CARE COORDINATION PROTOCOL VERSION 3.1 Outline of Changes from Previous Version 3.0

Transcription

1 CARE COORDINATION PROTOCOL VERSION 3.1 Outline of Changes from Previous Version 3.0 PAGE NO. SECTION CHANGES General 4 Definitions 5 Definitions The word re-assessment has been changed to reassessment throughout the document. The definition of a case conference has been revised to more clearly define expectations of a formal case conference and to distinguish between scheduled and unscheduled case conferences. The following phrase has been added to the definition of DOT. In most instances, Care Coordination Programs provide modified DOT services, e.g. not seven (7) days a week. 5 Definitions The definition of Comprehensive Care Plan is re-ordered alphabetically. 8 Definitions The words is provided are added to the definition of Quality Management Language has been updated to reflect new appendix letter for the Reassessment Form (now Appendix CC) The following stipulation has been revised as follows: All reminders within three days are encouraged to be an actual conversation with the patient rather than a voic . The following stipulation has been revised as follows: If unable to successfully contact the patient within the three days prior to the scheduled service, a visit to the patient s home should be attempted to locate and accompany the patient Language has been updated to reflect the Referrals/Appointments Tracking Log (Appendix V) The following stipulation has been added: Asking whether the patient requires assistance with childcare every time a reminder is provider (if applicable). The following stipulation has been moved from bullet point 2.1.7: Asking whether the patient requires assistance with childcare every time a reminder is provided. Bullets were reordered. The expected duration of a health promotion session has been changed FROM minutes TO minutes. This new bullet has been added: Health promotion topics and conversations may be conducted in stand-alone sessions (encounters) focused solely on health promotion or may be incorporated into other service type Page 1 of 5

2 encounters (e.g. accompaniment). All other sub-bullets under were re-numbered to correspond Language has been updated to reflect new appendix letter for the Services Tracking Log (now Appendix FF) and for the Curriculum Coverage Log (now Appendix X). 16 Footer Updated HOPWA contact phone number to (347) Language has been updated to reflect new appendix letter for the Reassessment Form (now Appendix CC) The frequency for Reassessments is changed FROM days TO six (6) months Language has been updated to reflect new appendix letter for the Reassessment Form (now Appendix CC) The following stipulation has been added: Patients receiving DOT must be enrolled in Track D Language has been updated to reflect new appendix letter for the Monthly DOT Log (now Appendix AA) This new bullet has been added under Patient Enrollment Eligibility clarifying that clients must be at least 18 years of age. All other sub-bullets under were re-numbered to correspond. The Comprehensive Care Plan time requirement has been updated to reflect a minimum frequency of every six (6) months The phrase that could impact the client s care plan has been added The phrase treatment plan has been changed to medical treatment plan Revisions have been made to more clearly define a formal case conference and to distinguish between scheduled and unscheduled case conferences. Language has been updated to reflect new appendix letter for the Care Coordination Case Conference Form (now Appendix BB). Added this new bullet which includes a detailed definition of a formal case conference including required attendees. Page 2 of 5

3 Previous bullet now becomes bullet and all numbering of sub-bullets changes to correspond The word formal has been added to the following phrase Another option for formal case conferences The following stipulation regarding the induction period requirement has been added: Patients enrolled initially in Track A are not subject to the induction period requirement Completed the statement by adding the word week to read once per week Table 1 This bullet has been reworded as follows: Accompaniment to medical specialists and social services programs is beneficial and encouraged. This bullet has been reworded as follows: The Care Coordinator should tailor his or her approach according to patient successes and challenges. Reference to Track A has been removed from this table since the induction period is no longer required for this track Language has been updated to reflect new appendix letters for the Pill Box Logs (now Appendix Y and Z) Language has been updated to reflect new appendix letter for the Status Change Information Form (Track and Treatment Status) (now Appendix DD). Language has been updated to reflect new appendix letter for the Reassessment Form (now Appendix CC) and for the Status Change Information Form (Track and Treatment Status) (now Appendix DD) Reassessment frequency has been changed FROM three to four times per year TO twice per year Language has been updated to reflect new appendix letter for the Reassessment Form (now Appendix CC) This language has been updated to clarify that either a new Comprehensive Care Plan may be created or the current Comprehensive Care Plan may be updated. A new Comprehensive Care Plan must be created at least once per year Language has been updated to reflect new appendix letter for the Reassessment Form (now Appendix CC). Page 3 of 5

4 Language has been updated to reflect the Referrals/Appointments Tracking Log (Appendix V) The word outreach has been changed to outreach for client re-engagement Language has been updated to reflect new appendix letter for the Services Tracking Log (now Appendix FF) and for the Referrals/Appointments Tracking Log (Appendix V) Language has been updated to reflect new appendix letter for the Services Tracking Log (now Appendix FF) Language has been updated to reflect new appendix letter for the Reassessment Form (now Appendix CC). 59 Appendix B 61 Appendix D The following statement has been added: Care Coordination program staff members are not allowed to provide child care services. List of NYC Authorized Syringe Exchange and Selected Sterile Syringe Access Programs in NYC has been updated. 63 Appendix E The address for GMHC, Inc. has been updated. 104 Appendix Q Common Demographics Form has been updated. 106 Appendix R Intake Assessment Form has been updated. Page 4 of 5

5 117 Appendix S Adherence Assessment (ART Daily Regimens Only) has been updated. 120 Appendix T Adherence Assessment (ART Non-Daily Regimens Only) has been updated. 123 Appendix U Comprehensive Care Plan has been updated. 129 Appendix V 132 Appendix W Referrals/Appointments Tracking Log has been added. This form contains information previously (and no longer) collected in the Comprehensive Care Plan. PCSM form has been added. This form contains information previously (and no longer) collected in the Reassessment Form. 138 Appendix Y Pill Box Log (ART Only) For Daily Regimens has been updated. 141 Appendix Z Pill Box Log (ART Only) For Non-Daily Regimens has been updated. 150 Appendix CC Reassessment Form has been updated. 160 Appendix DD 162 Appendix EE Status Change Information Form (Track and Treatment Status) has replaced portions of the former (no longer used) Patient Status Change Information Form. Status Change Information Form (Case Closure/Suspension) has replaced portions of the former (no longer used) Patient Status Change Information Form. 164 Appendix FF Services Tracking Log has been updated. Page 5 of 5