Resources
Your client is homeless and has a limited income. Name 4 applications you are going to complete with them
1. Coordinated entry
2. SPOA
3. ESSHI
4. RSP- just an email
5. Cornerstone
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.
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
Name 3 reasons why someone would be discharged?
1. Graduation
2. Voluntary Discharge
3. moving out of county
4. in an excluded setting
What agencies provide diapers? (2)
Salvation Army
Tristate pregnancy
St. Paul's
Someone can remain pended for how long?
6 months.
True or False. You need to call your PP after their hospitalization to confirm they attended their follow up appointment?
True
Best practice would be to take them if they are agreeable to this.
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, Mulberry house (if a senior)
Gaps in Care should be discussed with the client and also may be reflected in the client's ______?
Care Plan
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. Their goals are confirmed when you first reach out to them and then the CM enters the Care Plan in.
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.
Your 60 year old client has become homeless. You have applied them to all housing options and they are afraid of going into the shelter system. Where else could they go?
Assisted Living Facility
Care Plan goals should be SMART goals. What does SMART stand for?
specific, measurable, achievable, realistic, and time-bound
Can kind of hospital alert could also be an incident? (2)
Death (if not of natural causes)
Suicide Attempt
Overdose
Do you need to have the client sign the initial care plan?
No, there is a signed signature page in the intake already.
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?
Rotary Club, Jewish Family Services, Deacon Fund, United Way, People for People (if they are working), Salvation Army, service dollars
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
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
The DOH 5055 and comprehensive assessment need to be completed within what timeframe?
364 days of the previous one.
What are the 3 sections in the AWARDS discharge?
1.Disposition Statement/ explanation for discharge
2.Interventions/ Goals/ What was accomplished
3. Discharge Summary-demographics, enrollment info, & discharge reason