Q&A
MIHP Coordinator Meetings Grand Rapids, May 8, 2017 Troy, May 10, 2017 Gaylord, May 16, 2017 Marquette, May 18, 2017
Medicaid/Medicaid Health Plans Responses to questions under this section were provided by our Medicaid colleagues. If you have questions about specific situations pertaining to Medicaid or Medicaid Health Plans, contact your consultant. Transportation 1. MIHP needs to be at the table when the MHP and state are talking about transportation. Comment is duly noted. MDHHS works to organize and facilitate meetings that include MIHPs as well as MHPs. Comment can also be provided to MDHHS when new policies are proposed. See MDHHS website for details. 2. Policy 1704 NEMT Transportation. Places a major barrier for undocumented families. CHAMPS is not in Spanish. Clients currently concerned with ICE at the door and are delivering their infants at home. 3. Immigration issues. Forcing people to stay home. Doors not being answered. Now having to get approved by CHAMPS is causing barriers. Undocumented people do not read or write, especially in English. 4. ICE issues for our undocumented clients as barriers continue to grow due to limitations, i.e., transportation, no MOMS postpartum visit coverage. 5. Proposed Medicaid Policy 1704 – NEMT. Do they have to enroll before they go to the appt? How do we facilitate this for families? 6. CHAMPS transportation approval: a. How long before signing in and getting approved? b. Is there a fee to get approved? c. What is the link to sign up? d. Can we help them sign up? 7. If doing background check, you are just doing state, not tribal, convictions. What do you get to be cleared? How long does it take to get cleared? 8. Does NEMT “provider” include anyone transporting a client – not only agency staff, but clients themselves and people they find to transport them? • How long will it take to get approval from CHAMPS? • I assume Medicaid policy will update by the start of this new policy so we know what needs to be documented related to this change. We provide gas vouchers ahead of time to clients and currently include all fields necessary. • Comment: This change will GREATLY affect how our MIHP can help our clients ACCESS care and may affect how many potentially follow through with medical appointments without our giving them gas vouchers. (We are a tribal site and can give them a gas voucher ahead, knowing we’ll get reimbursed.) How long the CHAMPS approval takes and clients getting 1
vouchers for friend/family to transport will hinder and/or stop our ability to help when drivers change at the last minute. This could also affect clients choosing to enroll in MIHP! 9. Could an MIHP provider enroll a staff member to provide transportation to clients under the Fee-For-Service policy? 10. Does the CHAMPS enrollment of NEMT apply to mileage reimbursement by MHPs for Medicaid beneficiaries or just FFS? Implementation of proposed policy 1704 is on hold until further notice. 11. NEMT: a. What are our options with reimbursement for pregnant women who are transporting themselves? Medicaid Provider Manual: MIHP Chapter: Section 2.10 TRANSPORTATION— Transportation services are available to help MIHP-enrolled pregnant and infant beneficiaries access their health care and pregnancy-related appointments and for a mother to visit her hospitalized infant. Pregnancy-related appointments include those for oral health services, WIC services, behavioral or substance use disorder treatment services, and childbirth and parenting education classes. Through the completion of the Risk Identifier, the MIHP provider must assess each MIHP beneficiary’s need for transportation services. Please refer to 2.10.A. Transportation for MIHP Medicaid Health Plan Enrollees and 2.10.B. Transportation for MIHP Fee For Service Beneficiaries for additional details. b.
Are we doing all we can to reduce barriers? MDHHS is working to comply with federal requirements as outlined in the policy while minimizing any potential barriers to access for beneficiaries.
c.
A healthy pregnancy outcome can outweigh the small amount of $ provided for NEMT. Again, are we (MSA) doing all that can be done to reduce barriers to access transportation? See part b above.
12. Are health plan beneficiaries located in CHAMPS or are only Fee-For-Service beneficiaries located in CHAMPS? Beneficiary eligibility and health plan enrollment status information is available in CHAMPS. 13. 5.8. Are MIHP providers responsible to provide transportation to FFS clients and for non-medical pregnancy-related services? Medicaid Provider Manual: MIHP Chapter: Section 2.10 TRANSPORTATION— 2
Transportation services are available to help MIHP-enrolled pregnant and infant beneficiaries access their health care and pregnancy-related appointments and for a mother to visit her hospitalized infant. Pregnancy-related appointments include those for oral health services, WIC services, behavioral or substance use disorder treatment services, and childbirth and parenting education classes. Through the completion of the Risk Identifier, the MIHP provider must assess each MIHP beneficiary’s need for transportation services. Section 2.10.B—Transportation for MIHP Fee For Service Beneficiaries The MIHP may provide transportation to MIHP Fee-for-Service (FFS) beneficiaries for medical/health care services and pregnancy related appointments when no other means of transportation are available, including transportation from the local MDHHS office. 14. MHP transportation. Ride-alongs not allowed. This is not culturally ok. Women of other cultures cannot get into a taxi or other transportation if a male provider. They are required to have an escort or chaperone. Medicaid Provider Manual: MIHP Chapter: Section 2.10.A: Transportation for MIHP Medicaid Health Plan Enrollees MHPs are responsible for providing transportation for pregnancy-related appointments for MHP enrolled MIHP and NFP participants. MIHPs are subject to the MHP’s internal processes for the coordination of transportation services for MHP enrollees. Health Plans 15. Can someone at MDHHS please communicate with Molina that we don’t have to bill private insurance prior to billing Molina? We’ve communicated this to them and provided the MDHHS FAQ document, but they are still requiring us to do this. Because MIHP is a Medicaid only benefit, TPL rules do not apply. This has been and will continue to be communicated to all parties as necessary. MIHPs should contact individual health plans for any billing related issues. Medicaid Provider Manual: MIHP Chapter: Section 3--Reimbursement MIHP services are a Medicaid only benefit. MIHP providers are not required to secure other insurance adjudication response(s) for claims for MIHP services prior to billing Medicaid FFS or MHPs, as the parameters of other carriers would never cover MIHP services. 16. I had a mom who delivered at 26 weeks. Meridian refused to pay mileage for her to go to the NICU to see the baby. Mom is breastfeeding and taking pumped milk to infant as well. Can the health plans refuse to pay PP mileage for preterm babies? Medicaid Provider Manual: MIHP Chapter: Section 2.10 Transportation
