125 comments
Hello,
I have reviewed the TCM BI Draft and have the below feedback-
The Virginia Department of Education updated its definition of brain injury which should be updated in this document as well.
The CDC https://www.cdc.gov/traumaticbraininjury/get_the_facts.html describes an injury received during childhood is different and affects brain development.
Page 10: Exclusions: Brain damage secondary to other neurological insults (eg. infection of the brain, stroke, anoxia, brain tumor, Alzheimer's, and other conditions causing dementia and other diseases causing neurodegenerative diseases) is not considered a TBI. These are not TBI but they ARE brain injuries and should be considered.
“Critical Incident” means any incident that threatens or impacts the well-being of the member. Critical incidents shall include, but are not limited to, the following incidents: medication errors, theft, suspected physical or mental abuse or neglect, financial exploitation, and sentinel events.
Expand this by adding “development of a pressure ulcer, hospitalization”
“Facility” means, for the purpose of coordinating services between the community and facility, an acute care hospital, freestanding psychiatric hospital, long term care hospital, psychiatric or addictions focused residential treatment facility or nursing facility.
Expand this by adding licensed assisted living facility.
“Home” means a place of temporary or permanent residence, not including a hospital, ICF/ID, nursing facility, or licensed residential care facility.
Expand this by adding licensed assisted living facility.
Question how will some of the Case Management KSA be validated and measured.
Examples are
• Advocating for continuity of services, system flexibility and community integration, proper utilization of facilities and resources, accessibility, and participant rights; and
• Demonstrating a positive regard for individuals and their families (e.g., treating people as individuals, allowing risk taking, avoiding stereotypes of people with a brain injury, respecting individual and family privacy, and believing individuals can grow and contribute to their communities).
• Being persistent and remaining objective.
• Working as a team member, maintaining effective inter- interagency and intra[1]agency working relationships.
• Establishing and maintaining ongoing supportive relationships with individuals and their families; and,
Please clarify what is considered "conflict of interest" (COI) in providing services. In the draft it states the following:
"Pursuant to 42 CFR 441.301(c)(1)(vi), providers of HCBS for the individual, or those who have an interest in or are employed by a provider of HCBS for the individual, must not provide case management or develop the person-centered plan of care, except when the State demonstrates that the only willing and qualified entity to provide case management and/or develop person-centered plan of cares in a geographic area also provides HCBS. In order to meet this requirement an individual that provides case management services must not be employed (directly, or as a contractor) by an entity that provides other HCBS services. Furthermore, an individual or entity that provides case management/support coordination services must not have an interest (as defined in 42 CFR 411.354) in a provider of other HCBS services."
Throughout the development of these services the stance has been that an agency can't provide TCM services and waiver services. In our most recent meeting with DMAS what was communicated was that an agency could provide both TCM and waiver services however they couldn't be the provider of both to the same individual.
These are two very different stances which affect services among existing providers. Clarification is needed.
1. “Brain Injury” means a brain injury for purposes of this program is defined as brain damage due to a blunt blow to the head; a penetrating head injury; crush injury resulting in compression to the brain; severe whiplash causing internal damage to the brain; or head injury secondary to an explosion." This is not a definition of TBI that’s used anywhere to my knowledge, and I do not understand why crush injury resulting in compression of the head is specially singled out for mention. Please consider using one of the standard, currently existing definitions, like that of the CDC: TBI is defined as a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury.
2. “Case management” means a service that includes the following activities: Educating and counseling the individual to guide him Needs to change to them, or him or her, or something else
3. "Certification is valid for three years, requiring staff to renew their status and stay current with treatment issues and protocols in the process. For more information see..."
The certification is only good for one year, and you should use the link to the actual program
https://www.biausa.org/professionals/acbis
rather than the one for the Center for Neuroskills, which is a private provider in California and Texas.
