2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
2013 Practitioner and Provider Manual - Presbyterian Healthcare ...
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Long-Term Carecoordinators <strong>and</strong> providers in engaging members<strong>and</strong> improving health outcomes through increasedhealth literacy <strong>and</strong> personal responsibility. CHWs,also known as promotoras, are lay health workers<strong>and</strong> advocates for members who assist individuals<strong>and</strong> families in obtaining the knowledge <strong>and</strong> skillsnecessary to achieve optimal health <strong>and</strong> well-being.Community health representatives (CHRs) play asimilar role in tribal communities. CHWs <strong>and</strong> CHRsplay a key role inEngaging members, their families, <strong>and</strong>caregivers in culturally appropriate,individually tailored health education to ensurethey have the tools needed to activelyparticipate in their careDelivering interdisciplinary care planning,including the completion of CNAs <strong>and</strong> formalHRAsFacilitating integrated care by helpingmembers access appropriate physical health,behavioral health, <strong>and</strong> long-term care servicesBuilding relationships with community-basedsocial service organizations across NewMexico to ensure that members can obtainneeded non-medical social support servicessuch as transportation, food, <strong>and</strong> housingCHWs <strong>and</strong> CHRs may be part of a member’s ICPT<strong>and</strong> are a valuable resource for providers forcoordinating <strong>and</strong> ensuring that a member’s holisticcare needs are met.Nursing Facility Level of Care: Care PlanDevelopmentOnce a member is assessed as eligible for NFLOC, the care coordinator develops a care planwith the member <strong>and</strong>/or legal guardian orrepresentative, as well as anyone else the memberchooses. The care planning process is based onthe CNA, which incorporates elements of the NewMexico Personal Care Option need determination<strong>and</strong> the assessment used for long-term care waiverclients. The care planning process incorporates themember’s medical, functional, behavioral, socialsupport, <strong>and</strong> community participation needs <strong>and</strong>preferences as part of a holistic plan for HCBS.Members who elect to use the SDCB work withtheir support broker (<strong>and</strong> their EOR or authorizedagent) to identify the needed services within thescope of covered services <strong>and</strong> the HSD-providedannual allotment. The budget plan is incorporatedinto the member’s care plan.The assessment is used as the basis fordetermining the types <strong>and</strong> amount <strong>and</strong> duration ofHCBS the member needs. Based on establishedcriteria for individual need level, the carecoordinator develops an individual HCBS plan asfollows:The member <strong>and</strong>/or representative identifyspecific HCBS the member desires/needs.The care coordinator educates the member ontheir option to elect the SDCB, <strong>and</strong> explainsthe self-assessment tool that must becompleted for members electing this option.The care coordinator ensures that the HCBSincluded in the care plan <strong>and</strong> (for SDCB) the10-112014 <strong>Practitioner</strong> <strong>and</strong> <strong>Provider</strong> <strong>Manual</strong> - Ver. 3
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