CASE MANAGEMENT POLICY

Size: px
Start display at page:

Download "CASE MANAGEMENT POLICY"

Transcription

1 CASE MANAGEMENT POLICY Subject: Acuity Scale Determination Effective Date: March 21, 1996 Revised: October 25, 2007 Page 1 of 1 PURPOSE: To set a minimum standard across Cooperative agencies regarding the frequency and duration of client contact based on an assessment of client needs. This acuity scale was developed to respond to the evolving needs of clients living with HIV/AIDS. Today, HIV/AIDS is defined as a chronic illness. As such, maintaining ongoing medical treatment becomes even more important. In addition to managing acute clinical symptoms, medical care is becoming more focused on containing the disease, slowing its progression, and managing HIV related symptoms. POLICY: Client acuity will be determined at intake, reassessment, and/or whenever substantial changes occur in a client s expressed needs. To support this shift, case managers will take a lead role to identify clients requiring medical case management. Medical case management is defined as a range of client-centered services that link clients with health care, psychosocial, and other services. The coordination and follow-up of medical treatments is a component of medical case management. These services ensure timely and coordinated access to medically appropriate levels of health and support services and continuity of care, through ongoing assessment of the client s needs and personal support systems. Medical case management includes the provision of treatment adherence counseling to ensure readiness for, and adherence to, complex HIV/AIDS treatments. Key activities include (1) initial assessment of service needs; (2) development of a comprehensive, individualized service plan; (3) coordination of services required to implement the plan; (4) client monitoring to assess the efficacy of the plan; and (5) bi-annual reevaluation and adaptation of the plan as necessary over the life of the client. It includes client-specific advocacy and/or review of utilization of services. Supportive services case management will also be offered to eligible clients. This service is defined as a social service that includes the provision of advice and assistance in obtaining medical, social, community, legal, financial, and other needed services. Supportive services case management does not involve coordination and follow-up of medical treatments, as medical case management does. Regardless of the type of case management provided, three key elements of a case manager s role are: initially assessing the service needs of clients, developing a comprehensive, individualized service plan with clients, and coordinating services required to implement the plan. The attached acuity scale is a tool that has been developed to assist case managers in completing these tasks. Additionally, case managers will play a key role in determining the appropriate level of case management services, medical case management, or supportive services case management. This acuity scale will help case managers begin to collect information to assist in that determination. PROCEDURE: Case managers will make periodic contact with clients to assess and monitor changing needs and the utility of the service plan. Frequency and type of contact should be based on client s acuity score. Case managers will act as liaisons between clients and service providers to facilitate implementation of the

2 service plan. Case managers will provide supportive counseling and encouragement to clients for whom appropriate services cannot be found or have yet to be implemented. The acuity scale is much more comprehensive and detailed than the prior scale. It is organized into two parts: social service and support needs assessment (Social Determinants of Health Scale Part 1) and medical and key core services needs assessment (Clinical Acuity Scale- Part 2). The social services section, called the Social Determinants of Health Assessment, evaluates the following areas A)Legal; B) Basic Living Needs; C) Transportation; D) Culture and Language; E) Social Support; F) Risk Reduction; G) Housing and Residential Needs; H) Income & Finances and I) Family and Dependents. The medical needs section assesses: 1) Medical Care (access and adherence); 2) Mental Health service needs 3) Substance Abuse service needs; and 4) Other Clinical Needs. These forms are intended to be used with the Client Intake/Case Status Change and Reassessment tool to assist in gathering client assessment information at baseline, during ongoing client assessments, and to collect and assess eligibility information. The client intake form provides basic information which case managers should refer to when completing the acuity tool. To be effective, both parts of the acuity scale must be administered during the same session. In addition, the tools must be completed with the client to assess client-identified needs in each of these areas. FORMS: Acuity Scale Instructions Acuity Part 1 Social Determinants Scale Acuity Part 2 Clinical Determinants Scale AIDS FOUNDATION OF CHICAGO Northeastern Illinois HIV/AIDS Case Management Cooperative

3 Acuity Scale Instructions Part 1 Social Determinants of Health This section of the acuity scale focuses on assessment of client social service needs. The information is similar to the information that is collected at an intake assessment and/or reassessment. Case managers should administer this section of the acuity scale prior to administering the clinical indicators portion of the acuity scale (Part 2). Administering the scale in this order will help case managers build strong working relationships and help facilitate conversations with clients. It will also help case managers identify acute social service needs of the client more quickly. Finally, case managers are more familiar with assessing social services needs, which may be a more comfortable format for both the case manager and client. The scale identifies common key areas where clients may require traditional case management supportive services. Information collected in these areas will help inform individual service plans, but should not replace traditional agency service plans. Administration Case managers will analyze each social service area based on client response to the general questions asked and the specific questions in specific sections. Case managers will assign a level of service need per general area. The levels of service need corresponding with highest level of need that the client identifies. For example, if a client answers yes to a question for level 3, they are assigned a value for level 3. For sections A- F, a specific question is provided which case managers should use as a guide for asking clients. Case managers are free to use additional probing techniques to help collect information to place the client in the appropriate level. Additional information to help complete the acuity for Sections G-I can be answered based on the clients answers to corresponding sections in the Client Intake/Case Status Change and Reassessment form. Ideally, the assessment should be administered in an informal conversational interview format. For each section, there are a series of yes/no and open ended questions that correspond to different levels of service need. Case managers are encouraged to ask these questions and assign a score to the client based on the responses to the questions. Case managers will utilize this information to develop a service plan that addresses client needs as identified in the responses. Case manager clinical judgment and follow up questions to the client are encouraged to help determine the level of service need per area. The scale uses a point system to determine degree of need. Points are assigned by levels. There are four levels that have the following point breakdown: Level 1: 0 points Level 2: 2 points Level 3: 4 points Level 4: 8 points A cumulative score for part 1 is obtained by summing up the total points for each section.

4 QUESTION BY QUESTION GUIDE Section A: Legal This section focuses on any legal issues the client may be currently experiencing. Case managers will want to collect information on past history of incarceration and what specific need(s) a client may have in this area. The probe question is provided below: Do you have any current or recent legal issues that require additional assistance (i.e. pending cases, powers of attorney, and living wills)? Do you have all the legal documents you need to care for yourself? Also, it is important to refer to the legal section of the Client Intake/Case Status Change and Reassessment form to help identify any recent incarcerations or pending court cases. Section B: Basic Living Needs Client basic needs and level of independent functioning are assessed in this section. This section provides important information as to the client s immediate food and shelter needs. Do you have basic living needs, such as clothes, food, etc? Can you perform activities that keep you independent in your home such as bathing, grooming, dressing, cooking, cleaning, etc? Section C: Transportation This section assesses the transportation needs. It is important to determine whether transportation factors play a role in accessing medical care. What type of transportation do you currently use to get to your primary care/medical and other clinical appointments, and have you experienced any gaps? Page 4 of the Client Intake/Case Status Change and Reassessment form will help to determine eligibility of the client to receive Ryan White funded transportation services. This section of the acuity scale will help to determine the level of need for those services. Section D: Culture and Language This section assesses cultural or language barriers that may impact access to medical or social

