Case Studies of Six State Personal Assistance Service Programs Funded by the Medicaid Personal Care Option. III. Gatekeeping and Supervision Functions: Eligibility, Needs Assessment, Case-Management, Medical Supervision


A. Eligibility Determination

Initial financial eligibility for Medicaid is assessed by the DSRS. Referrals can come from a number of sources (i.e. discharge planners, physicians, social workers, self, family, etc.). West Mont begins service upon verification of income eligibility, although in some cases they may initiate services for people who are not immediately income eligible but must spend down to Medicaid level. The agency technically has up to three weeks to notify the referral source of initiation of services, but in practice less time is required.

If there is a hazardous home situation or immediate risk of institutionalization, an emergency referral can be made. In these cases, the agency must contact the individual within 24 hours, and start providing services within 48 hours pending Medicaid verification.

Assessment of ADL needs is done by a West Mont nurse supervisor. At least one ADL is required for eligibility, and hands-on personal care rather than supervision must be the primary need of the applicant.

At the time of the assessment, the nurse supervisor give the referred individual a booklet which outlines the services which are and aren't covered, a list of West Mont contact personnel, and a description of the complaint procedure. There is an appeal process for denial of services, but some advocates felt that many consumers who are deemed ineligible for services realize that they can appeal.

B. Needs Assessment

A detailed plan of care is developed by the RN with the recipient, which assesses medical diagnosis, medications, diet, short and long term objectives, etc. As part of this plan of care, the type and frequency of specific ADL related tasks are listed. The client or surrogate is required to sign a consent and release form once the plan of care is adopted.

C. Case Management

Case-management is not a regular service of the Medicaid Personal Care program. People who need case-management are referred to the Waiver program. The SRS liaison, program mangers, and West Mont program director are all social workers.

D. Medical Supervision

The amount and consistency of nurse supervision increased when West Mont took over the program. West Mont RNs are required to complete a plan of care every 90 days. Originally RNs were required to complete a plan of care every 60 days, but the DSRS and West Mont decided that the majority of consumers were stable and the attendants consistent enough that this level of supervision was unnecessary.

The physician must order services, and is required to reauthorize services at least once a year. Nurse supervisors attempt to contact the recipient's physician verbally prior to assessment. In some cases, instead of waiting for the physician to initiate reauthorization of services, West Mont often completes the assessment and mails the results to the recipient's physician for a signature.

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