queens coordinated care partners, c. · includes the member, care manager and external providers)...

Queens Coordinated Care Partners, Inc.

Health Home Program

Initial Plan of Care Instrument

Plan of Care Development Guide

2018

Queens Coordinated Care Partners, Inc.

Queens Coordinated Care Partners, LLC.

Table of Contents

• Title/Cover Page……………………………………………………………………………………………………..……………………….. 1 • Table of Contents……………………………………………………………………………………………………………………….……. 2 • Workflow: How to Use this Instrument …………………………………………………………………………………………….……… 3 • QCCP Health Home Initial Plan of Care Instrument …………………………………………………………………………………….. 4

Initial Plan of Care Summary …………………………………………………………………………………………...…….. 4 o Demographic Informationo Health Home Program Eligibility - Current Chronic Health Condition(s)/Diagnoseso Strengths & Barrierso Client or Clients Representative & Case Manager/Agency Representative Signature

Clinical Goals• Cardiovascular Disease – Hypertension……………………………………………………………………………………… 5 • Cardiovascular Disease – Hyperlipidemia.…………………………………………………………………………………… 6 • Diabetes Mellitus Type I/II…………………………………………………………………………………………………... 8 • HIV/AIDS……………………………………………………………………………………………………………………. 10 • Chronic Kidney Disease (CKD)………………………………………………………………………………………..……..12 • Chronic Obstructive Pulmonary Disease (COPD)………………………………………………………………….….…….. 14 • Smoking, Exercise and Diet…………………………………………………………………………………………….……. 16 • Obesity………………………………………………………………………………………………………………….……. 18• Mental Health………………………………………………………………………………………………………….……... 20 • Substance Abuse/Addictive Behavior …………………………………………………………………………………..…… 22 • Transitional Care………………………………………………………………………………………………….………….. 24 • Safety Planning…………………………………………………………………………………………………….…………. 25 • Home and Community-Based Services (HCBS)……………………………………………………………………………... 26

Non-Clinical Goals• Benefits & Entitlements……………………………………………………………………………………………...……….. 27 • Education & Employment…………………………………………………………………………………………………….. 28 • Supportive Services………………………………………………………………………………………………………...…. 29 • Housing Assistance & Services…………………………………………………………………………………………..…… 30 • Legal Services…………………………………………………………………………………………………………………. 31 • Medical Insurance………………………………………………………………………………………………………...…… 32 • Blank Template……………………………………………………………………………………………………….……….. 33

• Dedication.……………………………………………………………………………………………………………………………………… 34

2 Queens Coordinated Care Partners, Inc.


Workflow – How to Use this Instrument

Purpose:

The purpose of this document is to serve as an educational resource, as well as an instrument for the development of an initial plan of care for the

Queens Coordinated Care Partners, Inc. (QCCP) Health Home. The QCCP Health Home Initial Plan of Care Instrument is to be used as an

alternative mechanism or method for meeting Health Home requirements regarding the development of a completed and signed Health Home Plan of

Care for all enrolled QCCP Members. In addition, this instrument is to be used as an educational resource to help care team members learn, develop

and/or strengthen their understanding of Plan of Care development, S.M.A.R.T Goals, as well as laboratory metrics and values associated with

chronic health conditions and/or diagnoses most prevalent among enrolled QCCP Health Home Members.

Workflow:

The QCCP Health Home Initial Plan of Care Instrument was designed to capture Health Home member demographic information, strengths and

weaknesses, clinical and non-clinical goals, chronic health condition program eligibility, as well as provide the means for the care team (which

includes the member, care manager and external providers) to develop and complete a mutually agreed upon initial plan of care. As such, this

document is to include the following information and is only considered to be complete when all information and sections and fields listed are filled.

Required Fields:

• Demographic Information: Client Name, Date of Birth, CIN/Medicaid ID• Chronic Health Condition Health Home Eligibility: 2 or More Chronic Health Conditions OR HIV/AIDS OR Serious Mental Illness (SMI)• Current List of Clinical Goals• Current List of Non-Clinical Goals• Include Corresponding Chronic Health Condition/Diagnosis, Clinical Goal, Non-Clinical Goal Instrument Section

Required Actions:

• Instrument is to be Signed and Dated by Member or Legal Representative and Care Manager/CMA Staff Member• A Copy of Signed Instrument is to be Uploaded to RMA EMR system• Clinical/Non-clinical Goal(s) and Tasks Identified and Mutually Agreed Upon Must be Transferred to RMA Plan of Care Tab - Once the

information/PHI data is successfully transferred to the RMA, the members Health Home Plan of Care is to be considered Live in the RMA and should be edited, reviewed and/or updated in the RMA as required by current QCCP Policy.



Initial Plan of Care Instrument

Client Name: CIN: DOB : Date:

( √ ) Strengths Patient Understands Diagnosis Patient Attends Medical Appointments Independently Patient is Adherent to Medication Regimen Patient is Willing to Make Small Changes Patient is Willing to Reconsider Treatment or Change at a Later Date Patient has Support Systems Available Patient has Overcome Past Trauma or Crisis Patient can Self-Identify Triggers Patient has Hope that Improvement is Possible Patient Acknowledges the Role Self Plays in Recovery Patient is Honest about Well-being or Struggles Patient has been out of Criminal Justice System for over 6 Months Patient is Motivated to Attend and/or Go Back to School / Work Patient has Strong Connection to Spirituality Patient Enjoys a Hobby

( √ ) Barriers Patient is Not Engaged in Care Patient is Actively Experiencing Mental Health Symptoms Patient is in Pre-Contemplative Phase for __________________________ Patient Needs Additional Social Supports Patient is Not Ready to Explore Increasing Social Interactions Patient is Not Aware of Triggers Patient Requires High Level of Encouragement to Improve Sense of Hope Patient is Unstably Housed Patient Requires Transportation Assistance Patient has Recent Involvement with Criminal Justice System Patient has Limited Health Literacy Patient has Lack of Access to Kitchen/Cooking Devices

CHRONIC HEALTH CONDITIONS

1.

2.

3.

4.

CLINICAL GOALS:

1.

2.

3.

4.

NON-CLINICAL GOALS:

1.

2.

3.

4.

Sign Date Client or Clients Representative Signature

Case Management Agency Representative Signature



Topic: Cardiovascular Disease - Hypertension

Problem: Check (√)

Stage Systolic (mmHg)

Diastolic (mmHg)

Normal Less than 120

AND Less than 80

Pre-Hypertension

120-129 AND Less than 80

Stage 1 Hypertension

130-139 OR 80-89

Stage 2 Hypertension

140 or Higher

OR 90 or Higher

Goal: To Link to Cardiologist/Specialty Provider and Remain Engaged in Care. Goal: To Adhere to Medical Care Appointments with Cardiologist. Goal: To Adhere to Hypertension Medication Regimen and Diagnostic Testing. Goal: To Increase Knowledge and Frequency of Daily Exercise Routines and Healthy Eating

Habits. Goal: To Increase Health Literacy Regarding Cardiovascular Disease.

To Link to Cardiologist / Specialist in the Next ________ Days. Tasks Responsibility Target Date

Research and Discuss Linkage to Available Providers in Community. o Client o Care Manager Other: Contact PCP / MCO to Discuss Referral to Cardiologist. o Client o Care Manager Other: Contact Potential Providers and Schedule Medical Appointment. o Client o Care Manager Other: Attend Scheduled Initial Medical Appointment on________________. o Client o Care Manager Other:

To be Adherent to Scheduled Medical Appointments with PCP and Cardiologist/Specialist Provider(s) for Next _________ Days.

Tasks Responsibility Target Date Plan ( Weekly / Monthly ) Medical Appointment Schedule with Client. o Client o Care Manager Other: Attend Medical Appointment with Cardiologist on _________________. o Client o Care Manager Other:

Attend Follow-up Medical Appointment with PCP on _______________. o Client o Care Manager Other: Other: o Client o Care Manager Other: To be Adherent to Hypertension Medication Regimen/Treatment Plan and Diagnostic Testing for Next _______ Days.

Responsibility

Tasks Responsibility Target Date Review Treatment Plan and Medication Regimen. o Client o Care Manager Other: Client will Obtain Diagnostic Labs / Blood Pressure Reading. o Client o Care Manager Other: Client will take Medication Regimen for Hypertension as Prescribed. o Client o Care Manager Other: Measure BP ( at Home / at Pharmacy ) Every ______ ( Weeks / Months ). o Client o Care Manager Other:

( Develop / Review / Adhere to ) Healthy Eating Plan/Diet for HTN. o Client o Care Manager Other:

( Develop / Review / Adhere to ) Exercise Activity Program/Plan. o Client o Care Manager Other: ( Develop / Review / Adhere to ) Smoking Cessation Program/Plan. o Client o Care Manager Other: Other: o Client o Care Manager Other:

______________________________________________________________

______________________________________________________________

Care Coordination & Adherence



Topic: Cardiovascular Disease - Hyperlipidemia

Problem: Metric Optimal (mg/dL)

Intermediate (mg/dL)

High (mg/dL)

Measure

Total Cholesterol

Less than 200 200 – 239 Greater than 239 O I H

LDL “Bad” Cholesterol

Less than 130 130 – 159 Greater than 159 O I H

HDL “Good” Cholesterol

Greater than 60 60 – 40 Less Than 40 O I H

Triglycerides Less than 150 150 – 199 Greater than 199 O I H

Goal: To Link to Cardiologist/Specialty Provider and Remain Engaged in Care. Goal: To Adhere to Medical Care Appointments with Cardiologist. Goal: To Adhere to Cholesterol Medication Regimen and Diagnostic Testing. Goal: To Coordinate Care with Providers. Goal: To Increase Health Literacy Regarding Cardiovascular Disease.

To Link to Cardiologist / Specialist in the Next ________ Days. Tasks Responsibility Target Date

Research and Discuss Linkage to Available Providers in Community. o Client o Care Manager Other: Contact Potential Providers and Schedule Medical Appointment. o Client o Care Manager Other: Contact PCP / MCO to Discuss Referral to Cardiologist. o Client o Care Manager Other: Attend Scheduled Initial Medical Appointment on________________. o Client o Care Manager Other:

To be Adherent to Scheduled Medical Appointments with PCP and Cardiologist/Specialist Provider(s) for Next _________ Days.

Tasks Responsibility Target Date Plan ( Weekly / Monthly ) Medical Appointment Schedule with Client. o Client o Care Manager Other: Attend Medical Appointment with Cardiologist on _______________. o Client o Care Manager Other:

Attend Follow-up Medical Appointment with PCP on ____________. o Client o Care Manager Other:

Other: o Client o Care Manager Other: To be Adherent to Cholesterol Medication Regimen/Treatment Plan and Diagnostic Testing for Next _______ Days.

Responsibility

Tasks Responsibility Target Date Review Treatment Plan and Medication Regimen. o Client o Care Manager Other: Client will Complete Diagnostic Labs / Blood Lipid Panel. o Client o Care Manager Other: Client will take Medication Regimen for High Cholesterol as Prescribed. o Client o Care Manager Other: ( Develop / Review / Adhere to ) Healthy Eating Plan/Diet. o Client o Care Manager Other: ( Develop / Review / Adhere to ) Exercise Activity Plan. o Client o Care Manager Other: ( Develop / Review / Adhere to ) Smoking Cessation Program/Plan. o Client o Care Manager Other: Other: o Client o Care Manager Other:

_____________________________________________________

_____________________________________________________




Topic: Cardiovascular Disease (Continued) Case Conferences / Tests & Services / Healthy Literacy

To Complete Case Conference in the Next ______________ Days. Tasks Responsibility Target Date

Discuss Course of Treatment with PCP / Cardiologist. o Client o Care Manager Other: Discuss Patients Medication Regimen – Route, Frequency, and Duration. o Client o Care Manager Other: Discuss Management of Condition(s). o Client o Care Manager Other: Discuss Referral or Linkage to Cardiologist/Specialist. o Client o Care Manager Other: Other: o Client o Care Manager Other: Complete Tests and/or Procedures During Next ________ Month(s).

Tasks Responsibility Target Date Complete Blood Lipid Profile to Calculate Cholesterol and Triglyceride. o Client o Care Manager Other:

Complete ECG (Electrocardiogram) to Test Heart Rhythm / Risk for MI. o Client o Care Manager Other: Complete Echocardiogram to Evaluate Heart Health, Heart Rhythms. o Client o Care Manager Other:

Complete Exercise Stress Test to Determine Cause of Chest Pain and/or Function of Heart During Exercise or Exertion.

o Client o Care Manager Other:

Complete Chest X-Ray to Capture Images of the Chest Cavity. o Client o Care Manager Other:

Complete Thalium Stress Test to Determine Strength of Blood Flow and/or Blockages and Damage Following Heart Attack (MI).


Complete Cardiac Catheterization to Evaluate Extent of Coronary Artery Blockage from Plaque / Perform Coronary Angioplasty w/ Stenting


Complete Angioplasty to Improve Blood Flow, Relieve Chest Pain. o Client o Care Manager Other: Complete Carotid Artery Surgery. o Client o Care Manager Other: Complete Coronary Artery Bypass Graft Surgery (CABG). o Client o Care Manager Other:

Complete Surgery for Pacemaker. o Client o Care Manager Other: Other: o Client o Care Manager Other: To Improve Health Literacy Regarding Cardiovascular Disease Care Management within the Next _______ Days

Tasks Responsibility Target Date Discuss Understanding of CVD Diagnosis and Care Management (What Causes Diabetes, Signs & Symptoms, Role of Providers etc.)


Provide CVD Care Resources (in Language: _____________ ). o Client o Care Manager Other:

To ___________________________________ in Next ________ Days.

Tasks Responsibility Target Date Other: o Client o Care Manager Other:

Other: o Client o Care Manager Other:



Topic: Diabetes Mellitus Type I/II

Problem Normal Pre-Diabetes

Diabetes Type II

Measure

Hemoglobin A1c

5.7% or Less

5.7% - 6.4%

6.5% or Greater Normal Pre-

Diabetes Type II

Glucose Tolerance OGTT

140 mg/dL or Less

140 – 199 mg/dL

200 mg/dL or More Normal Pre-

Diabetes Type II

Fasting Glucose FBG

70 – 99 mg/dL

100 – 125 mg/dL

126 mg/dL or Higher

(More than One

Measure)

Normal Pre-Diabetes

Type II

Goal: To Link to Endocrinologist/Specialty Provider and Remain Engaged in Care.

Goal: To Adhere to Treatment Plan, Medication Regimen, Scheduled Medical Appointments and Testing.

Goal: To Increase Health Literacy Regarding Diabetes Mellitus.

To Link to Endocrinologist / Specialist in the Next ________ Days. Tasks Responsibility Target Date

Research and Discuss Linkage to Available Providers in Community. o Client o Care Manager Other: Contact PCP / MCO to Discuss Referral to Endocrinologist. o Client o Care Manager Other: Contact Potential Providers and Schedule Medical Appointment. o Client o Care Manager Other: Attend Scheduled Initial Medical Appointment on________________. o Client o Care Manager Other:

To be Adherent to Scheduled Medical Appointments with PCP and Endocrinologist/Specialist Provider(s) for Next _________ Days.

