This section provides an overview of each agency currently
participating in the NWD Network. Staff at all NWD agencies are expected to
understand and remember this information so that they will be able to identify
when a referral may be appropriate.
The section also describes a crosswalk that provides more
detail about the agencies and programs.
Staff are not expected to remember this level of detail but can use this
crosswalk when working with an individual to try to provide more information
about what another agency offers.
Adult Mental Health Division (AMHD)- Overview: AMHD is a statewide organization that provides mental health services for a subset of adult consumers with serious mental illness. Not all individuals with mental illness will qualify for AMHD services, and it is important for Door staff to consider additional referrals when referring to AMHD. However, it is important to note that all individuals experiencing an immediate mental health crisis, including individuals enrolled in Medicaid or who have other insurance, may contact the Crisis Line. All other individuals should contact the Central Contact line.
- Target Populations: The primary focus of AMHD is to provide services to adults (18+) with a severe and persistent mental or behavioral health issue (SPMI) who are uninsured or underinsured; are court ordered for evaluation, care, and custody to the Department of Health; and individuals in crisis. Individuals enrolled in Medicaid are considered insured, and, therefore, are generally not eligible for AMHD services.
- Programs:
- The Hawaii CARES Program is a 24/7
resource to access a team of trained and experienced professionals to help all individuals
in times of a mental health crisis. More information can be found at https://hicares.hawaii.gov/
resources/ - Community mental health services- Outpatient clinics providing mental health services and supports
- Clubhouses- Member-driven psychosocial rehabilitation and skill-building programs that focuses on improving quality of life through gainful employment and positive relationships.
- Hawai‘i Certified Peer Specialist (HCPS)- HCPS are persons in recovery from a mental illness who have received certification from AMHD to provide AMHD consumers with support in prompting self-determination, personal responsibility, and community integration.
- Hawai‘i State Hospital- Provides in-patient psychiatric services for court-ordered individuals.
- Referral Targeting Criteria: Individuals referred to AMHD should have an SPMI or treatable mental disorder, be uninsured, or be legally encumbered (i.e. court ordered to the Department of Health for care, assessment and/or treatment).
- How to Assist Someone to Access Services: NWD agency staff can make a referral through the Online Referral Tool for cases that do not involve an immediate health crisis. The AMHD Utilization Management Assessments Unit staff will contact the participant to conduct a telephonic assessment to establish eligibility and, if appropriate, to schedule an in-person eligibility determination appointment with an AMHD Assessor. The AMHD Utilization Management Assessments Unit is the entry point for all AMHD ongoing services (excluding crisis services). If the case involves a mental health crisis and the person is in imminent danger to themselves or others, the NWD agency staff should call 911 for immediate emergency assistance. If the case involves a mental health crisis and the person is not in imminent danger to themselves or others, the NWD agency staff should encourage the individual to seek assistance from their treatment provider(s) including their assigned community case manager (if different from the NWD agency staff) or their Primary Care Physician (PCP). The individual may also contact the the Hawaii CARES Program for telephonic support and to request a crisis worker (not a law enforcement officer) to provide on-site intervention. If consent is provided by the individual, the NWD agency staff should participate in triaging the participate to their case manager, PCP, and CARES. If the NWD agency staff also makes a referral through the online tool, the NWD agency staff should describe any referral to or calls made with the CLOH in the notes section of the online tool.
- Overview: ATRC is a non-profit organization that
links individuals with disabilities with technology and training to support
personal growth and gainful employment. ATRC works with the Department of
Education (DOE), Division of Vocational Rehabilitation (DVR), private insurance,
community foundations and other non-profits to connect individuals with
assistive technology. All individuals with disabilities and older adults may
utilize ATRC services, regardless of Medicaid or insurance status.
- What is Assistive Technology (AT)? AT is any item, piece
of equipment, software program, or product system that is used to increase,
maintain, or improve the functional capabilities of persons with disabilities. Assistive
technology helps people who have difficulty speaking, typing, writing, remembering,
pointing, seeing, hearing, learning, walking, and many other things. Different
disabilities require different assistive technologies.
- AT may be low-tech: communication boards made of cardboard or fuzzy felt.
- AT may be high-tech: computers that can be controlled by the voice or eyes.
- AT may be hardware: prosthetics, mounting systems, and positioning devices.
- AT may be computer hardware: special switches, keyboards, and pointing devices.
- AT may be computer software: screen readers and communication programs.
