Minnesota Minnesota

Community-Based Services Manual (CBSM)

Community-Based Services Manual (CBSM)


MnCHOICES

Page posted: 8/7/14

Page reviewed: 6/28/24

Page updated: 5/27/25

Legal authority

Minn. Stat. §256B.0911

Definitions

MnCHOICES: Term that refers to both the computer application used by lead agencies to complete long-term services and supports (LTSS) assessments, support plans and health risk assessments and the assessment conducted to determine eligibility for LTSS.

Lead agency: County, tribal nation or managed care organization (MCO).

Overview

Lead agencies use MnCHOICES to complete:

  • · Assessments for Medicaid waivers and state plan personal care assistance (PCA)/Community First Services and Supports (CFSS).
  • · Health risk assessments (HRAs).
  • · Support plans.

    • The MnCHOICES application:

  • · Fosters a person-centered assessment and support planning process.
  • · Creates an efficient and effective way to gather information.
  • · Determines eligibility for multiple programs using one assessment.
  • · Uses an electronic, rule-based system that ensures consistency and applies rules equally.
  • · Provides data to analyze impact, inform policy decisions and produce documentation required by federal and state law, including measuring quality outcomes for home and community-based services (HCBS).
  • · Fosters communication and collaboration between assessors, case managers and care coordinators to improve service delivery for people who access LTSS.

    • Assessment

    How is it used?

    Determine program and service eligibility

    Certified assessors use the MnCHOICES Assessment to determine program and service eligibility for:

  • · HCBS waivers: Brain Injury (BI) Waiver, Community Alternative Care (CAC) Waiver, Community Access for Disability Inclusion (CADI) Waiver, Developmental Disabilities (DD) Waiver and Elderly Waiver (EW).
  • · Alternative Care (AC) and temporary AC.
  • · PCA/CFSS.
  • · Consumer Support Grant (CSG).

    • For information about certified assessors, refer to CBSM – MnCHOICES certified assessors.

    Provide information to access other programs and services

    Certified assessors also use the MnCHOICES Assessment to help a person identify other programs to explore, such as:

  • · DD case management (Rule 185).
  • · Housing Stabilization Services.
  • · Moving Home Minnesota.
  • · Relocation service coordination targeted case management.
  • · Essential Community Supports (ECS).

    • Provide consistent assessment practices

    The assessment process includes a person-centered interview with the person to gather information about their needs, including:

  • · Planning and referrals driven by the person’s support needs and preferences.
  • · Informed decision-making.

    • For more information, refer to CBSM – Support planning for LTSS.

    Complete HRAs

    MCO care coordinators use HRAs to:

  • · Capture health care needs, health status and health risk factors.
  • · Gather information about a person’s needs related to daily life for both activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

    • MCO care coordinators cannot use HRAs to determine eligibility for waiver programs, PCA/CFSS or Housing Stabilization Services. However, an HRA does include items the care coordinator can use to refer the person for these programs and services.

    What does it replace?

    The MnCHOICES Assessment replaces:

  • · DD Screening Document, DHS-3067.
  • · Long-Term Care Consultation Services Assessment, DHS-3428.
  • · PCA Assessment and Service Plan, DHS-3244.

    • The MnCHOICES HRA replaces Minnesota HRA Form, DHS-3428H.

    What assessments are available in MnCHOICES?

    The MnCHOICES Assessment allows assessors and care coordinators to complete:

  • · Initial assessments.
  • · Reassessments.
  • · Initial assessment reviews (IARs).
  • · Functional needs updates (service change for AC and EW only).
  • · 65th birthday updates.
  • · HRAs.

    • Support Plan

    How is it used?

    Assessors, case managers and care coordinators use the MnCHOICES Support Plan to document the person’s goals, preferences and needs related to social inclusion, health, education, vocation and other services based on the person’s values and strengths.

    What does it do?

    The MnCHOICES Support Plan is a tool to create a person-centered plan for services and supports. It:

  • · Documents the person’s goals, strengths, needs and preferences.
  • · Includes assessment data to inform the person’s plan, including assessed needs, case mix and home care rating.
  • · Collects data on state and federal person-centered planning requirements.
  • · Calculates service rates for certain supports and services. For more information, refer to CBSM – Disability Waiver Rate System (DWRS) and CBSM – Rate methodologies for AC, ECS and EW service authorization.

