Community First Choice/Community Options Waiver

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A program where medically qualified individuals who have medical assistance are assisted to be able to stay in their home or a least restrictive environment as long as possible by giving them better access to medical care and needed equipment, and by result, decreasing emergency room visits, hospital stays, and nursing home stays.

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Community First Choice/Community Options Waiver

https://mygarrettcounty.com/groups/community-first-choicecommunity-options-waiver/

Measurements Target Goal Status Desired Trend Contributor January 2017 February 2017 March 2017 April 2017 May 2017 June 2017 July 2017 August 2017 September 2017 October 2017 November 2017 December 2017 January 2018 February 2018 March 2018 April 2018 May 2018 June 2018 July 2018 August 2018 September 2018 October 2018 November 2018 December 2018 January 2019 February 2019 March 2019 April 2019 May 2019 June 2019 July 2019 August 2019 September 2019 October 2019 November 2019 December 2019 January 2020 February 2020 March 2020 April 2020 May 2020 June 2020 July 2020 August 2020 September 2020 October 2020 November 2020 December 2020 January 2021 February 2021 March 2021 April 2021 May 2021 June 2021 July 2021 August 2021 September 2021 October 2021 November 2021 December 2021 January 2022 February 2022 March 2022 April 2022 May 2022 June 2022 July 2022 August 2022 September 2022 October 2022 November 2022 December 2022 January 2023 February 2023 March 2023 April 2023 May 2023 June 2023 July 2023 August 2023 September 2023 October 2023 November 2023 December 2023 January 2024 February 2024 March 2024 April 2024 May 2024 June 2024 July 2024 August 2024 September 2024 October 2024 November 2024 December 2024
# of Waiver/CFC Assessments Completed (New & Redets.) 14 Active Increase Elaine 12 17 18 19 21 21 15 13 13 19 14 8 18 18 15 21 24 17 16 20 17 23 14 0.09 18 19 15 14 22 9 21 17 14 25 21 14 17 19 17 17 10 14 15 17 23 15 18 13 18 17 19 13 15 15 18 15 17 14 13 10 14 8 20 11 17 13 13 25 21 14 11 14 11 14 22 16 20 25 12 8 12 9 22 13 16
Waiver/CFC Nurse Monitoring UNITS Completed and billed 400 Active Increase Elaine 780 816 842 706 805 515 537 549 443 489 386 565 485 225 306 372 570 604 592 475 478 572 475 648 500 464 338 416 322 392 247 405 443 398 355 445 495 478 381 550 542 518 534 517 511 417 514 512 350 401 439 562.99 423 408 444 531 447 323 460 417 403 356 344 370 315 237 402 327 320 362 307 278 405 267 394 315 257 296 354 455 257 206 371 352 263
Percentage of Waiver/CFC Assessments completed by requested due date (Referral Log Clinic Analysis Report in PatTrac) 70 Active Elaine 48 26 11 40 25 33 15 35 47 67 67 70 92 82 69 81 57 53 58 41 40 80 80 62 67 73 50 60 61 22 25 52 52 56 57 78 71 60 76 61 74 92 90 96 74 81 72 88
Total Number of Nurse Monitoring VISITS Completed in the month 30 Active 39 32 31 34 35 34 24 37 34 35 29 33 31 27 23 39 33 29 33 31 24 32 27 39 29 22 29 31 38 23 17 33 38 25
Number of Patients receiving C.F.C. /C.O.W. services on the last day of the month. 150 Active 167 171 173 173 175 176 181 185 180 184 189 192 192 200 182 206 181 192 206 218 246 255 285 297 309 330 333 349 355 350 358 363 361 365

