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IDT Meeting Minutes Assessment
Blank Assessment
Sorted by Member, Assessment Tool
Assessment for:
Member #:
Assessment Name: IDT Meeting Minutes Assessment - v4.0
Assessor: Govanka Roopchand
Assessment Date:
Assessment Comments:
1.
Participants who attended the IDT meeting:
Instructions:
Mark all that apply
1
Member
2
Member's Designee
3
Primary Care Provider (PCP) or designee
4
Behavioral Health Professional or designee
5
Care Manager
6
Member's Home Care Aide
7
Member's Nursing Facility Representative
8
Other
Other (specify):
2.
Did all IDT participants attend either in person or by phone?
Instructions:
1
No
2
Yes
3.
Select one
Who did not attend?
Instructions:
Mark all that apply
Skip if Q2 = 2
1
Member
2
Member's Designee
3
Primary Care Provider (PCP) or designee
4
Behavioral Health Professional or designee
5
Care Manager
6
Member's Home Care Aide
7
Member's Nursing Facility Representative
8
Other
Other (specify):
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Report Name: rptAssessmentBlank
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IDT Meeting Minutes Assessment - v4.0 - Blank Assessment
4.
Has the member signed a refusal form?
Instructions:
1
No
2
Yes
5.
Select one
Skip if Q2 = 2
Or
Q3 = 2 Or 3 Or 4 Or 5 Or 6 Or 7 Or 8
What is the reason for this IDT meeting?
Instructions:
Select one
1
Scheduled Meeting to develop PCSP
2
Change in Member's health status
3
Requested by Member or Member’s Designee
4
Requested by other IDT participant
Requested by:
6. Preventative Health Services Recommended: (Any increased frequency will need to be
made in a Service Request, outside of the IDT-PCSP):
Instructions:
Mark all that apply
1
Annual Physical/PCP visit
2
Colonoscopy (every 5 years when 50+ or family/medical history)
3
Dental exam (every 6 months)
4
Eye check (Vision - annually)
5
Hearing (Audiology - every 2 years)
6
Influenza (Flu) Vaccine (annually)
7
Mammogram (annually for women 40+ or family history)
8
Pneumovax (Pneumonia Vaccine in the last 5 years when 65+ or chronic disease)
9
Podiatry (e.g. routine diabetic foot care)
7. Transportation Member routinely uses:
Instructions:
Mark all that apply
1
Livery
2
Ambulette
3
Ambulance
4
Para-Transit/Access-a-ride
5
MetroPlus/MTA- Public Transportation
6
Personal Vehicle
Other (specify):
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Report Name: rptAssessmentBlank
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IDT Meeting Minutes Assessment - v4.0 - Blank Assessment
8.
Home Care Services
Instructions:
Select one
1
Personal Care Aide
2
Personal Care Aide Mutual/shared
3
Personal Assistant
4
Personal Assistant Mutual/shared
5
Home Health Aide
6
Service Not Required
7
Other
Specify exceptional circumstances:
9.
Frequency/Schedule for Home Care Services Period (Days x Hours)
Instructions:
10.
Skip if Q8 = 4 Or 6
Facility Based Care:
Instructions:
Select one
1
Adult Day Program
2
Social Day Program
3
Skilled Nursing Facility
4
Service Not Required
Specify name of Facility:
11.
Frequency/Schedule for Facility Based Care:
Instructions:
12.
Skip if Q10 = 3 Or 4
PERS: (Personal Emergency Response System)
Instructions:
Select one
1
Installation & ongoing PERS support
2
Ongoing PERS support
3
Service Not required
13.
Disposable Medical Supplies - DMS (Supply authorizations are for 6 months, with the
exception of Wound supplies that are authorized in 2 month increments.)
Instructions:
Select one
1
Continue Existing Supply List (no changes)
2
Update Existing Supply List (items to be added/removed after reviewing current supply list)
3
Service Not Required
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IDT Meeting Minutes Assessment - v4.0 - Blank Assessment
14.
Updates to DMS list
Instructions:
15.
Skip if Q13 = 1 Or 3
Home Medical Equipment to be ordered:
Instructions:
Mark all that apply
1
Hand Held Shower
2
Transfer Bench: Padded
3
Transfer Bench: Non-padded
4
Shower Chair
5
Raised Toilet Seat with Arms
6
Raised Toilet Seat without Arms
7
Grab Bars
8
Commode
9
Commode: Bedside
10
Blood Pressure Monitor
11
Therapeutic Pillow
12
Not Required
16.
Total Height (Inches)
Instructions:
17.