5 services. Cultural barriers also include barriers clients may experience due to their sexual orientation or religious beliefs. Do you or your family have any language or cultural barriers that prevent you from identifying and accessing services? Section E: Social Support System This section focuses on client self-assessment of type and quality of social support that the client receives from family, friends or professionals to help manage and cope with their HIV. (Note: this question is different than section G which assesses their role within their family and the dependents or family responsibilities they may have). This section should also be used to identify any potential domestic violence issues facing the client. Please describe your family, friends, and loved ones and their ability to support you as you treat your HIV/AIDS. Are you currently experiencing any emotional or physical abuse from any of these individuals? Section F: Risk Reduction This section helps case managers begin to discuss risk reduction to better understand the degree to which a client may be engaging in high risk behavior. When asking this question it is important to indicate that the question pertains to a specific time period (Past Month). Case managers should try to get client to quantify the frequency rather than give simply a percentage. For example, begin the question by stating Within the last month When possible, obtain actual number. For example, if the client states 20% of the time, clarify if that corresponds with 1 unsafe sexual encounter out of five, or 2 unsafe sexual encounters out ten. The acuity defines the 20% level as mild, > 20% to 50% as moderate, and over 50% as significant. Any level of high risk sexual practices represents a need for education and prevention counseling. These levels are designed to gauge the extent of the issue to be addressed in the service plan. How often have you engaged in any behaviors that put you at risk for re-infection of HIV, infection of another STD, or has put another person at risk for contracting HIV? How many times in the past year have you been diagnosed with an STD? SECTIONS G THROUGH I THE FOLLOWING SECTIONS ARE ADDITIONAL AREAS THAT CASE MANAGERS MUST ASSESS. IN ORDER TO COMPLETE THE REMAINING SECTIONS, IT IS NECESSARY TO REFER TO THE CLIENT S INTAKE FORM AS WELL AS THE

6 QUESTIONS IN EACH LEVEL. EACH OF THE FOLLOWING SECTIONS CORRESPOND TO AN IDENTIFIED DATA COLLECTION SECTION OF THE CLIENT INTAKE/CASE STATUS CHANGE AND REASSESSMENT FORM. Section G: Housing and Residential Needs This section relates to acute and long-term housing needs. Information on current living arrangements is provided in Client Intake/Case Status Change and Reassessment form. Section H: Income & Finances This section assesses the client s financial needs. This section assesses income sources and need for additional benefit services to adequately support the client. Section I: Family & Dependents This section assesses whether the client has dependents or needs support to manage own dependents. This section also focuses on the client s responsibilities as a provider to his/her own family. Instructions for obtaining an overall acuity rating for Part 1 The total acuity rating is the sum of scores for sections A to I. The range of scores will be The higher score should indicate the greatest need. After completing Part 1, case managers must then administer Part 2 of the acuity scale, Clinical Indicators.

7 Part 2 Clinical Determinants of Health This section of the acuity scale focuses on assessment of client clinical needs. The information is a more in depth assessment of the basic clinical information that is collected at an intake assessment and/or reassessment. Case managers should administer this section of the acuity scale after administering the social determinants portion of the acuity scale (Part 1). The clinical indicators address the core services that are identified in the Ryan White HIV/AIDS Treatment Modernization Act: medical care, substance use, mental health, and oral health. The scale identifies common key areas where clients may require case management supportive services in order to establish or maintain adherence to key clinical treatments in their HIV care. Information collected in these areas will help inform individual service plans, but should not replace traditional agency service plans. Administration Case managers will analyze each clinical service area based on client response to the general questions asked and the specific questions in specific sections. Case managers will assign a level of service need per general area. The levels of service need corresponding with highest level of need that the client identifies. For example, if a client answers yes to a question for level 3, they are assigned the point value for level three. Ideally, the assessment should be administered in an informal conversational interview format. For each section, there are a series of yes/no and open ended questions that correspond to different levels of service need. Case managers are encouraged to ask these questions and assign a score to the client based on the responses to the questions. Case managers will utilize this information to develop a service plan that addresses client needs as identified in the responses. Case manager clinical judgment and follow up questions to the client are encouraged to help determine the level of service need per area. The scale uses a point system to determine degree of need. Points are assigned by levels. Most questions have four response levels that have the following point breakdown: Level 1: 0 points Level 2: 2 points Level 3: 4 points Level 4: 8 points Some questions have a separate scoring format that is delineated on the forms and throughout the instructions. A cumulative score for Part 2 is obtained by summing up the total number of points for each section.

8 Section A: Medical Assessment (0 64 points) This section of the clinical acuity scale is intended to assess the level to which a client is enrolled and active in obtaining primary care and to assess any needs in this area. The clinical acuity scale Medical Assessment section is divided into 2 subsections: (A1) Access to Medical Care and (A2) HIV Medication Adherence. Section A1 assesses whether a client currently has a medical care provider, the adherence to the most recent medical visits, and frequency of missed appointments. Section A2 assesses the need for and access to HIV medications. It also assesses the degree to which a client reports being adherent to their HIV medication regiment for those clients currently prescribed and taking HIV medications. Section A1: Access to Medical Care A1a: Do you currently have a stable medical provider (Doctor, Nurse, etc) who you see for your HIV treatment? This is a yes/no question. If client responds no, you will automatically assign a score of 64 and move on to Section B (Mental Health Assessment). The rationale for assigning a score of 64 (the maximum number of points) relates to HIV being a chronic medical condition requiring ongoing primary medical care monitoring, so clients with no primary medical care currently should receive ongoing HIV medical care to monitor their HIV disease, slow its progression, and manage HIV related symptoms. Case managers should work with the client to coordinate a medical appointment within the 2 weeks following this assessment. If the client responds yes, move on to questions A1b and A1c. A yes response to question A1a is not assigned a point value. Case managers should work with the client to coordinate and monitor medical appointments. A1b: When did you last see your medical provider? There are four categories that a client can select: Within the last three months Between three and six months ago Between six months and one year More than one year ago (Level 1 = 0 points) (Level 2 = 2 points) (Level 3 = 4 points) (Level 4 = 8 points) A point score, ranging from 0 to 8, is assigned based on the client response. This follow-up question to A1a, along with question A1c, provides the case manager with pertinent information as to whether the client is seeing an HIV medical provider regularly. If the client scores zero points, skip to question A2a. A1c: How many of the last three doctor s appointments did you miss excluding the most recent appointment kept? There are 4 responses a client can select from:

9 None One Two Three (Level 1 = 0 points) (Level 2 = 2 points) (Level 3 = 4 points) (Level 4 = 8 points) NOTE: The frequency that a client should see their HIV medical provider depends on their health status (e.g. viral load levels, acute medical conditions) and current Public Health system treatment guidelines. The categories provided in the question are not intended to make any clinical assessment, but rather to provide case managers with a general indication of treatment adherence to determine need for primary care referrals. Section A2: HIV Medications and Treatment This section is intended to assess the degree to which clients who are being prescribed medications report being adherent to their prescribed HIV medication regimens. Responses in this section are weighted differently than the other sections for two reasons. First, medication adherence is an extremely important component of their overall medical care. Second, medication adherence is best viewed as a yes/no type of assessment. A client is either taking their HIV medication regularly or they are not, the degree of non-adherence is less important than the reasons for the non-adherence. A2a: Have you been prescribed medications for your HIV? This is a yes/no question and is not scored. Further information is needed to find out whether the client is not taking medication for clinically appropriate reasons or other reasons. If a client says no, ask question A2b. If a client responds yes, go to question A2c. A2b: Why are you currently not prescribed medications for your HIV? There are 4 responses a client can select from: Medical Provider says I do not need to be Medical Provider took me off my meds, or is assessing readiness I cannot get access to payment for the medications I don t want to be on medications (Level 1 =0 points) (Level 2 =2 points) (Level 3 =6 points)* (Level 4 =10 points)* *(Since medication access and non-adherence is such an important treatment component, lack of access to HIV medication or resistance to taking medication is scored at a higher level.) For those client s determined to be prescribed medications, the case manager must than administer questions A2c-A2e to assess the client s medication adherence. Assign point values based on client s responses to determine the degree of adherence. A2c: How often do you feel that you have difficulty taking your HIV medications on time? (By on time we mean no more than two hours before or after the time your doctor told you to take it.)

