MCCY & MCAW HOME VISIT/QUARTERLY CALL TEMPLATE INSTRUCTIONS
Complete all bold sections pertaining to the appropriate program during a MCCY/MCAW home visit or quarterly call. Instructions for each individual section are outlined in italics and examples are provided below the instructions. Please note that all topics may not be pertinent to the participant and all information may not be captured in the instructions. The intent of the home visit template is to provide a foundation for the participant/family interview and assessment to ensure their needs are being met. Explain the applicable MO HealthNet services that may be authorized through MCCY/MCAW. PDN, PCA and home health services should be considered for all participants, understanding that PCA and home health services cannot replace PDN services. If any unmet needs or barriers to obtaining services are identified in any section of the home visit template, a plan to address those unmet needs and steps taken should be documented, including who is responsible for completing each step.
Date and Time of Visit/Call: List the date and time the visit or call was completed.
- Example: 11/1/2022 1:00-2:00pm
DOB: List the participant’s DOB.
- Example: 1/1/2005
Name and Role of Persons Present for Visit/Call: List the responsible party name, participant name, MCCY/MCAW Service Coordinator name and any additional parties present for the visit or call, identifying each individual’s role behind their name.
- Example: Jane Doe (mom), John Doe (participant), Sally Jones, RN (SC) and Taylor Smith (PDN)
Responsible Party Information: List the name, phone number and email address (if applicable) of the participant’s responsible party(ies). Include any guardianship or legal custody information.
Example: Jane Doe (mom) has guardianship of John and a copy of the paperwork is on file.
Phone: 555-555-5555
Email: Jane.Doe@gmail.com
Major Diagnoses: List the participant’s diagnosis(es) related to authorized services.
- Example: Cerebral Palsy, tracheostomy status, epilepsy
PDN Assessment: Outline the participant’s PDN needs, including any section that is scored on the PDN Assessment (completed only when assessing participants for PDN services).
- Example 1: John requires continuous assessment, seizure observation/intervention, ventilator when sleeping, trach care TID, trach change weekly, oxygen PRN, pulse oximetry TID when not on ventilator, G-tube for continuous feeding overnight, bolus feeding one time per day and administration of multiple medications, CPT vest TID, nebulizer treatments BID, decubitus assessment/positioning and reinforcement teaching
Example 2:
Continuous Nursing Assessment: 30
Seizure Observation/Intervention: 10
Continuous Ventilator via Tracheostomy: 50
Continuous Oxygen, Stable: 25
Suctioning Q2H: 7
G-tube Feeds Q3H: 28
Multiple Medications via G-tube: 10
PDN Assessment Score: List the participant’s PDN Assessment score (completed only when assessing participants for PDN services).
- Example: 160
PCA Assessment: Outline the participant’s PCA needs, including any section that is completed the PCA Assessment (completed only when assessing participants for PCA services). Outline the participant’s current activities of daily living (ADLs), including the level of independence on ADLs (i.e. dressing, bathing, grooming, toileting, mobility, eating, ambulation, transfers, communication). If completed, enter the areas of functional abilities/limitations relevant to the participant.
- Example: John requires assistance with dressing, grooming, toileting, bathing and transferring. John is independent in eating and bed mobility.
MCAW Client Assessment Completed: State ‘Yes’ or ‘No’ if a Client Assessment was completed and the date of the last completed Client Assessment (complete only for MCAW participants and delete section for a MCCY participant).
- Example: Client Assessment completed 11/1/2022
MCAW Level of Care (LOC) Completed: State ‘Yes’ or ‘No’ if a LOC was completed and the date of the last completed LOC (complete only for MCAW participants and delete section for a MCCY participant).
Example: LOC completed 11/1/2022
MCAW LOC Score: List the participant’s LOC score (complete only for MCAW participants and delete section for a MCCY participant).
- Example: 45
Current Status and Significant Changes:
Outline the participant’s current status and any recent/significant changes that occurred since the participant’s last home visit, including but not limited to; recent illness and/or hospitalization, respiratory status (i.e. oxygen, trach, vent status), seizure activity, treatment regimens (i.e. IV medication, bowel/bladder programs, wound care, tube feedings, etc.).