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Transportation services are available to help MIHP-enrolled pregnant and infant beneficiaries access their health care and pregnancy-related appointments and for a mother to visit her hospitalized infant. Pregnancy-related appointments include those for oral health services, WIC services, behavioral or substance use disorder treatment services, and childbirth and parenting education classes. Through the completion of the Risk Identifier, the MIHP provider must assess each MIHP beneficiary’s need for transportation services MIHPs should work directly with individual health plans to coordinate transportation services for health plan enrollees. Should you confront barriers, please discuss with your consultant and provide as much specific information as possible. 17. In the February webinar meeting, the question was asked: Why do we need to notify the Health Plans with an enrollment letter within 14 days, then again on a monthly roster? Any answer to this yet? The enrollment letter is used to inform the MHP that MIHP services have been initiated for the beneficiary. Ongoing communication between the two parties is integral to providing the most appropriate and thorough coordination of care for the beneficiary. 18. Has anyone been told if all the meetings with the health plans are mandatory? If each health plan (like BCC) has 4 meetings a year, that would be 24 meetings, just for our agency alone. The MHPs are required per contract with the state, to meet with the MIHPs quarterly. Health plans are working to minimize the number of meetings for MIHPs in coordinating and planning these meetings as collaboratively as possible. The MHP/MIHP collaborative sessions that have been facilitated by MDHHS will count toward meeting that requirement. These meetings are not mandatory for MIHPs, but MIHPs are strongly encouraged to participate. 19. The health plans should be required to let MIHP know about changes in their personnel – not us! Because the MIHPs and MHPs work so closely on a regular basis, sometimes MIHPs learn of health plan personnel changes before the MDHHS managed care staff. MIHP Medicaid Reimbursement 20. Will there be any increased payment for services? Not sure how we will be able to continue an MIHP program in our county with more/continued requirements. We are currently the only provider in our county. Please provide guidance on how to financially maintain. Happy to provide quality care, proud of the services we provide. 21. The switch to MHPs, along with continuous changes to Certification Tools and forms, has created an extensive demand on office staff. Are rate increases being considered? 22. Please consider enhancing reimbursement for IMH visits to help pay for required reflective supervision for IMH providers. IMH visits should be reimbursed at a higher rate because they, by their nature, must be longer than 30 minutes. There are no plans to change the reimbursement rates at this time.
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23. Will agencies be considered out of compliance if paid more than $83.72 for a 99402 if that is in their contract with the MHP? No, the agency will not be out of compliance if the MHP chooses to reimburse you at a higher rate than the FFS rate. 24. Suboxone treats addiction well for pregnant women. I believe Medicaid policy is unclear to providers about whether Suboxone can continue to be billed to Medicaid postpartum and beyond. Can you explore the Medicaid reimbursement for Suboxone for pregnant/postpartum women and for use years after pregnancy, if needed? Thank you. Also, what does Medicaid cover for counseling? Medicaid eligible beneficiaries may receive treatment for substance use disorders (SUD) as a behavioral health benefit outside of the MIHP. Information about covered SUD services is outlined in the Behavioral Health Chapter of the Medicaid Provider Manual. Place of Service Codes for Billing 25. Many women don’t have one permanent home. We visit her at different friends and family homes all through her course of care. So will every visit be “mobile” code since she doesn’t have a permanent address? We had previously thought that “mobile” code was only use for public locations such as McDonalds or other community locations. 26. Please provide clarification on home or mobile visit when visiting at Grandma’s or another relative, in either forms instructions or Op Guide? If an MIHP visit occurs in a private residence, the Place of Service Code 12-Home, may be appropriately reported. Other 27. Why can’t a pregnant mother who is in jail be seen at the jail? It’s her residence. She keeps her Medicaid in jail now – not just MOMS insurance. Is this in the manual? Medicaid eligibility changes once a beneficiary is incarcerated and is limited to inpatient hospital services only during the period of incarceration. MIHP as a Medicaid service is not available in the jail setting. BEM 265, BAM 804 28. Baby had Medicaid while in foster care. Once he was adopted, he lost Medicaid coverage. MDHHS said they don’t continue coverage if adopted under one year old. Is this true? We thought this was part of the adoption subsidy. These babies have higher risk, especially drug-exposed. Continued coverage depends on the criteria outlined in the Bridges Eligibility Manual (BEM 177): https://dhhs.michigan.gov/OLMWEB/EX/BP/Public/BEM/117.pdf#pagemode=bookmarks If the child falls into any of the outlined categories, the Medicaid continues. If the child does not meet any of these specifications, the parent would have to apply for coverage.
