support plan plan.pdfpage 2 of 27 colorado assessment process restructuring initiative: draft...
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Colorado Support Plan Process Restructuring Initiative: Support Plan (6-22-18)
Support Plan
Key
Orange: Items, responses, and other language specifically for children
Green: Skip patterns
Red: Additional instructions
Purple: Script for assessor
Teal: Notes for automation
Denotes mandatory section/item
Yellow Highlight: Auto populate from Assessment or other Support Plan section
Teal Highlight: Items only for Reasessment
1. PARTICIPANT’S IDENTIFYING INFORMATION
1. Name of Individual:______________________ 2. Current Mailing Address:________________________ 3. City:_____________ 4. State:____________ 5. Zip Code:__________ 6. Preferred method of contact: Email Cell phone Work phone Home phone Texting
7. Preferred number/email address:_____ 8. Date of Birth:____________
9. Age:__________
10. What gender do you identify as?
Male Female Transgender Nonbinary/Gender-nonconforming
11. Method(s) participant likes to use to communicate with others:
Verbal English
Verbal Spanish
Verbal Other Language,
identify:___________
Sign Language
Writing/Braille
Gestures
Facial Expression
Texting/Email/Social Media
Electronic Device
Other:_________________
If Sign Language was not selected, skip to Item 13. 12. Type of sign language participant uses:
American Sign Language
Baby Sign
Cued Speech
Emoticon + Bodicon (facial expression + body language)
Home Signs, Gestures
International Sign Language
Limited or Close Vision Signing
Manual alphabet (finger spelling)
Signed English
Tactile (hand in hand) Signing
Other, describe:________________ 13. Method(s) participant likes others to use to communicate with him/her:
Verbal English
Verbal Spanish
Verbal Other Language,
identify:__________
Sign Language
Writing/Braille
Gestures
Facial Expression
Commented [AC1]: Automation: Pull from Intake for 6 and pull ONLY preferred method from Intake in 7.
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Support Plan (3-30-18)
Texting/Email/Social Media
Electronic Device
Other:________________
2. SUPPORT PLAN ADMINISTRATIVE INFORMATION
1. Support Plan Type:
Initial/Enrollment
Continued Stay Review [If selected auto-populate start and end dates from assessment.]
Revision [The dates must remain the same as the current active plan. Gray out dates. When revision is selected, a copy to be made and allow for edits.]
Community Care Transition (CCT) Certification Extension
Deinstitutionalization (DI)
Readmission to Institution 2. Location of Support Plan meeting:
Participant’s home
Other family member’s home
Other community setting
Case management agency office
Hospital
Nursing Facility
ICF/IID
Other:___________
3. Date Support Plan was Initiated:_________________
4. Support Plan Certification Period
A. Start:_______________ B. End:___________________
[For Support Plan type that equals initial/enrollment, Start Date is auto-populated based on the latter of one of the two: 1) program eligibility date or 2) functional eligibility determination date. Auto publish - on the start date; do not allow case managers to publish. For CSRs, dates should auto-populate from the assessment dates.]
5. Case manager name:____ 6. Case manager agency:__ 7. Case manager phone:_ 8. Individuals contributing to the plan:
A. Individual 1
i. Name:________________
ii. Relationship to participant
Spouse- Guardian
Spouse- Non-Guardian
Child or Child-in-law
Sibling
Parent/Guardian
Parent/Non-guardian
Guardian, other:___________
Partner/Significant Other
Other relative
Friend
Neighbor
Other:_________
Service/Provider Agency
Guardian Ad Litem
Advocate
iii. Individual invited to Support Plan meeting by: Participant Participant’s representative
Commented [AC2]: Automation: Only pull responses that are indicated as applicable.
Commented [AC3]: Lori needs to clarify with Tim how this will be operationalized in the automated system.
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Additional individuals can be added in automated version. 9. If individuals attending the Support Plan meeting were not invited by you, identify the individual’s
name, relationship, and reason they were included in the meeting.
3. EXPLANATION OF THE SUPPORT PLANNING PROCESS
1. I and/or my representative received a Handbook explaining the Assessment and Support Planning processes prior to my Support Plan meeting.
