INTEGRATED PLAN OF CARE. (a) The hospice core team shall develop an integrated plan of care for the new patient within 72 hours after the admission. The integrated plan of care shall be developed jointly by the employee who performed the initial assessment and at least one other member of the core team. The core team shall use the initial plan of care as a basis for team deci- sion−making and shall update intervention strategies as a result of core team assessment and planning collaboration. The care coor- dinator is responsible for ensuring that ensuing interventions by hospice employees are consistent with the initial and integrated plans of care.
INTEGRATED PLAN OF CARE. A person-centered care plan that addresses Acute Care and LTSS for Enrollees. The plan is developed by the STAR+PLUS MMP Service Coordinator with the Enrollee, their family and caregiver supports, as appropriate, and Providers. The Integrated Plan of Care will contain the Enrollee’s health history, a summary of current, short-term, and long-term health and social needs, concerns, and goals; and a list of required services, their frequency, and a description of who will provide such services. For Enrollees eligible for HCBS, the Enrollee’s ISP is incorporated into the Integrated Plan of Care.
INTEGRATED PLAN OF CARE. 2.6.3.1.Following the Comprehensive Health Risk Assessment (as described in Section 2.6.2), the STAR+PLUS MMP shall assign a Service Coordinator who works with the Enrollee, their family supports, Providers, and other Service Coordination Team members to develop a comprehensive, person-centered, written Integrated Plan of Care for each Enrollee.
