Support Plan Plan.pdfPage 2 of 27 Colorado Assessment Process Restructuring Initiative: Draft Support Plan (3-30-18) Texting/Email/Social Media Electronic Device Other:_____ 2. SUPPORT

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Colorado Support Plan Process Restructuring Initiative: Support Plan (6-22-18)

Support Plan

Key

Orange: Items, responses, and other language specifically for children

Green: Skip patterns

Red: Additional instructions

Purple: Script for assessor

Teal: Notes for automation

Denotes mandatory section/item

Yellow Highlight: Auto populate from Assessment or other Support Plan section

Teal Highlight: Items only for Reasessment

1. PARTICIPANT’S IDENTIFYING INFORMATION

1. Name of Individual:______________________ 2. Current Mailing Address:________________________ 3. City:_____________ 4. State:____________ 5. Zip Code:__________ 6. Preferred method of contact: Email Cell phone Work phone Home phone Texting

7. Preferred number/email address:_____ 8. Date of Birth:____________

9. Age:__________

10. What gender do you identify as?

Male Female Transgender Nonbinary/Gender-nonconforming

11. Method(s) participant likes to use to communicate with others:

Verbal English

Verbal Spanish

Verbal Other Language,

identify:___________

Sign Language

Writing/Braille

Gestures

Facial Expression

Texting/Email/Social Media

Electronic Device

Other:_________________

If Sign Language was not selected, skip to Item 13. 12. Type of sign language participant uses:

American Sign Language

Baby Sign

Cued Speech

Emoticon + Bodicon (facial expression + body language)

Home Signs, Gestures

International Sign Language

Limited or Close Vision Signing

Manual alphabet (finger spelling)

Signed English

Tactile (hand in hand) Signing

Other, describe:________________ 13. Method(s) participant likes others to use to communicate with him/her:

Verbal English

Verbal Spanish

Verbal Other Language,

identify:__________

Sign Language

Writing/Braille

Gestures

Facial Expression

Commented [AC1]: Automation: Pull from Intake for 6 and pull ONLY preferred method from Intake in 7.

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Colorado Assessment Process Restructuring Initiative: Draft

Support Plan (3-30-18)

Texting/Email/Social Media

Electronic Device

Other:________________

2. SUPPORT PLAN ADMINISTRATIVE INFORMATION

1. Support Plan Type:

Initial/Enrollment

Continued Stay Review [If selected auto-populate start and end dates from assessment.]

Revision [The dates must remain the same as the current active plan. Gray out dates. When revision is selected, a copy to be made and allow for edits.]

Community Care Transition (CCT) Certification Extension

Deinstitutionalization (DI)

Readmission to Institution 2. Location of Support Plan meeting:

Participant’s home

Other family member’s home

Other community setting

Case management agency office

Hospital

Nursing Facility

ICF/IID

Other:___________

3. Date Support Plan was Initiated:_________________

4. Support Plan Certification Period

A. Start:_______________ B. End:___________________

[For Support Plan type that equals initial/enrollment, Start Date is auto-populated based on the latter of one of the two: 1) program eligibility date or 2) functional eligibility determination date. Auto publish - on the start date; do not allow case managers to publish. For CSRs, dates should auto-populate from the assessment dates.]

5. Case manager name:____ 6. Case manager agency:__ 7. Case manager phone:_ 8. Individuals contributing to the plan:

A. Individual 1

i. Name:________________

ii. Relationship to participant

Spouse- Guardian

Spouse- Non-Guardian

Child or Child-in-law

Sibling

Parent/Guardian

Parent/Non-guardian

Guardian, other:___________

Partner/Significant Other

Other relative

Friend

Neighbor

Other:_________

Service/Provider Agency

Guardian Ad Litem

Advocate

iii. Individual invited to Support Plan meeting by: Participant Participant’s representative

Commented [AC2]: Automation: Only pull responses that are indicated as applicable.

Commented [AC3]: Lori needs to clarify with Tim how this will be operationalized in the automated system.

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Additional individuals can be added in automated version. 9. If individuals attending the Support Plan meeting were not invited by you, identify the individual’s

name, relationship, and reason they were included in the meeting.

3. EXPLANATION OF THE SUPPORT PLANNING PROCESS

1. I and/or my representative received a Handbook explaining the Assessment and Support Planning processes prior to my Support Plan meeting.