Yes No (Review Handbook with the participant/representative prior to proceeding)
2. The case manager discussed the following information with me and I understand (check all that apply): The contents of the handbook and any questions I/my representative have What person-centered goals are and how they will be developed What supports are available for making decisions and whether I would like this support Service options, including opportunities for participant-direction Differences in supports available for children transitioning to adult services (16+) Rights modifications for children transitioning to adult services (16+) What to expect and not expect from the development of my Support Plan Next steps after my Support Plan is developed How to report mistreatment (including abuse, neglect, exploitation) and other critical
incidents 3. The case manager discussed the following rights and responsibilities with me and I understand
(check all that apply): The rights and responsibilities of the participant, representative, and case manager
when developing my Support Plan The responsibility of my team (myself, family, and others I’ve invited to participate) to
provide accurate information throughout the Assessment and Support Planning process Complaint procedures My rights to appeal the contents/results of the Assessment and Support Plan My choice of providers My options for changing my case manager My options for changing my Case Management Agency My choice of where I live My choice of programs and services My responsibility to follow and cooperate with program requirements
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4. FOR REASSESSMENT ONLY- PROGRESS TOWARDS GOALS FROM PREVIOUS ASSESSMENT
1. I would like to complete this section.
Yes No (Skip to Section 5)
Goal
How Progress Towards
Goal Will be Measured
Timeframe for Achieving
Goal
(F)= Future Goal
Progress Made Towards
Goal- Use measures
identified in previous plan
Score of Progress Towards Goal
Systemic Barriers
Autofill from previous
assessment
Autofill from previous
assessment
Autofill from previous
assessment Text
Goal achieved, can remove
Goal being achieved but should remain active
Goal is on target to be accomplished
Goal relevant, barriers to overcome:__
Goal no longer relevant, should be removed. Explain:____
Text
Automation will include all goals from previous Support Plan.
5. PERSONAL GOALS
1. I would like to complete this section.
Yes No (Skip to Section 6)
Commented [AC4]: Lori to clarify if this should just be for CSR and Revision or for all Plans are that being updated.
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Goal Participant Ranking of
Goal
Representative Ranking of
Goal
Participant Rating of
How Meaningful
Goal Is
Representative Rating of How
Meaningful Goal Is
How Progress Towards
Goal Will be Measured
Timeframe for Achieving
Goal
(O)= Ongoing Goal
(F)= Future
Goal
1 to 5 with 1=Not Meaningful and 5 = Very Meaningful
Text Number Number Number Number Text Text
Additional goals can be added within the automated system.
2. Transition to Adult Services – Goals and/or activities that should be included to address transition to adult services. Only appear if triggered; trigger criteria shown in teal. Populate all fields that meet criteria into the goals table in 5.1 Apply for Adult SSI/LTC Medicaid (Trigger if participant will turn 18 in next 18 months) Develop replacement activities that will become active after the transition to an adult waiver (Trigger if participant is older
than 16 years, 7 months) Discuss replacement activities that will become active after the child is no longer eligible for EPSDT services, including
Private Duty Nursing (Trigger if participant is enrolled in EPSDT and will turn 18 within the Support Plan year, not triggered when “Develop replacement activities” is triggered because the items would be duplicative)
Develop replacement activities that will become active after the child is no longer eligible for EPSDT services, including Private Duty Nursing (Trigger if participant is enrolled in EPSDT and will turn 20 within the Support Plan year)
3. The DD Waiver Status Review Review Waiting List Status for the DD Waiver (Trigger if participant has IDD and not on the DD waiver)
Commented [AC5]: Pulling from Health module for diagnosis of DD/IDD from section 6 item gg and jj
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6. ACTIVITIES TO FULFILL GOALS
1. I would like to complete this section.
Yes No (Skip to Section 7) 2. Activities to fulfill goals:
Goal Ranked # 1 by Participant: Complete after Support
is Identified
Activities to fulfill goal
Start Date
End Date
Preference/ Guidance
Skills Building
Participant Direction
Identify Services and Supports to Fulfill the Activity
Support Sources
Challenges
Text field Date field
Date field
Text field Text field Text field
Unmet Need
Systemic
Challenges:
Other Challenges:
Additional goal tables with the activities will be added within the automated system based on goals entered in Section 5. Additional activities may be entered for each goal.
7. HEALTH AND SAFETY
1. Are there any health and/or safety issues that are not addressed by the personal goals:
Yes No (Skip to Section 8)
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2. Describe the health and/or safety issue to be addressed:
Description of Health and/or Safety Issue
Issue Identified By
I want to address issue
My Representative wants to address
issue
If I do not want to address, describe why
not
Proposing a multi-select of needs items from Assessment
that can be described.