Skip if Q15 = 12
Weight
Instructions:
Skip if Q15 = 12
18. Request for Behavioral Health Services:
Instructions:
Select one
1
Continue existing treatment plan
2
Eval – Member Linked to Provider
3
Eval – Member Needs Referral to Provider
4
Change in existing treatment plan
Specify reason for eval/Specify provider/Specify change and reason for treatment:
19. Request for Wound Care Services
Instructions:
Select one
1
Continue existing treatment plan
2
Eval – Member Linked to Provider
3
Eval – Member Needs Referral to Provider
4
Branch to Request for Wound Consultation
Change in existing treatment plan
Specify reason for eval/Specify provider/Specify the change and reason for treatment:
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IDT Meeting Minutes Assessment - v4.0 - Blank Assessment
19. Speech Therapy
1
Eval Not Recommended
2
Eval Recommended – Member Linked to Provider
3
Eval Recommended – Member Needs Referral to Provider
4
Continue existing treatment plan
20. Request for Physical Therapy:
Instructions:
Select one
1
Continue existing treatment plan
2
Eval – Member Linked to Provider
3
Eval – Member Needs a Provider
4
Change in existing treatment plan
Specify reason for eval/Specify provider/Specify the change and reason for treatment:
21. Request for Occupational Therapy:
Instructions:
Select one
1
Continue existing treatment plan
2
Eval – Member Linked to Provider
3
Eval – Member a Provider
4
Change in existing treatment plan
Specify reason for eval/Specify provider/Specify the change and reason for treatment:
21. CHHA/Skilled Home Services
1
Eval Not Recommended
2
Eval Recommended – Member Linked to Provider
3
Eval Recommended – Member Needs Referral to Provider
4
Continue existing treatment plan
22. Request for Speech Therapy:
Instructions:
Select one
1
Continue existing treatment plan
2
Eval – Member Linked to Provider
3
Eval – Member Needs a Provider
4
Change in existing treatment plan
Specify reason for eval/Specify provider/Specify the change and reason for treatment:
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Report Name: rptAssessmentBlank
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IDT Meeting Minutes Assessment - v4.0 - Blank Assessment
23. Request for CHHA/Skilled Home Services:
Instructions:
Select one
1
Continue existing treatment plan
2
Services needed – Member Linked to Provider
3
Services needed – Member Needs a Provider
4
Change in existing treatment plan
Specify reason for eval/Specify provider/Specify the change and reason for treatment:
24. Request for Respiratory Services:
Instructions:
Select one
1
Continue existing treatment plan
2
Services needed – Member Linked to Provider
3
Services needed – Member Needs a Provider
4
Change in existing treatment plan
Specify reason for eval/Specify provider/Specify the change and reason for treatment:
24. Respiratory Services
1
Eval Not Recommended
2
Eval Recommended – Member Linked to Provider
3
Eval Recommended – Member Needs Referral to Provider
4
Continue existing treatment plan
25. Other Referrals:
Instructions:
Mark all that apply
1
Evaluation for New Equipment/ Rehab Services
2
Evaluation for Specialty Mattress
3
Branch to Request for Specialty Mattress
Initiate Equipment Repair
Branch to Request for New Equipment/Rehab Services
Branch to Request for Equipment Repair
26.
What Service Determinations were made during this meeting?
Instructions:
Select one
1
An existing Service Plan was RENEWED (no changes)
2
A Service Plan with CHANGES was created
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Report Name: rptAssessmentBlank
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IDT Meeting Minutes Assessment - v4.0 - Blank Assessment
27.
The changes include:
Instructions:
Mark all that apply
Skip if Q26 = 1
1
An increase
2
A Denial
3
A Reduction
4
A Restriction
5
Stopped
Specify changes and explain why:
28.
Any additional services discussed and approved during this meeting?
Instructions:
1
No
2
Yes
Select one
(If yes) Specify:
29.
In addition to needed services, what was discussed during the meeting?
29. Behavioral Health Services
1
Eval Not Recommended
2
Eval Recommended – Member Linked to Provider
3
Eval Recommended – Member Needs Referral to Provider
4
Continue existing treatment plan
29. Physical Therapy
1
Eval Not Recommended
2
Eval Recommended – Member Linked to Provider
3
Eval Recommended – Member Needs Referral to Provider
4
Continue existing treatment plan
29. Occupational Therapy
1
Eval Not Recommended
2
Eval Recommended – Member Linked to Provider
3
Eval Recommended – Member Needs Referral to Provider
4
Continue existing treatment plan
Printed 5/12/2015 9:26:23 AM by Govanka Roopchand
Report Name: rptAssessmentBlank
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IDT Meeting Minutes Assessment - v4.0 - Blank Assessment
30.
Are there any issues or concerns that need to be addressed following the meeting?
Instructions:
1
No
2
Yes
Select one
If yes, explain:
Weight Summary:
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Report Name: rptAssessmentBlank
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