STEP BY STEP ENROLLMENT CHECKLIST

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1 d STEP BY STEP ENROLLMENT CHECKLIST Urgent Care Program for Individuals with Intellectual and Development Disabilities Provided by ACA through a Balancing Incentive Program Innovation Grant Thank you again for your support of the Urgent Care Program for Individuals with I/DD. Please use the checklist below to ensure that individuals served by your agencies are enrolled correctly. 1. Ensure each individual has a TABS number If the individual does not have a TABS number, they are not eligible for the program. Inform your supervisor and do not complete the enrollment form for the individual. 2. Contact eligible individuals to schedule an appointment with them, and if appropriate, their family member or caregiver. 3. Visit the eligible individuals and share the contents of the enrollment package 4a. Use the Individual/Family flyer in packet to explain the services Leave with individual 4b. If possible, show the short video at /aca urgent care 4c. Explain two consent forms Urgent Care Program and Authorization for Release of Health Information. Have the individual and/ or caregiver sign both of them. If requested, it is Ok to give the individual/family copies of the consent forms Take originals with you 4d. Complete the Enrollment form Take with you 4e. Complete one side of the PAM survey. (Instructions attached) Take with you 4. IMMEDIATELY after each individual enrollment, *FAX the following to AND send a confirmation to: Nicole@telehealthassociates.com. If you cannot fax the enrollment packet you may scan and it to Nicole or mail the enrollment packet to: Telehealth Associates, Inc. 11 Indian Field Road E. Setauket, NY Completed Enrollment form Signed Urgent Care Program consent form Signed Authorization for Release of Health Information consent form Completed PAM Survey Only need to complete one side *Please know that our fax number is a secure, private line that is dedicated exclusively for this project. There is no need for a cover letter when faxing over forms. 5. If individual declines to participate in the program, ONLY fill in the information in the red box on the bottom of the enrollment form. Indicate the reason for the denial and the name of agency making the visit. DO NOT list the name of individual or any other information on the top of the form. Fax or Mail ONLY the Enrollment form to the above address. If you have questions on filling out these forms, first contact your supervisor. If you still have additional questions contact: Nicole@TelehealthAssociates.com Advance Care Alliance (ACA) 60 E 42 nd St., Suite 1762 New York, NY Advance Care Alliance is a Partnership of Advance of Greater New York, LLC, Alliance Care Network, LLC and the Long Island Alliance, LLC.

d Urgent Care Program Let Us Help You with Your Urgent Health Care Needs You may now enroll in a new service that provides urgent care services at no cost to you or your family.

The grant funded pilot program is designed to improve access to and quality of care for individuals with intellectual and developmental disabilities.

The nurse will talk with you about what you should do to feel better.

A Team of Nurses Who Can Come to Your Home When you call 844 257 7163, the nurse on the phone will decide if you need help right away.

2 d Urgent Care Program Let Us Help You with Your Urgent Health Care Needs You may now enroll in a new service that provides urgent care services at no cost to you or your family. These are additional services and do not affect the services you already receive. The grant funded pilot program is designed to improve access to and quality of care for individuals with intellectual and developmental disabilities. Services include: Getting Health Care Advice 24 Hours a Day, Every Day Just call anytime day or night to speak with a nurse when you are not feeling well. The nurse will talk with you about what you should do to feel better. She or he might do one or more of the following: call 911, schedule a doctor s or clinic appointment for that same day or the next, tell you what to do at home, or send a team of nurses to your home. A Team of Nurses Who Can Come to Your Home When you call , the nurse on the phone will decide if you need help right away. If you need help on weeknights or weekends, a nursing team will visit you in your home and help you get the care you need. They will be available weeknights 6 pm to 10 pm and weekends 10 am to 6 pm. During weekdays the call center will help you schedule an appointment for that day or the next. Monitoring Your Vitals Signs from Your Home If you have serious health care needs, we can check your blood pressure and other vital signs each day. We have special equipment so you don t even have to leave your home. If your vital signs show that you might have a problem, a nurse will call you or send someone to help you. How You Can Receive Services To receive services, you must complete enrollment and consent forms. These documents are available from your Medicaid Service Coordinator (MSC), resident director, day program director or another staff person associated with your agency. This program is provided by the Advance Care Alliance (ACA) through a New York State Balancing Incentive Project (BIP) Grant. Advance Care Alliance (ACA) 60 E 42 nd St., Suite 1762 New York, NY Advance Care Alliance is a Partnership of Advance of Greater New York, LLC, Alliance Care Network, LLC and the Long Island Alliance, LLC.