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Risk Identifiers 1. Please proof-read the printed Risk Screeners and correct the errors, such as duplicated questions. We will look at the new Risk Identifiers for duplicated questions. 2. May I suggest someone run through a “test” screener, including entering it in the system? There are numerous quirks that are not apparent until you try to use the system. For example, when you want to discharge a maternal client, you can only locate the person by birthdate, forcing you to sift through all entries with the same birthdate. Once you complete the discharge, you must do a new search to pull up that person (this time you can do it by name), and print/save the discharge report. State staff do test the Risk Identifiers prior to release. The new Risk Identifiers will be piloted by a sample of MIHP providers. You may want to check to see that you are using Internet Explorer 11 (IE11), since many quirks are associated with using other browsers. 3. On IRI, breastfeeding always shows as incomplete – until you go back to the screen, change nothing and submit. Yes, this is a problem. We will consult with our IT team for a fix. 4. Professional credentials on risk screener. Please either change it to read nurse or social worker or allow proper credentials for LMSW, as well as RN. RN, SW, or LMSW. We will begin using the terms “nurse” and “social worker” (rather than credentials) where possible. 5. Bright Futures. If “not sure” is checked, does that count as a “not yet?” Yes. 6. I recently enrolled an infant whose mom is married to another woman. I wasn’t really sure how to answer the family planning question because if I choose “other,” it will flag a risk. Also, I wasn’t sure how to answer the FOB questions. Biological father is a donor but mom has a spouse who is assuming a parenting role. If I choose “not involved,” it will flag a risk. We will address this as we revise our risk identifiers. 7. Any type of 4 abuse questions comes out as high, but not specific for time period regarding in last year. 8. Why does an old episode of abuse automatically trigger a high level abuse for POC, but the actual POC states the abuse occurred within the last year? We are addressing this as we revise the Risk Identifiers. 9. It would be nice if the Risk Identifier questions related to abuse/violence and stress/depression were at the end of the RI. These are very personal questions and it would be better to have more time to 6
build a rapport with the client before diving into those questions first. It would be nice to have them at the end. 10. Currently, women have agreed to services for their infant and we bombard them with questions about their drinking, drug use and mental health. They feel regret that they subjected themselves to the interview. Please consider starting new IRI with friendlier questions related to the infant, not diving right into personal questions about the mother before any rapport can be established. We have made this change in the revised IRI.
IT 1. Has the IT problem been corrected for screeners that are incomplete but are over one year or the agency is closed and error comes up stating “screener is incomplete by another agency” and you cannot put in another screener? This is on the IT remedy list. 2. Print date? Entered date? Complete date? Confusing. 3. Print date, screening date, completed date. We are aware that the “completed date” changes every time you open or print a Risk Identifier. We will address this when the new Risk Identifiers are programmed. However, reviewers only look at the date that the Risk Identifier was administered (screening date) in order to match it to your billing documentation and the screening date does not change. 4. Please clarify how best to document re-entered Risk Identifiers. Document re-entered Risk Identifiers on the Contact Log or in the comments section on the Risk Identifier. 5. Discharges. Date comes out wrong when printing. This has been added to the IT fix list. 6. IT issue. If last visit was completed prior to MA number being entered in MRI or IRI, discharge will not allow dates to be entered. You must wait for 24 hours after completion of the Risk Identifier in order to enter the Discharge Summary. 7. It would be great to be able to review the Discharge Summary on one full screen prior to pushing the finalized button. I feel like this would cut down more errors on input into MILogin. We will look at incorporating a print preview function when we revise the Discharge Summaries. 8. I am suggesting that we be given 24 hours to correct errors on Risk Identifier and Discharge Summary before they are permanently saved. 7
9. Could we have a day or two after RI/discharges are done to make corrections? You have currently have 30 days to delete an incorrect IRI and re-enter it. This function is not yet available for the MRI, MDS and IDS. You cannot make corrections to completed Risk Identifiers and Discharge Summaries after they’ve been submitted. Once you press the submit button, you must do a deletion in order to enter a correct Risk Identifier or Discharge Summary into the database.
Plan of Care 1. We have been told that if we discover a new need during a visit that is not part of the POC, we cannot do interventions at that visit, rather we need to wait until the POC update is done and address at another visit, because technically the new domain is not part of the POC until POC 3 is signed. However, you have also said that at intake if we do interventions we can document “achieved” on the POC, but that contradicts the above at intake – POC has not been developed yet. So which is it? Will you reconsider and allow our staff to do interventions to an identified need at whichever they see fit and document in domain section? Yes, you can implement interventions on the day you identify a new risk domain before you pull the domain and add it to the POC 2. 2. Infant POC. Birth health (removed from score page). No POC for birth health. The MIHP Operations Guide (page 8.17) states: There is no POC 2 domain for birth health, although questions about it are included in the Infant Risk Identifier. Birth health is a static, onetime assessment and there are no interventions for it because we don’t have the ability to change the status of an event that occurred in the past. 3. The doctor’s notes and POC 3 should NOT be signed until the Risk Identifier score sheet is printed and entered into the chart, correct? Meaning the POC 3 and doctor’s note should be signed AFTER the print date on Risk Identifier, correct? No. You are required to view the score sheet online or print out it out prior to completing the Prenatal or Infant Care Communication Form. You may send the Communication Form to the medical care provider before the POC 3 is signed by both disciplines. You are not required to print out the score sheet and enter it into the chart before you send the Communication Form to the medical care provider. 4. When enrolling a maternal client, do we have to pull a POC 2 for breastfeeding if she is adamant that she will not breastfeed? 5. Do we pull a breastfeeding POC 2 if a beneficiary says she does not want to breastfeed at enrollment? Seems like we would have to pull a BF POC 2 for every maternal client, except those with a previous, positive experience. No, you don’t. 6. We have been told in the past that you could not add any POCs on the day of the RI and had to wait until the first professional visit. Today was said we could. Please clarify. 8
You can add a risk domain at the time that the POC 2 is initially developed (or at any time thereafter, as long as the criteria in Column Two are met). You must wait until the time of the first professional visit in order to change the risk level for a given domain. 7. Drug-exposed. Slightly confused in regards to drug-exposed code and addressing the high risk within 3rd visit. 8. If I pull an SEI POC 2 for a beneficiary on admission, am I required to start addressing it from visit 1, or can I wait to address the SEI POC 2 until visit 19? Also, if the SEI POC 2 is high, will I get dinged for not addressing it within the first 3 visits? No, you are not required to use the SEI interventions until the 19th visit, so you will not be cited if you don’t address the SEI domain within the first three visits, but you are encouraged to use the SEI interventions as soon as this risk is identified. Typically, if the infant is substance-exposed, the pregnant woman or mother will score out on the maternal alcohol and/or drugs domain, which must be addressed within the first three professional visits. Do not add the SEI PO2 to the chart until you plan to begin using the SEI interventions. Once you add the SEI POC 2 to the chart, you must begin to use the substance exposed infant progress note as well. The SEI billing code is used beginning with visit 19. 9. Can abuse/violence interventions be separate from CPS interventions? CPS needs more interventions as it’s very limited. We will consider this for future forms changes.
