IDHS: Illinois Department of Human Services



Illinois Department of Human Services ● Division of developmental Disabilities

Determination of Health & Medical Needs Questionnaire Page 1 of 3

Instructions: Use this form to request temporary additional direct support staff funding (53R or 53D) or an individual rate enhancement direct support staff add-on to address medical and/or health support needs for an individual in a residential or day program setting. The Division of Developmental Disabilities will consider authorizing a request for temporary additional direct support staff funding, or a request for an individual rate enhancement based on the individual’s health/medical needs only, if this completed form and all supporting documentation justifying the individual’s needs are sent to your Network Facilitator. If this request is for an individual in the HBS program, sign-off by the HBS Service Facilitator is required. These supports are not available for residents of private Intermediate Care Facilities (ICFs) or State Operated Facilities.

DHS/DDD Network of Requesting Agency:

[ ] Northwest [ ] Central [ ] Metro North Suburban [ ] Metro Chicago

[ ] North Central [ ] Southern [ ] Metro South Suburban

_____________________________________________________________________________ ___________

(Agency Name Requesting Enhanced Staff Support) (Agency ID #)

Individual’s Name: _________________________________________________________________________________

Social Security #: _________ - ______ - _________ D.O.B.: _________________, ________, ___________

This Additional Staff Support Request is for: (Check Only One)

Community Integrated Living Arrangement (CILA-60D) Services

Initial request for 53R Temporary Intensive Staff Support (348 hours)

Subsequent request for 53R funding (348 hours). Previous dates(s) of 53R: ________________________________

A Staff Add-On request to be included in the person’s 60D CILA residential rate.

Developmental Training (DT-31U) Services

Initial request for 53D Temporary Intensive Staff Support (115 hours)

Subsequent request for 53D Funding (115 hours). Previous dates(s) of 53D: ______________________

A Staff Add-On request to be included in the person’s 31U Developmental Training rate.

Adult Home-Based Support (AHBS), only applicable for Development Training 31U Services

Current Service Agreement that indicates 53D funding will be deducted from the individual’s monthly AHBS

allotment (Service Agreement must be signed by Individual/Legal Guardian and Service Facilitator).

Identify the Primary Residential, Developmental Training and/or HBS Service Provider(s) currently (or will be) authorized for this person. Identify the Primary Provider(s) by Name. (Check and Complete All That Apply)

Does this person receive any residential supports? No Yes - DD Residential Program Code: ______

If yes, residential provider’s name: ___________________________________________________________________

Does this person receive day program supports? No Yes - DD Day Program Code: ______

If yes, day program provider’s name: _________________________________________________________________

Does this person receive Adult Home-Based Support services? No Yes

HBS Service Facilitation Agency’s Name: ____________________________________________________________

Determination of Health & Medical Needs Questionnaire Page 2 of 3

In addition to the medical information requested, complete the following items. Use the directions as those for the Physical Status Review/Health Risk Screening Tool (PSR/HRST). Circle the appropriate score.

CARDIAC: (Circle the appropriate score.)

0. No diagnosed cardiac condition (Blood pressure is less than 130 systolic and 85 diastolic and more than 100 systolic and 60 diastolic without the use of medications.)

1. Requires minimal monitoring for individuals at risk (obesity [BMI of 30 or greater], diabetes, family cardiac problem history, smoker, high cholesterol levels, hypertension, atherosclerosis, sedentary lifestyle, male gender, males over 45 years of age and females over 50 years of age)

2. Has diagnosed cardiovascular disease or hypertension (inclusive of but not limited to congestive heart failure [CHF], cardiomyopathy, dysrhythmia(s) controlled by medication, monitoring, and/or diet)

3. Has progressively worsening diagnosed cardiac condition requiring medication (anticoagulants, nitroglycerin pills or patches, multiple hypertensive medications, antilipemics)

4. Has a history of hospitalization for cardiac intervention (pacemaker, history of cardiac catheterization, angioplasty, valve, replacement, angioplasty etc. for heart attack or stroke)

PULMONARY: (Circle the appropriate score.)

0 No diagnosed pulmonary condition (Chronic Obstructive Pulmonary Disease [COPD], asthma, chronic bronchitis, emphysema, lung cancer.)

1 A diagnosed pulmonary condition controlled with medication that does not interfere with physical activity.

2 Regular scheduled physician appointments more than twice a year for diagnosed pulmonary condition in addition to ongoing medication to control condition.

3 Has diagnosed pulmonary condition that requires constant monitoring by licensed health care personnel and frequent (at least one every 2 months) physician appointments, ER visits, or hospitalizations.

4 Has diagnosed pulmonary condition that requires constant oxygen in addition to medication and monitoring.

OSTEOPOROSIS: (Circle the appropriate score)

0. No diagnosis of osteoporosis or identified osteoporosis risk factors.

1. Presence of risk factors for osteoporosis (post-menopausal, anti-convulsant/medication therapy, inability to ambulate.)

2. Documented low bone density or normal bone density with history of non-trauma fractures.

3. Documented osteoporosis with a history of small bone fractures.

4. Documented osteoporosis with a history of multiple fractures or long bone/spinal fractures.

OTHER MEDICAL CONDITIONS: (Circle the appropriate score.)

0. No diagnosed medical conditions.

1. Has a minor short-term illness that requires outpatient treatment with a limited medication regime, such as flu, strep, urinary tract infection (UTI), or upper respiratory tract infections.

2. Acute medical conditions requiring short-term hospitalization for diseases requiring intravenous medications or treatments, such as pneumonia, aspiration pneumonia, cellulitis, pyelonephritis, etc.

3. Chronic medical condition requiring intermittent hospitalization, regularly scheduled physician visits, due to a chronic diagnosed condition.

4. Chronic medical condition that requires regular hospitalization and restricts the individual’s ability to participate in scheduled activities is life-threatening or terminal such as dialysis related to chronic renal failure, advanced liver disease, advanced lupus erythematosus, or cancer.

Determination of Health & Medical Needs Questionnaire Page 3 of 3

REQUIRED ATTACHMENTS:

1. The current Individual Service Plan (ISP) and any related special IDT/CST notes; and

2. A daily schedule showing specific times when 1:1 staffing is requested; and

3. A narrative clearly explaining why the individual requires 1:1 staff assistance with a description of how the assistance will be provided; and

4. A fading plan to reduce or eliminate additional staff, including the criteria to start fading; and

5. Current ICAP or SIB; and

6. Current MAR/TAR; and

7. CART & SST Considerations and Implementation Results (If available for temporary add-on;

Required if requesting Add-on included in the individual’s rate); and

8. Any relevant health care information related to the individual’s health.

The HBS Service Facilitator must discuss the request with anyone receiving HBS services and the guardian (if applicable). It must be understood by the receiver of HBS services that if granted, the cost of additional staff supports are within, and not in addition to, the monthly HBS funding allocation.

Signature(s):

________________________________ ___________ ________________________________ __________

Residential Provider Signature, or Date PAS/ISSA Provider’s Signature Date

Day Program Provider Signature, or

HBS Service Facilitator Signature (Circle which apply)

________________________________________________ ___________________________________________

PRINT Name of Residential/DT/HBS Provider Contact PRINT Name of PAS/ISSA Provider Contact

(_____) _________________________________________ (______) ____________________________________

Residential/DT/HBS Contact Phone Number Ext. PAS/ISSA Contact Phone Number Ext.

DHS-DDD USE ONLY - Internal Network Recommendation for a Health & Medical Needs Request

Residential Provider’s Name: _____________________________________________________________________

____ Recommend a Temporary INITIAL 53R award for Residential supports. Effective Date: ____________

____ Recommend a Temporary SUBSEQUENT 53R award for Residential supports. Effective Date: ______

____ Recommend a Staff Add-On of ______ hours/per week day [Monday–Friday] to be included in this person’s Residential Rate.

Note: Nine (9) hours/ per-week day would equal 1:1 for all paid awake hours

____ Recommend a Staff Add-On of _____ hours/weekend [Saturday-Sunday] to be included in this person’s Residential Rate.

Note: Sixteen (16) hours/weekend day would equal 1:1 for all paid awake hours.

Developmental Training (DT) Provider’s Name: _______________________________________________________

____ Recommend a Temporary INITIAL 53D award for DT. Effective Date: ____________________________

____ Recommend a Temporary SUBSEQUENT 53D award for DT. Effective Date: ______________________

____ Recommend a Staff Add-On of _____ hours /day for DT to be included in this person’s 31U Rate.

Note: Maximum recommendation may not exceed 5 hours/day in a Program 31U DT setting.

____ Incomplete Request – return to Requesting Agency Date: ______________________________________

____ Deny the 1:1 Staff Support Request – Behaviors and Documentation does not support the request. The Network Facilitator/BTS Representative will communicate the reason for a denial to the requesting agency and ISSA.

____ Deny the 1:1 Staff Support Request – Alternative resources and behavior management methods should be implemented before further consideration of a 1:1 Staff Support Request. The Network Facilitator/BTS Representative will communicate the reason for a denial to the requesting agency and ISSA.

_________________________________________________ ________________________ ____________________

Network Facilitator/BTS Representative’s Signature Date DHS/DDD Track-It Number

Health & Medical Needs Score Sheet

INTERNAL DHS/DDD USE ONLY

Physical Status Review with Additional Health & Medical Calculation Method to be completed by Network Staff

Individual’s Name: ___________________________________________ S. S. #:___________ - _____ - __________

Agency Name: ____________________________________________________________________________________

|Computation of Category Scores | |

| |Identification of Augmented Health Care Level |

|Enter ratings for each item and compute Category Score | |

| |Enter computed Category Scores AND add for the Total Score |

|Category and Item Item Score Category Score | |

| |FUNCTIONAL STATUS CATEGORY SCORE ___________ |

|FUNCTIONAL STATUS | |

|Eating __________ |Augmented PHYSIOLOGICAL SCORE ___________ |

|Ambulation +__________ | |

|Transfer +__________ |SAFETY STATUS CATEGORY SCORE ___________ |

|Toileting +__________ | |

|Day Program +__________ |FREQUENCY OF SERVICES CATEGORY SCORE ___________ |

| | |

|FUNCTIONAL STATUS CATEGORY SCORE __________ |TOTAL SCORE: ___________ |

| | |

|PHYSIOLOGIC (augmented) STATUS |Count the number of #4 ratings from the ITEMS from the left column and enter |

| |here: |

|Gastrointestinal __________ | |

|Seizures +__________ |Total of #4 ratings: ___________ |

|Anticonvulsant +__________ | |

|Skin Breakdown +__________ |Check if item “Treatment” was scored: _____ Yes _____ No |

|Bowel Function +__________ | |

|Nutrition +__________ | |

|Treatments +__________ | |

|- - - - - - - - - - - - - - - - - - - - - - - - - - | |

|Cardiac +__________ | |

|Pulmonary +__________ | |

|Osteoporosis +__________ | |

|Other Medical Conditions +__________ | |

| | |

|Augmented PHYSIOLOGICAL SCORE __________ (2 __________ | |

| | |

|SAFETY STATUS | |

|Injuries __________ | |

|Falls +__________ | |

| | |

|SAFETY STATUS CATEGORY SCORE __________ | |

| | |

|FREQUENCY OF SERVICES | |

|Prof. Health Care Services __________ | |

|Emergency Room Visits +__________ | |

|Hospital Admissions +__________ | |

| | |

|FREQUENCY OF SERVICES CATEGORY SCORE __________ | |

| | |

| | |

| | |

| | |

| | |

| |Circle the Health Care Level below. Use the total Score, number of #4 ITEM |

| |ratings and the Item “TREATMENTS” to identify the Health Care Level: |

| | |

| |Level 1: Total Score 0 – 13. Three or less #4 ratings. If item “Treatments” is |

| |scored “YES”, raise to Level 2. |

| | |

| |Level 2: Total Score 14 – 28. Three or less #4 ratings. If item “Treatments” is|

| |scored “YES”, raise to Level 3. |

| | |

| |Level 3: Total Score 29 – 42. Raise to Level 4 if 4 or more #4 ratings. If item|

| |“Treatments” is scored “YES”, raise to Level 4. |

| | |

| |Level 4: Total Score 43 – 58. Raise to Level 5 if 4 or more #4 ratings. If item|

| |“Treatments” is scored “YES”, raise to Level 5. |

| | |

| |Level 5: Total Score 59 – 75. Raise to Level 6 if 4 or more #4 ratings. If item|

| |“Treatments” is scored “YES”, raise to Level 6. |

| | |

| |Level 6: Total Score 75 or greater. If item “Treatments” is scored “NO”, lower |

| |to Level 5. To score at Level 6, item “Treatments” must be scored “YES”. |

| | |

| | |

| |____________________________________________ _______________ |

| |(Print Name of Network Facilitator who scored this (Date) |

| |Form) |

| | |

| |(Redraft date: 01-18-12) |

INTERNAL DHS USE ONLY - Reasoning

• The problem with the PSR/HRST for health issues is its lack of coverage of the Cardiovascular and Pulmonary issue as well as problems that may “slip through the ‘cracks’”. Cardiopulmonary disease is the number one killer in the United States and the incidence of disease in the intellectually disabled is higher than in the general population.

• However, if those systems and issues are addressed, the PSR/HRST has utility in helping to determine staffing. In addition, the facilities are used to complete it even though there is a problem in lack of instructors in the PSR/HRST in the community.

• Use of the modified PSR/HRST as presented will produce an objective method of determining staffing that is familiar to both providers and Network staff.

INTERNAL ONLY – Decision notes to determine need for Staff “Add-On”.

• Diagnoses (acute/chronic; diagnoses acuity [none ( life-threatening]

o Necessitates regular scheduled or frequent hospital/ER visits as result of degenerating health

o As needed treatment, i.e. brittle diabetes, tube feedings, dressing changes, physician visits, hospital admissions

o High Personal Care Needs

• Problems not directly addressed that may slip between the cracks

o Visual/Auditory disabilities (deaf, blind, seeing eye dog)

o Skeletal/Neuromuscular diseases that cause problems with ADL (activities of daily living) including but not limited to fractures, muscle spasms/weakness/decreased tone and paralysis.

o Drug load

• Before using the modified PSR/HRST, the network staff should:

o Learn how to complete the PSR/HRST and it application

o Learn the use of the PSR/HRST modifications

o Complete the modified PSR/HRST with the provider who can SHOW EVIDENCE for the scoring produced.

DIRECTIONS

• Use the scores in the PSR/HRST Categories I (Functional Status), III (Physiological), IV (Safety), and V Frequency of Service from the PSR?HRST in the most recent Nursing Services Packet.

• Add the previous three category scores to the Augmented Category III (Physiologic) total when calculating the final score. (Remember to NOT use Category II [Behavioral]).

• Calculate the score:

o If the individual is at Levels 1 or 2, no additional staffing.

o If the individual is at Level 3, consider temporary staff of more than _____ hours/day for the next ____ months. There must be a program developed and in place to resolve the problem. Determination of continued temporary staffing will be done by Network staff.

o If the individual is a t Level 4, additional staffing is likely but the number of hours needs to be resolved as well as the permanence of the additional hours

o If the individual is at Levels 5 or 6, award ongoing staff add-on corresponding to, at most, funding for 2 additional hours/day

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download