Thorough knowledge of methods for maximizing informal caregivers and community resources and integrating them into individual service plans.
Strong linkages with systems and services that are not directly within the scope of the CMO's responsibility but that are important to the organization's target population, including primary and acute health care services, and the capacity to arrange for those services to be made available to its enrollees.
Mechanisms to coordinate services internally and with services available from community organizations and other social programs.
Thorough knowledge of employment opportunities and barriers for the organization's target population.
Thorough knowledge of methods for promoting and supporting the use of mechanisms under which individuals direct and manage their own service funding.
(2) Adequate availability of providers.
Each organization applying to operate a CMO shall demonstrate to the department that it has adequate availability of qualified providers with the expertise and ability to serve its target population in a timely manner. To demonstrate an adequate availability of qualified providers, an organization shall assure the department that it has all of the following:
Agreements with providers who can provide all required services in the family care benefit.
Appropriate provider connections to qualify providers, on a timely basis, as needed to directly reflect the specific needs and preferences of particular enrollees in its target population.
Agreements with a broad array of providers representing diverse programmatic philosophies and cultural orientations to accommodate a variety of enrollee preferences and needs within its target population.
The ability to provide services at various times, including evenings, weekends and, when applicable, on a 24-hour basis.
The ability to provide an appropriate range of residential and day services that are geographically accessible to proposed enrollees' homes, families, guardians or friends.
Supported living arrangements of the types and sizes that meet its target population's preferences and needs and staff to coordinate residential placements who have shown capability in recruiting, establishing and facilitating placements with appropriate matching to enrollee needs.
The ability to recruit, select and train new service providers, including in-home providers, in a timely fashion and a program designed to retain individual providers.
The ability to develop residential options that meet individual needs and desired outcomes of its enrollees.
Mechanisms for assuring that all service providers meet required licensure, accreditation, or other quality assurance standards.
Mechanisms for assuring that any service provider dissatisfied with the CMO's contract requirements shall have the opportunity to request review by the department.
(3) Certification as a medical assistance provider.
The organization shall be certified by the department under s. DHS 105.47
(4) Organizational capacity.
The organization shall demonstrate that it has the organizational capacity to operate a CMO, including all of the following:
Financial solvency and stability and the ability to assume the level of financial risk required under the contract.
The ability to collect, monitor and analyze data for purposes of financial management and quality assurance and improvement and to provide that data to the department in the manner required under the contract.
The capacity to support consumer employment, training and supervision of family members, friends and community members in carrying out services under the consumer's service plan.
(5) Grievance and appeal processes.
The organization shall have a process for reviewing and resolving client grievances and appeals that meets the requirements under s. DHS 10.53 (2)
Standards for performance by CMOs. DHS 10.44(1)(1)
A care management organization shall comply with all applicable statutes, all of the standards in this subchapter and all requirements of its contract with the department.
(2) Case management standards.
The CMO shall provide case management services that meet all of the following standards:
The CMO's case management personnel shall meet staff qualification standards contained in its contract with the department.
The CMO shall designate for each enrollee a case management team that includes at least a social service coordinator and a registered nurse. The CMO shall designate additional members of the team as necessary to ensure that expertise needed to assess and plan for meeting each member's needs is available.
The CMO shall employ or contract with a sufficient number of case management personnel to ensure that enrollees' services continue to meet their needs.
The CMO shall provide the opportunity for enrollees to manage service and support funds, as provided under sub. (6)
. For enrollees managing service funding under sub. (6)
, the role of the case management team in providing assistance in planning, arranging, managing and monitoring the enrollee's budget and services shall be negotiated between the enrollee and the case management team and at a level tailored to the enrollee's need and desire for assistance. At a minimum, the case management team's role shall include:
An initial assessment sufficient to provide information necessary to establish an individual budget amount and to identify health and safety issues.
Monitoring the enrollee's use of the individual budget amount for purchase of services or support items.
Monitoring to ensure the enrollee reports service utilization adequately to allow the CMO to meet federal and state reporting requirements.
The CMO shall use assessment protocols that include a face-to-face interview with the enrollee and that comprehensively assess and identify all of the following:
The needs and strengths of each enrollee in at least the following areas:
Education and vocational activities, including any needs for job development, job modifications, and ongoing support on the job.
