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3. Function Portal Sessions Manual

Function Portal Sessions are used to document work completed. Coordinators should be documenting their work as it is done to prevent falling behind on documentation. All calls, visits, and other work done MUST be done in order for it to be verified.

Function Portal Sessions will tell you what is required for each and what other work must be done to complete it. Use the appropriate session type and follow its prompt to complete documentation. 


Introduction

How to create and submit sessions

  1. While in the page of the specific participant you need to document for, select the “Session” tab.
  1. Select the pink circle with the “+” in the bottom right hand corner.
    • This will bring up the “Add Session” box

  1. Select “Session Type” to open the dropdown list of sessions
  1. Select the type of session you’ve conducted.

Regardless of the type of session selected, the session cannot be fully submitted without the following:

  1. Valid Time Range – The start and end time of the session
  2. Answers to all required fields – each session has its own required fields
  3. Required attached documents* – PDF file of the document completed.
    • Not all sessions require attached documents. It will tell you if this is a requirement

Once all the necessary information is documented, the blue button on the bottom right corner of the “Add Session” box will change from ‘Save Draft’ to ‘Add Session

  1. After selecting ‘Add Session’ you will get a summary of the session.
    • The summary will tell you whether or not the session must be copied to Envolve as a general note. 
Example of a session that MUST be copied as a General Note in Envolve

Example of session that does not need to be copied to Envolve

Regular Sessions

Session NameDescription of session
7 and 14 day Follow upUsed to document follow-up calls with participants to ensure services are in place per the service plan from the NPO visit.
– DO NOT USE for non-NPO Participants
COVID-19 QuestionnaireUsed to document/upload COVID-19 Questionnaires prior to F2F visits.
Documentation UploadUsed for uploading miscellaneous documents.
HEDIS Supplement AssessmentUsed to calculate participant’s self efficacy and loneliness during Comprehensive Needs Assessments
Incident ReportUsed for documenting Critical Incidents and uploading Internal Incident Reports A & B
Incoming Call ReceivedUsed to document any calls received.
Monthly ContactUsed to document successful Monthly Contacts
Office NoteUsed to document any work that does not apply to the other possible sessions.
OPS 8 Outbound CallUsed to document confirmation about missed PAS visits from PHW OPS 8 Report
Outbound CallUsed to document any calls made
RN Health ConsultationUsed to document conversation had with Nurse Irene when discussing participant’s change in PAS hours.
Unsuccessful OutreachUsed to document unsuccessful outreaches to the participant
Welcome CallUsed to document the welcome call made to the participant before an NPO visit
– DO NOT USE for non-NPO Participants

Documenting Regular Sessions

7 and 14 day Follow up

A follow-up call with participants to ensure services are in place per the service plan from the NPO visit. 

DO NOT USE this session for non-NPO PARTICIPANTS

Coordinators MUST follow up 7 days after the NPO visit and complete a 7 day follow up FP session and MCA

If services have not started at the 7 day follow up, then SCs must also follow up 14 days after the NPO visit to confirm if their services have started or not (again), then continue to follow up with Outbound calls until services start. 

Example of completed 7-14 day follow up
  • Session requires:
    • “7 or 14 day Follow Up” MCA
    • FP Session comment describing the follow up
    • General note to Envolve

Process:

Complete the MCA

  • Coordinator must complete MCA in Envolve with “7 or 14 day Follow Up” as Type of Contact
    • Save as a PDF for Function Portal
    • Submit in Envolve

FP Session Comment – SC should describe the following in the FP Comment

  • Who was contacted for follow up?
  • HIPPA verification – State what was verified (name, DOB, address, phone#)
  • What services were requested in NPO visit; according to the participant, have services started or not
  • Are there authorizations for services on Envolve/Authorization spreadsheet?
  • How will SC follow up

General note to Envolve

  • After selecting “Add session” a summary of the session will come up. Copy the session and paste it into a “General Note” in Envolve

COVID-19 Questionnaire

A review of COVID-19 symptoms and exposure to ensure safety before completing F2F visits with participants

This is completed before F2F Comprehensive Needs Assessment visits to ensure participant and SC’s safety regarding COVID-19.

  • Session Requires:
    • Complete the Function Portal questions
    • “Unscheduled Contact” MCA
    • PHW Screening PDF
    • Staff Screening PDF
    • General Note to Envolve

Process:

Completing the Function Portal questions

  1. COVID-19
  • Does the participant have any of the following symptoms?
    • Fever
    • Cough
    • Shortness of breath
    • Sore Throat
    • Nausea
    • Vomiting
    • Diarrhea
    • Abdominal Pain
  • Has the participant experienced any of the above in the last 14 days? 
  • Has the participant or family of the household traveled outside of North America in the last 14 days?
  • Has the participant had contact or possible exposure to COVID in the last 14 days?
  • Is the participant on home quarantine or isolation due to possible exposure?
  • Has the participant or anyone in their home been discharged from the hospital due to COVID?
  • Is there a back up plan in case any services are temporarily on hold due to COVID?
    • If so, describe the backup plan
    • If no, has the participant agreed with developing a backup plan?
      • If so, describe the new backup plan

Complete the MCA

  • Coordinator must complete an MCA in Envolve with “Unscheduled Contact” as Type of Contact

Complete the PHW and Staff Screening Tools

  • SC must complete both PHW and Staff Screening PDFs and attach it to the session. 

General Note to Envolve

  • After selecting “Add session” a summary of the session will come up. Copy the session and paste it into a “General Note” in Envolve

Documentation Upload

A session for uploading miscellaneous documents if they could not be uploaded with a more appropriate session. This is primarily used to upload a 1768 form. 

  • Session Requires:
    • Uploaded document(s)
    • Comment describing the uploaded document
    • General note to Envolve

Process:

Uploading the document

  • Select “Choose File” under the heading of the type of document you are uploading

FP Session Comment – SC should describe what document is being uploaded, why it is being uploaded, and what is being done with said document.

General note to Envolve

  • After selecting “Add session” a summary of the session will come up. Copy the session and paste it into a “General Note” in Envolve

HEDIS Supplement Assessment

An assessment to review the participant’s self efficacy and loneliness in their day to day life.

  • Session requires
    • Appropriate answer to all required questions

Process

  1. Self-Efficacy Scale

This section MUST be answered by the participant, NOT the POA, legal rep, or responsible party.

  • Is the participant cognitively intact and able to provide efficacy information?
    • If the participant is cognitively able to provide answers, select “Participant is cognitively intact and able to provide efficacy information”
    • If the participant is is too cognitively impaired to answer these questions, select “There is documentation to support that the participant is too cognitively impaired

The following questions of this section must be answered by the participant. Have them give an answer from 1-10
“1” represents “not at all confident” and “10” represents “totally confident”

  • How confident do you feel that you can keep the fatigue caused by your disease from interfering with the things you want to do?
  • How confident do you feel that you can keep the physical discomfort or pain of your disease from interfering with the things you want to do?
  • How confident do you feel that you can keep any other symptoms or health problems you have from interfering with the things you want to do?
  • How confident do you feel that you can keep the emotional distress caused by your disease from interfering with the things you want to do?
  • How confident do you feel that you can do the different tasks and activities needed to manage your health condition so as to reduce your need to see a doctor?
  • How confident do you feel that you can do things other than just taking medication to reduce how much your illness affects your everyday life?

After answering all questions an average efficacy score will be generated

  1. Loneliness Scale

This section MUST be answered by the participant, NOT the POA, legal rep, or responsible party.

