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1. Overview of PHW Contacts and Comprehensive Needs Assessments

The following contacts are required by PHW at certain intervals or in different scenarios. It is Important to note the differences between the contacts, as some are Comprehensive Needs Assessments (aka. Visits) and others are simple contacts.

Types of Contacts


  • Monthly Contact – A Phone call to the participant to maintain communication, and make updates to participant information.
    • Requires: Calling the participant and documenting a Monthly Contact FP session
    • They do NOT need to be scheduled with the participant. Just call the participant before the due date (within the same month it is due) and complete the FP Session.
    • These are NOT Comprehensive Needs Assessments


  • Change Event – A Comprehensive Needs Assessment visit to document significant changes in the participant’s health, caregiver(s), and/or services. Schedule a Change Event visit when:
    • The participant reports a change in their health or caregiver(s) that requires a change in their services even if they aren’t due for a visit
    • The participant has had a Critical Incident, such as a Hospitalization or ER visit
    • The participant is requesting a change in their services
    • Requires:
      • Scheduling the visit with an Outbound, Incoming, or Monthly contact session
      • Completion of ALL appropriate documents for Comprehensive Needs Assessments (stated below)
  • Annual Contact – A Comprehensive Needs Assessment visit completed once a year to verify eligibility and make changes to the care plan.
    • The due date for Annual Contact visits is a rolling date from the last Change Event visit the participant had.
    • Requires:
      • Scheduling the visit with an Outbound, Incoming, or Monthly contact session up to 60 days before the assessment due date
      • Completion of ALL appropriate documents for Comprehensive Needs Assessments (stated below)
  • New Participant Orientation (NPO) – A Comprehensive Needs Assessment to initiate services with PHW. NPO visits will be scheduled if:
    • Participant is brand new to the waiver program.
      • These visits will be done by NPO Coordinators
    • Participant lost eligibility for more than 60 days or are new to PHW/are an MCO transfer to PHW.
      • These visits can be done by regular Service Coordinators.
      • SC MUST confirm this with their supervisor, who may or may not confirm with the PHW Account Manager is appropriate.

Documents for Comprehensive Needs Assessments

Change Event, Annual, and NPO Visits

  • InterRAI – Saved PDF that you have. Completed in Xodo or Adobe
  • Docusign Packet – Sent to you through Docusign link in email
  • Person Centered Service Plan (PCSP) – Sent to you through Docusign link in email
  • HEDIS Supplemental Assessment – FP Session
  • Function Portal Visit Session
    • Click on the “Document Visit” button on the right hand side of the sessions screen, under the scheduled session.
    • The FP Session will automatically create and submit the MCA for you, as well as make the General Note in Envolve
  • Health Risk Assessment (HRA/DSNP) – Found and completed through Envolve

Completed for visits with special circumstances:

  • Service Request Tool (SRT) – Sent to you through Docusign link in email
    • Completed for Annual visits (regardless if there is a requested change)
    • Completed when requesting new services, or requesting changes in services.
  • Covid Questionnaire  – Saved PDFs and Function Portal Session
    • Only done for F2F visits
  • RN Consultation – Function Portal Session
    • If Increase/Decrease of PAS is needed (based on participant request or SPG tool calculation) you will need to meet with Nurse Irene and document the conversation.

Visit/Assessment Process

Main Process/Overview

Purpose: To do a full assessment of the participant’s health, capabilities, recent changes, and needs so that requests in services and an appropriate service plan can be given to PHW for approval

You need to complete ALL of the documents for the Comprehensive Needs Assessment based on answer provided by the PARTICIPANT (and/or responsible parties present) within the compliance timeframe

The visit involves meeting with the participant and/or responsible parties either Face to Face, Virtually, or Telephonically.

The visit can take hours; both with and without the participant.

Main Strategy: Obtain all information needed for all of the documents, without wasting the participant’s time while filling out the documents.

This comes with experience, practice, and knowing everything asked in all documents.

COMPLIANCE – The SC MUST complete all documents of the Comprehensive Needs Assessment within 24 hours of scheduled meeting.

Once you submit the Docusign packet and Function Portal session then the Quality Assurance team will receive, review, and upload all documents of the visit to FP and Envolve. If there are errors that QA cannot fix, they will create a task, you and your SCS will be notified of the task in FP and Email.


Specific Details

  1. Schedule visit with the participant
    • Schedule upcoming due visits based on compliance dates (made by previous visits)
      1. Warn participants that visits can take anywhere between 2-3 hours. 
    • Confirm PCP and Pharmacy information with the participant!
      • Refer to the previous Medication Profile
      • Then you can reach out to the PCP and Pharmacy for a list of Diagnoses and Medications BEFORE the visit!
    • Document the Visit Scheduled session in FP 
      • This can be done via Incoming or Outbound Call session, Monthly Contact session.
  1. Confirm visits with participants ahead of time to prevent last minute cancellations
    • Call all visits scheduled for the week at the beginning of the week
    • Call all visits for the day, first thing in the morning on the day of the visit
  1. Notify Supervisor of visits for the day after they have been confirmed
    • Supervisor will send the Docusign Packet and PCSP for the visit through Docusign
  1. If time permits, prepare for your visit
    • Review documents from previous assessments in FP and Envolve. The more informed you are about your participant ahead of time, the visit will be more efficient and the participant will be happier.
    • Fill out whatever you can of the Comprehensive Needs Assessment documents BEFORE meeting with the participant, such as:
      • Use a previously completed InterRAI
        • Change Demographic and specific visit details such as the date and type of visit
        • Update the list of Medications from the Pharmacy
        • Update the stated Diagnoses from the PCP.
      • Complete the Docusign Packet based on the most recent Docusign Documents
      • Complete the PCSP Service Plan based on the participant’s current authorizations
        • Review prior Needs, Outcomes, and Goals to discuss with the participant.


  1. Call or visit the participant to complete the entire assessment with the participant
    1. Complete the InterRAI first
    2. Review Docusign packet
    3. Complete PCSP
    4. Complete HRA/DSNP
    5. Complete FP session
      • FP session will require Docusign Certificate and InterRAI as an attachment. Obtain the Docusign Certificate AFTER completing/submitting the Docusign packet and PCSP
        • Once completed, select “Review Documents” from the last email sent to complete the packet. 
        • Select “Other Actions” in the top right 
        • Select “View Certificate”
        • Download the certificate from the new webpage
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