10 Colo. Code Regs. § 2505-10-8.519

Current through Register Vol. 47, No. 24, December 25, 2024

Section 10 CCR 2505-10-8.519 - Case Management

8.519.1Repealed

8.519.2Repealed

8.519.3Repealed

8.519.4Repealed

8.519.5Repealed

8.519.6Repealed

8.519.7Repealed

8.519.8Repealed

8.519.9Repealed

8.519.10Repealed

8.519.11Repealed

8.519.12Repealed

8.519.13Repealed

8.519.14Repealed

8.519.15Repealed

8.519.16Repealed

8.519.17Repealed

8.519.18Repealed

8.519.19Repealed

8.519.20Repealed

8.519.21Repealed

8.519.22Repealed

8.519.23Repealed

8.519.27Transition Coordination Services

8.519.27.ADefinitions

1. At-Risk means a Medicaid member who lives outside of an institutional facility and has either received a Level of Care Screening to access Medicaid nursing facility services or is at risk for institutionalization as determined by the Department.

2. At Risk Diversion means a Person-Centered process through which services are arranged or provided to enable an At-Risk population member to avoid admission to an institution or institution-like setting to live instead in a less restrictive setting in the community.

3. Case Management Agency (CMA) means a public, private, or non-governmental non20 profit agency that meets all applicable state and federal requirements and is certified by the Department to provide case management services for Home and Community-based Services waivers pursuant to sections [25.5-10-209.5 C.R.S.] and pursuant to a provider participation agreement with the state department.

4. Community Needs and Preferences Assessment means the assessment that is completed by the Transition Options Team (TOT) to ensure a comprehensive understanding of the member's health conditions, functional needs, transition needs, behavioral concerns, social and cultural considerations, educational interests, risks and other areas that may require services and/or community resource support.

5. Community Risk Level means the potential for a member living in a community-based arrangement to require emergency services, to be admitted to an institution or institution-like setting, or Intermediate Care Facility for Individuals with Intellectual Disabilities, be evicted from their home or be involved with law enforcement due to identified risk factors.

6. Corrective Action Plan (CAP) means a written plan by the Transition Coordination Agency (TCA), and approved by the Department, which includes a detailed description of actions to be taken to correct non-compliance with regulations, and/or direction from the Department, and which sets forth the date by which each action shall be completed and the persons responsible for implementing the action. Corrective Action Plans may be requested by the Department at any time.

7. Post-Transition Monitoring means the activities performed by a Transition Coordination Agency (TCA) that occur after a member has successfully moved into the community or has been diverted from institutionalization and is a recipient of home-and community-based services.

8. Pre-Transition Coordination means the activities by the 1 TCA that occur before a member has moved into the community to prepare the member for success in community living and integration.

9. Risk Factors mean factors that include but are not limited to health, safety, environmental, community integration, service interruption, inadequate support systems and substance abuse that may contribute to an individual's community risk level.

10. Risk Mitigation Plan means the document that records the risk mitigation planning process. Risk Mitigation Plans are used to complete Pre-Transition and Diversion strategy development, conduct post-discharge monitoring of effectiveness of risk prevention strategies, document identification of additional risk factors, and revise risk incident response plans.

11. Risk Mitigation Planning means the process of identifying risk factors, developing options and actions to enhance opportunities and prevent adverse consequences that would result if risk is not managed. Risk mitigation planning includes identifying planned actions to take in response to an adverse consequence should a risk be realized.

12. Community Needs and Preferences Assessment means the process of capturing a comprehensive understanding of the member's health conditions, functional needs, transition needs, behavioral concerns, social and cultural considerations, educational interests, risks and other areas important to community integration and transition to a home and community-based setting.

13. Transition Coordination Services means support provided to a member who is transitioning or being diverted from a skilled nursing facility, extended SNF LOC hospital stay, intermediate care facility for individuals with intellectual disabilities, or regional center and includes the following activities: comprehensive assessment for transition or diversion, community risk assessment, development of a transition or diversion plan, referral and related activities, and monitoring and follow up activities as they relate to the transition or diversion.

14. Transition Coordinator (TC) means a person who provides Transition or Diversion Coordination Services and meets all regulatory requirements for a TC.

15. Transition Coordination Agency (TCA) means a public or private not-for-profit or for-profit agency that meets all applicable state and federal requirements and is certified by the Department to provide Transition/diversion Coordination Transition or Diversion support pursuant to a provider participation agreement with the Department.