  • Is the participant cognitively intact and able to provide efficacy information?
    • If the participant is cognitively able to provide answers, select “Participant is cognitively intact and able to provide efficacy information”
    • If the participant is is too cognitively impaired to answer these questions, select “There is documentation to support that the participant is too cognitively impaired
  • During the past month, the participant has often been bothered by feeling lonely?
    • If the participant has often felt lonely, they will need to answer the remaining questions
    • If the participant has NOT often felt lonely then they will not need to answer the remaining questions
  • How often do you feel that you lack companionship?
  • How often do you feel left out?
  • How often do you feel isolated from others?

After answering all questions the sum of responses will be generated

  1. PT/OT

This section may be answered by the Participant, POA, legal rep, or responsible party

  • Does the participant need Physical Therapy or Occupational therapy?
    • If the participant states they need PT or OT, you will need to answer Is the participant receiving PT/OT?
  • What home health services does the participant receive?
    • Select the services that the participant receives
      • Home Health Aid – this is NOT PAS (it is typically paid by Medicare)
      • Nurse Visit – Wound care nurse, RN, LPN
      • Other – includes Medicaid services such as: PAS, PERS, HDM, NMT

Incident Report

A session for uploading Incident Reports when SC is notified of a critical incident or when they are closing an Incident. 

  • Session Requires:
    • Uploading Incident Report Part A and Part B (if applicable)
    • Comment describing the Incident
    • General Note to Envolve

It is important that you upload a copy of the Incident Report, NOT the certificate.

Process:

Uploading Incident Report Part A & B

  • SC must complete Incident Report Part A in Docusign (which they receive by request from their SCS), download the filled out report and attach it to the Incident Report Session. 
    1. That way the report can be viewed in FP in the future. 
  • This must be done when completing Incident Reports A and B, together or separately 

Comment describing the Incident

  • SC should be putting in all information from Incident Report into the comment of the session. 

General note to Envolve

  • After selecting “Add session” a summary of the session will come up. Copy the session and paste it into a “General Note” in Envolve

Incoming Call Received

Used to document incoming unscheduled calls. You should discuss the following and document details of the call appropriately.

Note: This session cannot be submitted if the participant has Inactive Eligibility. Document the call as “Office note” or “Other”

  • Session Requires:
    • Appropriate answers to all required questions

Process

  1. Call Conditions
  • Visit Type – How are you contacting the participant?
    • Answer should always be Telephone
  • Was the Legal Representative invited to participate? – Did you or the participant try to involve the participant’s Legally Authorized Representative, if there is one at all?
    • Answer is based on if your participant has a rep and invited them or not
    • Based on you answer you may need to answer the following:
      1. Did the Legal Representative participate in the contact?
      2. Did the member request that the legal representative not participate?
  • Where did the visit take place? – Better known as “where did the contact take place?
    • Answer should always be Other
      • Then in Other visit location you should put Telephone
  • Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
    • If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
      • Caregiver name
      • Caregiver relationship 
      • Does the caregiver live with member? Answer should be – Yes
      • Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
      • Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
    • If the answer was “Other” then the coordinator needs to state what the Other residential location is
    • If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  • Information provided by** – Meaning who did the coordinator speak with during the call. This is also how you may document the call.
    • If information was provided by Enrollee, Authorized Representative, or both, details of the call will be documented under Contact follow-up description in 2) Resolution. 
    • If information was provided by Other or Enrollee and Other, details of the call should be documented in Information provided by other
  • Has the participant expressed the desire to move from an institutional setting to the community? – participants have to be currently residing in an institution, which most of our clients do not.
    • Answer is most likely – Participant has NOT expressed desire…
    • If the answer was “Participant has expressed desire …” the coordinator needs to state the current transition status
  • Did the participant’s demographics change?  – Has any of the information about the participant changed?
    • If there was a change, then the coordinator must state what the changes are. 
  1. Resolution
  • Is follow-up required for the contact?
    • Answer should always be – A follow-up is required
  • Do you need to schedule a visit?
    • If the participant’s visit is already scheduled, or they are NOT due for a visit, then the coordinator should select Do NOT need to schedule a visit. This will prompt Contact follow-up description
      • Contact follow-up description – detail the conversation had with the participant and/or legally authorized representative. 
    • If the participant is due for a visit and you schedule it with them in this call then you need to say Need to schedule a visit and this will prompt follow-up questions on the scheduled visit. 
      • Scheduled Visit – select the type of visit that was scheduled

If the type of visit scheduled is not listed, the coordinator should choose a visit, put in the date and time it is scheduled, but do NOT answer the compliance question.  SAVE the session DRAFT and notify the AVP so that they can put in the correct visit type. 

  • Visit scheduled for – date and time the visit is scheduled for
  • Is the scheduled visit after the compliance due date? – Is the date the visit is scheduled for before the due date?
    1. If the visit is scheduled after the compliance date, this will prompt the last 2 questions to generate
      1. Who were you trying to contact? – Who did you contact/schedule the visit with?
      2. Reason for contact – the type of visit that was scheduled. 

Monthly Contacts

A required Monthly phone call to the participant to maintain communication and update client information. You must discuss the following with the participant.

Note: This session cannot be submitted if the participant has Inactive Eligibility. Document the call as “Office note” or “Other”

