Master coordinating NHTD services with actionable steps for optimal results and quality care.
November 3, 2024
The Nursing Home Transition and Diversion (NHTD) Waiver is designed to assist individuals in leaving nursing homes or to help them remain in their communities. It provides essential services that enable participants to stay at home or return home safely if they are currently residing in a facility.
To be eligible for the NHTD Waiver, individuals must meet specific criteria set forth by the New York State Department of Health. Key eligibility points include:
Individuals applying to participate in the NHTD waiver must meet specific eligibility criteria. (New York State Department of Health)
Eligibility FactorRequirementResidencyMust reside in New York StateLong-Term Care NeedMust require assistance with daily living activitiesCommunity SafetyAble to safely live in the community with provided services
The program emphasizes individual rights, autonomy, and personal empowerment, focusing on health and welfare within the community, self-reliance, and independence [2].
NHTD Waiver services are categorized into two primary functions: Transition and Diversion.
The application process involves initial meetings with Regional Resource Development Centers (RRDCs) and Service Coordinators to develop an Individual Service Plan (ISP) tailored to each participant's needs.
Service TypeDescriptionTransition ServicesSupport for individuals moving from nursing homes to the communityDiversion ServicesSupports aimed at preventing admission to nursing homes
The program is designed to ensure that individuals have the resources needed to live independently while still receiving the care they may need. This approach promotes community inclusion and individual satisfaction as vital indicators of program success.
Navigating the application process for NHTD (Nursing Home Transition and Diversion) waivers requires understanding the referral process and the steps involved in applying and gaining approval.
In the Buffalo Region, the referral process allows interested individuals to submit a referral form, which can be completed by themselves or someone on their behalf. This form must be faxed or mailed to Headway. Verification of active Medicaid for the referred individual occurs during this stage. Additionally, basic eligibility criteria, including age, diagnosis, and Medicaid enrollment, will be reviewed.
Once the referral form is submitted, an initial interview is conducted by a Nurse Evaluator or a Regional Resource Development Specialist (RRDS). After the interview, their findings are presented at the weekly Headway Program Case Conference. This conference determines whether the referral can proceed to the application phase or if further information is necessary for a decision.
The application process for the NHTD program is structured and involves several key steps. Individuals in New York State must demonstrate their ability to live safely in the community with available services, supports, and resources [2]. Below is a detailed outline of the application sequence:
StepDescriptionReferralSubmit the referral form to a Regional Resource Development Center (RRDC).Intake MeetingAttend an intake meeting with RRDC representatives and Service Coordinators.Initial Service PlanCollaborate to develop an Initial Service Plan (ISP) tailored to individual needs.Application SubmissionComplete and submit the application for the NHTD waiver program.Application ReviewUndergo review by the RRDC to assess eligibility and necessity.NotificationReceive notice of approval or denial, along with information on next steps.Service CoordinationOnce approved, connect with a Service Coordinator for continued support and service planning.
The duration of the application process can vary, typically taking around 2 to 4 months under ideal circumstances. Participants officially become part of the NHTD waiver once their service plan is approved, and a start date for services is provided. The Service Coordinator plays a crucial role throughout this journey, assisting participants with the coordination and management of their services. If issues arise with the coordinator or a change is desired, participants can reach out to the RRDS Office for assistance.
Coordinating services under the NHTD waiver is essential for providing individuals with disabilities the support they need to maintain independence and quality of life. This section focuses on the development of service plans and the role of service coordinators.
The development of a service plan is a critical step for participants in the NHTD waiver program. After the interview process, the Nurse Evaluator or RRDS presents the case at the weekly Headway Program Case Conference to determine if the referral can proceed to application or if more information is needed for a determination. Following this, applicants are encouraged to contact approved Service Coordinator agencies or independent service coordinators to create a tailored service plan [1].
The service plan outlines the specific services and support that the participant will receive. It includes goals based on the individual’s needs, preferences, and any changes in circumstances. Regular assessments and modifications to the care plan are crucial, addressing health status, care needs, and overall satisfaction. Changes are implemented as necessary to ensure that all aspects of care align with the participant's evolving requirements [3].
Service Plan ComponentsDescriptionGoalsIndividualized objectives based on the participant's needs and preferencesServicesDetailed list of services provided, including frequency and durationAssessment ScheduleTimeline for regular evaluations of the care plan's effectivenessModification GuidelinesProcess for making changes to the plan as needs evolve
Service coordinators play a vital role in assisting participants throughout the NHTD waiver process. They facilitate the development of the service plan and ensure cohesive communication between service providers, aligning all aspects of care with the individual's plan [3].
Once a service plan is approved by Headway, participants officially become part of the NHTD waiver program, and a notice is sent to the county with a start date for services. Service coordinators advocate for the participant’s needs, ensuring effective coordination of care tailored to the individual's requirements.
