The Oregon Administrative Rules contain OARs filed through November 15, 2015

 

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DEPARTMENT OF HUMAN SERVICES,

AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES




 

DIVISION 28
CASE MANAGEMENT SERVICES
411-028-0000
Purpose
(1) The rules in OAR chapter 411, division
028 ensure case management services support the independence, empowerment, dignity,
and human potential of older adult individuals and adult individuals with disabilities
with the purpose of helping the individuals reside in their own home or in a community-based
setting.
(2) Case management services
are a component of an individual's comprehensive, person-centered plan for services.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SPD 15-2013(Temp),
f. & cert. ef. 7-1-13 thru 12-28-13; SPD 46-2013, f. 12-13-13, cert. ef. 12-15-13
411-028-0010
Definitions
Unless the context indicates otherwise,
the following definitions apply to the rules in OAR chapter 411, division 028:
(1) "Adult" means any person
at least 18 years of age.
(2) "Adult Protective Services"
mean the services provided in response to the need for protection from abuse described
in OAR chapter 411, division 020, OAR chapter 407, division 045, and OAR chapter
943, division 045.
(3) "Case Management" means
the functions described in OAR 411-028-0020 performed by a case manager or higher
level management staff.
(4) "Case Manager" means
a Department employee or an employee of the Department's designee that meets the
minimum qualifications in OAR 411-028-0040 who is responsible for service eligibility,
assessment of need, offering service choices to eligible individuals, service planning,
service authorization and implementation, and evaluation of the effectiveness of
Medicaid home and community-based services.
(5) "Collateral Contact"
means contact by a case manager with others who may provide information regarding
an individual's health, safety, functional needs, social needs, or effectiveness
of the individual's plan for services. Collateral contact may include family members,
service providers, medical providers, neighbors, pharmacy staff, friends, or other
professionals involved in the service coordination of an individual receiving Medicaid
home and community-based services.
(6) "Department" means the
Department of Human Services.
(7) "Designee" means an organization
that the Department contracts with or has an interagency agreement with for the
purposes of providing case management services.
(8) "Disability" means a
physical, cognitive, or emotional impairment which, for an individual, constitutes
or results in a functional limitation in one or more of the activities of daily
living defined in OAR 411-015-0006.
(9) "Individual" means an
older adult or an adult with a disability applying for or determined eligible for
Medicaid home and community-based services.
(10) "Medicaid Home and Community-Based
Services" mean the services for older adults and adults with disabilities approved
for Oregon by the Centers for Medicare and Medicaid Services.
(11) "Older Adult" means
any person at least 65 years of age.
(12) "OSIPM" means Oregon
Supplemental Income Program-Medical as defined in OAR 461-101-0010. OSIPM is Oregon
Medicaid insurance coverage for individuals who meet eligibility criteria as described
in OAR chapter 461.
(13) "Representative" is
a person either appointed by an individual to participate in service planning on
the individual's behalf or a person with longstanding involvement in assuring the
individual's health, safety, and welfare.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SPD 15-2013(Temp),
f. & cert. ef. 7-1-13 thru 12-28-13; SPD 46-2013, f. 12-13-13, cert. ef. 12-15-13;
APD 9-2014(Temp), f. 4-17-14, cert. ef. 4-21-14 thru 10-18-14; APD 35-2014, f. &
cert. ef. 10-1-14
411-028-0020
Scope of Case Management Services
(1) DIRECT CASE MANAGEMENT SERVICES.
Direct case management services are provided by a case manager or higher level staff,
who communicates directly with an individual or the individual's representative.
Direct case management services may occur by phone call, face-to-face contact, or
email. Direct case management services do not include contact with collateral contacts
unless the collateral contact is the individual's authorized representative. Direct
case management services include:
(a) An assessment as described
in OAR 411-015-0008.
(b) Service Plan development
and review as described in OAR 411-015-0008.
(c) Service options choice
counseling as described in OAR 411-030-0050.
(d) Risk assessment and monitoring:
(A) Identifying and documenting
risks;
(B) Working with an individual
to eliminate or reduce risks;
(C) Developing and implementing
a Risk Mitigation Plan;
(D) Monitoring risks over
time; and
(E) Making adjustments to
an individual's Service Plan as needed.
(e) Diversion activities.
This means assisting an individual with finding alternatives to nursing facility
admission.
(f) Other program coordination.
This means helping an individual navigate or coordinate with other social, health,