  • Session Requires:
    • Appropriate answers to all required questions

Process

  1. Visit Conditions
  • Visit Type – How are you contacting the participant?
    • Answer should always be Telephone
  • Was the Legal Representative invited to participate? – Did you or the participant try to involve the participant’s Legally Authorized Representative, if there is one at all?
    • Answer is based on if your participant has a rep and invited them or not
    • Based on you answer you may need to answer the following:
      1. Did the Legal Representative participate in the contact?
      2. Did the member request that the legal representative not participate?
  • Where did the visit take place? – Better known as “where did the contact take place?
    • Answer should always be Other
      • Then in Other visit location you should put Telephone
  • Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
    • If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
      • Caregiver name
      • Caregiver relationship 
      • Does the caregiver live with member? Answer should be – Yes
      • Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
      • Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
    • If the answer was “Other” then the coordinator needs to state what the Other residential location is
    • If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  • Information provided by** – Meaning who did the coordinator speak with during the call.
  • Has the participant expressed the desire to move from an institutional setting to the community? – participants have to be currently residing in an institution, which most of our clients do not.
    • Answer is most likely – Participant has NOT expressed desire…
    • If the answer was “Participant has expressed desire …” the coordinator needs to state the current transition status
  • Did the participant’s demographics change?  – Has any of the information about the participant changed?
    • If there was a change, then the coordinator must state what the changes are. 
  1. Medical Conditions
  • What changes to health did the participant report? – Does the participant feel like their health has changed at all?
  • Was there a change to the participant’s caregiver support system? – Has the participant’s primary or informal caregiver changed?
    1. If there was a change, then the coordinator must state the changes in Caregiver support system changes
  • Since last visit, has the participant visited any of these? – Has the participant seen their PCP, other medical specialist, or been to an Emergency Room or Hospital, or no?
    1. If there has been a visit the coordinator must state what type of visit and when in Provide details/reasons for the visit and include approximate dates
  • Does the participant have any special needs? 
    1. If the participant has special needs the coordinator must state what the special needs are in Special needs details
  1. Activities of Daily Living
  • Coordinators must state how much assistance the participant needs with the following ADLs
    • Bathing, Dressing, Grooming, Eating, Transferring, Toileting, and Bladder Management
  • Does the participant receive informal support for activities of daily living? 
    1. If the participant has informal support then the coordinator needs to state the name, relationship and average minimum and maximum hours of support they provide each day. 
  • Does the participant have unmet needs for daily living? – Does the participant need any services or devices? 
    1. If the participant has unmet needs then the coordinator needs to put in what these unmet needs are in Describe 
  • Does the participant use assistive devices/durable medical equipment for activities of daily living?
    1. If the participant feels they would benefit from assistive devices/durable medical equipment then the coordinator needs to state details in Describe
  1. Observations of Participant’s Mood/Behavior
  • Describe enrollee’s appearance, mood and behavior (happy, pleasant, relaxed, tired, stressed)
  1. Satisfaction
  • Is the participant satisfied with services and/or providers reflected on their plan of care? 
    1. If the participant is not satisfied with any of their services, the coordinator needs to state what they are doing to address the dissatisfaction
  • Is the participant receiving adult daycare services? – A common service that participants may receive
    • If the participant receives ADC services then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Is the participant receiving care coordination services? – All participants receive care coordination so the answer should always be – Participant is receiving care coordination services 
    • How satisfied is the participant with their Care Coordinator? – Coordinator must state the participant’s satisfaction with Amcord Care. 
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Does the participant have a health plan? – All participants have a health plan, it is PA Health & Wellness, therefore the answer should always be – Participant has a Health Plan
    • How satisfied is the participant with their Health Plan? – Coordinator must state the particpant’s satisfaction with PHW.
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Does the participant have a personal care attendant? – Most participants have a personal care attendant, it is PAS, therefore the answer is likely Participant has a personal care attendant
    • If the participant receives PAS, then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Does the participant have a transportation provider? – A common service that participants may receive
    • If the participant receives transportation services then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  1. Quality of Life
  • Coordinators must go through the following and answer honestly
    • Has the participant received a pneumovax vaccine since turning 65?
    • Has the participant received a flu vaccine in the last 12 months?
    • Does the participant have issues with bladder control?
      • If the participant has issues with bladder control, then SC must answer: bladder control issue frequency
    • Has the participant had a UTI in the past 3 months?
    • Does the participant have issues with bowel control?
      • If the participant has issues with bowel control, then SC must answer: bowel control issue frequency
    • Does the participant have any skin breakdown?
      • If the participant has skin breakdown, then SC must answer what type of breakdown there is (bruising, incision, tears, or wounds)
    • Has the participant had any falls since the last contact?
      • If the participant has had a fall, SC must answer the following:
        1. How many falls has the participant experiences in the last 3 months
        2. Did the falls result in an injury?
        3. If the fall resulted in an injury, then SC must answer Fall injury treatment
    • Is the participant able to do things they enjoy outside of their home and with whom they want?
    • Is the participant able to make decisions about their daily routine?
    • Does the participant feel safe in their home/where they live?
    • Does the participant have a paid or volunteer job in the community?
    • Does the participant like where they are living?
    • Does the participant see or talk to friends and family with whom they do not live?
  1. Schedule
  • Participant’s PAS schedule – select days of the week that the participant receives PAS
    • Total amount of hours per week that the participant receives in PAS – If the participant does not receive PAS, then SC should put in “0”
  • Participant’s ADC schedule – select days of the week that the participant receives ADC
    • Total amount of hours per week that the participant receives in ADC – If the participant does not receive ADC, then SC should put in “0”
  • Participant’s Informal Support schedule – select days of the week that the participant receives Informal Support
    • Total amount of hours per week that the participant receives in Informal Support – If the participant does not receive Informal Support, then SC should put in “0”
  • Scheduled Visit – If participant is due for a visit, then SC should be scheduling a visit. Otherwise select “no scheduled visits”
    • If a visit was scheduled, select the type of visit scheduled
      • If the type of visit scheduled is not listed, the coordinator should choose a visit, put in the date and time it is scheduled, but do NOT answer the compliance question.  SAVE the session DRAFT and notify the AVP so that they can put in the correct visit type
    • Visit scheduled for – date and time the visit is scheduled for
    • Is the scheduled visit after the compliance due date? – Is the date the visit is scheduled for before the due date?
      • If the visit is scheduled after the compliance date, this will prompt the last 2 questions to generate
        • Who were you trying to contact? – Who did you contact/schedule the visit with?
        • Reason for contact – the type of visit that was scheduled. 

Office Note

A miscellaneous session used to document work that does not fit into other sessions or when participant’s have inactive eligibility.

DO NOT USE WITHOUT PERMISSION FROM SUPERVISOR

Process

Provide a detailed explanation for why you are completing this session and what was involved.


OPS 8 Outbound Call

Used to document calls made to confirm missed PAS visits from PHW’s OPS 8 report. 

Note: This session cannot be submitted if the participant has Inactive Eligibility. Document the call as “Office note” or “Other”

  • Session Requires:
    • Appropriate answers to all required questions
      • Including “positive” answers to the reason codes from the PHW report
      • “Negative” answers to the reason codes not mentioned in the PHW report
      • Sufficient details in Resolution about:
        • The health and safety concerns addressed
        • Comments about the participant’s backup plan 

Process

  1. Call Conditions
  • Visit Type – How are you contacting the participant?
    • Answer should always be Telephone
  • Was the Legal Representative invited to participate? – Did you or the participant try to involve the participant’s Legally Authorized Representative, if there is one at all?
    • Answer is based on if your participant has a rep and invited them or not
    • Based on you answer you may need to answer the following:
      1. Did the Legal Representative participate in the contact?
      2. Did the member request that the legal representative not participate?
  • Where did the visit take place? – Better known as “where did the contact take place?
    • Answer should always be Other
      • Then in Other visit location you should put Telephone
  • Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
    • If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
      • Caregiver name
      • Caregiver relationship 
      • Does the caregiver live with member? Answer should be – Yes
      • Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
      • Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
    • If the answer was “Other” then the coordinator needs to state what the Other residential location is
    • If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  • Information provided by** – Meaning who did the coordinator speak with during the call. This is also how you may document the call.
    • If information was provided by Enrollee, Authorized Representative, or both, details of the call will be documented under Contact follow-up description in 2) Resolution. 
    • If information was provided by Other or Enrollee and Other, details of the call should be documented in Information provided by other
  • Has the participant expressed the desire to move from an institutional setting to the community? – participants have to be currently residing in an institution, which most of our clients do not.
    • Answer is most likely – Participant has NOT expressed desire…
    • If the answer was “Participant has expressed desire …” the coordinator needs to state the current transition status
  • Did the participant’s demographics change?  – Has any of the information about the participant changed?
    • If there was a change, then the coordinator must state what the changes are. 

2. Missed Dates

  • PAS Provider – name of the participant’s OAS provider on the OPS 8 report.
  • Missed Dates – list all the dates or the date range provided on the OPS 8 report

Reason codes for Missed Visits
You must select the “positive” answer for each code mentioned in the OPS 8 report
Even if it was not the appropriate reason for missed visit per the participant
Select the “negative” answer for all other codes that were NOT mentioned in the OPS 8 report
Even if they are the appropriate reason for missed visit per the participant