Maternal and Infant Care Communications Forms 1. 6.3 Confidentiality. Please clarify “using the beneficiary name is not acceptable in communications sent to medical care providers.” The entire statement in the MIHP Operations Guide (page 6.4) is as follows: Beneficiary information must be encrypted before it can be sent electronically. Using the beneficiary’s name, even though no other identifying information is provided, is not acceptable in electronic communications sent to the medical care providers or MHPs. MIHP providers that wish to send communications electronically must use encryption software. This applies to electronic communications only. You may use the beneficiary’s name when you mail or fax communications to the medical care provider and MHP. 2. Can a space be added to Communication Form MIHP 022 to say “not sent to MD?” We will consider this for future forms changes. 3. Do you need to send a “status update” doctor’s note when you receive a transfer chart? The MIHP Operations Guide (page 8.27) states: You are also required to notify the medical care provider if the beneficiary transfers to your MIHP, but you are not required to use the (Prenatal or 9
Infant Care Communication) form for this purpose. You may choose to write a note or call the medical care provider. If you call, it must be documented in the chart on the Contact Log. If you need to add a Plan of Care domain because it was omitted by the transferring agency, then you should update the doctor using the Prenatal or Infant Care Communication Form, noting that you are the beneficiary’s new provider on the cover letter.
PVPN 1. PVPN. Visit date and signature date may not be the same. Using an EMR auto-dates the signature line. 2. Clarify whether or not the date of the visit and the date of your signature should match. In our EMR, your signature is date-stamped when you enter a signature. 3. Does the date of the visit on page one of the PVPN need to match the date of signature? Which way is correct? The Professional Visit Progress Note Forms Instructions (page 6) state: Signature Date: The date required here is the date that the progress note was completed and signed. This date may be different from the “Date of Visit” documented on page one of the progress note. 4. Please evaluate the actual need for every box/question on the progress note. Do we really need to have a box for “first-time mom” on the progress note? Can we have a separate maternal note and infant note to prevent filling out in the “wrong” area? Yes, we intend to have separate PVPNs for pregnant and infant beneficiaries in Cycle 7. 5. Addendum to the PVPN does not preclude ding, just proves QA. That is correct. 6. Plan for next visit. Can you just put topic, or does it need an action word plus topic? The “Plan for Next Visit” - MIHP Professional Visit Progress Note” document is posted at the MIHP website. It states: When completing the “plan for next visit” field on the Professional Visit Progress Note, it’s good care coordination practice to be as specific as possible. This helps you, the other members of your team, and the beneficiary (who should know what to expect) to be clear about next steps and to prepare to implement them. It helps to start out with an action word. Here are some examples: 1. 2. 3. 4. 5. 6. 7.
Begin discussion on _______. Continue discussion on _______. Review educational materials or text4baby on _______. Follow up on _______. RN/SW/RD/IMHS will make next visit to follow up on _______. Discuss how last appointment with _______ went. Bring resources on _______ and discuss a possible referral to ______. 10
8. 9. 10. 11. 12. 13. 14. 15.
Attempt to address _______. Assist with _______. Evaluate readiness to change in _______ domain. Administer the ASQ-3/ASQ: SE/EPDS. Develop self-care action plan. Demonstrate how to _______. Assist beneficiary to practice _______. Begin transition to end of MIHP services.
7. One auditor said not to use N/A on progress notes, for example, “other visit information.” Please clarify. Use of N/A is optional.
MIHP Maternal and Infant Education Packet 1. Please make sure your information for IRI and MRI packets is updated – still refers to DHS rather than DHHS. This is on our list of goals. We intend to update the packet after the MIHP program improvements are implemented in the fall. Lynette Biery, Director, Bureau of Family Health Services, outlined some of these changes at our May coordinator meetings. When we update the packet, we will replace “MDCH” with “MDHHS.” 2. Please confirm/clarify 8.1D. c) “Give beneficiary the entire MIHP Maternal and Infant Education Packet. Do not split it into maternal and infant packets and hand them out separately.” So maternal clients are to be given all maternal and all infant packet info at maternal enrollment? Yes, the entire packet is handed out at the time of maternal enrollment. The intent is to provide the maternal beneficiary with basic information on infant health and development in case she is lost to service before the infant is born. As an alternative, you may assist her to sign up for text4baby. 3. Does the new FP birth control guide cover education information in the Ed Packet given to clients? It is not new and yes, it does. It is very extensive.
Monthly Visits 1. If we open a newborn and see her once a month or once every two weeks, she will be discharged well before she is one year old. Is that okay? If we do see her multiple times a month, do we have to document reasons why on the Contact Log? The progress notes should document/dictate the reason for multiple visits in a month. A physician’s order is needed to offer more than 9 visits. Infants must be transitioned out of the program no later than their 18-month birthdate. If there are no additional needs after the conclusion of the initial 9 visits, then you may discharge the infant prior to 12 months of age. 11
2. Regarding monthly visits, if we sign up a newborn with only 9 visits, that completes their case at 9 months old. How do we proceed? Yes, it’s acceptable to discharge the infant beneficiary before 12 months of age. There are only 9 infant visits to use over the 12 months of infancy (unless the medical care provider authorizes additional visits). It’s also acceptable to space the visits out over the 12 months, but be sure to document this rationale on the Contact Log. If it is necessary to see a beneficiary more frequently than once a month, document your rationale on the Contact Log. Seeing beneficiaries weekly or every two weeks may be necessary with some maternal and infant beneficiaries, but it should not be standard practice.
