Medicaid Best Practices | Center for Health Transformation

Best Practices in Medicaid - Ohio

The Center for Health Transformation is inviting leaders from all 50 states to share their transforming solutions for the Medicaid program. In order that key decision-makers and industry leaders from around the country may learn from others’ successes, it is our intention to provide this interactive resource for showcasing the most innovative practices in the country. Please note that the following contributions have not been edited by CHT staff and will remain open indefinitely to future updates.

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Delivering high quality, coordinated, long term care for the disabled and/or the infirm

Through funding awarded by CMS as part of a Nursing Home Transition Grant, the Ohio Department of Job and Family Services (ODJFS) is implementing the Ohio Access Success Project, which supports the relocation of persons from nursing facilities to home and community-based settings. ODJFS has contracted with Easter Seals of Ohio, the Independent Living Options, Inc. of Cincinnati, and the Brain Injury Association of Ohio, Inc. to provide the day-to-day implementation of this project, including marketing, referrals, education, assessment, relocation planning and implementation, relocation funding, and follow up.

Two new services were recently added to ODJFS’ Ohio Home Care Waiver and Transitions II Carve-Out Waiver, approved under 1915(c) authority: social work/counseling services and nutritional consultation services. Social work/counseling services are transitional services provided to the consumer, authorized representative, caregiver, and/or family member on a short-term basis to promote the consumer’s physical, social and emotional well-being, promoting the development and maintenance of a stable and supportive environment for the consumer. Social work/counseling services can include crisis interventions, grief counseling and/or other social service interventions that support the consumer’s health and welfare. Nutritional consultation services provide nutritional guidance to a consumer with special dietary needs and takes into consideration the consumer’s cultural and ethnic background and dietary preferences and/or restrictions.

Under ODJFS-administered HCBS waivers, approved under 1915(c) authority, consumers will soon be able to utilize non-legally responsible family members, including legal guardians of adult consumers, to provide nursing and personal care aide services.

Transparent and publicly-accessible measurements of patient outcomes and/or quality improvements

The following initiatives and activities are part of the Ohio Department of Job and Family Services’ quality management plan and ongoing program monitoring processes for its HCBS waivers, approved under 1915(c) authority.

The Ohio Department of Job and Family Services (ODJFS) operates an incident management, investigation and response system (IMIRS) that requires all ODJFS-administered waiver providers to report incidents involving waiver consumers. Incidents must be reported to ODJFS and the Case Management Agency (CMA) within 24 hours, at which time ODJFS will contact the appropriate investigatory agency (e.g., public children services agency, county board of MR/DD for major unusual incidents, local mental health case manager, Ohio Department of Health or Ohio Board of Nursing, etc.) and/or law enforcement authority with jurisdiction over the matter. Additionally, ODJFS reviews all available information to determine if adequate safeguards are in place to protect the consumer’s health and welfare. Substantiated incidents will result in the issuance of a “cease and desist” letter to the provider and request for a plan of correction. Sanctions may be imposed against the provider by ODJFS. ODJFS operates a consumer and provider occurrence report tracking system (C-PORTS) that allows ODJFS and the CMA to share live information, and track incidents and provider occurrences, in order to ensure appropriate and timely investigatory follow-up and prevention planning. C-PORTS also allows ODJFS to analyze trends and patterns about incidents and providers. It is a source of information when ODJFS conducts site and desk reviews while monitoring the CMA’s compliance with contractual responsibilities regarding reporting, investigation and follow-up of critical incidents.
ODJFS meets monthly with the Ohio Olmstead Task Force to share information and solicit input. The 10-12 member committee is an important conduit for direct communication and involvement of consumers, caregivers and key stakeholders in the development of the structure, function, training components, oversight and administrative policies and procedures related to the ODJFS-administered HCBS waivers.
ODJFS utilizes a Secret Shopper activity to monitor the effectiveness of its contracted case management agency’s information and referral systems. ODJFS staff call each of four regional offices, asking questions and requesting information as if they were a consumer or applicant. Some ODJFS staff are able to ask questions in another language. The results are incorporated into ODJFS’ comprehensive annual site review of the case management agency and other ongoing monitoring reports.

Efforts to combat fraud and abuse

As part of its monitoring processes for its HCBS waivers, the Ohio Department of Job and Family Services conducts face-to-face structural reviews with providers at least annually, or as needed if provider occurrences (including provider billing violations or suspected Medicaid fraud) are reported. Included in the structural review is a unit of service verification audit that compares services authorized, delivered and billed as they relate to the consumer’s All Services Plan. ODJFS reports any/all provider overpayments to the department’s Surveillance and Utilization Review Section (SURS), and the Ohio Attorney General’s Medicaid Fraud Control Unit, as appropriate. Additionally, at any point in time a consumer or the Case Manager may find evidence of alleged billing violations (e.g., date of service is not authorized, duplicate billing, not allowable family member providing services, RN performing personal care aide services and billing as waiver nursing, etc.). The Case Management Agency is required to investigate the allegation and upon verification, makes referrals to SURS for follow-up.

What are your future plans?

In the future, ODJFS is planning to develop a new child day health care HCBS waiver service, utilize legally-responsible family members as HCBS waiver providers, and develop a self-directed care HCBS waiver under Independence Plus authority. Ohio House Bill 66, our biennial budget bill passed June, 2005, calls for a Voucher Pilot program. ODJFS is to apply for a waiver of federal Medicaid requirements to implement a pilot program allowing up to 200 Medicaid recipients to receive a spending authorization to pay for the cost of medically necessary health care services. The spending authorization cannot exceed seventy percent of the average cost under the Medicaid program for providing nursing facility services to an individual. An individual participating in the pilot will also receive necessary support services, including fiscal intermediary and other case management services. The Voucher concept was among the many Ohio Commission to Reform Medicaid recommendations to the Governor and General Assembly to control the cost of Medicaid, improve choice and improve care.