  1. AR – Participant/Family refused HHA or was unavailable
  • Did the participant refuse or was unavailable?
    1. Participant refused or was unavailable – positive answer
    2. Participant did NOT refuse or was unavailable – negative answer
  • If selecting the Positive answer, the SC must answer the following:
    • Dates for when the participant refused or was unavailable – All dates mentioned in the OPS 8 report that coincide with the AR reason code
    • Is this a recurring problem for the participant? 
      • If this is the first time choosing this reason code, then you should select “This has NOT been a recurring problem”
      • If this is not the first time choosing this reason code, then you should select “This has been a recurring problem” then provide details in the comment
    • Reason for participant being unable to keep scheduled visits?
    • Follow-up actions being taken
  1. HU – Hospitalization unplanned
  • Did the participant have an unplanned hospitalization?
    1. Participant had an unplanned hospitalization – positive answer
    2. Participant did NOT have an unplanned hospitalization – negative answer
  • If selecting the Positive answer, the SC must answer the following:
    • Dates for unplanned hospitalizations – All dates mentioned in the OPS 8 report that coincide with the HU reason code
    • Were there HHA/PAS services missed due to an unplanned hospitalization? – If so answer the following:
      • Comment about hospitalization
      • First date of Hospitalization
      • Hospital Name
    • Was the SC made aware of the Hospitalization – If so, leave a comment about how they were made aware and when
    • Was the PCSP adjusted due to the Hospitalization? – If so, leave a comment about what was adjusted and when
    • Has the CHC-MCO/SCE observed a trend of unplanned hospitalizations? 
      • If this is the first time choosing this reason code, then you should select “has  NOT observed a trend of unplanned hospitalizations”
      • If this is not the first time choosing this reason code, then you should select “This has been a recurring problem” then provide details in the comment
  1. UN – Agency was unable to staff the case
  • Was the agency unable to staff the case?
    1. The agency was unable to staff the case – positive answer
    2. The agency was ABLE to staff the case – negative answer
  • If selecting the Positive answer, the SC must answer the following:
    • Dates for when the agency was unable to staff – All dates mentioned in the OPS 8 report that coincide with the UN reason code
    • Why weren’t the services received? – Reason why the agency was unable to provide staff
      • If selected Other describe the reason provided
    • What did the agency do to address the missed service to ensure the participant wasn’t at risk?
      • If selected Other describe the reason provided
    • Has the issue that caused the gap… been resolved?
      • If NOT then provide comment
    • Was the backup plan initiated? – Describe the backup plan
  1. CV – All other cases where the agency could not staff due to COVID-19
  • Were there cases when the agency could not staff due to COVID-19?
    1. There were cases when the agency could not staff – positive answer
    2. There were NO cases when the agency could not staff – negative answer
  • If selecting the positive answer, the SC must answer the following:
    • Dates for when the agency could not staff – All dates mentioned in the OPS 8 report that coincide with the CV reason code
    • Did the provider contact the CHC-MCO to report a change? – Provide comment describing the answer
    • Did the CHC/MCO contact the participant? – Provide comment describing the answer
    • Did the missed service cause any health and safety concerns? – If so, describe the health and safety concerns
    • What follow up actions were taken? – describe follow-up actions
  1. FA – Participant is in the hospital or nursing facility due to COVID-19
  • Was the participant in the hospital or nursing facility due to COVID-19?
    1. The participant was in the hospital or nursing facility due to COVID-19 – positive answer
    2. The participant was NOT in the hospital or nursing facility due to COVID-19 – negative answer
  • If selecting the positive answer, the SC must answer the following:
    • Dates for when the agency could not staff – All dates mentioned in the OPS 8 report that coincide with the FA reason code. 
    • Follow-up call completed date?
    • Discharge planning – describe what plans were made regarding ptp’s discharge from the hospital or facility
    • Is the visit scheduled? – If the visit is scheduled then put in the visit scheduled date
    • Comments –  comment describing the situation
  1. IS – Participant refused due to COVID-19, receiving service through informal supports
  • Did the participant refuse due to COVID-19, receiving service through informal supports?
    1. The participant refused due to COVID-19 – positive answer
    2. The participant did NOT refused due to COVID-19 – negative answer 
  • If selecting the positive answer, the SC must answer the following:
    • Dates for the participant refusing due to COVID-19 – All dates mentioned in the OPS 8 report that coincide with the IS reason code
    • Is the participant’s informal support able to maintain assistance? – If UNABLE make a comment describing why
    • Are the participant’s needs being met? If NOT describe what needs are not being met
    • Is the reassessment needed? If NOT describe why
  1. SI – Participant refused, self-isolating due to COVID-19, not receiving service
  • Did the participant refuse while self-isolating due to COVID-19?
    1. The participant refused while self-isolating -positive answer 
    2. The participant did NOT refuse while self isolating – negative answer
  • If selecting the positive answer, the SC must answer the following:
    • Dates for the participant refusing while self-isolating due to COVID-19 – All dates mentioned in the OPS 8 report that coincide with the SI reason code. 
    • How are needs being met without formal services – Describe how participant’s needs are being met
  1. TX – Worker switched to cover another case due to staffing limitations as a result of COVID-19. 
  • Did the worker switch to cover another case due to staffing limitations as a result of COVID-19?
    1. The worker switched to cover another case – positive answer
    2. The worker did NOT switch to cover another case – negative answer
  • If selecting the positive answer, the SC must answer the following: 
    • Dates for the worker switching to cover another case – All dates mentioned in the OPS 8 report that coincide with the TX reason code
    • Are the participant’s needs being met? – if NOT describe what needs are not being met
    • Was the backup plan initiated? – Describe what was initiated or why it wasn’t
    • Additional Information 
  1. Resolution
  • How were the health and safety concerns addressed?
    • Describe in detail what major health and safety concerns the participant has and what was done to manage them
  • Was the participant’s backup plan able to be implemented?
    • Describe in detail what the participant’s backup plan is and how it was implemented, or why a backup plan was not implemented

Outbound Call

Used to document calls made by the service coordinator. You should discuss the following and document details of the call appropriately.

Note: This session cannot be submitted if the participant has Inactive Eligibility. Document the call as “Office note” or “Other”

  • Session Requires:
    • Appropriate answers to all required questions

Process

  1. Call Conditions
  • Visit Type – How are you contacting the participant?
    • Answer should always be Telephone
  • Was the Legal Representative invited to participate? – Did you or the participant try to involve the participant’s Legally Authorized Representative, if there is one at all?
    • Answer is based on if your participant has a rep and invited them or not
    • Based on you answer you may need to answer the following:
      1. Did the Legal Representative participate in the contact?
      2. Did the member request that the legal representative not participate?
  • Where did the visit take place? – Better known as “where did the contact take place?
    • Answer should always be Other
      • Then in Other visit location you should put Telephone
  • Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
    • If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
      • Caregiver name
      • Caregiver relationship 
      • Does the caregiver live with member? Answer should be – Yes
      • Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
      • Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
    • If the answer was “Other” then the coordinator needs to state what the Other residential location is
    • If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  • Information provided by** – Meaning who did the coordinator speak with during the call. This is also how you may document the call.
    • If information was provided by Enrollee, Authorized Representative, or both, details of the call will be documented under Contact follow-up description in 2) Resolution. 
    • If information was provided by Other or Enrollee and Other, details of the call should be documented in Information provided by other
  • Has the participant expressed the desire to move from an institutional setting to the community? – participants have to be currently residing in an institution, which most of our clients do not.
    • Answer is most likely – Participant has NOT expressed desire…
    • If the answer was “Participant has expressed desire …” the coordinator needs to state the current transition status
  • Did the participant’s demographics change?  – Has any of the information about the participant changed?
    • If there was a change, then the coordinator must state what the changes are. 
  1. Resolution
  • Is follow-up required for the contact?
    • Answer should always be – A follow-up is required
  • Do you need to schedule a visit?
    • If the participant’s visit is already scheduled, or they are NOT due for a visit, then the coordinator should select Do NOT need to schedule a visit. This will prompt Contact follow-up description
      • Contact follow-up description – detail the conversation had with the participant and/or legally authorized representative. 
    • If the participant is due for a visit and you schedule it with them in this call then you need to say Need to schedule a visit and this will prompt follow-up questions on the scheduled visit. 
      • Scheduled Visit – select the type of visit that was schedule

If the type of visit scheduled is not listed, the coordinator should choose a visit, put in the date and time it is scheduled, but do NOT answer the compliance question.  SAVE the session DRAFT and notify the AVP so that they can put in the correct visit type. 

