Home and Community Based Services Manual


7.00 Show-Me Home

Introduction

Show-Me Home (SMH) is a Money Follows the Person (MFP) program that supports adults with disabilities and older adults in Missouri to transition from an institutional setting to specified community settings. SMH was awarded by the Centers for Medicare and Medicaid Services (CMS) to the Department of Social Services (DSS) in January 2007 and implemented in collaboration with the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS).

Eligibility Criteria

All SMH participants must meet the following criteria:

  • Currently reside in a Skilled Nursing Facility (SNF) for at least the last sixty (60) consecutive days
    • Consecutive days shall include any hospitalizations, home visits, and short-term rehabilitation services covered by Medicare, etc., as long as the participant is not discharged from the facility.
    • Residential Care Facilities (RCF) and Assisted Living Facilities (ALF) do not meet the SNF eligibility criteria for participation in the SMH program.
  • Currently receive MO HealthNet benefits in the SNF prior to transition
    • The Medicaid benefits must be in effect on the day of discharge from the SNF.
  • Eligible for Medicaid benefits after the transition to the community
  • Move to qualified housing in which the health and welfare of the potential participant can be assured. Qualified housing includes the following:
    • A home owned or leased by the potential participant or the potential participant's family member.
    • An apartment with an individual lease, with lockable entry and exit points, which includes living, sleeping, bathing, and cooking areas over which the potential participant or the potential participant’s family have domain and control.
    • A community-based residence in which no more than four unrelated individuals reside
  • Agree to the terms set forth in the SMH Participation Agreement.

In addition to the eligibility criteria specified above, the health and welfare of the potential participant cannot be compromised as a result of the transition to a community setting.

Referrals

The SMH Database tracks all SMH referrals and must be updated throughout the transition process, as instructed by the SMH Project Director. Direct referrals for SMH can be made through any of the following ways:

Referrals may also be generated as a result of the Section Q Long Term Care Minimum Data Set (MDS) questionnaire.

  • SNF staff enter MDS referrals into the SMH Database, which are then routed to the appropriate SMH contractor for the potential participant’s county of residence.
  • The SMH contractor makes a face-to-face contact with the resident for Options Counseling, updates the SMH Database, then forwards the referral to the appropriate DSDS staff for follow-up and a decision on eligibility for SMH services.

In addition, MDS Q+ Index potential referrals are generated by algorithms within the MDS system and transferred to the SMH Database for review by SMH contractors according to the terms of the contract.

Procedures

Upon receipt of a referral, DSDS staff shall conduct an assessment with potential participants, utilizing the InterRAI HC for individuals appropriate for HCBS. When HCBS is not appropriate, DSDS staff shall use the SMH HCBS Referral/Assessment form to determine eligibility for other SMH services and ensure it is uploaded into the participant’s electronic case record.

The assessment shall be conducted within ten (10) business days from receipt of the referral notification and the following shall apply:

  • If the potential participant has a legal guardian or invoked Durable Power of Attorney (DPOA), DSDS staff shall make arrangements to include the guardian or invoked DPOA in the assessment process.
  • Documentation shall be included in the participant’s electronic case record to reflect if the guardian or invoked DPOA chose to participate in the assessment process.
  • A Nursing Facility Level of Care (NF LOC) score is not required for participation in SMH. However, an NF LOC score is required if HCBS needs are identified and will be authorized.

DSDS staff is responsible for determining that all eligibility criteria are met and shall:

  • Discuss the contents of the SMH Participation Agreement with the potential participant to ensure they are aware of the requirements for participation in SMH
  • Obtain the participant’s signature on the agreement to indicate the participant wishes to proceed
  • Open a case in the electronic case record system
  • Upload the signed agreement to the participant’s electronic case record
  • Notify SMH DSDS oversight staff of the new enrollment
  • Potential participants who do not meet eligibility criteria for participation in SMH during the initial assessment visit shall not complete the SMH Participation Agreement

DSDS staff shall send an Adverse Action Notice to participants not eligible for enrollment. SMH appeals and hearings shall follow the Adverse Action and Appeal and Hearing process outlined in the HCBS Manual.

Note: Only DSDS staff may deny enrollment in SMH. If a referral is first received by a SMH contractor and preliminary screening indicates the individual will not be eligible for participation in SMH, the contractor must complete the Referral Notification and submit it to DSDS staff for review and a final decision.

  • If DSDS staff identifies a need for additional screening, the contractor will be notified to complete Options Counseling or other necessary action.
  • DSDS staff shall complete the Adverse Action Notice when necessary and process any Appeal and Hearing as outlined in the HCBS Manual.

Once the SMH Participation Agreement has been signed, the participant will begin working with a Transition Coordinator (TC), from the SMH contractor that provides services in their area. This applies to all participants, even those who will not need HCBS following transition. The TC shall assist the participant in determining their needs, finding appropriate housing, requesting any necessary SMH services funding, and verifying the safety and accessibility of potential housing.

The TC shall discuss and provide participants with resource information regarding the SMH program, community resources, and adult protective services. Appropriate brochures can be requested from SMH DSDS oversight staff.

The TC shall complete a Transition Plan (Plan) for each SMH participant in consultation and agreement with the participant and/or family members, participant’s legal representative, SNF discharge planner, and DSDS staff. The Plan must address each of the areas included on the form, with particular attention to the participant’s backup strategy for emergencies.

The Plan must be fully completed and signed by the participant and TC before it can be approved by DSDS staff. Once approved, DSDS staff shall upload a copy of the completed Plan to the participant’s electronic case record.

