registered nurse with at least one-year experience in home care to participate on the LTCC team. Approval is granted based on information provided in the request.

    Managed care teams

    For people who receive their health care services under certain prepaid MA program, the managed care organization is responsible to determine service eligibility for HCBS programs included in their member’s benefit sets.

    Prepaid MA programs that include home and community-based services are:

    Managed care organizations may contract with county or tribal LTCC teams to perform LTCC functions. County and tribal LTCC staff can access information about a person’s managed care enrollment through the Medicaid Management Information System in the Recipient subsystem on the RPPH screen.

    Tribal teams

    DHS may contract with federally recognized tribes to provide LTCC services.

    LTCC forms

    The LTCC Supplemental Form for Assessment of Children under 18 DHS-3428C (PDF) is required when screening a child age 18 years or under. It provides a guide for determination of age-appropriate dependencies for the eight activities of daily living. A child may not be dependent in an ADL, if the amount of assistance needed is similar to the assistance appropriate for a typical child of the same age.

    CBSM Forms and scroll down to Screening Forms / Required waiver forms

    Additional Resources

    AC, EW, CADI & BI Waiver Case Mix Classification Worksheet DHS-3428B (PDF)
    Comparison of LTCC, RSC and CAC, CADI, BI Waivers for Persons with Disabilities (PDF)

    Instructions for completing and entering the LTCC Screening Document DHS-4625 (PDF)

    Level of Care DSPM page
    Minnesota Centers for Independent Living Contact Information

    Process and Procedures

    Access

    To initiate LTCC services, a person or their representative with the person’s consent may contact the LTCC team in the county which they are located at the time of their request.

    Assessment

    The assessment process identifies:

  • • Level of care
  • • Need for supports and services
  • • Natural and informal caregiver supports
  • • Person's preferences and goals
  • • Strengths and functional skills
  • • Service options and alternatives in support of informed choice
  • • Financial resources including all third party payers
  • LTCC assessment includes the following activities:

    1. Inform and educate the general public regarding availability of LTCC services for individuals.
    2. Conduct the intake process.
    3. Schedule the assessment.
    4. Travel to and from assessment (but not mileage costs).
    5. Assess individual health, psychosocial, functional needs, strengths and preferences.
    6. Assess level of care.
    7. Assess for vulnerability issues and services that address them.
    8. Assess environmental needs for safety and access.
    9. Determine the natural supports and informal providers who are able to meet the assessed needs of a person.
    10. Identify services to maintain the person in the most integrated living environment.
    11. Provide options and resources in support of informed choice including financial resources.
    12. Provide information regarding MHCP.
    13. Review the requirements for MHCP eligibility.
    14. Make a referral for final determination of MHCP eligibility.
    15. Provide written recommendations regarding available cost-effective community services.
    16. Develop a community support plan.
    17. Prepare and approve the Long-Term Care Screening Document.
    18. Record LTCC screenings into MMIS.
    Lead agency staff use the LTC Screening Document – LTCC, CADI, CAC, AC, MSHO, EW, BI, CSG DHS-3427 (PDF).

    If Field 17 is checked yes, there is a history of a developmental disability or related condition diagnosis, then refer the person to the DD screening team for a comprehensive diagnostic assessment. Upon completion of the assessment, if the person qualifies for Rule 185 Case Management, complete the DD Screening Document DHS-3067 (PDF).

    LTCC meeting attendance requirements

    Conduct LTCC assessments in a face-to-face interview with the following:

  • • Person being assessed
  • • Person’s legal representative as required by legally executed documents
  • • Other individuals as requested by the person
  • People requested to attend the interview may provide information on the needs, strengths and preferences of the person necessary to develop a support plan that ensures health and safety. However, they cannot be a provider of service nor have any financial interest in the provision of services.

    Consumer information

    LTCC staff must give the person receiving an assessment or LTCC support plan and/or their legal representative, the following materials and information:

  • • Community assistance available, such as caregiver support services
  • • Freedom to accept or reject the recommendations of the team (Information and Signature Sheet for PAS\EW\AC\CADI\BI DHS-2727 (PDF)
  • Minnesota Health Care Programs DHS-3182 (PDF)
  • • Notice of the right to appeal the determination of level of care including a statement to the effect that the decision affects payment for nursing facility services under Medical Assistance, and eligibility for the level of care waiver programs and the Alternative Care program. (Appeals)
  • • Purpose of preadmission screening and community assessment (Promoting and Supporting Independent Community Living DHS-2497 (PDF)
  • • Right to appeal the county agency’s final decisions regarding public programs eligibility according to Minn. Stat. §256.045 (Notice of Action Home and Community-Based Waiver Program and AC DHS-2828 (PDF)
  • • Right to confidentiality under the Minnesota Government Data Practices Act, Minnesota Statutes, chapter 13 (Information access and privacy DHS-2667 (PDF)
  • Transition assistance