    • What does it replace?

    The MnCHOICES Support Plan replaces:

  • · MnCHOICES Community Support Plan with Coordinated Services and Supports, DHS-6791B.
  • · MnCHOICES Coordinated Services and Supports Plan Signature Sheet, DHS-6791D.
  • · Managed Care Collaborative Care Plan.

    • What does it create?

    The MnCHOICES Support Plan allows support planners to create and revise:

  • · Support plans, including the ability to individually print the following sections: About me – my care team, about me – my life, about plan and care coordination next step indicator report.
  • · PCA/CFSS Type B service agreements.
  • · Standard service agreements for all programs.

    • For information about the support planning process, refer to CBSM – Support planning for LTSS.

    Non-covered functions

    The MnCHOICES Assessment does not determine eligibility for all programs and services that may be available to the person. For example, the MnCHOICES Assessment does not:

  • · Assess for mental health targeted case management services.
  • · Determine diagnoses.
  • · Determine financial eligibility for Minnesota Health Care Programs (MHCP).
  • · Determine eligibility for the Family Support Grant (FSG).
  • · Determine eligibility for DD case management services (Rule 185).
    Note: Certified assessors can use the MnCHOICES Assessment to gather a person’s social history and inform them of potential eligibility for DD case management services. The lead agency’s qualified developmental disabilities professional (QDDP) determines the person’s eligibility through the diagnostic determination process. For more information, refer to DD Screening Document Codebook – Diagnosis determination.

    • Lead agency responsibilities

    Lead agencies are responsible to:

  • · Establish and maintain a team of qualified case managers and assessors (refer to CBSM – Waiver, AC and ECS case management and CBSM – MnCHOICES certified assessors).
  • · Meet technical specifications for the computer application (refer to PartnerLink – MnCHOICES workstation technical specifications).
  • · Ensure all users of the MnCHOICES application complete the required annual data privacy courses per lead agency protocol (refer to Handling MN Information Securely).
  • · Complete all required assessments (refer to CBSM – Assessment applicability and timelines).
  • · Ensure timelines are met.

    • User support

    Training

    DHS provides the following training to support computer application users:

  • · MnCHOICES Certified Assessor Training (MnCAT).
  • · MnCHOICES Content and Workflow modules for the MnCHOICES Assessment, HRA and their associated support plans.
  • · Building Your Skills and Advancing Skills Support Planning Training.
  • · Rates Training.
  • · MnCHOICES New Mentor Training.

    • For more information, refer to PartnerLink – MnCHOICES training and recent webinars and TrainLink – DSD training archive.

    MnCHOICES technical mentors

    DHS recommends all lead agencies have MnCHOICES mentors to:

  • · Encourage and coach staff.
  • · Provide hands-on technical support.
  • · Help identify technical issues and problem-solve those issues.
  • · Foster collaboration between the lead agency and DHS.
  • · Receive, review and share communication from DHS.

    • Help Desk

    MnCHOICES mentors can submit inquiries to the MnCHOICES Help Desk using MnCHOICES Help Desk Contact Form, DHS-6979. For more information, refer to PartnerLink – MnCHOICES Help Desk.

    When using MnCHOICES Help Desk Contact Form, DHS-6979, mentors have the option to contact either the technical team or the policy team directly by indicating on the form whether their question is “technical,” “policy” or “other.”

    Additional resources

    CBSM – Assessment applicability and timelines
    CBSM – Documents produced within the MnCHOICES application
    CBSM – DWRS
    CBSM – IAR
    CBSM – MnCHOICES certified assessors
    CBSM – Person-centered practices
    CBSM – Support planning for LTSS
    DHS – Case manager and care coordinator toolkit
    DHS – MnCHOICES (overview information)
    DHS – MnCHOICES Matters (electronic mailing list with information, updates and resources)
    Disability Hub MN – Housing toolkit
    Disability Hub MN – Informed choice toolkit
    PartnerLink – MnCHOICES (supporting materials and other important information)
    PartnerLink – Revised MnCHOICES assessment and support planning documents

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