Free HSRS Long Term Support Module Deskcard - Wisconsin

2009 HSRS LONG-TERM SUPPORT MODULE DESKCARD
MODULE TYPE A HISPANIC / LATINO (Field 7a) Y = Yes N = No RACE (Field 7b) Code up to five. A = Asian B = Black or African American I = American Indian or Alaska Native P = Native Hawaiian or Pacific Islander W = White CLIENT CHARACTERISTICS (Field 8) NOTE: For COP, COP-W, and Locally Matched CIP IB the first Client Characteristic is used for monitoring significant proportions. 34 Developmental disability - brain injury - occurred at age 21 or earlier 35 Developmental disability - brain injury - occurred after age 21* 23 Developmental disability - cerebral palsy 25 Developmental disability ­ autism spectrum 26 Developmental disability - mental retardation 27 Developmental disability - epilepsy 28 Developmental disability - other or unknown 86 Severe emotional disturbance 02 Mental illness (excluding SPMI) 03 Serious and persistent mental illness (SPMI) 04 Alcohol client 05 Drug client 10 Chronic alcoholic 12 Alcohol and other drug client 07 Blind / visually impaired 08 Hard of hearing 32 Blind/deaf 79 Deaf 09 Physical disability / mobility impaired 36 Other handicap 55 Frail elderly 57 Abused/neglected adults/elder 18 Alzheimer's disease / related dementia** 77 Challenging behavior - not for use as first client characteristic. 37 Fragile / frail medical condition - not for use as first client characteristic. 87 Prader Willi 88 Asperger Syndrome 89 Pervasive developmental disorder 91 Hurricane Katrina evacuee 92 Hurricane Rita evacuee 93 Chapter 54/55 adults/elderly * For COP purposes Code 35 clients are counted as physically disabled. ** For COP purposes Code 18 clients under 65 are counted as physical disability; clients 65 and over are counted as elderly. 1

LEVEL OF CARE (Field 9) 1 Highest function screen eligibility is Level I 2 Highest function screen eligibility is Level IIA 3 Highest function screen eligibility is Level IIB 4 Meets functional screen special eligibility Level III only. Has physician's diagnosis of Alzheimer's disease or a related disorder. 5 Meets functional screen special eligibility Level III only special SPMI level or referred from an IMD and does not meet functional screen Levels I or II. 6 Meets functional screen special eligibility Level III only. Is referred under Interdivisional Agreement 1.67 or has lost level of care eligibility under the waivers. 7 Functional screen Level IV - does not meet any of the above level of care or is grandfathered in with ICF 3, 4, or ICF-MR4-level of care determination prior to 11-01-83. 8 Has been ongoing COP recipient since prior to 1-1-86 and is therefore COP eligible without a level of care determination. 9 Has not had a level of care assigned as yet; level of care will be determined PRIOR to service provision. B Brain injury Codes 4, 5, 6, 8, and 9 are not waiver eligible For use with LTS Codes (Field 26) 1, 4, 8, and R M DD1A N DD1B O DD2 P DD3 For use with children's waivers only R DD ­ children all levels S Psychiatric hospital ­ children - MH T Nursing home ­ children - PD U Hospital ­ children - PD MARITAL STATUS (Field 10) 1 Married 2 Divorced 3 Separated 4 Widow / widower 5 Never married 6 Legally separated 9 Unknown / other LIVING ARRANGEMENT (Field 11) PRIOR AND CURRENT 06 State mental health institute - not a current living arrangement - may be used for COP assessment, plan, applicant register 07 ICF / MR: not state center - not a current living arrangement - may be used for COP assessment, plan, applicant register 21 Adoptive home 22 Foster home - nonrelative 23 Foster home - relative 24 Treatment foster home 27 Shelter care facility 30 Person's home or apartment