Yes No (Review Handbook with the participant/representative prior to proceeding)

2. The case manager discussed the following information with me and I understand (check all that apply): The contents of the handbook and any questions I/my representative have What person-centered goals are and how they will be developed What supports are available for making decisions and whether I would like this support Service options, including opportunities for participant-direction Differences in supports available for children transitioning to adult services (16+) Rights modifications for children transitioning to adult services (16+) What to expect and not expect from the development of my Support Plan Next steps after my Support Plan is developed How to report mistreatment (including abuse, neglect, exploitation) and other critical

incidents 3. The case manager discussed the following rights and responsibilities with me and I understand

(check all that apply): The rights and responsibilities of the participant, representative, and case manager

when developing my Support Plan The responsibility of my team (myself, family, and others I’ve invited to participate) to

provide accurate information throughout the Assessment and Support Planning process Complaint procedures My rights to appeal the contents/results of the Assessment and Support Plan My choice of providers My options for changing my case manager My options for changing my Case Management Agency My choice of where I live My choice of programs and services My responsibility to follow and cooperate with program requirements

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4. FOR REASSESSMENT ONLY- PROGRESS TOWARDS GOALS FROM PREVIOUS ASSESSMENT

1. I would like to complete this section.

Yes No (Skip to Section 5)

Goal

How Progress Towards

Goal Will be Measured

Timeframe for Achieving

Goal

(F)= Future Goal

Progress Made Towards

Goal- Use measures

identified in previous plan

Score of Progress Towards Goal

Systemic Barriers

Autofill from previous

assessment


assessment


assessment Text

Goal achieved, can remove

Goal being achieved but should remain active

Goal is on target to be accomplished

Goal relevant, barriers to overcome:__

Goal no longer relevant, should be removed. Explain:____

Text

Automation will include all goals from previous Support Plan.

5. PERSONAL GOALS



Commented [AC4]: Lori to clarify if this should just be for CSR and Revision or for all Plans are that being updated.

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Goal Participant Ranking of

Goal

Representative Ranking of

Goal

Participant Rating of

How Meaningful

Goal Is

Representative Rating of How

Meaningful Goal Is

How Progress Towards

Goal Will be Measured

Timeframe for Achieving

Goal

(O)= Ongoing Goal

(F)= Future

Goal

1 to 5 with 1=Not Meaningful and 5 = Very Meaningful

Text Number Number Number Number Text Text

Additional goals can be added within the automated system.

2. Transition to Adult Services – Goals and/or activities that should be included to address transition to adult services. Only appear if triggered; trigger criteria shown in teal. Populate all fields that meet criteria into the goals table in 5.1 Apply for Adult SSI/LTC Medicaid (Trigger if participant will turn 18 in next 18 months) Develop replacement activities that will become active after the transition to an adult waiver (Trigger if participant is older

than 16 years, 7 months) Discuss replacement activities that will become active after the child is no longer eligible for EPSDT services, including

Private Duty Nursing (Trigger if participant is enrolled in EPSDT and will turn 18 within the Support Plan year, not triggered when “Develop replacement activities” is triggered because the items would be duplicative)

Develop replacement activities that will become active after the child is no longer eligible for EPSDT services, including Private Duty Nursing (Trigger if participant is enrolled in EPSDT and will turn 20 within the Support Plan year)

3. The DD Waiver Status Review Review Waiting List Status for the DD Waiver (Trigger if participant has IDD and not on the DD waiver)

Commented [AC5]: Pulling from Health module for diagnosis of DD/IDD from section 6 item gg and jj

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6. ACTIVITIES TO FULFILL GOALS


Yes No (Skip to Section 7) 2. Activities to fulfill goals:

Goal Ranked # 1 by Participant: Complete after Support

is Identified

Activities to fulfill goal

Start Date

End Date

Preference/ Guidance

Skills Building

Participant Direction

Identify Services and Supports to Fulfill the Activity

Support Sources

Challenges

Text field Date field

Date field

Text field Text field Text field

Unmet Need

Systemic

Challenges:

Other Challenges:

Additional goal tables with the activities will be added within the automated system based on goals entered in Section 5. Additional activities may be entered for each goal.

