TITLE 8 ††††††††††††††† SOCIAL SERVICES

CHAPTER 326††† CASE MANAGEMENT SERVICES

PART 10†††††††††††††† TRAUMATIC BRAIN INJURY TRUST FUND PROGRAM

 

8.326.10.1†††††††††††† ISSUING AGENCY:Aging and Long-Term Services Department.

[8.326.10.1 NMAC - N, 11/15/07]

 

8.326.10.2†††††††††††† SCOPE:This rule applies to the general public.

[8.326.10.2 NMAC - N, 11/15/07]

 

8.326.10.3†††††††††††† STATUTORY AUTHORITY:Subsection (E) of Section 9-23-6 NMSA 1978

[8.326.10.3 NMAC - N, 11/15/07]

 

8.326.10.4†††††††††††† DURATION:Permanent

[8.326.10.4 NMAC - N, 11/15/07]

 

8.326.10.5†††††††††††† EFFECTIVE DATE:11/15/07, unless a later date is cited at the end of a section.

[8.326.10.5 NMAC - N, 11/15/07]

 

8.326.10.6†††††††††††† OBJECTIVE:The objective of this rule is to establish policies, procedures and to define standards of the New Mexico aging and long-term services department traumatic brain injury (TBI) trust fund program that will provide timely services for persons with qualifying brain injuries that are a result of a trauma caused by an outside force in order to promote independence and to assist the individual in accessing long term services and access to community resources when there is no other funding available.

[8.326.10.6 NMAC - N, 11/15/07]

 

8.326.10.7†††††††††††† DEFINITIONS:

††††††††††††††† A.††††††††††† "Acquired brain injury" means a brain injury that is the result of a metabolic disorder, cerebral vascular insults, surgical procedures, tumors, anoxia (lack of oxygen) or other internal causes and does not fit the criteria for traumatic brain injury.

††††††††††††††† B.††††††††††† "Activities of daily living" means those tasks that define an independent existence and care of one's personal needs and may include: personal hygiene, preparing and consuming meals, cleaning the home, doing laundry, shopping for groceries, managing personal finances and transporting oneself to and from various locations in the pursuit of self-care.

††††††††††††††† C.††††††††††† "Aging and long-term services department (ALTSD)" means the agency of New Mexico state government that oversees the services for the elderly and disability populations, which include the TBI trust fund program.

††††††††††††††† D.††††††††††† "Crisis" means an emergency situation that may be a serious potential danger a turning point in an acute injury or an emergency or an unstable or crucial time in which a decisive change is impending or a situation that has reached a critical phase and may include; homeless status, zero finances, unemployment due to TBI, separation from support systems, potential danger or abandonment.

††††††††††††††† E.†††††††††††† "Crisis interim period" means a short-term period of 90 days that can be reassessed and extended for another 90-day period, limited to no more than one consecutive year, if goals or services have not reached completion or until another funding source can be obtained.

††††††††††††††† F.†††††††††††† "Education" means providing individuals training in life skills or activities of daily living, which they can apply day to day, to help them to attain an independent lifestyle.

††††††††††††††† G.††††††††††† "Fiscal intermediary agency" means an agency that processes reimbursement and funding for services and goods for eligible recipients of the New Mexico aging and long-term services department TBI program.

††††††††††††††† H.††††††††††† "Grievance" means a complaint or disagreement with regard to how or whether a service provided through the program is or can be provided.

††††††††††††††† I.††††††††††††† "ICD 9 code" means an International Code of Diseases diagnosis assigned to a traumatic brain injury, which has been obtained from and documented in writing by a duly licensed physician or psychologist.

††††††††††††††† J.†††††††††††† "Imminent" means a pending crisis that is bound to happen with a clear and present danger to the health and safety of a person who has sustained a traumatic brain injury and who has exhausted all available resources.

††††††††††††††† K.††††††††††† "Independence" means the ability to live and perform activities of daily living with little or no assistance from others and to access available community resources.

††††††††††††††† L.††††††††††† "Individual" means an individual who has been approved for services in the TBI program through an application process and who has provided medical documentation of an appropriate ICD9 code.

††††††††††††††† M.†††††††††† "Individual living plan" means a written individualized plan with definite goals and strategies to accomplish that are aimed at assisting an individual in achieving strategies that lead to eventual independence including goals, measurable objectives, contact, progress, referrals, outcome of services and other payor resources.All TBI services must be in the ILP, service coordinator, life skills and crisis interim.

††††††††††††††† N.††††††††††† "Interim" means an intervening time defined by the TBI program as temporary, transitional services within a defined period with a definite goal.

††††††††††††††† O.††††††††††† "Legal resident of New Mexico" means a person residing in New Mexico at the time of application.

††††††††††††††† P.††††††††††† "Life skills coach" means a person who provides training in activities of daily living for TBI individuals that aids in their return to a lifestyle where they function as independently as possible.

††††††††††††††† Q.††††††††††† "Limited service coordination" means contact between the service coordinator and the individuals once a month either face-to-face or by telephone to monitor status of crisis interim services or life skills coaching, which continue after the "active" period to ensure the continuity and completion of specific limited services.

††††††††††††††† R.††††††††††† "Payor of last resort" means a source of funding for TBI program services that is not to be used until all other possible payor sources have been denied or exhausted.

††††††††††††††† S.††††††††††† "Residency" means that a person must be a legal resident of New Mexico and must be able to produce documentation of a physical location of New Mexico and not reside in an institution or be in the process of being institutionalized.

††††††††††††††† T.††††††††††† "Risk" means a possible loss or injury, a dangerous element or factor or a degree of probability of loss.

††††††††††††††† U.††††††††††† "Self-determination" means the right of individuals to make decisions that direct the path their life follows in regard to medical, financial and all other matters.

††††††††††††††† V.††††††††††† "Service coordination" means the coordinating of goods and services and the referring of community resources available for delivery to individuals through the use of an individual living plan (ILP).

††††††††††††††† W.†††††††††† "Short-term" means an intervention period with beginning and end points within which the trust fund may be used to prevent or alleviate a crisis situation until circumstances stabilize or other funding is obtained.

††††††††††††††† X.††††††††††† "Traumatic brain injury (TBI)" means an insult to the brain from an outside physical force that may or may not have produced a diminished or altered state of consciousness. The term applies to open or closed head injuries resulting in an impairment of cognitive ability and/or physical functions but not necessarily both.Impairments in one or more areas such as: cognition; language; memory; attention; reasoning; abstract thinking; judgment; problem-solving; sensory; perceptual, and motor abilities; psychosocial behavior, physical function, information process and speech.Impairments may be either temporary or permanent and may cause partial or total functional disability and/or psychosocial disorientation.

††††††††††††††† Y.††††††††††† "TBI crisis interim services" means services for individuals that are critical when there has been a sudden change in the course of the medical, psychological or physical condition of an individual diagnosed with TBI or when there is an imminent risk to an individual's health and safety.

††††††††††††††† Z.††††††††††† "TBI formulary" means the list of medications approved by the TBI trust fund for treatment of the TBI and related conditions, which are listed as:brand name medications; generic name medications and category of medications.Access to this formulary is through TBI service coordinators.

††††††††††††††† AA.†††††††† "TBI trust fund program" means a short-term crisis interim program of up to 90-day increment duration, during which time services, goods and supports for the treatment of the TBI and conditions directly related to the TBI are offered to eligible individuals along with referrals to community resources that offer the opportunity to apply for long-term services, in order to promote an independent lifestyle of self-reliance.After the initial 90 days, a reassessment shall be done to determine whether there remains a need for an extension of additional periods of 90 days, limited to no more than one consecutive year, to complete any services that have been initiated.

††††††††††††††† BB.†††††††† "TBI uniqueness" means that crisis interim services are intended to provide unique TBI specific services that are not available for eligible individuals from any other funding source.

††††††††††††††† CC.†††††††† "Unit price system (UPS)" means the reimbursement for TBI services for direct care activities under state general funded contracts through the unit price system of the administrative services division of the aging and long term services department according to the component and service unit.

[8.326.10.7 NMAC - N, 11/15/07]

 

8.326.10.8†††††††††††† STANDARDS FOR PROVIDING SERVICES GOODS AND SUPPORTS TO INDIVIDUALS WITH TRAUMATIC BRAIN INJURIES (TBI):TBI services are provided through three contractor components: service coordination, life skills coaching and crisis interim services. These services enhance the individual's self-determination and promote independence.They include the expectation of individual and family participation.

[8.326.10.8 NMAC - N, 11/15/07]

†††††††††††††††

8.326.10.9†††††††††††† ELIGIBILITY REQUIREMENTS FOR INDIVIDUALS:

††††††††††††††† A.††††††††††† Diagnosis:Individuals are eligible for TBI service coordination services if they have a diagnosis of traumatic brain injury which has been documented in writing by a duly licensed physician or psychologist.Eligibility must be further substantiated by the assignment of an international code of diseases (ICD 9) TBI diagnosis obtained from their licensed practitioner of record.