Specialty Provider Designation 1. If I do not seek to be designated by MDHHS as a specialty provider, can I still provide MIHP services to Spanish-speaking only clients? We have translation services available for these clients. We are the only MIHP provider for our county. Yes, you can continue to provide services to Spanish speakers. It is entirely up to you to decide whether or not you want to seek specialty provider status. 2. Please define how many of the educational materials you want provided with specialty provider application. Also, this is a lot of paperwork. How about having the reviewers verify this during our certification review! We have not set a limit on educational materials. Please provide a few of your specialty educational materials. Your application needs to be approved by your state consultant prior to your certification review.
Safety Plans 1. If mom refuses a safety plan but we tried to address it, do we document it as an intervention and just note mom’s response (i.e. does not consider it to be an issue)? Yes. Document it as an intervention, because you did address it, and note that the beneficiary refused to develop a safety plan. 2. How come an infant safety plan isn’t required when there is a high risk? Safety plans are required for other high risks (depression, domestic violence, etc.). The MIHP Infant Safety POC 2 (Intervention #6) states: Assist with development of plan to address identified safety risk. This prompts you to develop specific safety plans geared toward the individual infant’s particular safety risks (e.g., unsafe sleep practices, no car seat, drowning, etc.).
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1. Is it OK to administer an ASQ-3/ASQ: SE2 before two months (or age-adjusted before two months) if infant is at least one month old? MIOP has conflicting information. 2. We need clarification on expectations of when to do first ASQ and ASQ: SE. Ops Guide has two different statements: one is “two months”; one is “one month.” We reviewed the developmental screening section in the MIHP Operations Guide and did not find a statement that either the ASQ-3 or the ASQ: SE-2 should be administered to an infant who is one-month old. There are several statements like the following: The ASQ authors have determined that an infant must be at least one month old before it’s appropriate to administer the ASQ-3. Likewise, the infant must be at least one month old before it’s appropriate to administer the ASQ: SE-2. Several years ago, we made an MIHP program decision that agencies are not required to administer the ASQ-3 until the infant is at least 2 months old. We made another MIHP program decision to require agencies to administer the 2-month ASQ: SE-2 questionnaire before the infant reaches 3 months old (but not before 1 one month of age per the ASQ authors).
Certification Review 1. Consider putting chart review tool in order of the required documentation, i.e., consents, MRI/IRI, POC 1, POC 2, POC 3 (not in order of audit tool). You may always cut and paste the items to create your own chart review tool. 2. When does Cycle 7 start? Cycle 7 starts November 1, 2017. 3. The cycle changing every time does not help us learn. Why can’t they stay the same twice so we can master it until on to the next cycle? There is a new cycle every 18 months, although the current cycle has been shortened to 16 months to accommodate the changes that Lynette Biery, Director, Bureau of Family Health Services, has outlined for our program. New cycles are necessary to reflect the changing evidence base, Medicaid policy changes and program developments. We are always working to improve program quality and certification review is key to the process. The push for continual quality improvement in health care is stronger than ever. The vast majority of indicators do not change every 18 months. 4. Can the reviewers scan the preliminary findings at the audit as part of QA? The reviewers are no longer providing the Preliminary Findings of Not Met Indicators at the end of the onsite review. Instead, they email this document to the agency within 5 business days after the end of the review. This change is intended to increase the accuracy of the findings. 5. Did you notice that the agencies that had zero Not Mets are large systems?
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Yes, these are agencies that have resources beyond MIHP reimbursement. However, over the years, we have had some smaller agencies that also achieved zero Not Mets.
MIHP Major Changes 1.
What changes, if any, do you anticipate to the MIHP program as a result of federal budget, proposed changes to Medicaid funding, and changes to ADA? At this point, we don’t have enough information about what may happen at the federal level to know whether or not there will be any implications for MIHP, but we trust that The State of Michigan will continue to make the provision of health care services for pregnant women and infants a high priority.
2. 3.
Will MDHHS be asking for input from MIHP providers as they develop the big program changes we heard about today? While making all of these changes this year, bring in a group of coordinators to help identify the issues. We incorporate feedback from the field on an ongoing basis.
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Lynnette said several times that MIHP was returning to its case management roots. I didn’t even know that we left our case management roots (we call it care coordination – we have care coordinators). The only example she gave was that we would be talking with the medical care provider over the phone instead of sending written communications. What is the difference between case management and care management? We will have a session on this at our October, 2017 coordinator meetings.
Other MIHP 1. When did the version.2 of the Op Guide come out and how different is it from the original version 1? This is important, as we spend a great deal of time reading and making notes on this 175-page document. Version.2 was posted on or about January 25, 2017. There were two changes: a. 8.21. “whether or not the beneficiary was asked if satisfied with MIHP services/needs being met must be asked at every visit” was changed to “should be asked at every visit.” b. 8.14. “If you make a referral during this risk assessment visit, document it on the Professional Visit Progress Note or on the optional MIHP Referral Follow-Up form” was changed to “document it in the risk identifier within the comments section.” 2. Is it mandatory to use the revised MIHP confidentiality guidelines? We have an agency form – is that acceptable?
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It is not mandatory to use the revised confidentiality guidelines as your staff confidentiality agreement; you can use your own form for that purpose. However, it is mandatory for all staff to have their own copy of the MIHP Field Confidentiality Guidelines. 3. If you require writing PCP name on PHI consent and client signs but doesn’t want info shared, you increase our risk of violating HIPAA or creating a disruption in the client relationship. If the beneficiary does not want information shared with her PCP, write “Beneficiary refuses to release info to PCP” in the “Name of Prenatal Care Provider” box. If the beneficiary doesn’t have a PCP, write “None at this time” or “N/A” in the “Name of Prenatal Care Provider” box. 4. If the first visit after Risk Identifier is not done within 30 days after Risk Identifier (as stated on required timelines), does client need to be discharged from services? For example, unable to contact client or continues to cancel visits. No, if you intend to keep trying to connect with the client, you would not need to discharge her. Be sure to document this on the Contact Log. 5.
