The AFC provider must ensure the delivery of direct care to members in a qualified setting as described in 130 CMR 408.435 by a qualified AFC caregiver, as described in 130 CMR 408.434, who lives in the residence and who is selected, supervised, and paid by the AFC provider. AFC must be ordered by a PCP and delivered by a qualified AFC caregiver under the supervision of the RN, LPN, & the MDT, in accordance with each member’s written plan of care. Direct Care includes 24-hour supervision, daily assistance with ADLs and IADLs as defined in 130 CMR 408.402, and other personal care as needed.

The AFC provider must provide nursing oversight by a registered nurse who meets the qualifications as described in 130 CMR 408.433(C)(2)(a), who is not related to the member, who is licensed in MA, a Licensed Practical Nurse meeting the qualifications ooutlined in 130 CMR 408.433(E)(a),   Nursing oversight services must be individualized to meet the needs of each member in accordance with the member’s plan of care, and must include all of the following activities:

1. Identifying member expectations of lifestyle, interests, cultural/spiritual, indicators of quality of life together with the member.
2. Completing or coordinating all applicable clinical assessments & clinical evaluations in collaboration with the member, gathering member information re: health status, cognitive abilities, behavioral challenges, and medical conditions.
3. Developing the member’s interim & final AFC plan of care, with input from the member or responsible party, all members of the MDT, & other individuals designated by the member.
4. Completing a semi-annual health status report for each member.
5. Ensuring implementation of the AFC plan of care by all involved.
6. Coordinating the delivery of AFC with any other health services or supportive services the member is receiving from MassHealth or other agencies or organizations, including but not limited to, visiting nurse services, therapy services, Department of Developmental Services (DDS) services, Department of Mental Health (DMH) services, and Massachusetts Rehabilitation Commission (MRC) services;
7. Conducting on-site visits with each member at the qualified setting:
8. LEVEL 1 SERVICE MEMBERS: for members authorized for level I service payment, conduct on-site visits every other month, or more often as the member’s condition warrants, where such visits alternate with the required visits by the care manager to ensure the member receives one visit by the nurse or care manager every month, provided that, as determined by the MDT in accordance with 130 CMR 408.433(B), a Community Health Worker may conduct up to three (3) non-consecutive on-site visits per 12-month period in place of the registered nurse.
9. LEVEL II SERVICE MEMBERS: for level II service payment, conduct on-site visits every month, or more often as the member’s condition warrants, to ensure the member receives one visit by the nurse and one visit by the care manager every month, provided that, as determined by the MDT in accordance with 130 CMR 408.433(B), a Community Health Worker may conduct up to six (6) non-consecutive on-site visits per 12-month period in place of the registered nurse.
10. Completing a nursing progress note for each on-site visit or encounter and upon significant change.
11. Monitoring each member’s health status and documenting those findings in the member’s medical record for each on-site visit or encounter, or more often as the member’s condition warrants.
12. Disease education/management about resources/preventive care.
13. Accessing emergency services/care.
14. Educating the member about hygiene and health concerns/health advocacy.
15. Reporting changes in the member’s condition to the member’s PCP.
16. Coordinating the implementing the PCPs form & approval for AFC with the member, AFC caregiver & AFC provider personnel.
17. Developing, in conjunction with the MDT the AFC caregiver, and the member or responsible party, an emergency backup and personal care contingency plan for each member receiving AFC that includes an alternative plan for the member if the AFC caregiver is temporarily unable to provide care; and
18. Overseeing, monitoring, supporting, training, and evaluating AFC caregivers.
19. Qualified setting safety management on visits.
20. Specialized healthcare procedures/techniques as applied to individual members.

Care management must be provided by a qualified AFC care manager, as described in 130 CMR 408.433(C)(3)(a), who is not related to the member, and who is responsible for coordinating care and monitoring the needs of the member in conjunction with the registered nurse.

