Conflict Free Case Manager

Overview:

• Knowledgeable of and skilled in strategies to support the participant to lead and be maximally responsible for their own person-centered planning process. The case manager shall provide necessary information and support to ensure that the participant fully directs the process as much as possible and is enabled to make informed choices and decisions.
• Knowledgeable of and comply with all Agency policies and standards.
• Knowledgeable about the full range of services available to participants and shall ensure that participants are informed of available resources and services. The case manager shall make any needed referrals.
• ensure that a participant has the right and option to receive services under conditions of acceptable risk. “Acceptable risk” is defined as the level of risk a participant—after consultation as appropriate with their Authorized Legal Representative, as defined below—is willing to accept after the informed consent process.
• . Competent to assist participants in completing any necessary forms for the annual Medicaid renewal or other Medicaid eligibility forms needed to ensure that there are no service disruptions.
• Able to effectively communicate the participant’s opportunity to self-direct, inform participants of the potential benefits, liabilities, risks and responsibilities associated with choosing self-direction, and support the participant in fulfilling participant responsibilities to the Fiscal Intermediary.
• . Capable of providing services in an efficient, effective, and collaborative manner to avoid duplication of services, costs, and administrative tasks.
• Responsive to requests for information and/or assistance from individuals in a timely manner.
• . Capable of informing all participants of the Agency’s grievance procedures in keeping with participants’ preferred language and English proficiency.
• . Capable of informing all individuals regarding the right to be free from abuse, neglect, and exploitation, and how to identify and report Critical Incidents, consistent with participants’ preferred language and English proficiency.
• . Respectful of the cultural needs of participants of different racial, ethnic, economic, linguistic, and religious backgrounds.
• Capable of ensuring that participants receive person-centered services in the least restrictive and most appropriate setting in accordance with their needs and preferences, as required by State and federal law and the U.S. Supreme Court Olmstead
• Respectful of the participant’s rights, strengths, values, and preferences, encouraging the participant to create, direct, and fully participate in their individualized written person-centered plan possible.
• Capable of facilitating a participant’s person-centered planning process, supporting them to fully direct the process as much as possible. The process shall be timely and occur at times and locations chosen by and convenient to the individual. Person-centered planning shall reflect a process which ensures that the settings in which the individual receives services are chosen by the individual from among setting options. The case manager shall ensure that the participant chooses who is included in and excluded from the person-centered planning process (e.g., friends and family members, natural supports, and others who support the participant throughout the day, such as therapists or clergy).
• Capable of supporting the participant and their support network in establishing person-centered goals.
• Capable of using the information from assessments and considering the participant’s person-centered goals to discuss all available options with the individual and their support network and agree upon strategies built upon the strengths of the individual to achieve these goals.
• Capable of supporting a participant to develop a person-centered plan driven by the participant’s choices, needs, interests, preferences and wishes, the development of which provides the participant with options, meaningful choices and opportunities, utilizing the EOHHS template. The person-centered plan shall:
• Reflect clinical and support needs as identified through an assessment of functional needs.
• Reflect the services that will enable the participant to live fully supported in the least restrictive setting. The development of such supports and services shall be based on both the needs identified through a functional needs assessment of the individual and the preferences, choices, and priorities of the participant.
• Reflect preferences, goals, and desired outcomes identified by the individual or their representative.
• Identify the services and supports (paid and unpaid) that will assist the participant to achieve identified goals and desired outcomes, and the providers of those services and supports, including natural supports and services which the participant elects to self-direct, if applicable.
• . Reflect that the settings in which the participant receives services are chosen by the participant from among a meaningful array of setting options and choices.
• Reflect risk factors and measures in place to minimize them, including individualized backup plans and strategies when needed.
• . Be written in such a manner that is understandable to both the participant receiving services and supports, and the individuals supporting them. The written plan shall be written in plain language and in a manner that is accessible to participants with disabilities and participants who are limited English proficient in compliance with 42 C.F.R. § 435.905(b).
• Be finalized and agreed to, with the informed consent of the participant and/or Authorized Legal Representative in writing and signed by all individuals and providers responsible for its implementation.
• Be distributed to the participant and other individuals involved in the plan.
• Prevent the provision of services and supports that are duplicative or do not align with the participant’s person-centered plan.
• Fully document any modifications, or exceptions, to the CMS required HCBS settings rule at 42 C.F.R. § 441.301(c)(4). Modifications to the HCBS settings rule shall be documented in the person-centered plan and satisfy the following: i. Identify a specific and individualized assessed need for the modification.
• . Document the positive interventions and supports used prior to any modifications to the person-centered service plan.
• Document less intrusive methods of meeting the need that have been tried but did not work.
• . Include a clear description of the condition that is directly proportionate to the specific assessed need.
• Include a regular collection and review of data to measure the ongoing effectiveness of the modification.
• Include established time limits for periodic reviews to determine if the modification is still necessary or can be terminated.
• Include informed consent of the individual or their authorized legal representative; and
• Include an assurance that interventions and supports will cause no harm to the individual.

1. Monitoring shall include at least monthly contact with the participant via a method of contact chosen by the participant and agreed upon in the person-centered plan. If the participant chooses monitoring through telehealth, monitoring must include a face-to-face visit at least once every six (6) months. Any other individual chosen by the participant, including an Authorized Legal Representative, may also participate in monitoring; however, participation by other individuals is in addition to the participant’s involvement and shall not be a substitute for required contact with the participant.

• . For case managers serving Elders and Adults with Disabilities (EAD), the Rhode Island Department of Human Services (DHS) shall administer the initial assessment. On an annual basis (or more frequently if there is a significant change in the participant’s life),
• The participant’s person-centered plan, including the participant’s goals and strategies as applicable, shall be updated at least annually or more frequently if the participant requests and/or if there is a significant change in the participant’s life that would alter the amount and type of formal and informal services and supports needed.
• Capable of maintaining all current and previous, complete, and accurate paper or electronic records in a file for each participant, in accordance with the Participant Record Policy. Participant records shall include, but are not limited to:
• A written Authorization to release information or documentation as to why a written Authorization to release information could not be obtained.
• Current demographic and assessment information regarding the participant.

• Case notes that shall focus on the individual’s progress and any emergent issues that need to be addressed.

Any other correspondence received or sent which is relevant to the participant.

• If the case manager is taking direction from an Authorized Legal Representative of the participant, there shall be a copy of the participant’s designation of the Authorized Legal Representative or other legal documentation maintained in the individual’s case management records. If applicable, Guardianship/Power of Attorney and other advanced directives.

• Competent to conduct reassessments for the EAD population.
• a case manager serving the EAD population, with input and participation by the participant and their support network, shall reassess the individual’s strengths and needs using the assessment tool(s) approved by EOHHS. The case manager shall make every effort to assure the completeness and accuracy of the reassessments and utilize the reassessment to update the person-centered plan as indicated above.