Tasks Responsibility Target Date Plan ( Weekly / Monthly ) Medical Appointment Schedule. o Client o Care Manager Other:

Attend Medical Appointments Scheduled on ___________. o Client o Care Manager Other:


Other: o Client o Care Manager Other: To be Adherent to Diabetes Medication/Treatment Regimen and Diagnostic Testing for Next _______ Days.

Tasks Responsibility Target Date Review Treatment Plan and Medication Regimen. o Client o Care Manager Other: Complete A1c (Blood Sugar Level) Monitoring Daily o Client o Care Manager Other: Adhere to Insulin and/or Oral Diabetes Medication Regimen Daily. o Client o Care Manager Other: ( Develop / Review / Adhere to ) Healthy Eating Plan/Diet for DM. o Client o Care Manager Other: ( Develop / Review / Adhere to ) Exercise Activity Program/Plan. o Client o Care Manager Other: ( Develop / Review / Adhere to ) Smoking Cessation Program/Plan. o Client o Care Manager Other: Other: o Client o Care Manager Other:

_______________________________________________

_______________________________________________

_______________________________________________




Topic: Diabetes Mellitus Type I/II (Continued) Case Conferences / Testing & Services / Healthy Literacy


Discuss Course of Treatment with PCP / Endocrinologist. o Client o Care Manager Other: Discuss Medication Regimen – Route, Frequency, and Duration. o Client o Care Manager Other: Discuss Management of DM Condition(s) and Symptoms. o Client o Care Manager Other: Discuss Medication Side Effects and/or Diet Restrictions. o Client o Care Manager Other: Discuss Referral or Linkage to Endocrinologist/Specialist. o Client o Care Manager Other: Other: o Client o Care Manager Other: To Complete Diagnostic Tests/Labs within Next ________ Days.

Tasks Responsibility Target Date Obtain Diagnostic Lab Measures – A1C & Blood Sugar Range o Client o Care Manager Other:

( Achieve / Maintain ) A1C < 7. o Client o Care Manager Other:

( Achieve / Maintain) Blood Sugar Range (70-100). o Client o Care Manager Other:

Other: o Client o Care Manager Other: To Link to Diabetes Care Providers/Services in Next_____ Days.

Tasks Responsibility Target Date Connect to Nutritionist / Nutrition Program. o Client o Care Manager Other: Connect to Ophthalmologist for Eye Exam (ex. Blurry Vision ) o Client o Care Manager Other: Connect to Podiatrist to Examine ( ex. Foot Pain / Circulation ). o Client o Care Manager Other:

Connect to Nephrologist to Examine Kidney Function. o Client o Care Manager Other: Other: o Client o Care Manager Other: To Increase Health Literacy / Understanding of Diabetes Care Management in the Next ______________ Days.

Tasks Responsibility Target Date Discuss Understanding of Diabetes Diagnosis and Care Management (What Causes Diabetes, Signs & Symptoms, Role of Providers etc.)


Provide Diabetes Care Resources (in Language: _____________ ). o Client o Care Manager Other:

Educate Use of Glucometer and Glucose Monitoring. o Client o Care Manager Other:

Develop Daily Log for Self-Management. o Client o Care Manager Other:

To ___________________________________ in Next ________ Days.





Topic: HIV/AIDS

Problem: Check (√)

Viral Load (VL) (copies/mL)

Check (√)

CD4 (T-Cell) (per /uL)

Unknown Unknown

< 20 or <50 *Undetectable VL

> 200

< 200

200 – 400 <= 200 *CDC Definition of AIDS> 400

Goal: To Link to Infectious Disease (ID) Provider/Specialty Provider and Remain Engaged in Care.

Goal: To Adhere to Treatment Plan, Antiretroviral Medication Regimen, Scheduled Medical Appointments and Testing.

Goal: To Increase Health Literacy Regarding HIV/AIDS.

Goal: To Use Prevention Measures to Reduce HIV Transmission/Risk.

To Link to Infectious Disease (ID) Provider in the Next _______ Days. Tasks Responsibility Target Date

Research and Discuss Linkage to Available Providers in Community. o Client o Care Manager Other: Contact PCP / MCO to Discuss Referral to Infectious Disease Provider. o Client o Care Manager Other: Contact Potential Providers and Schedule Medical Appointment. o Client o Care Manager Other: Attend Scheduled Initial Medical Appointment on________________. o Client o Care Manager Other:

To be Adherent to Scheduled Medical Appointments with PCP and/or ID/Specialist Provider(s) for Next _________ Days.

Tasks Responsibility Target Date Plan ( Weekly / Monthly ) Medical Appointment Schedule with Client. o Client o Care Manager Other: Attend Medical Appointment with ID Provider on _________________. o Client o Care Manager Other:

Attend Follow-up Medical Appointment with PCP on _______________. o Client o Care Manager Other:


To be Adherent to Antiretroviral (ART) Medication/Treatment Regimen and Diagnostic Testing for Next _______ Days.

Responsibility

Tasks Responsibility Target Date Review Treatment Plan and Medication Regimen. o Client o Care Manager Other: Complete Diagnostic Labs for VL and CD4 Every _________ Months. o Client o Care Manager Other:

Obtain Medication(s) from Pharmacy. o Client o Care Manager Other: Client will take ART Medication(s) as Prescribed. o Client o Care Manager Other: Client will Complete Diagnostic Testing for STIs / Hepatitis B / C . o Client o Care Manager Other: Other: o Client o Care Manager Other:

__________________________________________________

__________________________________________________




Topic: HIV/AIDS (Continued) Case Conferences / Tests & Services / Healthy Literacy


Discuss Course of Treatment with PCP / ID Provider. o Client o Care Manager Other:

Discuss Medication Regimen – Route, Frequency, and Duration. o Client o Care Manager Other:

Discuss Management of Condition(s). o Client o Care Manager Other:

Review Patient Adherence to ART Medication. o Client o Care Manager Other: Other: o Client o Care Manager Other: To Complete Diagnostic Tests/Labs within Next ________ Days.

Tasks Responsibility Target Date Obtain Diagnostic Lab Measures – Viral Load & CD4 o Client o Care Manager Other:

( Achieve / Maintain ) VL < 20 copies/mL. o Client o Care Manager Other:

( Achieve / Maintain) CD4 Range > 200. o Client o Care Manager Other:

Other: o Client o Care Manager Other: To Link to HIV/AIDS Care Providers/Services in Next_____ Days.

Tasks Responsibility Target Date Connect to Education and Prevention Services. o Client o Care Manager Other:

Connect to PrEP/PEP. o Client o Care Manager Other:

Connect to Harm Reduction Services. o Client o Care Manager Other:

Connect to HIV / Hepatitis C / STI Testing Services o Client o Care Manager Other: Other: o Client o Care Manager Other: To Increase Health Literacy / Understanding of HIV/AIDS Care Management in the Next ______________ Days.

Tasks Responsibility Target Date Discuss Understanding of HIV/AIDS Diagnosis and Care Management (What Causes HIV/AIDS, Signs & Symptoms, Role of Providers etc.)


Provide HIV/AIDS Care Resources (in Language: _____________ ). o Client o Care Manager Other:

To ___________________________________ in Next ________ Days.


