Resources
Your client is homeless and has a limited income. Name 3 applications you are going to immediately complete with them
1. Coordinated entry
2. ESSHI
4. RSP- just an email
5. The Cornerstone
5. SPOA- if they have SMI
What is the longest someone can remain pended?
6 months
After receiving a hospital alert, you have ___ business days to reach out to the PP.
2
A care plan must be completed with the client __/year.
twice
Every 6 months
Name 3 reasons why someone would be discharged?
1. Graduation
2. Voluntary Discharge
3. moving out of county
What agencies provide diapers? (2)
Salvation Army
Tristate pregnancy
What are some examples of a excluded setting (3) and what is its impact on our services?
We cannot bill for an individual while they are in an excluded setting.
Jail, inpatient hospitalization, rehab (physical or substance use), assisted living facility, and nursing home.
You get a hospital alert on your client but you are unable to reach them. What are your next steps?
Reaching out to a peer, emergency contact, the hospital or another provider we have consent to speak to
True or False: Completing yearly paperwork with a client does not need to be mentioned in a note
False.
It must be documented for auditing purposes but also to fully document what took place in that visit.
What needs to be closed out in FCM as a part of the discharge process?
The Care Plan
Your client is socially isolated. Where might be good supports to refer them to?
Compeer, Hudson House, Social program, Mulberry house (if a senior), or a friendly visitor (JFS)
In addition to addressing a Gap In Care in a progress note, what else needs to be completed in FCM to close a gap in care?
Updating the status on the Gap In Care tab.
Where can you check to see if your client signed a healtheconnections consent?
Colorful sheet
Documents in FCM
Intakes completes all of the yearly paperwork except the _____
Care Plan.
But they do get the signature page signed for you.
If the CES Tool determines someone should graduate our program, who other than the client should you have this conversation with as well?
A care team member.
*For all discharges as well
Your client is interested in finding employment and ask you to connect them to employment or vocational services. Where can you apply them?
ACCESS VR
CORE (if they qualify)
Orange County Career Center
T/F If an initial care plan is not entered within the first 90 days, we can never receive payment for that client.
False- 60 days
What kind of hospital alert could also be an incident? (3)
Death (if not of natural causes)
Suicide Attempt
Overdose
What qualifying conditions does someone need to enroll in our program?
1 SMI or HIV diagnosis
2 chronic conditions
What forms need to be mailed to a client when they are being discharged? (2)
DOH 5235- Notice of Disenrollment
Healtheconnections consent- with the denial checked off
Your client needs $400 to pay their electric company so their electric is not shut off. Where could you apply them? (3)
DSS, Rotary Club (if they live in middletown), Jewish Family Services, Deacon Fund, People for People (if they are working), Salvation Army, or service dollars
Care Plan goals should be SMART goals. What does SMART stand for?
specific, measurable, achievable, realistic, and time-bound
Your client goes into the hospital after a fall. What kind of supports should you discuss with them to help them continue to live independently? (2)
1. Home Health Aide
2. Home accessibility supports
3. Life alert device
What is the minimum amount of care plan goals needed?
3
How often are CES Tools completed?
after 12 months of enrollment, every 6 months after.