1 Doc #: PCA-1-003545-09282016_10172016

Person-Centered Treatment Plan Integrated Health Homes (IHH)

What is important to the member? (The plan must reflect what is important to the member as well as ensure health and welfare.)

1. Strengths

2. Preferences

3. Needs (Clinical and Support)

4. Desired Outcomes

5. Strategies for Solving Disagreements

6. Risk factors and plans to minimize

7. Cultural preferences

Member Full Name

Member Address Phone

Date of Birth Date of Assessment Medicaid ID Date of Treatment Plan

Treatment Plan Effective Dates

Date of Addendum(s)

IHH Contact Name & Phone Number

Emergency Contact & Phone Number

Secondary Emergency Contact & Phone Number

2 Doc #: PCA-1-003545-09282016_10172016

People Chosen by the Member to Participate in Treatment Planning Name Relationship to Member Contact Information

Individuals Important for Member Support (please include emergency staff information) Name Relationship Phone Number Alternate Number

Diagnostic and Statistical Manual for Mental Health Disorders (DSM-V)) Description Code

Primary: Secondary: Secondary: Secondary:

Plan Summaries

A. Crisis Plan for Medical/Physical Health (This should address how the member communicates he/she is not feeling well, the ability to perform first aid, and names/addresses/phone numbers of PCP, dentist, and hospital of choice. Plan should address any medical conditions from assessment. Include medications and the emergency after hours contact and number. Please include the Integrated Health Homes after hours phone number. Member should have an index card size for coping techniques/phone #s).

3 Doc #: PCA-1-003545-09282016_10172016

B. Crisis Plan for Mental Health (This should be written on an index size card and include the IHH emergency contact information. Triggers, self- help methods, natural supports and name/address/phone number of hospital of choice and behavioral health providers, including medications. Address mental health risks from the assessment.)

C. Crisis Plan for Physical Safety (This should address what to do in case of fire and severe weather. Is member able to call 911? If not, who will assist them and how? Address any personal risks from the assessment.)

Emergency Plan of Action (for dependents, including pet) Please include information from past, present, and ongoing resources

Emergency Backup Support and Crisis Response System (for the support service interruptions/delays/changes)

Emergency Backup Staff (To be designated by the provider.)

4 Doc #: PCA-1-003545-09282016_10172016

RISK ASSESSMENTS (medical health, mental health and environmental, social, transportation, education, vocational risks)

Risk Factor Measure Taken to Minimize

Rights Restrictions

“Rights Restrictions” indicates limitations that are not imposed on the general public. Some areas could include communication, medical or mental health treatment, mobility, maintenance of personal funds, finances, self-administration of medications, privacy, type of work, religion, place of residence or whom one would live with.

Each restriction must address the following: what restriction is being addressed, why it is needed, and if there is a plan to restore this restriction if the consumer is not working on an activity that would restore the right. All restrictions are to be reviewed annually or sooner if noted in the plan. Any rights restrictions must be in accordance with 441 IAC 77.25(4)

Restriction: Reason: Plan to restore

Restriction: Reason: Plan to restore

Restriction: Reason: Plan to restore

5 Doc #: PCA-1-003545-09282016_10172016

Goals and Interventions (Each goal must include observable and measurable goals with the desired outcomes and interventions and supports needed to meet those goals. These goals must include incremental action steps as appropriate and identify the staff people, business, or organizations responsible for carrying out the interventions and supports. Please ensure that the individual directs the process to the maximum extent possible. Each goal should be focused on individual choice and the identified areas of concern. Interventions and supports must include less intrusive methods).

Measurable Goal(s)/ Desired

Outcomes

Interventions/Supports/ Responsible Parties

Date Added Date Due Date

Complete

1

2

3

4

5

6 Doc #: PCA-1-003545-09282016_10172016

Habilitation Services

Service Package The care coordinator must list all recommended Medicaid, non-Medicaid, and unpaid services. Service and support choices must be prompt, and should occur at times and locations convenient to the member. It is assumed that a goal marked as complete above will no longer require the associated service in this package.