††††††††††††††† B.††††††††††† Definition of TBI:As stated in Subsection X of 8.326.10.7 NMAC.

††††††††††††††† C.††††††††††† Residency:Eligible individuals must be legal residents of the state of New Mexico.They must to able to produce documentation of the physical location of their New Mexico residence.Those residing in an institution or in the process of transitioning to an institutional setting are not eligible for service coordination services through the TBI program.Those individuals who have a confirmed discharge date and are transitioning into the community are eligible for service coordination for a 30-day period prior to planned discharge date.

††††††††††††††† D.††††††††††† Service Coordination Duplication:Those served by other service coordination programs or systems are not eligible to receive service coordination through the TBI program.Such service coordination program might include:

††††††††††††††††††† (1)†††† medicaid salud service coordination;

††††††††††††††††††† (2)†††† medicaid adult therapy service coordination;

††††††††††††††††††† (3)†††† early periodic screening diagnostic testing service coordination;

††††††††††††††††††† (4)†††† medicaid waiver programs;

††††††††††††††††††† (5)†††† mi via waiver;

††††††††††††††††††† (6)†††† developmental disability waiver;

††††††††††††††††††† (7)†††† family infant toddler;

††††††††††††††††††† (8)†††† medically fragile;

††††††††††††††††††† (9)†††† HMOs; and

††††††††††††††††††† (10)†††† other private insurances.

††††††††††††††† E.†††††††††††† Determination of Eligibility:The service coordination contractor is responsible for determining eligibility for the traumatic brain injury (TBI) program and maintaining documentation of eligibility status.Proof of eligibility status including qualifying ICD 9 codes must be provided to the elderly and disability services division/TBI program or its designee upon request.

††††††††††††††† F.†††††††††††† Limited Service Coordination:With written approval by TBI program manager or designee, rare exceptions may be made to allow individual cases to be opened for TBI program service coordination at the same time the individual is receiving non-TBI service coordination from programs such as those listed in Subsection D above.Limited service coordination of no more than 30 days may be used to make referrals of individuals to life skills coaching, crisis interim services and or to assist non-TBI program case managers in securing appropriate TBI resources for their individuals.

††††††††††††††† G.††††††††††† Non-TBI Service Coordination:Other case managers include such systems as those listed in Subsection D above.TBI service coordination contractors are responsible for determining eligibility for TBI life skills coaching for an individual that is receiving their service coordination from non-TBI program case managers and they must maintain documentation of proof of eligibility in the individual's records.

[8.326.10.9 NMAC - N, 11/15/07]

 

8.326.10.10††††††††† SERVICE COORDINATION SERVICES PROVIDERS FOR TRAUMATIC BRAIN INJURY TRUST FUND PROGRAM:

††††††††††††††† A.††††††††††† Service Coordination Services:TBI service coordination is a problem-solving function that is intended to insure continuity of services and prevents fragmentation of services and endeavors to tap into any and all resources that are appropriate and accessible for eligible individuals.It is the responsibility of TBI service coordinators to neither under nor over-utilize available services.Service coordination includes the following scope of services:

††††††††††††††††††† (1)†††† process the application and assess the service needs for each individual through an appointed visit to determine the unique needs of the individual;

†††††††††† †††††††††(2)†††† identify the appropriate services, supports and goods to meet the individual's needs;

††††††††††††††††††† (3)†††† coordinate the delivery of services for the individual;

††††††††††††††††††† (4)†††† assist the individual in obtaining the qualifying ICD 9 code and access to services supports and goods;

††††††††††††††††††† (5)†††† develop an individual living plan (ILP) that includes all the services, goods, and supports recommended to the individual including referrals to life skills coaching (LSC) crisis interim services (CIS) and any other potential resources available in the local community;

††††††††††††††††††† (6)†††† reassess needs every 90 days to ensure that the services the individual is receiving continue to be appropriate;

††††††††† ††††††††††(7)†††† maintain a 24-hour emergency response system that allows individuals to contact them.An emergency response written policy should be provided to all individuals and available for review by ALTSD;

††††††††††††††††††† (8)†††† create a transition plan for eventual discharge from service coordination services; and

††††††††††††††††††† (9)†††† document or record evidence of all services listed in this scope of services that are provided by the program to the individual in the individual's permanent TBI program record.

††††††††††††††† B.††††††††††† Entry into the TBI program:Service coordinators must initiate entry into the TBI program funded services that include life skills coaching (LSC) and crisis interim services (CIS).

††††††††††††††††††† (1)†††† Service coverage area for the TBI service coordination contractor must be throughout at least one entire program region as specified in the contract provider agreement with ALTSD.

††††††††††††††††††† (2)†††† Frequency of contact with individual shall be no less than one hour face to face each month unless otherwise approved in writing by the TBI program manager or designee.

††††††††††††††††††† (3)†††† Limited services coordination is available to individuals who continue to receive crisis interim services or life skills coaching and these individuals must be contacted monthly either face to face or by telephone. This contact may be less than one hour.

††††††††††††††††††† (4)†††† Assist individuals with application process.Individuals must be found eligible prior to receiving life skills coaching or crisis interim services.

††††††††††††††††††† (5)†††† Facilitate independent living to individuals who have qualified for TBI services.

††††††††††††††††††† (6)†††† Coordinate with other case managers from Medicaid, waivers, and private insurance especially when the individual is transitioning from the TBI program into another system.

††††††††††††††††††† (7)†††† Facilitate team meetings with individual and other program agencies or individual professionals to streamline services.

††††††††††††††††††† (8)†††† Complete an individual living plan (ILP), which shall be written and developed by the individual and their service coordinator and shall include:

††††††††††††††††††††††††††††† (a)†††† goals and objectives;

†††††† †††††††††††††††††††††††(b)†††† education and support necessary to reach goals and objectives;

††††††††††††††††††††††††††††† (c)†††† number of hours per month the individual will receive TBI service coordination;

††††††††††††††††††††††††††††† (d)†††† expected measurable outcomes;

††††††††††††††††††††††††††††† (e)†††† time frames for reaching goals and meeting objectives;

††††††††††††††††††††††††††††† (f)†††† plans for discharge or transference to another program or payor source;

†††††††††††††††††††††††††††† (g)†††† identification of all persons, services and or products necessary to reach the individual's goals and accomplish their objectives shall be included in the ILP; and

††††††††††††††††††††††††††††† (h)†††† identification and estimated cost of services and or goods provided by crisis interim services.

††††††††††††††††††† (9)†††† TBI life skills coaching and or crisis interim services can not be initiated until the individual's service coordinator has included the services in the ILP.

†††††††††††††††††† (10)†††† Maintain case records of each individual served including but not limited to:

††††††††††††††††††††††††††††† (a)†††† two page application;

††††††††††††††††††††††††††††† (b)†††† intake form;

††††††††††††††††††††††††††††† (c)†††† initial assessment;

††††††††††††††††††††††††††††† (d)†††† eligibility documentation (ICD 9 code and medical records substantiating the TBI);

††††††††††††††††††††††††††††† (e)†††† individual living plan (ILP) which includes goals, measurable objectives, revisions of ILP, referrals;

††††††††††††††††††††††††††††† (f)†††† contacts, progress, outcomes of services and documentation of other payor resources; and

††††††††††††††††††††††††††††† (g)†††† maintain a copy of the life skills ILP.