10 Never Rarely Most of the time All of the time (Level 1 = 0 pts) (Level 2 = 2 pts) (Level 3 = 4 pts) (Level 4 = 8 pts) If a client has difficulty quantifying this, ask them to give you their best guess, or respond with the first response that comes to their head. Remind them that the goal is to support adherence, not penalize non-adherence. A2d: On average, how many days PER WEEK would you say that you missed at least one dose of your HIV medications? Never (Level 1 = 0 pts) 1 3 days per week (Level 2 = 2 pts) 4 6 days per week (Level 3 = 4 pts) Every day (Level 4 = 8 pts) A2e: When was the last time you missed at lest one dose of your HIV medications? Never (Level 1 = 0 pts) More than two weeks ago (Level 2 = 2 pts) 1 2 weeks ago (Level 3 = 4 pts) Within the past week (Level 4 = 8 pts) HOW TO SCORE SECTION A Scores from section A1 and A2 are summed together to get an overall score for the medical assessment section. Scores can range from 0 to 64. The higher the score the greater the need to work with the client to ensure that they enter and remain connected with a medical care provider. In service planning, any area with a score of 4 or higher should be addressed with an objective in the service plan. For example, if the client indicates that they have missed doses 4 6 days in the last two weeks (a score of 4), as measured in question A2d, the case manager should probe further to reduce the barriers to adherence for this client. Section B: Mental Health Assessment (0-40 points) The purpose of this section is to: 1) assess level of emotional distress (mental health symptoms) client is currently experiencing; 2) whether that distress is affecting their ability to maintain medical care and 3) to decide whether referral to mental health services is needed. The clinical acuity scale Mental Health Assessment section is divided into 2 subsections: (B1) Access to Mental Health Care and (B2) Psychiatric Medication Adherence. Section B1 assesses whether a client currently has a mental health issue and, if the client currently has a mental health provider, the adherence to the most recent treatment visits, and frequency of missed appointments. Section B2 assesses the need for and access to psychiatric medications. It also assesses the degree to which a client reports being adherent to their medication regiment for those clients currently prescribed and taking psychiatric medications.

11 Section B1: Access to Mental Health Care B1a: Has your mental or emotional health ever affected your ability to complete your activities of daily living? This is a yes/no question. If client responds no, a score of zero is recorded and you skip to Section C Substance Use Assessment. If a client reports yes, a score of 8 is assigned to this question. B1b: Have you ever been treated for mental illness? This question is not assigned a point value. It just provides information that may be used for service planning. For example, a client may report no emotional distress which may be due to them seeing a mental health provider. It also seeks to predict future activities to treat mental illness, by assessing past treatment seeking behaviors. B1c: Do you currently have a counselor/psychiatrist/therapist that you see for your mental health treatment? If the client responds yes, ask question B1d. This question is not scored. B1d: How many of the last three doctor s appointments did you miss excluding the most recent appointment kept? There are 4 responses a client can select from: None One Two Three (Level 1 = 0 points) (Level 2 = 2 points) (Level 3 = 4 points) (Level 4 = 8 points) This question helps assess the degree of engagement in mental health care. It may be helpful to do some probing to find out why a client may not be seeing a clinician regularly, if determined that the client is experiencing mental or emotional disruptions. Section B2: Psychiatric Medication B2a: Are you currently being prescribed medications for your mental illness? This is a yes/no question and is not scored. If no, skip to Section C Substance Use Assessment. For clients who are being prescribed medications, the case manager must than administer questions B2b-B2d to assess the client s medication adherence. Assign point values based on client s responses to determine the degree of adherence. B2b: How often do you feel that you have difficulty taking your mental illness medications on time? (By on time we mean no more than two hours before or after the time your doctor told

12 you to take it.) Never Rarely Most of the time All of the time (Level 1 = 0 pts) (Level 2 = 2 pts) (Level 3 = 4 pts) (Level 4 = 8 pts) If a client has difficulty quantifying this, ask them to give you their best guess, or respond with the first response that comes to their head. Remind them that the goal is to support adherence, not penalize non-adherence. B2c: On average, how many days PER WEEK would you say that you missed at least one dose of your medications? Never (Level 1 = 0 pts) 1 3 days per week (Level 2 = 2 pts) 4 6 days per week (Level 3 = 4 pts) Every day (Level 4 = 8 pts) B2d: When was the last time you missed at least one dose of your mental illness medications? Never (Level 1 = 0 pts) More than two weeks ago (Level 2 = 2 pts) 1 2 weeks ago (Level 3 = 4 pts) Within the past week (Level 4 = 8 pts) HOW TO SCORE SECTION B The maximum point score for this section is 40. Sum together scores from section B1 and B2 for a total score. Case managers should also refer back to the client intake to help inform service planning. The higher the score the greater the need to work with the client to ensure that they enter and remain connected with a mental health care provider. In service planning, any area with a score of 4 or higher should be addressed with an objective in the service plan. Note: There is some redundancy in client intake form and mental health assessment scale. These tools should be used in conjunction to inform the service plan. Section C: Substance Use Assessment (0 40 points) This section requires that you use information from both the substance use section of the client intake form and the questions asked here about substance use treatment history. Together this information will help you decide whether a substance use treatment referral is needed and provide information about the impact of substance use on a client s life. The clinical acuity scale Substance Use Assessment section is divided into 2 subsections: (C1) Access to Substance Use Treatment and (C2) Substance Use Medications and Treatment Adherence. Section C1 assesses whether a client currently has a substance use issue and, if the client currently has a treatment provider, the adherence to the most recent treatment visits, and

13 frequency of missed appointments. Section C2 assesses the need for and access to substance use medications and treatments. It also assesses the degree to which a client reports being adherent to their medication regiment for those clients currently prescribed and taking methadone or other medications. Section C1: Substance Use Access to Care C1a: Are you currently being treated for substance use? This is a yes/no question. If no, skip to Section D Other Clinical Needs. If yes, continue to question C1B. This information can be compared to the substance pattern questionnaire from the Intake/Case Status form to help inform whether or not the client has an historical or existing substance use issue. C1b: If yes, what type of treatment are you receiving? This question will help you determine the degree of substance use severity and level of support the client is seeking to address. Clients referred to more intensive substance use treatment settings usually will require more intensive and ongoing treatment. They also may be at high risk for medical treatment non-adherence. Self-Help, 12-step Outpatient Treatment Day Treatment Residential (Level 1 = 0 pts) (Level 2 = 2pts) (Level 3 = 4pts) (Level 4 = 8pts) C1c: Do you currently have a stable counselor/therapist who you see for your substance use treatment? If the client responds yes, ask question C1d. This question is not scored. C1d: How many of the last three counselor/therapist s appointments did you miss? There are 4 responses a client can select from: None One Two Three (Level 1 = 0 points) (Level 2 = 2 points) (Level 3 = 4 points) (Level 4 = 8 points) This question helps assess the degree of engagement in substance use treatment. It may be helpful to do some probing to find out why a client may not be accessing their treatment regularly. This will be helpful for individual service planning. Section C2: Substance Use Medications and Treatment C2a: Have you been prescribed medications (methadone, etc.) for your substance use?

