Annual

Annual Contact Session

Used to document Annual contact visits. 

• Session Requires:
  • Appropriate answers to all required questions
• Corresponding sessions:
  • InterRAI session
  • HEDIS session
  • HRA/DSNP
  • PCSP session
  • Required Forms session

Example:

Process

1. Once Annual visit is scheduled in Function Portal, there will be an alert on the right side of the screen to Document the Annual Session

Documentation

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

This information MUST match the answer provided in the PCSP in Function Portal

3. Did the member accept of decline the Virtual Visit? – select if the member accepted virtual visit or why they declined
   1. If the visit was done virtually, select Member Accepted
   2. If the virtual visit was declined for other reasons answer:
      1. Reason for declining Virtual Visit
4. 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?
   1. Answer is based on if your participant has a rep and invited them or not
   2. 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?
5. Where did the visit take place? – This should match the Visit Type answered above
6. Where does the participant currently reside? – Coordinator should be confirming the client’s address and type of residence, then choose the appropriate answer.
   1. If the answer was “Home (with a caregiver)” then the coordinator needs the following information about the caregiver.
      1. Caregiver name
      2. Caregiver relationship 
      3. Does the caregiver live with member? 
      4. Does the caregiver provide natural support? – meaning does the caregiver provide informal/unpaid support?
      5. Is the caregiver paid?– meaning does the caregiver provide formal/paid support?
   2. If the answer was “Other” then the coordinator needs to state what the Other residential location is
   3. If the answer was: “AFCH, ALF, Hospice, or Nursing Home” the the caregiver must state what the Residential location facility name
7. Information provided by – Meaning who did the coordinator speak with during the call.
   1. If the answer involved “Other” then the SC needs to state who this other person was and why they spoke to them.
8. 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.
   1. Answer is most likely – Participant has NOT expressed desire…
   2. If the answer was “Participant has expressed desire …” the coordinator needs to state the current transition status
9. Did the participant’s demographics change?  – Has any of the information about the participant changed?
   1. If there was a change, then the coordinator must state what the changes are.
10. Member materials provided – Describe any resources, materials, or referrals that were given to the participant
11. Was the member referred to Nurtur?
12. Was the member referred to Disease Management?
13. Was the member referred to Behavioral Health?
14. Did the CC review the Member Handbook with the enrollee/authorized representative?
    1. If the Handbook was NOT reviewed, explain why.
15. Which Advanced Directives does the enrollee have? – select the advanced directives the participant has or None, but importance was discussed
    1. 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 (Life Planning section)

2. Change Event
   1. Questions here will only generate based on the selection(s) to which of the following occurred? asked in the previous section
   2. 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.
   3. 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.
   4. 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)
   5. 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”
      1. If changes were selected, describe the details of the changes
   6. 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.
3. Medical Conditions
   1. What changes to health did the participant report? – select if the participant feels their health has improved, declined, or remained the same
   2. Were there any changes to the participant’s medications or diagnoses?
   3. 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.
      1. If any visits occurred, provide details about the type of visit, why it was completed, and approximately when it occurred.
   4. 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
4. Goals
   1. What is the participant’s status of goals …? – select which option best applies to the discussion of goals made with the participant.
      1. Describe what was discussed about the goals in Goal status comments
   2. What is the participant’s selection for Participant Directed Option? – does the participant have Tempus as a provider? If so, select “Enrollee elected PDO”. If not, select “Enrollee does not wish to elect PDO at this time”
      1. 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)
5. Informal Support
   1. Does the participant receive informal support for Activities of Daily Living?
      1. If “participant receives informal support” answer the following:
         1. Supporter name
         2. Relationship to the participant
         3. Minimum hours informal support may provide
         4. Maximum hours informal support may provide
6. Observations of Participant and Environment
   1. Describe Participant’s environment and any concerns
      1. If the visit is Face to face, describe your observations
      2. If the visit is over the phone, have the participant describe their environment.

This information should match the answers provided in the InterRAI and PCSP

2. How was the participant dressed? Were they clean? (nails, hair, clothing)
   1. If visit is Face to face describe your observations
   2. If visit is over the phone, state you were unable to observe
3. What was the participant wearing? – state which common assistive devices the participant wears
   1. Select if the participant was wearing dentures, hearing aids, and/or glasses.
4. How were they moving around? – How the participant ambulated or regularly ambulates
   1. 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

5. Participant Story – Basic health information about the participant
   1. You can cut and paste the story put into the PCSP for Daily Routine
      1. This story should include the following information”
         1. Name
         2. Age
         3. Gender and Race
         4. Diagnoses
         5. Number of Medications
         6. Living Accommodations
         7. Formal/Informal Support
         8. ADLs and IADLs they require assistance with

7. Observations of Participant’s Mood/Behavior
   1. 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
   1. Coordinators must state how much assistance the participant needs with the following ADLs
      1. Bathing, Dressing, Grooming, Eating, Transferring, Toileting, and Bladder Management
   2. 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. 
   3. 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 
   4. 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

9. Satisfaction
   1. 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
   2. Is the participant receiving adult daycare services? – A common service that participants may receive
      1. 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
   3. Is the participant receiving care coordination services? – All participants receive care coordination so the answer should always be – Participant is receiving care coordination services
      1. 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
   4. 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
      1. 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
   5. 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
      1. 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
   6. Does the participant have a transportation provider? – A common service that participants may receive
      1. 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
10. Quality of Life
    1. Coordinators must go through the following and answer honestly
       1. Has the participant received a pneumovax vaccine since turning 65?
       2. Has the participant received a flu vaccine in the last 12 months?
       3. Does the participant have issues with bladder control?
          1. If the participant has issues with bladder control, then SC must answer: bladder control issue frequency
       4. Has the participant had a UTI in the past 3 months?
       5. Does the participant have issues with bowel control?
          1. If the participant has issues with bowel control, then SC must answer: bowel control issue frequency
       6. Does the participant have any skin breakdown?
          1. If the participant has skin breakdown, then SC must answer what type of breakdown there is (bruising, incision, tears, or wounds)
       7. Has the participant had any falls since the last contact?
          1. 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
       8. Is the participant able to do things they enjoy outside of their home and with whom they want?
       9. Is the participant able to make decisions about their daily routine?
       10. Does the participant feel safe in their home/where they live?
       11. Does the participant have a paid or volunteer job in the community?
       12. Does the participant like where they are living?
       13. Does the participant see or talk to friends and family with whom they do not live?
11. Resolution
    1. Did the member or Legal Rep, if applicable, sign the PCSP?

This answer should match the answer provided in section 2

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