7. HEALTH AND SAFETY

1. Are there any health and/or safety issues that are not addressed by the personal goals:


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2. Describe the health and/or safety issue to be addressed:

Description of Health and/or Safety Issue

Issue Identified By

I want to address issue

My Representative wants to address

issue

If I do not want to address, describe why

not

Proposing a multi-select of needs items from Assessment

that can be described.

Me

Representative

case manager

Other:_____

Text Field

Additional health and/or safety issues may be added in automated system

3. Describe the activities necessary to meet the health and/or safety issue (Update Section 6 as necessary to meet the challenges that are entered within this table):

Health and Safety Issue 1 Participant/Rep Wants to Address: Autofill from Item 7.2 Complete after Health/

Safety Issue is Identified

Activities to fulfill health and safety

issue

Start Date

End Date

Preference/Guidance Skills

Building Participant Direction

Identify Services and Supports to Fulfill the

Activity

Support Sources

Challenges

Text field Date field

Date field

Text field Text field Text field

Unmet Need

Systemic

Challenges:

Other Challenges:

Additional rows will be added within the automated system based on health and safety issues identified in 7.2.

Commented [AC6]: This should only include issues that the participant/rep want to address in 7.2

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8. FOR REASSESSMENT ONLY- UTILIZATION OF SERVICES

1. Underutilization of services

Services for which

authorizations were 20% higher than

what was used

Reason for under-use of

services

Description of issue

Changes to my plan to

prevent this from

happening again

System changes

needed to prevent

this from happening

again

Autopopulate if system allows or

text field

Authorized more than I needed

I was not able to get all of the services that I needed

Text Text Text

9. DIRECTING MY SERVICES

Have brief discussion with participant and representative about participant directed services, including an overview of the programs, services that are available, direction that not waivers include the option to direct services, ability to have an authorized representative direct services if participant does not wish or is not able to, and responsibilities of the participant/authorized representative.

1. I am interested in discussing participant-directed services.

Yes, already enrolled in participant directed services (Skip to Item 7)

Yes, not currently enrolled in participant directed services

No (Skip to Section 10)

2. I want to be able to select, dismiss, and manage the people I want to help me, including family members or friends.

Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree

3. I want to be able to choose how much I pay the people who work for me.


4. I want to be able to manage a budget for my services.


Explain the participant’s participant-directed options (e.g., IHSS and CDASS) and the pros/cons of each based on the interests of the participant and authorized representative.

5. I am interested in receiving participant-directed services.


6. The assessment suggests I may be able to direct my supports within:

CDASS or IHSS IHSS only

For Reassessment Only – asked if participant receiving CDASS or IHSS 7. I/My child will continue participant-directed services during the service period identified within

this Support Plan.


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8. I have had challenges managing my/my child’s budget- CDASS only

Yes No N/A

9. I have had challenges finding help or managing people who work for me/my child.

Yes No (Skip to Item 11) N/A (Skip to Item 11)

10. Description of challenges

11. I would like to make the following changes to address the challenges I have with my/my

child’s self-directed services

Change programs, list program:

Get more support in managing my services, including training, describe support:

Select someone to be my authorized representative, identify person:

Make other changes, describe:

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10. CHOOSING MEDICAID HOME AND COMMUNITY-BASED SERVICES


Yes No (Select waiver option in last column and skip to Section 11)

2. I am eligible for the following Medicaid programs: Medicaid

HCBS Waivers and State Plan

Services

Services Has

Waiting List

Allows Participant Direction

Pros Cons Select Option

Auto-populate

Fixed field with service options for

Waiver/State Plan selected in Column 1

Additional programs can be added within the automated system.

11. IDENTIFYING MY SUPPORTS

1. I would like to identify unpaid supports and/or supports paid by another source.

Yes No (Skip to item 6)

The following table contains the caregiver supports that were documented during the Assessment process. case managers should review and update with the participant and representative. After review, complete the final column. Additional supports should be included in the second table within this section.

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2. Previously documented unpaid supports and paid family and friend caregivers. Additional individuals can be added within the automated system.