14 This is a yes/no question, and is most applicable to those with past or present opiate addiction. C2b: Have you missed any doses of your medication because you could not afford them or get them in any way? This is a yes/no question. A yes response is scored as 8 points, and may indicate a current need for treatment with barriers to accessing it. HOW TO SCORE SECTION C Sum the total responses to each section. The higher the score the greater the need to work with the client to ensure that they enter and remain connected with a substance use treatment provider. In service planning, any area with a score of 4 or higher should be addressed with an objective in the service plan. Section D: Other Clinical Needs (0 40 points) The information collected will help assess need for medical case management and informs individual treatment planning. The format for this section is different than Sections A-C as there is only one question per the five domains. In this section, it is important to assign a score for each section based on the highest level the client responds to. For each section, a general question is asked. The case manager is then provided with some examples of responses that would be appropriate for various levels and points to assign. Based on the response given, the case manager must make a clinical judgment about the appropriate level of need and assign that point value. Section D1: Knowledge of HIV Disease This section is intended to help case managers get an estimate of the client s HIV knowledge level. Based on clients responses, case managers should assign a score ranging from 0 to 8 for this section. Level 1 (0 points): Client is able to describe to their case manager: 1) that HIV/AIDS is a chronic illness; 2) requires ongoing medical care; and 3) there are available medical treatments that keep people with HIV/AIDS living longer. Case managers should ask these questions Can you tell me what CD4 T-cell count and viral load mean? Why is important to know and monitor your T-cell and viral load count? Can you tell me what highly active antiretroviral therapy (HAART)? If a client answers these questions correctly, score client as 0 in the domain. Level 2 (2 points): Client knows that s/he has a medical condition, but knows little about how the

15 virus affects the body. S/he also displays limited knowledge about medical treatment. The client will not be able to clearly answer the level 1 questions, but does demonstrate a basic understanding of HIV disease. Case managers should ask these questions: Do you feel your general knowledge of HIV disease is good enough that you do not need additional information? (y/n) Do you feel that you have a good understanding of the different types of HIV medications regimens? (y/n) If clients respond no, to either question, score as a 2. Level 3 (4 points): Client communicated inaccurate information about HIV disease progression. S/he is unaware how effective HIV medications can be for ongoing medical care. Case managers should ask these questions: Has anyone ever talked to you about HIV medications and how effective they are in keeping you healthy? (y/n) Do you think that because you are HIV+ positive there is no treatment that can help you? (y/n) Consider asking a true or false question from HIV educational materials you may have available at your agency. If a client responds no or continues to demonstrate inaccurate understanding, score as a 3. Level 4 (8 points): Clients is unable to answer the basic information about HIV disease (how HIV is transmitted, what HIV stands for, what AIDS stands for, etc.) Client does not know how they contracted HIV or how it spreads. Client exhibits no knowledge of HIV. Section D2: Nutrition This section assesses the need for nutritional services. The primary indicators are client selfreported physical symptoms associated with eating and digestion that interferes with day to day functioning (and potentially medication adherence). Are you having any problems with eating, weight gain, abdominal pain, nausea or diarrhea? How often do you eat? How do your prepare food? Describe a general day s eating habits. How do you manage nausea or diarrhea? Section D3: Oral Health

16 This section assesses the need for dental services. The primary indicator is level of pain client is experiencing and degree to which pain interferes with day to day functioning. The questioning should also address any denture needs or problems. Are you having any problems with you mouth or teeth, pain when chewing or eating, or have need for assistance with dentures? Section D4: Health Insurance & Medical Coverage Please remember to also review client responses from the Client Intake/Case Status Change and Reassessment forms prior to completing this section. How are you currently paying for your medical services and/or how are you paying for your medications? (Please refer to insurance and health coverage questions on Intake.) Section D5: Pregnancy The final section pertains to reproductive health. It is to be asked to both men and women. Case managers should adjust the wording of the question accordingly. That is, if asking the question is to a male, the question should be directed to determine if the client and his partner are currently pregnant or is planning to become pregnant. Are you currently or planning to become pregnant? If you are pregnant, was this a planned pregnancy? Are you currently receiving prenatal care? The scoring must take into account the current pregnancy status, future reproductive planning, and access to prenatal care. HOW TO SCORE SECTION D This section should be scored by summing the total of each section to obtain an overall score for section D for a total possible score of 40 points. The higher the score the greater the need to work with the client to ensure that these issues do not create barriers to clinical care. In service planning, any area with a score of 4 or higher should be addressed with an objective in the service plan. Instructions for obtaining an overall acuity rating for Part 2 Clinical Indicators The total acuity rating is the sum of scores for sections A through D. In prioritizing categories of need, scores in the clinical acuity scale should be addressed prior to the needs identified in the social determinants of health acuity tool, whenever possible. Social determinants that are identified as barriers to accessing clinical care should also be prioritized.

INTEGRATED CASE MANAGEMENT ANNEX A

INTEGRATED CASE MANAGEMENT ANNEX A INTEGRATED CASE MANAGEMENT ANNEX A NAME OF AGENCY: CONTRACT NUMBER: CONTRACT TERM: TO BUDGET MATRIX CODE: 32 This Annex A specifies the Integrated Case Management services that the Provider Agency is authorized

More information

STANDARDS OF CARE HIV AMBULATORY OUTPATIENT MEDICAL CARE STANDARDS I. DEFINITION OF SERVICES

STANDARDS OF CARE HIV AMBULATORY OUTPATIENT MEDICAL CARE STANDARDS I. DEFINITION OF SERVICES S OF CARE Oakland Transitional Grant Area Care and Treatment Services J ANUARY 2007 Office of AIDS Administration 1000 Broadway, Suite 310 Oakland, CA 94612 Tel: 510. 268.7630 Fax: 510.268-7631 AREAS OF

More information

NJ Level of Care and Assessment Process

NJ Level of Care and Assessment Process NJ Level of Care and Assessment Process CODING GUIDELINES AND LEVEL OF CARE Cheryl Hogan Division of Aging Services NJ Department of Human Services 1 5/28/2014 Goals To understand the assessment process

More information

I. Description. Triage Counseling is an individual level intervention that establishes a direct link between primary. Rural

I. Description. Triage Counseling is an individual level intervention that establishes a direct link between primary. Rural Rural triage Counseling 2 Triage Counseling is an individual level intervention that establishes a direct link between primary medical care and mental health services for patients living with HIV. The

More information

Adherence Nurse. I. Description. Treatment Adherence Nurse is an individual level intervention designed to actively engage formerly

Adherence Nurse. I. Description. Treatment Adherence Nurse is an individual level intervention designed to actively engage formerly 21 Currently/Formally Incarcerated Treatment Adherence Nurse Treatment Adherence Nurse is an individual level intervention designed to actively engage formerly incarcerated individuals who are HIV+ in

More information

Minnesota CHW Curriculum

Minnesota CHW Curriculum Minnesota CHW Curriculum The Minnesota Community Health Worker curriculum is based on the core competencies that are identified in Minnesota s CHW "Scope of Practice." The curriculum also incorporates

More information

Ryan White Part A. Quality Management

Ryan White Part A. Quality Management Quality Management Medical Case Management 2014 Broward County/Fort Lauderdale Eligible Metropolitan Area (EMA) The creation of this public document is fully funded by a federal Ryan White CARE Act Part

More information

CASE MANAGEMENT STANDARDS OF CARE FOR RYAN WHITE ACT-FUNDED SERVICES IN ORANGE COUNTY

CASE MANAGEMENT STANDARDS OF CARE FOR RYAN WHITE ACT-FUNDED SERVICES IN ORANGE COUNTY CASE MANAGEMENT STANDARDS OF CARE FOR RYAN WHITE ACT-FUNDED SERVICES IN ORANGE COUNTY Effective March 10, 2008 COUNTY OF ORANGE HEALTH CARE AGENCY Case Management Standards of Care TABLE OF CONTENTS Introduction

More information

Establishing an HIV/AIDS Pharmacy Practice in an Underserved Inner City Environment Facilitators and Barriers

Establishing an HIV/AIDS Pharmacy Practice in an Underserved Inner City Environment Facilitators and Barriers Establishing an HIV/AIDS Pharmacy Practice in an Underserved Inner City Environment Facilitators and Barriers Madeline Feinberg, Pharm.D Chase Brexton Health Services Baltimore Inner Harbor Overview of