16. Transition Options Team (TOT) means the group of people involved in supporting and implementing the transition or diversion, to include the person receiving services, the TC, the guardian, may include the home- and community-based services case manager, nursing facility social worker and others chosen by the individual receiving services as being valuable to participate in the transition process. The TOT is convened to work in a cooperative and supportive manner to develop and implement the transition or diversion plan, and to serve in an advocacy role with the member.

17. Transition period means the period of time in which the member receives Transition Coordination for the purpose of successful integration into community living. A transition period is complete when the member has successfully established community residence and is no longer in need of Transition Coordination based on the member's community risk level, or the member or guardian requests that TCM-TC services are discontinued.

18. Transition or Diversion Plan means the written document that identifies person-centered goals, assessed needs, and the choices and preferences of services and supports to address the identified goals and needs; appropriate services and additional community supports; outlines the process and identifies responsibilities of transition options team members; details a risk mitigation plan; and establishes a timeline that will support an individual in transitioning to or remaining in a community setting of their choosing.

19. Transition or Diversion Planning means the completion of the TCM-TC Community Needs and Preferences Assessment and Risk Mitigation Plan, facilitation of a transition or Diversion Recommendation, and developing a transition or Diversion Plan, in coordination with the TOT.

20. Transition Rrecommendation means a recommendation made by the TOTtransition options team regarding transition. The recommendation is made solely on availability of necessary supports and services identified by the Community Needs and Preference Assessment and the Risk Mitigation Plan.

8.519.27.BQualifications of Transition Coordination Agencies

1. In order to be approved as a TCA, the agency shall meet all of the following qualifications:

a. Have a physical location in Colorado.

b. Be a public or private not for profit or for-profit agency.

c. Demonstrate proof the agency has employed staff that meet TC qualifications.

d. Have a minimum of two (2) years of agency experience in assisting at-risk individuals to access medical, social, education and/or other services. Transition coordination agencies providing transition coordination in Colorado prior to December 31, 2018 are exempt from this requirement.

e. Provide transition or diversion coordination to members who select the agency and also reside in the county/counties for which the agency has elected to provide services.

f. Possess the administrative capacity to deliver transition or diversion coordination.

g. Have established community referral systems and demonstrate linkages and referral ability to make community referrals for services with other agencies.

h. Demonstrate ability to meet all applicable requirements contained within Sections 8.519.27, 8.763, the Medicaid State Plan and the provider participation agreement.

i. Financial reserves shall match one (1) month of expenditures associated to the number of members expected through that catchment area and provide stability for TCs, members and service providers.

j. All agencies are required to submit an audited financial statement or 1 equivalent to the Department for review upon request.

k. Possess and maintain adequate liability insurance (including automobile insurance, professional liability insurance and general liability insurance) to meet the Department's minimum requirements.

8.519.27.CFunctions of all Transition Coordination Agencies

1. In order to be approved as a TCA, the agency shall perform all of the following functions:

a. TCAs must be in compliance with all required agency performance standards and training guidelines to be in good standing with the Department. Failure to comply with required standards and training guidelines may result in suspension of referrals until a corrective plan is submitted by the TCA and approved by the Department.

b. TCAs shall be responsible to maintain sufficient documentation, as defined in TCM-TC training, of all transition or diversion coordination activities performed and to support claims within the Department designated data system and internal agency records.

c. TCAs may not provide guardianship services for any member for whom they provide transition or diversion coordination services.

d. TCAs shall be responsible to maintain, or have access to, information about public and private, state and local services, supports and resources and shall make information available to the member and/or persons inquiring upon their behalf.

e. TCAs shall respond to referrals for transition coordination support within two (2) business days and within one (1) business day for diversion coordination referrals and specify whether the referral is accepted or not by completing the Transition Services Referral Form.

f. TCAs shall assign and meet with the member within ten (10) state business days after accepting a transition referral and two (2) state business days after accepting a diversion referral.

g. TCAs shall assign one (1) primary person who ensures transition or diversion coordination is provided tof the member.

h. TCAs shall provide coordination in accordance with state business days as defined in 24-11-101(1) C.R.S.

i. TCAs shall maintain all documents, records, communications, notes, and other materials that relate to any work performed.

j. TCAs shall possess appropriate financial management capacity and systems to document and track services and costs in accordance with state and federal regulations.

