Department of Health (DOH) Developmental Disabilities Supports Division (DDSD) Policy Number: Supersedes: New. POLICY Policy Title:

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1 Department of Health (DOH) Developmental Disabilities Supports Division (DDSD) Policy Number: Supersedes: New POLICY Policy Title: Electronic Comprehensive Health Assessment Tool Requirements Effective Date: March 1, 2014 Approved: Signature on File Date: February 20, 2014 I. PURPOSE To outline the requirements for accurate and timely completion of the electronic Comprehensive Health Assessment Tool (e-chat) and added linked assessments, in order to identify the individual s needed health services and supports and to guide the development of Healthcare and Medical Emergency Response Plans (MERP) for adults receiving DD Waiver services. II. POLICY STATEMENTS A. Licensed nurses (RNs and LPNs) from a Provider agency will complete the e-chat, according to the DDSD standards, for individuals in Family Living, Supported Living, Intensive Medical Living and Customized Community Supports-group (CCS-G). All other DDW recipients may obtain an e-chat by adding Adult Nursing Services hours for assessment and consultation to their budget. B. The e-chat is a nursing assessment and, in accordance with the New Mexico Nurse Practice Act, may not be delegated by a licensed nurse to a non-licensed person. (See II.F.) C. LPN s may contribute to the content of the e-chat. An agency RN must review, may revise and must approve an e-chat that has been initiated by an LPN. This agency RN is to provide guidance to the LPN regarding the e-chat; Health Care Plans (HCP) or MERP s. Only RN s may approve an e-chat. The agency s supervising RN is not required to review and approve e-chat s that have been completed by staff RN s. D. Completion of the e-chat must be based upon the licensed nurse s firsthand knowledge of the individual and the review of clinical and non-clinical information from electronic and non-electronic data sources. This includes physician reports and reports or assessments from other clinical disciplines. Nurses must collaborate with others on the team, including the individual, family members, and direct support professionals (DSP). Page 1 of 5

2 1) The nurse must fully complete all the e-chat assessment questions and is required to document additional pertinent information in all comment sections that are clinically appropriate. No section may be skipped. 2) The final comment section must contain additional narrative notes regarding any health related issues that were not captured in the e-chat and reflect the nurse s complete clinical assessment of the individual s current health status, needs and a synopsis of progress toward care planned goals for individuals with established plans. 3) Information about the nurse s actions and decisions regarding Health Care Plans (HCPs) or Medical Emergency Response Plans (MERPs) are to be noted in the narrative section at the bottom of the e-chat Summary Sheet. i. Individuals, or guardians of individuals, who reside with Biological Family Living providers may determine to opt out of ongoing Adult Nursing Services. When this occurs, the nurse will note the guardian s decision in a progress note regarding the Consultation Meeting and will also note the outcome of that meeting in the narrative section the bottom of the e-chat Summary Sheet. These notes will indicate the reason why the nurse did not proceed with plans that were required or were to be considered. E. Non-nurses may enter data into the e-chat only from a paper version of the e-chat that has been completed, signed and dated by a licensed nurse. The RN must review and electronically approve the e-chat. The original paper version must be retained in the agency file. Non-nurses may not complete or approve the e-chat. F. For adults on the DD Waiver who are required or who choose to have an e-chat: 1) Upon new allocation or initial admission, an e-chat must be completed, entered into Therap and approved within no more than 3 business days of admission to a new provider agency, or two weeks following the initial ISP meeting, whichever comes first. 2) Upon transfer between agencies, an e-chat must be completed, entered into Therap and approved within 3 business days of transfer to the new provider agency, or two weeks following the transition meeting, whichever comes first. i. Prior to transfers and based upon actions agreed upon in the transition plan: 1. The receiving agency nurse may visit to complete their assessment. 2. The existing or sending agency must provide the receiving agency nurse with one year of medical records. Such records created by the sending agency within Therap may be transferred electronically once the receiving agency has accepted the referral from the case manager following Therap referral procedures. 3) An e-chat must be completed, entered and approved at least 14 calendar days prior to the annual ISP meeting. In order to reflect the individual s current condition, the e-chat may not be initiated any sooner than 45 calendar days before that meeting. 4) An e-chat must be completed, entered and approved, as needed, within 3 business days of a significant change of health status ( change of condition) and upon return from any hospitalization or sub-acute stay. Page 2 of 5

3 G. Based upon a review of the e-chat summary sheet and prudent nursing practice, the licensed nurse will develop healthcare plans and medical emergency response plans that are required. 1) The nurse will use their professional judgment to determine whether it is necessary to develop healthcare plans or medical emergency response plans that should be considered. 2) The nurse may combine related clinical issues into healthcare plans based on nursing judgment. This applies to plans that are labeled required or considered. 3) The Comprehensive Aspiration Risk Management Plan (CARMP) is a health care plan. The nurse must collaborate with the team as needed to complete the CARMP. A CARMP meets the required aspiration risk management plan listed on the e-chat summary sheet and the DDSD template must be used. No additional aspiration risk management plan shall be created. 4) The nurse will follow the DDSD Medical Emergency Response Plan policy and Procedure. 5) The nurse will indicate the date the HCP/CARMP and MERPs are developed on the e-chat summary sheet and may link electronic care plans or scanned plans. H. Individuals receiving Supported Living, Intensive Medical Living, Family Living services and Customized Community Supports - Group are required to have an e- CHAT completed annually per the DDSD Standards. 1) For individuals receiving Family Living services, the nurse will provide the individual and family/guardian with information regarding their professional recommendations for health care planning and indicate those services that are required or optional based on whether or not the person resides with Biological or Host/Surrogate Family Living providers. i. The nurse will proceed with care planning once prior authorization is received, if those services are selected and added to the budget. ii. The nurse will document actions or decisions regarding health care plans per section E.3.i. I. Nurses from the primary agency will professionally communicate with and collaborate with nurses from secondary agencies regarding health care plans and MERPs according to the DDSD standards. Plans will be developed by the secondary agency nurses that pertain to issues appropriate to the individual s time in that program. The secondary agency nurse is responsible for authoring, training and monitoring their own plans. J. The Health Passport for each individual shall be reprinted each time the e-chat is updated for any reason and whenever there is a change in contact information. III. APPLICABILITY Providers delivering Developmental Disabilities Waiver services to adults receiving Supported Living, Intensive Medical Living, Family Living, Adult Nursing Services and Customized Community Supports- Group. Individuals in Customized Community Supports (Individual or Small Group) and Customized In-Home Supports ( Independent or Living with Family and Friends), are not required to have an e-chat completed but may choose to do so by requesting Adult Nursing Services Assessment and Consultation units on their budget. Page 3 of 5

4 IV. DEFINITIONS Adult: means an individual who is age twenty-one or older, or who is at least eighteen years of age and receiving a Community Living Service. Collaboration: means professional communication via phone or face to face to discuss pertinent issues related to an individual s health needs. Collaboration involves the sharing of information, insights and plans for the purpose of informing both clinicians and other team members to provide the quality care and best possible outcomes for the individual. Collaboration between nurses related to e-chat and planning in specific settings includes access to electronic and paper health information, sharing of care plans and information. After collaboration, nurses are responsible for completing their own plans (HCP/CARMP and MERP) and are responsible for training, monitoring and updating these plans per DDSD Standards. Consultation Meeting: means a discussion with the individual, guardian and case manager where the nurse reviews the results of the e-chat and indentifies the nursing supports that may be provided through Ongoing Adult Nursing Services. After this meeting, the nurse will submit an Adult Nursing Services Prior Authorization (ANSPAR) form to the case manager which indicates the number and type of nursing hours requested for the budget. e-chat: means electronic Comprehensive Health Assessment Tool, maintained on a secure website under contract with Therap Services. The tool must be completed for each adult served through Developmental Disabilities Waiver funding two weeks prior to their annual Individual Service Plan (ISP) meeting, upon hospital discharge and upon significant change of condition. This process includes all linked assessments. Health Passport: means a standardized document that contains individual, physician and emergency contact information, complete list of current and historical medical diagnoses, health and safety risk factors, allergies, insurance information and advance directives. The Health Passport also includes a standardized form to use at medical appointments. LPN: means a Licensed Practical Nurse. Primary Provider: means the agency responsible as per the hierarchy to create and maintain the client record within Therap, in this order: Living Supports Provider; Adult Nursing Services Provider; Customized Community Supports - Group Provider. RN: means a licensed Registered Nurse. Secondary Provider: means any other agency that is not the Primary Provider on the individual s team that is also required to utilize Therap. Page 4 of 5

5 Significant Change in Health Status: means the individual has experienced one or more of the following: a decline in physical, cognitive or functional ability; a new diagnosis or event that requires a change in medication or treatment or requires creation or revision to a health care or medical emergency response plan; a change in medication or the medication route that would permanently alter the level of medication assistance. Therap: means the secure online documentation system provided under contract by Therap Services, LLC. V. REFERENCES Developmental Disabilities Waiver Service Standards New Mexico Nurse Practice Act DDSD Medical Emergency Response Plan Policy 2010 DDSD Aspiration Risk Management Policy and Procedure Page 5 of 5