Virtual Service Coordination & Family Assessment: Setting ...
Wellness Coordination: Service Definition and StandardsWellness Coordination: Service Definition and...
Transcript of Wellness Coordination: Service Definition and StandardsWellness Coordination: Service Definition and...
www.IN.gov/fssa Equal Opportunity/Affirmative Action Employer
Eric Holcomb, Governor State of Indiana
Division of Disability and Rehabilitative Services 402 W. WASHINGTON STREET, P.O. BOX 7083
INDIANAPOLIS, IN 46207-7083 1-800-545-7763
Wellness Coordination:
Service Definition and Standards
UPDATED September 27, 2017
The Bureau of Developmental Disabilities Services (BDDS) within the Division of Disability and
Rehabilitative Services (DDRS) developed this document as guidance for providers of Wellness
Coordination Services. The purpose of this document is to clearly outline the service definition,
requirements, and related responsibilities of Wellness Coordination Services.
2
TABLE OF CONTENTS
OVERVIEW OF WELLNESS ____________________________________________________ 3
EXPLANATION OF HEALTH SCORE_____________________________________________ 4
TIER REQUIREMENTS_________________________________________________________ 6
WELLNESS COORDINATION SERVICES_________________________________________ 8
FACE TO FACE VISITS
CONSULTATIONS
WELLNESS ASSESSMENT IN the DDRS data system
DATA COLLECTION
PLAN DEVELOPMENT AND IMPLEMENTATION
TRAINING
ONGOING SUPPORTS
TIMELINES____________________________________________________________________11
DOCUMENTATION STANDARDS________________________________________________ 13
WELLNESS ASSESSMENT REQUIRED INFORMATION 15
3
Section I: Service Definition
OVERVIEW OF WELLNESS
Wellness Coordination Services refers to the development, maintenance and routine monitoring of the
home and community-based service (HCBS) participant’s Wellness Coordination Plan, Risk Plans and
the medical services required to manage his/her health care needs.
Wellness Coordination Services are to be provided by a registered nurse (RN) or a licensed practical
nurse (LPN) under IC 25-23-1-1.2 working under the supervision of an RN.
Wellness Coordination Services extend beyond those services provided through routine doctor/health
care visits required under the Medicaid State Plan and are specifically designed for participants requiring
the assistance of an RN/LPN to properly coordinate their medical needs.
Wellness Coordination Services are for participants assessed with health scores of 5 or higher through
the ICAP process. Participants assessed with health scores of 0-4 would not require assistance of an
RN/LPN to coordinate medical needs.
Participants assessed with health scores of 5 or higher through the State’s objective based allocation
(OBA) process are eligible for Wellness Coordination Services. There are three (3) tiers of Wellness
Coordination Services. Each tier has a different requirement for RN or LPN involvement. The health
scores equate to the following tiers:
4
Section II: The Wellness Plan
EXPLANATION OF HEALTH SCORE
The Inventory for Client and Agency Planning (ICAP) assessment determines an individual’s overall
level of functioning for Broad Independence and General Maladaptive Factors. The ICAP Addendum is
a separate set of questions that determine an individual’s level of functioning of behavior and health
factors.
For health factors, the frequency and intensity of the individual’s health care needs are scored separately
on the ICAP addendum. The frequency and intensity scores are then added together to arrive at the
“total” health score. For example, if the frequency score is 4 and the intensity score is 5, the total health
score is 9. An individual qualifies to receive Wellness Coordination Services based on their total health
score.
WELLNESS ASSESSMENT
The Wellness Coordination service includes:
- The completion of a Wellness Coordination Plan
- documenting significant health history,
- capturing personal history, physician orders,
- updating risk assessments,
- documenting examinations, and evaluations.
Providers may use their own nursing assessment form which must be uploaded into the DDRS data
system. If the provider uses their own nursing assessment form, it must be updated quarterly and must
contain the information listed in Attachment B of this document. The baseline data points described
below are required to be a part of the Wellness Assessment.
PLAN DEVELOPMENT AND IMPLEMENTATION
Wellness Coordination includes the development, oversight and maintenance of a Wellness
Coordination Plan. A Comprehensive Medical Risk Plan may substitute for the Wellness Coordination
Plan or individual risk plans.
The Wellness Coordination Plan must include a description of the individual, identification of
the individual’s needs and risks, the history and current status of the individual, as well as
interventions, monitoring guidelines, documentation guidelines, notification guidelines,
training and education, and health outcomes.