  • Visit scheduled for – date and time the visit is scheduled for
  • Is the scheduled visit after the compliance due date? – Is the date the visit is scheduled for before the due date?
    1. If the visit is scheduled after the compliance date, this will prompt the last 2 questions to generate
      1. Who were you trying to contact? – Who did you contact/schedule the visit with?
      2. Reason for contact – the type of visit that was scheduled. 

RN Health Consultation

Used to document conversation had with Nurse Irene about participant’s health and needs

  • Session Requires:
    • Comment describing the discussion
    • General note to Envolve

SC should be putting in all information about the discussion


Unsuccessful Outreach

Used to document unsuccessful outreaches to the participant. Coordinators MUST call all other contacts/emergency contact and PAS agency after unsuccessfully reaching the participant in order to document as an Unsuccessful Outreach

Note: This session cannot be submitted if the participant has Inactive Eligibility. Document the call as “Office note” or “Other”

  • Session Requires:
    • Appropriate answers to all required questions

Process:

  1. Call Conditions
  • Visit Type – How are you contacting the participant?
    • Answer should always be Telephone
  • Where did the visit take place? – Better known as “where did the contact take place?
    • Answer should always be Other
      • Then in Other visit location you should put Telephone
  • Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
    • If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
      • Caregiver name
      • Caregiver relationship 
      • Does the caregiver live with member? Answer should be – Yes
      • Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
      • Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
    • If the answer was “Other” then the coordinator needs to state what the Other residential location is
    • If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  1. Unsuccessful Contact
  • Who were you trying to contact? – which primary contact were you calling
  • Method of contact – What type of contact you were completing (Likely Telephonic)
  • Reason for contact – What type of session were you trying to complete?
  • Reason for contact details – How the call to the emergency contact was completed. 
    • Note: An attempt to the Emergency contact MUST be made
  • Reason for Unsuccessful contact – Result of the contact to the participant
    • Note: If you were able to leave a voicemail, do so with your name, reason for the contact, and Amcord’s phone number. 
  • Reason for contact details – How the call to the PAS agency was completed
    • Note: Almost all participants have a PAS agency. Be sure to check the authorization spreadsheet (while the authorization tab is not functional)
  • Contact attempt number – Number of consecutive unsuccessful attempts that have been made
    • This is done by the system automatically. 

Welcome Call

Used to document the specific Welcome Call to new waiver participants before the NPO visit. 

  • Do NOT use for non-NPO participants  
  • Session Requires:
    • Answers to all questions
    • MCA with “Welcome Call” type of contact
    • General Note to Envolve

Process

  1. Welcome Call
  • Does the participant have a preference of a service coordinator?
    • If so, answer what Preferred Language and Other Preferences they have.
  • Comments – any additional comments by the SC or participant.
    • focus on details about follow up, contact, health information, etc.

Complete the MCA

  • Coordinator must complete MCA in Envolve with “Welcome Call” as Type of Contact
    • Save as a PDF for Function Portal
    • Submit in Envolve

General note to Envolve

  • After selecting “Add session” a summary of the session will come up. Copy the session and paste it into a “General Note” in Envolve

Scheduled Sessions

Session NameDescription of Session
Quarterly ContactUsed to document Quarterly Contacts
– Completed once every 3 months when the participant does not have a Change in Condition
Change EventUsed to document Change in Condition visits
– Completed when the participant has a significant change in their Health or Caregivers; when they’re requesting changes to their services; or to follow up on Critical Incidents. 
Annual ContactUsed to document Annual Contacts
– Completed once a year based on the last Change in Condition visit

Scheduling

To document these sessions, they need to be scheduled with the participant in advance.
Visits are scheduled in Outbound call, Incoming call, or Monthly contact sessions

Function Portal will notify you if upcoming due contact with the notification in the Dashboard, Calendar, and the right hand notification bar in the specific participant’s page

When scheduling the visit in the Incoming call, Outbound call, or Monthly contact sessions, they will automatically prompt which visits you can schedule, based on what is due:

Otherwise if the participant is NOT due for any visit, then the option for Change Event visit, will present itself


Documenting Sessions

After scheduling a visit the option to document or cancel the visit will present itself in the right hand notification bar in the specific participant’s page.

Note: FP will take about 15-20 to update itself with these options after the visit is scheduled.

Select “Document Visit” to start the FP session for that visit. Select “Cancel visit” if the visit was cancelled and/or rescheduled


Quarterly Contact

Used to document Quarterly Contacts

  • Session Requires:
    • Appropriate answer to all required questions

Process

  1. Visit Conditions
  • Visit Type – How are you contacting the participant?
    • Answer should always be Telephone
  • Was the Legal Representative invited to participate? – Did you or the participant try to involve the participant’s Legally Authorized Representative, if there is one at all?
    • Answer is based on if your participant has a rep and invited them or not
    • Based on you answer you may need to answer the following:
      1. Did the Legal Representative participate in the contact?
      2. Did the member request that the legal representative not participate?
  • Where did the visit take place? – Better known as “where did the contact take place?
    • Answer should always be Other
      • Then in Other visit location you should put Telephone
  • Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
    • If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
      • Caregiver name
      • Caregiver relationship 
      • Does the caregiver live with member? Answer should be – Yes
      • Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
      • Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
    • If the answer was “Other” then the coordinator needs to state what the Other residential location is
    • If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  • Information provided by – Meaning who did the coordinator speak with during the call.
    • If the answer involved “Other” then the SC needs to state who this other person was and why they spoke to them.
  • Has the participant expressed the desire to move from an institutional setting to the community? – participants have to be currently residing in an institution, which most of our clients do not.
    • Answer is most likely – Participant has NOT expressed desire…
    • If the answer was “Participant has expressed desire …” the coordinator needs to state the current transition status
  • Did the participant’s demographics change?  – Has any of the information about the participant changed?
    • If there was a change, then the coordinator must state what the changes are. 
  • Member materials provided – Describe any resources, materials, or referrals that were given to the participant
  • Was the member referred to Nurtur?
  • Was the member referred to Disease Management?
  • Was the member referred to Behavioral Health?
  1. Medical Conditions
  • Since last visit, has the participant visited any of these? – Has the participant seen their PCP, other medical specialist, or been to an Emergency Room or Hospital, or no?
    1. If there has been a visit the coordinator must state what type of visit and when in Provide details/reasons for the visit and include approximate dates
  • Does the participant have any special needs? 
    1. If the participant has special needs the coordinator must state what the special needs are in Special needs details

3. Activities of Daily Living

  • Coordinators must state how much assistance the participant needs with the following ADLs
    • Bathing, Dressing, Grooming, Eating, Transferring, Toileting, and Bladder Management
  • Does the participant receive informal support for activities of daily living? 
    1. If the participant has informal support then the coordinator needs to state the name, relationship and average minimum and maximum hours of support they provide each day. 
  • Does the participant have unmet needs for daily living? – Does the participant need any services or devices? 
    1. If the participant has unmet needs then the coordinator needs to put in what these unmet needs are in Describe 
  • Does the participant use assistive devices/durable medical equipment for activities of daily living?
    1. If the participant feels they would benefit from assistive devices/durable medical equipment then the coordinator needs to state details in Describe

4. Instrumental Activities of Daily Living

  • Coordinators must state how much assistance the participant needs with the following IADLs
    • Meal Preparation, Housework, Laundry, Shopping, Transportation, Manage Money, Manage Medications, Using Telephone.
  • Does the participant receive informal support for activities of daily living? 
    1. If the participant has informal support then the coordinator needs to state the name, relationship and average minimum and maximum hours of support they provide each day. 
  • Does the participant have unmet needs for daily living? – Does the participant need any services or devices? 
    1. If the participant has unmet needs then the coordinator needs to put in what these unmet needs are in Describe 
  • Does the participant use assistive devices/durable medical equipment for instrumental activities of daily living?
    1. If the participant feels they would benefit from assistive devices/durable medical equipment then the coordinator needs to state details in Describe