- Example: John was hospitalized from 11/1/2022-11/5/2022 for increased seizure activity, following an influenza diagnosis. He was given IV fluids and monitored for seizures during his hospitalization. Since discharge, his seizure activity stabilized and there were no changes to medication and treatment regimen for John. Jane (mom) reports John is still weak and recovering, but otherwise doing well at home.
Recent and/or Upcoming Appointments:
Outline the participant’s appointments that occurred since the last home visit and/or are upcoming.
- Example 1: John had an appointment on 11/1/2022 with his neurologist, Dr. Smith, and he will follow up annually in November 2023.
- Example 2: Dr. Smith (Neurology): 11/1/2022 with follow up annually
Medications and Changes:
Outline the participant’s current medication regimen and note any changes.
- Example 1: The participant’s current medication regimen includes: Onfi BID, Flonase QD and Diazepam PRN. John has had no changes to his medications since his last assessment.
Example 2:
Medications administered via G-tube
Furosemide discontinued
Epidiolex BID
Clonidine patch 0.2mg Q7D
Nexium BID
Diastat PRN
Albuterol PRN
Therapies and Assistive Devices:
Outline any participation in therapy services (i.e. speech, occupational, physical, music) and the use of any assistive devices (i.e. wheelchair, Hoyer lift, communication device, AFOs, etc.).
- Example: John attends PT in an outpatient clinic once a week. He wears bilateral AFOs and uses a stander for 45 minutes each day. John uses a wheelchair for mobility and there is a Hoyer lift in the home for transfers.
Diet and Nutrition:
Outline the participant’s current dietary regimen and nutritional needs, including but not limited to; participant’s feeding method (i.e. independently fed, adaptive utensils, positioning needs, G-tube) tube feeding frequency, volume, formula, current weight and/or significant weight changes and specific dietary needs.
- Example 1: John has a G-tube and requires 350mL bolus feeds of Kate Farms QID. He receives 50mL water flushes after each feed. His current weight is 120lbs.
- Example 2: John is able to feed himself using adaptive silverware, with monitoring due to concern of choking and aspiration. He recently passed a swallow study on 11/1/2022 and has advanced to a pureed diet. He had lost 20lbs due to swallowing concerns, but has now regained that weight. He is currently 125lbs.
Participant/Family Risks:
Outline the current participant/family risks including, but not limited to; home environment, social factors, individuals living in the home, caregiver availability and employment information, guardianship information, school information and accessible transportation. Assess participant/family risks that may be a barrier to receiving services.
- Example: John lives in a two story home with his mother, Jane, and younger sister, Jill. John’s bedroom is on the main floor and the home has been modified to meet John’s accessibility needs. Jane works as a teacher and Jill is attending college courses near their home. Jane has guardianship of John and a copy of the paperwork is on file. The family does not have an accessible vehicle and utilize transportation services for John. Outside of her daughter, Jane has a poor support system and voiced concern with her recent increase in home expenses.
Safety/Emergency Plan:
Discuss and outline the participant/family’s safety plan in the event of an emergency (i.e. fire, tornado, earthquake, flooding, etc.) including, but not limited to; extra supplies, go-bag, smoke detectors, carbon monoxide detectors, fire extinguisher, number of exits, accessibility of exits, exit plan, power company notification, generator, basement/shelter, written plan posted in the home, emergency contacts posted in the home. Provide participant/families with emergency planning and resources to ensure a plan is in place.
- Example: I reviewed the participant/family’s safety/emergency plan. John would need to be pushed in his wheelchair or carried out of the home in the event of an emergency. The home has a ramp at the front and back doors. The home has a basement and John would be transferred here in the event of a tornado. The family has a fire extinguisher in the home and a designated meeting place in the event of a fire. Jane (mom) voiced that they have not restocked their supplies in the go-bag and do not have a written plan in place. I encouraged Jane to put together a go-bag with essential supplies that can be taken out of the home quickly in the event of an emergency. I also outlined the importance of a written plan that is posted in the home so that caregivers in the home can easily reference it.
Priority Level: List the participant’s assigned Emergency Priority Level.
- Example: Priority Level: 1
Backup Caregiver Plan:
Outline the participant’s backup caregiver plan, including information regarding their availability and ability to provide care for the participant. If the participant/responsible party does not provide a reliable backup caregiver plan, discuss and assist with identifying potential backup caregiver options. If these efforts are unsuccessful, consider elevating to RC for additional assistance.