If participants have concerns regarding their service coordinator's performance or wish to change their coordinator, they can contact the RRDS Office for assistance [1]. This advocacy is crucial in ensuring that participants receive comprehensive care and remain informed about available resources and options throughout their care journey.
Coordinator ResponsibilitiesDescriptionService Plan DevelopmentAssist in creating a personalized service planCommunication FacilitationCoordinate communication among various service providersAdvocacyRepresent participant needs and preferences in service deliveryProblem ResolutionAddress concerns or issues related to services or coordination
Effective coordination of NHTD services contributes significantly to maintaining the independence and well-being of individuals in the program.
Navigating NHTD programs requires careful consideration of service providers and the available virtual conferencing options for appointments and coordination. This section outlines how to select appropriate service providers and utilize remote communication methods effectively.
Selecting qualified service providers is essential for successfully coordinating NHTD services. Service providers should meet specific criteria to ensure they can effectively address the needs outlined in the individual's service plan. Important considerations include the provider's licensure, qualifications, and experience in providing services in compliance with the Home and Community-Based (HCB) Settings Rule.
To facilitate the selection process, individuals can utilize the following factors:
FactorDescriptionLicensureEnsure the provider is licensed to deliver the required services.ExperienceEvaluate the provider's experience with NHTD services and similar cases.ReviewsCheck reviews and ratings from other clients.ComplianceConfirm the provider meets the HCB Settings Rule requirements.
Applicants for the NHTD waiver program must also complete a Freedom of Choice form, indicating their preferred providers. This process empowers individuals to choose suitable living arrangements and enact services effectively [4].
Virtual conferencing options provide an accessible way to coordinate services and communicate with providers. For appointments with organizations like Headway or other NHTD Waiver Programs, individuals can join a virtual waiting room for meetings with staff members. This method ensures that those who may have transportation challenges or health concerns can still receive the support they need.
Individuals can join video or auditory conferencing using specific links corresponding to their device type. The options are categorized as follows:
Device TypeJoining LinkAppleLink for Apple UsersAndroidLink for Android UsersMicrosoftLink for Microsoft Users
Instructions provided on the respective platforms guide users through the virtual meeting process. Utilizing these conferencing options allows for streamlined communication, assessment of needs, and planning of services while maintaining convenience and accessibility for all parties involved [1].
Ensuring that providers meet specific requirements is essential for effectively coordinating NHTD services. This section outlines the necessary licensure and qualifications as well as the policy implementation standards that service providers must adhere to.
NHTD Waiver Service Providers must be located in and able to provide services in New York State. They are required to meet all licensure and other qualifications as specified in the approved 1915(c) waiver application. Compliance with these criteria ensures that providers are equipped to offer the necessary services to individuals in need.
RequirementDetailsLocationMust provide services in New York StateLicensureMust meet state licensure requirementsQualificationsMust comply with the specifications of the 1915(c) waiver application
NHTD Waiver Service Providers are required to know, understand, and implement the waiver policies and procedures. This includes adhering to billing and documentation standards set by various organizations such as the Centers for Medicare & Medicaid Services (CMS), New York State Department of Health (NYSDOH), and eMedNY. Familiarity with these policies ensures that services are delivered effectively and in compliance with state and federal regulations.
Policy StandardRequirementsUnderstanding PoliciesKnowledge of waiver policies and proceduresBilling StandardsCompliance with CMS and NYSDOH requirementsDocumentation StandardsAdherence to eMedNY guidelines
By meeting these provider requirements, organizations can ensure a higher standard of care for individuals relying on NHTD services.
Quality care is essential in the NHTD waiver program, as it directly influences the well-being and overall satisfaction of program participants. This section will explore the importance of assessment and modification, as well as advocacy and communication, in ensuring optimal care.
Regular assessments play a pivotal role in monitoring the progress and well-being of individuals under the NHTD waiver program. These evaluations are conducted at scheduled intervals to assess the individual's health status, care needs, and satisfaction with the services received. By facilitating necessary modifications based on the outcomes of these assessments, the program aims to optimize the quality of life for participants [3].
Assessment FrequencyPurposeInitial AssessmentEstablish baseline health status and care needs.Monthly Check-InsMonitor ongoing health and satisfaction.Bi-Annual Comprehensive ReviewEvaluate overall success of the care plan and make needed adjustments.
Advocating for client needs and maintaining effective communication among service providers are crucial for ensuring quality care within the NHTD Waiver program. Active listening and client involvement in decision-making enhance individualized care and foster collaboration among providers. By promoting open communication, coordinators can ensure that participants receive integrated and seamless care.
Key components of effective advocacy and communication include:
By prioritizing advocacy and communication, the NHTD Waiver program can help maintain the independence and quality of life for all participants, ensuring they receive care that is tailored to their specific needs [3].
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