5. Observations of Participant and Environment

  • Who was present during the visit? – Select all who were present during the conversation
    • SC must be selected
  • Describe Participant’s environment and any concerns
    • Have the participant describe their environment and any concerns they have.
  • How was the participant dressed? Were they clean? (nails, hair, clothing)
    • State you were unable to observe due to the contact being done over the phone
  • What was the participant wearing? – state which common assistive devices the participant wears
    • Select if the participant was wearing dentures, hearing aids, and/or glasses.
  • How were they moving around? – How the participant regularly ambulates
    • Select if the participant moves with or without assistive devices, or if they are bed bound
  • Participant Story – Basic health information about the participant
    • This story should include the following information:
      • Name
      • Age
      • Gender and Race
      • Diagnoses
      • Number of Medications
      • Living Accommodations
      • Formal/Informal Support
      • ADLs and IADLs they require assistance with

6. Satisfaction

  • Is the participant satisfied with services and/or providers reflected on their plan of care? 
    1. If the participant is not satisfied with any of their services, the coordinator needs to state what they are doing to address the dissatisfaction
  • Is the participant receiving adult daycare services? – A common service that participants may receive
    • If the participant receives ADC services then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Is the participant receiving care coordination services? – All participants receive care coordination so the answer should always be – Participant is receiving care coordination services 
    • How satisfied is the participant with their Care Coordinator? – Coordinator must state the participant’s satisfaction with Amcord Care. 
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Does the participant have a health plan? – All participants have a health plan, it is PA Health & Wellness, therefore the answer should always be – Participant has a Health Plan
    • How satisfied is the participant with their Health Plan? – Coordinator must state the particpant’s satisfaction with PHW.
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Does the participant have a personal care attendant? – Most participants have a personal care attendant, it is PAS, therefore the answer is likely Participant has a personal care attendant
    • If the participant receives PAS, then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Does the participant have a transportation provider? – A common service that participants may receive
    • If the participant receives transportation services then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied

7. Quality of Life

  • Coordinators must go through the following and answer honestly
    • Has the participant received a pneumovax vaccine since turning 65?
    • Has the participant received a flu vaccine in the last 12 months?
    • Does the participant have issues with bladder control?
      • If the participant has issues with bladder control, then SC must answer: bladder control issue frequency
    • Has the participant had a UTI in the past 3 months?
    • Does the participant have issues with bowel control?
      • If the participant has issues with bowel control, then SC must answer: bowel control issue frequency
    • Does the participant have any skin breakdown?
      • If the participant has skin breakdown, then SC must answer what type of breakdown there is (bruising, incision, tears, or wounds)
    • Has the participant had any falls since the last contact?
      • If the participant has had a fall, SC must answer the following:
        1. How many falls has the participant experiences in the last 3 months
        2. Did the falls result in an injury?
        3. If the fall resulted in an injury, then SC must answer Fall injury treatment
    • Is the participant able to do things they enjoy outside of their home and with whom they want?
    • Is the participant able to make decisions about their daily routine?
    • Does the participant feel safe in their home/where they live?
    • Does the participant have a paid or volunteer job in the community?
    • Does the participant like where they are living?
    • Does the participant see or talk to friends and family with whom they do not live?

Change Event

Used to document Change in Condition visits.

  • Session Requires:
    • Appropriate answer to all required questions
    • Docusign Certificate
    • InterRAI

Process

  1. Visit Conditions
  • Which of the following occurred? – Select what change(s) occurred for the participant, necessitating the visit.
    • Select one, or BOTH, options based on the participant’s reported changes
  • Visit Type – How are you contacting the participant
    • Select the appropriate answer.
      • If the visit was Face to Face, answer:
        • Who was present during the visit?
      • If the visit was Telephonic, answer:
        • Reason for telephonic visit

This information MUST match the answer provided in PCSP page 1

  • Did the member accept of decline the Virtual Visit? – select if the member accepted virtual visit or why they declined
    • If the visit was done virtually, select Member Accepted
    • If the virtual visit was declined for other reasons answer:
      • Reason for declining Virtual Visit
  • Was the Legal Representative invited to participate? – Did you or the participant try to involve the participant’s Legally Authorized Representative, if there is one at all?
    • Answer is based on if your participant has a rep and invited them or not
    • Based on you answer you may need to answer the following:
      1. Did the Legal Representative participate in the contact?
      2. Did the member request that the legal representative not participate?
  • Where did the visit take place? – This should match the Visit Type answered above
  • Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
    • If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
      • Caregiver name
      • Caregiver relationship 
      • Does the caregiver live with member? Answer should be – Yes
      • Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
      • Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
    • If the answer was “Other” then the coordinator needs to state what the Other residential location is
    • If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  • Information provided by – Meaning who did the coordinator speak with during the call.
    • If the answer involved “Other” then the SC needs to state who this other person was and why they spoke to them.
  • Has the participant expressed the desire to move from an institutional setting to the community? – participants have to be currently residing in an institution, which most of our clients do not.
    • Answer is most likely – Participant has NOT expressed desire…
    • If the answer was “Participant has expressed desire …” the coordinator needs to state the current transition status
  • Did the participant’s demographics change?  – Has any of the information about the participant changed?
    • If there was a change, then the coordinator must state what the changes are.
  • Member materials provided – Describe any resources, materials, or referrals that were given to the participant
  • Was the member referred to Nurtur?
  • Was the member referred to Disease Management?
  • Was the member referred to Behavioral Health?
  • Did the CC review the Member Handbook with the enrollee/authorized representative?
    • If the Handbook was NOT reviewed, explain why.
  • Which Advanced Directives does the enrollee have? – select the advanced directives the participant has or None, but importance was discussed
    • If the answer was “Other Advanced Directives” explain what other advanced directives the ptp has.

This information should match the answers provided in the PCSP (pages 10-11; Life Planning)

  1. Change Event

Questions here will only generate based on the selection(s) to which of the following occurred? asked in the previous section

  • Describe what prompted the participant’s change in Health Condition – detailed description about the participant’s health changes and/or incidents that occurred to cause changes in health condition.
  • If the enrollee is not capable of making decisions …? – select if referral or other resources were provided to the participant regarding inability to make their own decisions and lack of legal representative.
  • Was this a significant change that required the HRA to be updated? – HRA is the Health Risk Assessment or DSNP (Dual eligible Special Needs Plan)
  • What changes are needed to the Plan of Care? – select all the changes that occurred within the PCSP, compared to previous, or select “No changes”
    • If changes were selected, describe the details of the changes
  • If enrollee/authorized rep was unable or refused to sign… explain why – If the PCSP could not be signed while in person, explain why. If the PCSP could not be signed because the visit was not Face to Face, state that.
  1. Medical Conditions
  • What changes to health did the participant report? – select if the participant feels their health has improved, declined, or remained the same
  • Were there any changes to the participant’s medications or diagnoses?
  • Since last visit, has the participant visited any of these? – select any of the listed appointments that the participant has attended since the last visit was done. If “No visits” occurred, select that.
    • If any visits occurred, provide details about the type of visit, why it was completed, and approximately when it occurred.
  • Does the participant have any special needs?
    • If the participant has special needs the coordinator must state what the special needs are in Special needs details
  1. Goals
  • What is the participant’s status of goals …? – select which option best applies to the discussion of goals made with the participant.
    • Describe what was discussed about the goals in Goal status comments
  • What is the participant’s selection for Participant Directed Option? – does the participant have Public Partnerships (PPL) as their PAS provider? If so, select “Enrollee elected PDO”. If not, select “Enrollee does not wish to elect PDO at this time”
    • If “Enrollee elected PDO” is selected, describe what the participant is doing with their PDO (such as who their DCW and back up plan is)
  1. Informal Support
  • Does the participant receive informal support for Activities of Daily Living?
    • If “participant receives informal support” answer the following:
      • Supporter name
      • Relationship to the participant
      • Minimum hours informal support may provide
      • Maximum hours informal support may provide
  1. Observations of Participant and Environment
  • Describe Participant’s environment and any concerns
    • If visit is Face to face describe your observations
    • If visit is over the phone, have the participant describe their environment.