Other: o Client o Care Manager Other: Other: o Client o Care Manager Other:



Topic: Chronic Kidney Disease (CKD)

Problem Stage Glomerular Filtration

Rate (GFR)

Check

(√)

Stage 1 (Normal or High GFR) > 90 mL/min

Stage 2 (Mild CKD) 60-89 mL/min

Stage 3A (Moderate CKD) 45 – 59 mL/min

Stage 3B (Moderate CKD) 30 – 44 mL/min

Stage 4 (Severe CKD) 15 – 29 mL/min

Stage 5 (End Stage CKD) < 15 mL/min

Goal: To Link to Nephrologist/Specialist Provider and Remain Engaged in Care.


Goal: To Increase Health Literacy Regarding Chronic Kidney Disease.

To Adhere to Scheduled Appointments with PCP / Specialist Provider(s) for Next ___________ Days.

Tasks Responsibility Target Date Plan ( Weekly / Monthly ) Medical Appointment Schedule with Client. o Client o Care Manager Other: Attend Medical Appointment with Cardiologist on _______________. o Client o Care Manager Other:



To be Adherent to Medication Regimen/Treatment Plan and Diagnostic Testing for Next _______ Days.

Responsibility

Tasks Responsibility Target Date Review Treatment Plan and Medication Regimen. o Client o Care Manager Other: Client will Complete Diagnostic Labs / Serum Creatinine Test (for GFR). o Client o Care Manager Other: Client will take Medication Regimen for High Blood Pressure. o Client o Care Manager Other: Client will take Medication Regimen for Diabetes Mellitus. o Client o Care Manager Other: ( Develop / Review / Adhere to ) Healthy Eating Plan/Diet. o Client o Care Manager Other:

( Develop / Review / Adhere to ) Exercise Activity Program/Plan. o Client o Care Manager Other:

( Develop / Review / Adhere to ) Smoking Cessation Program/Plan. o Client o Care Manager Other:


_______________________________________________

_______________________________________________

_______________________________________________

Stage 1 (Normal or High GFR) / Stage 2 (Mild CKD)




Topic: Chronic Kidney Disease (CKD) (Continued) Stage 1 & 2 Continued / Stage 4 & Stage 5 To Complete Case Conference in the Next ______________ Days.

Tasks Responsibility Target Date Discuss Course of Treatment with PCP / Nephrologist. o Client o Care Manager Other: Discuss Patients Medication Regimen – Route, Frequency, and Duration. o Client o Care Manager Other:

Discuss Management of Condition(s). o Client o Care Manager Other:

Discuss Referral or Linkage to Nephrologist (Recommended at Stage 3). o Client o Care Manager Other:


To Link to Chronic Kidney Disease Provider in Next _____ Days * (Recommended at Stage 3)

Responsibility

Tasks Responsibility Target Date Research and Discuss Linkage to Available Providers in Community. o Client o Care Manager Other: Contact PCP / MCO to Discuss Referral to Nephrologist. o Client o Care Manager Other: Contact Nephrologist/Specialist to Schedule Initial Appointment. o Client o Care Manager Other: Attend Scheduled Initial Medical Appointment on________________. o Client o Care Manager Other:


To Adhere to CKD Treatment Plan During Next ________ Days.

Tasks Responsibility Target Date Adhere to Medical Appointments with Nephrologist Every 3 Months. o Client o Care Manager Other: Complete Diagnostic Testing as Recommended by Nephrologist. o Client o Care Manager Other: Adhere to Appointments with Dietician/Nutritionist. o Client o Care Manager Other: Connect to Social Worker to Monitor Treatment Plan. o Client o Care Manager Other: Identify and Develop Plan for Hemodialysis/Peritoneal Dialysis. o Client o Care Manager Other:

Complete Process for Kidney Transplant Listing. o Client o Care Manager Other:

Adhere to Strict Healthy Diet Plan. o Client o Care Manager Other:

Attend Weekly Dialysis Treatment _______ Times a Week. o Client o Care Manager Other:

To ___________________________________ in Next ________ Days.

Tasks Responsibility Target Date Other: o Client o Care Manager Other: Other: o Client o Care Manager Other: Other: o Client o Care Manager Other:

Stage 4 (Severe CKD) / Stage 5 (End Stage CKD)



Topic: Chronic Obstructive Pulmonary Disease (COPD)

Problem:

Spirometry Test Required to Diagnose COPD - Presence of a Post-Bronchodilator FEV1/FVC <0.70 Confirms COPD - Presence of Persistent Airflow Limitation

Goal: To Link to Pulmonologist/Specialty Provider and Remain Engaged in Care.


Goal: To Increase Health Literacy Regarding COPD.

Goal: Make Home and Lifestyle Changes to Improve Symptoms

To Link to Pulmonologist / Specialist in the Next ________ Days.

Tasks Responsibility Target Date Research and Discuss Linkage to Available Providers in Community. o Client o Care Manager Other: Contact PCP / MCO to Discuss Referral to Pulmonologist. o Client o Care Manager Other: Contact Potential Providers and Schedule Medical Appointment. o Client o Care Manager Other:

Attend Scheduled Initial Medical Appointment on________________. o Client o Care Manager Other:

To be Adherent to Scheduled Medical Appointments with PCP and Pulmonologist/Specialist Provider(s) for Next _________ Days.

Tasks Responsibility Target Date Plan ( Weekly / Monthly ) Medical Appointment Schedule with Client. o Client o Care Manager Other: Attend Medical Appointment with Pulmonologist on ______________. o Client o Care Manager Other:



To be Adherent to COPD Medication Regimen/Treatment Plan and Diagnostic Testing for Next _______ Days.

Responsibility

Tasks Responsibility Target Date Review Treatment Plan and Medication Regimen. o Client o Care Manager Other:

Client will Complete Diagnostic Testing/Labs on _________________. o Client o Care Manager Other:

Client will use Bronchodilator for COPD Management as Prescribed. o Client o Care Manager Other: Discuss Environmental and Lifestyle Triggers. o Client o Care Manager Other: Monitor COPD Symptoms and Keep Log of Triggers. o Client o Care Manager Other: Adhere to Oxygen Treatment/Therapy as Prescribed. o Client o Care Manager Other: ( Develop / Review / Adhere to ) Exercise Activity Plan. o Client o Care Manager Other:

( Develop / Review / Adhere to ) Smoking Cessation Program/Plan. o Client o Care Manager Other:


__________________________________________________

__________________________________________________




Topic: Chronic Obstructive Pulmonary Disease (COPD) – (Continued) Case Conferences / Testing & Services / Healthy Literacy


Discuss Course of Treatment with PCP / Pulmonologist. o Client o Care Manager Other: Discuss Medication Regimen – Route, Frequency, Duration. o Client o Care Manager Other:

Discuss Management of COPD Condition(s) and Symptoms. o Client o Care Manager Other:

Discuss Medication Side Effects and/or Physical Activity Restrictions. o Client o Care Manager Other: Discuss Referral or Linkage to Pulmonologist/Specialist. o Client o Care Manager Other: Other: o Client o Care Manager Other: To Link to COPD Providers/Services in Next_____ Days.

Tasks Responsibility Target Date Schedule and Adhere to PCP Appointment for Physical/Follow-up. o Client o Care Manager Other: Connect to Respiratory Therapist. o Client o Care Manager Other: Connect to Gym / Exercise Specialist/Trainer. o Client o Care Manager Other: Connect to Hobby / Community Program: o Client o Care Manager Other: Other: o Client o Care Manager Other: To Change Home and Lifestyle Triggers in Next ______ Days.