Data Narrative

  • Measure 1: The number of Assessments completed. The assessment that AERS completes is called an InteRAI. It is a thorough collaborative diagnostic tool that is used to improve the quality of life of vulnerable persons through a seamless comprehensive assessment. The assessment captures the patient’s mental and physical health conditions, the medicines they take, and how well they function with ADL’s and IADL’s.  It also looks at patient’s need for housing, medical equipment, transportation.  The ultimate goal is to connect the patient with resources that will allow them to stay in their own home longer, living independently for as long as possible and also to reduce nursing facility and hospital admissions in the community.  In addition, it is used to approve someone for assistance in the home under the Medicaid Community First Choice or Community Option’s Waiver.  We list this measure as a goal, as it is the goal of AERS to assist as many individuals as possible to be able to stay in their homes or the community with any assistance that may be available and that they qualify for. We based this goal on how many assessments have been completed in the last two fiscal years, and comparing staffing then to what we have now.
  • Measure 2: The number of Nurse Monitoring Units that are completed. Nurse Monitoring is also an integral part of AERS’ duties to patients who are currently receiving services under the Community First Choice or Community Options Waiver Programs.  AERS nurses have been tasked by the state to oversee the care that patients are receiving under these programs, to be sure their needs are being met and the services that were written into the Plan of Service are being carried out.  Billing, reimbursement and tracking is done by the amount of time that is required to carry out these duties for each client.  It is calculated and paid in “units”, with time of greater than or equal to 8 minutes, but less than 23 minutes equaling one unit.  Two units is equal to a time of greater than or equal to 23 minutes, but less than 38 minutes, and it continues to go up from there.  Therefore, we chose to report units so that the work done reflects patients are being monitored on a consistent basis, and that monitoring is helping them access medical care and stay in their home. We based this goal on how many assessments have been completed in the last two fiscal years, and comparing staffing then to what we have now.
  • Measure 3: The percentage of InteRAI assessments that were referred to us monthly will be completed by the due date. This measure was chosen as it is the goal of AERS to complete assessments in the timeliest way possible in order to assist patients in getting some help as quickly as possible and ultimately reduce nursing facility and hospital admissions.  We are given a time frame by the state for the InteRAI to be completed within 15 business days from the date of the referral.  Sometimes, getting that accomplished is out of our control due to waiting on medical records to be received from the medical provider, not being able to get in contact with the patient to schedule their appointment, or a shortage of AERS staff.  Our goal is to get those completed by the due date at least 70% of the time, while maintaining sufficient staff. We based this goal on the percentage of assessments completed on time in the last two fiscal years when we were fully staffed with nurses. All assessments must be referred for completion to the AERS division of the health department, as mandated by the state. We realized that we were measuring 15 working days, but PatTrac only measures calendar days, so we changed our report in PatTrac to 21 calendar days, thereby more accurately reflecting 15 working days.  This was done late in the year, so we want to give several months to see if this change made a difference.
  • Measure 4: The number of Nurse Monitoring Visits completed - This measure was chosen because it is easier to compare number of visits, as opposed to # of units billed.
  • Measure 5: The number of clients being served on the program. This measure was chosen because we want to accurately reflect how many clients are being served by  these programs and show that the number of patients being served and the services they are receiving correlate to obtain the goals. We based this goal on the average number of patients that are in this program monthly.
Presently, the state mandates that the AERS division at the local health department is the only entity responsible for the initial and redetermination evaluations.  Therefore, all referrals for this program (most of which originate from MAP) must come to the health department AERS division. The data reported above is collected from the following sources: # of  assessments completed - obtained from a list maintained by the office administrator and reviewed with nursing staff # of Nurse Monitoring Units completed and billed in a month - Obtained from a report in LTSS, under Activity & Billing Reports, entitled SPA-NM Activity Report. Units are calculated based on how many minutes each activity required. % of Assessments completed by the due date -  a report in PatTrac , located under Clinic Reports, and titled Referral Log Clinic Analysis. # of Nurse Monitoring Visits completed in a month - obtained from the nurses, self-reporting # of patients receiving services in the current month - obtained from a report in PatTrac titled AERS Caseload by Program and Service Area.      

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