††††††††††††††† C.††††††††††† Administrative Requirements of Service Coordination Contractors:The intent of service coordination is to augment not replace the individual's natural supports in a non-obtrusive manner while focusing on those natural supports.Service coordination is intended to nurture individuality in the person's environment and when possible to allow the individual to live in their own home. Specified requirements are listed below:

††††††††††††††††††† (1)†††† have and follow confidentiality standards;

††††††††††††††††††† (2)†††† possess and maintain a current business license issued by the state, county or city government if required;

††††††††††††††††††† (3)†††† comply with all applicable federal or state regulations policies and procedures that apply to their business including but not limited to policies and procedures related to:

††††††††††††††††††††††††††††† (a)†††† service provision and appropriate supervision;

††††††††††††††††††††††††††††† (b)†††† professional documentation standards;

††††††††††††††††††††††††††††† (c)†††† training and education on TBI; and

††††††††††††††††††††††††††††† (d)†††† reimbursement of service coordination services;

††††††††††††††††††† (4)†††† demonstrate financial solvency;

††††††††††††††††††† (5)†††† establish and maintain separate financial reporting and accounting activities that are in accordance with state requirements;

††††††††††††††††††† (6)†††† maintain an automated data system for financial and program reporting purposes (note: direct linkage/modem to the aging and long term services department may be required);

††††††††††††††††††† (7)†††† have extensive knowledge of TBI and community resources individuals may access within their community, region, New Mexico and nationally and maintain an in-house directory of TBI resources on site;

††††††††††††††††††† (8)†††† have an established method of information and data collection;

††††††††††††††††††† (9)†††† have a readily accessible office in each geographic TBI program designated region served by the contract provider;

††††††††††††††††††† (10)†††† be able to respond to individual emergency situations within a reasonable amount of time after notification on a 24-hour basis;

††††††††††††††††††† (11)†††† purchase and maintain full professional liability insurance coverage;

††††††††††††††††††† (12)†††† establish and maintain appropriate written grievance procedures;

††††††††††††††††††† (13)†††† reports shall be submitted in the time frame and format prescribed by TBI program; reports will be submitted in the manner designated by the TBI program including a summary of the total hours of service coordination services provided to each individual;

††††††††††††††††††† (14)†††† organizations must avoid conflict of interest or duplication of services and may not provide other state general funded services to individuals with traumatic brain injures when they are also individuals for whom they provide TBI service coordination services;

††††††††††††††††††† (15)†††† comply with the following quality assurance system requirements:

††††††††††††††††††††††††††† ††(a)†††† assure that the individual achieves an optimal level of wellness and function by implementing timely and appropriate services and natural supports individualized to meet their need;

††††††††††††††††††††††††††††† (b)†††† assure timely assessment and implementation of necessary services supports and goods;

††††††††††††††††††††††††††††† (c)†††† insure that each individual's ILP addresses targeted realistic goals and objectives with measurable outcomes within a cost-effective and specific time frame;

††††††††††††††††††††††††††††† (d)†††† develop an ongoing monitoring process which provides for the evaluation of quality effectiveness and appropriateness of services and supports provided to the individual;

††††††††††††††††††††††††††††† (e)†††† utilize a monitoring system to track accurate data reported on individual issues and concerns regarding the individual from both internal and external resources;

††††††††††††††††††††††††††††† (f)†††† identify and resolve known or suspected issues that may have an impact on the individual;

††††††††††††††††††††††††††††† (g)†††† perform individual satisfaction surveys at time of inactivation that identify areas of need such as delays in implementation of services or supports, over and under utilization of services or supports and access to providers of services;

††††††††††††††††††††††††††††† (h)†††† employ a formal method of monitoring, regulating and documenting the quality of services or supports provided to determine if the goals and objectives of the ILP are being achieved and remain appropriate and realistic;

††††††††††††††††††††††††††††† (i)†††† arrange and participate in a quarterly individual progress review with other service contract and or subcontract providers to verify that the individual's goals and objectives remain appropriate and realistic;

††††††††††††††††††††††††††††† (j)†††† monitor and assure that services and supports are readily accessible to the individual;

††††††††††††††††††††††††††††† (k)†††† evaluate and monitor the appropriateness and timeliness of services delivered to the individual;

††††††††††††††††††††††††††††† (l)†††† maintain regular communication with all contract and subcontract providers delivering services and products to the individual;

††††††††††††††††††††††††††††† (m)†††† demonstrate that the quality of services has been evaluated and that all concerns and issues are identified including implementation of necessary corrective action plans; and

††††††††††††††††††††††††††††† (n)†††† maintain original individual records for each program individual in the local service coordination contractor agency.

††††††††††††††† D.††††††††††† Staffing Requirement Qualifications:TBI service coordinators must demonstrate their qualifications in one of the following ways:

††††††††††††††††††† (1)†††† have a current social worker license in good standing with the New Mexico board of social work examiners;

††††††††††††††††††† (2)†††† have a current registered nurse license, in good standing from the New Mexico board of nursing;

††††††††††††††††††† (3)†††† havea bachelor's degree in social work, counseling, nursing, special education or closely related field plus one year clinical experience related to the TBI population working in any of the following settings:

††††††††††††††††††††††††††††† (a)†††† home health or community health program;

††††††††††††††††††††††††††††† (b)†††† hospital;

††††††††††††††††††††††††††††† (c)†††† private practice;

††††††††††††††††††††††††††††† (d)†††† publicly funded institution or long term care program;

††††††††††††††††††††††††††††† (e)†††† mental health program;

††††††††††††††††††††††††††††† (f)†††† community based social service program; and

††††††††††††††††††††††††††††† (g)†††† other programs addressing the needs of individuals with TBI;

††††††††††††††††††† (4)†††† with prior approval from the TBI program manager or designee, exceptions to service coordinators qualifications can be made; providers requesting qualification exceptions must demonstrate relevant education internships and or volunteer experience of applicants and or staff;

†††††† †††††††††††††(5)†††† all TBI service coordinators whether subcontracting or employed by a TBI program contracting agency must meet these requirements and attend continuing education as determined by ALTSD;

††††††††††††††††††† (6)†††† notify the department if key personnel changes occur (the state reserves the right to review contract status if key personnel change);

††††††††††††††††††† (7)†††† service coordination agency agrees to pay the minimum hourly wage to service coordinators as stated in the request for proposals for TBI providers.

††††††††††††††† E.†††††††††††† Reimbursements For Service Coordination Services:Reimbursements for TBI service coordination services under state general funded contract with the aging and long-term services department is through the unit price system (UPS) of the administrative services division of the aging and long term services department.

††††††††††††††††††† (1)†††† Component unit rate is as stated by ALTSD in the request for proposals for TBI providers.

††††††††††††††††††† (2)†††† TBI service coordination services are calculated on a rate per hour as set by ALTSD and is payable through a monthly reimbursement not to exceed one-twelfth of the contractor's total contract for this service.Allocations for TBI service coordination services are based upon legislative appropriation and annual utilization review.

††††††††††††††††††† (3)†††† TBI service coordinators can bill for activities related to assisting individuals with the application process regardless of final eligibility determination within the initial 90-day period.

††††††††††††††††††† (4)†††† Activities that are not billable under the TBI trust fund include:

††††††††††††††††††††††††††††† (a)†††† services provided to persons once it has been established that the individual does not meet the definition of individuals with traumatic brain injuries (TBI);

††††††††††††††††††††††††††††† (b)†††† services provided to persons who are not residents of the state of New Mexico or who reside in an institution except those who have 30 days to transition into the community;

††††††††††††††††††††††††††††† (c)†††† services provided by other service coordination systems unless approved the TBI program manager or designee;

††††††††††††††††††††††††††††† (d)†††† direct intervention services, such as individual therapy, group therapy, support groups, homemaker personal care services personal attendant services, psychosocial rehabilitation services and or duplicate services that are being covered by TBI crisis interim services;

††††††††††††††††††††††††††††† (e)†††† individual outreach and identification activities in which a provider attempts to contact potential individuals;

††††††††††††††††††††††††††††† (f)†††† services that are not documented by the service coordinator in the individual's record;

††††††††††††††††† ††††††††††††(g)†††† travel to and from the individual's home except when the individual is being transported unless prior approval has been given in writing by the TBI program manager or designee;

††††††††††††††††††††††††††††† (h)†††† attendance at training and other personnel development activities which are not face to face with the individual;

††††††††††††††††††††††††††††† (i)†††† preparation of billing statements progress notes or quarterly reports; and

†††††††††††††††††††††††††††† (j)†††† service coordination contractors cannot charge eligible individuals according to a sliding fee scale for TBI services.

[8.326.10.10 NMAC - N, 11/15/07]

 

8.326.10.11††††††††† LIFE SKILLS COACHING SERVICES PROVIDERS FOR TRAUMATIC BRAIN INJURY TRUST FUND PROGRAM:New Mexico traumatic brain injury program, life skills coaching services are services provided to individuals with traumatic brain injury (TBI) to assist them in performing routine daily living tasks that will enhance their quality of life.Individuals are eligible to receive life skills coaching services that meet specific New Mexico TBI program requirements.