Twins. It is very confusing how to document and how to discharge the 2nd twin. The MIHP Operations Guide (pg. 8.19) states: In the case of multiple births, the following documents are to be completed separately for each infant: 1. 2. 3. 4. 5. 6.
Consent to Participate in Risk Identifier Interview/Participate in MIHP Consent to Release Protected Health Information Risk Identifier Plan of Care ASQ-3 and ASQ: SE-2 Information Summary Sheets Discharge Summaries
The Infant Checklist is completed only for the infant whose Medicaid ID is used to bill the blended visits. The MIHP Operations Guide (pg. 5.18) states: 1. There is a checkbox at the top of the Professional Visit Progress Note (PVPN) to document that a visit was blended. 2. POC 2 interventions provided for the beneficiary whose Medicaid ID is being used to bill are documented in the Domain/Risk Addressed section of the PVPN. 3. POC 2 interventions and any other activities, including referrals, that are done with or on behalf of any of the other multiples are documented under Other Visit Information on the PVPN. 4. The bended visit PVPN is filed in the chart of the beneficiary whose Medicaid ID is used to bill blended visits or in the family chart.
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The Infant Discharge Summary Forms Instructions explain how to complete a Discharge Summary for the twin whose Medicaid ID number is not being used for billing purposes. Please let your consultant know if you still have questions about multiples. 7. I would like clarification on how to provide services to a family when we are seeing baby and mom becomes pregnant. It is very complicated and we have received conflicting directions. The MIHP Operations Guide (page 5.14) states: If you’re visiting an infant and find out that the mother is pregnant, complete the infant visit and document the pregnancy in the infant’s chart. You can come back later to do a Maternal Risk Identifier or you can do the Maternal Risk Identifier that day, as long as you document why it was necessary to do it on the same day (e.g., if requested by the mom or if a great distance must be traveled). Develop the mother’s POC (Parts 1-3), and place it in her chart or add it to the family chart. As is the case for all beneficiaries, the POC must be completed before any professional visits can be provided. Bill the Maternal Risk Identifier visit under the mother’s Medicaid ID. You may choose to continue to bill visits under the infant’s Medicaid ID or to start billing under the mother’s Medicaid ID. Whether or not you are billing under the infant’s ID number, you must complete the ASQ-3s and ASQ: SE-2s on the infant. If you choose to continue to bill under the infant’s ID and additional maternal risks are identified by the Maternal Risk Identifier that weren’t included in the infant’s POC 2 as Maternal Considerations, revise the infant’s POC 2 to incorporate the additional risks. Update and sign the infant’s POC 3, acknowledging the addition of new domains, and send an Infant Care Communication to inform the infant’s medical care provider of the additional maternal risks, if the mother has consented to release PHI to the infant’s medical care provider. 8. Contact beneficiary/referral. Clarify “hospital referral of infant,” please. (For example, excludes a lactation consultant who we collaborate with and is helping us connect vs referring for high needs.) The MIHP must respond to referrals received prior to the infant’s discharge from the inpatient setting within two business days of hospital discharge. 9. Is a car seat at a 45-degree angle considered safe sleep? That info seems a little contradictory. A car seat that is properly installed in a car at the correct angle (45 degrees) is a safe position for baby to sleep for short periods of time while in the car. The infant must be properly dressed (no snowsuits, jackets, etc.), have nothing dangling from the car seat or attached to the car seat that could obstruct their breathing and no blankets/towels draped over the car seat. When the car seat is removed from the car and set on the ground, the angle changes to greater than 45 degrees) and the baby’s airway may be obstructed. This does not mean, however, that if you take a car seat out of the car, set it on the ground and prop it at a 45 degree angle that is safe sleep. To the contrary, a car seat is not a sleep environment that should be used for routine sleep for infants. In addition to potential suffocation risks, car seats are restrictive in nature and do not allow the infant to stretch and move as he/she would in a crib or bassinet. The small motions that babies make when they are laying on their back in a crib or bassinet are critical for their physical 16
development. If baby falls asleep while in a car seat and is not in the car (even if the car seat is at a 45 degree angle), they should immediately be placed to sleep on their back in a crib or bassinet for the remainder of the sleep. 10. Safe sleep. It would be helpful to be informed on why African-American and Indian are more at risk. This is never addressed. At this point, no one knows for sure exactly why African American and American Indian infants are at greater risk for Sudden Unexpected Infant Deaths (SUIDs). Research on this question is underway. Several theories exist and the answer is likely a combination of a number of them. For African American babies, significantly more are placed on their stomach to sleep, a known risk factor for SUID. In Michigan, according to 2012-2014 data from the Pregnancy Risk Assessment Monitoring Survey (PRAMS), 38.2% of African American infants were placed to sleep on their side, stomach, or a combination of positions compared to 16.5% of White infants. Similarly, African American babies are more often placed to sleep with another person (31.6% compared to 17.7% of White infants) and are more likely to sleep outside of a crib (17.2% compared to 9.2% of White infants). These behaviors are likely to increase the risk for SUIDs among African American infants. It is suspected that the increased incidence of these behaviors is due at least in part to cultural and familial traditions related to infant sleep. Additional factors may play a role including lack of safe and stable housing, lack of resources to purchase a safe sleep environment, lack of social supports and lack of access to health care, which