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)
Appears in 2 contracts
Samples: Contract for Services, Contract for Services
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)
Appears in 1 contract
Samples: Contract for Services
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)
Appears in 1 contract
Samples: Contract for Services
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 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 visit.
n. Patient self-management, anticipatory guidance for caregivers, and home care (if appropriate).
o. Method and frequency of communication among treatment team. To the extent possible, the communication plan should include those members of the child’s treatment team who may be outside the PIHP’s network.
2. Ensure that the child’s PCP and child welfare caseworker are primary participants in the development and periodic reviews of the comprehensive care plan. The child’s PCP is the lead for the child’s overall health care needs, and, the child welfare caseworker has the overall responsibility for all aspects of the child’s care. The participation of the PCP and child welfare caseworker will be key in eliminating duplication; mitigating caregiver confusion regarding the child’s health care treatment plan; and will be paramount to ensuring full coordination and integration of the child’s medical and non-medical needs.
3. Collaborate with the child welfare caseworker to obtain and incorporate input from the following:
a. The child, as appropriate.
b. The child’s out-of-home care provider.
c. The child’s parent/legal guardian.
d. Other individuals who are instrumental to the care and treatment of the child. The care plan will be communicated to the parent/legal guardian for input and feedback. Evidence of this action must be reflected in the care plan.
4. Collaborate with the broader health care team to prioritize the services necessary to address or further assess the child’s health care needs across the health care system, including primary care, specialty care, inpatient care and care that will be obtained outside of the PIHP provider network.
5. Collaborate with the child welfare caseworker to establish specific communication plans for each child.
6. Document the Comprehensive Care Plan, preferably according to the specifications for Care Plans in the ONC Interoperability Standards Advisory.
Appears in 1 contract
Samples: Contract for Services