- AT may be inclusive or specialized learning materials and curriculum aids.
- AT may be specialized curricular software.
- AT may be much more— self-help aids for daily
living, educational software, power lifts, pencil holders, eye-gaze and head
trackers are some of the many additional tools.
- Target Populations: All residents of Hawai‘i
with a disability, including young children and older adults with support needs.
- Programs:
- Equipment Loan Program: Allows participants to borrow devices before purchasing. This
service also includes consultation and demonstration.
- Information and
Assistance (I&A): Assists participants
with exploring technology to meet their goals and financial options for doing
so.
- Free Computers: Any person with a disability may apply for a free computer for
social, educational, or employment uses.
- Voice-Activated Home
Automation: For persons with disabilities, voice
recognition can provide greater independence in their homes. Supported in part
by a Christopher & Dana Reeve Foundation Quality of Life Grant.
- Camp Cool: An interactive technology exploration program for children with
disabilities and their siblings and friends. A fun opportunity for
children to increase their knowledge, interpersonal skills, and
self-confidence.
- Accessible Multimedia
Workstation: This workstation will allow a person
who is totally blind to record and mix audio for music, broadcasting and
cinema.
- Financial Loan Program: Hawai‘i residents with a disability can apply for a low interest
loan of $1,000 to $30,000 to acquire an AT device, accessible vehicle, or home
modification. This program is in partnership with American Savings Bank.
- Referral Targeting Criteria: Persons with any disability and of any age with a need to locate,
obtain, and use assistive technology.
- How to Assist Someone to Access Services: NWD agency staff can make a referral through the Online Referral Tool for all ATRC programs. ATRC staff will contact the participant to establish needs and goals. ATRC does not have an official intake form and an application is not required to enroll in most ATRC programs.
- Overview: The Hawai‘i ADRCs are operated by the county Area Agencies
on Aging (AAAs) and overseen by the Executive Office on Aging (EOA). They are a
general access point for older adults, individuals with disabilities, and
family caregivers to discuss publicly and privately funded LTSS options, and
enroll in services. All individuals, regardless of Medicaid or other insurance
status, may contact the ADRC. The ADRCs have a large database of providers and
community resources and provide participants enrolling in AAA services with a
person-centered Support Plan.
- Target Populations: Older adults age 60+ and individuals with disabilities. The
ADRC will also support younger individuals with a disability if they are not
eligible to receive information and assistance from another Door.
- Programs:
- Information and Referral- Using the comprehensive electronic resource database, ADRC
staff are able to provide detailed information and referrals for all callers.
- Kupuna Care- A State funded program designed to help non-Medicaid
eligible, older adults age 60+ so that they can continue living at home or in
the community. Kupuna Care assists families by providing a variety of different
long-term caregiving and support services, such as case management, adult day
care, personal care, and transportation assistance.
- Older Americans Act (OAA) Title III- A federally funded program that provides older adults with
supports to remain in their homes and communities. Services include home
delivered meals, congregate meals, personal care, and case management.
- Community Living Program (CLP)- A State program for seniors with support needs related to Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) that allows participants to control a small pool of dollars they can spend on LTSS in very flexible ways, including hiring family and friends to act as workers.
- Veteran-Directed Care (VDC)- In partnership with VHA, EOA and the ADRCs offer VDC for
veterans of any age with LTSS needs to provide the opportunities to self-direct
their own care and support. This program provides eligible Veterans with a pool
of dollars that they can use to buy LTSS, including hiring family and friends
as workers.
- Kupuna Caregivers- Provides
employed caregivers of Kupuna Care recipients with additional support and
services to ease the financial burden as the primary caregiver and allow
him/her to continue working.
- Several counties also offer supplemental programs. See the Finding the Most Recent Documents for Each Door section of the Staff Training Guide for brochures on these programs or contact the local ADRC for more options.
- Referral Targeting Criteria:
Participants should be: 1)
older adults (60+); 2) caregivers of older adults or caregivers over age 60 of
a person with a disability; or 3) grandparents raising grandchildren.
- How to Assist Someone to Access Services: The ADRC is the single access point for AAA programs including Kupuna Care, OAA Title III, CLP, and Kupuna Caregivers. The online Referral Tool may be used to refer individuals interested in a AAA program; those who have questions about the LTSS system; and individuals who would like to develop a plan for LTSS. After receiving the referral, ADRC Intake and Referral (I&R) staff will contact the participant and perform an initial screening to determine if there is a potential LTSS need. The ADRC then conducts an assessment to determine eligibility for services accessed through the AAA. ADRC case managers then develop a support plan with individuals enrolling in AAA services. Individuals may also request a support plan, regardless of whether they will receive AAA services.
