Description of tool: This is a care plan format that is used in Clay County for participants in the CADI and TBI waiver programs.

Transcription

1 HCBS Waiver Review Initiative Description of tool: This is a care plan format that is used in Clay County for participants in the CADI and TBI waiver programs. These tools were obtained from Clay County in August 2009 through the Minnesota Department of Human Services Waiver Review Initiative. To inquire if the tool is available in an accessible format, or if you have questions about the use of the tool, please contact Clay County Department of Social Services at (218) Assistance Provided by:

2 07/09 LONG TERM CARE CONSULTATION Community Support Plan Name Address Birthdate Phone Primary Contact Relationship to Member Contact's Phone Number Health Plan/ID#/Enrollment Date PMI Number LTCC County LTCC/Care Coordinator/Phone Financial Worker/Phone Primary Physician Date Reassessment Date CRF COR PROVIDERS: PRIMARY DIAGNOSIS: ICD 9: OTHER DIAGNOSIS: HEALTH CARE DIRECTIVE: LONG TERM CARE CONSULTANT REVIEW:

3 Independent Activities of Daily Living Consumer Needs Consumer Goals Interventions Goal Date Evaluation Reassessment continue Care Coordinator will Date Reviewed self-management of follow-up with member IADL'S. quarterly semi-annually Meal Prep Money management Housekeeping Laundry Shopping Phone Calls Transportation Medication Management Chores Independent continue to manage IADL'S with the assistance of informal caregiver. manage IADL's with the assistance of services and/or equipment. Referrals Existing Services Home Health Aide Personnel Care Asst. Skilled Nursing Visit Lifeline Meals on Wheels Homemaking Chore Services Plus Adult Foster Care Member declines recommended services.

4 Activities of Daily Living Consumer Needs Consumer Goals Interventions Goal Date Evaluation Reassessment Dressing continue Referrals Date Reviewed: Grooming to manage ADL's Existing Services Bathing independently. Eating Bed mobility/ continue positioning to manage ADL's with the Transferring assistance of informal Walking caregiver. Toileting Equipment: Independent manage ADL's with the assistance of services and/or equipment. Physician Home Health Aide Personnel Care Assist. Skilled Nursing Visit Plus Adult Foster Care Relocation Assistance Transitional Services PT/ OT/ ST Therapies DME provider: Caregiver (CG) Supports & Social Resources No informal CG Informal CG in place: Caregiver emotionally and/or physically at risk Can adequately care for self Cultural/language barriers Lack of social activities CG will utilize respite & community support systems as needed. receive culturally appropriate Consumer declines recommended services services. Transitional Services maintain Adult Foster Care Lack of interaction withaccess to health care f amily and/or friends system. Plus Dissatisfaction with living situation Lack of spiritual care Consumer expresses overall satisfaction with Coordinate communitybased formal & informal services for spiritual and/or cultural care: life Vocational Supports be involved in social activities through family and/or community. maximize their employment potential. Referrals Existing Services CG education/support materials: Respite Care Relocation Assistance Consumer declines recommended services. Date Reviewed:

5 Health Consumer Needs Consumer Goals Interventions Goal Date Evaluation Reassessment Consumer maintains Referrals Date Reviewed: poor health status or acknowledge health care Existing Services health status has declined, which places member at risk for ER, hospitalization, or NF placement. Consumer receiving specialized treatments or requires clinical monitoring. Notable deficit in selfmanagement or noncompliance with prescribed treatment plan. Consumer at risk for medication error or over medication. Consumer at risk of imbalanced nutrition due to: significant wt. loss/gain (>10#) poor appetite inadequate services difficulty eating Consumer is not current with immunizations. Consumer maintains adequate health status. risks & seek medical attention appropriate. follow diet as prescribed by physician that will meet his/her metabolic needs. receive information re: Flu, Pneumonia, & tetanus vaccines. continue to be compliant with recommended tx plan and/or medication management. seek awareness through education concerning health status & available tx options including community supports in order to self-direct care. remain free from hospitalization and remain in current living situation as long as possible. Physician Dietician Home Health Aide Personnel Care Asst. Skilled Nursing Visit Meals on Wheels Hospice Adult Protection Plus Adult Foster Care DME: Accompany member to medical appointments as needed. Date: Provide/arrange education re: Disease process(es) Medications Treatment plan Self-care Nutrition/weight management Dental providers Consumer declines recommended services. Flu: Pneumo: Tetanus:

6 Self-Preservation & Safety Consumer Needs Consumer Goals Interventions Goal Date Evalutation Reassessment Sensory Perception Date reviewed: Impaired Vision Hearing Safety at risk due to: Health Status Communication deficit Physical, emotional, sexual abuse Substance abuse Tobacco Alcohol Drugs Environmental hazards: Consumer adequately maintains safety/no notable safety risk present. continue selfmanagement of safety. continue to manage safety with the assistance of services and/or equipment. effectively communicate needs to family, caregivers, and care coordinator. remain free from falls & safe from environmental hazards. continue to remain free from abuse, neglect, and/or exploitation from self, other persons, or environments. receive information re: Tobacco Use Alcohol Use Drug Use Referrals Existing Services Lifeline Plus Adult Foster Care Relocation Asst. Transitional Svcs. s & technology: Hearing Loss Vision Loss Provide/arrange education re: Falls assessment & personal risk management plan. Home environment review: Declined by: Consumer Family Consumer declines recommended services

