wellness coordination: service definition and standardsplan or individual risk plans. the wellness...

www.IN.gov/fssa Equal Opportunity/Affirmative Action Employer

Eric Holcomb, Governor State of Indiana

Division of Disability and Rehabilitative Services 402 W. WASHINGTON STREET, P.O. BOX 7083

INDIANAPOLIS, IN 46207-7083 1-800-545-7763

Wellness Coordination:

Service Definition and Standards

UPDATED September 27, 2017

The Bureau of Developmental Disabilities Services (BDDS) within the Division of Disability and

Rehabilitative Services (DDRS) developed this document as guidance for providers of Wellness

Coordination Services. The purpose of this document is to clearly outline the service definition,

requirements, and related responsibilities of Wellness Coordination Services.

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TABLE OF CONTENTS

OVERVIEW OF WELLNESS ____________________________________________________ 3

EXPLANATION OF HEALTH SCORE_____________________________________________ 4

TIER REQUIREMENTS_________________________________________________________ 6

WELLNESS COORDINATION SERVICES_________________________________________ 8

FACE TO FACE VISITS

CONSULTATIONS

WELLNESS ASSESSMENT IN the DDRS data system

DATA COLLECTION

PLAN DEVELOPMENT AND IMPLEMENTATION

TRAINING

ONGOING SUPPORTS

TIMELINES____________________________________________________________________11

DOCUMENTATION STANDARDS________________________________________________ 13

WELLNESS ASSESSMENT REQUIRED INFORMATION 15

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Section I: Service Definition

OVERVIEW OF WELLNESS

Wellness Coordination Services refers to the development, maintenance and routine monitoring of the

home and community-based service (HCBS) participant’s Wellness Coordination Plan, Risk Plans and

the medical services required to manage his/her health care needs.

Wellness Coordination Services are to be provided by a registered nurse (RN) or a licensed practical

nurse (LPN) under IC 25-23-1-1.2 working under the supervision of an RN.

Wellness Coordination Services extend beyond those services provided through routine doctor/health

care visits required under the Medicaid State Plan and are specifically designed for participants requiring

the assistance of an RN/LPN to properly coordinate their medical needs.

Wellness Coordination Services are for participants assessed with health scores of 5 or higher through

the ICAP process. Participants assessed with health scores of 0-4 would not require assistance of an

RN/LPN to coordinate medical needs.

Participants assessed with health scores of 5 or higher through the State’s objective based allocation

(OBA) process are eligible for Wellness Coordination Services. There are three (3) tiers of Wellness

Coordination Services. Each tier has a different requirement for RN or LPN involvement. The health

scores equate to the following tiers:

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Section II: The Wellness Plan

EXPLANATION OF HEALTH SCORE

The Inventory for Client and Agency Planning (ICAP) assessment determines an individual’s overall

level of functioning for Broad Independence and General Maladaptive Factors. The ICAP Addendum is

a separate set of questions that determine an individual’s level of functioning of behavior and health

factors.

For health factors, the frequency and intensity of the individual’s health care needs are scored separately

on the ICAP addendum. The frequency and intensity scores are then added together to arrive at the

“total” health score. For example, if the frequency score is 4 and the intensity score is 5, the total health

score is 9. An individual qualifies to receive Wellness Coordination Services based on their total health

score.

WELLNESS ASSESSMENT

The Wellness Coordination service includes:

- The completion of a Wellness Coordination Plan

- documenting significant health history,

- capturing personal history, physician orders,

- updating risk assessments,

- documenting examinations, and evaluations.

Providers may use their own nursing assessment form which must be uploaded into the DDRS data

system. If the provider uses their own nursing assessment form, it must be updated quarterly and must

contain the information listed in Attachment B of this document. The baseline data points described

below are required to be a part of the Wellness Assessment.

PLAN DEVELOPMENT AND IMPLEMENTATION

Wellness Coordination includes the development, oversight and maintenance of a Wellness

Coordination Plan. A Comprehensive Medical Risk Plan may substitute for the Wellness Coordination

Plan or individual risk plans.