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State center for developmental disabilities - not a current living arrangement - may be used for COP assessment, plan, applicant register. 33 Nursing home - not a current living arrangement may be used for COP assessment, plan, applicant register. 37 Adult family home 1-2 beds 38 Adult family home 3-4 beds 43 Child group home 44 Residential care center (children) 50 Brain injury rehab unit - hospital 51 Brain injury rehab unit - nursing home 60 Supervised community living - not valid for CIP 1, BIW, CLTS-W. 61 CBRF 5 - 8 beds 63 CBRF independent apartment - not a current living arrangement for CIP 1, BIW, and CLTS-W. 64 CBRF 9 - 16 beds - not a current living arrangement for CIP I, BIW, and CLTS-W. 65 CBRF 17 - 20 beds - not a current living arrangement for CIP I, BIW, and CLTS-W. 66 CBRF 21 - 50 beds - not a current living arrangement for CIP I, BIW, and CLTS-W. Need department approval for COP, COP-W, CIP II. 67 CBRF 51 - 100 beds - not a current living arrangement for CIP I, BIW, and CLTS-W. Need department approval for COP, COP-W, CIP II. 68 CBRF over 100 beds - not a current living arrangement for CIP I, BIW, and CLTS-W. Need department approval for COP, COP-W, CIP II. 70 Residential care apartment complex- only for COP-W and CIP II participants - may be used for COP assessment, plan, applicant register. 98 Other living arrangement - only for COP assessment, plan, applicant register. PEOPLE 05 Living alone 09 Living alone with attendant care 10 Living with immediate family 11 Living with immediate family with live-in attendant care 15 Living with extended family 16 Living with extended family with live-in attendant care 18 Living with others 19 Living with others with live-in attendant care 90 Transient housing situation NATURAL SUPPORT SOURCE (Field 12) 1 Parent 2 Spouse 3 Child 4 Other relative 5 Nonrelative 6 None TYPE OF MOVEMENT / PRIOR LOCATION (Field 13) (Optional for COP assessment, plan, applicant register) N = Relocated from general nursing home F = Relocated from ICF / MR facility D = Diverted from entering any type of institution B = Relocated from brain injury rehab unit 3

SPECIAL PROJECT STATUS (Field 14) I ICF-MR initiative L Recipient of a CIP II loan slot COUNTY OF FISCAL RESPONSIBILITY (Field 15) 01 Adams 26 Iron 51 Racine 02 Ashland 27 Jackson 52 Richland 03 Barron 28 Jefferson 53 Rock 04 Bayfield 29 Juneau 54 Rusk 05 Brown 30 Kenosha 55 St. Croix 06 Buffalo 31 Kewaunee 56 Sauk 07 Burnett 32 La Crosse 57 Sawyer 08 Calumet 33 Lafayette 58 Shawano 09 Chippewa 34 Langlade 59 Sheboygan 10 Clark 35 Lincoln 60 Taylor 11 Columbia 36 Manitowoc 61 Trempealeau 12 Crawford 37 Marathon 62 Vernon 13 Dane 38 Marinette 63 Vilas 14 Dodge 39 Marquette 64 Walworth 15 Door 40 Milwaukee 65 Washburn 16 Douglas 41 Monroe 66 Washington 17 Dunn 42 Oconto 67 Waukesha 18 Eau Claire 43 Oneida 68 Waupaca 19 Florence 44 Outagamie 69 Waushara 20 Fond du Lac 45 Ozaukee 70 Winnebago 21 Forest 46 Pepin 71 Wood 22 Grant 47 Pierce 72 Menominee 23 Green 48 Polk 84 Menominee Tribe 24 Green Lake 49 Portage 92 Oneida Tribe 25 Iowa 50 Price COURT ORDERED PLACEMENT (Field 16) Y = Yes N = No MA WAIVER FINANCIAL ELIGIBILITY TYPE (Field 17) A = Categorically eligible B = Categorically financially eligible - special income limit C = Medically needy D = COP eligible INDICATOR FOR WAIVER MANDATE (Field 18) (Optional for COP assessment, plan, applicant register) A = MA waiver eligible B = Not MA waiver eligible C = MA waiver eligible but exempt CLOSING REASON (Field 20) 05 Moved out of state 06 Died 09 Service not available 11 Not or no longer income / asset eligible 14 Not or no longer level of care eligible 21 Services arranged without agency involvement 24 Insufficient funds in COP to provide services 32 Rejected individual service plan (ISP) 35 Private pay / other public funding sources used to pay for service 38 Voluntarily declined or terminated services 39 Transferred to or preferred nursing home care 41 Transfer to joint lead agency 43 Ineligible living arrangement

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44 45 46 47 48 50 51 52 53 54 55