7 Consumer Needs Consumer Goals Interventions Goal Date Evaluation Reassessment Emotional & Mental Health Consumer/family expressed Assessor note Isolation Aggression Sadness Anxiety Difficulty sleeping Hallucinations Disorientation to person, time, or place Forgetfulness Impaired decision making/judgment Impulsive behaviors Confusion Dementia Behaviors requiring cueing/ supervision Behaviors requiring intervention MMSE >10 No notable emotional/ mental health concern be assessed by health care provider resulting in modification & improvement of emotional stability. receive appropriate tx plan, including living arrangements & support systems. continue to manage emotional and mental health with appropriate services: utilize appropriate medication management for disease process acknowledge receipt of mailings from MSHO program. gain knowledge re: CA/Vit D benefits. Referrals Existing Services Personnel Care Assistance Hospice Physician Mental Health Services Community Integration Adult Protection Plus Adult Foster Care Relocation Assistance Transitional Services Other : Accompany member to medical appointments as needed. Date: Consumer declines recommended services Provide verbal education Date Reviewed: Other: Please review attachment for further information and assessment Knowledge deficit- Calcium & Vit. D benefits & osteoporosis & hip fracture risks in the elderly. Disabetes Heart Disease (CAD or CHF) take Cal/Vit D supplement receive disease management for diabetes receive disease for management for heart disease. Provide brochures & other educational materials: Assist consumer in contacting PharmD or MD to obtain further information or prescription. Refer consumer for disease management.

8 Budget Worksheet Service or Support Start/End Date Clay County Case Management Clay County Paraprofessional Annual Estimated Units of Service Per Week Estimated Cost Per Unit Cost Per Week or Month Case Mix Level CAP Amount Total # CC Units Total # CC Para Units Total Cost of Auth. Services $

9 Case Manager's Worksheet Client Receives Services Through: AC(A) EW(E) CADI(C) TBIW-NF(T) TBIW-NB(T) CAC (C-2) Service Unit HCPC Mod Provider Name & Number Start End Rate Units Cost Adult Day Care 15 min S5100 Adult Day Care Daily S5102 Assisted Living Monthly T2030 Assisted Living Plus Monthly T2020 TG Case Management 15 min. T1016 UC Case Management 15 min T1016 TF Aide(paraprofessional UC Consumer Directed Total T2028 Community Supports Day Program Supported Employment Day Program Supported Employment Cost 15 min T2019 Daily T2018 Family Training & 15 min S5110 Counseling Family Counseling 15 min S5110 Family Foster Care Monthly S5141 Adult Family Foster Care Daily S5140 Adult Family Foster Care Child Daily S5145 Corporate Foster Care Monthly S5141 HQ Hoome Delivered Meals Per Meal S5179 Home Health Aide 15 min G0156

10 Home Health Aide Visit T1021 Home Health Aide 15 min G0156 Extended Home Health Aide, MA Visit T1021 Homemaker 15 min S5130 ILS Counseling 15 min H2032 Modifications & Adaptations Per Item S5165 PCA 15 min T1019 PCA, Rn Supervision 15 min T1010 UA RN, MA Skilled Nurse Visit Per Visit T1030 Residential Care Monthly T2032 Respite Care, In 15 min S5150 Home Respite Care, In Daily S5151 Home Respite Care, Out of Home Daily H0045 Supplies & Per Item T2029 Equipment Extended Transportation, One Way Trip T2003 UC Transportation, Mileage S2015 UC Mileage Total Cost $

11 Signature Sheet for Community Support Plan Client Name: Client PMI# Reassessment Date: Date: I have been offered a choice between receiving community services and nursing home placement. Yes No Yes No I have discussed my Community Support Plan with my care coordinate or and agree with it. Yes No Yes No I understand that I will receive a copy of my Community Support Plan when it is finalized. Yes No Yes No I have been offered a choice of cost effective services. Yes No Yes No I have been offered a choice of providers. I do do not have an Advanced Directive. Yes No Yes No Yes No Yes No I would would not like further information about Advanced Directive. Reassessment Comments:

12 Reassessment Client's Signature Date Client's Signature Date Care Coordinator's Signature Date Care Coordinator's Signature Date Screener's Signature Date Screener's Signature DateSupport Plan was mailed/given on Support Plan was mailed/given on

13 EMERGENCY BACK-UP FOR WAIVER RECIPIENTS Emergency Medical Care If should require emergency care, the plan is to call 911 and admit to Guardian\Family\Primary Caregiver Notification of Emergency: NAME: Relationship: Contact #'s: If the guardian\family\primary Caregiver is not available and an emergency occurs, the provider will call: NAME: Relationship: Contact#'s: NAME: Relationship: Contact#'s: Continue to attempt to notify the Guardian\Family\Primary Caregiver. If the condition requires a physician to be contacted, the plan is to notify: PHYSICIAN NAME: Telephone: Emergency Notification Unavailable Staffing If an unforeseen event makes staffing unavailable, the plan is the provider will: A. Attempt to secure immediate trained staff B. Notify the following caregiver(s) to provide care if no other trained staff is available. NAME: Relationship: Contact #'s: NAME: Relationship: Contact #'s SPECIAL INSTRUCTIONS: