Or. Admin. Code § 410-138-0060 - Targeted Case Management Program - Provider Requirements
(1) This rule is in
effect for services rendered retroactive to July 1, 2009, except for the TCM
Asthma/Heathy Homes Program that is retroactive to July 1, 2010; Babies First!,
CaCoon, and Nurse-Family Partnership for services rendered effective January 1,
2017; and NNHV approved by CMS effective July 1, 2019.
(2) TCM Public Health Nurse Home Visiting
(Babies First!, CaCoon, NNHV, and Nurse-Family Partnership) targeted case
managers may be an employee of a Local County Health Department or other public
or private agency contracted by a Local Public Health Authority with the
demonstrated ability to meet all state and federal laws governing the
participation of providers in the state Medicaid program and the ability to
provide data to the Maternal and Child Health (MCH) Data System. TCM services
provided under the Universally Offered Newborn Nurse Home Visiting Program as
defined in Public Health 333, Division 6 Newborn Nurse Home Visiting must be
provided by certified providers.
(3) TCM Asthma/Healthy Homes, Early
Intervention/Early Childhood Special Education (EI/ECSE), and Human
Immunodeficiency Virus (HIV) provider organizations shall be unit of government
providers. TCM EI/ECSE providers may also be a subcontractor of a government
entity.
(4) TCM Substance Abusing
Pregnant Women and Substance Abusing Parents with Children Under Age 18
provider organizations shall be locally based agencies.
(5) TCM Federally Recognized Tribal
Governments providers shall be Indian Health Services/638 facilities.
(6) All providers shall demonstrate the
ability to provide all core elements of case management services including:
(a) Comprehensive assessment, which may
include triage and environmental assessment of client needs;
(b) Reassessment of the client's status and
needs annually or more frequently with a significant change in the client's
condition;
(c) Development and
periodic revision of a comprehensive care and service plan;
(d) Referral and linking/coordination of
services;
(e) Ongoing monitoring
and follow-up of referral and related services;
(f) A financial management capacity and
system that provides documentation of services and costs and provides
computerized tracking and monitoring to assure adequate follow-up and avoid
duplication.
(7) Except
for Federally Recognized Tribal Governments and the Newborn Nurse Home Visiting
Program, the TCM provider shall provide the non-federal matching share from
public funds in compliance with OAR
410-138-0005.
(8) If the provider is a subcontractor of a
governmental entity, the governmental entity shall make the non-federal
matching share with public fund payments in compliance with OAR
410-138-0005.
(9) All program providers shall demonstrate
the following TCM experience and capacity:
(a) Understanding and knowledge of local and
state resources and services available to the target population;
(b) Demonstrated case management experience
in coordinating and linking community resources as required by the target
population;
(c) Demonstrated and
documented experience providing services for the target population;
(d) An administrative capacity to ensure
quality of services in accordance with state and federal
requirements;
(e) A financial
management capacity and system that provides documentation of services and
costs;
(f) Capacity to document and
maintain client case records in accordance with state and federal requirements,
including requirement for recordkeeping on OAR
410-138-0007 and
410-120-1360; confidentiality
requirements in ORS 192.518-192.524,
179.505 and
411.320; and HIPAA Privacy
requirements applicable to case management services;
(g) A sufficient number of staff to meet the
case management service needs of the target population;
(h) Demonstrated ability to meet all state
and federal laws governing the participation of providers in the state Medicaid
program; and
(i) Enrolled as a TCM
provider with the Authority and meeting the requirements set forth in the
provider enrollment agreement.
(10) TCM Asthma/Healthy Homes Program case
managers shall possess the following additional qualifications:
(a) A current active Oregon registered nurse
(RN) license; or
(b) A registered
environmental health specialist; or
(c) An asthma educator certified by the
National Asthma Education and Prevention Program; or
(d) A community health worker certified by
the Stanford Chronic Disease Self-Management Program; or
(e) A case manager working under the
supervision of a licensed registered nurse or a registered environmental
specialist.
