(1) Health and wellness
support and services and the roles of various individuals are specifically
noted in the service recipient's Plan, per OAC
340:100-5-50
through
340:100-5-58.
(2) For a service recipient who receives
minimal services to maintain residence in his or her own homeor family home or
to maintain employment, the service recipient and his or her Team determines
the appropriate roles for members of the Team per applicable policy.
(3) For a service recipient who receives
residential, group home, or extensive health supports to remain in his or her
own homeor family home or maintain employment, the Team identifies specific
roles and protocols necessary to provide support as listed in (A) - (I) of this
paragraph.
(A) The Team identifies desired
health care outcomes or necessary supports through the Team process.
(B) Health issues identified through health
care evaluations and assessments that impact the service recipient's life are
incorporated and integrated by the Team into the Plan.
(C) When assessing health care services or
implementation strategies involving discipline-specific services, a
representative from that discipline participates in a consulting
role.
(D) For service recipients
who receive HCBS Waiver community residential supports or group home services,
invasive procedures are reviewed by the Team, including participation from any
other service provider as appropriate. Consent is assessed, per OAC
340:100-3-5.
(i) An invasive procedure is a procedure or
surgery that requires moderate to deep sedation or general anesthesia, changes
the service recipient's functional level following the procedure, or requires
changes to the Plan.
(ii) Invasive
procedures reviewed by the Team comprise both scheduled and emergency
procedures.
(iii) Team review of a
scheduled invasive procedure occurs prior to implementation of the proposed
procedure and includes, but is not limited to, a discussion of risk, benefit,
and possible alternatives. For both scheduled and emergency invasive procedures
the Team assesses service and support needs to promote healing or
rehabilitation.
(E) The
community residential supports or group home provider is responsible for
providing health care coordination.
(F) For a service recipient who requires
extensive health supports to remain in his or her own home or maintain
employment, the HCC is identified in the Plan when the HCC is a paid
support.
(G) The Team identifies a
HCC to ensure implementation and coordination of health care services for the
service recipient. The HCC:
(i) is a person
who has an understanding of the service recipient's health care needs and
lifestyle, and may be the service recipient, service recipient's family member,
foster parent, companion, residential provider staff, or other person who is
familiar with the service recipient's needs;
(ii) receives DDS required
training;
(iii) documents that
health concerns are addressed, monitored, and communicated;
(iv) supports the person to directly
communicate to the health care provider the reason for the medical consultation
whenever possible, or communicate on the service recipient's behalf;
(v) keeps the health care provider advised of
medical status and data regarding any target symptoms;
(vi) communicates health care provider orders
to core Team members and other service providers as appropriate;
(vii) presents Form 06HM005E, Referral Form
for Examination or Treatment, for HCBS Waiver recipients to the health care
provider at the time of the visit ensuring:
(I) Form 06HM005E is completed by the HCC
prior to the visit; and
(II) the
health care provider completes a short written summary of the
findings;
(viii) presents
Form 06HM073E, Referral Form for Psychiatric Examination or Treatment, for HCBS
Waiver recipients to the psychiatric health care provider at the time of the
visitensuring:
(I) Form 06HM073E is completed
by the HCC prior to the visit; and
(II) the psychiatric health care provider
completes a short written summary of the findings; and
(ix) when employed by a contract provider,
the employer develops and implements a procedure to ensure appropriate backup
if the HCC is unable, for any reason, to perform these duties.
(H) For service recipients who
receive HCBS Waiver community residential supports or group home services, the
DDS case manager submits a referral for a clinical pharmacist review:
(i) when requested by a Team member or
clinician participating with the Team;
(ii) when a review performed by the assigned
DDS case manager or nurse determines a referral is indicated;
(iii) annually or as needed when the service
recipient:
(I) receives five or more routine
medications;
(II) is experiencing
potential medication-related issues not resolved through other medical
intervention;
(III) uses a p.r.n.
medication routinely for more than three months with an average use of three
per week or 10 per month;
(IV)
takes two or more psychotropic medications, per OAC
340:100-5-26.1;
or
(V) takes three or more
anticonvulsant medications; or
(iv) when a service recipient receives an
order for a medication administered p.r.n for behavioral control, per OAC
340:100-5-26.1.
(I) The Team meets to review pharmacy
recommendations within 30-business days of receipt of a completed clinical
pharmacy review.
(J) For service
recipients who receive community residential supports or group home services
and are hospitalized the DDS case manager identifies preventative measures, and
reviews needed services and supports. When the service recipient is admitted to
a:
(i) non-psychiatric hospital the Team
holds a discharge planning meeting; or
(ii) psychiatric facility a review is
completed, per OAC
340:100-5-57.
A Team meeting is held if changes to the Plan are
identified.