The Missouri Department of Social Services and families of seven children with medically complex conditions settled a suit against the agency alleging it failed to meet federal requirements it provide approved in-home nursing services.
"Medically complex" describes the health status of a child who has a medical condition (or multiple conditions) that require ongoing specialized care. The condition may vary from rare illnesses to premature birth and may involve some sort of physical trauma.
By entering into the agreement on Aug. 31, Social Services denies any liability in connection with plaintiffs' claims. But Social Services agrees to a number of stipulations.
"Among other things, the settlement agreement incorporates measures to improve the availability of in-home nursing and care coordination services for these children," according to a Missouri Department of Social Services news release.
Staff at Social Services and MO HealthNet, the Missouri Medicaid program, were already trying to determine how to provide in-home nursing services, a challenge states are facing across the nation, according to Todd Richardson, MO HealthNet director. MO HealthNet is Missouri's Medicaid system.
"MO HealthNet was actively undergoing efforts regarding increasing nursing services and options for medially complex children, and this settlement gives us the unique opportunity to continue to collaborate with the plaintiffs and their advocates, as well as with industry stakeholders, to bring creative solutions to address nursing shortages and to support these children and families in the best ways possible," Richardson said.
The settlement helps the state avoid protracted litigation, while improving access to care and services, said Jane Perkins, legal director at the National Health Law Program, one of the organizations representing the families.
"The stark reality is that there are Medicaid-enrolled children with complex medical needs in states across the country who are not receiving the in-home nursing care they need," she said in the Social Services news release. "The stakes are life and death for these children, and the strain it places on families is tremendous. We hope this settlement will be helpful to other states as they work to improve coverage."
The settlement may be found at https://bit.ly/3xum10G.
"Plaintiffs' complaint in this action included factual allegations to support claims that defendants are violating federals statutes prohibiting disability discrimination (The Americans with Disabilities Act and ... the Rehabilitation Act) and the Medicaid Act, and sought declaratory and injunctive relief on those claims," the settlement states.
The parties entered the settlement to achieve four goals:
• Implement changes to Social Services' policies, procedures and practices that will bring more timely relief to plaintiffs, who are not receiving "private duty nursing" (PDN) services that they have been authorized to receive.
• Ensure the children authorized to receive PDN receive as much of the services authorized as possible.
• Ensure plaintiffs who do not receive all medically necessary services that they need to safely remain in the most integrated setting appropriate to their needs receive the service and crisis planning needed to ameliorate the risk of unnecessary institutionalization they faced.
• Avoid delay and expense and conserve judicial resources, as the parties recognize that this case involved legal issues that may take a prolonged time to fully litigate and resolve and further recognize that continued litigation will be expensive, lengthy and time-consuming.
Among other things, Social Services is required to explore the feasibility and adoption of a medical day care model and expanded use of telemedicine for virtual care management. The department is to explore health homes for medically fragile children and crisis support teams to address the acute needs of children not receiving PDN.
Social Services is required to take all actions necessary to implement increased Medicaid reimbursement rates for PDN services and is to publish a bulletin notifying PDN agencies of its expectations that rate increases pass directly to nurses providing care.
Social Services' service coordinators are to remain informed on discharge planning with children's families, and to document children's concerns, expected outcomes and priorities. Coordinators are to work with hospitals to arrange in-home PDN services so children who are medically stable can be discharged into community placements with necessary supportive services.
Coordinators are to document efforts to connect in-home PDN and other supportive services, and identify any foreseeable barriers to children receiving PDN. When a child is not receiving all authorized PDN hours (and faces imminent hospitalization) the coordinator is to work with the family to implement a back-up plan (which is to be re-evaluated quarterly to address current crises). If a child may benefit from additional services because of a change in their needs or because he or she is not receiving authorized PDN services the coordinator will refer their families to other providers, Department of Mental Health or other community resources.
DSS is to assure all children who receive services through Managed Care (Medicaid health care delivery system in which Medicaid pays a set amount to providers per month to provide health care for individuals with complex conditions) are assessed for all Medicaid-reimbursable services for which they might qualify, no less than twice annually. DSS must publish a provider bulletin regarding its policy allowing a child to receive more than 16 hours of PDN services in unique circumstances.
DSS is to report to plaintiffs' counsel quarterly, providing aggregated information broken down by county, recording the number of children authorized to receive PDN, the amount of PDN authorized and the amount of PDN delivered.