- Overview: CILs are community-based
organizations that promote full personal and community participation of people
with disabilities to help maintain, sustain, and maximize independence. They
focus on helping all individuals with disabilities realize independent living
goals. There are two CILs in Hawai‘i; Aloha Independent Living Hawai‘i, serving
the counties of Hawai‘i, Kauai, Maui (including Molokai and Lanai) and rural
Oahu, and Access to Independence, serving urban Oahu.
- Target Populations: All individuals with
disabilities, regardless of Medicaid or insurance status.
- Programs:
- Access to Independence
- Independent living skills- Workshops to develop independent living skills in
areas such as personal care, coping strategies, financial management, social
skills, and household management.
- Assisting people with disabilities with employment-related goals including employment preparation, resumes, applications, interviewing skills and obtaining employment.
- Educating people with disabilities about Assistive Technology and helping them find AT resources that will help them be more independent.
- Assisting people with disability learn how to process housing applications and seek alternative housing resources based on their income
- Peer counseling- Peer support through listening, teaching, information
sharing, and other similar services to our consumers.
- Advocacy- Work with an individual or group to resolve an issue, obtain
a needed support or service or promote a change in the practices, policies
and/or behaviors of third parties.
- Youth transition- Assist youth with disabilities in the transition
from high school to adulthood and empower them to live more independently
through advocacy, information/referral, peer support and independent living
skills training.
- Transition from institutions- Utilize all of our core
programs and services to assist individuals with disabilities residing in
institutional settings to move back into the community.
- Information and Referral - Connect people with services or resources, which will
meet their needs or help solve a problem they are experiencing
- Aloha Independent Living Hawai‘i-
- Peer counseling- Network of individuals with disabilities who provide
emotional and education support to enable others with disabilities to remain in
the community.
- Advocacy- Resolving system issues and promoting change.
- Independent living skills training- Life skills training to
support individuals to live independently.
- Transition support- Assisting individuals with transitions to employment,
further education, independent living, or from institutions.
- Referral Targeting Criteria:
Individuals
with a disability who have an independent living goal they have chosen to
pursue. If an individual wants a plan
that primarily focuses on meeting LTSS needs and does not involve independent
living, the NWD worker should consider a referral to another agency, such as
the ADRC instead.
- How to Assist Someone to Access Services: NWD agency staff can make a referral through the Online Referral Tool for all CIL programs. A CIL I&A specialist will contact the participant to discuss needs and goals. Additional assessment may occur depending on the program he/she would like to pursue to meet his/her independent living goal.
- Overview: CSHNB works with children, youth,
and families with special health care needs to reach optimal health, growth,
and development. CSHNB is the primary referral point in the NWD Network for
children with specific health care needs.
- Target Populations: Children and youth under the
age of 21 with special health needs, regardless of Medicaid or other insurance
status.
- Programs:
- Children and Youth with Special
Health Needs (CSHN)- Promotes family-centered, community-based, comprehensive,
coordinated care for children and youth with special health care needs from age
0-21.
- Early Intervention- Provides statewide services
for children age 0-3 with developmental delays or who have a biological risk
for developmental delays.
- Genomics- Promotes the prevention, detection, and treatment of genetic disorders, and provides genetics education for the professional and general community.
- Hawai‘i Childhood Lead Poisoning Prevention Program- Provides information and education on blood lead testing and ways to reduce a child’s exposure to lead, develops guidelines, and links families of lead-exposed children to services.
- Referral Targeting Criteria:
For CSHN
services, participants should be between the ages of 0-21; reside in Hawai‘i;
have a chronic medical condition that has lasted or may last at least one year;
and need assistance accessing specialized medical care.
- How to Assist Someone to Access Services: NWD agency staff can make a referral through the Online Referral Tool for CSHNB programs. CSHN intake staff will contact the participant and complete a brief intake process, discussing needs, goals, and health information, or make other referrals as needed. Additional program specific assessment may then occur.