(11) The TCM
case managers for the Public Health Nurse Home Visiting, Babies First!, CaCoon,
and Nurse-Family Partnership programs:
(a) May
be an employee of a local county health department or other public or private
agency contracted by a Local Public Health Authority;
(b) Shall be a licensed registered nurse with
experience in community health, public health, or child health nursing;
and
(c) May be a community health
worker, family advocate, or promotora working under the plan developed by a
licensed registered nurse. The minimum qualifications of the Community Health
Workers, Family Advocates, or Promotoras are as follows:
(A) High School Graduate or GED with
additional course work in human growth and development, health occupations, or
health education; and
(B) Two
years' experience in public health, mental health, or alcohol drug treatment
settings; or
(C) Any satisfactory
combination of experience and training that demonstrates the ability to perform
case management duties;
(D) The
case manager shall work under the policies, procedures, and protocols of the
state MCH Section.
(12) The TCM case managers for the Newborn
Nurse Home Visiting Program must be a licensed registered nurse and an employee
of a certified NNHV provider as defined in Public Health 333, Division 6
Universally Offered Newborn Nurse Home Visiting Program. The case manager shall
work under the policies, procedures, and protocols of the state MCH
Section.
(13) Additional
qualifications for TCM EI/ECSE provider organizations include the following:
(a) TCM EI/ECSE providers shall meet the
criteria to administer the provision of EI and ECSE within selected service
areas designated by the Oregon Department of Education, qualifying such
programs for state reimbursement under EI/ECSE Programs (OAR
581-015-2700 through
581-015-2910);
(b) Shall be contractors with the Oregon
Department of Education in the provision of EI/ECSE services or sub-contractors
with such a contractor and shall meet the following qualifications:
(A) Demonstrated case management experience
in conjunction with service coordination under OAR
581-015-2840 specified on a
child's Individualized Family Service Plan (IFSP) for coordinating and linking
such community resources as required by the target population; and
(14) Qualifications for TCM EI/ECSE
Supervisors of EI/ECSE service coordinators of targeted case management
services shall:
(a) Possess a minimum of a
master's degree in early childhood special education, or a related field and
have three years of experience with infants, toddlers, young children, and
families;
(b) Hold a Teacher
Standard and Practices Commission (TSPC) administrative endorsement or within
12 months of employment, complete authorization as an Early Childhood
Supervisor under OAR 581-015-2910; and
(c) Have a professional development plan
based on the content of the EI/ECSE competencies.
(15) Qualifications of EI and ECSE
Specialists performing case management/Targeted Case Management services shall:
(a) Possess a minimum of a baccalaureate
degree in early childhood, special education or a related field;
(b) Have a professional development plan
based on the content of the EI/ECSE competencies; and
(c) Hold one of the following credentials:
(A) TSPC licensure or endorsement in
EI/ECSE;
(B) TSPC licensure or
endorsement in a related field; or
(C) Within 12 months of employment,
authorization as an Early Childhood Specialist under OAR 581-15-2905.
(16) Qualifications of
EI and ECSE Related services personnel shall possess a minimum of a
baccalaureate degree and a valid license necessary to practice in Oregon.
Related services personnel who also provide service coordination as outlined in
OAR 581-015-2840 shall have:
(a) TSPC licensure in their area of
discipline; or
(b) State licensure
in their area of discipline; and
(c) A professional development plan based on
the content of the EI/ECSE competencies;
(d) Knowledge and understanding of the
Individuals with Disabilities Education Act (IDEA);
(e) Knowledge and understanding of the nature
and scope of services available under the Oregon EI/ECSE programs.
(17) In addition to the above, all
shall be employees of the ODE, its contractors or subcontractors, and shall
have demonstrated knowledge and understanding about:
(a) The ODE EI/ECSE programs OAR
581-015-2700 through
581-015-2910, including these
rules and the applicable Medicaid State Plan Amendment;
(b) Case Management experience in conjunction
with service coordination under OAR
581-015-2840 for coordinating
and linking such community resources as required by the target population to
assist clients in gaining access to needed medical, social, educational,
developmental, and other appropriate services in coordination with the eligible
child's IFSP;
(c) The Individuals
with Disabilities Education Act (IDEA);
(d) The nature and scope of services
available under the Oregon EI/ECSE program, including the TCM services, and the
system of payments for services and other pertinent information.
