Date: September 30, 2013

In accordance with ADvantage policies, all ADvantage contracted service providers have agreed to serve all assigned ADvantage Members, to accept all Members requesting transfer/assignment, to provide services and to follow defined guidelines when situations occur which interrupt services and/or lead to the inability to assure the Member's health and safety. 

The following provisions further explain options available to ADvantage service providers when facing barriers to the provision of services:

1. The IDT Meeting is designed as the initial step to address any unresolved concerns regarding the health and safety of Members, unacceptable risks to caregivers, and any barriers to the provision of authorized services. 
   
   
2. In the instance that an ADvantage Member or ADvantage service is determined to have a barrier that affects the Members’ continued receipt of a specific service, responsible action(s) must be taken to address the barrier to care.
   Simply withholding the authorized service or removing this service from the Member's Service Plan is not acceptable. Failure to address the barrier to care places the Member at greater risk and could be considered abandonment.
   
   
   • Examples of barriers to care that would result in the actions discussed include, but are not limited to, the following:
     
     
     1. Threatening behaviors or communications from the Member and/or others in the home, directed at Service Providers
        
        
     2. Exposure to potentially contagious conditions 
        
        
     3. Environments with insect infestations 
        
        
     4. Potentially hazardous or high risk situations occurring during delivery of services
        
        
3. In addition to the IDT meeting, the following tools have been created for the purpose of assisting ADvantage Case Managers to document and discuss barriers and unacceptable risks to the Member and Service Providers and any barriers to the provision of authorized services:
   
   
   • Critical Incident Report – Required by Service Providers to document occurrences of situations of acute risks to Member health and safety.
     
     
   • Provider Communication – Document barriers to care and risks to Members and Service Providers and to communicate between Service Providers and the AA. 
     
     
   • Provider Questions – Access to the AA for guidance and assistance as needed to address high risk situations.
     
     
   • Service Plan Goals – Specific steps or actions regarding the provision of services can be documented to clarify appropriate delivery of services, highlight requirements or limitations of services based on policy or contractual guidelines, and clearly justify how service will be provided or what back-up will be provided to meet Member’s needs.
     
     
   • Negotiated Risk Agreement – Allows Members to decline services, take specific actions, or follow recommendations that are determined necessary to assure the Member’s health and safety in their home.
     
     
   • Service Provider Safety Agreement (previously Behavioral Agreement) – Allows CM and Home Care RN to document barriers to care and needed actions to prevent disruption of needed services. This is intended to be a discussion with the Members to identify solutions to barriers of care.
     
     
   • To obtain copies of the Critical Incident Report, Negotiated Risk Agreement, or Service Provider Safety Agreement, please contact Provider Questions.
     
     
4. ADvantage Case Managers are assigned the responsibility for monitoring their Members for program appropriateness, in accordance with the eligibility criteria set forth in OAC 317: 35-17-3. These eligibility criteria include, but are not limited to the following (summarized):
   
   
   • Needs must be able to be met through ADvantage Program and other available compatible services
     
     
   • Home must be safe for the Member and Service Providers during the provision of services
     
     
   • Member has safe behavior and communications with Service Providers
     
     
   • Member is cooperative with the provision of services
     
     
   • Member provides accurate information regarding eligibility
     
     
   • Member requires at least one ADvantage service monthly
     
     
5. No services should be removed or withheld from any Member without professional documentation supporting the removal of those services and a corresponding request and approval by DHS of a grievance to dis-enroll the Member. 
   

If you have any questions regarding the information provided above, please feel free to contact us via your Smarter Mail account.