4 . "Functional Impairment” means impairments which are typically classified as difficulty completing (insert basic) activities of daily living (e.g., dressing, grooming, getting in and out of bed) and instrumental activities of daily living (e.g., preparing meals, managing finances, housework)."
5. “Under Managed Care Plan or Managed Care Organization (MCO)- "The Virginia Department of Medical Assistance Services (DMAS) is transitioning to Cardinal Care, a unifying brand encompassing all health coverage programs for Medicaid members. Cardinal Care will combine Virginia’s two existing managed care programs – Medallion 4.0 and Commonwealth Coordinated Care Plus (CCC Plus) – to create a single identity for all members receiving services through Medicaid health plan partners. The overarching brand and program alignment also includes fee-for-service Medicaid members, ensuring smoother transitions for individuals whose health care needs evolve over time” This not part of a definition. It is a statement of process and will quickly be outdated.
6. “Mayo Portland Adaptability Inventory (MPAI-4)” means the Mayo-Portland Adaptability Inventory version 4 (MPAI-4) is a tool that measures functional outcomes for post-acute brain injury programs, based upon 29 functional measures in three clinical areas.
7. “Qualified Brain Injury Support Provider (QBISP)” means certification in a training program through the ©Neurobehavioral Training Institute that promotes practical education for direct care staff that is supported by daily supervision to enhance care for persons with behavioral challenges. Training information can be found here: https://qbisp.training/” The QBISP Provider Course was originally developed as an alternative curriculum to ACBIS; it does not provide a certification, but a certificate. The “Brain Injury Basics” on-line and self-paced certificate program, developed by the Brain Injury Association of Virginia, for brain injury providers in Virginia, should be included as an acceptable alternative.
8. “BIS CM providers for MCO members must be contracted with the member’s assigned MCO.” Does this mean all of the BI CM programs have to contract with all the MCO’s?
9. “Providers of case management must ensure that enrolled individuals have free choice of the available providers of support coordination/case management services and free choice of the providers of other medical care under the State Plan for Medical Assistance”. But the Conflict of Interest rule does in fact limit free choice if someone wanted to receive TCM through an existing provider that offers both Case Management and Clubhouse service. Does this mean the CSB’s will have to choose between providing TCM and other services?
10. “Additionally, the case manager must complete the Mayo-Portland Adaptive Index-4 screening to determine whether the member meets the required severity threshold for BIS case management service. Members who do not meet the DMAS definition of TBI criteria nor have physician documented TBI will not need to be assessed using the MPAI-4 and shall be referred to their MCO to receive coordination of care”. How do the programs get reimbursed for their time conducting the assessment, if at the end of it all, someone scores a 49? This is huge time investment without any guardrails for reimbursement. And what exactly does the MCO level of care coordination consist of for someone with a moderate brain injury that impacts their ability to live independently?
QBIS and CBIS are not comparative to one another. QBIS doesn’t require any experience with the brain injury population and is a training that when completed provides a certificate. CBIS requires extensive contact (500 direct hours) with individuals with brain injury prior to being eligible to sit for the exam, provides certification, and requires that to be renewed annually (not every three years as listed in the draft).
Currently the manual requires a CM to hold a Bachelor’s Degree in a small number of specific degrees. There are numerous other human services degrees. This needs to be expanded.
If an agency has current staff that do not hold either a degree in one of the named fields or has no degree, how will this be handled in the eyes of DMAS? Will existing staff be grandfathered in? Will experience with human services or work within the brain injury population be considered in lieu of a degree? Can the requirements be listed as such-for example- staff must hold a bachelor’s degree in a relevant human services field or have X number of years of human services/brain injury field experience?
The TBI definition should match the Brain Injury Association of America definition:
"TBI is an alteration in brain function, or other evidence of brain pathology, caused by an external force. Traumatic impact injuries can be defined as closed (or non-penetrating) or open (penetrating),"
Two sections contradict one another: Page 10 and 13. Is the f2f requirement 60 or 90 days?
