1040 Children`s Respite Criteria & Instructions

Individuals with Developmental Disabilities
(Child 74-120)
Respite Entrance and Exit Criteria
Entrance Criteria
All criteria must be met to qualify for respite service
1. Consumer meets general admission criteria as a person with a Developmental
Disability, as defined in the Michigan Mental Health Code AND
2. Meets criteria for medical necessity AND
3. Resident of St. Clair County AND
4. Adult or child living with family or other natural, unpaid support givers* AND
5. Natural supports do not meet family’s respite needs based on D. D. Respite
Assessment (assessment to be developed by workgroup) AND
6. Family requests respite service
*When ADULT support giver is not being paid through Home Help/Chore Services or CLS OR when
CHILD support giver is not being paid through foster care.
Exit Criteria
Any one of the following would disqualify from respite service
1. Consumer relocates out of service area
Goals and dreams in the PCP have been substantially met and the consumer
no longer requires or desires respite services through CMH
3. Consumer no longer resides with family or other unpaid natural supports
4. Consumer remains with family or other unpaid support, but the natural support
network is now sufficient to meet the family’s respite needs
5. Consumer withdraws their consent for services
6. Consumer no longer meets entrance criteria
FORM #1040 Instructions
Rev. 2/14
Children with SED
Respite Entrance and Exit Criteria
Respite care services must only be provided on an intermittent or short-term basis due to the absence or
need for relief of the parent. “Short-term” means respite service is provided during a limited period of
time, for example, a few hours, few days, weekends, or vacation. Respite is not intended to be provided
on a continuous, long-term basis where it is a part of daily services that would enable an unpaid caregiver
to work.
In keeping with the Medicaid guidelines, Respite funds will be used to stabilize the high need
child/adolescent enabling them to remain in the home and community.
Admission Criteria: all criteria must be met
● The child/adolescent is a resident of St. Clair County and living with a parent/legal guardian.
(Foster Care parents are not eligible)
● The child/adolescent has been diagnosis with a serious emotional disturbance.
● The child/adolescent is under the age of 18 years.
● The child/adolescent meets criteria for medical necessity; in that, respite is required to assist/
maintain a goal of living in a natural community home by temporarily relieving the unpaid
primary caregiver.
● The child/adolescent has an open case with (CMH agency) and respite has been identified as
a need through the Family Centered Planning process.
● Family of a child/adolescent has insufficient natural supports to meet the family’s respite needs.
● The child cannot be receiving respite services from another program.
Authorization Guideline
Above 150
CAFAS Caregiver Score
Since respite is a temporary
relief for the primary caregiver, the score is considered
in the medical necessity
Hours of Respite per week
Up to 2 hours
Up to 4 hours
Up to 6 hours
■ For CAFAS score over 150, services must be part of
a plan that includes intensive community-based
mental health services
■ The amount of respite considered for authorization
will be based on the recommendation made by the
family centered planning team to the program
Continuing Stay Criteria
● Respite is meant to be a temporary support; therefore it should be authorized for a 3 month period of time.
Medical necessity must be fully established for each new authorization.
● Current symptoms and or functional impairments continue to meet admission criteria.
● Community options/natural supports which would meet the family’s respite needs are not available.
Discharge Criteria
● The family’s need for respite has been substantially met.
● The family is able to transition to community options/natural supports which would meet their respite needs.
● The child/adolescent no longer meets the admission criteria.
● The family withdraws consent for respite services.
● The family is non-compliant with the Family Centered plan of service.
Individuals with Developmental Disabilities
FORM #1040 Instructions
Rev. 2/14
(Child 74-120)
Respite Assessment
Training/Completion Instructions
The intent of the DD Respite Assessment is to standardize the assessment and authorization of
respite services across the St. Clair County CMH service area. As this assessment has been
developed and approved by the agency, it is the expectation that all clinicians and supports
coordinators will implement it in the standardized manner expressed in the instructions.
The definition of respite per the Michigan Medicaid Provider manual is “to provide an
occasional and intermittent break to the caregiver.” The tool is designed to look at potential
contributors related to the consumer’s support needs which may or may not take away from the
caregiver’s ability to function day to day, have adequate sleep time, have positive relationships
and get things done. Stress is not the rationale behind respite. Stress is subjective and occurs
without the responsibilities of parenting or caring for a disabled individual. Some people deal
with stress better than others.
Who completes and when assessment is completed:
The assessment should be implemented when a new consumer comes into services and annually
(MINIMUMLY) prior to the Person Centered Plan by the Support Coordinator/Designee based
on their knowledge of the consumer and family circumstances. It should be completed more
frequently as changes in family support system, natural supports, and/or additional services occur
for the consumer/family. If a family experiences a change in circumstance where upon reassessing may qualify for additional hours, the Support Coordinator/Designee should authorize
those additional hours in a specified short-term number of weeks to assist them through that
circumstance. This is, of course, after other potential services have been assessed for to possibly
provide support for the consumer/family. Ensure that you are differentiating between a family’s
choice and true need.
Assessment Format:
The assessment is divided into five areas which identify the level of support needed by the
consumer, level of support currently being provided to the consumer, medical and/or behavioral
intensity of the consumer and level of functioning by the consumer or support provided by the
caregiver for personal care and daily living skills. These are not meant to assess for specific
levels of Community Living Skills, Home Help/Chore Services, or parental stress but, may
assist you in determining other resources that may need to be addressed or pursued.
Rating Scale and Authorization:
Upon completion of the assessment, the scores for each section will be transferred to the rating
scale where the number of hours to be authorized will be determined.
FORM #1040 Instructions
Rev. 2/14