FIDA Online Training Module3

Copyright 2014 ValueOptions.® All rights reserved.

Interdisciplinary Care

Team (IDT)

1


Learning Objectives

2

1:

2:

3:

4

Understand Person-Centered Service Plan (PCSP)

Describe Health Assessments in IDT Context

Outline Interdisciplinary Team (IDT) Purpose & Roles

3:

4:


Interdisciplinary Team (IDT): Composition

3

Definition:

• Professionals from different medical and behavioral health

disciplines working toward a common goal and responsibility

of the group effort

Must include:

• Participant

• Behavioral Health Professional

• Primary Care Provider (PCP) or clinical designee from practice

• Primary Care Manager – IDT Lead

Can Include:

• Participant’s designee (i.e., caregiver, family)

• Home Care Aide(s)

• Nursing Facility Representative

• Other Providers


Interdisciplinary Team (IDT): Roles

4

The IDT is led by an assigned Care Manager at

the FIDA Plan

Under the FIDA Program, the IDT:

• Writes, monitors and participates in a person-centered health service plan (PCSP)

• Contributes to ongoing care management activities

• Authorizes FIDA covered health services

• Reviews participant health care plan at least every six

(6) months or whenever a significant change occurs


Interdisciplinary Team (IDT): Roles cont’d.

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Highly encouraged to work collaboratively

• The goal is for consensus with treatment decisions while

keeping participant’s specific needs and preferences in

consideration

If conflict with Treatment Decision(s):

• For care decisions requiring a provider with a specific

licensure and / or certification, decision always rests with

appropriately licensed and / or certified treating

member(s) of the IDT


IDT: Role of Participating Provider

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As a ValueOptions provider, you play an integral role for the FIDA plan

in that you provide the expertise to assess, evaluate, and provide

services related to mental health and / or substance abuse deemed

necessary to meet the requirements set forth by the Interdisciplinary

Care Team’s (IDT) Person-Centered Service Plan (PCSP).

• To support the PCSP, the following must be made available

to all IDT members, including, but not limited to:

Documentation of all care and services rendered to the

Participant

Current and past assessments, reassessments and any file

notes that include the Participant’s response to treatment

Medication records

A signed release permitting disclosure of personal information

http://www.valueoptions.com/providers/Forms/Administrative/Coordination_of_Care_Authorization_Form.pdf


FIDA Model of Care: Overview

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RN-assessor conducts initial assessment

IDT meets/ develops the PCSP/authorizes services

PCM coordinates

authorized services

Services

Reassessment


IDT: Initial Comprehensive Health Assessment

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Comprehensive Assessment

New York State Uniform Assessment System (UAS-

NY)

• The UAS-NY uses 22 items and sub-items from the

UAS-NY community assessment including:

Cognition and communication

Mood and behavior

Functional status (activities of daily living

performance)

Nutritional status


IDT: Review of Assessments

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After each participant assessment:

• The IDT meets (within 30 days) to review results,

authorize needed services and coordinate health

care for participant

Primary Care Manager (PCM) facilitates meetings

of the IDT and discussion of person-centered

service plan (PCSP)

PCM sends PCSP to IDT members for signatures

after each meeting

PCM sends participant hard copy of PCSP signed

by all IDT members


IDT: Comprehensive Health Assessment

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Reassessment:

Every 6 months - or -

When change in health status:

• Within 48-hr period prior to transition or

• Within 30-day period after discharge

Following the reassessment, the IDT meets to make necessary

updates to the PCSP.

PCSP meeting should be attended by the participant and all

IDT members.


Person-Centered Service Plan (PCSP)

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Personal Health Care Service Plan document:

• Prepared during IDT meeting no later than 30-days of

assessment

• Reviewed and / or amended within 30-days of

comprehensive reassessment

Components of the PCSP:

• Results of health risk assessment(s)

• Goals, interventions, health services, benefits and

preferences for care

Identifies:

• Personalized medical, behavioral and mental health needs

• Cultural, linguistic, special needs services, and other health

needs and goals


IDT: Purpose of PCSP

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Identifies who is responsible for implementation of

each portion of care plan

Determines clear communication for IDT members

for six(6) month duration of plan

Informs / offers health service alternatives such as:

• Home

• Institutional

• Community-based services

Discusses related obligations


IDT: Purpose of PCSP cont’d

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Evaluates effectiveness of current plan of care

and reevaluates or modifies as needed

Discusses problems, concerns or interventions

raised at last care planning

Determines care or service(s) for the six(6) month

care-plan duration

• Amount of time services are authorized

• Integration of technology into care plan


The IDT must:

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Educate, empower and facilitate the Participant to make choices

within the parameters of the FIDA Demonstration and to exercise

his or her rights and responsibilities, including the opportunity to

participate in Consumer Directed Personal Assistance Services;

Involve the Participant as an active team member, including

providing information and explanations using plain language

understandable to the Participant and/or caregiver, and stress

Participant-centered collaborative goal setting;

Arrange the supports necessary for the Participant to keep doing

things he or she enjoys, to follow through on prescribed treatments,

and to remain physically active;

Establish a set of guidelines or care responsibilities for the entire

team and distribute these to Participant;

Provide education to the Participants and families regarding

health and social needs;


The IDT must (cont’d):

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Identify the Participant’s informal support systems/networks in

relationship to his or her functional and safety needs;

Assess and assist the Participant in identifying and addressing

quality of life issues;

Deliver coordination with care providers across settings;

Assist the Participant in accessing reasonable accommodation

and accessible providers;

Offer information about and assist Participant in maintaining and

establishing community links;

Supply information about services available through the Area

Agency on Aging to adults age 60 and older;

Provide information about and assist Participant with housing and

transportation issues; and

Support the Participant and/or designated representative in

understanding the disease process, chronic illness, and/or disability

and realizing his/her role as the daily self-manager.


Resources

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Provider Connect

Provider Handbook

FIDA Training

Provider Webinar Calendar

New York State Department of Health

For additional information regarding the FIDA

Plan, please contact ValueOptions at:

[email protected]

*For a list of references, please send requests to: [email protected]

http://www.valueoptions.com/providers/Providers.htm

http://www.valueoptions.com/providers/Handbook.htm

http://www.valueoptions.com/providers/Network/Fully-Integrated-Duals-Advantage-FIDA.htm

http://www.valueoptions.com/providers/Webinars.htm

https://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm

mailto:[email protected]

mailto:[email protected]

FIDA Online Training Module3

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Transcript of FIDA Online Training Module3