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The Oregon Administrative Rules contain OARs filed through November 15, 2014
 
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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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