More information

Tennessee Health Link Guidelines: Adults Medical Necessity Criteria-Final

Tennessee Health Link Guidelines: Adults Medical Necessity Criteria-Final Tennessee Health Link Guidelines: Adults Medical Necessity Criteria-Final Program Description Tennessee Health Link service model is a program created to address the diverse needs of individuals requiring

More information

Project AIDS Care Waiver: Level of Need (LON) Assessment Case Management Tool

Project AIDS Care Waiver: Level of Need (LON) Assessment Case Management Tool Instructions: Identify the initial Level of Need (LON) by entering a number on the criteria that best describes the client's situation. Use the space labeled (B) for the first re-assessment, and the spaces

More information

MANAGED CARE READINESS

MANAGED CARE READINESS MANAGED CARE READINESS A SELF-ASSESSMENT TOOL FOR HIV SUPPORT SERVICE AGENCIES U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES HEALTH RESOURCES & SERVICES ADMINISTRATION HIV/AIDS BUREAU MANAGED CARE READINESS

More information

o Recipients must coordinate these testing services with other HIV prevention and testing programs to avoid duplication of efforts.

o Recipients must coordinate these testing services with other HIV prevention and testing programs to avoid duplication of efforts. E. GENERAL SERVICE DEFINITIONS & SERVICE DELIVERY The following section provides specific service definitions, service delivery and any special reporting requirements for each of the services funded in

More information

Activities of Daily Living (ADL) Critical Element Pathway

Activities of Daily Living (ADL) Critical Element Pathway Use this pathway for a resident who requires assistance with or is unable to perform ADLs (Hygiene bathing, dressing, grooming, and oral care; Elimination toileting; Dining eating, including meals and

More information

HEALTH AND BEHAVIOR ASSESSMENT & INTERVENTION

HEALTH AND BEHAVIOR ASSESSMENT & INTERVENTION Optum Coverage Determination Guideline HEALTH AND BEHAVIOR ASSESSMENT & INTERVENTION Policy Number: BH727HBAICDG_032017 Effective Date: May, 2017 Table of Contents Page INSTRUCTIONS FOR USE...1 BENEFIT

More information

RYAN WHITE HIV/AIDS PROGRAM SERVICES Definitions for Eligible Services

RYAN WHITE HIV/AIDS PROGRAM SERVICES Definitions for Eligible Services RYAN WHITE HIV/AIDS PROGRAM SERVICES Definitions for Eligible Services (Last Updated: July 15, 2013) Ryan White HIV/AIDS Program funds are intended to support only the HIV-related needs of clients. All

More information

Tube Feeding Status Critical Element Pathway

Tube Feeding Status Critical Element Pathway Use this pathway for a resident who has a feeding tube. Review the Following in Advance to Guide Observations and Interviews: Most current comprehensive and most recent quarterly (if the comprehensive

More information

HEALTH SERVICES POLICY & PROCEDURE MANUAL

HEALTH SERVICES POLICY & PROCEDURE MANUAL PAGE 1 of 7 References Related ACA Standards 4 th Edition Standards for adult Correctional Institutions 4-4368, 4-4369, 4-4370, 4-4371, 4-4372 PURPOSE To provide guidelines for prioritizing immediacy and

More information

DEPARTMENT OF HUMAN SERVICES DIVISION OF MENTAL HEALTH & ADDICTION SERVICES

DEPARTMENT OF HUMAN SERVICES DIVISION OF MENTAL HEALTH & ADDICTION SERVICES DEPARTMENT OF HUMAN SERVICES DIVISION OF MENTAL HEALTH & ADDICTION SERVICES ADDENDUM to Attachment 3.1-A Page 13(d).10 Service Description Community Support Services consist of mental health rehabilitation

More information

Skill 2: Client will identify triggers that have the greatest impact on his or her medical regimen

Skill 2: Client will identify triggers that have the greatest impact on his or her medical regimen OUTCOME AND SKILLS Outcome 1: Client will identify information sources regarding health and treatment Outcome 2: Client will identify factors that influence adherence to a medical regimen Skill 1: Client

More information

RYAN WHITE TITLE I SERVICE STANDARDS

RYAN WHITE TITLE I SERVICE STANDARDS RYAN WHITE TITLE I SERVICE STANDARDS 2 0 0 5 Chicago Area HIV Services Planning Council Chicago Department of Public Health Division of STD/HIV/AIDS Public Policy and Programs In collaboration with Midwest

More information

Child and Family Development and Support Services

Child and Family Development and Support Services Child and Services DEFINITION Child and Services address the needs of the family as a whole and are based in the homes, neighbourhoods, and communities of families who need help promoting positive development,

More information

NATIONAL ACADEMY OF CERTIFIED CARE MANAGERS

NATIONAL ACADEMY OF CERTIFIED CARE MANAGERS NATIONAL ACADEMY OF CERTIFIED CARE MANAGERS Content Domains and Care Manager Tasks The Care Manager Certification examination questions contain content from the following domains. The approximate percentage

More information

Whittier Street Health Center. Post Prison Release Program established February 2003

Whittier Street Health Center. Post Prison Release Program established February 2003 Whittier Street Health Center Post Prison Release Program established February 2003 Current programming is a Case Management and Care Coordination program. Whittier partners with several community based

More information

Behavioral Health Outpatient Authorization Request Self Service. User Guide

Behavioral Health Outpatient Authorization Request Self Service. User Guide Behavioral Health Self Behavioral Health Outpatient Authorization Request Self Service User Guide Introduction Tufts Health Plan Network Health has created this user guide to illustrate how to navigate

More information

Module 2: Learning Objectives Module 2: Retention, Adherence, and Psychosocial Support in PMTCT Programs

Module 2: Learning Objectives Module 2: Retention, Adherence, and Psychosocial Support in PMTCT Programs Module 2: Learning Objectives Module 2: Retention, Adherence, and Psychosocial Support in PMTCT Programs Define the terms retention, adherence, and psychosocial support Understand the importance of retention,

More information

OUTPATIENT SERVICES. Components of Service

OUTPATIENT SERVICES. Components of Service OUTPATIENT SERVICES Providers contracted for this level of care or service are expected to comply with all requirements of these service-specific performance specifications. Additionally, providers contracted

More information

Proceed with the interview questions below if you are comfortable that the resident is

Proceed with the interview questions below if you are comfortable that the resident is Resident Interview Interviewer Interview Date Resident Room Preparation Resident interviews should be conducted in a private setting so the resident feels comfortable providing honest answers without fear

More information

Blending Behavioral Health and Primary Care. Applying the Model. Brittany Tenbarge, Ph.D. Behavioral Health Consultant Licensed Clinical Psychologist

Blending Behavioral Health and Primary Care. Applying the Model. Brittany Tenbarge, Ph.D. Behavioral Health Consultant Licensed Clinical Psychologist Blending Behavioral Health and Primary Care Applying the Model Brittany Tenbarge, Ph.D. Behavioral Health Consultant Licensed Clinical Psychologist Overview Introducing the Model to Patients Key Components

More information

CLIENT REFERRAL PACKAGE

CLIENT REFERRAL PACKAGE p HEARTWOOD CENTRE FOR WOMEN CLIENT REFERRAL PACKAGE REFERRAL INFORMATION PACKAGE Heartwood, a residential treatment program, is a provincial tertiary 30 bed resource for women with substance dependence,

More information

Denise Figueroa. Gurabo Community Health Center, Inc. Gurabo, Puerto Rico

Denise Figueroa. Gurabo Community Health Center, Inc. Gurabo, Puerto Rico The One Stop Shop: An Integrated t Model of Early Intervention Services in HIV Care Denise Figueroa HIV Program Director Gurabo Community Health Center, Inc. Gurabo, Puerto Rico G URABO * SA N LO R ENZO

More information

Policy Review Sheet. Review Date: 14/10/16 Policy Last Amended: 19/10/17. Next planned review in 12 months, or sooner as required.