Me
Representative
case manager
Other:_____
Text Field
Additional health and/or safety issues may be added in automated system
3. Describe the activities necessary to meet the health and/or safety issue (Update Section 6 as necessary to meet the challenges that are entered within this table):
Health and Safety Issue 1 Participant/Rep Wants to Address: Autofill from Item 7.2 Complete after Health/
Safety Issue is Identified
Activities to fulfill health and safety
issue
Start Date
End Date
Preference/Guidance Skills
Building Participant Direction
Identify Services and Supports to Fulfill the
Activity
Support Sources
Challenges
Text field Date field
Date field
Text field Text field Text field
Unmet Need
Systemic
Challenges:
Other Challenges:
Additional rows will be added within the automated system based on health and safety issues identified in 7.2.
Commented [AC6]: This should only include issues that the participant/rep want to address in 7.2
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8. FOR REASSESSMENT ONLY- UTILIZATION OF SERVICES
1. Underutilization of services
Services for which
authorizations were 20% higher than
what was used
Reason for under-use of
services
Description of issue
Changes to my plan to
prevent this from
happening again
System changes
needed to prevent
this from happening
again
Autopopulate if system allows or
text field
Authorized more than I needed
I was not able to get all of the services that I needed
Text Text Text
9. DIRECTING MY SERVICES
Have brief discussion with participant and representative about participant directed services, including an overview of the programs, services that are available, direction that not waivers include the option to direct services, ability to have an authorized representative direct services if participant does not wish or is not able to, and responsibilities of the participant/authorized representative.
1. I am interested in discussing participant-directed services.
Yes, already enrolled in participant directed services (Skip to Item 7)
Yes, not currently enrolled in participant directed services
No (Skip to Section 10)
2. I want to be able to select, dismiss, and manage the people I want to help me, including family members or friends.
Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree
3. I want to be able to choose how much I pay the people who work for me.
Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree
4. I want to be able to manage a budget for my services.
Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree
Explain the participant’s participant-directed options (e.g., IHSS and CDASS) and the pros/cons of each based on the interests of the participant and authorized representative.
5. I am interested in receiving participant-directed services.
Yes No (Skip to Section 10)
6. The assessment suggests I may be able to direct my supports within:
CDASS or IHSS IHSS only
For Reassessment Only – asked if participant receiving CDASS or IHSS 7. I/My child will continue participant-directed services during the service period identified within
this Support Plan.
Yes No (Skip to Section 10)
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8. I have had challenges managing my/my child’s budget- CDASS only
Yes No N/A
9. I have had challenges finding help or managing people who work for me/my child.
Yes No (Skip to Item 11) N/A (Skip to Item 11)
10. Description of challenges
11. I would like to make the following changes to address the challenges I have with my/my
child’s self-directed services
Change programs, list program:
Get more support in managing my services, including training, describe support:
Select someone to be my authorized representative, identify person:
Make other changes, describe:
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10. CHOOSING MEDICAID HOME AND COMMUNITY-BASED SERVICES
1. I would like to complete this section.
Yes No (Select waiver option in last column and skip to Section 11)
2. I am eligible for the following Medicaid programs: Medicaid
HCBS Waivers and State Plan
Services
Services Has
Waiting List
Allows Participant Direction
Pros Cons Select Option
Auto-populate
Fixed field with service options for
Waiver/State Plan selected in Column 1
Additional programs can be added within the automated system.
11. IDENTIFYING MY SUPPORTS
1. I would like to identify unpaid supports and/or supports paid by another source.
Yes No (Skip to item 6)
The following table contains the caregiver supports that were documented during the Assessment process. case managers should review and update with the participant and representative. After review, complete the final column. Additional supports should be included in the second table within this section.
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2. Previously documented unpaid supports and paid family and friend caregivers. Additional individuals can be added within the automated system.
Caregiver Information
Distance from
Participant
Relationship to
Participant
Caregiver Help [Check all that apply]
Assessed Needs
Support is Assisting
With
Frequency: How Often
Any Assistance is
Provided
Back-up Planning
Participant would prefer
different caregiver
Likelihood of Continued Assistance
Caregiver Needs
Support Services/ Training
Guidance for Unpaid Support
Name:
Preferred Phone
#:
Preferred email:
Caregiver is:
Regular support
Back-up support
Lives with
Within 5-10 minutes
15-20 minutes
Longer than 20 minutes
Spouse
Parent
Adult Child
Other family member:_______
Friend
Neighbor
Other, specify
Self-care assistance (for example, bathing, dressing, toileting, or eating/feeding)
Mobility assistance (for
example, bed mobility, transfers, ambulating, or wheeling)
IADL assistance (for example, making meals, housekeeping, telephone, shopping, or finances)
Medication administration
(for example, oral, inhaled, or injectable medications).
Medical procedures/ treatments (for example, changing wound dressing, or home exercise program).
Management of equipment (for example, oxygen,
IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies).
Supervision (for example, due to safety concerns).
