Form 2410, Medical-Social Assessment and Individual Plan of Care

Effective Date: 9/2014

Availability

PDF: 2410.pdf

Instructions

Updated: 9/2014

Purpose

This form is used to summarize the services that will meet the needs identified during the assessment process and to document that Medically Dependent Children Program (MDCP) services are feasible and cost effective.

Procedure

The Individual Plan of Care (IPC) must be completed in full. Items that are not applicable should be marked with N/A. Note the sections regarding contact schedule and use of back-up plans.

Detailed Instructions

Individual Information — Top of Each Page

Name — Enter applicant's/individual's full name.

IPC Period (From – To) — Enter the dates the IPC begins and ends.

For an initial IPC, the From date is no later than 30 days of the eligibility determination date documented by the case manager on Form 2065-B, Notification of Waiver Services. If the From date is the:

  • first day of the month, the To date is the last day of the 12th month; or
  • any date except for the first day of the month, the To date is the last day of the 13th month.

For an annual IPC, the:

  • From date is the day after the current IPC ends; and
  • To date is the last day of the 12th month.

For an initial or annual IPC in which the applicant/individual ages out, the To date is the day before the applicant's/individual's 21st birthday.

Information completed by the MDCP case manager or nurse:

1. — Enter the applicant's/individual's date of birth.

2. — Enter the applicant's/individual's Medicaid number.

3. — Enter the applicant's/individual's Social Security number.

4. — Enter the name(s) of applicant's/individual's primary caregiver(s) and the primary caregiver's relationship to the applicant/individual (mother, father, aunt, etc).

5. — Enter the area code and telephone number of the primary caregiver(s).

6. — Enter the applicant's/individual's address.

7. — Leave blank.

8. — Enter the Resource Utilization Group (RUG).

9. — Enter the date Texas Medicaid and Healthcare Partnership (TMHP) determined medical necessity (MN).

10. — Check if this is an initial or annual IPC (use interim plan of care form for mid-year changes).

11. — Enter the full name of applicant's/individual's physician.

12. — Enter the physician's area code and telephone number.

13. — Enter the physician's street address.

14. — Enter the city in which physician is located.

15. — Enter the state in which physician is located.

16. — Enter the physician's ZIP code.

17. (Answer for initial cases only) — Check the box that represents the applicant's placement at the beginning of the eligibility process: Hospital, Nursing Facility (NF), Home, or specify if the placement is Other.

Part I — Medical Assessment

This section is completed by the MDCP nurse. If additional pages of health information items are attached, mark the box next to the Medical Assessment header.

18. — Check the box for the source of the information (family, physician or if other, specify). Enter the name of the person interviewed.

19. a-f: — List the applicant's/individual's diagnosis.

20. — Check the box to indicate whether the applicant/individual uses a ventilator. If yes, briefly describe the type and frequency of use.

21a. — Give the dates and reasons for any hospitalizations within the last 12 months.

21b. — List recent acute illnesses requiring physician evaluation, treatment or interventions.

21c. — List any planned or potential inpatient or outpatient hospitalizations within the next six months.

22a. — Describe relevant health information, including applicant's/individual's appearance, nutritional status, developmental disabilities, mobility and functional limitations.

22b. — Describe any current treatments in which the applicant/individual is involved.

22c. — Describe any medical equipment/assistive devices in use and/or needed.

22d. — Describe the applicant's/individual's prognosis, if known.

22e. — Describe the applicant's/individual's allergies.

23. — Check the appropriate box.

24. — Check the appropriate box.

25. — Indicate the short-term goals.

26. — Indicate the long-term goals.

The MDCP nurse signs and dates the form, and enters the region, area code and telephone number. The date documented on the form must be the date the interview was conducted.

Part II A — Social Assessment

27. — Give a brief description of the applicant's/individual's physical, emotional, cognitive, and behavioral functioning.

28. — Identify the household members' ages and relationship to the applicant/individual.

29. — Identify the primary caregiver(s).

29a. — Identify the abilities and limitations of the primary caregiver(s) regarding the provision of care to the applicant/individual.

29b. — Identify the abilities and limitations of others in the household regarding the provision of care to the applicant/individual.

30. — Enter family relationships and dynamics.

31a. — Note any financial resources or limitations or if a family is receiving assistance through the Health Insurance Premium Payment (HIPP) Reimbursement Program.

31b. — List the work schedules of the caregiver(s) as they impact the family's ability to provide care to the applicant/individual. For example, both parents work full time, the father's employment requires extensive traveling, etc. Describe the family's social resources and limitations.

32. — Describe any community resources the family utilizes.

33. — Indicate school district services.

33a. — Check if the applicant/individual receives homebound education and the number of hours per day, or check if the applicant/individual is home-schooled by choice.

33b. — Check if the applicant/individual attends public school, the number of hours per day and the type of classroom setting.

33c. — Check the method of school transportation.

34. — Describe any inclusion activities and indicate whether they have occurred or are in the planning stage.

35. — Describe any permanency planning discussions or activities underway.

36. — List any other special needs or considerations that impact the applicant's/individual's care. For example, a caregiver who is scheduled to undergo future medical intervention, a resource (sibling, aunt, etc.) who is available currently to assist with care, but will not be available past a certain date.

37a-c. — Describe any safety or environmental health hazards.

38a-c. — Describe any recommendations/actions to address identified safety/environmental health hazards.

The case manager signs and dates the form, and enters the region, area code and telephone number. The date documented on the form must be the date the interview was conducted.

Part II B — MDCP Schedule Planning Grid

39. — Document the typical schedule of the applicant/individual using codes noted in items 42-46. The hours that the applicant/individual attends school should be identified as S. Hours provided by other sources not listed are identified as O.

40. — Note any alternate schedules (summer, school breaks, etc.) and use a duplicate form, identified as page 3a., 3b., etc., if needed.

41. — List the total number of child care hours from all sources needed each week.

Note: All hours reflected in numbers 42 – 46 should be reflected on the schedule planning grid

42a. — Identify the number of nursing hours provided by the insurance company each week.

42b. — Identify the number of physical therapy (PT), occupational therapy (OT) or speech therapy hours provided by the insurance company each week.

43. — Non-Waiver Services: Complete 43a. for schooled-aged applicants/individuals and 43b. for applicants/individuals using personal care services (PCS).

43a. — Identify the number of hours the applicant/individual is at school or in a school setting such as the school bus.

43b. —Identify the number of hours provided by PCS each week.

44a. — Identify the number of private duty nursing hours provided through the comprehensive care program (CCP) each week.

44b. — Identify the number of PT, OT or speech therapy hours provided by Medicaid each week.

44c. — Identify the number of home health hours provided by Medicaid each week.

45a. — Identify the number of hands-on skilled/personal care provided by the primary caregiver(s) each week.

45b. — Identify the number of hours of general supervision provided by the primary caregiver(s) each week.

45c. — Identify the number of hours that the parent pays for child care each week.

46a. — Identify the number and type of respite hours through MDCP the family plans to use each week. The case manager may authorize respite to give the primary caregiver(s) a break from caregiving during the time identified in 45a. and 45b.

46b. — Identify the number and type of flexible family support service hours through MDCP the family plans to use each week. The case manager may authorize flexible family support services during the time identified in 45c., and while the parent is at work, school or job training.

46c. — Identify the number of employment assistance hours through MDCP the family plans to use each week.

46d. — Identify the number of supported employment hours through MDCP the family plans to use each week.

Part II C — Individual Plan of Care Summary

47a. — Check Yes or No to indicate whether the family is selecting to use respite during this plan of care period. Use the comment field as needed.

47b. — Check Yes or No to indicate whether the family is selecting to use flexible family support services during this plan of care period. Use the comment field to identify the setting where flexible family support services are to be delivered.

47c. — Check Yes or No to indicate whether the applicant/individual or family is selecting to use adaptive aids during this plan of care period. Use the comment field to identify the type of adaptive support.

47d. — Check Yes or No to indicate whether the applicant/individual or family is selecting to use minor home modifications during this plan of care period. Use the comment field to identify the type of home modification.

47e. — Check Yes or No to indicate whether the applicant/individual or family is selecting to use Financial Management Services during this plan of care period. Use the comment field as needed.

47f. — Check Yes or No to indicate whether the applicant/individual or family is selecting to use Transition Assistance Services during this plan of care period. Use the comment field as needed.