- Overview: DDD serves people with intellectual and/or developmental
disabilities (I/DD) who have functional limitations to support them with
remaining in the community. DDD
operates the Medicaid I/DD Waiver on
behalf of the DHS, the State Medicaid agency that is responsible for administering the Medicaid I/DD Waiver and
determining Medicaid eligibility and
Level of Care. Long-Term Adult Supports & Resources (LASR) and Family
Services and Supports Program (FSSP) do not require Medicaid eligibility.
- Target Populations: Individuals of all ages with intellectual and developmental
disabilities (I/DD) with functional limitations, with an without Medicaid
eligibility. DDD also provides dental care to additional populations with
disabilities.
- Programs:
- Medicaid I/DD 1915c Waiver- This federal and state-funded program provides people with
I/DD who are Medicaid-eligible and meet an assessed level of care with a range
of habilitative services and supports, such as adult day health, assistive
technology, community living services, career planning, employment supports,
personal emergency response system (PERS), personal assistance/habilitation,
and specialized equipment and supplies.
- Long-Term Adult Supports
& Resources (LASR)- This is a State-funded program for individuals age 18 and
above who are not eligible for the Medicaid I/DD waiver. LASR provides supports for building and
training employment skills; independent living skills; and enhancing social
relationships.
- Family Services and Supports Program (FSSP)- A program to help families support children and adults in the
family home. The program only provides
funding for services not covered by any other funding source (e.g., I/DD
waiver, insurance). Services are pre-approved by DDD and may include medical
supplies, nutritional supplements, and transportation.
- Hospital and Community Dental Services (HCDS)- Provides preventative, diagnostic, restorative, prosthodontics, and oral surgery to adults (age 20 and over) who are elderly, blind, disabled, or have other special needs; individuals with severe chronic mental illness or medically fragile; and individuals who live in State facilities. Dental services are not limited to individuals with I/DD. DDD services cannot supplant any other funding source (e.g, DOE, DVR, Medicaid health plan).
- Referral Targeting Criteria
(except for dental care): Referrals to DDD should have a severe, chronic
disability of an individual that:
- Is attributable to a mental or physical impairment or combination of mental and physical impairments;
- Is manifested before the individual attains age 22;
- Is likely to continue indefinitely;
- Results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, and economic sufficiency; and
- Reflects the individual’s need for a combination and sequence of special, interdisciplinary or generic care treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated.
- An individual from birth to age nine who has a substantial developmental delay or specific congenital or acquired condition may be considered to have a developmental disability without meeting three or more of the criteria described above, if the individual, without services and supports, has a high probability of meeting those criteria later in life.
- The mental or physical impairment cannot be primarily from dementia, mental illness, emotional disorders, substance abuse, sensory impairment, learning disabilities, attention deficit hyperactivity disorder, spinal cord injuries, or neuromuscular disorders.
- How to Assist Someone to
Access Services: For all DDD programs,
applicants should meet the central criteria of being a Hawai‘i resident and
having an intellectual or developmental disability. Applicants with U.S. citizenship may qualify
for the Medicaid I/DD waiver. If
participants potentially meet these criteria and the Referral Criteria listed above, staff should complete the following
steps:
- Discuss the programs that DDD offers;
- Ensure that the applicant obtains and provides copies of the following documents and records for the initial appointment with DDD: proof of U.S. citizenship and Hawaii residency; medical records about intellectual or developmental disability; past and current educational assessment and plans; and past and current psychological evaluations; proof of guardianship or authority to act on the applicant’s behalf, particularly where the applicant is age 18 and over; and
- Provide a referral through the Online Referral Tool.
- The DDD Intake Office will then contact the applicant to schedule a meeting with an intake worker. The intake worker will screen the application, review the documents and records, discuss potential programs, request additional information if necessary or available. The applicant has 90 working days of the application date to complete the application. The intake worker will make a determination about DDD eligibility within 30 working days of a completed application. If determined to be eligible for DDD services, the applicant will receive written notice of eligibility and be assigned to a case manager. If interested in the Medicaid I/DD waiver, the applicant must be Medicaid eligible and meet the level of care (LOC), which are determined by the Department of Human Services.
- Overview: DVR provides services to Hawai‘i community members who experience barriers to employment due to a disability. DVR is designed to assist job seekers with disabilities prepare, secure, and retain competitive employment in an integrated work setting. Not all individuals who require employment support will qualify for DVR services, however DVR staff can refer the participant to other employment agencies to provide similar support. Medicaid eligibility is not a requirement to receive DVR supports. Individuals who receive SSI or SSDi are presumed to be eligible for DVR services.