The Wellness Coordination Plan is to be developed within fourteen (14) calendar days of the
finalized Wellness Assessment or uploaded Nursing Assessment. Subsequently, plans are to be
uploaded into the DDRS data system by the provider within five (5) calendar days, as well as
shared with the Individual Support Team.
5
Associated risk plans are then reviewed or created within fourteen (14) calendar days for identified
health and wellness needs. Wellness Providers shall develop Risk Plans (there is no required State
format) that are person centered, approved by or developed by a nurse, and address the specific needs of
an individual in all associated risk areas.
Once the Wellness Coordination Plan is developed, the Wellness Coordinator is expected to
communicate with the individual’s case manager and any applicable Wellness Coordination dietitian,
pharmacist, physician, or specialists to share plan information and/or gather any consultations needed to
garner additional information or details about an individual and his/her healthcare needs.
All developed plans (Wellness Assessment, Wellness Coordination Plan are to be reviewed by the
IST at each quarterly meeting to address whether outcomes are being achieved and are appropriate.
TRAINING
The Wellness Coordination provider is responsible for the appropriate training of Direct Support
Professionals (DSPs) of all HCBS providers to ensure implementation of Risk Plans in a fashion that
recognizes the complexity of the individual’s needs and within an appropriate timeframe, with a
maximum timeframe of 30 days from the start of the service or when the risk plan has been revised. It is
expected that the wellness nurse provide relevant and necessary training on all risk plans. However, the
wellness nurse has the ability to determine the most appropriate means for the training to be supported
(via train the trainer, consultation, direct support, via web teleconference), based on the complexity of an
individual’s needs, and the Direct Support Professionals’ background and level of experiences. The
nurse is not required to personally conduct all of the trainings, but is responsible for determining the
most appropriate training plan/approach to be used, and documentation must reflect that the nurse
determined the most appropriate training approach and the individual’s medical needs were considered
in this decision.
6
Section III: Service Provision
TIER REQUIREMENTS (activities must occur weekly, regardless of the number of weeks in a month)
Health Score Range 5-6
Tier I: Health care needs require at least one weekly (Sunday - Saturday) consultation by RN or LPN.
Specifically tailored to address the identified person-centered needs outlined within the Wellness
Coordination Plan and ISP. This consultation includes face to face visits once a month. One of the face
to face visits per month may count as a consultation. One of the consultations may be a comprehensive
review of the individual’s records, charts and supporting health and wellness information. Consultations
include, but are not limited to, discussions with physicians, specialists, other health care providers, direct
support staff, and program staff. Face to face visits should be conducted in a private location that
respects the member’s privacy and dignity, and shall address specific individualized goals/needs as
outlined in the Wellness Coordination plan.
Combinations of services may include:
Three (3) consultations and one (1) face to face visit each month for months with four (4) weeks
*EXAMPLE combination of activities
Week 1 Consult with physician (via phone)
Week 2 Face to face visit with the individual receiving Wellness
Week 3 Consult with specialist
Week 4 Consult with direct support staff
Three consultations (one being a comprehensive record/chart review) and one face to face visit
each month for months with four (4) weeks
*EXAMPLE combination of activities
Week 1 Consult with physician (via phone)
Week 2 Face to face visit with the individual receiving Wellness
Week 3 Consult via individual’s chart review
Week 4 Consult with direct support staff
Four (4) consultations (one being a comprehensive record/chart review) and one (1) face to face
visit each month for months with five (5) weeks.
*EXAMPLE combination of activities
Week 1 Consult via individual’s chart review
Week 2 Consult with physician (via phone)
Week 3 Face to face visit with the individual receiving Wellness
Week 4 Consult with physician (via phone)
Week 5 Consult with direct support staff
7
Health Score Range 7-9
Tier II: Health care needs require at least one weekly (Sunday - Saturday) consultation by RN or LPN.
This consultation/review includes face to face visits at least twice monthly. One of the face to face visits
per month can count as a consultation. One of the consultations may be a comprehensive review of the
individual’s records, charts and supporting health and wellness information. Consultations include, but
are not limited to, discussions with physicians, specialists, other health care providers, direct support
staff, and program staff.