The Wellness Coordination Plan must include a description of the individual, identification of

the individual’s needs and risks, the history and current status of the individual, as well as

interventions, monitoring guidelines, documentation guidelines, notification guidelines,

training and education, and health outcomes.

The Wellness Coordination Plan is to be developed within fourteen (14) calendar days of the

finalized Wellness Assessment or uploaded Nursing Assessment. Subsequently, plans are to be

uploaded into the DDRS data system by the provider within five (5) calendar days, as well as

shared with the Individual Support Team.

https://in.uadvocare.com/public-documents/training/94D13507-B208-4A96-B6F0-AF242033FD2B.pdf

https://in.uadvocare.com/public-documents/training/94D13507-B208-4A96-B6F0-AF242033FD2B.pdf

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Associated risk plans are then reviewed or created within fourteen (14) calendar days for identified

health and wellness needs. Wellness Providers shall develop Risk Plans (there is no required State

format) that are person centered, approved by or developed by a nurse, and address the specific needs of

an individual in all associated risk areas.

Once the Wellness Coordination Plan is developed, the Wellness Coordinator is expected to

communicate with the individual’s case manager and any applicable Wellness Coordination dietitian,

pharmacist, physician, or specialists to share plan information and/or gather any consultations needed to

garner additional information or details about an individual and his/her healthcare needs.

All developed plans (Wellness Assessment, Wellness Coordination Plan are to be reviewed by the

IST at each quarterly meeting to address whether outcomes are being achieved and are appropriate.

TRAINING

The Wellness Coordination provider is responsible for the appropriate training of Direct Support

Professionals (DSPs) of all HCBS providers to ensure implementation of Risk Plans in a fashion that

recognizes the complexity of the individual’s needs and within an appropriate timeframe, with a

maximum timeframe of 30 days from the start of the service or when the risk plan has been revised. It is

expected that the wellness nurse provide relevant and necessary training on all risk plans. However, the

wellness nurse has the ability to determine the most appropriate means for the training to be supported

(via train the trainer, consultation, direct support, via web teleconference), based on the complexity of an

individual’s needs, and the Direct Support Professionals’ background and level of experiences. The

nurse is not required to personally conduct all of the trainings, but is responsible for determining the

most appropriate training plan/approach to be used, and documentation must reflect that the nurse

determined the most appropriate training approach and the individual’s medical needs were considered

in this decision.

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Section III: Service Provision

TIER REQUIREMENTS (activities must occur weekly, regardless of the number of weeks in a month)

Health Score Range 5-6

Tier I: Health care needs require at least one weekly (Sunday - Saturday) consultation by RN or LPN.

Specifically tailored to address the identified person-centered needs outlined within the Wellness

Coordination Plan and ISP. This consultation includes face to face visits once a month. One of the face

to face visits per month may count as a consultation. One of the consultations may be a comprehensive

review of the individual’s records, charts and supporting health and wellness information. Consultations

include, but are not limited to, discussions with physicians, specialists, other health care providers, direct

support staff, and program staff. Face to face visits should be conducted in a private location that

respects the member’s privacy and dignity, and shall address specific individualized goals/needs as

outlined in the Wellness Coordination plan.

Combinations of services may include:

Three (3) consultations and one (1) face to face visit each month for months with four (4) weeks

*EXAMPLE combination of activities

Week 1 Consult with physician (via phone)

Week 2 Face to face visit with the individual receiving Wellness

Week 3 Consult with specialist

Week 4 Consult with direct support staff

Three consultations (one being a comprehensive record/chart review) and one face to face visit

each month for months with four (4) weeks




Week 3 Consult via individual’s chart review


Four (4) consultations (one being a comprehensive record/chart review) and one (1) face to face

visit each month for months with five (5) weeks.







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Health Score Range 7-9

Tier II: Health care needs require at least one weekly (Sunday - Saturday) consultation by RN or LPN.

This consultation/review includes face to face visits at least twice monthly. One of the face to face visits

per month can count as a consultation. One of the consultations may be a comprehensive review of the

individual’s records, charts and supporting health and wellness information. Consultations include, but

are not limited to, discussions with physicians, specialists, other health care providers, direct support

staff, and program staff.