impacts both the infant’s health and the caregiver’s access to education on infant health and safety. Moreover, African American infants have higher incidences of known risk factors for SUIDS including exposure to smoking (prenatally and postnatally), prematurity and poverty all of which can contribute to increased deaths. Studies are currently underway to learn more about this. The following is a link to a study that explored why some African American parents are not following the recommendations set by the American Academy of Pediatrics and what health care providers are doing in response: https://www.researchgate.net/publication/262771007_Revisiting_Safe_Sleep_Recommendations _for_African-American_Infants_Why_Current_Counseling_is_Insufficient. In summary, the study was intended to better understand how low-income, African-American mothers understand and act upon safe sleep recommendations for newborns and how providers counsel mothers. Focus groups were conducted with 60 African-American, low-income, first-time mothers and telephone interviews with 20 providers serving these populations to explore provider counseling and patient decision making. The large majority of mothers reported understanding, but not following, the safe-sleeping recommendations. Key reasons for non-compliance included perceived safety, convenience, quality of infant sleep and conflicting information from family members. Mothers often take measures intended to mitigate risk associated with noncompliance, instead increasing SIDS risk. Providers recognize that many mothers are non-compliant and attribute non-compliance largely to cultural and familial influence. However, few provider attempts are made to mitigate SIDS risks from non-compliant behaviors. The study authors suggest that counseling strategies should be adapted to: (1) provide greater detailed rationale for SIDS prevention recommendations; and (2) incorporate or acknowledge familial and cultural preferences. Ignoring the reasons for sleep decisions by African-American parents may perpetuate ongoing racial/ethnic disparities in SIDS. 17
Unfortunately, similar data from Michigan PRAMS on infant sleep behaviors among American Indian and Alaska Native infants is not available due to the small sample size. However, we know from national sources that the SUID rate for American Indians (AI) and Alaska Natives (AN) is two to four times higher than the national average. The Healthy Native Babies Project, which was designed in 2006 to provide local support and resources to promote SUID risk-reduction messages within Indian Country, listed six common controllable risk factors within AI/AN communities that put infants at higher risk for SIDS. • Overheating during sleep • Maternal alcohol used during and after pregnancy • Bed-sharing • Stomach sleeping • Commercial tobacco use during pregnancy and in the baby’s living environment • Soft sleeping surfaces with loose bedding The following link from the Urban Indian Health Institute provides a good overview, as well as resource material, of issues related to American Indian and Alaska Native families and infant sleep: http://www.uihi.org/download/Safe-Sleep-and-SIDS-in-Indian-Country-Broadcast.pdf 11. Are we supposed to be advising our clients as to the health risks of using baby boxes? The research on baby boxes is emerging. They have not been adequately tested for safety and are unregulated. Additionally, they are currently not recommended by the American Academy of Pediatrics as a safe sleep environment for infants. The MDHHS - MIHP position is that use of a baby box requires monitoring and that MIHP should discuss a safe sleep transition plan with the family before the baby outgrows the box (typically by the time the baby reaches 4 months of age or 15 pounds). If families are using the box, additional issues should be discussed including general safety (i.e. box should not be placed on a surface where it could be tipped over, if box is on the floor it should be in an area where pets won’t get in to it or where it will not get stepped on, etc.) and proper usage such as not using the lid to the box, keeping the box dry and away from open flame, etc. Discussion of these safety issues does not equal endorsement of the box. It simply means that if the client chooses to use the box, they are provided with information that will help them to use it in the safest manner possible. The following are links to two sites where additional information about the boxes can be obtained: http://www.cribsforkids.org/packnplayvscardboardbox/ and https://www.nichd.nih. gov/sts/about/pages/faq.aspx 12. Home Visiting Conference. Are we put up in the hotel or do we have to pay? Expenses for lodging and meals (except for meals provided as part of the conference) are not covered; MIHP agencies are responsible for paying these costs. 13. What additional supports, incentives, etc., if any, can be provided to small-business MIHPs vs large entities? All MIHP agencies, at any time, can explore the possibility of obtaining additional funds by writing grant proposals. 18
14. Google voice 2nd number rings to phone. It appears that this question doesn’t apply to MIHP, but if it does, please clarify. 15. Where can we order the MIHP tote bags? MDHHS does not have MIHP tote bags for sale. We are in the process of obtaining information on where you can order MIHP tote bags. 16. Is there a way to streamline the paperwork to allow our programs to focus on providing MIHP services to our beneficiaries? 17. We spend more time doing paperwork than we do seeing our clients (sad emoji). We make every effort to minimize paperwork when we revise the forms at the end of a cycle. 18. Increase I Vaccinate message in the UP. They are not hearing/seeing the message I Vaccinate was started in certain areas of the state. We will inform our immunizations colleagues that MIHP agencies would like to see I Vaccinate in the UP. 19. Please consider statewide marketing/advertising for MIHP so families know what it is before we cold call!! This would advance your goal to enroll more women (especially high-risk). This would be the most cost-effective way to market (PSA, billboards, etc.). 20. It’s great to see campaigns such as “I Vaccinate.” Why hasn’t there been any advertisement via TV, radio, etc., on the MIHP program? Pandora, social media, TV, satellite, etc. We will look into this possibility.