47g. — Check Yes or No to indicate whether the applicant/individual or family is selecting to use Employment Assistance during this plan of care period. Use the comment field as needed.

47h. — Check Yes or No to indicate whether the applicant/individual or family is selecting to use Supported Employment during this plan of care period. Use the comment field as needed.

48. — Check Yes or No to indicate whether or not the applicant/individual or family had difficulty finding the provider, nurse or attendant of choice.

49. — If Yes is checked in 48, describe the difficulty (for example, the family was unable to obtain an attendant in the area).

50a. — Identify any services or equipment requested from another agency (lifts, aide services, etc.).

50b. — Identify the service/agency from which the service/equipment is requested (CCP, PCS, etc.).

50c. — Identify the date the service/equipment was requested. If unknown, provide a time frame.

50d. — Identify the status of the request (for example, the family states it has received no response; the request was denied and family is appealing; the family says it expects to hear in two weeks).

Document the follow-up schedule. At a minimum, the case manager reviews the plan of care every six months. If follow-up is needed, the case manager may schedule a face-to-face visit sooner. Some individuals/families will need only a minimum contact per year (one face-to-face visit and one telephone contact), while others will require or request more frequent contact.

51a. — If any items are identified in question 50, they must be reflected in the follow-up plan.

51b. — Indicate the planned date of contact or time frame.

51c. — Indicate the method of contact (telephone, mail, email, in person).

Part III — MDCP Individual Plan of Care/Budget Worksheet

52. — Indicate if this is an initial or annual IPC by marking the appropriate box.

53. — Indicate the RUG.

53a. — Indicate the IPC cost limit for the RUG.

54. — Indicate whether the applicant/individual is eligible for Supplemental Security Income (SSI).

54a. — Enter the date SSI eligibility was verified.

55a. — Enter the disability determination date.

55b. — Enter the latest Medicaid eligibility date.

Respite/Flexible Family Support Services Budget Items

56. — If using flexible family support services, check the setting in which the service will be delivered (child care, independent living, post secondary education).

56a. — Indicate respite services by using R and flexible family support services by using F. If the individual/family will self-direct attendants through the Consumer Directed Services (CDS) option, use FR to indicate that the attendant will deliver respite, and use FF to indicate that the attendant will deliver flexible family support services.

56b. — Indicate the date services will begin.

56c. — Indicate the date services will end. (56b – 56c may be a full IPC period or some period of time within the IPC period, such as June 1 – August 18).

56d. — Indicate the provider type the applicant/individual/family plans to use for the period from 56b to 56c.

  • For Respite or Flexible Family Support Services;
  • RN – RN
    LVN – LVN
    Att – HCSS attendant or an attendant hired under the CDS option
    AttDT – HCSS attendant with delegated tasks

  • For out-of-home Respite:
  • NF – Nursing Facility
    CC – Child Care
    SPF – Special Care Facility
    Hosp – Hospital
    HF – Host Families
    Camp – Camp

56e. — Indicate the number of hours per week the applicant/individual/family plans to use this provider type for the time period specified in 56b. to 56c.

56f. — Determine the number of days in the time period from 56b. to 56c. Divide the total number of days by 7 to get the number of weeks. Put the number of weeks in 56f.

56g. — Multiply the number of hours per week (56e.) by the number of weeks (56f.) to get the total number of hours. Put the total number of hours in 56g.

56h. — Enter the rate per hour for this provider type.

56i. — Multiply the rate per hour (56h.) by the total number of hours (56g.) to get the total cost. Repeat this process for each line in box 56 until all of the time periods for which the applicant/individual/family plans to use respite and flexible family support services are reflected in the budget.

56j. — Add up all of the costs in the boxes under 56i. for a total cost for respite and flexible family support services. Enter the total in 56j., Total 1.

Back-Up Plans

If the applicant/individual/family plans to share respite or flexible family support services between provider types or the applicant/individual/family wants to use a back-up provider of a different type, the case manager must budget funds to that provider or the back-up provider cannot be paid until the case manager completes an interim plan of care or budget revision. The case manager needs to consider the IPC budget as a line item budget. Just as funds budgeted for respite cannot be expended for minor home modifications, adaptive aids or flexible family support services, funds budgeted for an LVN cannot be expended for an RN (regardless of the rate the RN charges or whether the funds are available).