Moved out of county / closed on LTS Moved out of county / still open on LTS Refused to supply needed financial documentation Transfer to Pace Program Transfer to Partnership Program Not eligible - residency requirement (COP only) Declined further services due to estate recovery Moved to and now resides in DD center Moved to and now resides in ICF-MR Moved to and now resides in IMD Cannot support safe care plan / behavioral challenges 56 Cannot support safe care plan / medical issues 57 No formal / informal supports available in community 58 County has exceeded CBRF cap 60 Transferred to IRIS or Managed Care/Family Care COP SPC / SUBPROGRAM (Field 24) CODE SPC UNITS 095 01 Participant cost share None 095 02 Refunds, voluntary contributions None 101 Child day care Days 102 Adult day care Hours 103 22 Residential respite Hours 103 24 Institutional respite Hours 103 26 Home based respite Hours 103 99 Respite care - other Hours 104 10 Supportive home care / days Days 104 11 SHC - personal care / days Days 104 12 SHC - supervision services / days Days 104 13 SHC - routine home care services / Days days 104 14 SHC - chore services / days Days 104 20 Supportive home care / hours Hours 104 21 SHC - personal care / hours Hours 104 22 SHC - supervision services / hours Hours 104 23 SHC - routine home care services / Hours hours 104 24 SHC - chore services / hours Hours 106 01 Energy assistance None 106 02 Housing assistance None 106 03 Housing start-up None 107 30 Specialized transportation & escort 1 way trips 107 40 Specialized transportation & escort Miles 107 50 Transportation specialized Items 108 Prevocational services Hours 110 Daily living skills training Hours 112 46 Personal emergency response None systems 112 47 Communication aids Items 112 55 Specialized medical supplies Items 112 56 Home modifications Projects Items 112 57 Adaptive aids - vehicles 112 99 Adaptive aids - other Items 113 Consumer education and training Hours 114 Vocational futures planning Hours 202 01 Adult family home 1 - 2 beds Days 202 02 Adult family home 3 - 4 beds Days 5

203 204 205 301 401 402 403 403 403 406 503 506 506 506 506 506

Children's foster/treatment home Days Group home Days Shelter care Days Court intake and studies Hours Congregate meals Meals Home delivered meals Meals 01 Recreation activities Hours 02 Alternative activities Hours 03 Alternative / other Items Protective payments/guardianship None Inpatient stay None** 61 CBRF 5 - 8 licensed beds Days 63 CBRF independent apartment Days 64 CBRF 9 - 16 beds Days 65 CBRF 17 - 20 beds Days 66 CBRF 21 - 50 beds - need Days department approval 506 67 CBRF 51 - 100 beds - need Days department approval 506 68 CBRF over 100 beds - need Days department approval 507 03 Counseling and therapeutic Hours Resources - hours 507 04 Counseling and therapeutic Items/ Resources ­ items/services services 509 Community support None 510 Comprehensive community services Days 603 01 COP assessment Hours 603 02 COP plan Hours 604 Case management Hours 605 Advocacy and defense resources Hours 606 Health screening and accessibility Hours 610 Housing counseling Hours 615 Supported employment Hours 619 Financial management services Hours 704 Day treatment - medical Days 705 Detoxification - social setting None 706 Day services treatment Hours 710 Skilled nursing services Hours CIP IA, IB, IB-ICFMR and BIW SPC / SUBPROGRAM CODE SPC UNITS 095 01 Participant cost share None 102 Adult day care Hours 103 22 Respite care residential Hours 103 24 Respite care institutional Hours 103 26 Respite care home based Hours 103 99 Respite care other Hours 104 10 Supportive home care / days Days 104 11 SHC - personal care / days (opt) Days 104 12 SHC - supervision services / days Days (opt) 104 20 Supportive home care / hours Hours 104 21 SHC - personal care / hours (opt) Hours 104 22 SHC - supervision services / hours Hours (opt) 104 88 Supportive home care - worker None room and board 106 03 Housing start-up None 6

30 Specialized transportation & escort 1 way trips 40 Specialized transportation & escort Miles 50 Transportation specialized Items Prevocational services Hours Daily living skills training Hours 46 Personal emergency None response systems 112 47 Communication aids Items 112 55 Special medical and therapeutic Items supplies 112 56 Home modifications Projects Items 112 57 Adaptive aids - vehicles 112 99 Adaptive aids - other Items 113 Consumer education and training Hours 202 01 Adult family home 1 - 2 beds Days 202 02 Adult family home 3 - 4 beds Days 203 Children's foster/treatment home Days 402 Home delivered meals Meals 503 Inpatient ICF / MR stay None** 506 61 CBRF 5 - 8 licensed beds Days 507 03 Counseling and therapeutic services Hours 507 04 Counseling and therapeutic services Consults 604 Support and service coordination/ Hours case management 604 01 Support and service coordination/ Hours case management - face-to-face contact (optional) 604 02 Support and service coordination/ Hours case management - collateral contact (optional) 604 03 Support and service coordination/ Hours case management - face-to-face home contact (optional) 604 04 Support and service coordination/ Hours case management - other contact (optional) 609 10 Consumer directed supports Days* 610 Housing counseling Hours 615 Supported employment Hours 619 Financial management services Hours 706 10 Day services - adult Hours 706 20 Day services - children Hours 710 Nursing services Hours CIP II, COP-W, and COMMUNITY RELOCATION INITIATIVE SPC / SUBPROGRAM CODE SPC UNITS 095 01 Participant cost share / spend down None 095 02 Refunds, voluntary contributions None 102 Adult day care Hours 103 22 Residential respite Hours 103 24 Institutional respite Hours 103 26 Respite care - home based Hours 103 99 Respite care - other Hours 104 10 Supportive home care / days Days 104 11 SHC - personal care / days (opt) Days 104 12 SHC - supervision services / days Days (opt)

