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1. Overview of PHW Comprehensive Needs Assessments

Type of Assessments

  • New Participant Orientation (NPO) – The Initial Assessment – Completed for participants who are new to the Waiver program, lost eligibility for more than 60 days, or are new to PHW/MCO transfer to PHW.
    • Those who are new to the waiver program have NPO visits completed by coordinators from the NPO team.
    • Those with lost eligibility or are new MCO transfers to PHW can have NPO visits be done by regular Service Coordinators
      • Coordinators MUST confirm this with their supervisor, who may or may not confirm with the PHW Account Manager if appropriate.
  • Annual Assessment – Routine Reassessment – Completed once a year to verify eligibility and make changes to the care plan, can be scheduled up to 60 days before the due date.
  • Quarterly Assessment – Routine Reassessment – Completed once every 3 months to update any changes to the care plan, can be scheduled up to 30 days before the due date.
  • Trigger Event Assessment* – Return and Significant Change in Status Assessment – Completed to follow up on Critical Incidents or to address participant’s requested changes or new requests to the care plan. Trigger event is also completed if a participant calls and requests a visit.  Trigger visits must be completed within 14 days of the participant request or precipitating event (ie. hospitalization).
    • *Trigger visits are documented in these assessments as Change in Health Condition.
    • If a participant requires a Trigger visit, first the SC should check to see when the Annual or Quarterly are due.  If the annual is due within 60 days, then it should be completed as an annual.  If the quarterly is due within 30 days then it should be done as a quarterly.  If annual and quarterly are not due within those time periods then SC should proceed with doing a trigger visit.

Documents for Visits

Documents completed for every visit:

  • 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
  • Health Risk Assessments (HRA/DSNP) – Found and completed through Envolve
  • Member Contact Assessment (MCA) – Found and completed through Envolve
  • Function Portal Session
    • Copy and paste to General Notes in Envolve

Completed for visits with special circumstances:

  • Covid Questionnaire  – Saved PDFs and Function Portal Session
    • Only done for F2F visits
  • Service Request Tool* – Docusign Packet and Envolve
    • Only completed for any requested changes in services through the Waiver
      • Including New Requests, Increases, Decreases, and Terminations of services
    • The draft is made by the SC in the Docusign Packet. The official SRT is created and submitted by the QA department in Envolve.
  • 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

  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. 
      1. Quarterly visits can (and should) be scheduled up to 30 days in advance of their due date
      2. Annual visits can (and should) be scheduled up to 60 days in advance of their due date
    • Confirm PCP and Pharmacy information with the participant!
      • 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 Docusign and InterRAI section A with demographic info of 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 MCA
    6. 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 confirmation email. 
        • Select “Other Actions” in the top right 
        • Select “View Certificate”
        • Download the certificate from the new webpage
    7. Copy the FP session to a “General Note” in Envolve

Once you submit the Docusign packet and Function Portal session then the QA 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 email you and your supervisor for corrections. 


Other Contacts (Non-Visits)

Quarterly Low Risk Assessment
  • When a participant is due for a Quarterly Assessment, but they confirmed that they are not making any updates or changes to their needs/care plan, coordinators can complete a “Quarterly Low Risk Assessment” in its place
  • Consists of a phone call to the participant, review of the questions/topics covered in the Quarterly Low Risk Assessment Function Portal session. 
    • That’s all! No other documents are necessary, and FP will create the MCA and General Note in Envolve!
  • The Quarterly Low Risk Assessment can ONLY replace a Quarterly visit and ONLY if there are no updates or changes. 
    • If the participant has a critical incident, is due for an Annual, or is requesting a change then you CANNOT complete the Low Risk Assessment
Monthly Contact
  • Monthly Contacts are NOT scheduled visits. They are phone calls to the participant to maintain communication, and make updates to participant information.
  • Monthly Contacts only require the Function Portal session. FP will create the MCA and General Note in Envolve automatically.
Next 2. Compliance Time Frames
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