Three (3) consultations and two (2) face to face visits each month for months with four (4) weeks




Week 3 Consult with specialist and face to face visit with the individual receiving

Wellness


Three (3) consultations (one being a comprehensive record/chart review) and two (2) face to face

visits each month for months with four (4) weeks


Week 1 Face to face visit with the individual receiving Wellness and consultation

with direct support staff


Week 3 Comprehensive record/chart review


Four (4) consultations (one being a comprehensive record/chart review) and two (2) face to face

visits each month for months with five (5) weeks.





Week 4 Consult with physician (via phone) and face to face visit with the

individual receiving Wellness


Health Score Range 10

Tier III: Health care needs require at least twice weekly (Sunday - Saturday) consultation by RN or

LPN. This consultation/review includes face to face visits once a week, regardless of the number of

weeks within the month. One of the weekly face to face visits can count as a consultation. One of the

consultations may be a comprehensive review of the individual’s records, charts and supporting health

and wellness information. Consultations include, but are not limited to, discussions with physicians,

specialists, other health care providers, direct support staff, and program staff.

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Two (2) consultations and one (1) face to face visit per week.


Week 1 Face to face visit with the individual receiving Wellness, consultation with

direct support staff, and consultation with pharmacy (via phone)


direct support staff, and consultation with physician (via phone)


physician (via phone), and consultation with specialist (via phone)

Week 4 Consult with direct support staff, comprehensive record review, and face to

face visit with the individual receiving Wellness

Two (2) consultations (one being a comprehensive record/chart review), and one (1) face to face

per week.



direct support staff, and comprehensive record/chart review


direct support staff, and record/chart review


physician (via phone), and record/chart review

Week 4 Consult with IST, comprehensive record review, and face to face visit with

the individual receiving Wellness

*Examples shown above demonstrate sample combinations of activities under Wellness. Supporting

documentation of the service should reflect more detail and individualization than these examples

provide.

As medical events occur or a participant’s medical needs change, the Individualized Support Team (IST)

is expected to have the individual’s health score reassessed and to ensure the appropriateness of services.

If a team believes that an individual’s health score is incorrect they should coordinate with the entire

team to submit a Budget Review Questionnaire (BRQ) to BDDS requesting a review of the individual’s

Algo Score. The case manager will submit the BRQ based on the team’s agreement and commendation.

WELLNESS COORDINATION SERVICES

Consultations and face to face visits are direct services. A face to face visit requires the nurse to meet

one on one with the individual (group visits are not allowable). Consultations with professionals or the

IST may take place in person or through other communications. It should be noted that consultations and

face to face visits are allowed while an individual is hospitalized for a short period of time. In the event

of short term (30 days or less) inpatient stays, face to face visits with participants are allowable on date

of admission and date of discharge as well as any dates the participant is not in an institutional setting.

Consultations with professionals or the IST during member inpatient stays can be utilized in lieu of the

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face to face requirement for a given month and based on their assigned Wellness Coordination Tier

activities.

An individual hospitalized for the entire month could not have Wellness provided for that month.

FACE TO FACE VISITS

In implementing Wellness Coordination, face to face meetings are to occur per the tier requirements

directly with the individual when discussing their diagnosis, prognosis, and treatments (as well as

discussing weight, BMI and other measures) and must be documented in the individual’s records to

count as the face to face consultation with the individual. Face to face meetings must take place

individually with the participant, not in group settings with other individuals receiving the same service

from the Wellness provider. Appropriate HIPAA and privacy practices must be followed in the delivery

of this service.

Face to face meetings may also occur in a home or community based setting where the individual

commonly spends time. It is expected the nursing visits involving observations and assessments of the

individual will take place in the natural environment of the individual to accurately establish and

document how their environment is affecting their wellness.

CONSULTATIONS

Ongoing consultations should take place with the individual’s health care providers and the IST. A

consultation is defined as a conversation of two or more individuals to discuss the diagnosis, prognosis,

and treatment of a particular case. While consultations can take place in person or by other means of

communication, documentation must clearly show a collaborative discussion has taken place. One of the

face to face visits per month that takes place with the nurse can also count as a consultation with the

individual. The nurse and the team may decide on an individual basis who the consultations will

include.

