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.
(b) The integrated plan of care shall detail the scope and range of services to be provided, and shall:
1. Identify patient and family needs;
2. Specify service interventions to meet the identified needs;
3. Identify the employees responsible for providing the inter- ventions;
4. Include physician orders and medical procedures. If the physician’s orders were originally given orally, the registered nurse shall have immediately recorded and signed them and obtained the physician’s countersignature on the record within the next 10 days; and
5. Establish timeframes for evaluating the interventions needed to achieve the long−term and short−term goals and the effectiveness of those interventions as they relate to the identified patient and family problems or needs and the expected outcomes.
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.
2.6.3.2. Every Enrollee must have an Integrated Plan of Care, unless the STAR+PLUS MMP is unable to reach the Enrollee or the Enrollee refuses to have an Integrated Plan of Care and the attempts to reach the Enrollee or the Enrollee’s refusal is documented.
2.6.3.3. For all Enrollees, the STAR+PLUS MMP must ensure that the Integrated Plan of Care is in place within ninety (90) days of Enrollment, or upon receipt of all necessary eligibility information from the State, whichever is later.
2.6.3.4. The STAR+PLUS MMP shall utilize information gathered during the risk stratification process in order to update the Integrated Plan of Care.
2.6.3.5. The Integrated Plan of Care must:
2.6.3.5.1. 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 or what entity will provide such services.
2.6.3.5.2. Include, as applicable and consistent with Enrollee preferences, coordination with the Enrollee’s family and community support systems, including independent living centers, area agencies on aging, and local authorities, as applicable.
0.0.0.0.0. Xx agreed to and signed by the Enrollee or the Enrollee’s LAR to indicate agreement with the Integrated Plan of Care. The Enrollee maintains all Appeal rights if the Integrated Plan of Care is not signed.
2.6.3.5.4. Allow for financial management services and promote self-determination and may include information about accessing services outside of Covered Services, such as affordable, integrated housing.
2.6.3.5.5. Include opportunities for input from the Enrollee, their LAR, and the Service Coordination Team during the development, implementation, and ongoing assessment of ISP; and
2.6.3.5.6. Include a risk assessment that identifies and evaluates risks associated with the Enrollee’s care.
2.6.3.6. Integrated Plan of Care Expiration date
2.6.3.6.1. The STAR+PLUS MMP is required to conduct an annual reassessment for each Enrollee and update the Integrated Plan of Care prior to the expiration date or when there is a significant chang...
