Categories
< All Topics
Print

Home Mod/DME/SME Process

Home Modifications 

Home modifications are defined as environmental interventions aiming to support activity performance in the home. More specifically, home modifications often are changes made to the home environment to help people with functional disability or impairment to be more independent and safe in their own homes and reduce any risk of injury to themselves or their caregivers. 

Examples of Home Modifications include: Grab bars, stair glide, walk-in shower, ramp, VPL, door widening, handrails, railings. 

Process 
  1. Service Coordinator (“SC”) receives a request from the participant (“ptp”) and schedules a Change Event visit to complete a Comprehensive Needs Assessment
    • SC is also responsible for assisting the ptp with obtaining Proof of Home Ownership (POHO). Types of valid POHO include:
      • Mortgage Statements, Annual Property Tax Statements, and/or Warranty Deeds
        • If multiple names are on the POHO document or the participant has a landlord, then a notarized letter is needed.
          • This letter must include: Relationship to the participant, address of the home, and it must state they are granting permission
          • This letter must explicitly give PHW permission to complete a home modification and should NOT specify the exact modification being requested.

The notarized letter MUST be handwritten with a signature. It CANNOT be emailed
The SC is required to follow-up with the participant weekly until documents have been received

  1. Complete the Comprehensive Needs Assessment and ensure the need and request for the Home Mod is put in appropriately.
  • InterRAI sections G and Q must be completed accurately to reflect need for Home Mod. 
    • i.e. participant requests a stair glide but section G shows participant needs limited assistance climbing stairs, and section Q does not indicate that the participant does not need assistance maneuvering through rooms, then the request will be denied. 
  • Signed PCSP with the Home Modification request in the Service Plan.
    • PCSP must state: “Home adaptations evaluation is needed”; and indicate the participants’ barrier. (ie. Home adaptations evaluation is needed, the participant cannot maneuver up and down the stairs to the second floor. The bathroom and bedroom are on the second floor of the home.) 
      • This will allow the evaluator to determine if it is safer to have railings, stair glide, or other modifications in that specific home/situation. 
    • Amount – 1 unit
    • Provider – TBD
  1. Complete Service Request Tool (SRT) 
    • SRT should indicate the exact modification being requested. 
  1. Upload POHO to Envolve under document upload, document category: “long term services and supports’, document type: “POHO”

If an HA request is denied due to a lack of information and then the information is received after the denial  letter was sent the SC should consider this to be a NEW REQUEST and submit a NEW SRT indicating the NEW DATE the request is being submitted.

NOTE: PAHW will carry out the rest of the process in regards to evaluations and installation quotes. 

NOTE: Building new rooms is EXCLUDED as well as improvements to the home of general maintenance. 

Home Modification Repairs

If the SC has been informed from the participant that they need a repair of any kind to a previously installed modification:

  • The SC should confirm with the participant who the provider was. 
  • The SC may reach out to the provider to confirm if the installation is still under warranty.
    • If the installation is under warranty, the provider should be notified of the repair that is needed so they can schedule to go to the participants home and evaluate.
  • If the installation is no longer under warranty, the SC is required to confirm the make and model number of the modification. 
  • The SC can add this service to the PCSP, including the make and model number.
  • SRT is required

Durable Medical Equipment/ Specialized Medical Equipment 

Examples of DME: (Reusable): wheelchair, walker, recliner, hoyer lift, scooter, hospital bed, cane, commode, etc. 

Examples of SME: (Disposable): wet wipers, barrier cream, gloves, incontinence supplies such as: diapers, pads and liners.

Process

If the Participant is requesting Durable Medical Equipment:

  1. SC receives the request and assists the participant with obtaining a script from their Primary Care Physician
  • The PCP should send the script to the chosen provider. 
  • If the PCP sends the script directly to the SC, the SC may utilize the vendor form to send the request with the script to the chosen provider.
    • It is recommended that the SC inquire if the item being requested is covered by the chosen provider prior to sending the documents.
  1. If the item was successfully covered by insurance, the SC adds all requested items to the PCSP during the NEXT visit. PAHW requires to see all services that the participant is receiving.
  • The PCSP should state: “This item is covered under Medicare (or other insurance)”.
  • Anytime the PCP sends a script to the provider, an SRT is not needed even though the participant only has MA and no Medicare, unless otherwise specified through a task.

In certain circumstances, the item being requested may be denied by the participants insurance. If this happens, the SC will receive a task requesting the assistance to obtain denial paperwork from the provider. Once the SC obtains these documents, they must be uploaded to Envolve and call into PHW to task the Waiver queue.

If the Participant is requesting Specialized Medical Equipment (Monthly Supply Items):

  1. The SC must schedule a Change Event visit since a new service is being requested.
  • When adding monthly supply items to the PCSP, They must be added by how much the participant will utilize DAILY (ask the participant how much they use daily on average during the assessment).
    • PCSP should PCSP should state: the participant needs ‘x’  amount of ‘x’ per day on average and “size”. 
    • The SC should also add the name of the chosen provider for PHW to utilize
  • The InterRAI should match what is being requested on the PCSP. For instance, if the participant is requesting diapers, section H should indicate issues with incontinence.
  • SRT is required.
Keep in mind the following: 
  • Recliners: 
    • Recliners are only partially covered by insurance and must be added to the PCSP with an SRT. 
    • The SC is required to assist the participant with obtaining a script. 
      • Two scripts are required and must be uploaded to Envolve 
        • chair portion of lift chair 
        • mechanical portion of seat lift 
    • The PCSP must state the following: 
      • “chair portion of lift chair” 
      • Do not add “recliner” 
  • Glove Requests: 
    • Please instruct the participant to first reach out to their HHA/PAS provider for gloves as they are the first provider. 
    • If for some reason the PAS provider is unable to supply gloves then the request may be made by following the above process. 
  • Diagnoses: 
    • Items will require a specific diagnosis 
    • Participants may not always be eligible for what they are requesting. 
      • i.e. If your participant is requesting diapers, but your InterRAI reflects that they are not incontinent and they do not have any incontinent diagnosis, then they will not be qualified to receive diapers. 
    • This goes for insurance AND waiver coverage. 
  • Order of Mobility with DME items
    • A participant who is requesting a walker and a wheelchair will need to decide which is more pertinent to their needs.
      • i.e. If the participant already has a wheelchair, they cannot receive a walker, if they have a walker already, they cannot receive a cane. If they start with a cane then they ARE allowed to receive a walker, and then a wheelchair but this cannot go in reverse order.

Previous HEDIS Assessment Guide
Next OPS-8 Process Guide
Table of Contents