Clarification to this clause is needed. Does this need to be in effect for ALL providers? CSBs as well?
QBIS and CBIS are not comparative to one another. QBIS doesn’t require any experience with the brain injury population and is a training that when completed provides a certificate. CBIS requires extensive contact (500 direct hours) with individuals with brain injury prior to being eligible to sit for the exam, provides certification, and requires that to be renewed annually (not every three years as listed in the draft).
The manual requires CM to hold a Bachelor's Degree in a very small, and random number of specific degrees. This should be expanded to all human services degrees.
I strongly believe existing staff should be grandfathered in. Experience within this field and the brain injury population should be considered in lieu of a degree.
This wording makes much more sense: "staff must hold a bachelor’s degree in a relevant human services field or have X number of years of human services/brain injury field experience.
Are persons with an ABI not included? Per the Brain Injury Association of America -
"Non-Traumatic Brain Injury: Often referred to as an acquired brain injury, a non-traumatic brain injury causes damage to the brain by internal factors, such as lack of oxygen, exposure to toxins, pressure from a tumor, stroke, near-drowning, aneurysm, tumor, infectious disease that affects the brain (i.e. meningitis), lack of oxygen supply to the brain (i.e. heart attack).
The handbook states: "BIS case managers must either hold at least a bachelor's degree in one of the following fields: social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling OR be licensed by the Commonwealth as a registered nurse. BIS case managers must be certified as a Qualified Brain Injury Services Provider or a Certified Brain Injury Specialist prior to independently delivering billable BIS case management services.
Are other human service degrees not accepted? Will current employees without these credentials be grand fathered in? Can applicants without the appropriate credentials be hired under direct supervision of someone with the appropriate credentials?
To become a Certified Brain Injury Specialist one must have 500 direct hours with individuals with a BI - applicants may not have this upon hire as they need the hours.
Case managers must, "Gather materials to document that the member meets the medical necessity criteria for the service and submit the documentation for review and authorization of reimbursement."
Is there a time frame in which the reviewer has to review and authorize/not authorize the approval and communicate this to the submitting case manager? Will there be opportunity for the CM to submit additional information if the authorization is initially denied?
There is confusion on the frequency of face to face visits. The draft states 60 days in one section and 90 days in a different section.
This clause should encompass ALL providers to include the CSB. A change in wording is needed.
Definition of BI is not consistent with the definition of Brain injury as defined in the Code of VA:
§ 37.2-403. Definitions. "Brain injury" means any injury to the brain that occurs after birth that is acquired through traumatic or non-traumatic insults. Non-traumatic insults may include but are not limited to anoxia, hypoxia, aneurysm, toxic exposure, encephalopathy, surgical interventions, tumor, and stroke. "Brain injury" does not include hereditary, congenital, or degenerative brain disorders, or injuries induced by birth trauma.
Certified Brain Injury Specialist: Certification is valid for 1 year (not 3 as stated) and for more information, people should be directed to https://www.biausa.org/professionals/acbis. This is the website of the Academy of Certified Brain Injury Specialists
The last bullet of the description Case Management Services described on P. 1 should be modified to read Educating and counseling the individual and family to guide him them to develop supportive relationships that promote the individual support plan.
Page 2
Definition of Family (for the purpose of receiving individual and family/caregiver training
Services) includes a statement that it shall not include persons who are compensated to care for an individual. However in some rural areas, where caregiving providers are in short supply, spouses, parents and/or other relatives may be paid through Consumer Directed Care as a matter of necessity.
Page 3
Definition of Mayo Portland Adaptability Inventory: at the end it cites “three clinical areas” Recommend listing the subscales: Ability, Adjustment and Participation
Page 4
“Qualified Brain Injury Support Provider (QBISP)” A more comprehensive training is required for Targeted CMs. The Brain Injury Association of Virginia has curriculum expertise and can be contracted to create an appropriate training program.