Long-term care outcomes that are consistent with the values and preferences of the enrollee in at least the following areas:
Self-determination of daily routine, services, activities and living situation.
The CMO, in partnership with the enrollee, shall develop an individual service plan for each enrollee, with the full participation of the enrollee and any family members or other representatives that the enrollee wishes to participate. The CMO shall provide support, as needed, to enable the enrollee, family members or other representatives to make informed service plan decisions, and for the enrollee to participate as a full partner in the entire assessment and individual service plan development process. The service plan shall meet all of the following conditions:
Reasonably and effectively addresses all of the long-term care needs and utilizes all enrollee strengths and informal supports identified in the comprehensive assessment under par. (e) 1.
Reasonably and effectively addresses all of the enrollee's long-term care outcomes identified in the comprehensive assessment under par. (e) 2.
and assists the enrollee to be as self-reliant and autonomous as possible and desired by the enrollee.
Is cost-effective compared to alternative services or supports that could meet the same needs and achieve similar outcomes.
If the enrollee and the CMO do not agree on a service plan, provide a method for the enrollee to file a grievance under s. DHS 10.53
, request department review under s. DHS 10.54
, or request a fair hearing under s. DHS 10.55
. Pending the outcome of the grievance, review or fair hearing, the CMO shall offer its service plan for the enrollee, continue negotiating with the enrollee and document that the service plan meets all of the following conditions:
Would not have a significant, long-term negative impact on the enrollee's long-term care outcomes identified under par. (e) 2.
Balances the needs and outcomes identified by the comprehensive assessment with reasonable cost, immediate availability of services and ability of the CMO to develop alternative services and living arrangements.
Was developed after active negotiation between the CMO and the enrollee, during which the CMO offered to find or develop alternatives that would be more acceptable to both parties.
The CMO shall reassess each enrollee's needs and strengths as specified under par. (e) 1.
and long-term care outcomes as specified under par. (e) 2.
and adjust the individual service plan based on the findings of the re-assessment, as specified in par. (j) 5.
The CMO shall provide, arrange, coordinate and monitor services as required by its contract with the department and as specified in the enrollee's individual service plan. The CMO shall provide opportunity for each enrollee to be involved, to the extent that he or she is able and willing, in all of the following:
The selection of service providers from within the CMO's network of providers.
The recruiting, interviewing, hiring, training and supervision of individuals providing personal care and household assistance in the enrollee's home.
The CMO shall provide assistance to enrollees in arranging for and coordinating services that are outside the direct responsibility of the CMO.
The CMO shall meet timeliness standards as specified in its contract with the department, that shall include all of the following:
Immediately upon enrollment, the CMO shall provide services to preserve the health and safety of the enrollee. Within 5 days of enrollment, the CMO shall develop and implement an initial service plan based on information received from the resource center and the CMO's initial assessment of the enrollee's needs.
The CMO shall complete a comprehensive assessment, as specified under par. (e)
not later than 30 days after enrollment.
Within 60 days of enrollment, the CMO shall, jointly with the enrollee and any other individual identified by the enrollee, develop an individualized service plan as specified under par. (f)
The CMO shall provide services and support items in accordance with the time frames specified in each enrollee's individualized service plan.
The CMO shall review each enrollee's service plan and adjust services if indicated by the review, as follows:
Whenever a significant change occurs in the enrollee's health, functional capacity or other circumstances.
When requested by the enrollee, the enrollee's representative, the enrollee's primary medical provider, or an agency providing services to the enrollee.
As often as necessary in relation to the stability of the enrollee's health and circumstances, but not less than every 180 days.
The CMO shall provide required reports in a timely manner as specified in its contract with the department.
(3) Service monitoring.
A CMO shall do all the following:
Develop and implement standards for CMO service provider qualifications and written procedures and protocols for assessing whether providers meet the standards. Provider qualification standards established by a CMO shall meet or exceed standards that are specified in its contract with the department.
Develop and implement written procedures and protocols that assure that services furnished are consistent with the needs and strengths identified under sub. (2) (e) 1.
, the long-term care outcomes identified under sub. (2) (e) 2.
and the individual service plan under sub. (2) (f)
for each enrollee.