Tasks Responsibility Target Date Reduce or Quit Smoking – Enroll in a Smoking Cessation Program. o Client o Care Manager Other:

Reduce / Remove Environmental Triggers (Pollution, Irritants). o Client o Care Manager Other:

Discuss Physical Activity Levels and Potential Action Steps. o Client o Care Manager Other: Exercise at Gym for ________ Minutes _________ Times a Week. OR Walk for ___________ Minutes _________ Times a ( Day / Week ).


To Increase Health Literacy / Understanding of COPD Care Management in the Next ______________ Days.

Tasks Responsibility Target Date Discuss Understanding of COPD Diagnosis and Care Management (What Causes COPD, Signs & Symptoms, Role of Providers etc.)


Provide COPD Care Resources (in Language: _____________ ). o Client o Care Manager Other:

To ___________________________________ in Next ________ Days. Tasks Responsibility Target Date





Topic: Smoking, Exercise and Diet Problem:

Reduce Tobacco Use/Smoking in the Next _______ Days by Smoking _________ Cigarettes / Tobacco Product per ________ Day / Week.

Tasks Responsibility Target Date Smoke Less than _____ Cigarettes/Tobacco Products per ( Day / Week ). o Client o Care Manager Other:

Stop Cigarettes/Tobacco Product for ____________ ( Days / Weeks ). o Client o Care Manager Other:


To Discuss Smoking Cessation to Determine Willingness to Quit.

Tasks Responsibility Target Date Discuss Current Smoking / Tobacco Use and Assess Stage of Change. o Client o Care Manager Other:


To Increase Physical Activity Levels in the Next __________ Days. Tasks Responsibility Target Date

Research and Identify Nearby Programs/Parks to Exercise. o Client o Care Manager Other:

Plan Weekly Exercise Schedule with Client. o Client o Care Manager Other:

Exercise for _______ Minutes _________ Times a ( Day / Week ). o Client o Care Manager Other:

Improve Flexibility/Balance by Stretching _____ Times a ( Day / Week ) o Client o Care Manager Other:

To join a Gym or Recreation Program in the Next ________ Days.

Tasks Responsibility Target Date Research Potential Exercise Programs or Gyms for Enrollment Information and Hours.


Discuss Exercise Limitations with Medical Provider. o Client o Care Manager Other:

Enroll in Gym or Recreation Program _________________. o Client o Care Manager Other:

To Lose __________ lbs. in the Next __________ ( Days / Months ).

Tasks Responsibility Target Date Discuss Exercise Preferences and Limitations with Client. o Client o Care Manager Other:

Develop Weekly Exercise Plan. o Client o Care Manager Other:

Exercise at Gym for ________ Minutes _________ Times a Week. OR Walk for ___________ Minutes _________ Times a ( Day / Week ).


________________________________________________

________________________________________________

________________________________________________



Topic: Smoking, Exercise and Diet (Continued)

Link to a Nutritionist and/or Program in the Next _________ Days.

Tasks Responsibility Target Date

Discuss Linkage to Nutritionist and/or Nutrition Program with Client. o Client o Care Manager Other:

Conduct Case Conference with PCP to Discuss Referral to Nutritionist. o Client o Care Manager Other: Complete Referral to Community Nutrition Education Program. o Client o Care Manager Other: Attend Nutrition Education Workshops at Least 1/Month. o Client o Care Manager Other: Follow-up with Nutritionist/RD/Nutrition Program to Discuss Adherence/Progress in Program.


Follow-up with Client to Discuss Successes/Limitations of Program. o Client o Care Manager Other: Increase Understanding of Dietary Label. o Client o Care Manager Other: Increase Intake of Healthy Foods in the Next __________ Days.


Eat Lean Meats at Least ______ times per ( Day / Week ) o Client o Care Manager Other:

Eat Vegetables during ______ meals per ( Day / Week ) o Client o Care Manager Other:

Cook at Home at Least ______ ( Day / Week ) OR Other:


Reduce Fat and Sugar Intake in the Next _________ Days.


Drink Less than ____ Sugary Carbonated Beverages per ( Day / Week ). o Client o Care Manager Other:

Drink Less than _____ Alcoholic Beverages per ( Day / Week ). o Client o Care Manager Other:

Eat Fast Food Less than _____ Times a ( Day / Week ). o Client o Care Manager Other:

Eat Fried and/or High-Fat Foods up to ______ per ( Day / Week ) OR Other:


Educate and Link to Supportive Services in Next ___________ Days.


Research and Identify Nearby Farmers Markets. o Client o Care Manager Other: Provide Educational Materials/Tools in Language: ________________. o Client o Care Manager Other: Research and Identify Nearby Food Pantry Locations/Times. o Client o Care Manager Other: Other: o Client o Care Manager Other: Other: o Client o Care Manager Other:



Topic: Obesity

Problem Check ( √ ) BMI Category Underweight: Below 18.5 Normal:18.5 – 24.9 Overweight: 25.0 – 29.9 Class 1 Obesity: 30 to < 34.9 Class 2 Obesity: 35 to < 39.9 Class 3 Obesity: 40 or Higher

Goal: To Increase Physical Activity. Goal: To Increase Knowledge of Healthy Eating Habits and Eat Well-Balanced Diet. Goal: To Review Healthy Weight Loss Alternative Therapy/Surgery.

To Increase Physical Activity Levels in the Next __________ Days.

Tasks Responsibility Target Date Discuss Linkage to Gym/Recreation Program in Community. o Client o Care Manager Other:

Research and Identify Nearby Programs/Parks where Client can Exercise – ( Walk / Run / Bike / Swim / Lift Weights )


Plan Weekly Exercise Schedule with Client. o Client o Care Manager Other:

Exercise at Gym for ________ Minutes _________ Times a Week. OR Walk for ___________ Minutes _________ Times a ( Day / Week ).



To join a Gym or Recreation Program in the Next ________ Days.

Tasks Responsibility Target Date Research and/or Contact Potential Exercise Programs or Gyms for Enrollment Information and Hours.


Discuss Exercise Limitations with Medical Provider. o Client o Care Manager Other: Enroll in Gym or Recreation Program _________________. o Client o Care Manager Other:

To Lose __________ lbs. in the Next __________ ( Days / Months ). Responsibility

Tasks Responsibility Target Date Discuss Exercise Preferences and Limitations with Client. o Client o Care Manager Other:

Develop Weekly Exercise Plan. o Client o Care Manager Other: Exercise at Gym for ________ Minutes _________ Times a Week. OR Walk for ___________ Minutes _________ Times a ( Day / Week ).



______________________________________________________________

______________________________________________________________

Nutrition / Weight Loss



Topic: Obesity (Continued) Nutrition / Weight Loss (Continued) Link to a Nutritionist and/or Program in the Next _________ Days.

Tasks Responsibility Target Date Discuss Linkage to Nutritionist and/or Nutrition Program with Client. o Client o Care Manager Other: Conduct Case Conference with PCP to Discuss Referral to Nutritionist. o Client o Care Manager Other:

Complete Referral to Community Nutrition Education Program. o Client o Care Manager Other: Attend Nutrition Education Workshops at Least 1/Month. o Client o Care Manager Other: Follow-up with Nutritionist/RD/Nutrition Program to Discuss Adherence/Progress in Program.


Follow-up with Client to Discuss Successes/Limitations of Program. o Client o Care Manager Other: Increase Understanding of Dietary Label. o Client o Care Manager Other:

Increase Intake of Healthy Foods in the Next __________ Days.

Tasks Responsibility Target Date Eat Lean Meats at Least ______ times per ( Day / Week ) o Client o Care Manager Other:

Eat Vegetables during ______ meals per ( Day / Week ) o Client o Care Manager Other:

Cook at Home at Least ______ ( Day / Week ) OR Other:


Reduce Fat and Sugar Intake in the Next _________ Days.