    At the initial and annual LTCC assessments, the LTCC team provides transition assistance to persons residing in a nursing facility, hospital, regional treatment center or Intermediate Care Facility for Persons with Developmental Disabilities who request or are referred for assistance.

    Transition assistance services must include the following:

  • • Information about the Centers for Independent Living and other organizations that provide assistance with relocation efforts and contact information
  • • Referrals to Minnesota Health Care Programs
  • • Referrals to programs that provide assistance with housing
  • Two reports will be sent to each county quarterly that list persons under age 65 years:

  • • One report lists persons who live in NF’s located in the county
  • • One report lists persons who are the financial responsibility of the county
  • Use the reports to schedule mandatory, annual LTCC screenings for persons under the age of 65 years.

    County responsibilities

    Counties develop transition processes with institutional social workers and discharge planners to ensure the following are met:

  • • Persons receive information about available transition assistance on admission to the facility
  • • Plans for transition and follow-up for the person’s return to the community are developed and include notification of other local agencies when a person who may require assistance is screened by one county for admission to a facility located in another county
  • If a person who is eligible for a Minnesota Health Care Program is admitted to a nursing facility, the nursing facility must include a consultation team member or the case manager in the discharge planning process.

    LTCC support plan

    The county where the person is located is responsible to develop the LTCC community support plan. The CSP developed in conjunction with the LTCC program is abbreviated in comparison to the CSP developed for the Alternative Care program, waivers or targeted case management services. The LTCC community support plan:

  • • Is a written summary of the LTCC assessment
  • • Details a person’s strengths, needs, preferences and community support options as assessed
  • Whether or not the person is eligible for one of the MHCPs, the LTCC team must provide the person and/or their legal representative with a written LTCC CSP upon request. The exception to this is when a person chooses to receive services in a long-term care facility.

    The LTCC team:

  • • May use the Community Support Plan with the Coordinated Services and Supports Plan, DHS-6791B (PDF), Community Support Plan, DHS-4166 (PDF) or a similar form developed by the lead agency
  • • Must document the most cost-effective alternatives available were offered to the person (community services and living arrangements that cost the same or less then NF care)
  • All persons who choose HCBS services must receive a written LTCC Community Support Plan within 10 working days of their face-to-face assessment date. LTCC services end with the development and delivery of a written CSP.

    If a person wants or needs assistance with implementation or further development of a CSP, the county may refer the person to any of the following for assistance:

  • • Community organization or case management service provider
  • • County or tribal case management service provider
  • • Managed care organization care coordinator or case manager
  • Billing

    Non MA participant

    Enter screening document information through the Person Master Index Number function in MMIS as part of the entry of a Long Term Care Screening Document. See the MMIS User Manual, MinnesotaCare chapter, for further information about assigning a PMIN. County workers are required to enter the correct username and password to access the MMIS User Manual.

    Non Minnesota resident

    1. Use code “089” (out of state) in the County of Residence field.
    2. Use code of the county completing the assessment in the County of Service and/or County of Financial Responsibility fields as well as the LTCC county field.

    65th birthday assessment

    Lead agencies have a two-month period before or after the person’s 65th birthday to complete assessments and LTCC screening documents. During the two months before the birthday, lead agencies receive payment as fee-for-service with activity type 08 (65th birthday screen).

    On or after the 65th birthday, lead agencies may:

  • • Bill the assessment to a managed care organization if they have a contract with MCO
  • • Use the funds passed through nursing facility payments to the county to contribute toward the cost
  • Over age 65

    Funds passed through nursing facility payments to the county contribute toward the cost of completing all required LTCC and PAS activities, including private pay.

    Additional payment information

    A claim will deny and post an edit if the following occur:

  • • MMIS does not have an approved LTC Screening Document with an activity type of 02, 04, 06 or 08
  • • Previous LTCC claim for the same date of service has been paid
  • MHCP information regarding submitting billing claims

    Timelines

    For timeline information, see CBSM – Assessment applicability and timelines.

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