††††††††††††††† A.††††††††††† Life Skills Coaching Services:services are focused on coaching individuals to live independently in their homes and communities.Life skills coaching is not designed to provide substitute task performance.It is customized for each individual and is usually provided in the person's home, place of work or wherever an activity would normally occur.Life skills may also be provided to family members to help them adjust to their changed roles and circumstances following the traumatic brain injury of their family member.Life skills coaching for individuals with traumatic brain injuries are those services that may include but are not limited to:

††††††††††††††††††† (1)†††† assist individuals with housing and household management including:

††††††††††††††††††††††††††††† (a)†††† locating affordable housing,

††††††††††††††††††††††††††††† (b)†††† signing a rent or lease agreement,

†††††††††††††† †††††††††††††††(c)†††† cleaning the house,

††††††††††††††††††††††††††††† (d)†††† shopping for household goods,

††††††††††††††††††††††††††††† (e)†††† cooking meals,

††††††††††††††††††††††††††††† (f)†††† laundry, and

††††††††††††††††††††††††††††† (g)†††† use of everyday tools and appliances;

††††††††††††††††††† (2)†††† assist individuals in applying nutritional principles in developing menus along with comparative shopping and food preparation;

††††††††††††††††††† (3)†††† coach individuals on activities of daily living such as personal care including but not limited to hygiene, grooming and dressing;

††††††††††††††††††† (4)†††† coach individuals on their physical, medical and emotional health maintenance;

††††††††††††††††††† (5)†††† coach medication reminder cues;

††††††††††††††††††† (6)†††† train individuals in the use of assistive devices and other durable medical equipment including communication devices;

††††††††††††††††††† (7)†††† assist individuals with employment and education needs;

††††††††††††††††††† (8)†††† teach individuals on the best ways to utilize and access public transportation;

††††††††††††††††††† (9)†††† help individuals become aware of community resources and how they can gain access to them;

††††††††††††††††††† (10)†††† assist individuals to learn and practice sensible money management;

††††††††††††††††††† (11)†††† coach individuals on ways to most effectively interact and communicate with family members and other caregivers;

††††††††††††††††††† (12)†††† coach individuals in the development and use of anger management skills;

††††††††††††††††††† (13)†††† coach individuals in memory skills;

††††††††††††††††††† (14)†††† provide coaching to improve time management skills;

††††††††††††††††††† (15)†††† help individuals recognize and avoid common dangers to self and possessions, which may include basic safety skills including interaction with strangers, first aid, fire safety, crossing streets and common public courtesy;

††††††††††††††††††† (16)†††† assist individuals with other social, recreational and cognitive skills as specified in their ILP;

††††††††††††††††††† (17)†††† coach individuals on their communication skills;

††††††††††††††††††† (18)†††† coach individuals on childcare and parenting skills;

††††††††††††††††††† (19)†††† assist with other social, medical or educational skill needs as recognized by the individual, individual's service team and or the family.

††††††††††††††† B.††††††††††† Administrative Requirements of Life Skills Coaching Services Contractors:Life skills coaching is intended to provide coaching of the skills that an individual needs to function in their home environment, their job and or their community.

††††††††††††††††††† (1)†††† Service coverage area for TBI life skills coaching services should be throughout at least one entire TBI program region as specified in the contract provider agreement with ALTSD.

††††††††††††††††††† (2)†††† Based on an initial assessment and 90-day reassessment of need, individuals may receive TBI life skills coaching for up to four hours per day, five days per week for up to one year.When it becomes evident that no progress is being made by the individual the lack of progress must be documented in the individual's record.A team staffing must be called to determine if the life skills coaching the individual is receiving is still appropriate and if it should or should not be changed or continue.The team should be comprised of the individual, the life skills coach(s), the service coordinator(s) family members and other appropriate professionals including applicable crisis interim services staff.

††††††††††††††††††† (3)†††† Life skills coaching services shall follow a behavioral model for individuals in the program and be conducive to desirable behavior for everyday life and to assist the individual in learning coping skills to help improve interrelationships.

††††††††††††††††††† (4)†††† Life skills coaching services shall be provided in a one to one basis or in a small group setting of no more than four individuals and shall be based on the needs of the individual.Coaching shall take place in the individual's residence or wherever the activity would take place naturally.

††††††††††††††††††† (5)†††† Facilitate independent living skills by providing life skills coaching services to individuals with TBI to increase their ability to live independently.

††††††††††††††††††† (6)†††† An independent living skills assessment must be completed for each individual who is determined to be eligible for life skills coaching service.This assessment must:

†††† †††††††††††††††††††††††††(a)†††† be completed prior to beginning life skills coaching services;

††††††††††††††††††††††††††††† (b)†††† consist of an evaluation of daily living skills through observation, testing, questioning and consultationwithin the individual's everyday environment; home, work, school and general community setting;

††††††††††††††††††††††††††††† (c)†††† determine the individual's capabilities, long and short term goals, and needs in employment, education, transportation, housing, home management, finances, money management, self-advocacy, socialization, recreation, community living, self-care, attendant care needs, communication, and ability to access community resources;

††††††††††††††††††††††††††††† (d)†††† include medical documentation of a traumatic brain injury by a duly licensed physician or psychologist, including an assigned ICD 9 code;

††††††††††††††††††††††††††††† (e)†††† include a written ILP for life skills coaching services that covers: goals and objectives, training necessary to reach those goals and objectives, number of hours per month the individual will receive life skills coaching , expected measurable outcomes, time frames for reaching goals and meeting objectives, plans for discharge and or transition out of life skills coaching services, identification of the service coordinator(s) other persons, services, programs and or products necessary to help the individual reach targeted goals and accomplish those objectives, and identification and estimated costs of crisis interim goods and or services;

††††††††††††††††††††††††††††† (f)†††† be reviewed and updated quarterly; and

††††††††††††††††††††††††††††† (g)†††† begin life skills coaching only after the individual's service coordinator has included life skills services in the individual's ILP and a life skills coaching plan has been submitted to the service coordinator.

††††††††††††††††††† (7)†††† Maintain case records oneach individual served including but not limited to: the two page application, initial life skills assessment, eligibility documentation (ICD 9 code),ILP which includes goals, measurable objectives, contact, progress, revisions of ILP that reflect changes in goals and objectives, referrals and outcomes of services.

††††††††††††††††††† (8)†††† Have and follow confidentiality standards.

††††††††††††††††††† (9)†††† Maintain a current business license issued by the state, county or city government if required.

††††††††††††††††††† (10)†††† Life skills coaching contractors must comply with all applicable federal and state regulations, policies and procedures that apply to their business.

††††††††††††††††††† (11)†††† Demonstrate financial solvency.

††††††††††††††††††† (12)†††† Establish and maintain separate financial reporting and accounting activities that are in accordance with state requirements.

††††††††††††††††††† (13)†††† Maintain an automated data system for financial and program reporting purposes (note: direct linkage/modem to the aging and long term services department may be required).

†††††††††††††††††† (14)†††† Be knowledgeable of TBI resources within their community, their region, New Mexico and nationally and maintain an in house directory of TBI useful resources on site.

††††††††††††††††††† (15)†††† Have an established method of information and data collection.

††††††††††††††††††† (16)†††† Have a readily accessible office in each geographic region serviced by the contract provider.

††††††††††††††††††† (17)†††† Comply with all federal and state regulations, policies, and procedures, including but not limited to policies and procedures related to:

††††††††††††††††††††††††††††† (a)†††† service provision and appropriate supervision;

††††††††††††††††††††††††††††† (b)†††† professional documentation standards;

††††††††††††††††††††††††††††† (c)†††† training andeducation; and

††††††††††††††††††††††††††††† (d)†††† reimbursement of life skills coaching services.

††††††††††††††††††† (18)†††† Purchase and maintain full professional liability insurance coverage.

††††††††††††††††††† (19)†††† Establish and maintain appropriate written grievance procedures.

††††††††††††††††††† (20)†††† Reports shall be submitted in the time frame and format prescribed by TBI program.Reports will be submitted in the manner designated by the TBI program including a summary of the total hours of life skills coaching services provided to each individual.

††††††††††††††††††† (21)†††† Organizations must avoid conflict of interest or duplication of services and may not provide other state general funded services to individuals with traumatic brain injuries when they are also individuals for whom they provide TBI life skills coaching services.

††††††††††††††††††† (22)†††† Comply with the following quality assurance system requirements:

††††††††††††††††††††††††††††† (a)†††† assure that the TBI individual achieves an optimal level of wellness and function by implementing timely and appropriate services and natural supports individualized to meet their needs;

††††††††††††††††††††††††††††† (b)†††† assure timely assessment and implementation of necessary services, supports and goods;

††††††††††††††††††††††††††††† (c)†††† insure that each individual's ILP addresses targeted realistic goals and objectives with measurable outcomes within a cost-effective and specific time frame;

†††††††††††† †††††††††††††††††(d)†††† develop an ongoing monitoring process which provides for the evaluation of quality effectiveness and appropriateness of services and supports provided to the individual;

††††††††††††††††††††††††††††† (e)†††† utilize a monitoring system to track accurate data reported on individual issues and concerns regarding the individual from both internal and external resources;

††††††††††††††††††††††††††††† (f)†††† identify and resolve known or suspected issues that may have an impact on the individual, perform annual individual satisfaction surveys that identify areas of need such as delays in implementation of services or supports, over and under utilizationof services or supports and access to providers of services;

†††††††††††††††††††††† †††††††(g)†††† employ a formal method of monitoring regulating and documenting the quality of services or supports provided to determine if the goals and objectives of the ILP are being achieved and remain appropriate and realistic;

†††††††††††††††††††††† †††††††(h)†††† arrange and participate in a quarterly individual progress review with other service contract and or subcontract providers to verify that the individual's goals and objectives remain appropriate and realistic;

††††††††††††††††††††††††††††† (i)†††† monitor and assure that services and supports are readily accessible to the individual;

††††††††††††††††††††††††††††† (j)†††† evaluate and monitor the appropriateness and timeliness of services delivered to the individual;

††††††††††††††††††††††††† ††††(k)†††† maintain regular communication with all contract and subcontract providers delivering services and products to the individual;

††††††††††††††††††††††††††††† (l)†††† demonstrate that the quality of services has been evaluated and that all concerns and issues†† are identified including implementation of necessary corrective action plans; and

††††††††††††††††††††††††††††† (m)†††† maintain original individual records for each program individual in the local service coordination contractor agency.