107 107 107 108 110 112

104 104 104 104 104 104 104 106 106 107 107 107 110 112 112 112 112 112 112 114 202 202 402 503 506 506 506 506 506 506 506 507 507 604 604 619 706 710 711

13 SHC - routine home care services / days (optional) 14 SHC - chore services / days (opt) 20 Supportive home care / hours 21 SHC - personal care / hours (opt) 22 SHC - supervision services / hours (opt) 23 SHC - routine home care services / hours (optional) 24 SHC - chore services / hours (opt) 01 Energy assistance - when relocating from nursing home 03 Housing start-up - when relocating from nursing home 30 Specialized transportation and escort - trips 40 Specialized transportation and escort - miles 50 Specialized transportation Daily living skills training 46 Personal emergency response systems 47 Communication aids 55 Specialized medical supplies 56 Home modifications 57 Adaptive aids - vehicles 99 Adaptive aids - other Vocational futures planning 01 Adult family home 1 - 2 beds 02 Adult family home 3 - 4 beds Home delivered meals Inpatient stay 61 CBRF 5 - 8 licensed beds 63 CBRF independent apartment 64 CBRF 9 - 16 beds 65 CBRF 17 - 20 beds 66 CBRF 21 - 50 beds - need department approval 67 CBRF 51 - 100 beds - need department approval 68 CBRF over 100 beds - need department approval 03 Counseling and therapeutic resources - hours 04 Counseling and therapeutic resources - items / services Case management 04 Case management - other contact (optional) Financial management services Day services treatment Skilled nursing services Residential care apartment complex

Days Days Hours Hours Hours Hours Hours None None 1 way trips Miles Items Hours None Items Items Projects Items Items Hours Days Days Meals None** Days Days Days Days Days Days Days Hours Items/ services Hours Hours Hours Hours Hours Days

*Only used with Memorandum of Understanding (MOU) **HSRS days are calculated by counting the SPC Start Date but not the End Date

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CHILDREN'S LONG-TERM SUPPORT WAIVER SPC / SUBPROGRAM CODE SPC 095 01 Participant cost share 103 22 Residential respite 103 24 Institutional respite 103 26 Home based respite 103 99 Respite care - other 104 10 Supportive home care / days 104 11 SHC - personal care / days (opt) 104 12 SHC - supervision services / days (opt) 104 20 Supportive home care / hours 104 21 SHC - personal care / hours (opt) 104 22 SHC - supervision services / hours (opt) 104 88 Supportive home care - worker room and board 106 03 Housing start up 107 30 Specialized transportation and escort - trips 107 40 Specialized transportation and escort - miles 107 50 Transportation specialized 110 Daily living skills training 112 46 Personal emergency response systems 112 47 Communication aids 112 55 Special medical and therapeutic supplies 112 56 Home modifications 112 57 Adaptive aids - vehicles 112 99 Adaptive aids - other 113 Consumer education and training 202 01 Adult family home, 1-2 beds 202 02 Adult family home, 3-4 beds 203 Children's foster/treatment home 503 Inpatient stay 507 03 Counseling and therapeutic services 507 04 Counseling and therapeutic resources 512 604 604 604 604 604 609 610 615 619 706 710 Intensive in-home autism services Support and service coordination Support and service coordination face-to-face contact (optional) Support and service coordination collateral contact (optional) Support and service coordination face-to-face home contact (optional) Support and service coordination other contact (optional) Consumer and family directed supports Housing counseling Supported employment Financial management services Day services - children Nursing services 9

