-COMPREHENSIVECAREPLANREVIEW-ODISHome…730综合护理计划审查该回家…

1、.CHAPTER 700 COMPREHENSIVE CARE PLAN REVIEW730 - COMPREHENSIVE CARE PLAN REVIEWPOLICY STATEMENTCare coordinators conduct formal reviews of each CCSP clients Comprehensive Care Plan periodically according to established schedule.POLICY BASICS POLICY BASICS (contd.)The care coordinator completes the f

2、irst formal review of each CCSP client's Comprehensive Care Plan (CCP) within 30 days of the Level of Care (LOC) certification date. After the 30-day review, care coordinators complete CCP reviews as needed but no less frequently than every three months (90 days).The care coordinator develops th

3、e care plan, involving the client in decisions to the extent possible. The CCP identifies the clients needs, goals and interventions used by the agency or person responsible for providing services.At each CCP review, care coordinators use AIMS to complete the following:1.Client Assessment Protocols

4、(Caps)2.Service Order3. Evaluation4. Medication List5. Case NotesAt each CCP review, care coordinators use forms to complete the following:1. Authorization for Release of Information and Informed Consent (signature page)2. Nutritional Screening Initiative Checklist, if applicable3. Client Referral F

5、orm-Home Delivered Meals, if applicable.At each care plan review, the care coordinator generates, from AIMS, any documents which require an original signature. CC obtains signature(s)/signs, sends copies to providers as appropriate and files signed documents in the case record.There is no grace peri

6、od beyond the CCP due date. CCP reviews completed past the quarterly due date are out of compliance. If the due date for the next CCP review falls on a weekend or holiday, the care coordinator completes the quarterly review before the due date. Intervening weekends or holidays do not change the CCP

7、review due date.If a client is unavailable to complete the CCP review because of hospitalization, a visit out of town, or for another reason, care coordinator documents attempts to complete the CCP review in a timely manner in the case notes. Note the reason for delay on the service order, and send

8、this information to the provider at CCP review. Complete the CCP review as soon as possible.The care coordinator may conduct CCP reviews before the required care plan review date, but completes CCP reviews no later than the scheduled due date.EXAMPLE: On January 05, 2013, the care coordinator admits

9、 (certifies the LOC) the client to CCSP and brokers service(s). The first CCP review is due by February 04, 2013, and the second CCP review no later than May 05, 2013 (in this example 5/5/13 is a Sunday so the care plan must be completed on or before Friday, May 3 to meet standard of promptness). Su

10、bsequent CCP reviews are due at a minimum of every 90 days.PROCEDURES PROCEDURES (contd.)PROCEDURES (contd.)Use the following procedures to complete each CCP review.1.Prepare for the CCP review as follows: · Review the case file to become familiar with client situation at the time of the last c

11、ontact· Note any item which needs updating during the CCP review· Assure that client LOC is current.2. Telephone the client to schedule a home visit to conduct CCPreview.3.During the home visit, use AIMS to update current or complete new CAPs interventions, Service Order, Evaluation, and M

12、edication List. Include dates of entry when completing Comments documentation in the CCP review. · Document changes in clients physician or medications on the Medication List 4. Address additional triggers and evaluate goals indicated on the previous CCP to: assure that services ordered remain

13、appropriate determine client need for continued CCSP services.5. Review services that care giver or others provide. Identify any new services a client may be receiving from the community. Include all services on the Service Order. 6. Determine how frequently providers are delivering services indicat

14、ed on the Service Order. Use the care plan evaluation screen to document whether client is satisfied with services being provided. 7. Use the care plan evaluation screen to document compliance and satisfaction for clients who receive ALS or ADH. At a minimum, review the following in the clinical rec

15、ord: RN Supervisory notes Progress notes Documentation of any additional services being rendered Hospital admission notes, if applicable Medication list and prescription label instructions.§ Discuss concerns about non compliance with client care and/or physical environment with the Lead Care Co

16、ordinator and/or the assigned Care Coordination and Provider Specialist 8. Discuss with client and/or the care giver any changes in problems, interventions, and goals. Document change on the CAPs page. 9. Determine if client needs a change in services and the reason for any needed change. If a CCSP

17、service is discontinued changed or a new service needed, a reassessment may be required; however, if the LOC was certified within the past 180 days, physician approval of the new service is permitted without a reassessment. (See If/Then Chart 730.1) NOTE: Adding Home Delivered Meals, Medical Social

18、Services, or Out-of-Home Respite Services at any time, regardless of the date of the most recent LOC certification date does not require a reassessment. Adding skilled services, more than 60 days after the most recent LOC certification does require a reassessment.10. Document verification or the cli

19、ents response regarding eligibility or continued eligibility for Medicaid. If a client is PMAO, contact DFCS to determine the status of Medicaid application and document the information in case notes. 11. Obtain client signature on the Authorization of Information and Informed Consent during the hom

20、e visit and remind the client to contact CC with concerns. NOTE: At the 30 day review, discuss contents of CCSP folder with the client, if not discussed at the initial assessment. Provide the client/family member with contact information for Care Coordination.12. Telephone CCP reviews are allowable

21、only in extenuating circumstances, such as a care coordinator vacancy. If such an event occurs, the AAA must first obtain a temporary waiver from the Division of Aging Services, which will allow care coordinators to conduct CCP reviews by telephone for a specified period of time. In the comments sec

22、tion of Service Order, document the reason that the CCP review was conducted by telephone instead of in person.13. Send a copy of newly completed, Care Plan, Service Order and signed Authorization of Information and Informed Consent form to each provider. NOTE: Send these copies to providers no late

23、r than three days prior to the due date of the CCP review. 14. Update client information in AIMS. Include changes in address, living arrangements, diagnoses, and other information.15. Generate and send SAFs authorizing providers to continue services, if applicable.16. Retain the new Care Plan, Service Order, Evaluation, and Medication List in the clients electronic file. IF:THEN:If most recent assessment occurred within 180 days and