(18) TCM HIV providers shall have
the financial management capacity and system that provides documentation of
services and costs and is able to generate quarterly service utilization
reports that can be used to monitor services rendered against claims submitted
and paid. The service utilization reporting requirements are as follows:
(a) Report on the number of unduplicated
clients receiving services during the reporting period;
(b) Report on the number of full time
equivalent (FTE) case managers providing services during the reporting period;
and
(c) Report on the number of
distinct case management activities performed during the reporting period
(Triage Assessments, Comprehensive Assessments, Re-Assessments, Care Plan
Development, Referral and Related Services, and Monitoring Follow-Up) along
with the total number of 15-minute increments associated with each activity
category.
(19) TCM HIV
case managers shall possess the following education and qualifications:
(a) A current active Oregon registered nurse
(RN) license or Bachelor of Social Work, or other related health or human
services degree from an accredited college or university; and
(b) Documented evidence of completing the
Authority's HIV Care and Treatment designated HIV Targeted Case Manager
training and shall participate in the Authority's on-going training for HIV
targeted case managers. The training may either be provided by the Authority or
be approved by the Authority and provided by the TCM provider
organization.
(20) The
TCM Substance Abusing Pregnant Women and Substance Abusing Parents with
Children Under Age 18 case manager shall:
(a)
Possess a combination of education and experience necessary to support case
planning and monitoring. The case manager shall be able to demonstrate an
understanding of issues relating to substance abuse and community
supports;
(b) Demonstrate
continuous sobriety under a nonresidential or independent living condition for
the immediate past two years;
(c)
Meet at least one of the following qualifications:
(A) Be a licensed Medical Provider, Qualified
Mental Health Professional, or Qualified Mental Health Associate; or
(B) Possess certification as an Alcohol and
Drug Counselor (CADC) level I, II, or III; or
(C) Complete a Peer Services Training Program
following a curriculum approved by the Authority's Addictions and Mental Health
Division and be:
(i) A self-identified person
currently or formerly receiving mental health services; or
(ii) A self-identified person in recovery
from a substance use disorder who meets the abstinence requirements for
recovering staff in alcohol and other drug treatment programs; or
(iii) A family member of an individual who is
a current or former recipient of addictions or mental health
services;
(d)
Work under the supervision of a clinical supervisor. The clinical supervisor
shall:
(A) Meet the requirements in Oregon
administrative rule for alcohol and other drug treatment programs;
(B) Be certified or licensed by a health or
allied provider agency to provide addiction treatment; and
(C) Possess one of the following
qualifications:
(i) Five years of paid
full-time experience in the field of alcohol and other drug counseling;
or
(ii) A Bachelor's degree and
four years of paid full-time experience in the social services field with a
minimum of two years of direct alcohol and other drug counseling experience;
or
(iii) A Master's degree and
three years of paid full-time experience in the social services field with a
minimum of two years of direct alcohol and other drug counseling
experience;
(e)
Satisfy continuing education requirements as specified by the agency providing
clinical supervision specific to alcohol and other drug treatment;
and
(f) Work in compliance with
Medicaid policies, procedures, and protocols.
(21) A Federally Recognized Tribal
Governments TCM provider shall be an organization certified as meeting the
following criteria:
(a) A minimum of three
years' experience of successful work with Native American children, families,
and elders involving a demonstrated capacity to provide all core elements of
tribal case management including: assessment, case planning, case plan
implementation, case plan coordination, and case plan reassessment;
(b) A minimum of three years case management
experience in coordinating and linking community medical, social, educational,
or other resources as required by the target population;
(c) Administrative capacity to ensure quality
of services in accordance with tribal, state, and federal requirements;
and
(d) Evidence that the TCM
organization is a federally recognized tribe located in the State of
Oregon.
(22) The
following are qualifications of Tribal Case Managers within provider
organizations:
(a) Completion of training in
a case management curriculum;
(b)
Basic knowledge of behavior management techniques, family dynamics, child
development, family counseling techniques, emotional and behavioral disorders,
and issues around aging;
(c) Skill
in interviewing to gather data and complete needs assessment in preparation of
narratives/reports, in development of service plans, and in individual and
group communication;
(d) Ability to
learn and work with state, federal and tribal rules, laws and guidelines
relating to Native American child, adult, and elder welfare and to gain
knowledge about community resources and link tribal members with those
resources;
(e) Knowledge and
understanding of these rules and the applicable Medicaid State Plan
Amendment.
Notes
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
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