Combinations of services may include:
Three (3) consultations and two (2) face to face visits each month for months with four (4) weeks
*EXAMPLE combination of activities
Week 1 Consult with physician (via phone)
Week 2 Face to face visit with the individual receiving Wellness
Week 3 Consult with specialist and face to face visit with the individual receiving
Wellness
Week 4 Consult with direct support staff
Three (3) consultations (one being a comprehensive record/chart review) and two (2) face to face
visits each month for months with four (4) weeks
*EXAMPLE combination of activities
Week 1 Face to face visit with the individual receiving Wellness and consultation
with direct support staff
Week 2 Face to face visit with the individual receiving Wellness
Week 3 Comprehensive record/chart review
Week 4 Consult with direct support staff
Four (4) consultations (one being a comprehensive record/chart review) and two (2) face to face
visits each month for months with five (5) weeks.
*EXAMPLE combination of activities
Week 1 Consult via individual’s chart review
Week 2 Consult with physician (via phone)
Week 3 Face to face visit with the individual receiving Wellness
Week 4 Consult with physician (via phone) and face to face visit with the
individual receiving Wellness
Week 5 Consult with direct support staff
Health Score Range 10
Tier III: Health care needs require at least twice weekly (Sunday - Saturday) consultation by RN or
LPN. This consultation/review includes face to face visits once a week, regardless of the number of
weeks within the month. One of the weekly face to face visits can count as a consultation. One of the
consultations may be a comprehensive review of the individual’s records, charts and supporting health
and wellness information. Consultations include, but are not limited to, discussions with physicians,
specialists, other health care providers, direct support staff, and program staff.
8
Combinations of services may include:
Two (2) consultations and one (1) face to face visit per week.
*EXAMPLE combination of activities
Week 1 Face to face visit with the individual receiving Wellness, consultation with
direct support staff, and consultation with pharmacy (via phone)
Week 2 Face to face visit with the individual receiving Wellness, consultation with
direct support staff, and consultation with physician (via phone)
Week 3 Face to face visit with the individual receiving Wellness, consultation with
physician (via phone), and consultation with specialist (via phone)
Week 4 Consult with direct support staff, comprehensive record review, and face to
face visit with the individual receiving Wellness
Two (2) consultations (one being a comprehensive record/chart review), and one (1) face to face
per week.
*EXAMPLE combination of activities
Week 1 Face to face visit with the individual receiving Wellness, consultation with
direct support staff, and comprehensive record/chart review
Week 2 Face to face visit with the individual receiving Wellness, consultation with
direct support staff, and record/chart review
Week 3 Face to face visit with the individual receiving Wellness, consultation with
physician (via phone), and record/chart review
Week 4 Consult with IST, comprehensive record review, and face to face visit with
the individual receiving Wellness
*Examples shown above demonstrate sample combinations of activities under Wellness. Supporting
documentation of the service should reflect more detail and individualization than these examples
provide.
As medical events occur or a participant’s medical needs change, the Individualized Support Team (IST)
is expected to have the individual’s health score reassessed and to ensure the appropriateness of services.
If a team believes that an individual’s health score is incorrect they should coordinate with the entire
team to submit a Budget Review Questionnaire (BRQ) to BDDS requesting a review of the individual’s
Algo Score. The case manager will submit the BRQ based on the team’s agreement and commendation.
WELLNESS COORDINATION SERVICES
Consultations and face to face visits are direct services. A face to face visit requires the nurse to meet
one on one with the individual (group visits are not allowable). Consultations with professionals or the
IST may take place in person or through other communications. It should be noted that consultations and
face to face visits are allowed while an individual is hospitalized for a short period of time. In the event
of short term (30 days or less) inpatient stays, face to face visits with participants are allowable on date
of admission and date of discharge as well as any dates the participant is not in an institutional setting.
Consultations with professionals or the IST during member inpatient stays can be utilized in lieu of the
9
face to face requirement for a given month and based on their assigned Wellness Coordination Tier
activities.
An individual hospitalized for the entire month could not have Wellness provided for that month.
FACE TO FACE VISITS
In implementing Wellness Coordination, face to face meetings are to occur per the tier requirements
directly with the individual when discussing their diagnosis, prognosis, and treatments (as well as
discussing weight, BMI and other measures) and must be documented in the individual’s records to
count as the face to face consultation with the individual. Face to face meetings must take place
individually with the participant, not in group settings with other individuals receiving the same service
from the Wellness provider. Appropriate HIPAA and privacy practices must be followed in the delivery
of this service.
