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Providing Health Care for People with Disabilities: Competency Planning Checklists

Care Management/Care Coordination

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Care Management / Care Coordination

(Adapted and excerpted from Disability-Competent Care Self-Assessment Tool***)		 Yes No Unsure Comments and follow up
S.1. The interdisciplinary care team (IDT) develops an individualized, respectful, professional relationship with participants, honoring their preferences, goals, values, and their decisions including the right to take risks. [See below definition of dignity of risk]        
S.2. We check with participants to see it they have an existing participant plan of care (IPC) care plan that they would be willing to share with the IDT.        
S.3. The IDT coordinates with care managers involved with individuals outside of their health plan (such as independent living centers, Area Agencies on Aging) to ensure services are integrated and coordinated.        
S.4. If a participant’s decision is inconsistent with the IDT’s recommendation, their choice should be respected while the IDT continues to educate and advocate for recommended options.        
S.5. We ensure that participants can designate a family member or other person to be involved in IDT-related communications including program planning and implementation.        
S.5.a.

  • We document this in the individual plan of care (IPC) and communicate this to all IDT members.

        
S.5.b.

  • This designated person can include a guardian, conservator and other designated lead.

        
S.6.

When participants have difficulty identifying or asserting their preferences, IDT members 

consistently seek their perspective and preferences.

        
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Care Management / Care Coordination

(Adapted and excerpted from Disability-Competent Care Self-Assessment Tool***)		 Yes No Unsure Comments and follow up
S.7. The IDT or a designated team member is able to meet, either in person or virtually, within 24 to 48 hours if the participant’s needs or situation changes?        
S.7.a.

  • The need for timeliness will vary depending on the urgency of the situation, so IDT members maintain flexibility in their daily schedules to be able to address emerging concerns.

        
S.7.b. The assessment, IPC and current notes are available to anyone providing afterhours coverage.        
S.7.c. We upload key information to real-time systems and access real-time hospitalization or care reports from other providers.        
S.8. Comprehensive and Multidimensional Assessment        
S.8.1. The initial assessment is comprehensive and multidimensional, incorporating all aspects of the participant’s life. Areas to cover include, but are not limited to:        
S.8.1.a.

  • Participant’s strengths, goals, and priorities

        
S.8.1.b.

  • Demographic, contact, financial, and eligibility information

        
S.8.1.c.

  • Social activities

        
S.8.1.d.

  • Functional assessment (activities of daily living [ADL], instrumental activities of daily living [IADL], or copy of assessment   participant provides that was completed already (ASK!)

        
S.8.1.e.

  • Medical diagnoses and history

        
S.8.1.f.

  • Behavioral health screening (s).

        
S.8.1.g

  • Nutrition (food access, preparation, diet, etc.)

        
S.8.1.h.

  • Document all health-related services (including behavioral management, exercises, medications, equipment use, skilled therapies, rehabilitation therapies) and all current providers

        
S.8.1.i.

  • Long-term services and supports (LTSS)

        
S.8.1.j.

  • Home and community environment, safety, accessibility, and health risks

        
S.8.1.k.

  • Formal, informal, and social supports

        
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Care Management / Care Coordination

(Adapted and excerpted from Disability-Competent Care Self-Assessment Tool***)		 Yes No Unsure  
S.8.2. The assessment identifies additional expertise needed for the participant’s care. The Interdisciplinary Team (IDT) incorporates the expertise of other clinicians or care providers as needed, including rehabilitation therapists, behavioral health providers, dieticians, peers, LTSS providers, or specialists (such as palliative care practitioners)., either on an ongoing or consulting basis.        
S.8.3. We identify participants’ transportation needs as part of the initial assessment.        
S.8.3.a.

  • We identify participants’ transportation needs as part of the initial assessment.

        
S.8.3.b.

  • Transportation services are available 24/7 to meet urgent needs.

        
S.8.3.c.

  • Policies regarding transportation assistance to health care appointments are cleaS.

        
S.8.3.d.

  • Participants are given information regarding how to provide feedback to the CCO on transportation concerns.

        
S.8.3.e.

  • IDT advocates when issues that arise to ensure safe, dependable, and accessible service.

        

Definitions

Dignity of risk - the right of participants to choose to take some risk in engaging in life experiences, even if that choice is not one recommended by a health professional (e.g., choosing to smoke).

*** Disability Competent Care Self-Assessment Tool : CMS Medicaid-Medicare Coordination Office Resources for Integrated Care Webpage https://www.resourcesforintegratedcare.com/node/101 (more in RESOURCES section)

Source: Providing Health Care for People with Disabilities: Competency Planning Checklists by June Isaacson Kailes - published 10/01/2016

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