Individual Care Plan. An individualized care plan will be developed for each enrollee that includes member goals and preferences, measurable objectives and timetables to meet medical needs, behavioral health and long-term support needs. It must include timeframes for reassessment. Participating Plans are required to engage enrollees and/or their representatives to play an active role in designing their care plans. Service coordination for behavioral health is discussed further in section IV.D.iv of this appendix.
Individual Care Plan. 1. Case Managers shall respect the inherent dignity of each person served. Services shall be Client-driven and shall seek to increase the Client’s sense of empowerment, self-advocacy and medical self- management while enhancing the Client’s overall health status.
Individual Care Plan. Consumers take part in a multidisciplinary assessment which informs the development of a care plan with their clinician and/or the MDT. Family and carers may be included if appropriate. The plan is informed by a consumer’s stage of care, clinical presentation and support requirements. Stages of care have been developed to facilitate consistency and accountability across care plans for consumers and staff. Guidelines regarding Stage of Care are detailed in Attachment B. The care plan includes: • Risk assessment • Treatment goals • Stage of care • Distress tolerance plan • Medication • Meal plan • Movement plan • Use of electronic devices • Agreed leave • Sexual safety The care plan is reviewed and updated at each MDT and the updated plan is added to DHR.