3 d ENROLLMENT FORM FOR URGENT CARE PROGRAM Participant Name: Agency Affiliation: TABS# Date of birth: (MM/DD/YYYY) Phone: ( ) Medicaid# Address: Residential Nurse: (IF APPLICABLE) Residential Nurse Phone: ( ) Caregiver Name & Relationship: Phone: ( ) Type of Residence: (PLEASE CHECK ONE) IRA supportive ISS/CSS Other (Specify) IRA supervised (nursing service 24/7) Private Home with Family or Friends Non-related Family Home Where do you receive your ARTICLE 16 services: (PLEASE CHECK ALL THAT APPLY) Suffolk County Applicants Only Long Island Select Healthcare (LISH) 250 Marcus Boulevard, Hauppauge 159 Carleton Avenue, Central Islip 62 Pine Street, East Moriches 221 N. Sunrise Hwy. Service Road, Manorville 883 East Main Street, Riverhead 75 Landing Meadow Road, Smithtown I do not use any of the above LISH Article 16 clinics (SPECIFY CLINIC YOU USE) Where do you receive your ARTICLE 28 services: (PLEASE CHECK ALL THAT APPLY) Long Island Select Healthcare (LISH) 120 Plant Avenue, Hauppauge 33 Terryville Road, Port Jefferson Station 75 Landing Meadow Road, Smithtown 883 East Main Street, Riverhead 159 Carleton Avenue, Central Islip 221 N. Sunrise Hwy. Service Road, Manorville HealthCare Choices (HCC) th Avenue, Brooklyn I do not use any of the above Article 28 clinics (SPECIFY CLINIC YOU USE) Primary Physician: Phone: ( ) Current medical conditions: (Ex: diabetes, hypertension, etc.) Current medications: If individual does not agree to participate, please check the appropriate box or boxes. I do not think I need the services Other Privacy / I do not want someone in my home Name of Agency making visit: MSC/Other Completing Form: Date Completed (MM/DD/YYYY) Phone: ( ) Advance Care Alliance (ACA) 60 E 42 nd St., Suite 1762 New York, NY Advance Care Alliance is a Partnership of Advance of Greater New York, LLC, Alliance Care Network, LLC and the Long Island Alliance, LLC.

4 Urgent Care Program Consent Form The goal of the Urgent Care Program is to make it easier for you to get health care when you need it right away. To provide you health care in the best way, health care providers and other people involved in your care will need to talk to each other and share your health information. By signing this form, you agree to be in the Urgent Care Program. By signing this form, you give permission to the Urgent Care Program s health care partners, to get, see, read and copy your health information. You give them permission to share your health information with one another. The health information may be from before or after the date you sign this form. Your health information may be about illnesses or injuries you have had. It may be test results, like X rays or blood tests. It may be the medicines you are now taking or have taken before. Your health information is private and cannot be given to other people without your permission under New York State and U.S. laws. The organizations that can get your health information must obey all these laws. They cannot give your information to other people unless you agree or the law says they can give the information to other people. You do not have to sign this form. If you choose not to sign this form, you will still be able to get health care and health insurance. Please read all the information on this form before you sign it. I agree to participate in the Urgent Care Program and I agree that the Urgent Care Program s health care partners can get ALL of my health information. I also AGREE that the Urgent Care Program s partners may share my health information with each other. I can change my mind and take back my consent at any time by signing a Withdrawal of Consent Form (DOH 5058) and giving it to one of the Urgent Care Program partners or Medicaid Service Provider. Print patient name: Date of patient birth: Patient Medicaid ID number: Signature of patient or patient s legal representative: Date: Print name of legal representative: Relationship of legal representative to patient (if applicable): Print name of witness: Signature of witness:

5 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION (Please Fill In ALL Sections In RED) Patient Name (PLEASE PRINT) Date of Birth (MM/DD/YYYY) I, or my authorized representative, authorize to provide, on an (NAME OF AGENCY ENROLLING INDIVIDUAL) ongoing basis, any health information regarding my care and treatment (including my entire medical record) as necessary for my participation in the Urgent Care Program to each and any of the following: Family Residences and Essential Enterprises, Inc. (FREE), PSCH, Inc., Developmental Disabilities Institute, Inc. (DDI), United Cerebral Palsy Association of Greater Suffolk, Inc. (UCP), Block Institute, and/or Institute for Community Living, Inc. (ICL) as set forth on this form. The information that may be released includes (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information HIV-Related Information In accordance with applicable law, I understand that: This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate lines above. In the event the health information described above includes any of these types of information, and I initial the line on the box above, I specifically authorize release of such information to the person(s) indicated above. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) or the New York City Commission of Human Rights at (212) These agencies are responsible for protecting my rights. I have the right to revoke this authorization at any time by writing to the health care provider listed above. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. Information disclosed under this authorization might be redisclosed by the recipient and this redisclosure may no longer be protected by federal or state law. Reason for release of information: At request of individual Other: for participation in the Urgent Care Program If not the patient, name of person signing form (PLEASE PRINT) Date or event on which this authorization will expire: 6 months after my discharge from, or termination of, the Urgent Care Program Authority to sign on behalf of patient: X X All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form. Signature of Patient or Representative Authorized by Law X Date (MM/DD/YYYY) X * Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts. GWTDOCS v2

6 Primer on Obtaining Valid & Reliable PAM Responses We appreciate your participation in obtaining PAM responses from potential participants of the ACA Urgent Care Program. Below are instructions for administering the PAM survey. The forms in your enrollment packets are double sided. On one side is the survey for the individual titled Individual Survey. If the individual is not competent to answer for him/herself, have the caregiver fill out the Caregiver Survey on the other side. Follow instructions below. Return the completed survey in the self addressed envelope enclosed in the enrollment packet. To get the most reliable and valid PAM responses, we recommend the following approach, which is based on research studies and the experiences of our diverse roster of clients. Introduction is key: Ensure the individual understands the intent of the survey, how it will be used, and the personal benefits to the individual. Set the stage: I ll read you a set of questions designed to help me know how to best support you. There are no right or wrong answers, only what is most true for you today. Emphasize that all answers and results are confidential, yet might be viewed by a health coach, if appropriate, to build the best support program. Reinforce that the answers will not be used to decrease their health care benefits or services, or be used against them in anyway. To achieve the best results, the individual must be completely honest in responding. Give the individual space and time Set the stage: This is important, so please feel free to take as much time as you need to answer the questions. Allow the individual adequate time to answer each statement. Do not coax the individual for a response. Silence is OK; the individual is being thoughtful in his/her answers. Avoid rephrasing or re interpreting the statement if the individual does not respond quickly. Read each question exactly as it appears on the survey. Do not add, remove, change, or interpret words, or ask the questions out of order. Set the stage: Let me read the question again. Is there a particular part of the question I can repeat for you or better explain? If the individual hesitates or asks for clarification, read the statement and response categories a second time. This is generally sufficient. If the individual still doesn t respond or is confused after reading the questions twice: o Read the statement a third time, or o Explain or re phrase the statement in a simpler manner. See the next page for rephrasing of statements (Statements 1 5 typically don t pose a problem, and statements 6 10 only rarely cause confusion.) If you ve tried the above steps without a response, select N/A for the answer. If an individual cannot or will not respond to a PAM statement, select N/A. Insignia Health One SW Columbia Street, Suite 700, Portland, OR 97258, USA Tel: (503) info@insigniahealth.com Rev

