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3. HRA/DSNP Training

HRA or Health Risk Assessment/DSNP or Dual eligible Special Needs Plan is completed with all Comprehensive Needs Assessment visits

The most important aspect of all documents for Comprehensive Needs Assessments is about being consistent with your answers. If you complete the InterRAI and PCSP before the HRA/DSNP, then you’ll have most of the answers needed for the HRA/DSNP!

All questions of the DSNP must be answered
Questions that are highlighted are similar, if not exactly the same, as questions in other documents to assist with consistency.

Member Information

Demographic information about the participant. Most of these questions are covered in FP, InterRAI, and PCSP.

Questions needing extra information:
Race – If Other is selected, type in the ptp’s race
Ethnicity – If Other is selected, type in the ptp’s ethnicity
Preferred Language – If Other is selected, type in the ptp’s preferred language
Problems with hearing, vision, and speech … – If yes is selected, explain the problems

Questions that were asked/answered in other documents:
Address, phone number, email – Function Portal
Race – InterRAI (Section B, question 2)
Ethnicity – InterRAI (Section B, question 2)
Preferred Language – InterRAI (Section B, question 3); PCSP (Page 1, Communication Preference)
Highest level of education – PCSP (Page 2, Educational Background)
Problems with hearing, vision, or speech – PCSP (Page 1, Communication Preference)

Additional Notes:
Problems with hearing, vision, and speech – Glasses are NOT a special service, therefore you should select No if glasses are the only “device” the participant uses.

Global Health/Safety

General questions about the participant’s health

Questions needing extra information:
How would you rate your health – If poor is selected, explain why
How ready are you to make changes – If 8-10, is selected, explain what changes the ptp is ready to make
Doctor or Provider – If yes is selected, state their name. This will also prompt the question:
Have you seen your provider in the last 12 months? – If yes is selected, select what they saw their provider for.
How many medications are you taking – If the ptp takes medications, then state if anything prevents the ptp from taking them, and if they ever forget.
Are you male or female – based on the answer, more questions may present themselves

Questions that were asked/answered in other documents:
How would you rate your health – InterRAI (Section J, question 8)
Doctor or Health care provider – FP; Docusign (Medication Profile); PCSP (page 4, Person Centered Team)
# of times in Hospital or ER – should correlate with participant’s medical history
How many medication are you taking – InterRAI (Page 10, Medication List); Docusign Packet (Medication Profile)
Height and Weight – InterRAI (Section K, question 1)
Do you eat at least 2 meals per day – should correlate with SPG rationale (Meal Prep)
Do you have problems with teeth or mouth – InterRAI (Section K, question 4)
Do you participate in regular physical activity – Should correlate with InterRAI (section G, question 4a) and SPG tool
Have you received a Flu shot – InterRAI (Section N, question 1f)

Additional Notes:
Participant’s height – here in the HRA-DSNP you put height in for feet and inches, but in the InterRAI you put TOTAL inches.

Social Concerns

Questions regarding participant’s social involvement and living arrangements

Questions needing extra information:
Do you have a paid or volunteer job – If yes, I have a paid job is selected you will then have to state the scale value of how health problems have affected their work productivity.
Do you have concerns about having enough money – If yes is selected then describe the concerns.
Do you always feel safe in your home – If no is selected, describe why not.
Do you have a primary caregiver – If yes is selected (as it likely will) state if the caregiver adequately supports their needs, and who they are.

Questions that were asked/answered in other documents:
Do you have a paid or volunteer job – PCSP (pages 7-8, Community Integration)
Have you been living in stable housing – PCSP (page 5, Living Preferences/Housing)
Do you always feel safe in your home -PCSP (page 5, Living Preferences/Housing)
Do you have access to safe, reliable telephone – PCSP (page 7, Living Preferences/Housing)
Do you have problems with transportation – PCSP (page 9, Community Integration)
Do you have a primary caregiver? – PCSP (page 10, Caregiver Information)

Physical Health

Questions pertaining to participant’s physical health diagnoses

Questions that were asked/answered in other documents:
Each of these questions – PCSP (page 15, Physical Health)

Additional Notes:
All of the participant’s diagnoses should be listed here AND match the diagnoses stated in FP, PCSP, InterRAI, and Docusign Packet

Behavioral Health

Questions regarding the participant’s mental and behavioral health

Questions needing extra information:
How satisfied are you with your life? – If very dissatisfied is selected, explain why
Do you feel that stress is affected your life? – If yes is selected, select the plan being used to manage stress
Do you have a history of substance misuse – If yes is selected select the type of misuse and if they have received treatment for it in the past 6 months.
– If no is then selected, select if the participant would like help for getting treatment.
Have you been diagnosed with a behavioral health disorder – If yes is selected, list the diagnoses
Are you receiving treatment for a behavioral health disorder – If no is selected, select if they would like help receiving treatment.

Questions that were asked/answered in other documents:
Feelings of loneliness, depression, and little interest – Correlates with InterRAI (sections E and F)
Have you been diagnosed with a behavioral health disorder – matches diagnoses stated in InterRAI, PCSP, Docusign and FP.
Do you have trouble falling or staying asleep, or sleeping too much? – matches InterRAI (Section J, question 3)

Pain

Questions regarding participant’s pain.

Questions needing extra information:
During the last month, have you had pain – If yes is selected (as it probably will be) you will need to answer the rest of the questions listed.

Questions that were asked/answered in other documents:
All questions – matches PCSP (pages 11&12, Pain/ADL’s); correlates with InterRAI (Section J, Health Conditions)

Activities of Daily Living

Questions regarding the participant’s ability to complete ADLs

Questions needing extra information:
Do you need help with the following activities – If yes is selected (as it probably will be) you will need to answer the rest of the questions listed.
Do you use any assistive devices? – If yes is selected, select the items used.
Do you receive any home health services? – If yes is selected, as it probably will be, select what types of home health services they receive.
Have you fallen in the last year? – Depending on the answer selected, more specific questions will be made

Questions that were asked/answered in other documents:
Do you need help with the following activities – match PCSP (pages 11&12, Pain/ADL’s), correlate with InterRAI (Section G, Functional Status)
Do you use any assistive devices – match PCSP (page 12, Pain/ADL’s); InterRAI (Section G, question 3)
Do you receive any home health services – match PCSP (page 12, Pain/ADL’s); correlate with PCSP Service Plan
Have you fallen in the past year – possibly correlates/matches with InterRAI (Section J, Health Conditions)

Additional Notes:

  • For ADLs, the answers given here should correlate with the detailed scores for the same tasks in the InterRAI (Section F, Functional Status)
    • If the task has a score of 0-2 in the InterRAI, then you should select yes to say the ptp is able to complete the task themselves.
    • If the task has a score of 3-6 in the InterRAI, then you should select no to say the ptp is NOT able to complete the task themselves.

For example – If you gave the participant a 0, for eating in the InterRAI, then in the PCSP and HRA-DSNP you should select yes for Are you able to eat meals and snacks by mouth without help? If you gave them a 5, on the other hand, then you should select no.

– For Home Health Services – if the participant receives PAS (as most do) then you should select Yes and then select the services they receive.
PAS would be classified as Personal Care

Life Planning

Questions needing extra information:
Are you interested in participating in care team meetings – If yes is selected, select the individuals the participant would like involved.

Questions that were asked/answered in other documents:
Do you have an Advanced Directive or Living Will – match PCSP (page 10, Life Planning)

General Information

Assessment completed by – SC name
Relationship to member – Other
– Service Coordinator

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