- Example: John’s sister, Jill, lives in the home and is fully trained as a backup caregiver. She recently started attending college courses and her availability is more limited. I encouraged Jane (mom) to look into additional options for backup care for John. I discussed additional services available for John through MCCY/MCAW, Medicaid and outside resources to ensure the participant is utilizing all available services.
Current Authorized Services and Providers:
List the participant’s current authorization of services and their selected providers in the appropriate section and remove those that are not applicable.
PDN: Provider:
PCA: Provider:
APC: Provider:
ARN: Provider:
MCAW Supplies: Provider:
Example:
PDN: 100 hours/week (NOT to exceed 16 hours/day) Provider: Advantage Nursing Services
MCAW Supplies: Briefs-2 cases/mo, Gloves-3 boxes/mo Provider: Rehab Specialty Medical
Are Services Being Delivered as Authorized?
Indicate whether services are being provided in accordance with the approved authorization, including service type, frequency, duration and provider. If not, provide follow up in the ‘Customer Service Concerns’ section.
Are Supplies Being Delivered as Authorized?
Indicate whether supplies are being delivered in accordance with the approved authorization, including item type, quantity and delivery schedule. If not, provide follow up in the ‘Customer Service Concerns’ section.
Changes to Authorization:
List any change(s) in the participant’s authorization and/or selected provider agency and outline the reasoning.
- Example 1: PDN: Increased from 100 hours/week to 112 hours/week (NOT to exceed 16 hours/day), due to John requiring continuous G-tube feeds, compared to bolus feeds QID.
- Example 2: I sent a Program Change Request to the MCCY/MCAW Program Manager for PDN: 112 hours/week (NOT to exceed 18 hours/day, 3 days/week), as Jane (mom) requested to allow 18 hours/day of PDN services to accommodate her work schedule and coverage. I communicated with Jane that any authorization exceeding the MHN guidelines of 112 hours/week and 16 hours/day must be approved by the Program Manager. I explained that I would contact her once I received a determination.
Customer Service Concerns:
Discuss the participant’s currently authorized services and outline any concerns. If the participant/family voices any customer service concerns (i.e. lack of staff, issues with supply delivery, etc.) outline the resources provided and plan made to address these needs, including assessment of the participant’s eligibility for other services available through MCCY/MCAW and/or Medicaid. Provide the participant/family with updates regarding changes in SHCN and MHN policies, procedures or guidelines and/or CSR changes that occurred within the last six (6) months (i.e. allowance of more than one provider, family member as PDN, etc.) and offer/provide a current provider list and/or to contact the provider agencies in the region on the participant’s behalf via an email blast. If a request was made to change the current authorization (i.e. increase/decrease authorized hours) and/or that is outside of the MCCY/MCAW guidelines and you are approving or denying the request, outline the justification for the agreed upon change and/or resources that were provided for additional assistance if the request was denied. If a request to change the authorization was made that requires Program Manager approval, outline the actions taken to follow up on that request. Once all actions that are within the SC’s purview to address the participant’s customer service concerns and barriers to receiving services have been taken, communicate the ongoing issues with the MCCY/MCAW Regional Coordinator and MCCY/MCAW Program Manager in attempt to address barrier removal, as appropriate.
- Example 1: John currently has one nurse that works 8:00am-4:00pm M-F and a second nurse that works 11:00pm-7:00am on M-Th. John does not have nightshift nursing on Friday-Sunday or any weekend dayshifts covered. Jane voiced that the agency is currently advertising for staff and she has self-advertised, as well. I reminded Jane that John could utilize multiple providers in the home and provided an updated PDN list. I also outlined that it is allowed for a family member who is a licensed nurse to staff up to 40 hours/week of John’s authorized PDN hours. John’s current supply authorization is being met and Jane voiced no concerns at this time.
- Example 2: John is authorized for 112 hours/week of PDN services, but has only been able to utilize 60 hours/week due to lack of PDN staff. His PDN agency has advertised for staff. Jane, his mother, is aware that she can use multiple providers in the home. Jane has worked with several agencies and has been trying to find full staffing for the last six months. I have previously provided an updated PDN provider list and explained that a family member who is a licensed nurse can staff up to 40 hours/week of John’s authorized PDN hours. Because of her continuing inability to find full staffing for his authorized hours, I offered to contact the provider agencies on John’s behalf and sent an email blast to all of the PDN provider agencies in the region. I also assessed need for other allowable services, such as PCA and home health services. I communicated the ongoing concerns with my RC and PM to discuss options for barrier removal.
