fida online training module3
DESCRIPTION
FIDA Online Training for NYC Providers - Module 3TRANSCRIPT
Copyright 2014 ValueOptions.® All rights reserved.
Interdisciplinary Care
Team (IDT)
1
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Learning Objectives
2
1:
2:
3:
4
Understand Person-Centered Service Plan (PCSP)
Describe Health Assessments in IDT Context
Outline Interdisciplinary Team (IDT) Purpose & Roles
3:
4:
Copyright 2014 ValueOptions.® All rights reserved.
Interdisciplinary Team (IDT): Composition
3
Definition:
• Professionals from different medical and behavioral health
disciplines working toward a common goal and responsibility
of the group effort
Must include:
• Participant
• Behavioral Health Professional
• Primary Care Provider (PCP) or clinical designee from practice
• Primary Care Manager – IDT Lead
Can Include:
• Participant’s designee (i.e., caregiver, family)
• Home Care Aide(s)
• Nursing Facility Representative
• Other Providers
Copyright 2014 ValueOptions.® All rights reserved.
Interdisciplinary Team (IDT): Roles
4
The IDT is led by an assigned Care Manager at
the FIDA Plan
Under the FIDA Program, the IDT:
• Writes, monitors and participates in a person-centered health service plan (PCSP)
• Contributes to ongoing care management activities
• Authorizes FIDA covered health services
• Reviews participant health care plan at least every six
(6) months or whenever a significant change occurs
Copyright 2014 ValueOptions.® All rights reserved.
Interdisciplinary Team (IDT): Roles cont’d.
5
Highly encouraged to work collaboratively
• The goal is for consensus with treatment decisions while
keeping participant’s specific needs and preferences in
consideration
If conflict with Treatment Decision(s):
• For care decisions requiring a provider with a specific
licensure and / or certification, decision always rests with
appropriately licensed and / or certified treating
member(s) of the IDT
Copyright 2014 ValueOptions.® All rights reserved.
IDT: Role of Participating Provider
6
As a ValueOptions provider, you play an integral role for the FIDA plan
in that you provide the expertise to assess, evaluate, and provide
services related to mental health and / or substance abuse deemed
necessary to meet the requirements set forth by the Interdisciplinary
Care Team’s (IDT) Person-Centered Service Plan (PCSP).
• To support the PCSP, the following must be made available
to all IDT members, including, but not limited to:
Documentation of all care and services rendered to the
Participant
Current and past assessments, reassessments and any file
notes that include the Participant’s response to treatment
Medication records
A signed release permitting disclosure of personal information
Copyright 2014 ValueOptions.® All rights reserved.
FIDA Model of Care: Overview
7
RN-assessor conducts initial assessment
IDT meets/ develops the PCSP/authorizes services
PCM coordinates
authorized services
Services
Reassessment
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IDT: Initial Comprehensive Health Assessment
8
Comprehensive Assessment
New York State Uniform Assessment System (UAS-
NY)
• The UAS-NY uses 22 items and sub-items from the
UAS-NY community assessment including:
Cognition and communication
Mood and behavior
Functional status (activities of daily living
performance)
Nutritional status
Copyright 2014 ValueOptions.® All rights reserved.
IDT: Review of Assessments
9
After each participant assessment:
• The IDT meets (within 30 days) to review results,
authorize needed services and coordinate health
care for participant
Primary Care Manager (PCM) facilitates meetings
of the IDT and discussion of person-centered
service plan (PCSP)
PCM sends PCSP to IDT members for signatures
after each meeting
PCM sends participant hard copy of PCSP signed
by all IDT members
Copyright 2014 ValueOptions.® All rights reserved.
IDT: Comprehensive Health Assessment
10
Reassessment:
Every 6 months - or -
When change in health status:
• Within 48-hr period prior to transition or
• Within 30-day period after discharge
Following the reassessment, the IDT meets to make necessary
updates to the PCSP.
PCSP meeting should be attended by the participant and all
IDT members.
Copyright 2014 ValueOptions.® All rights reserved.
Person-Centered Service Plan (PCSP)
11
Personal Health Care Service Plan document:
• Prepared during IDT meeting no later than 30-days of
assessment
• Reviewed and / or amended within 30-days of
comprehensive reassessment
Components of the PCSP:
• Results of health risk assessment(s)
• Goals, interventions, health services, benefits and
preferences for care
Identifies:
• Personalized medical, behavioral and mental health needs
• Cultural, linguistic, special needs services, and other health
needs and goals
Copyright 2014 ValueOptions.® All rights reserved.
IDT: Purpose of PCSP
12
Identifies who is responsible for implementation of
each portion of care plan
Determines clear communication for IDT members
for six(6) month duration of plan
Informs / offers health service alternatives such as:
• Home
• Institutional
• Community-based services
Discusses related obligations
Copyright 2014 ValueOptions.® All rights reserved.
IDT: Purpose of PCSP cont’d
13
Evaluates effectiveness of current plan of care
and reevaluates or modifies as needed
Discusses problems, concerns or interventions
raised at last care planning
Determines care or service(s) for the six(6) month
care-plan duration
• Amount of time services are authorized
• Integration of technology into care plan
Copyright 2014 ValueOptions.® All rights reserved.
The IDT must:
14
Educate, empower and facilitate the Participant to make choices
within the parameters of the FIDA Demonstration and to exercise
his or her rights and responsibilities, including the opportunity to
participate in Consumer Directed Personal Assistance Services;
Involve the Participant as an active team member, including
providing information and explanations using plain language
understandable to the Participant and/or caregiver, and stress
Participant-centered collaborative goal setting;
Arrange the supports necessary for the Participant to keep doing
things he or she enjoys, to follow through on prescribed treatments,
and to remain physically active;
Establish a set of guidelines or care responsibilities for the entire
team and distribute these to Participant;
Provide education to the Participants and families regarding
health and social needs;
Copyright 2014 ValueOptions.® All rights reserved.
The IDT must (cont’d):
15
Identify the Participant’s informal support systems/networks in
relationship to his or her functional and safety needs;
Assess and assist the Participant in identifying and addressing
quality of life issues;
Deliver coordination with care providers across settings;
Assist the Participant in accessing reasonable accommodation
and accessible providers;
Offer information about and assist Participant in maintaining and
establishing community links;
Supply information about services available through the Area
Agency on Aging to adults age 60 and older;
Provide information about and assist Participant with housing and
transportation issues; and
Support the Participant and/or designated representative in
understanding the disease process, chronic illness, and/or disability
and realizing his/her role as the daily self-manager.
Copyright 2014 ValueOptions.® All rights reserved.
Resources
16
Provider Connect
Provider Handbook
FIDA Training
Provider Webinar Calendar
New York State Department of Health
For additional information regarding the FIDA
Plan, please contact ValueOptions at:
*For a list of references, please send requests to: [email protected]