Provider News Bulletin

Q3 2024

Attention DD Providers! Are you looking for individuals to enroll in your waiver programs or thinking about expanding a program? Several Care Design NY members are approved for services and seeking enrollment in various programs. Care Design NY's NDPR team has begun providing this data on a monthly basis. You should receive this email mid-month and it will highlight the number of members seeking a waiver service in each region. We hope this data is helpful for agencies to understand current program needs in your region. 

If you have not received this information and would like to be added to the mailing list, please open a ticket with NDPR and we can assist to ensure you get this information moving forward. Providers can also access this information on our website.

If you have feedback or suggestions for future provider webinars, please share your thoughts with the Provider Relations department here.

This education series is open to Care Design NY members, families, and the public and will be held via Microsoft Teams.

With the transition from Medicaid Service Coordination (MSC) to Care Management, the Life Plan replaced the Individualized Service Plan (ISP) as the document guiding service delivery. The Life Plan is meant to be centered around the person being supported, capturing their desires and needs and documenting goals and supports that assist the person to live a safe, healthy and satisfying life. 

OPWDD Waiver Service Providers and the Care Manager are all critical to supporting individuals in the development of their Life Plan. Each of us has distinct and equally important roles in this process, many of which are driven by regulations and requirements. In general, the Care Manager facilitates the Life Plan Process with input from the individual, their circle of support, and their service providers, and the providers put the plan into action. At times it can feel challenging to develop a plan that takes all of this into account while not losing focus on the individual. After all, the Life Plan is their plan. 

At CDNY, we have developed internal best practices focused on the Care Manager’s role in the Life Plan development process. We hope that by sharing those practices here you will have a better understanding of why Care Managers facilitate the Life Plan processes in a particular way, what to expect during the process, and how you can best collaborate with Care Managers to ensure your critical role is included. 

The Life Plan process challenges us to look at the whole person. This includes exploring what is most important to the person – their desires, hopes and dreams, as well as what may be most important for them in areas including healthcare and mental health. To meet these expectations, a high-quality preparation process is needed. For this reason, at least a month before the Life Plan meeting, the Care Manager will complete the IAM (It’s All About Me) Assessment and other recent assessments (such as the CAS, CANS and DDP-2) with the person and, when appropriate, their advocate/natural supports. The Care Manager will also review recent events, including medical appointments, hospitalizations, and new/updated evaluations and assessments. Providers should expect Care Managers to engage them in this process. This is a critical time for you to share information about your ongoing work with the individual, which may mean sending any new evaluations to the Care Manager. Important information and documents to consider sharing include: medical/health status, Plans of nursing Services, Behavior Support Plans, medication updates/changes, safeguard needs and Staff Action Plans. 

Following the assessment process, the Care Manager creates a draft Life Plan based on the information gathered. At least seven days before the Life Plan meeting, the Care Manager will send the draft Life Plan to the person and/or their advocate, as well as to waiver service providers, for review. It is important that providers review the draft Life Plan and provide any initial feedback at this time. It is also highly recommended that you use this time to prepare a draft Staff Action Plan to be brought to and discussed at the Life Plan meeting. 

During the Life Plan meeting, the Care Manager is responsible to ensure that the person is the focus of the meeting and should provide them an opportunity to open the meeting and provide input to the Care Manager and provider(s) about their expectations for the meeting. The Care Manager will ensure the draft Life Plan is reviewed and everyone participates. The Care Manager and providers should discuss the goals and safeguards in the Life Plan to ensure they make sense to the person, and all should come to an agreement on how each provider can collaboratively address the goals in a way that keeps the person at the center. All meeting participants should leave the meeting with a good understanding of what the finalized Life Plan will look like. The connection of high-level goals on the Life Plan to detailed activities to be included in the Staff Action Plan should be fully discussed. This will help ensure an accurate Life Plan without need for extensive revisions. It is recommended that the Care Manager, individuals and providers close out the meeting by scheduling the next Life Plan meeting review date. 

After the Life Plan meeting, it is critical for the Care Manager to complete the new Life Plan and get it approved by the person and/or their advocate in a timely manner. This ensures individuals can quickly receive needed services and have goals addressed efficiently. When finalizing revisions to the draft Life Plan, Care Managers may reach out to the individual/advocate and provider(s) to ensure accuracy on any areas not fully discussed during the Life Plan meeting. Care Management supervisory oversight is also engaged during this time to ensure all required Life Plan elements are included. The Care Manager will then send the Life Plan to the person/their advocate for written approval; once signed by the person/advocate, the Life Plan is considered finalized and will be sent to the person’s service provider(s) for agreement and implementation. Waiver providers should send the finalized SAP to the Care Manager. 

Care Management Leadership is always available to answer questions about the person-centered Life Planning Process. We look forward to continued collaboration with all our valued provider partners in supporting individuals to achieve their life goals.

Please contact the Network Development and Provider Relations team by opening a ticket here with any questions or concerns. 

 Thank you, 

 Care Design NY 

 Network Development and Provider Relations