Advocacy or facilitation of person's participation in
appropriate medical care (for example, transportation to or from appointments).
Other advocacy not related to medical care
Assistance with daily (or routine) problem solving
Non-medical transportation
Social opportunities
Other, describe:____
Proposing a multi-select of
assessed needs. Need to
discuss with automation
team.
Less than once a month
About once a month
About once a week
3-4 times a week
Once a day
2 or more times/day < continuously
Continuously
As needed
What I should do if the support does not show up:________________________________________
Support
source responsible for arranging back-up
Who else can help, how they can help, and any other concerns I have if my other
supports are not available (optional if support responsible for arranging back-up):_______________________________________
Yes, describe___________
No
Can continue providing
Cannot continue
providing
Do not know
Can increase amount of assistance
Need to decrease amount of assistance
Does transition plan need to be developed for primary caregiver?
Yes
No
Yes, describe:______________
No
Text
Payment Source
Unpaid
Waiver
Medicaid-Other
Paid by another source
3. Other sources of unpaid support and paid family caregivers- Are there any other potential sources of unpaid supports or paid family caregivers beyond what was identified during the assessment? Prompt to see if there are other source of support, such as churches or neighbors, that should be considered. Yes No (Skip to 4)
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Support Source Name
Relationship to
Participant
Contact Information
Assessed Needs
Support is Assisting
With
Amount, Duration,
And Frequency of Any Support
Back-up Planning Guidance
for Supports
Other Considerations
Caregiver is:
Regular support
Back-up support
Spouse Parent Adult Child Other
family member:_
Friend Neighbor Other,
specify
Preferred
Phone #:
Preferred
email:
Proposing a multi-select of
assessed needs. Need
to discuss with automation
team.
Text What I should do if the support does not show up:______________
Support source responsible for arranging back-up
Who else can help, how they can help, and any other concerns I have if my other supports are not available (optional if support responsible for arranging back-up):_________________
Text Text
Additional support sources can be added within the automated system.
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4. LTSS Supports Paid for by Another Source- Other paid sources of support that will be utilized to allow me achieve my goals.
Name/ Agency
Information
Payment Source
Caregiver Help [Check all that apply]
Assessed Needs
Support is Assisting With
Frequency: How Often Assistance is
Provided
Back-up Planning
Participant would prefer
different caregiver
Will Support Continue
Caregiver Needs
Support Services/ Training
Name/ agency:
Preferred
Phone #:
Preferred
email:
Individual/ agency is:
Regular support
Back-up support
Self-paid
Paid by other family member/ friend
Medicaid
Medicare
Private LTC Insurance
Private
Health Insurance
VA
Other:__
Self-care assistance (for example, bathing, dressing, toileting, or eating/feeding)
Mobility assistance (for example, bed mobility, transfers, ambulating, or wheeling)
IADL assistance (for example, making meals,
housekeeping, telephone, shopping, or finances)
Medication administration (for example, oral, inhaled, or injectable medications).
Medical procedures/ treatments (for example, changing wound dressing, or home exercise program).
Management of equipment (for example, oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies).
Supervision (for example, due to safety concerns).
Advocacy or facilitation of person's
participation in appropriate medical care (for example, transportation to or from appointments).
Other advocacy not related to medical care
Assistance with daily (or routine) problem solving
Non-medical transportation
Social opportunities
Other, describe:____
Proposing a multi-select of assessed
needs. Need to discuss with
automation team.
Less than once a month
About once a month
About once a week
3-4 times a week
Once a day
2 or more times/day < continuously
Continuously
As needed
What I should do if the support does not show up:________________________________________
Support source responsible for
arranging back-up
Who else can help, how they can help, and any other concerns I have if my other supports are not available (optional if support responsible for
arranging back-up):_______________________________________
Yes, describe:_______
No
Yes
No
If “No”: ➢ Why will care end:__ ➢ When will care
end:__
Yes, describe:_____________
No
5. Other sources of paid support- Are there any other potential sources of paid supports beyond what was identified in during the assessment? Yes No (Skip to 6)
Support Source Name/ Agency
Contact Information
Assessed Needs Support is
Assisting With
Amount, Duration, And Frequency of
Support
Back-up Planning Guidance for
Supports
Other Considerations
Individual/agency is:
Preferred
Phone #:
Proposing a multi-select of
assessed needs. Need to discuss
Text What I should do if the support does not show up:______________
Text Text
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Regular support
Back-up support
Preferred
email:
with automation team.
Support source responsible for arranging back-up
Who else can help, how they can help, and any other concerns I have if my other supports are not available (optional if support responsible for arranging back-up):_________________
Additional support sources can be added within the automated system.