Page 6
Qualifications for BIS Case Managers should include that within 6 months of employments, a TCM provider should attain a higher certification than QBISP - The Brain Injury Association of Virginia can provide this training
Page 7
Case manager must have skills in:
Page 9
As part of the intake process, the case manager must collect existing medical documentation that demonstrates the member’s diagnosis of a traumatic brain injury. If there is no documented diagnosis, then the case manager shall assist the member in accessing a physician who can document whether the member has a diagnosis that is eligible for receipt of the brain injury case management service. – This can include a Neuropsychological Evaluation. An evaluation needed to confirm a BI diagnosis will be (should be) covered by Medicaid.
Additionally, the case manager must complete the Mayo-Portland Adaptive Index-4 screening to determine whether the member meets the required severity threshold for BIS case management service. The MPAI-4 screening should be done in person with the support of family member(s) or others who know the individual well. This is not an appropriate tool for someone with severe cognitive impairment.
Page 10
Exclusions are contradictory to the state definition of brain injury as defined in the Code of VA:
§ 37.2-403. Definitions.
"Brain injury" means any injury to the brain that occurs after birth that is acquired through traumatic or non-traumatic insults. Non-traumatic insults may include but are not limited to anoxia, hypoxia, aneurysm, toxic exposure, encephalopathy, surgical interventions, tumor, and stroke. "Brain injury" does not include hereditary, congenital, or degenerative brain disorders, or injuries induced by birth trauma.
Page 14
Person Centered Planning Requirements
There have been several conflicting interpretation and guidance provided in the work group on how the Conflict of Interest provision is applied. For the majority of the time the various workgroups were convened, we were told by DMAS, that a provider could not be a provider of Targeted Case Management and a provider of other HCSB services. Our provider alliance was told to pick a lane as either a case management provider OR a provider of other HCBS services. However, more recently, we have been told that the conflict of interest is related only specifically to the person enrolled in services and that a provider could not provide both case management services and other HCBS services to the same enrolled person. Under this interpretation, a provider could provide both case management and other HCSB services, just not to the same individual at the same time. These are two vastly different interpretations of the conflict of interest statutes. We request that these interpretations be clarified in writing to all potential interested parties. Additionally, we would expect that the same standards be applied to ALL providers of BI TCM, so that existing providers of other HCBS would be ineligible to provide TCM if the initial interpretation of the conflict of interest is valid.
Page 6 of the proposed TCM services states:
"BIS case managers must either hold at least a bachelor's degree in one of the following fields: social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services, counseling OR be licensed by the Commonwealth as a registered nurse."
The current list of potential degrees is extremely limiting for a provider to be able to find and retain appropriate personnel to provide this service. There are many human service degrees that current and prospective case managers hold that are not on this list and thus as written would them ineligible to provide targeted case management.
More inclusive language that reflects the wide breadth of human service degrees available from our colleges and universities might be:
"completion of at least a Bachelor's degree in a human services field, including but not limited to social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehab, rehabilitation counseling, special education, or human services,
Changing the requirement to include the bolded words" including but not limited to" would ensure that the breadth of human service degrees is acceptable for being a BIS case manager.
Additionally, I recommend adding years of experience providing case management also be included in the requirements if someone does not have a degree in a human service field. Our field is full of individual who have embarked on second careers and bring a wealth of relevant experience to the field and simply by not having a bachelor's degree in a human service field that would prohibit them from being a BIS case manager. I would suggest a minimum of 2 years of case management experience be an acceptable alternative for individuals lacking a Bachelor's human service degree (I do think a person needs to have a Bachelor's degree for this position though).
Lastly, the brain injury service provider community has been providing brain injury case management for over 20 years in the Commonwealth. We need to find a way to be able to grandfather existing case managers into TCM who may lack the specific degree requirements listed above. Adding an specified minimum number of years of professional case management experience would allow these existing case managers many of which have years of specific brain injury case management experience to remain eligible to provide targeted case management.