The simple method for budgeting back-up plans is to determine first whether the applicant/individual/family plans to share the hours or have a back-up for emergencies. If they plan to share the hours among two or more provider types, the case manager calculates a percentage. The case manager documents each provider in the plan at the appropriate level.

Note: If a case manager writes a plan that contains two plans (for example, an LVN all year or an RN all year), only the first plan will be entered. The "or" part of the plan cannot be entered. If the case manager issues an authorization to a provider whose type is not on the plan (for example, to an RN when all of the hours are budgeted for an LVN), the authorization cannot be entered and the provider will not be paid until the case manager completes an interim plan of care or budget revision. The provider can only be paid for the number of units authorized. If the provider needs more hours as a back-up provider, the case manager must do a budget revision.

Transition Assistance Services (TAS)

57. — Enter the total authorized amount for TAS in Total 2.

Minor Home Modifications Budget Items

58a. — Indicate the type of modification (doorway widening, ramp, bathroom modifications).

58b. — Enter the estimated cost.

58c. — Add all totals in 58b to get a total amount of this request (subtotal).

58d. — List any previous expenditures for home modifications (from any IPC periods).

58e. — Add line 58c. (subtotal) + line 58d. If this total is more than $7,500, the request will put the individual over the lifetime maximum service limit and the individual/family may need to contribute to the cost of the Minor Home Modification as an Enhancement.

58f. — Add the specification fee if applicable. The specification fee is not included in the $7,500 lifetime maximum service limit. Enter the total in the large box to the right of Total 3.

58g. — Enter the cost of any maintenance/repair being requested for a previously approved MDCP Minor Home Modification. The amount may not exceed $300 annually. (This becomes Total 4.)

Adaptive Aids Budget Items

59a. — Enter the type of adaptive aid.

59b. — Enter the estimated cost of the adaptive aid.

Repeat this process on subsequent lines for each adaptive aid requested.

59c. — Add all totals in 59b. to get a total amount for adaptive aids, Total 5.

Employment Assitance (EA) and Supported Employment (SE) Budget Items

60a. — Indicate employment assistance by using EA and supported employment by using SE. If the individual/family will self-direct through the Consumer Directed Services (CDS) option, use EAV to indicate employment assistance and use SEV to indicate supported employment.

60b. — Indicate the data services will begin.

60c. — Indicate the data services will end. (60b - 60c may be a full IPC period or some period of time within the IPC period, such as June 1 - August 18).

60d. — Indicate the number of hours per week the applicant/individual/family plans to use this provider type for the time period specified in 60b. to 60c.

60e. — Determine the number of days in the time period from 60b. to 60c. Divide the total number of days by 7 to get the number of weeks. Put the number of weeks in 60e.

60f. — Mulitply the number of hours per week (60d.) by the number of weeks (60e.) to get the total number of hours. Put the total number of hours in 60f.

60g. — Enter the rate per hour for this provider type.

60h. — Mulitply the rate per hour (60g.) by the total number of hours (60f.) to get the total cost. Repeat this process for each line in box 60 until all of the time periods for which the applicant/individual/family plans to use employment assistance and supported employment are reflected in the budget.

60i. — Add up all of the costs in the boxes under 60h. for a total cost for employment assistance and supported employment. Enter the total in 60i., Total 6.

61. (Total) — Add the totals from each category: Total 1+2+3+4+5+6 to get the total IPC budget. If this amount exceeds the amount in 53b. (the maximum annual cost limit for the individual's RUG), revise the plan. If this amount is below the maximum annual cost limit, the plan should not be revised at this time. However, should the family or applicant's/individual's needs change, the plan may be revised and the total annual cost limit remains available to the individual when needed.

62. — Enter the name of the primary caregiver.

63. — Enter the primary caregiver's relationship to the applicant/individual.

Part IV — Individual Plan of Care – Signature/Approval

64. — The primary caregiver may sign, date and indicate the ability to authorize plan changes verbally, or may require that all plan changes be submitted for his/her signature.

65. — The case manager signs the form to confirm that the plan was completed in collaboration with the primary caregiver and that he/she has reviewed the family's rights and responsibilities, indicating that plan changes can be made, if needed. The case manager signs and dates the form after the entire IPC has been completed.

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