LTSS Service Plan. A LTSS Service Plan to identify and address how LTSS needs will be met and how services will be provided in accordance with the PCSP. The LTSS Service Plan must include the following: • All LTSS services necessary to support the Participant in living as independently as possible and remaining as engaged in their community as possible. • For the needs identified in the comprehensive needs assessment, the interventions to address each need or preference, reasonable long-term and short-term goals, the measurable outcomes to be achieved by the interventions, the anticipated time lines in which to achieve the desired outcomes, and the staff responsible for conducting the interventions and monitoring the outcomes. • Potential problems that can be anticipated, including the risks and how these risks can be minimized to xxxxxx the Participant’s maximum functioning level of well-being. • Participant decisions around self-directed care and whether the Participant is participating in Participant-Direction. • Communications plan. • How frequently specific services will be provided. • Whether and, if so, how technology and telehealth will be used. • Participant choice of Providers. • Individualized Back-Up Plans. • The person(s)/Providers responsible for specific interventions/services. • Participant’s available, willing, and able informal support network and services. • Participant’s need for and plan to access community resources, non- covered services, and other supports, including any reasonable accommodations. • How to accommodate preferences for leisure activities, hobbies, and community engagement. • Any other needs or preferences of the Participant. • Participant’s goals for the least restrictive setting possible, if they are being discharged or transitioned from an inpatient setting. • How the CHC-MCO will coordinate with the Participant’s Medicare, Veterans, BH-MCO, other health coverage, and other supports. • Participant’s employment and educational goals. The PCSP may specify the need for referrals and the need for assistance from the Service Coordinator in obtaining referrals. To the extent that the PCP is part of the PCSP development or PCTP process, the PCSP may also articulate referrals that the Service Coordinator will enter in the appropriate systems. The PCSP must consider both In and Out-of-Network Covered Services to support the individual in the environment of their choice as well as caregivers’ support needs. PCSPs must be completed no more than ...
LTSS Service Plan. A LTSS Service Plan to identify and address how LTSS needs will be met and how services will be provided in accordance with the PCSP. The LTSS Service Plan must include the following: • All LTSS services necessary to support the Participant in living as independently as possible and remaining as engaged in his or her community as possible. • For the needs identified in the Assessment, the interventions to address each need or preference, reasonable long-term and short- term goals, the measurable outcomes to be achieved by the interventions, the anticipated timelines in which to achieve the desired outcomes, and the staff responsible for conducting the interventions and monitoring the outcomes. • Potential problems that can be anticipated, including the risks and how these risks can be minimized to xxxxxx the Participant’s maximum functioning level of well-being. • Participant decisions around self-directed care and whether the Participant is participating in Participant-Direction. • Communications plan. • The scope, amount, duration and frequency that specific services will be provided. • Whether and, if so, how technology and telehealth will be used. • Participant choice of Providers.