Examples of consultations include:

Discussion with health care professionals about the individual’s health status

Discussion with Direct Support Professionals (DSP) in regards to the individuals health

status

Updating the IST during team meetings

Chart reviews, entry of medical appointments, scheduling, etc. are considered as standards of

documentation of health care services and are not considered as a consultation.

DATA COLLECTION

Regardless of their identified Wellness tier, individuals’ vitals must be collected and recorded on a

quarterly basis on the Wellness Assessment. The six (6) baseline data points to be recorded are:

Height

Weight

Body Mass Index (BMI)

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Annual flu vaccination date

Annual physical date

Annual dental visit date

ONGOING SUPPORTS

Ongoing Wellness Coordination includes:

- face to face visits (per tier requirements),

- ongoing consultations with the individual’s health care providers and the IST,

- reviewing and updating the wellness or risk plan quarterly or when an individual’s status changes,

- attending team meetings or reporting on Wellness Coordination for team meetings, and

- coordinating and monitoring of the HCBS participant’s wellness or risk plan and the medical

services required to manage his/her health care needs.

The Wellness Coordinator ensures the IST members work closely together to meet the individual’s

health and wellness needs. All related plans are to be reviewed by the support team at the quarterly

meeting to address whether outcomes are being achieved and are appropriate.

In addition, the Wellness Assessment (or provider’s Nursing Assessment) may serve as the quarterly

report and must be reviewed and/or updated and finalized each quarter at least five (5) calendar days

prior to the individual’s quarterly meeting in order for the IST to be able to review the most recent data

available. The Wellness Assessment can then be printed for review at the quarterly meeting. If a

quarterly meeting is missed/unscheduled, an updated assessment must still be finalized in the same

quarter of the missed quarterly meeting.

All plans should be reviewed and revised by the nurse as needed, but at least annually, when there is a

new diagnosis, hospitalization or change in status. The plans should then be submitted to the team for

review and implementation.

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Attachment A: Wellness Provision and Associated Timelines

TIMELINES

The following table reflects the components of Wellness Coordination in regards to the

timelines, frequency, documentation standards, and documentation upload requirements.

Component Timeline Documentation Standard

Wellness Coordination added

to an individual’s Cost

Comparison Budget (CCB)

and a Notice of Action (NOA)

is issued to the provider.

Provider has two (2) business

days from receipt of the NOA

to contact the HCBS

participant and schedule an

initial appointment.

Documentation supporting the

service as outlined in this

guidance document must be

retained by the provider in the

individual’s records. The

provider must also upload

documentation into the DDRS

data system.

Initial meeting Within seven (7) business days

of beginning the service, the

provider meets with the

individual and his or her

guardian, if applicable, to

identify medications, health

care needs, doctor

appointments, and any other

relevant information needed to

develop the HCBS

participant’s plan.

Documentation is completed

in person. Providers may use

their own assessment form

when completing the

assessment but all BDDS

required information is to be

included.

Documentation must be

retained by the provider in the

individual’s records. Provider

must also upload the

documentation into the

DDRS data system.

Initial Wellness Assessment Completed and uploaded

within forty five (45)

calendar days of beginning

service.

Uploaded to the DDRS data

system by the provider staff;

the finalized assessment

serves as the quarterly report.

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Quarterly Wellness

Assessment

Data may be carried forward

from the most recent

assessment. The assessment is

reviewed and updated

quarterly, and finalized at

least five (5) calendar days

prior to quarterly team

meeting. (*see page 9)

Uploaded to the DDRS

data system by the

provider; the assessment

may serve as the

quarterly report.

Wellness Coordination Plan Created within fourteen

(14) calendar days of initial

finalized Wellness

Assessment and updated

annually. The plan must

also be reviewed during

quarterly meetings and

updated as needed.

Wellness Coordination Plan

is to be uploaded into the

DDRS data system “Provider

Documents Area” by the

provider within five (5)

calendar days of initial

completion and whenever

updated.