Goal # Service

Date of Service Added

Provider Provider Contact Info $ Source # of

Units Member Directed

Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □

Please answer all questions. Yes No 1. Are there additional services, resources and supports that are needed but unavailable?

If YES, please describe:

2. Are there services offered that were declined? If YES, please describe:

3. Does this plan include the purchase/control of self-directed service(s)? If YES,describe the service(s):

4. Does the plan exclude unnecessary or inappropriate services and supports?

7 Doc #: PCA-1-003545-09282016_10172016

Please note that for Habilitation services, the expectation is that the intensity of the service will be reduced as quickly as is possible based on medical necessity guidelines, and that the service plan will be reviewed at each reduction in intensity level.

Residential Setting Selected (complete this section if member is in a residential setting) Please answer all questions. Yes No

1. Were other residential settings discussed with the member?2. Does the setting ensure the member’s rights of privacy, dignity, respect, and

freedom from coercion or restraint?3. Can the member have visitors at any time? If NO, please explain:

4. Is the setting physically accessible to the member? If NO, please explain:

Home Based Habilitation Services (HBH) (complete section if member receives HBH services) Please answer all questions. Yes No

1. Where was the member living and what services were they receiving at the time ofHabilitation enrollment? n/a n/a

2. What is the current living environment?n/a n/a

3. Is it the least restrictive environment? If NO, please explain:

4. Is this the most appropriate integrated setting for the member? If NO, please explain:

5. Does the member have access to the benefits of community living? If NO, pleaseexplain:

6. What is the number of on-site supervision hours per day? n/a n/a 7. How many residents live/will live with the resident? n/a n/a 8. Is the member in a licensed facility with sixteen or fewer residents? If YES, please

explain and address the member’s opportunity for community integration andindependence opportunities:

9. Did the member have a choice in his/her providers and services? If NO, pleaseexplain:

8 Doc #: PCA-1-003545-09282016_10172016

Community Housing Assessment (complete this section for all members) Safety Yes No

1. Is the environment free of all forms of abuse and neglect (Emotional, physical, verbal,sexual, domestic violence and neglect)?

2. Is there safety equipment on the premises? (smoke detectors, extinguishers)3. Is the environment free of health risks?4. Is there evidence of illegal activity in the environment? (Selling/ using drugs, and

prostitution)5. a. Does the member know what to do in case of an emergency? (Fire, illness, injury,

severe weather) or has 24 hour support?) b. If no to 5a, does the member have support?c. If no to 5a and 5b is there an emergency plan in place?

Affordability 1. Is the member paying less than 40% of their incomes towards housing? Intermediate

Care Facilities, Residential Care Facilities and members under the age of 18 areexempt).

2. How much is the member paying for rent or housing? N/A N/A

3. What is the member’s total income? N/A N/A

4. What percentage of this income is used for rent or housing? N/A N/A

5. Is the member receiving a rent subsidy? If YES, what type of subsidy?

6. Does the member live in an RCF/ICF, or is the member under the age of eighteen?Accessibility

1. Does the living environment allow for freedom of movement (i.e. narrow doorways)?2. Does the living environment support communication (i.e. TDD)?3. Does the living environment support community involvement? (nearby public

transportation such as taxi cabs or buses if needed)Acceptability

1. Has the member (rather than guardian) chosen the location of residence and withwhom he/she lives?

2. Was the environment found acceptable to the member at the time of choice? (givenpossible availability, monetary, or other constraints)

3. Did the member’s with guardians give input into their living situation to the greatestextent possible?

All four elements of safety, affordability, accessibility and acceptability need to be present to consider the environment as community housing and elements should be verified annually. Are safety, affordability, accessibility, and acceptability expectations met? YES □ NO □

