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, PCSP, HEDIS etc), while others require just a Function Portal session.

Types of Contacts

Scheduled

• Quarterly Contact – A face to face visit or telephone 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 if being completed Face to Face.
  • Telephonic quarterlies can be completed via the session alert on the right hand side of the Function Portal session. These DO NOT need to be scheduled in advance, but are REQUIRED to be completed by the due date. It is recommended to attempt completion two weeks before their due date.
  • 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 be telephonic.
  • If only 1 (or none) of the visits are face to face, then the quarterlies should be face to face.
  • IMPORTANT: 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.
  • Participant lost eligibility for more than 60 days or are new to PHW/are an MCO transfer to PHW.
  • You will schedule NPO’s through a welcome call session, NOT an outbound or incoming call session.
    • 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) – FP Session
• HEDIS Supplemental Assessment – FP Session
• Visit Session– FP 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

Completed for visits with special circumstances:

• Service Request Tool (SRT) – FP session
  • Completed for Annual/NPO visits (regardless if there is a requested change)
  • Completed when requesting new services, or requesting changes in services.

Visit/Assessment Process

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 review.

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 Face to Face. Face to Face visits are the requirement, only for Quarterly contacts would a Telephonic 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.

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

Once you submit the Function Portal sessions then the Quality Assurance team will receive, review, and upload all documents of the visit to FP and Envolve if needed. 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.

ALL TASKS FROM QA MUST BE RESOLVED PRIOR TO THE TIME THE DUE DATE AND TIME SPECIFIED IN THE TASK

Specific Details/Tips

1. Schedule visit with the participant
   • Schedule upcoming due visits based on compliance dates
     • 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 that the visit was scheduled, in the appropriate FP session. 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
4. If time permits, prepare for your visit
   • Review documents from previous assessments in FP. The more informed you are about your participant ahead of time, the more efficient the visit will be.
   • Fill out whatever you can of the Comprehensive Needs Assessment sessions 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.
       • Even if there is previous information present from a past visit, the SC MUST confirm the information and NOT ASSUME that information is still accurate and current from the last assessment.

5. Visit the participant to complete the entire assessment with the participant

1. Complete the InterRAI in Function Portal
2. Complete PCSP in Function Portal
3. Complete the HEDIS in Function Portal
4. Complete Visit note session in Function Portal