Revision 18-1; Effective June 15, 2018

 

 

Community Care Services Eligibility (CCSE) asked each region to designate a complex needs coordinator. This appendix provides a description of the role and expectations of the designated complex needs coordinator.

While there are other situations which require the expertise of the coordinator, the primary responsibilities are in the coordination of high needs individuals transitioning from children's programs to adult programs. Due to the complexity of some of these situations, the skills of the complex needs coordinator are necessary.

Outlined below are the duties of the complex needs coordinator. Regional directors may assign additional staff to assist with these duties, but the designated coordinator will be the point of contact for issues and questions.

 

Quarterly Comprehensive Care Program (CCP) Transition Report

The designated complex needs coordinator is responsible for:

  • completing the quarterly CCP Transition Report for the region and submitting it back to the state office Special Initiatives coordinator by the designated due date. The report includes all transitioning individuals, including Personal Care Services (PCS) to Primary Home Care (PHC) applicants;
  • being the point of contact for any questions on the quarterly CCP Transition Report;
  • ensuring the 12-month visit and contacts are made and reporting back to the state office CCSE contact any individuals who may potentially be over the cost limit based on current services;
  • identifying the high needs individuals and ensuring all aging out assessments are started on time and remain on track; and
  • submitting frequent progress reports to the state office CCSE contact on the individuals who have been identified as high needs.

 

Identification and Tracking of High Needs Aging Out Individuals

The complex needs coordinator is responsible for:

  • identifying the aging out individuals who may be close to the cost limit or have other issues that may complicate the development of an acceptable individual service plan (ISP);
  • coordinating the regional interdisciplinary team (IDT) meetings, as needed;
  • being the regional contact person for state office staff for questions on pending applications or ongoing individuals with high needs;
  • requesting and participating in the state office IDT, including assuring the chronology and other required documentation are submitted; and
  • assisting with collecting and submitting the required medical and service documentation if a physician's clinical visit is required for the Rider 36 General Revenue (GR) process.

 

Providing Assistance and Overview of High Needs Assessments

The complex needs coordinator is responsible for:

  • working with the assigned case worker and other regional staff on all high needs assessments;
  • reviewing the draft ISP packet to check for the following;
    • Are the Medical Necessity/Level of Care (MN/LOC) and Resource Utilization Group (RUG) levels set correctly? Is the individual a ventilator patient and if so, is the RUG coded correctly for the 6 to 23-hour or 24-hour vent care?
    • Are the nursing hours calculated correctly? Are the registered nurse (RN) required hours included? Has the type of nursing (specialized or non-specialized) been discussed and set up correctly?
    • Do the nursing hours reflect the informal support hours the family has agreed to, and is this information reflected the same on Form 8598, Non-Waiver Services? Is the family in agreement with the plan and is Form 8598 signed in agreement with the overall plan?
  • assisting regional staff in working with provider agencies and contract management to assure a cost effective ISP is developed that assures health and safety and is ready to be implemented on the age out date; and
  • working with state office staff if the Rider 36 process is initiated.

 

Regional Complex Needs Coordinators Procedures for Individuals in the STAR+PLUS Program

The role of the complex needs coordinator is different in STAR+PLUS areas due to the differences in STAR+PLUS procedures. Listed below are the complex needs coordinator's responsibilities for individuals in STAR+PLUS.

 

Quarterly CCP Transition Report

The designated complex needs coordinator is responsible for:

  • completing the quarterly CCP Transition Report for the region and submitting it back to the state office Special initiatives coordinator by the designated due date;
  • being the point of contact for any questions on the quarterly CCP Transition Report; and
  • ensuring all STAR+PLUS Home and Community Based Services (HCBS) aging out referrals (Form H3676, Managed Care Pre-Enrollment Home Health Assessment Authorization) are sent on time.

 

Identification and Tracking of High Needs Aging Out Individuals

The complex needs coordinator will be responsible for coordinating with the STAR+PLUS Support Unit (SPSU) supervisor for:

  • identifying the aging out individuals who may be close to the cost limit or have other issues that may complicate the development of an acceptable ISP and reporting this information to HHSC-MCO and state office staff;
  • being the regional contact person for state office and HHSC-MCO staff for questions on pending applications or ongoing individuals with high needs;
  • assisting with collecting and submitting the required medical and service documentation for an IDT or for when a physician's clinical visit is required for the Rider 36 GR process;
  • working with HHSC-MCO and state office staff if the Rider 36 process is initiated.