UNITS None Hours Hours Hours Hours Days Days Days Hours Hours Hours None None 1 way trips Miles Items Hours None Items Items Projects Items Items Hours Days Days Days None** Hours Items/ services Hours Hours Hours Hours Hours Hours Days Hours Hours Hours Hours Hours

01 02 03 04 20

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COMMUNITY OPPORTUNITIES & RECOVERY (COR) WAIVER SPC / SUBPROGRAM CODE SPC UNITS 095 01 Participant cost share None 095 02 Refunds, voluntary contributions None 103 22 Residential respite Hours 103 24 Institutional respite Hours 103 26 Respite care home based Hours 103 99 Respite ­ other Hours 104 10 Supportive home care ­ days Days 104 11 SHC ­ personal care days (optional) Days 104 12 SHC ­ supervision services/days Days (optional) 104 13 SHC ­ routine home care services/ Days days (optional) 104 14 SHC ­ chore services/days (optional) Days 104 20 Supportive home care ­ hours Hours 104 21 SHC ­ personal care/hours (optional) Hours 104 22 SHC ­ supervision services/hours Hours (optional) 104 23 SHC ­ routine home care services/ Hours hours (optional) 104 24 SHC ­ chore services/hours (optional) Hours 104 30 Short term supervision & observation Days 106 01 Energy assistance ­ when relocating None from nursing home 106 03 Housing start-up ­ when relocating None from nursing home 107 30 Specialized transportation and escort - 1 way trips trips 107 40 Specialized transportation and escort - Miles miles 107 50 Specialized transportation Items 110 Daily living skills training Hours 112 46 Personal emergency response systems None 112 55 Specialized medical supplies Items 112 56 Home modifications Projects 112 57 Adaptive aids ­ vehicles Items 112 99 Adaptive aids ­ other Items 113 01 Natural supports training Hours 114 01 Vocational recovery Hours 202 01 Adult family home 1-2 beds Days 202 02 Adult family home 3-4 beds Days 402 Home delivered meals Meals 403 04 Peer/advocates supports Hours 506 61 CBRF 5-8 licensed beds Days 507 03 Counseling & therapeutic resources Hours hours 507 04 Counseling & therapeutic resources Items/service 604 Case management Hours 605 01 Benefit counseling Hours 609 20 Consumer & family directed supports Days 609 30 Consumer & family directed support Hours 610 Housing counseling Hours 619 Financial management services Hours 706 Day services treatment Hours 710 Skilled nursing services Hours 711 Residential care apartment complex Days 10

ICF-MR RESTRUCTURING INITIATIVE 896 ICF-MR/NH resident` None REGISTER OF ELIGIBLE APPLICANTS 897 Institutional resident None 898 No publicly funded ongoing service None to meet long-term care needs 899 Some publicly funded ongoing None services but no COP or Waiver service SPC End Date required when COP or waiver service begins, or removed from list. TARGET GROUP (Field 25) 01 Developmental disability 31 Mental health 18 Alcohol and other drug abuse 57 Physical or sensory disability 58 Adults and elderly (age 65 and over) LONG-TERM SUPPORT CODE (Field 26) 1 CIP 1A 2 CIP II 3 COP - waiver 4 CIP 1B 6 BIW 7 COP 8 CIP 1B - locally matched slot B BIW - locally matched slot F Children's autism - DD G Children's autism ­ MH P Children's autism - PD H Children's long-term support - DD state match I Children's long-term support - DD local match J Children's long-term support - MH state match K Children's long-term support - MH local match L Children's long-term support - PD state match M Children's long-term support - PD local match N Community relocation initiative R CIP1B ­ ICFMR S Transfer - sending county cost T COR Community Opportunities and Recovery waiver FUNDING SOURCE (Field 27) Required for LTS codes 8, B, I, K, M CP COP match funding CA Community aids match funding FS Family support match funding RO Conditional release FC ACT-405 AZ Alzheimer's funding (only allowed with SPC 899) LO County tax levy or sales tax FT Family care transfer (only for LTS codes 2, 4) ND Nursing home diversion (only for LTS code 2) MF Money follows the person (only for LTS codes 1, N, R, T) SOS DESK (608) 266-9198 8:00 - 11:30 A.M. and 12:30 - 4:00 P.M. or leave a voice mail message. E-mail Address: [email protected] FAX (608) 267-2437 HSRS Handbook and Terminal Operator's Guide: http://www.dhs.wisconsin.gov/HSRS/index.htm 11

WI Department of Health Services Division of Enterprise Services F-22018I (Rev. 01/2009)

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