6. Voluntary Support Calendar- The Support Calendar is a voluntary spreadsheet that will allow me to plan the type and amount of support that I will need during different weeks. For example, I may need a different level of support during a work week than I do during a holiday or vacation week.
Support Calendar was completed:
Yes No
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7. Medicaid HCBS waiver and State Plan services to be Authorized- The following services will be authorized to help me
achieve my goals. Update all support sources previously discussed prior to completing this item.
Funding Stream
Service Unit Type # of Units
Unit Rate Start End Assessed
Need Guidance
to workers Skills
Building
Provider Agency
Populate from Waiver/
State Plan selected in Section 10
Dropdown tailored to funding stream selected
Fixed field based on
service option selected in Column 2
Fixed field based on
service option selected in Column 2
Select items from Assessment
Outputs
☐
Dropdown w/ TBD Option
Populate from Waiver/
State Plan selected in Section 10
☐
Dropdown w/ TBD Option
Total Cost of Services:
Additional services can be added within the automated system.
8. I have been informed that:
I have a choice of available long-term services and supports;
I have the right to select among qualified providers;
I can change providers at any time;
A provider has the right to accept or deny my request for services
9. I have been given a list of qualified providers or provided with directions on how to access this list.
Yes, given a list of providers during the meeting
Yes, provided directions on how to access a list of providers. How to access this list (e.g., website, mail):______________
(Skip to Item 11)
No (Skip to Item 11)
10. I had enough providers to choose from.
Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree
Items 11-14 are for Reassessment Only 11. I want to change providers. [Required for re-assessment, change in provider, or request for additional services]
Yes No (Skip to Item 15)
I want to change the following providers:
Commented [AC7]: Automated system should allow for autocalculation
Commented [AC8]: Lori to confirm how Plan would flow if only provider or service change is requested. Is entire Plan supposed to be revised?
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12. I have selected a new provider during this meeting.
Yes for all providers I wanted to change (Skip to Item 15)
Yes for some providers I wanted to change, identify remaining providers:_____
No 13. My case manager’s plan for helping me find a new provider:
14. Target date for finding a new provider:_________ 15. I have selected CDASS or IHSS as one of my services.
Yes, and this is my initial enrollment in participant directed programs
Yes, and I have previously been enrolled in participant directed programs (Skip to Item 19)
No (Skip to Section 12)
Items 16-18 are For Initial Selection of CDASS or IHSS Only
16. When I manage people who are paid to help me, this is how I would do the following: [Ask authorized representative if one has been identified. Record brief summary in the boxes below. Emphasize that it is okay to be uncertain about how to address these tasks – the individual and/or authorized representative will receive training on how to perform tasks.] A. Find/select workers to hire
B. Train workers
C. Give workers directions
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D. Deal with a worker who is not doing her/his job well
E. Dismiss a worker who is not meeting my needs
F. Manage my service budget (Ask only if CDASS is selected)
17. I can self-direct my services:
With very little or no support
With support, describe: ______________
If another person acts as an authorized representative: Representative name:__________________ Relationship to me:____________________
I have decided not to self-direct my services- Update service selection in item 7 and response to item 15 to reflect this decision
18. I would like the following training to help me direct my supports and/or manage my budget (if applicable):
19. For Reassessment Only- I need to change or update the provider who helps me with my participant directed program.
No (Skip to Section 12) Yes, identify change/update needed:____________________
20. I would like to select the following FMS agency (ask only if CDASS selected) – Drop down list of agencies (Includes TBD option)
21. I would like to select the following IHSS agency (ask only if IHSS selected) – Drop down list of agencies (Includes TBD option)
12. PROVISIONS FOR TEMPORARY INCREASE IN SERVICES
1. My plan will include the ability to temporarily increase services:
Yes No (Skip to Section 13)
Items 2-6 may be completed for additional scenarios in the automated system 2. Description of circumstances that may result in need to temporarily increase services:
3. Voluntary Support Calendar- The Support Calendar is a voluntary spreadsheet that will allow me to plan the type and amount of support that I will need during different weeks. For example, I may need a different level of support during a work week than I do during a holiday or vacation week. If support calendar was previously completed, update as necessary based on potential temporary service needs.
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Support Calendar was completed:
Yes No
4. Medicaid HCBS waiver and State Plan services to be Authorized on a Temporary Basis
Funding Stream
Service Unit Type
# of Units
Unit Rate
Assessed Need
Guidance to workers
Skills Building
Provider Agency
Populate from
Waiver/ State Plan
selected in Section
10
Dropdown tailored to funding stream selected
Fixed field
based on service option
selected in
Column 2
Fixed field
based on service option
selected in
Column 2
Select items from Assessment
Outputs
☐
Dropdown w/ TBD Option
☐
Dropdown w/ TBD Option
Total Cost of Services:
Additional services can be added within the automated system.