- Target Populations: All individuals with disabilities who need employment and/or individuals age 55 or over who are blind or visually impaired and require independent living services.
- Programs:
- Vocational Rehabilitation
(VR) Employment Training- Provides employment coaching, support, and training to
individuals with a variety of disabilities.
- Ho'opono Services for the
Blind- Provides
support and training to individuals who experience blindness or are visually
impaired. Programs include:
- New Visions- Provides orientation, mobility, reading, and life skills
training to all individuals
- Older Individuals Who Are Blind (OIB)- Supports older adults in
adapting to vision loss
- Business Enterprise Program- Provides employment support and training.
- Referral Targeting Criteria:
Participants
should be an individual with a disability that requires assistance to prepare
for, secure, retain, regain, or advance in employment and/or an individual who
is blind, visually-impaired, or deafblind and age 55 or older who needs independent
living services
- How to Assist Someone to Access Services: NWD agency staff can make a referral through the Online Referral Tool for all DVR programs. If the participant experiences blindness or visual impairment as identified by the Referral Tool, Ho‘opono I&A staff will contact the participant to discuss needs and goals. If the participant does not experience blindness or visual impairment, Vocational Rehabilitation (VR) staff will contact the participant and conduct an initial screening. After this initial discussion, the participant will be supported to complete an application for the program(s) he/she would like to pursue. If the individual is potentially eligible based upon the application, a case manager will conduct a program-specific assessment
Education for Homeless Children and Youth (EHCY)
- Overview: The State of Hawaii is federally mandated to support children and youth experiencing homelessness to continue receiving an education. The EHCY ensures these individuals can enroll in school, remain within their school of origin, receive transportation to and from them, and be provided with academic support.
- Target Populations: Students statewide from Pre-K to 12th grade experiencing homelessness or unstable housing
- Programs:
- Community Liaison Support: Assist students and families with referrals for housing, healthcare, food, and additional services as needed. Community liaisons can also help navigate how to enroll in school, receive transportation, school meals and educational support.
- Referral Targeting Criteria: Homeless children and youth in this instance are defined by the U.S. Department of Education as “individuals who lack a fixed, regular, and adequate nighttime residence and includes not only those living in emergency or transitional shelters but also those living in shared housing because of a financial emergency or natural disaster, among many other potential living situations.” Other examples include living in a car, motel, or having inadequate living accommodations (i.e., lack of water, electricity).
- How to Assist Someone to Access Services: NWD agency staff can use the Online Referral Tool to refer individuals to the EHCY. An EHCY liaison in their area will complete an eligibility questionnaire and assess specific needs.
Early Intervention Services (EIS)
- Overview: EIS is a federal and state-mandated program that offers various developmental support services for infants and toddlers across Hawai’i between birth to three years of age. EIS offers in-person, telepractice or combination care, giving families options. The programs are typically of no cost to the families and not restricted based on income (although payments may be processed through Medicaid or private insurance with parental advisory). All eligible children receive a care coordinator to facilitate the process.
- Target Populations: Children under 3 years of age that have developmental delays or are biologically at-risk for such delays.
- Programs:
- Early Childhood Services Program (ECSP): These services aim to assist children in the five developmental areas that include physical, cognitive, communication, social, and adaptive development. These services range from assisting children with problem solving to helping them with eating and dressing by themselves.
- Care Coordination: All eligible children will be paired with a care coordinator to have the child evaluated, establish the family's main goals and concerns, construct an Individualized Family Support Plan and more.
- United Cerebral Palsy Early Intervention Program: Evaluates development of children with cerebral palsy and connects family with resources, an Individualized Family Support Plan, direct services such as occupational therapy and additional referrals.
- Referral Targeting Criteria: Children under 3 years of age that are presenting with a delay in 1 or more of the following areas:
- Physical (sitting, walking, crawling)
- Cognitive (paying attention, solving problems)
- Communication (talking, understanding)
- Social/emotional (playing, self-confidence)
- Adaptive (eating, dressing themselves)
- Children with no existing delays may be eligible if they have a diagnosed physical or mental condition that will likely result in developmental delay if not provided early intervention services. Examples include chromosomal abnormalities or autism spectrum disorder.
- How to Assist Someone to Access Services: Children meeting the referral criteria can be referred to EIS using the Online Referral tool. EIS care coordinators will work with the families to complete an intake form to evaluate the child’s eligibility. Those eligible will work with service providers to create an Individualized Family Support Plan to utilize services such as speech therapy or special education.