and assistance programs.
(g) Crisis response and intervention.
This means assisting an individual with problem resolution.
(h) Service provision issues.
This means assisting an individual with problem solving to resolve issues that occur
with providers, services, or hours that don't meet the individual's needs.
(2) INDIRECT CASE MANAGEMENT
SERVICES. Indirect case management services are services provided by a case manager
or higher level staff, in which direct contact with an individual is not occurring.
Indirect case management services include:
(a) Monitoring Service Plan
implementation. Reviewing implementation of an individual's Service Plan by reviewing
and comparing authorized and billed services to ensure that adequate services are
being provided.
(b) Service options choice
counseling. This means assisting an individual's caregiver, family member, or other
support person with understanding all available Medicaid home and community-based
service options.
(c) Risk monitoring. Working
with a collateral contact to review an individual's risks, eliminate or reduce risks,
and develop and implement a Risk Mitigation Plan. Adjustments to an individual's
Service Plan based on risk monitoring activities are classified as direct case management.
(d) Diversion activities.
This means finding alternatives to nursing facility admission. Diversion activities
do not include transition activities to help an individual move from a nursing facility.
(e) Adult protective services
referral including collateral contact.
(f) Other program coordination.
This means helping collateral contacts navigate or coordinate with other social,
health, and assistance programs.
(g) Service provision issues.
This means assisting with problem solving issues that occur with providers, services,
or hours that do not meet an individual's needs.
(h) Other case management
activities not included in any criteria in this section of the rule.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SPD 15-2013(Temp),
f. & cert. ef. 7-1-13 thru 12-28-13; SPD 46-2013, f. 12-13-13, cert. ef. 12-15-13;
APD 9-2014(Temp), f. 4-17-14, cert. ef. 4-21-14 thru 10-18-14; APD 35-2014, f. &
cert. ef. 10-1-14
411-028-0030
Eligibility for Case Management Services
To be eligible for case management services
a person must:
(1) Be 18 years of age or
older;
(2) Be eligible for OSIP-M;
and
(3) Meet the functional impairment
level within the service priority levels currently served by the Department as outlined
in OAR 411-015-0010 and OAR 411-015-0015.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SPD 15-2013(Temp),
f. & cert. ef. 7-1-13 thru 12-28-13; SPD 46-2013, f. 12-13-13, cert. ef. 12-15-13;
APD 9-2014(Temp), f. 4-17-14, cert. ef. 4-21-14 thru 10-18-14; Administrative correction,
11-24-14
411-028-0040
Qualified Case Manager
Staff working for the Department or
the Department's designee must meet the following requirements to provide case management
services:
(1) A bachelor’s degree
in a behavioral science, social science, or a closely related field; or
(2) A bachelor’s degree
in any field and one year of human services related experience that may include
providing assistance to people and groups with issues such as economical disadvantages,
employment barriers and shortages, abuse and neglect, substance abuse, aging, disabilities,
prevention, health, cultural competencies, or inadequate housing; or
(3) An associate’s
degree in a behavioral science, social science, or a closely related field and two
years of human services related experience that may include providing assistance
to people and groups with issues such as economical disadvantages, employment barriers
and shortages, abuse and neglect, substance abuse, aging, disabilities, prevention,
health, cultural competencies, or inadequate housing; or
(4) Three years of human
services related experience that may include providing assistance to people and
groups with issues such as economical disadvantages, employment barriers and shortages,
abuse and neglect, substance abuse, aging, disabilities, prevention, health, cultural
competencies, or inadequate housing.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SPD 15-2013(Temp),
f. & cert. ef. 7-1-13 thru 12-28-13; SPD 46-2013, f. 12-13-13, cert. ef. 12-15-13
411-028-0050
Frequency of Case Management Services
A case manager who meets the requirements
in OAR 411-028-0040 must provide the following case management services to an eligible
individual receiving Medicaid home and community-based services:
(1) A direct case management
service as described in OAR 411-028-0020 must be provided to an eligible individual
no less than once in each calendar quarter.
(2) An indirect case management
service must be provided in every calendar month a direct case management service
was not provided.
Stat. Auth.: ORS 410.070
Stats. Implemented: ORS 410.070
Hist.: SPD 15-2013(Temp),
f. & cert. ef. 7-1-13 thru 12-28-13; SPD 46-2013, f. 12-13-13, cert. ef. 12-15-13


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