††††††††††††††† C.††††††††††† Staffing Requirement Qualifications:TBI life skills coaches must demonstrate their qualifications in one of the following ways listed below.

††††††††††††††††††† (1)†††† Have a current registered nurse license in good standing from the New Mexico board of nursing.

††††††††††††††††††† (2)†††† Have a bachelor's degree in social work, counseling, nursing, special education or closely related field plus one year clinical experience related to the TBI population working in any of the following settings:

†††† †††††††††††††††††††††††††(a)†††† home health or community health program;

††††††††††††††††††††††††††††† (b)†††† hospital;

††††††††††††††††††††††††††††† (c)†††† private practice;

††††††††††††††††††††††††††††† (d)†††† publicly funded institution or long term care program;

††††††††††††††††††††††††††††† (e)†††† mental health program;

††††††††††††††††††††††††††††† (f)†††† community based social service program; and

††††††††††††††††††††††††††††† (g)†††† other programs addressing the needs of individuals with traumatic braininjuries.

††††††††††††††††††† (3)†††† With prior approval from the TBI program manager or designee exceptions to life skills coaching qualifications can be made.Providers requesting qualification exceptions must demonstrate relevant education internships and or volunteer experience.Other qualifications may be:

††††††††††††††††††††††††††††† (a)†††† associate's degree and a minimum of three years experience in the mental health or traumatic brain injury field; and

††††††††††††††††††††††††††††† (b)†††† high school graduation or general educational development (GED) test and a minimum of five years experience in the mental health or traumatic brain injury field.

††††††††††††††††††† (4)†††† All TBI life skills coaches whether subcontracting or employed by contractor must meet requirements and attend continuing education as determined by ALTSD.

††††††††††††††††††† (5)†††† Prior written approval from the TBI program is required for any intern providing life skills coaching in the TBI program.

††††††††††††††††††† (6)†††† Notify the department if key personnel changes occur.The state reserves the right to review contract status if key personnel change.

†††††††††††††††††††† (7)††† Life skills coaching agency agrees to pay the minimum hourly wage to life skills coaches as stated in the request for proposals for TBI providers.

††††††††††††††† D.††††††††††† Reimbursement for Life Skills Coaching Services:Reimbursements for TBI life skills coaching services under state general funded contract with the aging and long term services department is through the unit price system (UPS) of the administrative services division of the aging and long term services department.

††††††††††††††††††† (1)†††† Component unit service rate is as stated by ALTSD in the request for proposals for TBI providers at 20 hours per week per individual maximum.

††††††††††††††††††† (2)†††† TBI life skills coaching services is calculated on a rate per hour as set by ALTSD and is payable through a monthly reimbursement not to exceed one-twelfth of the contractor's total contract for this service.Allocations for TBI life skills coaching services are based upon legislative appropriation and annual utilization review.

††††††††††††††††††† (3)†††† Activities that are not billable include:

††††††††††††††††††††††††††††† (a)†††† services provided to persons who do not meet the definition of individuals with traumatic brain injuries (TBI);

††††††††††††††††††††††††††††† (b)†††† services provided to persons who are not residents of the state of New Mexico or who reside in an institution or who are served through a separate system such as one provided through the medicaid waiver programs;

††††††††††††††††††††††††††††† (c)†††† direct intervention services such as individual therapy, support groups, homemaker personal care services, personal attendant services, psychosocial rehabilitation services and or services that are being paid by TBI crisis interim services;

††††††††††††††††††††††††††††† (d)†††† individual outreach and identification activities in which a provider attempts to contact potential individuals;

††††††††††††††††††††††††††††† (e)†††† services that are not documented by the TBI life skills coach in the individual's file;

††††††††††††††††††††††††††††† (f)†††† travel to and from the individual's home, except when the individual is provided transportationfor service and support coaching which has been included in the ILP, unless prior approval has been given in writing by the TBI program;

††††††††††††††††††††††††††††† (g)†††† attendance at training and other personnel development activities which are not face to face with the individual;

††††††††††††††††††††††††††††† (h)†††† preparation of billing statements progress notes or quarterly reports; and

††††††††††††††††††††††††††††† (i)††† life skills coaching contractors cannot charge eligible individuals according to a sliding fee scale for TBI services.

[8.326.10.11 NMAC - N, 11/15/07]

 

8.326.10.12††††††††† CRISIS INTERIM SERVICES TO INDIVIDUALS WITH TRAUMATIC BRAIN INJURY TRUST FUND PROGRAM: Crisis interim services to individuals with traumatic brain injury (TBI) are provided through a contracted fiscal intermediary agency that processes reimbursement and funding for services and goods for eligible recipients of the ALTSD trust fund.Individuals are eligible to receive crisis interim services that meet specific New Mexico TBI program requirements.

††††††††††††††† A.††††††††††† Crisis Interim Services Eligibility Requirements:Services are focused on funding services, supports and goods for individuals who have a current service coordinator through the TBI program.External case managers must access crisis interim through the TBI service coordinator.TBI service coordinators are responsible for determining initial eligibility and arranging for crisis interim service or products with the fiscal intermediary agent.The fiscal agent must comply with the following:

††††††††††††††††††† (1)†††† obtain copies of the individual's two page application, qualifying ICD 9 code and referral form from the service coordinator;

††††††† ††††††††††††(2)†††† have a written comprehensive ILP that includes all services, products, estimated costs, duration and or limits, before the contract fiscal agent may fund the services or product;

††††††††††††††††††† (3)†††† ensure through a copy of the service coordination ILP that the applicant receiving funding has exhausted any other financial resources and that services are provided only until other resources can be made available; and

††††††††††††††††††† (4)†††† applicants may be eligible to receive funding when there is an accelerated need for services on a short-term basis to protect the individual if the person has an exacerbated condition that has caused a critical need or if needs have suddenly and drastically changed.

††††††††††††††† B.††††††††††† Funding Limits Per Individual:There is a maximum yearly and lifetime coverage for each individual with a TBI and it is determined by the individual's need based on service coordinator assessment(s) and availability of funding.The qualifications for funding are that:

††††††††††††††††††† (1)†††† all TBI individuals may or may not qualify for or receive the yearly or lifetime maximum;

††††††††††††††††††† (2)†††† there is a one-time only initial housing assistance in a lifetime;

††††††††††††††††††† (3)†††† a one-time only $10,000 lifetime limit on environmental modifications;

††††††††††††††††††† (4)†††† crisis interim funding is limited up to $25,000 lifetime maximum per year per TBI individual and is dependent on legislative appropriation; and

††††† ††††††††††††††(5)†††† crisis interim funding is limited up to $75,000 lifetime maximum per TBI individual and is dependent on legislative appropriation.

††††††††††††††† C.††††††††††† Provisions for Utilization of Services Provided to Individual:The individual is given freedom of choice to select needed goods or a provider for a given service based on the ILP, then conveys the choice to the service coordinator who then notifies the fiscal intermediary agent through submission of a referral, to contact the provider and set up a letter of agreement and or contract, to provide said services to the individual.The crisis interim services record shall reflect the express service details stated in the individual's ILP and in the service coordinator's referral and shall include:

††††††† ††††††††††††(1)†††† a copy of the doctor's order recommending services due to TBI as applicable;

††††††††††††††††††† (2)†††† the service being provided;

††††††††††††††††††† (3)†††† the 90 days timeline;

††††††††††††††††††† (4)†††† the number of sessions and hours per week or the particular service(s) or item(s) provided;

††††††††††††††††††† (5)†††† the fee charged per hour or for the specified item; and

††††††††††††††††††† (6)†††† in the case of provider services, notify the service coordinator who in turn notifies individual that anagreement has been completed; start date of services begins with the initial appointment for the individual.

††††††††††††††† D.††††††††††† Duration of Services:Crisis interim funding shall be limited to 90 days in duration.Exceptions to this 90-day timeline, may be made by the crisis interim contractor.