Hi'ilei Developmental Screening Program (HDSP)- Overview: A program within the Children with Special Health Needs Branch, Hiʻilei Developmental Screening Program provides developmental screening and information for families of children birth to 5 years who are interested in supporting their young child to reach optimal development. No cost to families.
- Target Populations: Children should be between the ages of 0 to 5 years
- Program: Hiʻilei Developmental Screening Program is a free resource for parents of children from birth to 5 years old. The program provides developmental screening via a mail or online screen, activities to help a child develop, referrals for developmental concerns, and information about state/community resources.
- Referral Targeting Criteria: Child should be between the ages of 0 to 5 years, reside in Hawaii, and need or want a developmental screen for their child
- How to Assist Someone to Access Services: NWD agency staff can make a referral through the Online Referral Tool to the Hiʻilei Developmental Screening Program. Hiʻilei staff will mail a developmental screen and pre-paid envelope to the family. Families complete the screen and mail it back to the Hiʻilei Program. Families will receive screening results, activities to help a child develop, referrals for developmental concerns, and information about state/community resources. Families will also receive information about the option to do an online screen at https://www.asqonline.com/family/628176.
- Overview: MQD is the State’s Medicaid administrator and provides eligible low-income adults and children access to health and medical coverage through managed care plans. The QUEST Integration (QI) program is designed to provide Quality care, Universal access, Efficient utilization, Stabilizing costs, and to Transform the way health care is provided to beneficiaries. Medicaid benefits are managed by the contracted QI Managed Care Organizations (MCOs), known as Health Plans, that include AlohaCare, HMSA, Kaiser Permanente, Ohana Health Plan, and UnitedHealthcare Community Plan.
- Target Populations: Medicaid beneficiaries and applicants who are generally low
income and potentially meet the Medicaid financial eligibility criteria.
- Programs:
- QUEST Integration (QI)- The State’s Medicaid program that provides a wide array of
services for Medicaid beneficiaries. QI services include:
- Primary and acute care
services (e.g., diagnostic tests, dialysis, durable medical equipment,
habilitation, hospice, non-emergency transportation, and in-patient and
outpatient services)
- Behavioral health services
(e.g., inpatient psychiatric hospitalizations, crisis management; medications
and management; psychiatric evaluation and treatment; substance abuse
treatment)
- Long Term Services and Supports (LTSS)
- Nursing Home or ICFID Institutional Services
- Home and Community Based
Services (HCBS)- Medicaid beneficiaries who meet
a nursing facility level of care (NF-LOC) as determined by the DHS 1147 form
can qualify for HCBS. These services may include adult day care, adult day
health, assisted living facility, companion services, environmental
accessibility adaptations, home delivered meals (HDM), moving assistance,
non-medical transportation, personal assistance, personal emergency response
systems (PERS), residential care, respite care, private duty nursing, and
specialized medical equipment.
- At Risk Services- Medicaid beneficiaries who require LTSS but do not meet
NF-LOC and are at risk of declining to an institutional LOC, based on
functional assessment results from the DHS 1147 form, may qualify for the
following HCBS services:
- Home Delivered Meals
- PERS
- Chore
- Personal Assistance
- Adult Day Care
- Adult Day Health
- Private Duty Nursing
- I/DD 1915c Waiver- Medicaid beneficiaries with Intellectual or Developmental
Disabilities (I/DD) who meet an assessed level of care may receive a range
of specialized HCBS and supports that
include adult day health, personal assistance habilitation, residential
habilitation, assistive technology, community learning services, career
planning, employment supports, personal emergency response system (PERS),
private duty nursing, respite, chore and equipment and supplies. For more
information about how to access the I/DD Medicaid waiver, see the DOH/DDD
description above.
- Referral Targeting Criteria:
Low income individuals of
all ages with no health insurance and/or a need for LTSS.
- How to Assist Someone to Access Medicaid Services: If the individual is currently enrolled in a QI Health Plan, he/she should be referred to their Service Coordinator at that QI Health Plan using the referral tool. If the individual would like to apply for Medicaid and needs help, staff should complete the following steps:
- If the individual is unsure whether they
- If potentially Medicaid eligible: The individual, may apply
for Medicaid three different ways:
- Online: Create a Medicaid account and complete the online application. NWD staff may help the individualif needed: https://medical.mybenefits.hawaii.gov/web/kolea/home-page?p_p_id=58&p_p_lifecycle=0&p_p_state=maximized&p_p_mode=view&saveLastPath=0&_58_struts_action=%2Flogin%2Fcreate_account
- By Phone: Call the MQD Customer
Services Branch: Oahu 524-3370 Neighbor
Island toll Free: 1-800-316-8005.
- Paper Application: Complete and submit the DHS1100 Form
- Fax on Oahu: Dillingham 587-3543 Kapolei: 692-7379 or
- Drop off application: To the nearest MQD eligibility office. Be sure to keep a personal copy of the application.
- If the individual needs additional support to complete his/her application or has questions about accessing Medicaid, staff should complete the Online Referral Tool and provide a referral to MQD.
- After submitting the Medicaid application, the Medicaid eligibility worker will determine if the applicant is potentially eligible for Medicaid. Applicants requesting LTSS will need to provide additional financial documents with their application. If determined to be Medicaid eligible, the applicant will be enrolled in the QI health plan of their choice. Their QI health plan will conduct a telephone welcome and screening interview. If the new member is requesting QI HCBS or At Risk services, a QI service coordinator from the member’s new health plan will conduct a face to face health and functional assessment, including completion of the DHS 1147 form and a service plan for the QI member.
- Overview: OVS’ primary role is to
support veterans, potential veterans, and families of veterans with
understanding and accessing veteran benefits. Veterans who are not enrolled
with the VA can contact OVS to receive support in understanding the access
process, completing applications, and understanding the benefits available to
veterans. As described below, OVS offers additional programs and supports in
addition to this information and facilitation role. Within NWD, OVS should be
the primary point of contact for veterans, potential veterans, and their
spouses and beneficiaries looking to enroll in veteran services.
- Target Populations: Veterans or potential
veterans with LTSS needs
- Programs:
- Veteran advocacy &
support- OVS
may act on behalf of veterans, their families, and survivors to secure
appropriate rights, benefits, & services. This includes receiving,
investigating, and resolving disputes or complaints related to veterans’
benefits.
- Veteran burials- Arrangements for burials for
qualified veterans and their dependents.
- Veteran license plates- For the same cost as a
regular license plate. Veterans can choose an applicable plate for their
service.
- Special housing for disabled
veterans- Payment
by the State of up to $5,000 to each qualified totally disabled Veteran for the
purpose of purchasing or remodeling a home to improve handicapped
accessibility. Award of payment
pending the availability of State funds and Veterans Affairs approval.
- Referral Targeting Criteria:
Referrals
to OVS should be potentially a Veteran or the spouse of a Veteran.
- How to Assist Someone to Access Services: NWD agency staff can make a referral through the Online Referral Tool for all OVS programs. OVS Outreach staff will contact the participant to discuss his/her needs and goals. A program-specific application is required for programs administered by OVS, including burials, license plates, and special housing.
- Overview: SHIP's mission is to empower, educate, and assist Medicare-eligible individuals, their families, and caregivers through objective outreach, counseling, and training to make informed health insurance decisions that optimize access to care and benefits.
- Target Populations: Medicare beneficiaries, soon-to-be retirees, and representatives of Medicare beneficiaries
- Referral Targeting Criteria: Clients with Medicare-related questions
- How to Assist Someone to Access Services: NWD agency staff can make a referral through the Online Referral Tool to Hawaii SHIP. Primary and secondary staff will forward requests to the SHIP program assistant who will assign the inquiries to certified volunteer Medicare counselors. Counselors will contact clients to discuss needs, goals, and health information, or make other referrals as needed. Additional program-specific assessments may then occur. Initial contact will be made within 5 business days.
- Overview: The VA Pacific Islands
Health Care System (VAPIHCS) provides eligible veterans with outpatient medical
and mental health care through their main Ambulatory Care Clinic on Oahu
(Honolulu) and through seven Community Based Outpatient Clinics (CBOCs).
- Target Populations: Veterans with established VA
eligibility who have LTSS needs
- Programs: VHA programs include:
- Community Adult Day
Health (CADH): Provides veterans at risk of nursing home placement with social activities, peer support, companionship and recreation in a licensed community adult day health program during business hours.
- Community Living Center
(CLC): Provides a skilled nursing environment that
houses a variety of special programs for persons needing short and long stay services.
The goals of care are to restore function, reduce decline, maximize
independence, and provide comfort when dying.
