Comprehensive Care Plan Development. A comprehensive Care Plan shall be developed within thirty (30) days from the completion of the health risk assessment based on available information including but not limited to issues or needs identified by risk and comprehensive assessments, medical records and/or previous utilization to the extent records are available, and Enrollee and/or family input. In addition for Nursing Facility Enrollees, information located at the Nursing Facility should be considered. If the comprehensive assessment was not conducted face-to-face, a face to-face-visit must be offered to non-EW Enrollees as a part of the care planning development process. A face-to- face visit must occur as a part of the care planning development for Enrollees receiving EW services. The Care Plan should incorporate an interdisciplinary/holistic and preventive focus and include advance directive planning and Enrollee participation. For Elderly Waiver Enrollees, the comprehensive Care Plan shall also meet the specifications for the Care Plan pursuant to section 6.1.24.2.
(a) Interdisciplinary/Holistic Focus. The Care Plan shall employ an interdisciplinary and holistic approach by incorporating the unique primary care, acute care, long term care, mental health and social service needs of each Enrollee with appropriate coordination and communication across all Providers. For Nursing Facility Enrollees this includes review of the Nursing Facility chart, gathering input from Nursing Facility staff, participating in facility meetings and family conferences and communication and coordination with other Providers. For community and Community NHC Enrollees this includes appropriate written or verbal communication with physician or other Providers, attending appointments with Enrollees as needed and involving family members as appropriate in the care planning process and visits.
Comprehensive Care Plan Development. A comprehensive Care Plan shall be developed within 30 days from the completion of the health risk assessment based on available information including but not limited to issues or needs identified by risk and comprehensive assessments, medical records and/or previous utilization to the extent records are available, and Enrollee and/or family input. In addition for Nursing Facility Enrollees, information located at the Nursing Facility should be considered. The Care Plan should incorporate an interdisciplinary/holistic and preventive focus and include advance directive planning and Enrollee participation. For Elderly Waiver Enrollees, the comprehensive Care Plan shall also meet the specifications for the Care Plan pursuant to section 6.1.11(B).
(a) Interdisciplinary/Holistic Focus. The Care Plan shall employ an interdisciplinary and holistic approach by incorporating the unique primary care, acute care, long term care, mental health and social service needs of each Enrollee with appropriate coordination and communication across all Providers. For Nursing Facility Enrollees this includes review of the Nursing Facility chart, gathering input from Nursing Facility staff, participating in facility meetings and family conferences and communication and coordination with other Providers. For community and Community NHC Enrollees this includes appropriate written or verbal communication with physician or other Providers, attending appointments with Enrollees as needed and involving family members as appropriate in the care planning process and visits.
Comprehensive Care Plan Development. An Enrollee Comprehensive Care Plan shall be developed within sixty (60) calendar days of enrollment. For each Enrollee, the MCO shall develop a Comprehensive Care Plan based on the needs assessment, the establishment of goals and objectives, the monitoring of outcomes through regular follow-up, and a process to ensure that Care Plans are revised as necessary and as determined during team care planning conferences with the Enrollee.
(1) MnDHO Comprehensive Care Plan Basis. MnDHO Comprehensive Care Plan shall be based on the results of a health assessment and the LTCC Screening Assessment and will include:
(a) the Community Support Plan for Enrollees receiving Home and Community-based Services or State Plan home care services pursuant to Section 6.1.16; and
(b) a risk management plan that identifies any risks to health and safety;
(c) plans for addressing the risks;
(d) informed choices made by the Enrollee to manage his or her own risk;
(e) a back up emergency plan; and
(f) a crisis intervention plan for any Enrollee at risk.
(2) Interdisciplinary/Holistic Focus. The Comprehensive Care Plan shall employ an interdisciplinary and holistic approach by incorporating the unique primary, acute, long term care, mental health and social service needs of each Enrollee with appropriate coordination and communication across all Providers. For Nursing Facility Enrollees, this includes review of the facility chart, gathering input from Nursing Facility staff, participating in facility meetings and family conferences and communication and coordination with other providers. For community, and community NHC Enrollees, this includes appropriate written or verbal communication with physician or other providers, attending appointments with Enrollees as needed and involving family members as appropriate in the care planning process and visits.
