5. Referral, Coordination and/or Monitoring of Services

Applies to staff activities that include making referrals to, coordinating, and/or monitoring the delivery of specific LTSS or other health care services or other supports that may prevent someone from going into an institution.  This code refers to specific services or supports. Relevant activities include:

• Referral and/or coordination of services including gathering any information that may be required in advance of referrals, evaluations and provision of services. 
• Monitoring individual’s services and supports, excluding monitoring service providers as an entire agency
• Preparing documentation for case review, monitoring an individual’s case, including meeting with support staff to discuss care, visiting an individual who is a ward of the county/state, and accompanying individuals to appointments.
• Gathering information for facilitating prior authorizations, including following up with other partner agencies for information.
• Providing follow-up contact to ensure an individual has received services. 
• Arranging for transportation for an individual or family to access services, as well as arranging for or providing interpreter (including sign language) services that assist an individual or family to access and understand services.

Additional considerations for time study:
This code should be used for all activities related to referral, coordination or monitoring of services, including:

• Paperwork 
• Clerical activities, including making copies of related materials and faxing related information
• Time spent reviewing voicemails or emails
• Time spent consulting with a supervisor or co-workers or supervising  
• Conducting research on related topics
• Travel including time spent arranging transportation 
• Time spent entering information about the activity into a database or software program
• Calls, emails, or other communications to obtain clarification of an inquiry

Do not use this code if the activity is part of conducting the assessment or developing the support plan.


Time Study Codes

• 5a. Medicaid related- Use when (1) a participant is Medicaid eligible or (2) facilitating access to a Medicaid covered service (e.g., assisting a non-Medicaid eligible individual to access a Medicaid funded personal care).
• 5b. At risk for spenddown and institutionalization- The following criteria must be met to select this code:
• The time must be spent assisting an individual in accessing supports that may prevent or delay the individual from entering a nursing facility or other Medicaid-funded institution; and
• Individual determined to be at risk of institutionalization, at risk of spenddown as indicated by the Hawaii Spenddown Worksheet, AND have a Support Needs Screen score of 2 or higher.                   
• 5c. Not Medicaid related- Use for all other referral, coordination and/or monitoring of services activities, such as social services, educational services, legal services, housing services, Food Stamps and nutrition services, employment and job training.