- Community Nursing Home Program (CNH): Provides VA contracts for the care of veterans
in community nursing homes.
- Community Clergy Training
(CCT): Provides
increased access points to support VA and community physical and mental health
care for partnering with faith-based organizations in rural communities.
- Geriatric
Consultation/Geri-PACT/Falls Prevention Clinics: Geriatric consultations are provided in an outpatient setting
for older veterans with primarily geriatric syndromes (memory impairment, falls,
incontinence, etc.)
- Home-Based
Primary Care (HBPC): A home care program that offers comprehensive
longitudinal primary care by an interdisciplinary team of VA staff in the homes
of veterans with complex, chronic, disabling disease for whom routine
clinic-based care is not effective. The HBPC
goal is to maximize function, minimize institutionalization, and maintain
quality of life.
- Homemaker/Home Health Aid
Program (H/HHA): Provides veterans at risk of nursing home placement with personal care services (i.e., bathing, grooming, toileting assistance) through a community agency to continue to live at home.
- Hospice
and Palliative Care (HPC) Unit: Provides inpatient holistic care to veterans
threatened with a life-limiting illness. Focus is often on symptom management
and comfort for the Veteran.
- Hospital
in Home (HiH): Provides veterans on Oahu an opportunity to
receive short-term acute medical care in the comfort of their own home. Services
include IV therapy, wound care, and close monitoring and are provided following
acute diagnosis.
- Medical Foster Home (MFH): Provides an
alternative to nursing home placement. Veterans receive 24/7 personal
care and supervision in a family/homelike environment.
- Palliative Care and Consult
Team (PCCT): Provides outpatient
interdisciplinary Hospice and Palliative Care Consult services to assist staff,
veterans, and their families with chronic disease care and end-of-life planning
issues.
- Purchased Skilled Home Care (PSHC): Provides care in the home to veterans that are homebound and
in need of skilled services such as Nursing, Physical, Occupational and Speech
therapy, or Social Services.
- Rehabilitation Medicine (Rehab): Provides inpatient and outpatient rehabilitation services (Physical, Occupational, Speech, Recreation, and Music therapy) to facilitate the Veteran's ability to remain in the most independent and least restrictive living environment through therapeutic interventions.
- Respite Care: Provides temporary relief to the spouse or other caregiver
from the burden of caring for a chronically ill or disabled Veteran at
home.
- State Veterans Home
(SVH) Oversite: The
Yukio Okutsu SVH is located in Hilo and provides both Adult Day Health and Nursing
Home care to eligible veterans.
- Veteran-Directed Care (VDC): Provides veterans at risk for nursing home
placement with the opportunity to manage a monthly budget to directly hire
workers and/or purchase goods and services to meet their needs in a home
environment, thus avoiding nursing home placement.
- Referral Targeting Criteria:
Participants
with LTSS needs enrolled as a Veteran.
- How to Assist Someone to Access Services: NWD agency staff can make a referral through the Online Referral Tool for all VHA programs. The Door Referral Contact (DRC) at the VAPIHCS will review the referral and determine which program the veteran should be referred to. This means that NWD staff should understand VA programs, however do not need to determine which specifically the participant should be referred to. Intake staff from VHA will contact the participant and perform an initial screening to determine potential needs and program eligibility. Program-specific application and assessment will then occur based on identified programs. Veterans can apply for VA health care benefits with any of our staff members (Health Benefits Advisors) in the Spark M Matsunaga VA Medical Center, ACC 2d flr Check in/Registration. Business hours Mon-Fri are from 0730-1600. We encourage that veterans come in person so they understand the full scope of VA medical benefits package, but more so, the final process to completing intake by taking a picture for the new Veterans Health Identification Card (VHIC). Please bring 2 forms of valid identification as the proofing process for VHIC issuance requires proper identification. Veterans may also apply online by accessing this link: https://www.vets.gov/health-care/apply. For assistance with completing the form online, veterans may call the toll free number at 877-222-8387, Mon-Fri 8:00 am to 8:00 pm (ET). Enrollment may also occur via phone at 1-800-214-1306. New enrollees applying for VA health for the first time, we offer a “New Initial Examination”, however wait times have exceeded 30 days. Veterans may still elect to have their NIE with VA and will be assigned a primary care physician upon completion of their appointment. Veterans may also elect to receive a NIE with the Choice program should there be a need to be seen sooner than 30 days. Veterans may contact the Choice Program at 866-606-8198.