This information should match the answers provided in the InterRAI (Section Q) and PCSP (Page 5)

  • How was the participant dressed? Were they clean? (nails, hair, clothing)
    • If visit is Face to face describe your observations
    • If visit is over the phone, state you were unable to observe
  • What was the participant wearing? – state which common assistive devices the participant wears
    • Select if the participant was wearing dentures, hearing aids, and/or glasses.
  • How were they moving around? – How the participant ambulated or regularly ambulates
    • Select if the participant moves with or without assistive devices, or if they are bed bound

This information should match the answers provided in the InterRAI (Section G)

  • Participant Story – Basic health information about the participant
    • You can cut and paste the story put into the PCSP (Page 2) for Daily Routine
      • This story should include the following information”
        • Name
        • Age
        • Gender and Race
        • Diagnoses
        • Number of Medications
        • Living Accommodations
        • Formal/Informal Support
        • ADLs and IADLs they require assistance with
  1. Observations of Participant’s Mood/Behavior
  • Describe the enrollee’s appearance, mood and behavior … – describe anything you can about the participant, even if the visit is not Face to Face.

8. Activities of Daily Living

  • Coordinators must state how much assistance the participant needs with the following ADLs
    • Bathing, Dressing, Grooming, Eating, Transferring, Toileting, and Bladder Management
  • Does the participant receive informal support for activities of daily living? 
    1. If the participant has informal support then the coordinator needs to state the name, relationship and average minimum and maximum hours of support they provide each day. 
  • Does the participant have unmet needs for daily living? – Does the participant need any services or devices? 
    1. If the participant has unmet needs then the coordinator needs to put in what these unmet needs are in Describe 
  • Does the participant use assistive devices/durable medical equipment for activities of daily living?
    1. If the participant feels they would benefit from assistive devices/durable medical equipment then the coordinator needs to state details in Describe

All of this information should match the answers provided in InterRAI

  1. Satisfaction
  • Is the participant satisfied with services and/or providers reflected on their plan of care? 
    1. If the participant is not satisfied with any of their services, the coordinator needs to state what they are doing to address the dissatisfaction
  • Is the participant receiving adult daycare services? – A common service that participants may receive
    • If the participant receives ADC services then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Is the participant receiving care coordination services? – All participants receive care coordination so the answer should always be – Participant is receiving care coordination services 
    • How satisfied is the participant with their Care Coordinator? – Coordinator must state the participant’s satisfaction with Amcord Care. 
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Does the participant have a health plan? – All participants have a health plan, it is PA Health & Wellness, therefore the answer should always be – Participant has a Health Plan
    • How satisfied is the participant with their Health Plan? – Coordinator must state the particpant’s satisfaction with PHW.
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Does the participant have a personal care attendant? – Most participants have a personal care attendant, it is PAS, therefore the answer is likely Participant has a personal care attendant
    • If the participant receives PAS, then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Does the participant have a transportation provider? – A common service that participants may receive
    • If the participant receives transportation services then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  1. Quality of Life
  • Coordinators must go through the following and answer honestly
    • Has the participant received a pneumovax vaccine since turning 65?
    • Has the participant received a flu vaccine in the last 12 months?
    • Does the participant have issues with bladder control?
      • If the participant has issues with bladder control, then SC must answer: bladder control issue frequency
    • Has the participant had a UTI in the past 3 months?
    • Does the participant have issues with bowel control?
      • If the participant has issues with bowel control, then SC must answer: bowel control issue frequency
    • Does the participant have any skin breakdown?
      • If the participant has skin breakdown, then SC must answer what type of breakdown there is (bruising, incision, tears, or wounds)
    • Has the participant had any falls since the last contact?
      • If the participant has had a fall, SC must answer the following:
        1. How many falls has the participant experiences in the last 3 months
        2. Did the falls result in an injury?
        3. If the fall resulted in an injury, then SC must answer Fall injury treatment
    • Is the participant able to do things they enjoy outside of their home and with whom they want?
    • Is the participant able to make decisions about their daily routine?
    • Does the participant feel safe in their home/where they live?
    • Does the participant have a paid or volunteer job in the community?
    • Does the participant like where they are living?
    • Does the participant see or talk to friends and family with whom they do not live?
  1. Resolution
  • Did the member or Legal Rep, if applicable, sign the PCSP?

This answer should match the answer provided in section 2

  • Did the external Service Coordinator sign the PCSP? – Answer should always be YES (you are the external service coordinator)
  • Was there a change to the services authorized? – Are there any changes to the services being requested during this visit?
    • If a change is requested, answer the following:
      • Was there an increase or decrease in the amount of services?
      • Did the member request the increase/decrease?
      • What was the reason for the increase?

Annual Contact

Used to document Annual contact visits.

  • Session Requires:
    • Appropriate answer to all required questions
    • Docusign Certificate
    • InterRAI

Process

  1. Visit Conditions
  • Which of the following occurred? – Select what change(s) occurred for the participant, if any.
    • Select one, or BOTH, options, or leave it blank based on the participant’s reported changes
  • Visit Type – How are you contacting the participant
    • Select the appropriate answer.
      • If the visit was Face to Face, answer:
        • Who was present during the visit?
      • If the visit was Telephonic, answer:
        • Reason for telephonic visit

This information MUST match the answer provided in PCSP page 1

  • Did the member accept of decline the Virtual Visit? – select if the member accepted virtual visit or why they declined
    • If the visit was done virtually, select Member Accepted
    • If the virtual visit was declined for other reasons answer:
      • Reason for declining Virtual Visit
  • Was the Legal Representative invited to participate? – Did you or the participant try to involve the participant’s Legally Authorized Representative, if there is one at all?
    • Answer is based on if your participant has a rep and invited them or not
    • Based on you answer you may need to answer the following:
      1. Did the Legal Representative participate in the contact?
      2. Did the member request that the legal representative not participate?
  • Where did the visit take place? – This should match the Visit Type answered above
  • Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer. 
    • If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver. 
      • Caregiver name
      • Caregiver relationship 
      • Does the caregiver live with member? Answer should be – Yes
      • Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
      • Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
    • If the answer was “Other” then the coordinator needs to state what the Other residential location is
    • If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
  • Information provided by – Meaning who did the coordinator speak with during the call.
    • If the answer involved “Other” then the SC needs to state who this other person was and why they spoke to them.
  • Has the participant expressed the desire to move from an institutional setting to the community? – participants have to be currently residing in an institution, which most of our clients do not.
    • Answer is most likely – Participant has NOT expressed desire…
    • If the answer was “Participant has expressed desire …” the coordinator needs to state the current transition status
  • Did the participant’s demographics change?  – Has any of the information about the participant changed?
    • If there was a change, then the coordinator must state what the changes are.
  • Member materials provided – Describe any resources, materials, or referrals that were given to the participant
  • Was the member referred to Nurtur?
  • Was the member referred to Disease Management?
  • Was the member referred to Behavioral Health?
  • Did the CC review the Member Handbook with the enrollee/authorized representative?
    • If the Handbook was NOT reviewed, explain why.
  • Which Advanced Directives does the enrollee have? – select the advanced directives the participant has or None, but importance was discussed
    • If the answer was “Other Advanced Directives” explain what other advanced directives the ptp has.

