Initial Orders and Assessment: Staff will contact the client within 1 business day of agency receipt of referral with orders from a licensed medical provider.

Agencies must initiate services per orders specified by the referring licensed medical care provider or within 2 business days of receipt of the referral with orders, whichever is earlier.

Initiation of service must consist of a comprehensive assessment of the status of the client’s physical, psychosocial, and home safety.

Components of assessments:

• Past medical history relevant to services to be provided
• Acute or chronic health conditions
• Current system of support to meet basic needs and activities of daily living
• Fall risk
• Cognition and level of consciousness
• Access to food and emergency assistance
• Access to primary and specialty medical care
• Ability to self-manage prescribed therapies
• Skilled nursing services require a head-to-toe assessment
• Current regimen and response to prescribed symptom management and prevention
• Current medication list
• Emergency contact(s)
• Home and environmental safety

1. Percentage of clients with documentation of a referral for services from a licensed medical provider prior to initiation of services. (Pilot Measure)

2. Documentation that a comprehensive assessment was completed by the Home and Community-Based Health Services provider within 2 business days of receipt of the referral with orders for assessment or at the time specified by the ordering provider.

Implementation of Care Plan: Staff will be complete a care plan based on the primary medical care provider’s order that includes:

• Current assessment and needs of the client, including activities of daily living needs (personal hygiene care, basic assistance with cleaning, and cooking activities)
• Need for Home and Community-Based Health Services
• Types, quantity, and length of time services are to be provided

The care plan is updated at least every 60 calendar days.

3. Percentage of clients with documentation of a client-centered care plan that follows the primary medical care provider’s orders as written.

4. Percentage of clients with documentation of review and update to their care plan every 60 calendar days at a minimum.

Coordination of Services and Referrals: If referrals are deemed necessary the agency will:

• Assist clients in making informed decisions on choices of available service providers and resources to meet their individual needs.
• Coordinate referrals to ancillary services as appropriate and approved by the client and the client’s primary care provider.
• Ensure and document care coordination across the multidisciplinary team as applicable to the client.

5. Percentage of clients with referrals to ancillary services that have documentation of consultation with the client or primary caretaker, and the primary care provider to ensure coordination of care and mutual approval of the plan of care. (Pilot Measure)

Transfer/Discharge: A transfer or discharge plan must be developed for any of the following circumstances: 

• Agency is not able to meet the level of care required by the client.
• Client transfers services to another service program.
• Client discontinues services.
• Client relocates out of the service delivery area.
• The agency determines the clients’ home or current residence is not physically safe or appropriate for the provision of Home and Community-Based Health Services.

All services transferred must be accompanied by a referral to an appropriate service provider.

6. Percentage of clients transferred or discharged from services with documentation of a transfer or discharge plan developed in coordination with the client or client’s designated caregiver to facilitate a safe transfer, handoff, or discharge from services.