k. TCAs shall maintain and update records of persons receiving transition or diversion coordination in accordance with reporting requirements of the Department's data system.

l. TCAs shall establish and maintain working relationships with community-based resources, supports, and organizations, hospitals, service providers, and other organizations that assist in meeting the needs of members.

m. TCAs shall have a system for recruiting, hiring, evaluating, and terminating employees. Transition coordination agencies' employment policies and practices shall comply with all federal and state laws.

n. TCAs shall ensure staff have access to statutes and regulations relevant to the provision of authorized services and shall ensure that appropriate employees are oriented to the content of statutes and regulations. TCAs shall provide transition coordination for members without discrimination on the basis of race, religion, political affiliation, gender, national origin, age, sexual orientation, gender expression, or disability.

o. TCAs shall provide information and reports as required by the Department including, but not limited to, data and records necessary for the Department to conduct operations.

p. TCAs shall allow access by authorized personnel of the Department, or its contractors, for the purpose of reviewing services and supports funded by the Department and shall cooperate with the Department in evaluation of such services and supports.

q. TCAs shall establish agency procedures sufficient to execute transition or diversion coordination according to the provisions of these regulations. Such procedures shall include, but are not limited to:

i. Referral Management

ii. Assessment of community needs and preferences

iii. Transition or Diversion Planning

iv. Risk Mitigation Planning

v. Service and support coordination for non-Medicaid transition or diversion-related services and supports

vi. Monitoring of the Risk Mitigation and Transition or Diversion Plans

vii. Denial and discontinuation of Transition or Diversion Coordination Services

viii. Management of interstate TCM-TC transfers

ix. Complaint Procedure that includes the requirement to share information, such as points of contact within the agency, to members, families and referring agencies who may wish to file a complaint

8.519.27.DQualifications of Transition Coordinators

1. TCs must be employed by an approved TCA. TC minimum experience:

a. A bachelor's degree; or

b. Five (5) years of relevant experience in the field of LTSS, which includes Developmental Disabilities; or

c. Some combination of education and relevant experience appropriate to the requirements of the position.

d. Relevant experience is defined as:

i. Experience in one of the following areas: long-term care services and supports, gerontology, physical rehabilitation, disability services, children with special health care needs, behavioral science, special education, public health or nonprofit administration, or health/medical services, including working directly with persons with physical, intellectual or developmental disabilities, mental illness, or other vulnerable populations as appropriate to the position being filled; and,

ii. Completed coursework and/or experience related to the type of administrative duties performed by case managers may qualify for up to two (2) years of required relevant experience.

iii. For members for whom the TC is providing transition or diversion coordination, TCs may not:

1) Be related by blood or marriage to the member

2) Be related by blood or marriage to any paid caregiver of the member

3) Be financially responsible for the member

4) Be the member's legal guardian, authorized representative, or be empowered to make decisions on the member's behalf through a power of attorney

8.519.27.ETraining

1. TCs must complete and document the following trainings within sixty (60) days from the date of hire and prior to providing transition or diversion coordination services independently, and thereafter on an annual basis:

a. Assessment of community needs/preferences and risk factors

b. Transition or Diversion Planning

c. Risk Mitigation Plan development, monitoring and revision

d. Referral 1 for non-Medicaid services

e. Monitoring services

f. Case documentation

g. Person-centered approaches to planning and practice

h. Housing voucher application and housing navigation services

8.519.27.FFunctions of Transition Coordinators

1. TCs must perform all the following activities. These activities are the only activities billable under transition coordination:

a. Coordinate (TOT) activities including:

i. Facilitate completion of an assessment which identifies preferences, needs and any risk factors the member may have in a community-based setting within six (6) weeks of first meeting with the member for a Transition Plan and within one (1) week of first meeting with the member for a Diversion Plan.

ii. Facilitate development of a Risk Mitigation Plan to address identified risk factors within eight (8) weeks of accepting a transition referral and two (2) weeks of accepting a diversion referral.

iii. Identify supports and services that will be required to address the member's needs, preferences, and risk factors.

iv. Complete a transition recommendation from the TOT within six (6)weeks of first meeting with the member but not before the first TOT meeting.