Tasks Responsibility Target Date Drink Less than ____ Sugary Carbonated Beverages per ( Day / Week ). o Client o Care Manager Other:

Drink Less than _____ Alcoholic Beverages per ( Day / Week ). o Client o Care Manager Other:

Eat Fast Food Less than _____ Times a ( Day / Week ). o Client o Care Manager Other:

Eat Fried and/or High-Fat Foods up to ______ per ( Day / Week ) OR Other:


Complete Weight-loss Surgery (Class 2/3 ONLY) in Next ____ Days.

Tasks Responsibility Target Date Conduct Case Conference with Surgeon to Review Upcoming Surgery. o Client o Care Manager Other:

Review Surgery/Procedure Instructions and Post-Surgery Care. o Client o Care Manager Other:








Topic: Mental Health

Problem: PHQ-9 Score

Depression Severity Check (√)

PHQ-9 Scoring Value

1 – 4 Minimal Depression Not At All 0

5 – 9 Mild Depression Several Days + 1

10 – 14 Moderate Depression More than Half the Days + 2

15 – 19 Moderately Severe Depression Nearly Every Day + 3

20 - 27 Severe Depression Total PHQ-9 Score

Goal: To Link to Therapist / Psychiatrist and Remain Engaged in Care. Goal: To Adhere to Mental Health Care Appointments with Therapist / Psychiatrist. Goal: To Adhere to Medication Regimen and Recovery Plan. Goal: To Develop Safety Plan. Goal: To Increase Understanding/Health Literacy of Mental Health Diagnosis.

To Link to Therapist / Psychiatrist in the Next ________ Days. Tasks Responsibility Target Date

Research and Discuss Linkage to Available Providers in Community. o Client o Care Manager Other: Contact PCP / MCO to Discuss Referral to Therapist / Psychiatrist. o Client o Care Manager Other: Contact Potential Providers and Schedule MH Appointment. o Client o Care Manager Other: Attend Scheduled MH Appointment on________________. o Client o Care Manager Other:

To be Adherent to Scheduled Mental Health Appointments with Therapist / Psychiatrist for Next ____________ Days.

Tasks Responsibility Target Date Plan ( Weekly / Monthly ) MH Appointment Schedule with Client. o Client o Care Manager Other: Attend MH Appointment(s) on ____________________. o Client o Care Manager Other:

Attend Follow-up MH Appointment on _______________. o Client o Care Manager Other: Other: o Client o Care Manager Other: To be Adherent to MH Medication Regimen/Recovery Plan and Diagnostic Testing for Next _______ Days.

Responsibility

Tasks Responsibility Target Date Review Medication Regimen and Recovery Plan with Client. o Client o Care Manager Other: Obtain Diagnostic Labs / List of Medications. o Client o Care Manager Other: Client will take Medication Regimen as Prescribed. o Client o Care Manager Other: Identify Community / Peer / Family Support Systems. o Client o Care Manager Other: Other: o Client o Care Manager Other:

___________________________________________

___________________________________________

___________________________________________

___________________________________________




Topic: Mental Health (Continued) Case Conferences / Supportive Services / Health Literacy


Conduct Case Conference with Therapist / Psychiatrist and Discuss Course of Treatment, Management of Diagnosis Symptoms and Triggers.


Discuss Medication Regimen – Route, Frequency, Duration. o Client o Care Manager Other: Obtain Comprehensive Psychosocial Assessment. o Client o Care Manager Other: Obtain Comprehensive Psychiatric Evaluation. o Client o Care Manager Other: Discuss Referral or Linkage to Additional Supportive Services. o Client o Care Manager Other: Discuss Safety Planning with Therapist / Psychiatrist. o Client o Care Manager Other:

To Link to Peer Support Services or ___________________________ in the Next ________________ Days.

Tasks Responsibility Target Date Research, Identify and Discuss Linkage to Service Provider / Program. o Client o Care Manager Other: Complete Referral / Program Admission to Services Provider / Program. o Client o Care Manager Other:

Attend Appointment / Program on __________________________. o Client o Care Manager Other:

Other: o Client o Care Manager Other: To Link to HCBS: ________________________________________ in the Next __________Days.

Responsibility

Tasks Responsibility Target Date Complete HARP Eligibility Assessment. o Client o Care Manager Other: Upload Assessment Data to UAS and Determine Eligibility for Services. o Client o Care Manager Other: Submit LOSD Authorization Request to MCO. o Client o Care Manager Other: Review LOSD Determination and Discuss Available Providers. o Client o Care Manager Other: Submit Referral/Supporting Documentation to HCBS Provider. o Client o Care Manager Other: Develop and Complete HARP Plan of Care. o Client o Care Manager Other: Submit Completed HARP Plan of Care to MCO. o Client o Care Manager Other: To Increase Healthy Literacy / Understanding of Mental Health Diagnosis and Recovery Goals in the Next ________________ Days.

Tasks Responsibility Target Date Discuss Understanding of Mental Health Diagnosis and Care Management of Diagnosis, Symptoms & Triggers, and Role of Providers.


Provide Mental Health Care Resources (in Language :______________). o Client o Care Manager Other:




Topic: Substance Abuse /Addictive Behavior

Problem: Substance

Past Use?

Past 3 Months Thinking About Change?

Tobacco No Yes Preparation Action Maintenance

Alcohol No Yes Preparation Action Maintenance

Marijuana No Yes Preparation Action Maintenance

Cocaine No Yes Preparation Action Maintenance

Crack No Yes Preparation Action Maintenance

Heroin No Yes Preparation Action Maintenance

PCP/Hallucinogens No Yes Preparation Action Maintenance

Crystal Meth No Yes Preparation Action Maintenance

Rx Pills No Yes Preparation Action Maintenance

K2 (Synthetics) No Yes Preparation Action Maintenance

Goal: To Link to Substance Use Provider / Services and Remain Engaged in Care.

Goal: To Adhere to Treatment / Recovery Plan.

Goal: To Assess Readiness/Willingness to Change Substance Use/Addictive Behavior.

Goal: To Abstain, Reduce and/or Reduce Harm of Substance Use/Addictive Behavior.

To Link to Substance Use Provider / Services in the Next ______ Days. Tasks Responsibility Target Date

Research and Discuss Linkage to Available Providers in Community. o Client o Care Manager Other:

Contact Potential Providers, Schedule Intake Appointment/Submit Referral. o Client o Care Manager Other:

Connect to Harm Reduction / Needle Exchange. o Client o Care Manager Other:

Connect to AA/NA/Self-Help Group. o Client o Care Manager Other:

Connect to Recovery Readiness. o Client o Care Manager Other:

Connect to Outpatient Substance Use. o Client o Care Manager Other:

Connect to Outpatient Alcohol Program. o Client o Care Manager Other:

Connect to Methadone Maintenance. o Client o Care Manager Other:

Connect to Inpatient Substance Use. o Client o Care Manager Other:

Connect to Inpatient Alcohol Program. o Client o Care Manager Other:

Connect to Detox. o Client o Care Manager Other:


__________________________________

__________________________________

__________________________________

__________________________________

Care Coordination



Topic: Substance Abuse / Addictive Behavior (Continued) Case Conferences / Harm Reduction & Recovery

To Complete Case Conference with Provider in the Next ________ Days. Tasks Responsibility Target Date

Discuss Course of Treatment with Substance Use Provider / Counselor. o Client o Care Manager Other: Discuss Program – Frequency, Duration, Intensity. o Client o Care Manager Other: Discuss Management of Triggers / Negative Behaviors. o Client o Care Manager Other: Other: o Client o Care Manager Other:

To Adhere to Substance Use Service/Programs During Next ______ Days. Tasks Responsibility Target Date

Attend Program/Service ___________ Times a ( Day / Week / Month ). o Client o Care Manager Other:

Other: o Client o Care Manager Other: To ( Abstain / Reduce ) Substance Use/ Addictive Behavior During Next_____ Days.