The draft states that one of the agency requirements is to "guarantee that individuals have access to emergency services on a 24-hour basis. This may be done via a phone answering service and/or coordination with other MCOs and DBHDS administered crisis services." Further clarification is needed to describe what this entails -- an overarching office-wide voicemail that will switch on after-hours that instructs consumers to contact their MCO/crisis services if needed? Phone answering services meaning...? CMs would need to rotate being on-call?
Multiple places in the manual list descriptions of brain injury.
Pg 1- "Brain Injury means...explosion."
-This paragraph describes a traumatic brain injury, not all brain injury.
-Whiplash is a neck injury, not a brain injury. This should be changed to "...to the brain;
coup-countrecoup and other internal damage to the brain caused by violent shaking or
movement."
-The description for TBI is on Pg 1 but defined again on Pg 5 with some different wording.
the handbook states: "BIS case managers must either hold at least a bachelor's degree in one of the following fields: social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling OR be licensed by the Commonwealth as a registered nurse”
Are other human service degrees not accepted? Having degree requirements this narrow in scope will further impede our ability to fill vacancies. If there is a master’s degree does the area of discipline for the bachelors not matter? Will current employees without these credentials be grandfathered in? Can we consider changing the language to read “including but limited to” the listed fields of study?
There is continued confusion regarding the Conflict of Interest provision and there are two vastly different interpretations of the conflict of interest statutes. Initially the workgroups were told by DMAS, that a provider could not be a provider of Targeted Case Management and a provider of other HCSB services. Then, more recently, we have been told that the conflict of interest is related only specifically to the person enrolled in services and that a provider could not provide both case management services and other HCBS services to the same enrolled person. Under this interpretation, a provider could provide both case management and other HCSB services, just not to the same individual at the same time. These are extremely different scenarios, and we need this clarified and applied to all providers of TCM.
There is inconsistency on the frequency of face to face visits. The draft states 60 days in one section and 90 days in a different section. And what if a client PREFERS and REQUESTS virtual visits- do they not have this choice?
“Must have a physician document tbi”. Can documentation also be provided by a psychologist in a Neuro-Psychological Evaluation? How about Nurse Practitioner or Physicians Assistant?
Several times throughout the manual requirements listed include making contact with a client's significant other or family. Consent must be given by the client and this is only stated in one place on pg 16, number 4.
This is not stated before requirements for communication with the family begin to appear in the document. Any time discussions with family are listed, there is no mention of "with client consent."
“Guarantee that individuals have access to emergency services on a 24-hour basis. This may be done via a phone answering service and/or coordination with other MCOs and DBHDS administered crisis services”
Can you clarify if each agency must provide 24 hour emergency services themselves or rather inform individuals of the emergency services that are available to them?
Pg 17 states reimbursement will be provided only for "active" case management clients, as defined. This is not defined in the document.
Pg. 1 Certified Brain Injury Specialist lists a requirement of 500 hours of direct work with patients. However, the Brain Injury Association of America states, "...direct work with an individual or individuals with brain injury." Medical professionals are encouraged not to use the word "patient," but client or individual instead. The experience also does not have to come from a medical setting.
All through the document, brain injury is not defined well at all. Using a more recognized and consistent definition by brain injury providers is preferred, such as the definition from Brain Injury Association. It would also be helpful to show the definition of acquired brain injury and how it will differentiate between a traumatic brain injury for eligibility. The document treats any brain injuries not traumatic as secondary damage. This is NOT accurate and significant brain injuries due occur when they are not considered traumatic in definition. Traumatic only describes that there is some sort of impact to the brain, versus an acquired injury that does not occur with an impact or incident that is a direct result of the injury. A clear and comprehensive definition is needed for better understanding and informing those of why they may or may not be eligible for TCM.
What is meant by authorized services? How do we know what services will be considered authorized under case management activities?