This information should match the answers provided in the PCSP (pages 10-11; Life Planning)

  1. Change Event

Questions here will only generate based on the selection(s) to which of the following occurred? asked in the previous section

  • Describe what prompted the participant’s change in Health Condition – detailed description about the participant’s health changes and/or incidents that occurred to cause changes in health condition.
  • If the enrollee is not capable of making decisions …? – select if referral or other resources were provided to the participant regarding inability to make their own decisions and lack of legal representative.
  • Was this a significant change that required the HRA to be updated? – HRA is the Health Risk Assessment or DSNP (Dual eligible Special Needs Plan)
  • What changes are needed to the Plan of Care? – select all the changes that occurred within the PCSP, compared to previous, or select “No changes”
    • If changes were selected, describe the details of the changes
  • If enrollee/authorized rep was unable or refused to sign… explain why – If the PCSP could not be signed while in person, explain why. If the PCSP could not be signed because the visit was not Face to Face, state that.
  1. Medical Conditions
  • What changes to health did the participant report? – select if the participant feels their health has improved, declined, or remained the same
  • Were there any changes to the participant’s medications or diagnoses?
  • Since last visit, has the participant visited any of these? – select any of the listed appointments that the participant has attended since the last visit was done. If “No visits” occurred, select that.
    • If any visits occurred, provide details about the type of visit, why it was completed, and approximately when it occurred.
  • Does the participant have any special needs?
    • If the participant has special needs the coordinator must state what the special needs are in Special needs details
  1. Goals
  • What is the participant’s status of goals …? – select which option best applies to the discussion of goals made with the participant.
    • Describe what was discussed about the goals in Goal status comments
  • What is the participant’s selection for Participant Directed Option? – does the participant have Public Partnerships (PPL) as their PAS provider? If so, select “Enrollee elected PDO”. If not, select “Enrollee does not wish to elect PDO at this time”
    • If “Enrollee elected PDO” is selected, describe what the participant is doing with their PDO (such as who their DCW and back up plan is)
  1. Informal Support
  • Does the participant receive informal support for Activities of Daily Living?
    • If “participant receives informal support” answer the following:
      • Supporter name
      • Relationship to the participant
      • Minimum hours informal support may provide
      • Maximum hours informal support may provide
  1. Observations of Participant and Environment
  • Describe Participant’s environment and any concerns
    • If visit is Face to face describe your observations
    • If visit is over the phone, have the participant describe their environment.

This information should match the answers provided in the InterRAI (Section Q) and PCSP (Page 5)

  • How was the participant dressed? Were they clean? (nails, hair, clothing)
    • If visit is Face to face describe your observations
    • If visit is over the phone, state you were unable to observe
  • What was the participant wearing? – state which common assistive devices the participant wears
    • Select if the participant was wearing dentures, hearing aids, and/or glasses.
  • How were they moving around? – How the participant ambulated or regularly ambulates
    • Select if the participant moves with or without assistive devices, or if they are bed bound

This information should match the answers provided in the InterRAI (Section G)

  • Participant Story – Basic health information about the participant
    • You can cut and paste the story put into the PCSP (Page 2) for Daily Routine
      • This story should include the following information”
        • Name
        • Age
        • Gender and Race
        • Diagnoses
        • Number of Medications
        • Living Accommodations
        • Formal/Informal Support
        • ADLs and IADLs they require assistance with
  1. Observations of Participant’s Mood/Behavior
  • Describe the enrollee’s appearance, mood and behavior … – describe anything you can about the participant, even if the visit is not Face to Face.

8. Activities of Daily Living

  • Coordinators must state how much assistance the participant needs with the following ADLs
    • Bathing, Dressing, Grooming, Eating, Transferring, Toileting, and Bladder Management
  • Does the participant receive informal support for activities of daily living? 
    1. If the participant has informal support then the coordinator needs to state the name, relationship and average minimum and maximum hours of support they provide each day. 
  • Does the participant have unmet needs for daily living? – Does the participant need any services or devices? 
    1. If the participant has unmet needs then the coordinator needs to put in what these unmet needs are in Describe 
  • Does the participant use assistive devices/durable medical equipment for activities of daily living?
    1. If the participant feels they would benefit from assistive devices/durable medical equipment then the coordinator needs to state details in Describe

All of this information should match the answers provided in InterRAI

  1. Satisfaction
  • Is the participant satisfied with services and/or providers reflected on their plan of care? 
    1. If the participant is not satisfied with any of their services, the coordinator needs to state what they are doing to address the dissatisfaction
  • Is the participant receiving adult daycare services? – A common service that participants may receive
    • If the participant receives ADC services then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Is the participant receiving care coordination services? – All participants receive care coordination so the answer should always be – Participant is receiving care coordination services 
    • How satisfied is the participant with their Care Coordinator? – Coordinator must state the participant’s satisfaction with Amcord Care. 
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Does the participant have a health plan? – All participants have a health plan, it is PA Health & Wellness, therefore the answer should always be – Participant has a Health Plan
    • How satisfied is the participant with their Health Plan? – Coordinator must state the particpant’s satisfaction with PHW.
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Does the participant have a personal care attendant? – Most participants have a personal care attendant, it is PAS, therefore the answer is likely Participant has a personal care attendant
    • If the participant receives PAS, then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  • Does the participant have a transportation provider? – A common service that participants may receive
    • If the participant receives transportation services then coordinator must state how satisfied they are with the service
      1. If the participant is dissatisfied with the service, coordinator needs to state the reason they are dissatisfied
  1. Quality of Life
  • Coordinators must go through the following and answer honestly
    • Has the participant received a pneumovax vaccine since turning 65?
    • Has the participant received a flu vaccine in the last 12 months?
    • Does the participant have issues with bladder control?
      • If the participant has issues with bladder control, then SC must answer: bladder control issue frequency
    • Has the participant had a UTI in the past 3 months?
    • Does the participant have issues with bowel control?
      • If the participant has issues with bowel control, then SC must answer: bowel control issue frequency
    • Does the participant have any skin breakdown?
      • If the participant has skin breakdown, then SC must answer what type of breakdown there is (bruising, incision, tears, or wounds)
    • Has the participant had any falls since the last contact?
      • If the participant has had a fall, SC must answer the following:
        1. How many falls has the participant experiences in the last 3 months
        2. Did the falls result in an injury?
        3. If the fall resulted in an injury, then SC must answer Fall injury treatment
    • Is the participant able to do things they enjoy outside of their home and with whom they want?
    • Is the participant able to make decisions about their daily routine?
    • Does the participant feel safe in their home/where they live?
    • Does the participant have a paid or volunteer job in the community?
    • Does the participant like where they are living?
    • Does the participant see or talk to friends and family with whom they do not live?
  1. Resolution
  • Did the member or Legal Rep, if applicable, sign the PCSP?

This answer should match the answer provided in section 2

  • Did the external Service Coordinator sign the PCSP? – Answer should always be YES (you are the external service coordinator)
  • Was there a change to the services authorized? – Are there any changes to the services being requested during this visit?
    • If a change is requested, answer the following:
      • Was there an increase or decrease in the amount of services?
      • Did the member request the increase/decrease?
      • What was the reason for the increase?
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