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Adult Care Home Case Management Services Table of Contents

I. STATEMENT OF PHILOSOPHY AND PURPOSE

II. LEGAL BASE

III. DEFINITION OF TERMS

IV. ELIGIBILITY FOR ENHANCED ADULT CARE HOME PERSONAL CARE

A. Adult Care Home Identifies a Potential Heavy Care Resident

B. Adult Care Home Makes Referral to Case Manager

C. Case Manager Assessment of Resident’s Eligibility for Enhanced ACH/PC

D. Case Manager Initial Decision Regarding Resident’s Eligibility for Enhanced ACH/PC

E. Application Process for Adult Care Home Case Management Services

V. PROVISION OF CASE MANAGEMENT SERVICES

A. Assessment of Residents

B. Setting Goals and Developing a Service Plan

C. Monthly Contact

D. Quarterly Reviews

E. Reassessment of Residents

VI. DOCUMENTATION AND PROGRAM REPORTING

A. Resident Records

B. Program Reporting

VII. CHANGES IN HEAVY CARE RESIDENTS’ NEEDS

A. Adult Care Home Responsibilities

B. Case Manager Responsibilities

VIII. OTHER CHANGES AFFECTING HEAVY CARE RESIDENTS

A. Notifying the Case Manager of Death, Discharge, or Hospitalization of a Heavy Care Resident

B. Resuming Services When a Heavy Care Resident is Re-Admitted to an Adult Care Home

C. Changes in Ownership

IX. METHODS OF SERVICE PROVISION

A. Direct Service Provision

B. Contract with a Qualified Individual

C. Contract with Another Public Agency

X. RESOLVING DISAGREEMENTS ABOUT THE CASE MANAGER’S DECISION

A. Requesting a Local Hearing

B. Requesting a State Hearing After a Local Hearing

APPENDICES

APPENDIX A - DMA 3050R - Instructions for Completing the Adult Care Home Personal Care Physician Authorization and Care Plan

APPENDIX B - DMA-3019 - Individual Authorization Form ACH/CMS Case Manager's Authorization of Enhanced ACH/PC Payment

APPENDIX C - Key Addresses and Telephone Numbers

APPENDIX D – Case Manager’s Decision Notice

APPENDIX E - Local Hearing Decision Notice

APPENDIX F - The 6-Item Short Blessed Test (SBT)

APPENDIX G - Geriatric Depression Scale

APPENDIX H – Eco-Map

APPENDIX I - Adult Care Home/DSS Case Management Eating Assessment Tool and Tips

APPENDIX J – Adult Care Home/DSS Case Management Adult Incontinence Assessment Tool and Tips

APPENDIX K - Tips for Communicating with Residents with Dementia and Non-Verbal Residents.

APPENDIX L – Request for State Appeal

APPENDIX M – Medical Abbreviations and Symbols List

APPENDIX N – Date Chart

APPENDIX O - Procedure for Authorizing Ambulation/Locomotion for ACH Residents with a Current DMA-3050 That Shows a Performance Code of 3 or 4 For Ambulation/Locomotion

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