Special Considerations

Many factors can affect the participant’s ability to complete a transition to the community. Housing needs, health issues, or other concerns may prevent a potential participant from being able to transition immediately following the referral. The participant and TC shall notify DSDS staff when the applicant is prepared to return to the community.

If the potential participant returns to the community within a year of the initial SMH assessment, another face-to-face assessment is not required. DSDS staff shall make a telephone contact to update the information obtained during the original face-to-face assessment to ensure the participant’s care needs can still be met.

When the participant is ready to move to the community setting and is eligible for HCBS, DSDS staff shall complete the participant’s Person Centered Care Plan (PCCP) in the electronic case record. Development of the PCCP is based on the participant’s anticipated needs. SMH participants may be eligible for all HCBS authorized by DSDS, excluding RCF/ALF Personal Care. If the participant chooses Consumer-Directed Services (CDS), they must be able to self-direct their care and meet all other criteria for CDS participation.

DSDS staff may need to adjust the PCCP after the participant’s move to reflect actual needs. SMH participants are eligible for SMH demonstration services funding based on individual needs to assist with initial transition costs. The SMH demonstration services funding is available throughout the first 365 days of the move and is designed to assist with expenses related to establishing a home in the community. Any tangible items purchased with this funding become the property of the SMH participant, whether the participant remains in the community or not. The funds can be utilized for various items, including the following:

  • Rent deposits
  • Utility deposits
  • Cleaning supplies
  • Toiletries
  • Furniture
  • Household items
  • Groceries
  • Vehicle modifications
  • Durable medical equipment

The TC must request reimbursement for SMH demonstration services funding. Requests are submitted to SMH DSDS oversight staff for review before reimbursement will be authorized. The TC will be notified of the payment decision upon completion of the review.

The TC shall use the following guidance when considering purchasing an item using SMH demonstration services funding:

  • Items needed to facilitate the move back to the community
  • Items needed to maintain a community residence

Participation

Participation in the SMH program requires a series of three (3) Quality of Life surveys. These surveys are administered by contracted surveyors. The first survey is to be completed while the individual is residing in the SNF. The second survey is completed at the conclusion of the first year in the community, and the third at the conclusion of the second year in the community.

  • SMH Project Director’s staff will schedule the initial survey upon receipt of the signed Participation Agreement from DSDS staff.
  • A potential participant who is not surveyed before leaving the facility may be disqualified from participation in SMH. If DSDS staff becomes aware of a potential participant transitioning to the community that has not completed the survey, a request for the survey shall be made by notifying the SMH Project Director’s staff.
  • Tracking the participant and scheduling surveys beyond the first year are not the responsibility of DHSS.
  • SMH participants may refuse to participate in the Quality of Life surveys; any such refusal shall be documented in the SMH Database and the HCBS electronic case record.

Participation in the SMH program is limited to 365 days of community residence (one year) following the participant’s actual transition back to the community. Hospital and SNF days are not counted toward this time period.

The TC is required to make at least monthly contact with the participant throughout the year. Extensive tracking of SMH participants is required by CMS; therefore, the TC shall obtain as much information as possible during the monthly contacts.

Any information or incident that is critical to the health and welfare of the participant shall be documented in the SMH Database and the participant’s electronic case record. The TC shall notify DSDS staff when documentation has been added to a participant’s electronic case record. Examples include, but are not limited to:

  • Hospitalization or re-institutionalization (including the reason)
  • Critical incidents which could harm the participant such as abuse, neglect or exploitation
  • Emergency situations that could endanger the health and welfare of a participant and may lead to a critical incident if not addressed. Situations could include:
    • lack of transportation to a medical appointment
    • life support equipment repair or replacement needed
    • critical health issues
    • direct service/support workers not showing up
    • ambulance calls/ER visits, injuries/accidents
  • Involvement with the criminal justice system

When there is an inpatient admission to a SNF for more than thirty (30) days, the participant shall be disenrolled from SMH. However, the participant can be re-enrolled for SMH services without re-establishing the sixty (60) day SNF residency requirement if they are able to return to their community residence. Any inpatient days would not be counted toward the 365 days allowable during the first year.

In some cases, the SMH participant’s circumstances may change to the extent that continued participation in the program is not appropriate. In that event, DSDS staff shall gather documentation outlining the reasons that the disenrollment of the participant is being recommended. Those reasons may include, but are not limited to, the following:

  • The participant has transitioned to the community, and it is determined that the health and welfare of the participant can no longer be assured in a community setting
  • The participant is no longer Medicaid eligible
  • The participant has moved to a non-qualified living arrangement

Documentation shall describe the issues and behaviors which resulted in this recommendation, as well as collateral contacts with other persons and agencies involved in the participant’s plan.

After review of all information, DSDS staff will document the decision in the participant’s electronic case record. If the SMH participant is disenrolled or denied services, DSDS staff shall send an Adverse Action Notice to the participant. The SMH participant has the right to appeal the decision, following the Adverse Actions and Appeal and Hearing processes outlined in the HCBS Manual. DSDS staff shall also notify SMH DSDS oversight staff and the SMH Project Director when a participant is no longer enrolled for SMH.

Prior enrollment as a SMH participant does not disqualify a person from re-enrollment if they return to a community setting. DSDS staff shall review previous circumstances to determine the likelihood of a successful transition and obtain approval from DSDS Supervisor and the SMH Project Director prior to reenrolling the participant. All SMH criteria must be met in order to re-enroll.

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