v. Facilitate completion of a Transition or Diversion Plan if the member chooses to proceed with the transition or diversion

b. Conduct Pre-Transition or Diversion Coordination including:

i. Facilitate completion of transition or diversion assessment, Risk Mitigation and Transition or Diversion Plans

ii. Complete, as needed, housing voucher application, including assistance to obtain necessary documents

iii. Collaborate, as needed, with housing navigation services to obtain a voucher and locate housing

iv. Assist member to create a transition or diversion budget

v. Collaborate with housing navigation services, Division of Housing, voucher administrators and property managers to establish a community-based living arrangement for eligible members.

vi. Coordinate any medication, home modification and/1 or durable medical equipment needs with the nursing facility or HCBS case manager prior to discharge to ensure that all components of the Transition or Diversion Plan are in place prior to discharge

vii. Assist member in preparing for discharge, including being present at the nursing facility on the day of discharge to ensure requirements of discharge plan are addressed

viii. Meet with the member at their home on the day of discharge to ensure that providers and services needed upon discharge are in place and the household set-up is complete

c. Conduct Post-Transition or Diversion Monitoring that meets the member's need as documented in the risk mitigation plan and occurs at the frequency and type to meet the member's community risk level Post-Transition or Diversion monitoring includes:

i. Ensuring that members receive services in accordance with their Transition/Diversion Plan and Risk Mitigation Plan

ii. Post-Transition or Diversion Monitoring may include as determined by the community risk level:

1) Face-to-face in the member's residence

2) Face-to-face in the community.

3) By telephone, electronic, video or virtual communication

d. Post-Transition or Diversion Monitoring includes:

i. Provision of support services to aid in sustaining community-based living

ii. Response to risk incidents and notifying the CMA and Adult Protection Services (APS) as required

iii. Revision of Risk Mitigation Plan as needed

iv. Assessing the need for independent living skills training

v. Problem-solving community integration issues

vi. Supporting community integration activities

vii. Monitoring service provision, to include contacting guardians, providers, and case management agencies

viii. Requesting that member completes a TCM-TC satisfaction survey prior to discharge and at the end of the transition or diversion period to evaluate the member's experience of the following:

1) Transition or Diversion Planning

2) Transition or Diversion Plan implementation

3) Transition or Diversion Coordination process

4) Level and adequacy of services provided

5) Overall member satisfaction e. Post-transition or Diversion Monitoring may not duplicate services for Life Skills Training (LST), defined in 10 CCR 2505-10, § 8.553.3; Transition Setup defined in 10 CCR 2505-10, § 8.553.4; Home Delivered Meals, defined in 10 CCR 2505-10, § 8.553.5; and Peer Mentorship, defined in 10 CCR 2505-10, § 8.553.6.

8.519.27.GTransition Coordination Agencies Approval

1. A TCA shall maintain Department provider approval in accordance with quality assurance standards and requirements set forth in the sDepartment's rules and direction. Department approval is needed for continued receipt of TCM-TC referrals.

a. Approval as a TCA shall be based on an evaluation of the agency's performance in the following areas:

i. The frequency of requests for TCA changes and/or complaints received by the Department pertaining to agency performance

ii. The agency's compliance with program requirements, including compliance with transition coordination standards adopted by the Department

iii. The agency's performance of administrative functions, including, timely reporting, program management, on-site visits to individuals, community coordination and outreach and individual monitoring;

iv. Financial accountability

v. The maintenance of qualified and trained personnel to perform transition coordination duties

vi. Continual performance and quality assurance activities and

vii. Overall member satisfaction as indicated by member satisfaction surveys

2. The Department or its designee shall conduct reviews of the TCA

a. At least sixty (60) days prior to expiration of the previous approval date the Department shall notify the TCA of the outcome of the review, which may be approval, provisional approval, or denial of approval.

b. The Department shall conduct evaluations as needed based on incidents of member, nursing facility and/or provider complaints regarding TCA performance and/or non-compliance with TCM-TC agency requirements.

8.519.27.HConflict of Interest for Transition Coordination Agencies

1. If a TCA also provides services under HCBS waivers, a policy must be in place to avoid conflict of interest and provide a free choice of providers to members. The HCBS case management agency shall be responsible for all service brokering for Medicaid HCBS services.

10 CCR 2505-10-8.519

46 CR 13, July 10, 2023, effective 7/30/2023

47 CR 05, March 10, 2024, effective 3/30/2024

47 CR 16, August 25, 2024, effective 9/15/2024

47 CR 23, December 10, 2024, effective 12/30/2024