This doesn't support person-centered approach to case management.
QBIS and CBIS are not comparative to one another. QBIS doesn’t require any experience with the brain injury population and is a training that when completed provides a certificate. CBIS requires extensive contact (500 direct hours) with individuals with brain injury prior to being eligible to sit for the exam, provides certification, and requires that to be renewed annually (not every three years as listed in the draft).
Working with individuals with a brain injury takes time and experience to understand the impact of a brain injury and how it may affect a person. Brain injury is very misunderstood, even in the medical field itself, and requires some experience or more training that meets somewhere in the middle of QBIS and CBIS.
Information for following up with CBIS should be through BIAA, not the site listed in the manual.
This current definition is very lacking and closed off in terms of various incidents that could potentially occur. I do not see a mention of more typical incidents we may see that would include self-harm, substance use and behaviors such as elopement.
What about virtual support options? Many providers are able to reach a greater number of clients and support them better with the option of virtual services that can supplement in-person support when needed.
Through the document, brain injury eligibility should be more consistently defined for TCM versus brain injury service provider definition for services. Regardless of whether an individual has a TBI or an ABI, we will serve them through case management services and the TCM manual could help make that distinction as it would be confusing to members as it is already confusing to me as a provider.
It is mentioned in the manual a lot about meeting standards determined by DMAS, but how do we know what these standards are? Where and how do we access them? Have they been determined? How do we review them?
Sometimes goals are not medically necessary as they support building up social engagement and building community to help improve social and emotional well being, which is shown through studies to be perhaps one of the best ways to improve outcome, being able to have choice of interacting with others and participate in activities that can increase social relationships with others.
Plan of care language should be changed to individual service plan as that is what is already in use and reflects a more person-centered practice.
How will we know whether or not a service request meets criteria for providers to submit for reimbursement? How does that practice person-centered services? What is the timeline for a request? How long are we waiting before we can move forward with a client to provide needed services? What if there are emergency circumstances? What if services need to be provided before authorization related to housing, safety, food needs, medical attention and so on? What does this look like if not approved?
Again, I have not seen anything in the manual holding standards for the timeliness of authorizations from DMAS and MCO's. How long does it typically take to process an authorization? How can we access support if an authorization is timely?
TBI definition on page 5 is very lacking and should be defined as BIAA does, for standards of practice already established across the commonwealth.
What does a guarantee of access to emergency services look like on a 24 hour basis? We do not provide crisis/emergency support in day to day and respond to incidents as appropriate. Current precautions include voice messaging systems that refer individuals to contact local emergency services. Is this acceptable? What is this expected to look like? Does this mean an on-call schedule? What will an answering service provide? Still rotating on-call for individuals? This is not clear. We are not qualified to provide crisis support other than referring individuals to appropriate providers and mandated reporting or contacting CIT officers and local CSB for response.
Manual states in accordance with requirements at state and federal level, what does this look like and how do we know if current storage and maintenance meets this requirement? Does this impact our paperless approach?
Bottom of page 5, the agency must participate in reporting activities, but does not state what those are, just that they are defined by DMAS. Would it be how we currently report and measure goals? Would it be a new system to learn, what would the reporting entail for TCM?
Qualifications and credentials are very boxed in definitions for individuals to fit into that provide quality services. This should be expanded as degree field is not as relevant as interacting with consumers, making assessments, having good work ethic and being knowledgeable about brain injury. Those things can easily outweigh a degree and current very knowledgeable case managers may not fit into this category, which would be a loss to our ability to provide quality services. In point, this should be expanded.
Also, QBISP versus CBIS are NOT comparable to be a qualified. One is easily achievable without any knowledge of brain injury really and the other is much more comprehensive.
One page 6, near the bottom, it states that BIS CM's must have knowledge of different types of assessments and their uses in service planning. Does this just mean MPAI? Are there other assessments we should be utilizing? What does this look like?