Quarterly Visit

Used to document Quarterly Contacts.

• Session Requires:
  • Appropriate answer to all required questions

Process

1. Contact the participant to Schedule their Quarterly visit
   1. Pay close attention to the amount of face to face visits have been completed at this point in the year, of the 2 that are required, when scheduling your Quarterly (see blue section in alerts, in the below example)
2. The Incoming call or Outbound call sessions will be used to schedule the Quarterly visit in function portal.
3. Once Quarterly visit is scheduled in Function Portal an alert to document the Quarterly will appear on the right side of the screen
4. Click “document” and it will open the Quarterly session that needs to be completed.

Example:

Documentation

1. Visit Conditions
   1. Visit Type – How are you contacting the participant?

• Select the appropriate answer
  • Face to Face 
  • Telephone

2. 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?
3. Where did the visit take place? – Better known as “where did the contact take place?

• Select the most appropriate answer
  1. The answer should correspond with the answer from “visit type”

4. 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.
     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?
   • If the answer was “Other” then the coordinator needs to state what the Other residential location is
   • If the answer was: “AFCH, Assisted Living Facility, Hospice, or Nursing Home” then the Service coordinator must state the name of the Residential location facility
5. Information provided by – Meaning who did the service coordinator speak with during the call or visit
   • If the answer involved “Other” then the coordinator needs to state who this other person was and why they spoke to them. 
6. 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

7. 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. 
8. Member materials provided – Describe any resources, materials, or referrals that were given to the participant
9. Was the member referred to Nurtur?
10. Was the member referred to Disease Management?
11. Was the member referred to Behavioral Health?

2. Medical Conditions
   1. 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?
      • 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
   2. 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

3. Activities of Daily Living
   • Coordinators must state how much assistance the participant needs with the following ADLs
     1. Bathing, Dressing, Grooming, Eating, Transferring, Toileting, and Bladder Management

1. Does the participant receive informal support for activities of daily living? 
   • 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.
2. Does the participant have unmet needs for daily living? – Does the participant need any services or devices?
   • If the participant has unmet needs then the coordinator needs to put in what these unmet needs are in Describe 
3. Does the participant use assistive devices/durable medical equipment for activities of daily living?
   • 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
     1. Meal Preparation, Housework, Laundry, Shopping, Transportation, Manage Money, Mange Medications, Using Telephone
   2. Does the participant receive informal support for activities of daily living? 
      • 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?
      • 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?
      • 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
   1. Who was present during the visit? – select all who were present during the conversation
      • SC MUST be selected
   2. Describe Participant’s environment and any concerns
      • Have the participant describe their environment and any concerns they have. 
   3. 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
   4. 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.
   5. 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
   6. Participant Story – Basic Health information about the participant
      • 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

6. Satisfaction
   1. Is the participant satisfied with services and/or providers reflected on their plan of care?
      • 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
      • 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
      • 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
      • 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
      • 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
      • 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
   1. 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 past year?
      • 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
      • Has the participant had a UTI in the past 3 months?
      • 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
      • 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)
      • 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?
   1. 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?

If the Participant has past Quarterly Visits that have been completed, the Service Coordinator is still responsible for asking all questions during the interaction and verifying any past information is correct.

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Practice Quarterly Visit

1. Go into one of the participants assigned to you in Test Function Portal and schedule a Quarterly Visit
   • Schedule it for 5 minutes from the time you are submitting your incoming/outbound call session (make sure you are not scheduling it for a future date or the alert will not show up)
2. Once it is scheduled, allow time for the alert to pop up on the right hand side of the Test Function Portal screen
3. Document your practice Quarterly Visit and submit.
   • Let your Supervisor know once it is completed, so they can review with you and answer any questions you may have.