Policy Review Sheet. Review Date: 14/10/16 Policy Last Amended: 19/10/17. Next planned review in 12 months, or sooner as required. Category: Care Management Sub-category: Care Practice Page: 1 of 10 Policy Review Sheet Review Date: 14/10/16 Policy Last Amended: 19/10/17 Next planned review in 12 months, or sooner as required. Note:

More information

Discharge Planning for Patients Hospitalized for Mental Health Treatment Interpretative Guidelines for Oregon Hospitals

Discharge Planning for Patients Hospitalized for Mental Health Treatment Interpretative Guidelines for Oregon Hospitals Discharge Planning for Patients Hospitalized for Mental Health Treatment Interpretative Guidelines for Oregon Hospitals May 2016 1 PURPOSE This document is meant to offer interpretative guidance for Oregon

More information

ProviderReport. Managing complex care. Supporting member health.

ProviderReport. Managing complex care. Supporting member health. ProviderReport Supporting member health Managing complex care Do you have patients whose conditions need complex, coordinated care they may not be able to facilitate on their own? A care manager may be

More information

Objectives. Models of Integrated Behavioral Health Care 9/23/2015

Objectives. Models of Integrated Behavioral Health Care 9/23/2015 Models of Integrated Behavioral Health Care Carlton D. Craig, Ph.D. Vernon R. Wiehe Endowed Professor in Family Violence University of Kentucky College of Social Work Carlton.craig@uky.edu (859)-257-6657

More information

Tennessee Health Link Guidelines: Adults Medical Necessity Criteria

Tennessee Health Link Guidelines: Adults Medical Necessity Criteria Tennessee Health Link Guidelines: Adults Medical Necessity Criteria https://providers.amerigroup.com Program description The Health Link service model is a program created to address the diverse needs

More information

HEALTH 30. Course Overview

HEALTH 30. Course Overview HEALTH 30 Description This course emphasizes attitudes, attributes and skills along with knowledge-based components to assist juniors to minimize health risks and avoid behaviors which interfere with well

More information

Cedars HOPE, Inc. RESIDENT APPLICATION

Cedars HOPE, Inc. RESIDENT APPLICATION Cedars HOPE, Inc. RESIDENT APPLICATION Agency Name: Agency address: REFERRING AGECNY INFORMATION Fax: Referring Person Name: Contact Email Date of Referral: / / Name: APPLICANT INFORMATION Date of birth:

More information

MENTAL HEALTH SERVICES

MENTAL HEALTH SERVICES MENTAL HEALTH SERVICES I. DEFINITION OF SERVICE Mental Health includes psychological and psychiatric treatment and counseling services offered to individuals with a diagnosed mental illness, conducted

More information

Medical Case Management

Medical Case Management Definition: services (including treatment adherence) is the provision of a range of consumer-centered consumer activities focused on improving health outcomes in support of the HIV Care Continuum. Consumer

More information

Form CMS (5/2017) Page 1

Form CMS (5/2017) Page 1 Use this pathway for a resident who has pain symptoms or can reasonably be expected to experience pain (i.e., during therapy) to determine whether the facility has provided and the resident has received

More information

When preparing for an ACE certification exam,

When preparing for an ACE certification exam, Introduction to Coaching CHAPTER 1 APPENDIX B Exam Content Outline For the most up-todate version of the Exam Content Outline, please go to www.acefitness.org/ HealthCoachexamcontent and download a free

More information

Management of patients with TB/HIV Gunta Kirvelaite

Management of patients with TB/HIV Gunta Kirvelaite Management of patients with TB/HIV Gunta Kirvelaite Riga East Clinical hospital, Centre for tuberculosis and lung diseases. Head of outpatient department. MDR TB physician. WHO Collaborating Centre for

More information

SECTION 3. Behavioral Health Core Program Standards. Z. Health Home

SECTION 3. Behavioral Health Core Program Standards. Z. Health Home SECTION 3 Behavioral Health Core Program Standards Z. Health Home Description Health home is a healthcare delivery approach that focuses on the whole person and provides integrated healthcare coordination

More information

MODULE 8 1. Module 8 Learning Objectives. Adolescent HIV Care and Treatment. Module 8: Module 8 Learning Objectives (Continued) Session 8.

MODULE 8 1. Module 8 Learning Objectives. Adolescent HIV Care and Treatment. Module 8: Module 8 Learning Objectives (Continued) Session 8. Adolescent HIV Care and Treatment Module 8 Learning Objectives Module 8: Supporting Adolescents Retention in and Adherence to HIV Care and Treatment After completing this module, participants will be able

More information

Federal Requirements of Participation for Nursing Homes Summary of Key Changes in the Final Rule Issued September 2016 Phase 2

Federal Requirements of Participation for Nursing Homes Summary of Key Changes in the Final Rule Issued September 2016 Phase 2 Federal Requirements of Participation for Nursing Homes Summary of Key Changes in the Final Rule Issued September 2016 Phase 2 On September 28, 2016, the Centers for Medicare & Medicaid Services (CMS)

More information

I. Description. Getting Started Intake Case Management is an individual level intervention for HIV+ individuals. Currently/Formally Incarcerated

I. Description. Getting Started Intake Case Management is an individual level intervention for HIV+ individuals. Currently/Formally Incarcerated 18 Currently/Formally Incarcerated Getting Started Intake Case Management Getting Started Intake Case Management is an individual level intervention for HIV+ individuals to help ease their transition from

More information

Rule 31 Table of Changes Date of Last Revision

Rule 31 Table of Changes Date of Last Revision New 245G Statute Language Original Rule 31 Language Language Changes 245G.01 DEFINITIONS 9530.6405 DEFINITIONS 245G.01, subdivision 1. Scope. 245G.01, subdivision 2. Administration of medication. 245G.01,

More information

Ryan White Part A. Quality Management

Ryan White Part A. Quality Management Quality Management Mental Health Services Broward County/Fort Lauderdale Eligible Metropolitan Area (EMA) The creation of this public document is fully funded by a federal Ryan White CARE Act Part A grant

More information

HIV SERVICES ACUITY TOOL PILOT IMPLEMENTATION MEETING. October 16, 2014

HIV SERVICES ACUITY TOOL PILOT IMPLEMENTATION MEETING. October 16, 2014 HIV SERVICES ACUITY TOOL PILOT IMPLEMENTATION MEETING MDPH Office of HIV/AIDS & BPHC HIV/AIDS Ser vices Division October 16, 2014 1 AGENDA Background: How did we get here? Introducing the tool Components

More information

Understanding and Using ASAM Criteria in Substance Use Disorder Treatment Planning

Understanding and Using ASAM Criteria in Substance Use Disorder Treatment Planning Understanding and Using ASAM Criteria in Substance Use Disorder Treatment Planning WHAT? This guidance document has been developed to provide an overview of the American Society of Addiction Medicine (ASAM)

More information

Care Model for Tufts Health Plan Senior Care Options

Care Model for Tufts Health Plan Senior Care Options Care Model for Tufts Health Plan Senior Care Options Tufts Health Plan Core Principles The overarching construct for the Tufts Health Plan Senior Care Options (SCO-SNP) is to improve access to medical,

More information

DEPARTMENT OF COMMUNITY SERVICES. Services for Persons with Disabilities

DEPARTMENT OF COMMUNITY SERVICES. Services for Persons with Disabilities DEPARTMENT OF COMMUNITY SERVICES Services for Persons with Disabilities Alternative Family Support Program Policy Effective: July 28, 2006 Table of Contents Section 1. Introduction Page 2 Section 2. Eligibility

More information

ATTACHMENT II EXHIBIT II-C Effective Date: February 1, 2018 HIV/AIDS SPECIALTY PLAN

ATTACHMENT II EXHIBIT II-C Effective Date: February 1, 2018 HIV/AIDS SPECIALTY PLAN ATTACHMENT II EXHIBIT II-C Effective Date: February 1, 2018 HIV/AIDS SPECIALTY PLAN The provisions in Attachment II and the MMA Exhibit apply to this Specialty Plan, unless otherwise specified in this

More information

Transitions of Care: From Hospital to Home

Transitions of Care: From Hospital to Home Transitions of Care: From Hospital to Home Danielle Hansen, DO, MS (Med Ed) Associate Director, LECOM VP Acute Care Services & Quality/Performance Improvement, Millcreek Community Hospital Objectives Discuss

More information

TACT Target Population Youth Must Meet the Following Criteria? (Please check all that apply.)