††††††††††††††††††† (1)†††† Continuation of crisis interim services funding is contingent upon receipt of a 90-day reassessment conducted in collaboration with, and the authorization in writing by the individual's service coordinator.It is determined within each 90-day time frame if the needs being addressed still exist and cannot be provided by another payor source.Reassessment must be conducted every 90 days and documentation of reassessment and continuing need must be established and recorded in the individual's crisis interim record and service coordination file.

††††††††††††††††††† (2)†††† After services have been inactivated for an individual, the individual may have services reestablished due to an exacerbated condition or extended past the initial 90 days due to continued need of a critical nature.Reassessment and documentation is required as detailed in Paragraph (1), above.

††††††††††††††††††† (3)†††† Justification for continuing crisis interim services funding must be recorded with proper documentation and corroborating written assessment or progress note from a physician or licensed medical provider such as a physical or occupational therapist stating support for ongoing services.

††††† ††††††††††††††(4)†††† Crisis interim services may be extended or continue past the 90-day duration until a necessary product can be obtained or modification to the individual's environment or automobile can be completed.A 90-day reassessment is not usually required during the interval between assessment and delivery, if the situation is that the initial task cannot be completed during the first 90 days.The cause for delay beyond 90 days must be recorded in the crisis interim individual's record and service coordination file and updated every 90 days until completion of the project or modification has been completed or the goods ordered are delivered.

[8.326.10.12 NMAC - N, 11/15/07]

 

8.326.10.13††††††††† TBI CRISIS INTERIM SERVICES GOODS AND SUPPORTS OFFERED TO INDIVIDUALS WITH TRAUMATIC BRAIN INJURY TRUST FUND PROGRAM:Crisis interim services for individuals with TBI include but are not limited to the items listed below.

††††††††††††††† A.††††††††††† Special Equipment:TBI crisis interim services funds may be used to pay for equipment that fills the need of a individual, that is specifically not paid for by medical assistance division (MAD) programs, medicare, the special education-individuals with disability education act (IDEA) program, department of vocational rehabilitation (DVR), HMOs, private insurance, or another payor source.The equipment must be necessary because of the individual's TBI and a prescription or a written assessment provided by a physician or licensed therapist must be submitted to justify the equipment requested.

††††††††††††††† B.††††††††††† Assistive Technology Assessment Services:Funds from TBI crisis interim services may be used to provide assistive technology assessment.

††††††††††††††††††† (1)†††† Assistive technology assessment services are the systematic application of technologies to assist persons diagnosed with TBI to improve communications skills and the ability to perform activities of daily living.

††††††††††††††††††† (2)†††† Services shall be provided by an individual or agency with a minimum of a post-Master's degree in assistive technologies; an individual or agency who is certified by the rehabilitation engineering and assistive technologies society of north America (RESNA); or an individual or agency who demonstrates a working knowledge of assistive technologies, a physician or rehabilitation provider agency.Services shall include assessment, recommendations and training by a healthcare professional.

††††††††††††††† C.††††††††††† Initial and or Emergency Housing Costs:Funds from TBI crisis interim services may be used to pay initial and or emergency rent, security deposit and utility start-of-service and or one month maintenance of service charges.This is a one-time only lifetime occurrence.Housing plans shall adhere to the following guidelines:

††††††††††††††††††† (1)†††† a copy of a lease or rental agreement letter that contains the name of the leaser, the address of the property and a contact name and phone number for verification of rental intent shall be obtained by the service coordinator and placed in the individual's permanent file;

†††††††††††††††††† (2)†††† a copy of the lease or rental agreement shall be sent with the referral to crisis interim and placed in the individual's record;

††††††††††††††††††† (3)†††† a written plan shall detail the manner in which initial housing and utility costs will be paid and included in the individual's file;

††††††††††††††††††† (4)†††† start up and or emergency utility costs shall be submitted to crisis interim to be paid within 30 days of the signed rental agreement;

††††††††††††††††††† (5)†††† housing plan shall include documentation that the TBI individual has sufficient long-term resources to sustain on-going housing expenses; and

††††††††††††††††††† (6)†††† document evidence that TBI funds are not being used to pay for housing that could have been provided by another more appropriate payor source.

††††††††††††††† D.††††††††††† Environmental Modifications:Funds from the TBI crisis interim services may be used to make an individual's home accessible due to individual's TBI and related physical limitations and must meet the following requirements:

††††††††††††††††††† (1)†††† no home improvements requested by the individual will be covered by crisis interim funds;

††††††††††††††††††† (2)†††† funds can only be used to make the individual's home more accessible because of their TBI condition, this includes but is not limited to, widening doorways, installing ramps and modifying bathrooms;

††††††††††††††††††† (3)†††† an assessment on the proposed environmental modification must be done by a licensed physical or occupational therapist to justify the service;

††††††††††††††††††† (4)†††† for any modification over $250 at least one contractor bid shall be obtained by the service coordinator, which include blueprint and or written description of plan and price itemization for materials and labor, along with any other supporting documentation and submitted by the service coordinator to ALTSD for consideration and a written decision;

††††††††††††††††††† (5)†††† there is a one-time only $10,000 lifetime maximum for all TBI crisis interim funded services that may be used for environmental modifications;

††††††††††††††††††† (6)†††† funds cannot be used to purchase a home;

††††††††††††††††††† (7)†††† only contractors with current license in good standing can be engaged to do environmental modifications;

††††††††††††††††††† (8)†††† individual shall provide proof of property ownership, and, if residing in or renting someone else's property, provide written permission from landlord for any environmental modification funded by the TBI crisis interim services program;

††††††††††††††††††† (9)†††† the crisis interim provider in collaboration with the individual's service coordinator shall show evidence that TBI funding was the most appropriate payor source to fund an environmental modification;

††††† ††††††††††††††(10)†††† collaboration with other funding sources must include:

††††††††††††††††††††††††††††† (a)†††† detailed description/plan of the project including total cost;

††††††††††††††††††††††††††††† (b)†††† documentation of specific portion to be funded by the TBI program as the payor of last resort; and

††††††††††††††††††††††††††††† (c)†††† documentation that contractor acknowledges the specific portion and amount of the project for which the TBI program is responsible; and

††††††††††††††††††† (11)†††† all environmental modifications shall be reviewed and approved by ALTSD in writing.

††††††††††††††† E.†††††††††††† Retrofit Automobile:Funds from TBI crisis interim services shall be used to modify an automobile specifically for the use of the individual with TBI and include the following criteria:

††††††††††††††††††† (1)†††† can be used to install a van lift, hand controls and modified seating;

††††††††††††††††††† (2)†††† cannot be used for the purchase of an automobile nor for auto repairs; and

††††††††††††††††††† (3)†††† the crisis interim provider in collaboration with the individual's service coordinator will show evidence that the TBI program was the most appropriate payor source to fund retrofitting an automobile for an individual with TBI.

††††††††††††††† F.†††††††††††† Transportation:Funds from crisis interim services may be used to provide transportation for individuals with TBI, that is specifically not paid for by medical assistance division (MAD) programs, medicare, the special education-individuals with disability education act program (IDEA), department of vocational rehabilitation (DVR), HMO's, private insurance, or other payor sources.Planned transportation should be included in the ILP. Individuals may use funding for transportation to get to medical and therapy care for treatment of conditions directly related to the TBI, but only if they cannot access other funding sources to get them to appointments.

††††††††††††††† G.††††††††††† Public/Private Transportation:Crisis interim fiscal agents may reimburse for public transportation, taxi services and mileage reimbursement for actual mileage according to an approved rate when a private vehicle is used.Individuals may not be reimbursed for transportation costs submitted more than 90 days past the date the transportation was provided or the trip was taken.

††††††††††††††† H.††††††††††† Respite Care:Funds from crisis interim services may only be used to provide an individual's primary caregiver, as identified in the ILP, with temporary respite.Respite may be provided for a period up to 72 hours per week that may or may not include overnight hours.TBI program funds cannot be used to pay for respite care provided by home health aids or salaried employees.Funds may be used for respite care that is specifically not paid for by medical assistance division programs, medicare, HMOs, private insurance or other payor sources.

††††††††††††††† I.††††††††††††† Home Health Aide, Homemaker or Companion:Funds from TBI crisis interim services may be used to contract for the services of a home health aide, a homemaker or companion from a licensed agency that meet the quality personnel standards as stipulated by the agency and state licensing.The required license of contractors providing these services must be in good standing and current.TBI crisis interim services funds may only be used to pay for home health sides, homemaker or companion services that are not paid for by medical assistance division (MAD) programs, medicare, the special education-individuals with disability education act program (IDEA), department of vocational rehabilitation (DVR), HMOs, private insurance, or other payor source.