5. Describe any changes that will occur to the type, duration, frequency, or level of other supports included in the Support Plan if the temporary increase is implemented.
6. Process for implementing the temporary increase:
13. REFERRALS
Referral Agency
Reason for referral
Who will follow-up
Contact Information for Referral
Additional referrals can be added within the automated system.
14. BACK-UP PLANS
1. Planning back-up supports- What should occur if my support source does not show up. Update if authorized services/supports changed the type or amount of back-up previously documented
Support Source
Support source
responsible for
arranging back-up
What I should do if the support
does not show up
Who else can help, how they can help, and any other
concerns I have if my other supports are not available
(optional if support
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responsible for arranging back-up)
Paid Supports
Auto-populate from 11.3-4
☐
☐
Unpaid Supports
Auto-populate from items 1-2 in Section 11
☐
☐
Medicaid Waiver/State Plan Supports
Auto-populate from provider name in item 7 in Section 11
☐
☐
2. Contact Information for My Back-up Supports- Contact information for people and
agencies listed above:
Name Phone Number to
Call Phone Number to
Text Email Address
Auto-populate from supports identified as “back-up” in Section 11
Auto-populate from supports identified as “back-up” in Section 11
Auto-populate from supports identified as “back-up” in Section 11
Auto-populate from supports identified as “back-up” in Section 11
Additional back-up supports can be added within the automated system.
15. DISASTER RELOCATION PLANNING
1. I would like to develop a Disaster Relocation Plan or provide information about my current
Disaster Relocation Plan.
Yes No (Skip to Section 16)
2. My provider has or will develop a Safety Plan for me and/or my information has been entered into or will be entered into a provider or other system for safety and disaster response used by first responders in my area, such as Smart911: Not entered (Skip to 3) Developed by provider (Skip to Section 16) Entered into response system, date of last update:_______________ Will be entered into response system, date information will be entered:____________
a. Name of system:___________________ b. Weblink for system:_________________
(Skip to Section 16 if response other than “Not Entered” was selected)
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3. Emergency Contacts and Relocation Sites- If I need to move to another location in an emergency, these individuals/organizations should be contacted. I have also ranked my preferences for where I should be relocated.
Name/
Organization (Order should reflect priority
of individuals to contact)
Relationship Primary Phone
Number
Secondary Phone
Number
Options for
Relocation (Rank your preference)
Address (Enter only if
site is a relocation option)
1 Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Choose an item.
Click or tap here to enter text.
2 Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Click or tap here to enter text.
Choose an item.
Click or tap here to enter text.
4. If I need to relocate because of an emergency, this is what I will need to take:
Medication & Equipment to Take
Information to Take Special Instructions to
Share
Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter
text.
16. MINIMIZING MY RISKS
1. I depend on medical devices that require electricity.
No (Skip to Item 4) Yes
2. I have applied for an energy assistance program.
No (Discuss whether participant would like more information) Yes
3. I have a back-up generator.
No
Yes, my provider is responsible for making sure I have electricity (Skip to Item 4) Yes, I have a back-up generator (Skip to Item 3b)
a. I need to get a back-up generator.
No, do not want one. Why not:_________________ (Skip to Item 4)
Yes, but cannot get one due to systemic barriers or other issues:_____ (Skip to Item 4)
Yes, plan for obtaining back-up generator:____________________ (Skip to Item 3e)
b. The back-up generator is activated by:___________ c. The last time the generator was tested to see if it was working:___/___/_____ d. My primary and back-up caregivers are trained on how to activate the back-up generator.
No, plans for training and/or reasons why some people will not be trained:__________
Yes
e. Plan if back-up generator is not available or cannot be used:
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4. Activities for which there are unmet needs:
Activities to Fulfill Goals- Populate from Section 6
Challenges to Fulfilling Goals- Populate from Section 6
Activities to Meet Health and Safety Issues- Populate from Item 7.3
Challenges to Meeting Health and Safety Issues- Populate from Item 7.3
5. Assessed needs not attached to a support source, Medicaid service, or unmet need- Prepopulate:
6. Health and/or safety issues I choose not to address:
Description of Health and/or Safety Issue- Populate from Item 7.2
Why I Do Not Want to Address Health and/or Safety Issue- Populate from Item
7.2
7. Summary of Health and/or safety risks related to medical/health conditions:
No risks (Skip to 8) Risks adequately described in items 1 through 6 (Skip to 8)
Additional risks, describe:
8. Summary of Health and/or safety risks related to behaviors:
No risks (Skip to 9) Risks adequately described in item 1 through 6 (Skip to 9)
Additional risks, describe:
9. Summary of Health and/or safety risks related to environment or other issues:
No risks (Skip to 10) Risks adequately described in item 1 through 6 (Skip to 10)
Additional risks, describe:
10. Plans for reducing risks:
11. Have changes been made to services or guidance to workers in Sections 6,7, 10 and/or 11 to reduce risks?
No
Yes, describe changes:
22 | P a g e
12. Summary of remaining risks:
13. ☐ I understand and am willing to accept those risks
14. ☐ My legal representative understands and is willing to accept those risks (if applicable)
17. MODIFICATION OF RIGHTS/SETTINGS EXCEPTION
1. Were emergency control procedures used since the last assessment?
No (Skip to 3) Yes
2. Are actions being taken to prevent the need for continued use of emergency control procedures?
No, describe why not:
Yes, describe actions:
3. I will be in a setting in which certain actions must be taken before my rights are modified: No (Skip to Section 18) Yes
4. Reasons for the modification:
Modification #
Observable and measurable description of behavior or
other issue to be changed or improved
Assessment item(s) that
demonstrate why issue has been
targeted
Efforts to use positive interventions and less intrusive alternatives
as an alternative
1 Text Text box Text box
2 ☐ Same text As Above
If not checked, Text Field
☐ Same text As
Above
If not checked, Text Field
☐ Same text As Above
If not checked, Text
Field
5. Types of modifications:
Modification #
Classification of modification:
Plans for putting
modification in place
Informed consent has
been documented
for mod.
Plans for making sure
staff understand when and how to put
the modification
in place
Providers to implement
modification
Commented [AC9]: For automation- 17.4-6 should be dynamic tables, with 5-6 mirroring the number of modifications entered in 4.
23 | P a g e
1
Safety Control Procedures
Access to the greater community
Choice of Setting
Right to Privacy
Independent decision-making, initiative or autonomy
Choice of services and who provides them
Access to personal possessions
Access to dangerous objects or hazardous materials
Access to specific areas in living space
A unit lockable by the individual
Choice of roommates
Freedom to furnish or decorate sleeping or living units
Freedom and support to control own schedules and activities
Access to food at any time
Choice of visitors at any time
Access to media and Internet
Other:_____________________
Text box ☐ Text box
Checkboxes for all providers identified in authorized
services in item 11.7
2
Safety Control Procedures
Access to the greater community
Choice of Setting
Right to Privacy
Independent decision-making, initiative or autonomy
Choice of services and who provides them
Access to dangerous objects or hazardous materials
Access to personal possessions
Access to specific areas in living space
A unit lockable by the individual
Choice of roommates
Freedom to furnish or decorate sleeping or living units
Freedom and support to control own schedules and activities
Access to food at any time
Choice of visitors at any time
Access to media and Internet
Other:_____________________
☐ Same text
As Above
If not
checked, Text
Field
☐
☐ Same text
As Above
If not
checked, Text
Field
Checkboxes for all providers identified in authorized
services in item 11.7
24 | P a g e
6. Plans for monitoring and removing modifications:
Modifications #
Who will
monitor
How will effectiveness be measured
What data will
be collected
Changes necessary to remove
modification
Timeline for reviewing whether modification is still
necessary
1 Text box Text box Text box Text box Text box
2
☐ Same
text As Above
If not
checked, Text Field
☐ Same text
As Above
If not checked, Text
Field
☐ Same
text As Above
If not
checked, Text Field
☐ Same text
As Above
If not checked, Text
Field
☐ Same text As
Above
If not checked, Text Field
7. I have questions or concerns about the rights modifications process. No Yes, document concerns and discussion:
8. Human Rights Committee (HRC) review necessary? Autopopulate based on whether adult in an IDD waiver in 11.7.
No (Skip to Section 18)
Yes, because: Of a rights modification Of a restrictive procedure Use of psychotropic medication 1) administered by a paid support and/or 2) receiving
residential habilitation 9. HRC Review Status/Outcome
To be submitted (Skip to Section 18)
Submitted, awaiting review (Skip to Section 18)
Review completed 10. HRC review outcome and recommendations:
18. ADVANCE DIRECTIVES
For participants <18 years old, start with Item 2. 1. Participant has someone who assists with or is legally authorized to make decisions (e.g., POA,
DPOA, legal guardian, etc.):
No [Skip to Item 5] Yes
2. Name of individual(s) or agency(ies) assisting or authorized in making decisions: _______________________________________________________________________________
