Visits Overview

Visits Overview

Overview of PHW Visits

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 require a Function Portal Session as well as the completion of Comprehensive needs assessments (InterRAI, HRA, PCSP, HEDIS etc), while others require just a Function Portal session. For any participants that require an Interpreter to be able to speak their preferred language, the SC should be calling through Voyance to complete any interactions or assessments. Interpreter services are available for the SC to utilize at any time.



  • Quarterly Contact – A visit or phone call to the participant to maintain communication, and make updates to participant information and is done every 3 months.  Function portal will indicate when a Quarterly is due in the alerts on the right side of the screen.
    • Requires: A visit or call to the participant and the completion of a Quarterly contact Session in Function Portal
    • Quarterly contacts have to be scheduled in advance with the participant or POA and are scheduled in an Outbound call or Incoming call session in Function Portal.
    • Quarterly can be Telephonic or Face to Face
      • We are required to complete at least 2 F2F contacts with the ptp each year (also tracked in Function Portal). If these are done with Annual or Change Event visits, then the Quarterlies can all be telephonic. 
      • If only 1 (or none) of the visits are face to face, then the quarterlies should be face to face. 
    • These are NOT Comprehensive Needs Assessments, only the Function Portal session is completed for documentation.
  • Change Event – A 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 call or Incoming call session
      • Completion of ALL appropriate documents for Comprehensive Needs Assessments (stated below)
  • Annual Contact – A visit completed once a year to review the participants services and plan of care, making changes as needed
    • The due date for Annual Contact visits is a rolling date from the last visit that took place.
    • Requires:
      • Scheduling the visit with an Outbound call or Incoming call 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.

Documents for Comprehensive Needs Assessments

Change Event, Annual, and NPO Visits

  • InterRAI – completed in Function Portal Session
  • Person Centered Service Plan (PCSP) – completed in Function Portal Session AND must be signed by ptp/poa at the visit
  • Required Forms – completed in Function Portal Session AND must be signed by ptp/poa at the visit
  • HEDIS Supplemental Assessment – completed in FP Session
  • SRT – completed in Function Portal 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) – completed in Function Portal session

Completed for visits with special circumstances:

  • Covid 19 Screening  – Function Portal Session
    • Only done for F2F visits (Annual, Change Event, and NPO are all required to be done F2F)
  • RN Consultation – Function Portal Session
    • If the Service Coordinator needs to discuss special circumstances about the diagnosis or symptoms that the participant reports at the visit, then the SC will discuss with Nurse Irene and document the conversation if they have questions about the diagnosis and how it affects the participants functioning.

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 answers 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.  Face to Face visits are the requirement, only in special circumstances would a Telephonic or Virtual visit be done at this time.

The visit can take a significant amount of time to complete; both with and without the participant.  When scheduling you need to be aware of this and make the participant aware as well.

Main Strategy: Obtain all information needed for all of the documents, in the most concise way possible and ensure consistency between the documents.

This comes with experience, practice, and becoming familiar with the information covered in the documents.

COMPLIANCE – The SC MUST complete all documents of the Comprehensive Needs Assessment within 24 hours of visit taking place.

Once you submit all of the Function Portal sessions 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.  Service Coordinators and their Supervisors 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)
      • Make participants aware that visits can take anywhere between 2-3 hours. 
    • Confirm PCP and Pharmacy information with the participant
      • Refer to the previous Medication Profile
      • You can reach out to the PCP and Pharmacy for a list of Diagnoses and Medications BEFORE the visit or ask the participant to have the information readily available for when you arrive at the visit
    • Document the scheduling of the visit in a session in FP
      • This can be done via Incoming Call or Outbound Call sessions.
  2. 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
  3. Notify Supervisor of visits for the day after they have been confirmed
    • This takes place during the Team’s morning meeting
  4. Prepare for the visit
    • Review documents from previous assessments in FP. The more informed you are about your participant ahead of time, the more efficient the visit
    • Fill out whatever you can of the Comprehensive Needs Assessment documents BEFORE meeting with the participant, such as:
    • Complete the PCSP Service Plan based on the participant’s current authorizations
      • Review prior Needs, Outcomes, and Goals to discuss with the participant.
  5. Complete the Covid screening session in Function portal, if the visit is face to face, prior to the visit.

Service Coordinators are responsible for asking all questions for the assessments at the visit, even if there is documentation from a prior visit, it must be confirmed with the participant.

  1. Visit the participant to complete the entire assessment with the participant or the Power of Attorney
    1. Complete the InterRAI in Function Portal
    2. Complete Required Forms session in Function Portal AND have the ptp/poa sign the documents
    3. Complete PCSP in Function portal AND have the ptp/poa sign the document
    4. Complete HRA/DSNP in Function Portal
    5. Complete the HEDIS in Function Portal
    6. Complete Visit note session in Function Portal
    7. Complete SRT session in Function Portal
No Comments

Sorry, the comment form is closed at this time.