Face to face meetings may also occur in a home or community based setting where the individual
commonly spends time. It is expected the nursing visits involving observations and assessments of the
individual will take place in the natural environment of the individual to accurately establish and
document how their environment is affecting their wellness.
CONSULTATIONS
Ongoing consultations should take place with the individual’s health care providers and the IST. A
consultation is defined as a conversation of two or more individuals to discuss the diagnosis, prognosis,
and treatment of a particular case. While consultations can take place in person or by other means of
communication, documentation must clearly show a collaborative discussion has taken place. One of the
face to face visits per month that takes place with the nurse can also count as a consultation with the
individual. The nurse and the team may decide on an individual basis who the consultations will
include.
Examples of consultations include:
Discussion with health care professionals about the individual’s health status
Discussion with Direct Support Professionals (DSP) in regards to the individuals health
status
Updating the IST during team meetings
Chart reviews, entry of medical appointments, scheduling, etc. are considered as standards of
documentation of health care services and are not considered as a consultation.
DATA COLLECTION
Regardless of their identified Wellness tier, individuals’ vitals must be collected and recorded on a
quarterly basis on the Wellness Assessment. The six (6) baseline data points to be recorded are:
Height
Weight
Body Mass Index (BMI)
10
Annual flu vaccination date
Annual physical date
Annual dental visit date
ONGOING SUPPORTS
Ongoing Wellness Coordination includes:
- face to face visits (per tier requirements),
- ongoing consultations with the individual’s health care providers and the IST,
- reviewing and updating the wellness or risk plan quarterly or when an individual’s status changes,
- attending team meetings or reporting on Wellness Coordination for team meetings, and
- coordinating and monitoring of the HCBS participant’s wellness or risk plan and the medical
services required to manage his/her health care needs.
The Wellness Coordinator ensures the IST members work closely together to meet the individual’s
health and wellness needs. All related plans are to be reviewed by the support team at the quarterly
meeting to address whether outcomes are being achieved and are appropriate.
In addition, the Wellness Assessment (or provider’s Nursing Assessment) may serve as the quarterly
report and must be reviewed and/or updated and finalized each quarter at least five (5) calendar days
prior to the individual’s quarterly meeting in order for the IST to be able to review the most recent data
available. The Wellness Assessment can then be printed for review at the quarterly meeting. If a
quarterly meeting is missed/unscheduled, an updated assessment must still be finalized in the same
quarter of the missed quarterly meeting.
All plans should be reviewed and revised by the nurse as needed, but at least annually, when there is a
new diagnosis, hospitalization or change in status. The plans should then be submitted to the team for
review and implementation.
11
Attachment A: Wellness Provision and Associated Timelines
TIMELINES
The following table reflects the components of Wellness Coordination in regards to the
timelines, frequency, documentation standards, and documentation upload requirements.
Component Timeline Documentation Standard
Wellness Coordination added
to an individual’s Cost
Comparison Budget (CCB)
and a Notice of Action (NOA)
is issued to the provider.
Provider has two (2) business
days from receipt of the NOA
to contact the HCBS
participant and schedule an
initial appointment.
Documentation supporting the
service as outlined in this
guidance document must be
retained by the provider in the
individual’s records. The
provider must also upload
documentation into the DDRS
data system.
Initial meeting Within seven (7) business days
of beginning the service, the
provider meets with the
individual and his or her
guardian, if applicable, to
identify medications, health
care needs, doctor
appointments, and any other
relevant information needed to
develop the HCBS
participant’s plan.
Documentation is completed
in person. Providers may use
their own assessment form
when completing the
assessment but all BDDS
required information is to be
included.
Documentation must be
retained by the provider in the
individual’s records. Provider
must also upload the
documentation into the
DDRS data system.
Initial Wellness Assessment Completed and uploaded
within forty five (45)
calendar days of beginning
service.
Uploaded to the DDRS data
system by the provider staff;
the finalized assessment
serves as the quarterly report.
12
Quarterly Wellness
Assessment
Data may be carried forward
from the most recent
assessment. The assessment is
reviewed and updated
quarterly, and finalized at
least five (5) calendar days
prior to quarterly team
meeting. (*see page 9)
Uploaded to the DDRS
data system by the
provider; the assessment
may serve as the
quarterly report.