TACT Target Population Youth Must Meet the Following Criteria? (Please check all that apply.) Transitional Age Community Treatment Team (TACT) Referral Form (Please Print or Type Referral Information) The TACT Team is designed for youth 16 to 24 years of age in need of assistance transitioning

More information

Illinois Birth to Three Institute Best Practice Standards PTS-Doula

Illinois Birth to Three Institute Best Practice Standards PTS-Doula Illinois Birth to Three Institute Best Practice Standards PTS-Doula The Ounce recognizes that there are numerous strategies that can be employed to effectively serve pregnant and parenting teens and their

More information

Balance of State Continuum of Care Program Standards for Permanent Supportive Housing Programs

Balance of State Continuum of Care Program Standards for Permanent Supportive Housing Programs 1 Balance of State Continuum of Care Program Standards for Permanent Supportive Housing Programs The Balance of State Continuum of Care developed the following Permanent Supportive Housing Program standards

More information

CLINICAL PRACTICE EVALUATION II: CLINICAL SYSTEMS REVIEW

CLINICAL PRACTICE EVALUATION II: CLINICAL SYSTEMS REVIEW Diplomate: CLINICAL PRACTICE EVALUATION II: CLINICAL SYSTEMS REVIEW A. INFORMATION MANAGEMENT 1. Does your practice currently use an electronic medical record system? Yes No 2. If Yes, how long has the

More information

LONG TERM CARE SETTINGS

LONG TERM CARE SETTINGS LONG TERM CARE SETTINGS Long term care facilities assist aged, ill or disabled persons who can no longer live independently. In this section, we will briefly examine the history of long term care facilities

More information

Ryan White Provider Capacity & Capability Report. Orlando Service Area August 2017

Ryan White Provider Capacity & Capability Report. Orlando Service Area August 2017 Ryan White Provider Capacity & Capability Report Orlando Service Area August 2017 1 Acknowledgements This needs assessment and report were made possible through the collaborative efforts of the following

More information

ITT Technical Institute. NU260 Maternal Child Nursing SYLLABUS

ITT Technical Institute. NU260 Maternal Child Nursing SYLLABUS ITT Technical Institute NU260 Maternal Child Nursing SYLLABUS Credit hours: 8 Contact/Instructional hours: 160 (40 Theory Hours, 120 Clinical Hours) Prerequisite(s) and/or Corequisite(s): Prerequisites:

More information

Providing and Documenting Medically Necessary Behavioral Health Services

Providing and Documenting Medically Necessary Behavioral Health Services Providing and Documenting Medically Necessary Behavioral Health Services Presented by: David Reed, Office Chief, Division of Behavioral Health and Recovery Marc Bollinger, LISCW, CEO, Great Rivers BHO

More information

Implementation of A Centralized Medical Case

Implementation of A Centralized Medical Case Implementation of A Centralized Medical Case Management System RWA 457: Angelique Croasdale, MA, Project Manager Ryan White Part A, City of Hartford Department of Health and Human Services Fredericka Close,

More information

Innovative Community Based Care Community Transitional Care Team

Innovative Community Based Care Community Transitional Care Team Innovative Community Based Care Community Transitional Care Team Canadian Association of Nurses in AIDS Care April 2007 CTCT Homelike community transitional residence for IDU s requiring long-term IV antibiotics

More information

Making the Connection:

Making the Connection: Making the Connection: Standards of Care for Client-Centered Services Food Services San Francisco EMA Includes San Francisco City and County, San Mateo County, and Marin County Prepared for San Francisco

More information

Hospice and End of Life Care and Services Critical Element Pathway

Hospice and End of Life Care and Services Critical Element Pathway Use this pathway for a resident identified as receiving end of life care (e.g., palliative care, comfort care, or terminal care) or receiving hospice care from a Medicare-certified hospice. Review the

More information

ACTIVITIES OF DAILY LIVING (ADL)

ACTIVITIES OF DAILY LIVING (ADL) ACTIVITIES OF DAILY LIVING (ADL) BEHAVIORAL DEFINITIONS 1 Demonstrates substandard hygiene and grooming, as evidenced by strong body odor, disheveled hair, or dirty clothing 2 Fails to use basic hygiene

More information

Psychosocial Rehabilitation Medical Necessity Criteria

Psychosocial Rehabilitation Medical Necessity Criteria Program Description Psychosocial Rehabilitation Medical Necessity Criteria Psychosocial Rehabilitation (PSR) is a community-based program that promotes recovery, community integration, and improved quality

More information

BERKELEY COMMUNITY MENTAL HEALTH CENTER (BCMHC) OUTPATIENT PROGRAM PLAN 2017

BERKELEY COMMUNITY MENTAL HEALTH CENTER (BCMHC) OUTPATIENT PROGRAM PLAN 2017 BERKELEY COMMUNITY MENTAL HEALTH CENTER (BCMHC) OUTPATIENT PROGRAM PLAN 2017 REVIEWED AND UPDATED NOVEMBER 2017 OUR MISSION PHILOSOPHY The staff of the Berkeley Community Mental Health Center, in partnership

More information

SAMPLE PURCHASING SPECIFICATIONS FOR REPRODUCTIVE HEALTH SERVICES

SAMPLE PURCHASING SPECIFICATIONS FOR REPRODUCTIVE HEALTH SERVICES SAMPLE PURCHASING SPECIFICATIONS FOR REPRODUCTIVE HEALTH SERVICES 1 This document sets forth illustrative language in the form of sample specifications for the purchase of reproductive health services

More information

Michigan Medicaid Nursing Facility Level of Care Determination

Michigan Medicaid Nursing Facility Level of Care Determination Michigan Department of Health and Human Services Michigan Medicaid Nursing Facility Level of Care Determination Applicant's Name: Medicaid ID: Field 1 (Last) (First) (M.I.) Field 2 Date of Birth: Field

More information

Standards for Community-Based Care Registered Nurse Delegation

Standards for Community-Based Care Registered Nurse Delegation Division 47 Standards for Community-Based Care Registered Nurse Delegation 851-047-0000 Rule Summary, Statement of Purpose and Intent These rules provide standards and guidance for nurses to delegate specific

More information

We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal.