Trainings The Wellness Coordination

provider is responsible for the

training of all HCBS providers

to ensure implementation of the

Risk Plans. The wellness nurse

is responsible for determining

and documenting the most

appropriate means for the

training to be supported (via

train the trainer, consultation,

direct support, via web

teleconference), based on the

complexity of an individual’s

needs, and the Direct Support

Professionals’ background and

level of experiences.

Retained by the provider in

the individual’s records.

Provider may choose to

upload into the DDRS data

system.

Visit logs, consultations,

nursing notes, other

documentation related to

Wellness Coordination as

outlined in 460 IAC 6-25-1

Retained by the provider in

the individual’s records.

Provider may choose to

upload into the DDRS data

system.

http://www.in.gov/legislative/iac/T04600/A00060.PDF?

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DOCUMENTATION STANDARDS

Wellness Coordination Services documentation shall include the professional standards applicable to the

professional licensing requirements (registered nurse (RN) or a licensed practical nurse (LPN) under IC

25-23-1-1.2 working under the supervision of an RN) and the individual’s Individualized Support Plan

(ISP) as outlined in Policy Number: BDDS 460 1216 038 Policy: Maintenance of Records of Services

Provided.

Documentation standards include:

Documentation of face to face visits (per tier requirements);

Documentation of weekly consultations/reviews (per tier requirements);

o Other activities, as appropriate (outlined in 460 IAC 6-25-3 Documentation of health

care services received by an individual):

o The date of health and medical services provided to the individual.

o A description of the health care or medical services provided to the individual.

o The signature of the person providing the health care or medical service for each date a

service is provided.

o Additional information and documentation is required in this standard, including

documentation of the following:

An organized system for medication administration.

An individual's refusal to take medication.

Monitoring of medication side effects.

Seizure tracking.

Changes in an individual's status.

An organized system of health-related incident management.

If applicable to this provider, an investigation of the death of an individual.

Services must address needs identified in the person centered planning process and be outlined in

the ISP;

The Wellness Coordination provider will provide a report to IST members at least quarterly.

o The Wellness Assessment must be reviewed and finalized quarterly, serving as the

quarterly report. There is no need for a separate written report to be submitted by

providers

Providers may choose to upload documentation into the DDRS data system that is not captured in other

documentation. All providers are responsible for maintaining documentation in the office and home

files.

Service notes should include the date, time, and summary of services delivered. For instance, if a

consultation occurred, the note should state the date it took place, the length of time, participants

involved, and a summary of the discussion.

http://www.in.gov/fssa/files/Maintenance_of_Records_of_Services_Provided.pdf

http://www.in.gov/fssa/files/Maintenance_of_Records_of_Services_Provided.pdf

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Attachment B: Required Components of Initial and Quarterly Wellness Assessments

Wellness Assessment - Required Information Demographic

Last Name

First Name

Date of Birth

Medicaid Recipient ID

Vital Signs

Vitals Date taken

Temp

Pulse

Respirations

Blood Pressure

Height

Weight

BMI

Allergies Allergy

Reaction

Diagnosis Diagnosis

Date of Diagnosis

Significant Health History

Health History Infection/Center

Description

Date

Treatment

Hospitalization Date From

Date To

Where

Why

Outcome

Family History Health Issue

Pain/Illness Indication How Pain Indicated

How Illness Indicated

Personal History

Personal History Exercise

Sleep Pattern

Sexual Activity Past

Sexual Activity Present

Risks Risk

Past

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Frequency/Quantity

Present

Frequency/Quantity

Lab Results Lab/Test

Date

Results

Physician Orders

Adaptive Supports Adaptive Support

Response

Sides

Nutrition/Hydration Nutrition/Hydration

Description

Dining/Dysphagia Dining Option

Input

Additional Dining/Dysphagia Dining Option

Risk Assessments

Skin Risk Info Sensory Perception

Moisture

Activity

Mobility

Nutrition

Friction

RMT (Risk management Tool) Medical/Health: Following conditions exist...

Fall Risk Risk Factor/Scale

Health and Systems Review

Examinations/Evaluations/Assessments Health Review

Date

Results

System Review System Review

Results

Remarkable Physical Findings System Review

Area

Left/Right

Findings

Description

Document Review Document Review

Date

Description

Final Review Positive/Negative Trends

Referrals or Appointments