7 Re phrasing Options for PAM Statements 6 10 (Use only after reading a statement twice.) 6. I am confident that I can follow through on medical treatments I may need to do at home. Potential trouble spots: Correct, contextual understanding of the terms confident, medical treatments, and follow through. Rephrase: I m sure I can do what my doctor tells me to do at home. (Provide an example of a medical treatment that has relevance for the individual dietary change, smoking cessation, take Rx s correctly.) 7. I have been able to maintain (keep up with) lifestyle changes, like eating right or exercising. Potential trouble spots: Correct, contextual understanding of the terms maintain, keep up with, and lifestyle changes. Rephrase: I have been successful making and staying on track with healthy behaviors like eating right or exercising. 8. I know how to prevent problems with my health. Potential trouble spots: Correct, contextual understanding of the terms prevent, and problems. Rephrase: I know how to stop health troubles from happening in the first place. 9. I am confident I can figure out solutions when new problems arise with my health. Potential trouble spots: Correct, contextual understanding of the terms confident, solutions, and arise. Rephrase: I m sure that I will know the right things to do when I have a new health problem come up. 10. I am confident that I can maintain lifestyle changes, like eating right and exercising, even during times of stress. Potential trouble spots: Correct, contextual understanding of the terms confident, maintain, lifestyle changes, and times of stress. Rephrase: I m sure I can keep doing healthy things, like eating right and exercising, even when I am having a lot of stress in my life. Insignia Health One SW Columbia Street, Suite 700, Portland, OR 97258, USA Tel: (503) info@insigniahealth.com Rev

8 Patient Activation Measure Caregiver Survey Care g iv e r Caring for TABS ID Date Below are statements people sometimes make about caring for the health of someone else. Please indicate how much you agree or disagree with each statement as it applies to you personally as a caregiver. Click on the circle to the left of the answer that is most true for you today. If the statement does not apply, select N/A When all is said and done, I am responsible for seeing that this person s health is managed properly. Taking an active role in this person s health care is one of the most important factors in determining her/his health and ability to function. 3. I know what each of this person s prescribed medications do. 4. I am confident that I can tell when this person needs to get medical care and when I can handle the problem myself. 5. I am confident I can tell a doctor the concerns that I have about this person s health even when he or she does not ask. 6. I am confident that I can follow through on medical treatments I need to do for this person at home. 7. I am able to help this person maintain lifestyle changes (like eating, diet or exercise) for his/her condition. 8. I know how to prevent problems with this person's health 9. I am confident that I can figure out solutions when new situations or problems arise with this person's health 10. I am confident that I can help this person with lifestyle changes, like diet and exercise, even during times of stress. Patient Activation Measure. Caregiver PAM University of Oregon. All Rights reserved Insignia Health. All Rights Reserved. Proprietary and Confidential. For use with a valid copyright license only. Rev

9 Patient Activation Measure Individual Survey Name TABS ID Date Below are statements people sometimes make when they talk about their health. Please indicate how much you agree or disagree with each statement as it applies to you personally. Click on the circle to the left of the answer that is most true for you today. If the statement does not apply, select N/A. 1. When all is said and done, I am the person who is responsible for taking care of my health. 2. Taking an active role in my own health care is the most important thing that affects my health. 3. I know what each of my prescribed medications do. 4. I am confident that I can tell whether I need to go to the doctor or whether I can take care of a health problem myself. 5. I am confident that I can tell a doctor concerns I have even when he or she does not ask. 6. I am confident that I can follow through on medical treatments I may need to do at home. 7. I have been able to maintain (keep up with) lifestyle changes, like eating right or exercising. 8. I know how to prevent problems with my health. 9. I am confident I can figure out solutions when new problems arise with my health. 10. I am confident that I can maintain lifestyle changes, like eating right and exercising, even during times of stress. Patient Activation Measure. PAM University of Oregon. All Rights reserved Insignia Health. All Rights Reserved. Proprietary and Confidential. For use with a valid copyright license only. Rev

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