††††††††††††††† J.†††††††††††† Nursing Care:Funds from crisis interim services may be used to provide private duty nursing services that are specifically not paid for by medical assistance division (MAD) programs, medicare, HMO's, private insurance or other payor sources.These services may include:

††††††††††††††††††† (1)†††† direct nursing care provided in an individual's home; and

††††††††††††††††††† (2)†††† a registered nurse (RN) or a licensed practical nurse (LPN) that provides services only under the orders of the individual's physician; nursing services provided by crisis interim services must be in compliance with the New Mexico Nurse Practice Act.

††††††††††††††† K.††††††††††† Therapies:All therapists providing services under TBI crisis interim services must hold a current license and be in good standing from their respective licensing authority.Funds from TBI crisis interim services may be used to provide necessary therapies as listed below:

††††††††††††††††††† (1)†††† outpatient mental and or behavioral health;

††††††††††††††††††† (2)†††† physical therapy;

††††††††††††††††††† (3)†††† occupational therapy; and

††††††††††††††††††† (4)†††† speech and language therapy.

††††††††††††††† L.††††††††††† Prescribed Medications:Funds from TBI crisis interim services may be used to provide prescription medications used to treat their TBI symptoms or directly related conditions when they are not available and or covered by any third party payors, medical assistance division (MAD) programs, medicare, the special education-individual with disability education act program (IDEA), department of vocational rehabilitation (DVR), HMO's, private insurance or by another payor sources.Crisis interim services may provide:

††††††††††††††††††† (1)†††† prescription medications listed in the TBI program formulary (exceptions to the TBI program formulary must be approved in writing from the TBI Program Manager or designee);

††††††††††††††††††† (2)†††† individuals may not be reimbursed for prescription medications in cases where the receipt evidencing purchase is submitted more than 90 days past the date the prescription was filled;

††††††††††††††††††† (3)†††† for reimbursement, the individual must submit the pharmacy print out, which has on it:individualís name, the date, doctor's name, name of the medication and the price paid; and

††††††††††††††††††† (4)†††† if feasible, and the fiscal agent is able to set up an agreement with certain pharmacies, individuals may have scripts filled with the billing sent directly to crisis interim services for payment; service coordinator is responsible for checking receipts submitted by individuals to avoid duplicate payments on those submitted through the pharmacy.

††††††††††††††† M.†††††††††† Health Insurance Deductibles or Co pays:Funds from TBI crisis interim services may be used to pay health insurance deductibles or co pays from long-term services and private insurance to hospital or physician(s) for services and treatment for TBI or conditions directly related to TBI.Payment of insurance premiums are not covered by the TBI program.

††††††††††††††† N.††††††††††† Other Use of Crisis Interim Funds:TBI crisis interim services funds may be used to provide other limited services.Those services provided by a licensed practioner may require a script or a letter of recommendation from a physician or therapist.

††††††††††††††††††† (1)†††† Special training and education to individual and family in the use of tools and methods needed to promote recovery and independence of the individual.

††††††††††††††††††† (2)†††† Assistive devices evaluations to show justification for said devices for treatment of TBI.

††††††††††††††††††† (3)†††† Neuropsychological evaluations if there is no other payor source.Individual must present physician's order or script for approval of evaluation in order for crisis interim services fund to cover the cost.

††††††††††††††††††† (4)†††† Training in the use of new equipment or existing equipment that has been modified for the individual's use.

††††††††††††††††††† (5)†††† Special health and dietary items as needed because of the TBI or conditions directly related to the TBI.

††††††††††††††††††† (6)†††† Limited alternative therapies such as massage, acupuncture, and chiropractic can be provided if a contractor designated to provide the therapy is able to document the proven effectiveness of the therapy.Practitioners must possess a current license and be in good standing with respective field.

††††††††††††††††††† (7)†††† Experimental therapies are not usually covered.All questionable experimental therapies require prior written approval by the TBI program manager or designee.

††††††††††††††† O.††††††††††† Aging and Long-Term Services Department (ALTSD), reserves the right to approve or disapprove any and all contractors used by the fiscal intermediary agent.

††††††††††††††† P.††††††††††† All Billings and Receipts Submitted to Crisis Interim Services, for all goods, services and supports, shall be submitted for payment or reimbursement within 90 days of the service date, by the individual, service coordinator and or vendor.

††††††††††††††† Q.††††††††††† Waiver of Requirements:Only ALTSD and or TBI trust fund program manager or designee can make exceptions to the provisions of the crisis interim services standards with the following stipulations:

††††††††††††††††††† (1)†††† requests for waivers to the provisions and services provided by the TBI program must be made in writing;

††††††††††††††††††† (2)†††† requests must have accompanying documentation justifying the exception; and

††††††††††††††††††† (3)†††† approval must be made in writing and must be placed in the individual's crisis interim record and service coordination permanent file.

[8.326.10.13 NMAC - N, 11/15/07]

 

8.326.10.14††††††††† CRISIS INTERIM SERVICES FISCAL INTERMEDIARY AGENT FOR TRAUMATIC BRAIN INJURY TRUST FUND PROGRAM:TBI crisis interim services fiscal agent contractor manages and tracks the expenditures on individuals of the TBI trust fund program, procures goods and arranges contracts and letters of agreement with vendors and contractors who provide the goods, services and supports.

††††††††††††††† A.††††††††††† Administrative Requirements for the Crisis Interim Services Fiscal Agent:

††††††††††††††††††† (1)†††† Non-TBI program case management may request goods and services for an eligible individual through the TBI service coordinator.Other case managers might include such systems as medicaid salud, medicaid waiver programs, HMO's and other insurances.†† The crisis interim services fiscal agent is responsible for maintaining documentation of eligibility and other required documents as described in Paragraphs (1), (2), (3) and (4) of Subsection A of 8.326.10.12 NMAC, per individual.TBI service coordination contract providers determine initial eligibility for all crisis interim services and are responsible for monitoring all individuals receiving any TBI services.

††††††††††††††††††† (2)†††† Service coverage area should be throughout at least one entire TBI program region as specified in the contract/provider agreement with ALTSD.

††††††††††††††††††† (3)†††† Facilitate independent living by assistance and services to the individual with TBI that will promote the ability for independent living.

††††††††††††††††††† (4)†††† At least one representative of the TBI fiscal agency shall attend all quarterly trainings held by the TBI program for providers.

††††††††††††† ††††††(5)†††† Have and follow confidentiality standards.

††††††††††††††††††† (6)†††† Crisis interim providers must document evidence, in an individual's record that reasonable attempts have been made to verify that other payor source coverage is not available to pay for services or goods.

††††††††††††††††††† (7)†††† Denial of payment of benefits from an individual's other payor source should be documented in the record before crisis interim provides the service or goods.Documentation should be obtained from the service coordinator and must include a copy of a written denial or a dated detailed accounting of a verbal denial and placed in the individual's record.Minimal documentation of the denial must consist of the date, payor source, naming of the person spoken to and reason for denial.

††††††††††††††††††† (8)†††† Maintain an extensive directory of TBI resources within their community, their region, New Mexico and nationally, on site.

††††††††††††††††††† (9)†††† Have an established method of information and data collection.

††††††††††††††††††† (10)†††† Have a readily accessible office in each TBI program geographic region served or means to communicate with other TBI program contractors or subcontractors effectively by phone.

††††††††††††††††††† (11)†††† Each individual receiving crisis interim services shall be informed of all available service providers, vendors or contractors that are eligible to provide the TBI services or goods in their region.The individual shall be the sole decision maker of who is to provide service or goods from all eligible entities that could fill his or her needs.In no instance shall a fiscal agent dictate the provider, vendor or contractor that shall provide the service, or goods.Self-referral by a crisis interim fiscal agent, or an affiliate of the crisis interim agent, shall not be allowed.

††††††††††††††††††† (12)†††† Establish and maintain appropriate written grievance procedures for individuals and other TBI services providers.

††††††††††††††††††† (13)†††† Reports shall be submitted in the time frame and format prescribed by TBI program.Reports will be submitted in the manner designated by the TBI program including a summary of the total hours billed for service rendered, expenditures per individual and all other data requested by ALTSD.

††††††††††††††††††† (14)†††† Crisis interim services providers shall avoid conflict of interest and or duplication of services and shall not provide TBI program service coordination or life skills coaching in the same region(s) in which they are a TBI program fiscal agent.