Care management performed by the AFC care manager shall include the following activities:

1. Identifying member expectations of lifestyle, interests, cultural/spiritual, indicators of quality of life together with the member.
2. Conducting initial and ongoing psychosocial evaluation of a member’s appropriateness for AFC in collaboration with the member.
3. Completing the qualified setting home study.
4. Evaluating, supporting, and training AFC caregivers.
5. Assisting with the development of the member’s interim and final AFC plan of care with input from the member or responsible party, all members of the MDT, and other individuals designated by the member.
6. Ensuring implementation of the AFC plan of care.
7. Conducting on-site visits with each member at the qualified setting:
8.      LEVEL I MEMBERS: for level I service payment, conduct on-site visits every other month, or more often as the member’s condition warrants, where such visits alternate with the required visits by the nurse to ensure the member receives one visit by the nurse or care manager every month, provided that, as determined by the MDT in accordance with 130 CMR 408.433(B), a community health worker may conduct up to three (3) non-consecutive on-site visits per 12-month period in place of the AFC care manager;

1)     LEVEL II MEMBERS: for level II service payment, conduct on-site visits every month, or more often as the member’s condition warrants, to ensure the member receives one visit by the nurse and one visit by the care manager every month, provided that, as determined by the MDT in accordance with 130 CMR 408.433(B), a community health worker may conduct up to six (6) non-consecutive on-site visits per 12-month period in place of the AFC care manager.

1.  Assisting with coordination of AFC with any other health services or supportive services the member is receiving from MassHealth, a managed care organization, an accountable care organization or other agencies or organizations including, but not limited to, visiting nurse services, therapy services, Department of Developmental Services (DDS) services, Department of Mental Health (DMH) services, and Massachusetts Rehabilitation Commission (MRC) services.
2.   Completing a care manager progress note corresponding with each on-site visit or encounter, or more often as the member’s condition warrants.
3.   Reporting changes in the member’s condition to the member’s AFC registered nurse;
4.   Assisting with making referrals to appropriate service providers if the member requires services other than those provided by the AFC provider.
5.  Conducting regular, periodic evaluations, at least annually, to ensure that each qualified setting where AFC is provided meets the requirements of 130 CMR 408.435.

            vii.   Providing timely assistance and responding to urgent or emergency needs of the member.

          viii.   Developing, in conjunction with the MDT, the AFC caregiver, and the member or responsible party, an emergency backup and personal care contingency plan for each member, receiving AFC that includes an alternative plan for the member if the AFC caregiver is temporarily unable to provide care.

1.    Qualified setting safety focus on visits.
2.    Education on community services available.

Accordion Content

A community health worker with at least 1 year experience working with elders & adults with disabilities, will provide members & caregivers culturally appropriate health education, information, support & counseling, participate in development, implementation & ongoing review of the POC, complete visit notes & conduct on-site visits according to MassHealth statutes in collaboration with the member.

MEMBER VISIT GUIDELINES: The MDT may determine when the community health worker visits are appropriate in place of the RN/LPN or Care Manager visit based upon needs.

The CHW may provide visits in place of the RN or CM only as follows:

1. LEVEL I MEMBERS:
2. RN/LPN VISITS:conduct up to three (3) non-consecutive on-site visits per 12-month period in place of the RN/LPN.
3. CM VISITS:conduct up to three (3) non-consecutive on-site visits per 12-month period in place of the AFC care manager.
4. LEVEL II MEMBERS:
5. RN/LPN VISITS:up to six (6) non-consecutive on-site visits per 12-month period in place of the RN/LPN.
6. CM VISITS:up to six (6) non-consecutive on-site visits per 12-month period in place of the AFC care manager.

VISIT DOCUMENTATION:  documentation of visits will include findings as well as any actions taken to address issues or problems discovered.

5. The Scope of our Providers services is shared with:
6. Members served by our services upon start of service with our Provider
7. Staff & Caregivers upon hire/contract with our Provider
8. Referral sources
9. Payer sources
10. Other involved individuals
11. The general public through marketing materials