9 Doc #: PCA-1-003545-09282016_10172016

Treatment Plan Disagreement Resolution Strategy

Process for Requesting Updates to Person Centered Treatment Plan

Additional Comments

Discharge Summary (to be completed at time of discharge)

Date of Discharge:

Reason for Discharge:

Recommended Action/Referrals Upon Discharge:

Summary of Progress and Outcomes:

10 Doc #: PCA-1-003545-09282016_10172016

Habilitation Service Hours (to be completed at each person-centered treatment plan review)

Average Number of hours per week received in the past 30 days. hours/week

Habilitation Service Hours Recommendation By Team Continue same average hours per week member has received in the last 30 days?

YES □ NO □ Adjust average hours per week? YES □ NO □ Hours per week adjusted to:____________ hours/week

Comments:___________________________________________________________________________________________________________________________________________________ Note: The Assessment and the Treatment Plan should identify the barrier(s) to a less intensive level as well as indicate specific interventions to be employed to address these barrier(s) in order to increase the member’s community integration and increased use of skills independent of staff.

Treatment Plan Signatures (Please include signatures of all responsible members. Please also provide a copy of this document to all parties involved within 30 days of this meeting.)

Date of Meeting

We, the undersigned, have been involved in the development of this treatment plan and are in agreement with this plan/addendum as discussed today. However, if upon receipt of a typed copy an involved party disagrees with any component, we will contact the IHH team for follow- up.

Name Title/Agency Signature Member in Service

Invitees Not in Attendance Name Title/Agency Signature

11 Doc #: PCA-1-003545-09282016_10172016

Person-Centered Treatment Plan Checklist YES NO • Has this annual meeting and planning process been driven by the member?• Has the member selected the attendees in addition to the time and location for this meeting?• Have direct care providers been included in this meeting? Have providers who could attend

(Psychiatrists, PCP, Nurse Practitioner) been given input for planning?• Has the member been offered choices for providers and services?• Did all participants use plain language during the meeting and within the plan including the

reflection of cultural considerations?• Has this member received services in the most community-integrated setting possible?• Was a strategy to solve disagreements discussed during this meeting and is it addressed in

the plan?• Has the team determined a method to request updates and addressed that in the plan?• With the team, has this member discussed goals/preferences related to relationships,

community participation, employment, income and savings, healthcare and wellness, andeducation?

• Has this member established realistic and attainable goals with the assistance of the team?• Does each challenge area identified in the assessment have at least one related goal?

Additionally, does any preferred subject of focus identified by the member also have arelated goal?

• While discussing goals, have there been assurances that all interventions and supports willnot cause harm to the member?

• Does the member have access to the benefits of community living?• Have risk factors been discussed and a plan to minimize all identified risk factors developed?• Have the member’s rights to privacy, dignity, respect, and freedom from coercion or restraint

been addressed during this meeting?• Have the member’s strengths, preferences, and needs pertaining to clinical and support

methods been discussed?• Does the member have a key to his/her home, privacy in this home, a choice of roommates,

and the freedom to furnish and decorate his/her environment within the boundaries of thelease agreement? If “no”, please explain below.

• Does the member have the freedom and necessary support to manage his/her schedule,personal visitors, and activities? If “no”, please explain below.

• Has or will the member have supports and/or services in the community that are unpaid.(Examples include family, peers, church, clubs, etc.)?

• Does the member have unrestricted access to food? If “no”, please explain below.

• Is the member’s housing rented/owned/occupied under a legally enforceable agreement?• Has a review of all restrictions has been conducted and be revised as needed? Has a

documented plan to reduce or eliminate these restrictions been included in this treatmentplan?

• Have the team members responsible for monitoring this plan been identified in the plan?• Has each participant in the meeting signed this plan including the member?• Have all team members been provided with a copy of this treatment plan within 30 days?• Has copy of this treatment plan been filed and available in the member’s health record?