Wellness Coordination Plan Created within fourteen
(14) calendar days of initial
finalized Wellness
Assessment and updated
annually. The plan must
also be reviewed during
quarterly meetings and
updated as needed.
Wellness Coordination Plan
is to be uploaded into the
DDRS data system “Provider
Documents Area” by the
provider within five (5)
calendar days of initial
completion and whenever
updated.
Trainings The Wellness Coordination
provider is responsible for the
training of all HCBS providers
to ensure implementation of the
Risk Plans. The wellness nurse
is responsible for determining
and documenting the most
appropriate means for the
training to be supported (via
train the trainer, consultation,
direct support, via web
teleconference), based on the
complexity of an individual’s
needs, and the Direct Support
Professionals’ background and
level of experiences.
Retained by the provider in
the individual’s records.
Provider may choose to
upload into the DDRS data
system.
Visit logs, consultations,
nursing notes, other
documentation related to
Wellness Coordination as
outlined in 460 IAC 6-25-1
Retained by the provider in
the individual’s records.
Provider may choose to
upload into the DDRS data
system.
13
DOCUMENTATION STANDARDS
Wellness Coordination Services documentation shall include the professional standards applicable to the
professional licensing requirements (registered nurse (RN) or a licensed practical nurse (LPN) under IC
25-23-1-1.2 working under the supervision of an RN) and the individual’s Individualized Support Plan
(ISP) as outlined in Policy Number: BDDS 460 1216 038 Policy: Maintenance of Records of Services
Provided.
Documentation standards include:
Documentation of face to face visits (per tier requirements);
Documentation of weekly consultations/reviews (per tier requirements);
o Other activities, as appropriate (outlined in 460 IAC 6-25-3 Documentation of health
care services received by an individual):
o The date of health and medical services provided to the individual.
o A description of the health care or medical services provided to the individual.
o The signature of the person providing the health care or medical service for each date a
service is provided.
o Additional information and documentation is required in this standard, including
documentation of the following:
An organized system for medication administration.
An individual's refusal to take medication.
Monitoring of medication side effects.
Seizure tracking.
Changes in an individual's status.
An organized system of health-related incident management.
If applicable to this provider, an investigation of the death of an individual.
Services must address needs identified in the person centered planning process and be outlined in
the ISP;
The Wellness Coordination provider will provide a report to IST members at least quarterly.
o The Wellness Assessment must be reviewed and finalized quarterly, serving as the
quarterly report. There is no need for a separate written report to be submitted by
providers
Providers may choose to upload documentation into the DDRS data system that is not captured in other
documentation. All providers are responsible for maintaining documentation in the office and home
files.
Service notes should include the date, time, and summary of services delivered. For instance, if a
consultation occurred, the note should state the date it took place, the length of time, participants
involved, and a summary of the discussion.
14
Attachment B: Required Components of Initial and Quarterly Wellness Assessments
Wellness Assessment - Required Information Demographic
Last Name
First Name
Date of Birth
Medicaid Recipient ID
Vital Signs
Vitals Date taken
Temp
Pulse
Respirations
Blood Pressure
Height
Weight
BMI
Allergies Allergy
Reaction
Diagnosis Diagnosis
Date of Diagnosis
Significant Health History
Health History Infection/Center
Description
Date
Treatment
Hospitalization Date From
Date To
Where
Why
Outcome
Family History Health Issue
Pain/Illness Indication How Pain Indicated
How Illness Indicated
Personal History
Personal History Exercise
Sleep Pattern
Sexual Activity Past
Sexual Activity Present
Risks Risk
Past
15
Frequency/Quantity
Present
Frequency/Quantity
Lab Results Lab/Test
Date
Results
Physician Orders
Adaptive Supports Adaptive Support
Response
Sides
Nutrition/Hydration Nutrition/Hydration
Description
Dining/Dysphagia Dining Option
Input
Additional Dining/Dysphagia Dining Option
Risk Assessments
Skin Risk Info Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction
RMT (Risk management Tool) Medical/Health: Following conditions exist...
Fall Risk Risk Factor/Scale
Health and Systems Review
Examinations/Evaluations/Assessments Health Review
Date
Results
System Review System Review
Results
Remarkable Physical Findings System Review
Area
Left/Right
Findings
Description
Document Review Document Review
Date
Description
Final Review Positive/Negative Trends
Referrals or Appointments