Adult Initial Plan of Care
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1 Plan Date: Section I Member Information: Name (Last, First, MI): IA Completion Date: DOB SLA #: Medicaid: SSN #: Address: City:. Parish: State: Zip: Phone: Cell: Fax: Emergency Contact: Phone: If member lives in out-of-home care please indicate: Hospital [ ] Residential SA [ ] Nursing/LTC Facility [ ] Other [ ] (please indicate): Name of Agency/Location: MIS # (if applicable): Address: City: Parish: State: Zip: Phone: Cell: Fax: Emergency Contact: Phone: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 1
2 Independent Assessor (Required for Adult Medicaid 1915i recipients): Name: Agency (if applicable): MIS# Address: City: Parish: State: Zip: Phone: Cell: Fax: Medical Care: Primary Care Physician: Address: MIS # (if applicable): City: Parish: State: Zip: Phone: Cell: Fax: Primary Medical Issues or Health Concerns: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 2
3 Section II Vision/Mission/Strengths Member s Vision (Hopes and dreams for the future In the Member s own words) Family/Support Vision (Hopes and dreams for the future In their own words) Family/Support Team Goal: Strengths: Primary Treatment Diagnosis: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 3
4 Identified Needs (Mental Health, Substance Abuse, and Medical Needs Requiring Treatment) Addressed via this POC Yes No LOUISIANA HEALTHCARE CONNECTIONS PAGE 4
5 Section 3 In the section below, each identified need (listed above) being addressed in this POC is required to have a completed Plan for Identified Needs (PIN). Plan for Identified Needs 1 Objective/ Goal Statement: Start Date: Outcome Statement: Discharge Criteria: D/C Date: Strategies/ Assigned Tasks Frequency: Duration: Responsible Party/Agency/Contact info: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 5
6 Barriers: Life Domain Area of Need: Family [ ] Residence [ ] Social [ ] Education/Vocational [ ] Medical [ ] Psychological/emotional/behavioral [ ] Safety [ ] Clinical Summary: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 6
7 Plan for Identified Needs 2 Objective/ Goal Statement: Start Date: Outcome Statement: Discharge Criteria: D/C Date: Strategies/ Assigned Tasks Frequency: Duration: Responsible Party/Agency/Contact info: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 7
8 Barriers: Life Domain Area of Need: Family [ ] Residence [ ] Social [ ] Education/Vocational [ ] Medical [ ] Psychological/emotional/behavioral [ ] Safety [ ] Clinical Summary: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 8
9 Plan for Identified Needs 3 Objective/ Goal Statement: Start Date: Outcome Statement: Discharge Criteria: D/C Date: Strategies/ Assigned Tasks Frequency: Duration: Responsible Party/Agency/Contact info: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 9
10 Barriers: Life Domain Area of Need: Family [ ] Residence [ ] Social [ ] Education/Vocational [ ] Medical [ ] Community [ ] Psychological/emotional/behavioral [ ] Safety [ ] Clinical Summary: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 10
11 Plan for Identified Needs 4 Objective/ Goal Statement: Start Date: Outcome Statement: Discharge Criteria: D/C Date: Strategies/ Assigned Tasks Frequency: Duration: Responsible Party/Agency/Contact: info: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 11
12 Barriers: Life Domain Area of Need: Family [ ] Residence [ ] Social [ ] Education/Vocational [ ] Medical [ ] Community [ ] Psychological/emotional/behavioral [ ] Safety [ ] Clinical Summary: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 12
13 Plan for Identified Needs 5 Objective/ Goal Statement: Start Date: Outcome Statement: Discharge Criteria: D/C Date: Strategies/ Assigned Tasks Frequency: Duration: Responsible Party/Agency/Contact: info: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 13
14 Barriers: Life Domain Area of Need: Family [ ] Residence [ ] Social [ ] Education/Vocational [ ] Medical [ ] Community [ ] Psychological/emotional/behavioral [ ] Safety [ ] Clinical Summary: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 14
15 Projected Course of Treatment: (identify Services projected to be needed over the next up to 12 months) Service Type: Frequency Intensity (units/week) Projected Projected Provider Start Date: End Date: LOUISIANA HEALTHCARE CONNECTIONS PAGE 15
16 Section 4 Natural/Community/Informal Supports (include frequency of contact) 5. Discharge Information: Discharge Criteria (what needs to be accomplished for this POC to be discharged be specific) 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 16
17 Section 5 Crisis Plan Name: Date: Behavioral/Mental Health Diagnosis: Current Medications: Brief History: Triggers: Potential Crisis: Preferred De-escalation Techniques Identified by Member (be specific): 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 17
18 Action Steps/Assigned Tasks Adult Initial Plan of Care Person Responsible Party/Agency/Contact info: LOUISIANA HEALTHCARE CONNECTIONS PAGE 18
19 Action Steps/Assigned Tasks Backup plan Person Responsible Party/Agency/Contact info: LOUISIANA HEALTHCARE CONNECTIONS PAGE 19
20 Section 6 6 Team Members (Family, Supports and Others, and Agencies involved in plan development): Team Member Relationship/Role/Vocation Agency Contact Information 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 20
21 Section 7 Adult Initial Plan of Care Signature indicates understanding of the POC and agreement to participate in the POC. Plan of Care Signatures: Member: Date: Parent/Guardian: Independent Assessor: Team Member: Team Member: Team Member: Team Member: Agency Representative: Agency Representative: Agency Representative: Agency Representative: Agency Representative: Agency: Agency: Agency: Agency: Agency: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 21
22 Section 8 Section 8 90 Day Review Date: Completion and signature of this section indicates that the Provider and the member have reviewed the Initial Plan of Care (POC) and agree with the established POC Plan for Identified Needs (PINs) relevant to this provider/agency. If significant changes are needed, please contact the Community-Based Care Manager to complete a Plan of Care Update Form. 90 Day Review Clinical Summary: Member: Parent/Guardian: Agency Representative: Agency Representative: Agency: Agency: 2015 LOUISIANA HEALTHCARE CONNECTIONS PAGE 22
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