Tasks Responsibility Target Date Discuss Positives/Negatives of Behavior/Substance Use. o Client o Care Manager Other:

Assess Stage of Change OR Readiness to Abstain / Reduce Behavior. o Client o Care Manager Other:

Provide Substance Use/Quitting Help Resources (in Language: _____________). o Client o Care Manager Other:

Client will Abstain from ____________________________________________ . o Client o Care Manager Other:

Client will Reduce the Frequency of _____________ by ___________________ . o Client o Care Manager Other:

Client will Reduce the Amount of _______________ by ___________________ . o Client o Care Manager Other:


To Reduce the Harm of the Substance Use/Addictive Behavior During Next_____ Days.

Tasks Responsibility Target Date Client will Reduce the Harm of _______________ by _____________________ . o Client o Care Manager Other:


Other: o Client o Care Manager Other: To ___________________________________ in Next ________ Days.


Other: o Client o Care Manager Other: Other: o Client o Care Manager Other:



Topic: Transitional Care

Problem: Hospital/Facility Name Admission Date Pending Discharge

Discharge Date Social Worker/Provider Name

Telephone # Encounter Date

Follow-Up Needed

To Conduct Case Conference with Social Worker/Attending Provider in Next ______Days to Discuss Clinical Event Details, Outcomes and Needs.

Tasks Responsibility Target Date Review Hospital Alert/Clinical Event Notification for Admission/Event Details. o Client o Care Manager Other:

Research Provider Contact Information from Admission/Event Details. o Client o Care Manager Other:

Contact Attending SW/Provider to Discuss and Verify Clinical Event Details. o Client o Care Manager Other:

Conduct Case Conference with SW/Provider to Discuss Aftercare Planning. o Client o Care Manager Other:

Schedule Field Visit with SW/Provider and/or Client. o Client o Care Manager Other:


To Link to ____________________________________ in Next _______ Days.




To Schedule __________________________________ in Next _______ Days.




To _________________________________________ in Next ________ Days. Tasks Responsibility Target Date



________________________________________________

________________________________________________

________________________________________________

Care Coordination



Topic: Safety Planning

Problem:

To Develop Safety Plan in Next ____________Days. Tasks Responsibility Target Date

Discuss and Identify Warning Signs and Triggers. o Client o Care Manager Other: Discuss and Identify People or Social Settings that Provide Distractions / Stress / Potential Harm.


Discuss and Identify People I can Ask for Help. o Client o Care Manager Other: Discuss and Identify Internal Coping Strategies. o Client o Care Manager Other: Identify Professionals or Agencies I can Contact During a Crisis. o Client o Care Manager Other: Identify Nearby Hospitals or Medical Facilities. o Client o Care Manager Other: Discuss Plan for Environmental Emergency. o Client o Care Manager Other: Discuss Making Environment Safe. o Client o Care Manager Other: Research Social Support Programs or Services. o Client o Care Manager Other: Other: o Client o Care Manager Other:

To Adhere to Safety Action Plan for Next ____________ Days.

Tasks Responsibility Target Date Develop and Provide Client with Copy of Developed Action Plan (Emergency Contacts, Resources, Providers, etc. )


Follow-up with Client Regarding Safety Plan Adherence Every __________ Days / Weeks.



Responsibility

Tasks Responsibility Target Date o Client o Care Manager Other:





____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________



Topic: Home and Community-Based Services (HCBS)

Problem: Active Need Home and Community-Based Services (HCBS) Psychosocial Rehabilitation (PSR) Community Psychiatric Support & Treatment (CPST) Habilitation/Residential Support Services Family Support and Training Crisis Respite Short-Term Long-Term Empowerment Services – Peer Support Education Support Services

Employment Pre-Vocational Transitional Intensive Ongoing

To Complete HARP Eligibility Assessment in Next _______ Days. Tasks Responsibility Target Date

Meet with Client and Complete HARP Eligibility Assessment. o Client o Care Manager Other:

Upload Assessment Data to UAS and Determine Eligibility for Services. o Client o Care Manager Other:

Review Eligibility Determination and HCBS Referral Process. o Client o Care Manager Other:

Discuss Applicable HCBS and Determine Interest in Referral for HCBS. o Client o Care Manager Other:

To Link to HCBS: ___________________________ in Next _____ Days.

Tasks Responsibility Target Date Develop and Submit LOSD Authorization Request to MCO. (If in the Form of an Initial POC, Request Must Include at Minimum: Section 1, 2, 3, 4, 6).


Review LOSD Determination and Discuss Available HCBS Providers. o Client o Care Manager Other:

Submit Referral/Supporting Documentation to HCBS Provider. o Client o Care Manager Other:

Schedule Initial Appointment/Assessment with HCBS Provider. o Client o Care Manager Other:

Conduct Case Conference with HCBS Provider to Discuss Services/Needs. o Client o Care Manager Other:

Determine Frequency, Scope and Duration of HCBS. o Client o Care Manager Other:

Attend Scheduled Sessions/Appointments with HCBS Provider. o Client o Care Manager Other:

To Complete and Submit HARP POC within Next ____________ Days.

Tasks Responsibility Target Date Develop Initial HARP POC (LOSD Request) and Review with Client. o Client o Care Manager Other:

Review Supporting Documentation and Complete Risk Assessment (Section 7). o Client o Care Manager Other:

Obtain HCBS Frequency, Scope and Duration and Add to HARP POC. o Client o Care Manager Other:

Complete and Review Final HARP POC with Client (Signature Required*). o Client o Care Manager Other:

Submit Completed and Signed HARP POC to MCO. o Client o Care Manager Other:

________________________________________________

________________________________________________

________________________________________________



Topic: Benefits & Entitlements

Problem: Active Need Benefits/Entitlements

SSI/SSDI (SSA) Public Assistance (HRA) SNAP (HRA) HEAP (HRA) Health Bucks Program Meal Delivery (Meals on Wheels, Gods Love We Deliver) HASA (HRA)

To Complete Application for ( SSI / SSDI ) in Next _______ Days. Tasks Responsibility Target Date

Review Eligibility and Application Requirements on SSA.gov. o Client o Care Manager Other:

Discuss Required Documentation Required to Complete Application. o Client o Care Manager Other:

Obtain Required Documentation: SS#/Card, Proof of Age, Income, Citizenship Status, Resources, Living Arrangement, Work History etc.


Complete and Submit Application via ( Mail / In-Person ). o Client o Care Manager Other:

To Complete Application for ( Public Assistance / SNAP / HEAP ) in Next _________ Days.

Tasks Responsibility Target Date Create Account and Review Eligibility on mybenefits.ny.gov. o Client o Care Manager Other:

Discuss Required Documentation Required to Complete Application. o Client o Care Manager Other:

Obtain Required Documentation: SS Card, Proof of Income-Pay Stubs, Rent/Mortgage Receipt, List of Household Resources etc.


Complete and Submit Application via ( Online Web Portal / In- Person ). o Client o Care Manager Other:

Complete Application for Meal Delivery Program in Next ____ Days. Tasks Responsibility Target Date

Review Eligibility and Discuss Application Requirements. o Client o Care Manager Other:

Obtain Supporting Medical/Supportive Documentation. o Client o Care Manager Other:

Complete and Submit Application for _________________________. o Client o Care Manager Other:

Complete Application for HASA in the Next ________ Days. Tasks Responsibility Target Date

Review and Confirm Program Eligibility from Provider/Medical Doc. o Client o Care Manager Other:

Obtain Supporting Medical/Supportive Documentation (M11Q, W-488X, SSA4814) from ID Provider.