Other Services:
Assess and list any other services the participant is receiving, outside of MCCY/MCAW services, including but not limited to; Children and Youth with Special Health Care Needs (CYSHCN), Family Partnership, Department of Mental Health (DMH) waiver, Senate Bill 40 (SB-40) Board, First Steps, Head Start, Division of Senior and Disability Services (DSDS): Long Term Services and Supports (LTSS), private insurance, Medicare, Social Security benefits, other Medicaid services and any other local agencies. If the participant is enrolled in other services, inquire about caseworker/service coordinator information and list it. Include the services that the participant is receiving through each respective agency. If you are aware of additional services the participant may be eligible for, educate the participant/responsible party on the services and discuss if a referral or assessment for additional services would be beneficial to the participant. If the participant/family states a need for services or an additional need is identified by the SC, outline what steps were made to make a referral and connect them with the additional resources.
Example:
DMH: John receives supplies through the Community Support Waiver and his caseworker is Sarah Smith (555-555-5555/sarah.smith@gmail.com).
CYSHCN: Jane stated John is in need of an adaptive car seat. I emailed a referral to the CYSHCN Service Coordinator for Region 5 (Tim Jones: 555-555-5555/tim.jones@outlook.com).
Transition Plan:
If the participant is age 13-21, discuss and review a plan for a transition into adult services at regular intervals. Provide the participant/responsible party with resources to connect with adult services. Document coordination of a transition meeting and collaboration with Department of Mental Health (DMH) and DSDS Long Term Services and Supports (LTSS) to ensure the participant has adequate services in place when they turn 21 and age out of MCCY.
- Example: Jane (mom) and I discussed options for John’s adult services, as he turned 20 last month. John has established care with adult physicians and Jane has guardianship of John. A copy of the paperwork is on file. I outlined the services that John may be eligible for through DMH, SHCN and LTSS. I explained that six months prior to John turning 21 and aging out of MCCY, a meeting with all agencies would be completed to review John’s service options and that John would only be able to be enrolled in one waiver at a time. Jane voiced understanding and stated she is unsure what services would be best for John, as he currently receives services through a DMH waiver, as well as MCCY.
Personal Goals:
Discuss goals for the participant and outline the goals stated by the participant/family.
- Example: Jane voiced that John’s goal is to stay healthy and remain in the home.
Plan to Address Identified Barriers and Referrals for Additional Services
Document all follow-up action steps to address any barriers identified during the assessment and who is responsible for completing the steps, if they are not already addressed in the individual section. Outline all identified referrals for additional services, including other Medicaid-funded services, and the reason for the referral. If there are identified barriers or needed referrals that require further assistance, please bring them to the attention of the MCCY/MCAW Regional Coordinator and MCCY/MCAW Program Manager to confer on potential solutions.
- Example 1: Jane voiced concern with paying monthly bills and I connected her with local resources.
- Example 2: Jane stated that John’s current PDN is going to be on maternity leave for the next three months and is concerned about coverage during this time. I provided mom with a current PDN provider list and directed her to contact the agency to discuss a staffing coverage plan. I assessed John’s eligibility for other additional services, including PCA and home health services. If these efforts do not improve the family’s situation, I will elevate the issue to my RC.
- Example 3: Jane voiced concern regarding John’s MHN supply coverage. I provided Jane with the number for MHN Constituent Services and sent a referral via email to MHN.
- Example 4: John’s mother, Jane, will be having surgery on 1/1/2023 and will not be able to provide John’s care for two weeks, due to lifting restrictions. I contacted the MCCY/MCAW Regional Coordinator and discusses the need for a temporary increase for 24/7 PDN services during the two weeks of Jane’s recovery. The RC agreed that the need was justified and I will proceed with submitting a Program Change Request to the MCCY/MCAW Program Manager.
Most Recent SCA: List the month and year of the most recent Service Coordinator Assessment (SCA).
Example: 11/1/2022
Next Visit: List the month and year of the next home visit.
- Example: February 2023
Other: List any information not outlined in other sections of the home visit template that are pertinent to the participant’s assessed needs.