We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal. Appointment Date: Appointment Time: Dear Orion Member, We want to thank you for your interest in the Orion Weight Loss Program. We are looking forward to helping you reach your weight loss goal. Enclosed

More information

5. Personal Care Services

5. Personal Care Services 5. Personal Care Services Chapter IV - Services to Children A. Overview A child who requires personal care services is a child with a chronic medical condition or with medical needs requiring specialized

More information

Understanding Health Care in America An introduction for immigrant patients

Understanding Health Care in America An introduction for immigrant patients Patient Education Understanding Health Care in America An introduction for immigrant patients The health care system in the United States is complex. Some parts of the system are different in different

More information

RALF Behavior Management Rules IDAPA

RALF Behavior Management Rules IDAPA RALF Behavior Management Rules IDAPA 16.03.22 DEFINITIONS: 010.10. Assessment. The conclusion reached using uniform criteria which identifies resident strengths, weaknesses, risks and needs, to include

More information

2017 HUD CoC Competition Evaluation Instrument

2017 HUD CoC Competition Evaluation Instrument 2017 HUD CoC Competition Evaluation Instrument For all HUD CoC-funded projects in the Chicago Continuum of Care [PROJECT COMPONENT] . General Instructions Each year, as the Collaborative Applicant, All

More information

HCMC Outpatient Mental Health Programs. External Referral Form

HCMC Outpatient Mental Health Programs. External Referral Form HCMC Outpatient Mental Health Programs External Referral Form Thank you for your interest in the Day Treatment, Partial Hospital Program, or Dialectical Behavior Therapy Intensive Outpatient Program. All

More information

Patient Rights and Responsibilities

Patient Rights and Responsibilities Developed / Edited By: UNION HOSPITAL Reviewed By: Approved By: Policy Number: AG-245 Elkton, Maryland Effective Date: 11/2009 Hospital Policies and Procedures Patient Rights and Responsibilities Departments

More information

NOVA SCOTIA DEPARTMENT OF HEALTH AND WELLNESS CONTINUING CARE BRANCH

NOVA SCOTIA DEPARTMENT OF HEALTH AND WELLNESS CONTINUING CARE BRANCH NOVA SCOTIA DEPARTMENT OF HEALTH AND WELLNESS CONTINUING CARE BRANCH Subject: Service Eligibility Policy Original Approved Date: November 19, 2004 Revised Date: January 24, 2011 Approved by: Original signed

More information

Welcome to LifeWorks NW.

Welcome to LifeWorks NW. Welcome to LifeWorks NW. Everyone needs help at times, and we are glad to be here to provide support for you. We would like your time with us to be the best possible. Asking for help with an addiction

More information

HealthStream Regulatory Script

HealthStream Regulatory Script HealthStream Regulatory Script Advance Directives Version: [May 2006] Lesson 1: Introduction Lesson 2: Advance Directives Lesson 3: Living Wills Lesson 4: Medical Power of Attorney Lesson 5: Other Advance

More information

ADULT LONG-TERM CARE SERVICES

ADULT LONG-TERM CARE SERVICES ADULT LONG-TERM CARE SERVICES Long-term care is a broad range of supportive medical, personal, and social services needed by people who are unable to meet their basic living needs for an extended period

More information

Houston/Harris County County Continuum of Care: Priorities and Program Standards for Emergency Solutions Grant

Houston/Harris County County Continuum of Care: Priorities and Program Standards for Emergency Solutions Grant Houston/Harris County County Continuum of Care: Priorities and Program Standards for Emergency Solutions Grant Prepared By: Coalition for the Homeless Houston/Harris County, Lead Agency of the Continuum

More information

Bridging practice and research: A Survey of evidence-based practices used in HIV Care for linkage, retention and adherence support

Bridging practice and research: A Survey of evidence-based practices used in HIV Care for linkage, retention and adherence support Bridging practice and research: A Survey of evidence-based practices used in HIV Care for linkage, retention and adherence support K. Rivet Amico, University of Connecticut José M. Zuniga, IAPAC No conflicts

More information

MEDICAL POLICY No R5 PSYCHOLOGICAL EVALUATION AND MANAGEMENT OF NON-MENTAL HEALTH DISORDERS

MEDICAL POLICY No R5 PSYCHOLOGICAL EVALUATION AND MANAGEMENT OF NON-MENTAL HEALTH DISORDERS PSYCHOLOGICAL EVALUATION AND MANAGEMENT OF NON-MENTAL HEALTH DISORDERS Effective Date: September 8, 2014 Review Dates: 10/07, 10/08, 10/09, 6/10, 6/11, 6/12, 6/13, 8/14, 8/15, 8/16, 8/17 Date Of Origin:

More information

Woonsocket Health Hut Handbook

Woonsocket Health Hut Handbook Woonsocket Health Hut Handbook Keeping Kids Healthy at School and at Home A partnership of Thundermist Health Center of Woonsocket and the Woonsocket School Department. Serving Woonsocket High School.

More information

ADVANCED DIRECTIVES ACKNOWLEDGEMENT FORM Patient Name: Date: I do have an Advanced Directive / Living Will / Durable Power of Attorney for medical or health care decisions. I do not have an Advanced Directive

More information

Dear Kaniksu Patient,

Dear Kaniksu Patient, Dear Kaniksu Patient, Welcome to Kaniksu Health Services (KHS), a Community Health Center that provides quality and affordable medical, pediatric, dental, behavioral health and veteran care, regardless

More information

Family Intensive Treatment (FIT) Model

Family Intensive Treatment (FIT) Model Requirement: Frequency: Due Date: Family Intensive Treatment (FIT) Model Specific Appropriation 372 of the General Appropriations Act for Fiscal Year 2014 2015 N/A N/A Description: From the funds in Specific

More information

ELIGIBILITY/REFERRAL, SCREENING, AND ADMISSION FORM COMAR

ELIGIBILITY/REFERRAL, SCREENING, AND ADMISSION FORM COMAR 6910 Annapolis Road Hyattsville, MD 20784 Telephone: (301) 925-9120 Fax: (301) 851-5199 4607 69 th Avenue Hyattsville, MD 20784 Telephone: (301) 386-0014 Fax: (301) 386-0018 ELIGIBILITY/REFERRAL, SCREENING,

More information

10/3/2016 PALLIATIVE CARE WHAT IS THE DEFINITION OF PALLIATIVE CARE DEFINITION. What, Who, Where and When

10/3/2016 PALLIATIVE CARE WHAT IS THE DEFINITION OF PALLIATIVE CARE DEFINITION. What, Who, Where and When PALLIATIVE CARE What, Who, Where and When Mary Grant, RN, MS ANP Connections Nurse Practitioner Palliative Care Program Oregon Region WHAT IS THE DEFINITION OF PALLIATIVE CARE DEFINITION The Center for

More information

Dear Treatment Provider:

Dear Treatment Provider: Dear Treatment Provider: Thank you for referring your patient to the OCD Institute, a residential and partial hospital program for adults with obsessive compulsive disorder (OCD). We are a behaviorally-oriented

More information

Initial Pool Process: Resident Interview

Initial Pool Process: Resident Interview Initial Pool Process: Resident Interview Care Area Probes Response Options Choices Are you able to make choices about your daily life that are important to you? I d like to talk to you about your choices.

More information

Staying Healthy Guide Health Education Classes. Many classroom sites. Languages. How to sign up. Customer Service

Staying Healthy Guide Health Education Classes. Many classroom sites. Languages. How to sign up. Customer Service Staying Healthy Guide Health Education Classes We care about the health of our members. That is why our health plan offers health education classes to help our members stay healthy and learn how to be

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: residential_treatment 7/1999 6/2017 6/2018 6/2017 Description of Procedure or Service A residential treatment

More information

SUMMARY OF THE STATE GRANT OPPORTUNITIES IN THE PATIENT PROTECTION AND AFFORDABLE CARE ACT: H.R (May 24, 2010)

SUMMARY OF THE STATE GRANT OPPORTUNITIES IN THE PATIENT PROTECTION AND AFFORDABLE CARE ACT: H.R (May 24, 2010) National Conference of State Legislatures 444 North Capitol Street, N.W., Suite 515 Washington, D.C. 20001 SUMMARY OF THE STATE GRANT OPPORTUNITIES IN THE PATIENT PROTECTION AND AFFORDABLE CARE ACT: H.R.

More information

Ryan White Part A Quality Management

Ryan White Part A Quality Management Quality Management Mental Health Services Broward County/Fort Lauderdale Eligible Metropolitan Area (EMA) The creation of this public document is fully funded by a federal Ryan White CARE Act Part A grant

More information

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Use for a resident who has potentially unnecessary medications, is prescribed psychotropic medications or has the potential for an adverse outcome to determine whether facility practices are in place to

More information