Submit Application to HRA via ( Fax / Mail / In-Person ). o Client o Care Manager Other:

________________________________________________

________________________________________________

________________________________________________



Topic: Education & Employment

Problem: Active Need Education/Employment GED College/Continuing Education ESL Program Library Card Workforce1 Access - VR HCBS: Employment Services HCBS: Education Support Services

To Link to _____________________________ in Next _______ Days. Tasks Responsibility Target Date

Research Available Programs and Program Eligibility/Requirements. o Client o Care Manager Other:

Complete and Submit ( Application / Referral ) for Program Admission. o Client o Care Manager Other:


To Link to _____________________________ in Next _______ Days.

Tasks Responsibility Target Date Research Available Programs and Program Eligibility/Requirements. o Client o Care Manager Other:



To Obtain Library Card in Next ___________ Days.

Tasks Responsibility Target Date Research Available Library Locations and Discuss Directions. o Client o Care Manager Other:

Visit Library _________ Times a ( Week / Month ). o Client o Care Manager Other:

To Link to HCBS: _________________________ in Next _____ Days. Tasks Responsibility Target Date

Complete HARP Eligibility Assessment. o Client o Care Manager Other:

Discuss HARP and Applicable HCBS. o Client o Care Manager Other:


Submit LOSD Authorization Request to MCO. o Client o Care Manager Other:

Review LOSD Determination and Discuss Available Providers. o Client o Care Manager Other:


Develop and Complete HARP Plan of Care. o Client o Care Manager Other:

________________________________________________

________________________________________________

________________________________________________



Topic: Supportive Services

Problem: Active Need Supportive Home Health Aid (HHA) / CDPAP Adult Day Care Program SUD Counseling/Program Medical/Medicaid Transportation Access-A-Ride Reduced-Fare MetroCard HCBS:

To Link to _____________________________ in Next _______ Days. Tasks Responsibility Target Date

Research Available Programs and Program Eligibility/Requirements. o Client o Care Manager Other:



To Link to _____________________________ in Next _______ Days.

Tasks Responsibility Target Date Research Available Programs and Program Eligibility/Requirements. o Client o Care Manager Other:



To Obtain Reduced-Fare MetroCard in Next ___________ Days.

Tasks Responsibility Target Date Determine Program Eligibility and Discuss Program Requirements. o Client o Care Manager Other:



To Link to HCBS: _________________________ in Next _____ Days. Tasks Responsibility Target Date

Complete HARP Eligibility Assessment. o Client o Care Manager Other:

Discuss HARP and Applicable HCBS. o Client o Care Manager Other:


Submit LOSD Authorization Request to MCO. o Client o Care Manager Other:

Review LOSD Determination and Discuss Available Providers. o Client o Care Manager Other:


Develop and Complete HARP Plan of Care. o Client o Care Manager Other:

________________________________________________

________________________________________________

________________________________________________



Topic: Housing Assistance & Services

Problem: Active Need Housing

NYCHA NYC Housing Connect Breaking Ground 2010e Supportive Housing Senior Housing LINC/SEPS Voucher SCRIE/DRIE Other:

To Complete Application for NYCHA in Next ____ Days.

Tasks Responsibility Target Date Create Account on NYCHA Self-Service Portal (selfserve.nycha)/ o Client o Care Manager Other:

Complete and Submit NYCHA Application via Web Portal. o Client o Care Manager Other:

Register for Online Access and Review Results/Application Progress. o Client o Care Manager Other:

To Complete Application(s) on NYCHousingConnect in Next ____ Days.


Create Account on NYC Housing Connect Web Portal. o Client o Care Manager Other:

Identify Applicable Listings and Submit Lottery Application(s). o Client o Care Manager Other:

Register for Online Access and Review Results/Application Progress. o Client o Care Manager Other:

To Complete 2010eSupportiveHousing Application in Next ______ Days.

Tasks Responsibility Target Date Review Eligibility and Required Supporting Documentation for Submission. o Client o Care Manager Other:

Obtain Required Supporting Documentation: Psychosocial Assessment, Psychiatric Evaluation, Physical/PPD Test (if applicable) etc.


Complete and Submit Housing Application to HRA. o Client o Care Manager Other:


To Complete Application(s) for _________________ in Next _____ Days. Tasks Responsibility Target Date

Research and Obtain Application and Instructions. o Client o Care Manager Other:

Review Housing Opportunity / Housing Program Eligibility. o Client o Care Manager Other:

Submit Application for ______________________________________. o Client o Care Manager Other:

________________________________________________

________________________________________________

________________________________________________



Topic: Legal Services

Problem: Active Need Legal

Eviction Prevention Immigration Status US Citizenship Creating a Will Do Not Resuscitate (DNR) Guardianship Criminal Justice Other:

To Link to ____________________________ in Next ________ Days.

Tasks Responsibility Target Date Research Available Legal Providers for _________________________. o Client o Care Manager Other:

Submit Referral / Application for ______________________________. o Client o Care Manager Other:



To Link to ____________________________ in Next ________ Days.

Tasks Responsibility Target Date Research Available Legal Providers for _________________________. o Client o Care Manager Other:

Submit Referral / Application for ______________________________. o Client o Care Manager Other:



To ___________________________________ in Next ________ Days.








________________________________________________

________________________________________________

________________________________________________



Topic: Medicaid Insurance

Problem:

To Complete Application Process to Apply / Reapply for Medicaid Insurance in Next ________ Days.

Tasks Responsibility Target Date Research Medicaid Insurance Information to Determine Application Process Category: https://www.health.ny.gov/health_care/medicaid/#apply


Contact NYS of Health: Health Plan Marketplace: (855) 355-5777. o Client o Care Manager Other:

Contact Managed Care Organization: _________________________. o Client o Care Manager Other:

Contact Medicaid Helpline: (800) 541-2831. o Client o Care Manager Other:

Contact HRA: (718) 557-1399. o Client o Care Manager Other:

Submit Application and Supporting Documentation. o Client o Care Manager Other:

Verify Medicaid Insurance via MAPP, ePACES etc. o Client o Care Manager Other:








________________________________________________

________________________________________________

________________________________________________

Access to Care & Services



Topic:

Problem Goal:

Goal:

Goal:

Goal:









Responsibility





______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________



The QCCP Health Home Initial Plan of Care Instrument was Developed by the

Queens Coordinated Care Partners, Inc. Health Home and the QCCP Operations Committee.

QCCP would like to thank the QCCP Operations Committee for their hard work and commitment.

QCCP would like to acknowledge the following Case Management Agency Network Representatives:

Operations Committee Network Representation Advocacy Center of Queens County (ACQC)

APICHA Argus Community Brightpoint Health

Community Healthcare Network (CHN) New Horizons Counseling Center

Puerto Rican Family Institute (PRFI) Mount Sinai Queens

National Association of Drug Abuse Problems (NADAP) MediSys – Jamaica Hospital

NY Presbyterian Queens The Bridge

Queens Coordinated Care Partners, Inc. Team Members

Executive Director, Valentine Hernandez

Operations Manager, Brian Timmermans

Administrative Manager, Oscar Laluyan

Financial Manager, Naresh Sallick

Director of Quality, Rebecca Hoberman



queens coordinated care partners, c. · includes the member, care manager and external providers)...

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