††††††††††††††††††† (15)†††† Quality assurance system requirements:Crisis interim contractors must comply with the stipulations listed below:

††††††††††††††††††††††††††††† (a)†††† assure that the TBI individual achieves an optimal level of wellness and functioning by implementing timely and appropriate services and natural supports that are individualized to meet their needs;

††††††††††††††††††††††††††††† (b)†††† assure timely assessment and implantation of necessary services and supports;

††††††††††††††††††††††††††††† (c)†††† ensure that each individual's ILP addresses targeted, realistic goals and objectives with measurable outcomes within a cost-effective and specific time frame, as it applies to crisis interim services;

††††††††††††††††††††††††††††† (d)†††† develop an ongoing monitoring process which provides for the evaluation of quality effectiveness, and appropriateness of services and supports provided to the individual;

††††††††††††††††††††††††††††† (e)†††† develop a monitoring system to track accurate data reported on individual issues and concerns regarding the individual from both internal and external resources;

††††††††††††††††††††††††††††† (f)†††† identify and resolve known or suspected issues that may have an impact on the individual;

††††††††††††††††††††††††††††† (g)†††† perform annual individual satisfaction surveys thatidentify areas of need such as delays in implementation of services or supports over and under utilization of services or supports and access to providers or service;

††††††††††††††††††††††††††††† (h)†††† employ a formal method of checking, regulating and documenting the quality of services or supports provided to determine if the goals and objectives of the ILP are being achieved and remain appropriate and realistic, as the ILP applies to crisis interim services;

††††††††††††††††††††††††††††† (i)†††† participate in quarterly individual progress reviews called by the service coordinator and which include the individual and life skills coach(s) if possible, to verify that the individual's goals and objectives remain appropriate and realistic;

††††††††††††††††††††††††††††† (j)†††† monitor and assure that services and supports are readily accessible to the individual;

††††††††††††††††††††† ††††††††(k)†††† evaluate and monitor the appropriateness and timeliness of crisis interim services to the individual that may affect crisis interim services;

††††††††††††††††††††††††††††† (l)†††† maintain regular communication with all providers delivering other TBI services to the individual that may affect crisis interim services; and

††††††††††††††††††††††††††††† (m)†††† demonstrate that the quality of services has been evaluated and that all concerns and issues are identified, including implementation of corrective action plans.

††††††††††††††† B.††††††††††† Staffing Requirement Qualifications:TBI crisis interim service staff must demonstrate their qualifications to serve TBI individuals by compliance with certain stipulations.

††††††††††† ††††††††(1)†††† Have a current registered nurse license in good standing, from the New Mexico board of nursing.

††††††††††††††††††† (2)†††† Have a bachelorís degree in social work, counseling, nursing, special education or closely related field.

††††††††† ††††††††††(3)†††† Have clinical experience related to the TBI population, working in any of the following settings:

††††††††††††††††††††††††††††† (a)†††† home health or community health program;

††††††††††††††††††††††††††††† (b)†††† hospital;

†††††††††††† †††††††††††††††††(c)†††† private practice;

††††††††††††††††††††††††††††† (d)†††† publicly funded institution or long term care program;

††††††††††††††††††††††††††††† (e)†††† mental health program; and

††††††††††††††††††††††††††††† (f)†††† community based social service program; and other program addressing the needs of individuals with traumatic brain injuries (TBI).

††††††††††††††††††† (4)†††† Demonstrate relevant education, internships, and or extensive medical volunteer experience.

††††††††††††††††††† (5)†††† With prior approval from the TBI program manager or designee exceptions to crisis interim personnel qualifications can be made.Providers requesting qualification exceptions must demonstrate relevant education internships and or volunteer experience.Other qualifications may be:

††††††††††††††††††††††††††††† (a)†††† associate's degree and experience in the mental health or traumatic brain injury field; and

††††††††††††††††††††††††††††† (b)†††† high school graduation or general educational development (GED) test and extensive experience in the mental health or traumatic brain injury field.

††††††††††††††††††† (6)†††† All TBI crisis interim services contractors, whether contracting with the fiscal agent or employed by the agent, must meet these requirements and attend continuing education as determined by ALTSD.Contractor crisis interim services providers must have the required education, and be duly licensed by the state of New Mexico within their respective disciplines.Crisis interim service fiscal agents are responsible for verifying the status of contractor licenses.

††††††††††††††††††† (7)†††† Notify the department if key personnel changes occur.The state reserves the right to review contract status if key personnel change.

††††††††††††††† C.††††††††††† Reimbursement for Crisis Interim Services:Reimbursement for TBI crisis interim services under state general funded contract with aging and long-term services department (ALTSD) is through the unit price system (UPS) of the administrative services division of ALTSD.

†† †††††††††††††††††(1)†††† Component unit service rate per unit is stated by ALTSD in the request for proposals for TBI providers.No more than 25,000 units may be spent on a single eligible individual with TBI during a contract year.Under the direction of the crisis interim services contractor, and as described on the eligible individual's ILP, a licensed or certified (whenever applicable) direct service provider, or vendor of goods, will provide goods and services to the individual with TBI.The crisis interim contractor is responsible for reimbursement made to the direct service provider or vendor in accordance with the ILP and or crisis plan.When feasible, all goods and services provided under TBI crisis interim services contracts are to be consistent with the human services department (HSD) medicaid waiver, or medicaid rates.

††††††††††††††††††† (2)†††† Reimbursement by the ALTSD to the contractor for TBI crisis interim services is payable through a monthly reimbursement not to exceed one-twelfth of the contractor's total contract for this service.Allocations for TBI crisis interim services are based upon legislative appropriation and annual utilization review.

††††††††††††††††††† (3)†††† Activities not billable include:

††††††††††††††††††††††††††† ††(a)†††† services provided to persons who do not meet the definition of individuals with traumatic brain injuries (TBI) as defined in section 8.326.10.7 in these regulations;

††††††††††††††††††††††††††††† (b)†††† individuals that do not have an ICD 9 code on file;

††††††††††††††††††††††††††††† (c)†††† services provided to persons who are not legal residents of the state of New Mexico, who reside in an institution or who are served through a separate system, such as one provided through the medicaid waiver programs;

††††††††††††††††††††††††††††† (d)†††† duplication of services that are being funded by any other payor source;

††††††††††††††††††††††††††††† (e)†††† individual outreach and identification activities in which a fiscal agent attempts to market their services to potential individuals;

††††††††††††††††††††††††††††† (f)†††† services that are not documented by the TBI crisis interim services staff person in the individual's file;

††††††††††††††††††††††††††††† (g)†††† travel to and from the individual's home, except when the individual is being transported, unless approved in writing by the ALTSD TBI program;

††††††††††††††††††††††††††††† (h)†††† attendance at training and other personnel development activities which are not face to face with the individual;

††††††††††††††††††††††††††††† (i)†††† preparation of billing statements, progress notes or quarterly reports; and

††††††††††††††††††††††††††††† (j)†††† crisis interim services contractors cannot charge eligible individuals according to a sliding fee scale for TBI services and bill them to the ALTSD.

[8.326.10.14 NMAC - N, 11/15/07]

 

8.326.10.15††††††††† GRIEVANCE AND APPEALS PROCESSES FOR TRAUMATIC BRAIN INJURY TRUST FUND PROGRAM:The provider will have written individual grievance procedures, which provide the individual and or their representative with a process for expressing dissatisfaction with the program services.The procedures will explain and permit an orderly resolution of informal and formal grievances.These procedures should be presented in a culturally competent format, at a language level understandable by the individual and or their representative.

††††††††††††††† A.††††††††††† Grievances:

††††††††††††††††††† (1)†††† Ensure that a written grievance procedure is provided to the individual at the time of intake and available upon request thereafter.

††††††††††††††††††† (2)†††† Ensure that the grievance procedures clearly explain to individuals which staff members are assigned to receive informal and formal complaints, the expected procedure and the time frames for doing so.

††††††††††††††††††† (3)†††† Ensure that a staff member is designated as having primary responsibility for the maintenance of the grievance procedures, review of their operation, and revision of related policies and procedures whenever necessary.

††††††††††††††††††† (4)†††† Ensure that procedures are in place for tracking, investigating, recording, resolving and appealing decisions concerning grievances made by the individual, their representative or others.

††††††††††††††††††† (5)†††† Ensure that all provider grievance procedures and any subsequent changes are approved by ALTSD and included in the intake documentation.

††††††††††††††††††† (6)†††† Ensure there is no discrimination against an individual solely on the grounds that the individual or their representative filed a grievance.

††††††††††††††† B.††††††††††† Appeals:

††††††††††††††††††† (1)†††† If the individual and or their representative do not agree with the outcome of an informal or formal grievance filed and reviewed at the provider agency, they may appeal, in writing, to the TBI program manager.

††††††††††††††††††† (2)†††† The TBI program manager will review the written appeal along with any supporting documentation as applicable and will respond in writing to the individual filing the appeal within 30 days with notification of the outcome to the provider agency.

[8.326.10.15 NMAC - N, 11/15/07]

 

HISTORY OF 8.326.10 NMAC:[RESERVED]