3. Is this individual a legal guardian?
No
Yes, limited guardianship. Describe:_____________________________________________
Yes, full guardianship
25 | P a g e
[If Yes, skip to Item 5] 4. Decision making capacity:
Trustee
Representative Payee
Legally Authorized Representative
Responsible Party
Conservator
Power of Attorney (POA)
Surrogate Decision-maker for health care decisions (DPOA)
Other parent
Partner of parent
Stepparent with no legal authority
Family
Friend
Advocate
Other:_______________________
5. I have established advance healthcare directives.
No [Skip to Item 8] Yes
If yes, type of advance healthcare directive: Durable power of attorney
Health care advocate
Advance directives concerning care (e.g., DNR, extraordinary measures, etc.)
Physician Orders for Life-Sustaining Treatment (POLST)
5 Wishes
Other
6. My advance healthcare directives are located:_____________________________ 7. Sharing directives with my doctor, healthcare/service provider, and/or family/friends.
Already shared with everyone I want
Choose not to share
Want to share. Who I need to share with and who will share it:____________________
8. I would like assistance to establish or update advance healthcare directives.
Yes, establish Yes, update No
If yes, I want assistance with developing/updating: Durable power of attorney
Health care advocate
Advance directives concerning care (e.g., DNR, extraordinary measures, etc.)
Physician Orders for Life-Sustaining Treatment (POLST)
5 Wishes
Other
9. The following person will help me develop, update, and/or share my advance directives. Name of Person: Relationship: Contact Information: Development, updates, and/or sharing will occur by:__________
19. CASE MANAGEMENT MONITORING
1. Minimum monitoring my case manager is required to do:
Quarterly face-to-face (IDD waivers)
Quarterly phone (other waivers)
☐ I understand these requirements
Commented [AC10]: For automation: Populate based on waiver selected in Section 11.
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Colorado Support Plan Process Restructuring Initiative: Support Plan (3-19-18)
2. I would prefer that my case manager check in with me:
The minimum amount required
More than the minimum, describe:
3. My preferences for how my case manager contacts me (rank preferences, put N/A if do not have):
__ In person __ By telephone __ By email
__ By text __ Other, describe:_____________
4. When I meet with my case manager in person, I would prefer these meetings happen at: My home Other location(s) where services are
being delivered:_________________ 5. If something important occurs, such as a change to my service eligibility or a support worker will
not show up, I would prefer that the following people also be notified:
No one
The following people:
Person 1’s Name:______________________________________ Phone number:______ Primary email:______ Primary text number:________
Person 2’s Name:______________________________________ Phone number:______ Primary email:______ Primary text number:________
Additional individuals may be added in the automated version 6. My case manager should contact me or my legal representative prior to responding to questions
from the following people/entities:
No one
Any individual or entity for whom previous authorization has not been given
The following people:
Person 1’s Name:______________________________________ Phone number:______ Primary email:______ Primary text number:________
Person 2’s Name:______________________________________ Phone number:______ Primary email:______ Primary text number:________
7. Other things I would prefer that my case manager do or not do when monitoring my plan or
services:
20. COMMENTS, GUIDANCE, AND CONCERNS FROM MEMBERS OF MY TEAM
1. Comments, guidance, and concerns about services, supports, next steps, or other areas of the Plan. If no comment, enter “None”. If there is no representative of the category, enter “N/A”.
a. case manager
☐ case manager attests that the services and supports included in this Plan are
related to an assessed need or a personal goal. b. Agency Representative. Identify agency: Click or tap here to enter text.
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Colorado Support Plan Process Restructuring Initiative: Support Plan (3-19-18)
c. Agency Representative. Identify agency: Click or tap here to enter text.
d. Other Support. Identify name and relationship: Click or tap here to enter text.
e. Other Support. Identify name and relationship: Click or tap here to enter text.
f. Other Support. Identify name and relationship: Click or tap here to enter text.
2. Summary of changes to the plan to address team members’ comments, guidance, or concerns:
3. Parent, Guardian, or Legal Representative comments, guidance and concerns (If applicable)
4. Summary of the changes to the plan to be taken to address parent, guardian, or legal representative’s comments, guidance, or concerns:
5. My comments, guidance and concerns
6. Summary of the changes to the plan to address my comments, guidance, or concerns:
7. I led the creation of my Support Plan as much as I wanted and am capable of.
Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree
8. My representative believes that he/she was able to play a leading role in creating my Support Plan.
Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree
Not applicable
9. Date all providers signed off on services:_______________
10. Date participant considers plan as final:_______________