Comprehensive Care Plan - Requirements Sample Clauses

Comprehensive Care Plan - Requirements. The HCC must ensure that each child has a comprehensive health care plan that is based on information collected during the information gathering (assessment) process. The initial care plan must be developed within the first 60 days of the child’s enrollment in the PIHP. In developing the comprehensive health care plan, the child’s HCC will do the following: 1. Ensure that the care plan is child-centric and comprehensive. A child-centric plan addresses the unique needs of the child - recognizing the need for an enhanced schedule for physical, behavioral and dental care, as necessary; assuring continuity of care; and flexibility on location of services consistent with evidence-informed practices. For example, mental health services could be delivered in the home or another community-based setting, rather than in a clinic or hospital setting. A comprehensive care plan includes the following, at a minimum, a. Relevant prior and current diagnoses b. Current medications c. The names of all individuals who are instrumental to the child’s care and treatment, including the name and contact information for the child’s legal guardian. d. The names of external supports (e.g., school nurse, public health nurse, community-based case managers, Birth-3 lead care coordinator) e. The name of the lead prescriber for all children with 2 or more psychotropic medication prescriptions f. The name of the provider responsible for metabolic monitoring of every child who is prescribed an antipsychotic medication g. The enhanced periodicity schedule for comprehensive HealthCheck exams h. The tracking and timely follow up on referrals i. Short and long-term treatment goals j. Barriers to care k. An individualized crisis/action plan for behavior management (if appropriate) l. An action plan for exacerbation of a chronic condition m. Transitions between inpatient and outpatient settings, including home care. The transition plan must address the need for prompt follow up with the child’s PCP after an inpatient stay or emergency room visit n. Patient self-management, anticipatory guidance for caregivers, and home care (if appropriate)

Comprehensive Care Plan - Requirements. The HCC must ensure that each child has a comprehensive health care plan that is based on information collected during the information gathering (assessment) process. The initial care plan must be developed within the first 60 days of the child’s enrollment in the PIHP. In developing the comprehensive health care plan the child’s HCC will do the following: Ensure that the care plan is child centric and comprehensive. A child-centric plan addresses the unique needs of the child—recognizing the need for an enhanced schedule for physical, behavioral and dental care, as necessary; assuring continuity of care; and flexibility on location of services consistent with evidence-informed practices. For example, mental health services could be delivered in the home or another community-based setting, rather than in a clinic or hospital setting. A comprehensive care plan includes the following, at a minimum: a. Relevant prior and current diagnoses. b. Current medications. c. The names of all individuals who are instrumental to the child’s care and treatment, including the name and contact information for the child’s legal guardian. d. The names of external supports (e.g., school nurse, public health nurse, community-based case managers, B to 3 lead care coordinator). e. The name of the lead prescriber of all children with 2 or more psychotropic medication prescriptions. f. The name of the provider responsible for metabolic monitoring of every child who is prescribed an antipsychotic medication. g. The enhanced periodicity schedule for comprehensive HealthCheck exams. h. The tracking and timely follow up on referrals. i. Short and long-term treatment goals.