WIC 1. How does a new WIC breastfeeding mom get the breastfeeding WIC package as opposed to the nonbreastfeeding package? When a post-partum mom (fully breastfeeding, partially breastfeeding, or non-lactating) comes into the clinic, there will be a discussion between the Competent Professional Authority (CPA) and client on how she is feeding her infant. From there, an appropriate food package will be assigned. Peer counselors are also available in most clinics to help clients with their breastfeeding needs. Also, as of October 1st, 2017 all local agencies are required to have an International Board Certified Lactation Consultant (IBCLC) on staff. Fully breastfeeding women do get a larger food package, which is an incentive to keep moms breastfeeding exclusively. Please refer to our MI-WIC Policy 7.02 Maximum Food Package for a detailed list of the maximum food packages for each appropriate client category. Please follow this link: http://www.michigan.gov/documents/mdch/7.04_Max_Food_Package_316132_7.pdf
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2. How does a mom switch to a breastfeeding package? Who initiates the discussion? Please see the answer above. 3. Mother, baby was assigned Similac at birth and wants to continue with WIC and has a doctor’s letter. WIC refuses to give her Similac. What can she do? WIC Regulations require that States our size execute an Infant Formula Rebate Contract with a single manufacturer. The current Michigan WIC infant formula manufacturer contract with Mead Johnson Nutrition (Enfamil) is effective November 1, 2016 through October 31, 2021. Staff are unable to authorize non-contract infant formulas, with any other manufacturer (like Abbotts’s Similac) for healthy infants without qualifying conditions. 4. How can a mother get her formula changed, if needed? Does WIC give our Similac or just Enfamil? To switch to another authorized primary infant formula, the caregiver can contact the local WIC clinic. See above regarding authorized primary contract formulas. Similac Alimentum, Similac NeoSure, Similac PM 60/40, and Similac Special Care 24 are approved WIC formulas (see List of Authorized WIC Formulas, Effective 5/1/17) , but are only prescribed for qualifying conditions and require a Special Formula/Food Request form signed by the medical provider. Please refer to MI-WIC Policy 7.03 Food Package for Qualifying Conditions at http://www.michigan.gov/mdhhs/0,5885,7-339-71547_4910_19205_48542-191418--,00.html 5. Are all WIC agencies partnering with Sprout to service 35 families who receive both WIC and food stamps with fresh fruits and veggies delivered to their homes? How long is this service? Will families rotate yearly or will it always be on a first come, first served basis? The State WIC Agency does not partner with Sprout. Local WIC Agencies are expected to follow the State WIC approved process when offering nutrition education for WIC Project FRESH. It is the agency’s responsibility to ensure all nutritional education opportunities are in accordance with WIC policies. 6. I have heard that WIC has to now implement a connection with a home vising program. Is that a state mandate? What connections, if any, will be formally made between WIC and MIHP? According to MI-WIC Policy 6.05 Maternal Child Outreach and Coordination: 1. WIC Staff shall identify WIC eligible/applicants who are pregnant women, infants and children who need health insurance, Maternal or Infant Health Program (MIHP) or other maternal child health or outreach services. 2. WIC shall make available/refer to resources within the agency/community that can provide or coordinate services needed by WIC clients. Reference: http://www.michigan.gov/documents/mdch/6.05_Maternal_Child_Outreach_and_Coord_fin al_080812_394760_7.pdf
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7. Please educate clients at WIC that they can only have one MIHP. We have shared this suggestion with our colleagues at WIC. 8. WIC should present to those working with refugees: Catholic Social Services, Bethany, and Samaritas Lutheran. We have shared this suggestion with our colleagues at WIC.
Comments on the Meeting 1. Need to establish meeting ground rules. Limit sidebars. Be respectful. We can do this. 2. Need more time for questions. Need more time for networking. Need open questions time. Need team building time. Need ability to make complaints Need a motivational speech! We need to leave meetings on a positive note, not heavy material. Need more laughs and positives! We will consider all of these suggestions as we plan future meetings. 3. Tried to put too much content into the day and some presentations were cut short that had good content. Be realistic with timeframes to enhance learning. 4. The coordinator meetings always seem rushed when it comes to the actual MIHP information given. Due to unforeseen circumstances, additional information had to be presented at the last minute. We will try to have more realistic timeframes at future meetings. 5. Need better speakers that are not monotone. 6. The speakers were not captivating. If we don’t need the continuing education credits, why are we forced to stay? You need to stay because you are responsible for providing your staff with the all of the information presented by all of the speakers for professional development purposes. You may choose to leave early, but this will affect your rating on Indicator #44 at your certification review. 7. Loved how consultants tag-teamed! Thank you. 8. Need MHPs at meetings.
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The MHPs are invited to every coordinator meeting. 9. Please make sure all presentations are made available. a. Can you send Lynette Biery’s power point so we can reference it? b. Will Lynette’s slides be made available? They were not included in the handouts and difficult to read on screen. c. Please send out the WIC slides, other slides that were missing, and links to videos. d. Will the WIC slides be made available? e. Will the I Vaccinate toolkit and slides be made available? They are not in the handout. f. Can you send the slide with the most Not Met indicators? g. Please make available the comforting NAS baby handout. h. Can you email Ms. Suzette’s slides? i. Birthing hospitals list was not in the packet. We will post all of the requested materials at https://events.mphi.org. Click on “Educational Offerings” at the top of the page and scroll down to MIHP. 10. Please provide results of chart review with any additional errors found via email or website. We will work on posting the mock chart we used for the chart review activity, along with the answer sheet. 11. Please add Happiest Baby on the Block baby-calming methods (5 S’s) to the safe sleep resource list and MIHP website. We will. 12. Many of the resources given at the trainings are for people in the Lansing or Detroit areas. It would be nice to get some for all areas we serve. We looked at the resources mentioned in the MIHP updates provided at the May meetings and they were all statewide (except for Flint residents and former residents) or national resources. Once in a while, a presenter will mention a resource that is specific to a particular area. 13. October required 2-day training. Will this be open to more than two persons per agency? No, as usual, it will be open to two people per agency. 14. Future topic suggestion: Human Trafficking. There will be a session on human trafficking at the Michigan Home Visiting Conference in August, but we will add this topic to our list of potential MIHP training topics. 15. I am suggesting that we have a more centralized location option for the MIHPs in the Thumb Area. Frankenmuth would be my suggestion. 16. It would be great to have a training in the Central Michigan area: Mt. Pleasant, Bay City, Saginaw or Frankenmuth. 22
Our event planner will take this into consideration. She is always willing to investigate new potential venues. 17. Please consider regular (monthly?) conference calls/go to meetings (web) for MIHP state staff and coordinators in addition to the emails with so much info. CSHCS, the lead program, and WIC do this with policy changes monthly/every other month. This is being planned for every other month. Our first MIHP Community of Practice Call will be on September 26, 2007 from 9-11 a.m. The second call will be on November 30, from 3-5 p.m. 18. Directory of topics on coordinator emails to view archives. We will provide a listing of covered topics twice a year.
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