Caregiver Information

Distance from

Participant

Relationship to

Participant

Caregiver Help [Check all that apply]

Assessed Needs

Support is Assisting

With

Frequency: How Often

Any Assistance is

Provided

Back-up Planning

Participant would prefer

different caregiver

Likelihood of Continued Assistance

Caregiver Needs

Support Services/ Training

Guidance for Unpaid Support

Name:

Preferred Phone

#:

Preferred email:

Caregiver is:

Regular support

Back-up support

Lives with

Within 5-10 minutes

15-20 minutes

Longer than 20 minutes

Spouse

Parent

Adult Child

Other family member:_______

Friend

Neighbor

Other, specify

Self-care assistance (for example, bathing, dressing, toileting, or eating/feeding)

Mobility assistance (for

example, bed mobility, transfers, ambulating, or wheeling)

IADL assistance (for example, making meals, housekeeping, telephone, shopping, or finances)

Medication administration

(for example, oral, inhaled, or injectable medications).

Medical procedures/ treatments (for example, changing wound dressing, or home exercise program).

Management of equipment (for example, oxygen,

IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies).

Supervision (for example, due to safety concerns).

Advocacy or facilitation of person's participation in

appropriate medical care (for example, transportation to or from appointments).

Other advocacy not related to medical care

Assistance with daily (or routine) problem solving

Non-medical transportation

Social opportunities

Other, describe:____

Proposing a multi-select of

assessed needs. Need to

discuss with automation

team.

Less than once a month

About once a month

About once a week

3-4 times a week

Once a day

2 or more times/day < continuously

Continuously

As needed

What I should do if the support does not show up:________________________________________

Support

source responsible for arranging back-up

Who else can help, how they can help, and any other concerns I have if my other

supports are not available (optional if support responsible for arranging back-up):_______________________________________

Yes, describe___________

No

Can continue providing

Cannot continue

providing

Do not know

Can increase amount of assistance

Need to decrease amount of assistance

Does transition plan need to be developed for primary caregiver?

Yes

No

Yes, describe:______________

No

Text

Payment Source

Unpaid

Waiver

Medicaid-Other

Paid by another source

3. Other sources of unpaid support and paid family caregivers- Are there any other potential sources of unpaid supports or paid family caregivers beyond what was identified during the assessment? Prompt to see if there are other source of support, such as churches or neighbors, that should be considered. Yes No (Skip to 4)

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Support Source Name

Relationship to

Participant

Contact Information

Assessed Needs

Support is Assisting

With

Amount, Duration,

And Frequency of Any Support

Back-up Planning Guidance

for Supports

Other Considerations

Caregiver is:

Regular support

Back-up support

Spouse Parent Adult Child Other

family member:_

Friend Neighbor Other,

specify

Preferred

Phone #:

Preferred

email:


assessed needs. Need

to discuss with automation

team.

Text What I should do if the support does not show up:______________

Support source responsible for arranging back-up

Who else can help, how they can help, and any other concerns I have if my other supports are not available (optional if support responsible for arranging back-up):_________________

Text Text

Additional support sources can be added within the automated system.

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4. LTSS Supports Paid for by Another Source- Other paid sources of support that will be utilized to allow me achieve my goals.

Name/ Agency

Information

Payment Source

Caregiver Help [Check all that apply]

Assessed Needs

Support is Assisting With

Frequency: How Often Assistance is

Provided

Back-up Planning

Participant would prefer

different caregiver

Will Support Continue

Caregiver Needs

Support Services/ Training

Name/ agency:

Preferred

Phone #:

Preferred

email:

Individual/ agency is:

Regular support

Back-up support

Self-paid

Paid by other family member/ friend

Medicaid

Medicare

Private LTC Insurance

Private

Health Insurance

VA

Other:__

Self-care assistance (for example, bathing, dressing, toileting, or eating/feeding)

Mobility assistance (for example, bed mobility, transfers, ambulating, or wheeling)

IADL assistance (for example, making meals,

housekeeping, telephone, shopping, or finances)

Medication administration (for example, oral, inhaled, or injectable medications).

Medical procedures/ treatments (for example, changing wound dressing, or home exercise program).

Management of equipment (for example, oxygen, IV/infusion equipment, enteral/parenteral nutrition, or ventilator therapy equipment and supplies).

Supervision (for example, due to safety concerns).

Advocacy or facilitation of person's

participation in appropriate medical care (for example, transportation to or from appointments).

Other advocacy not related to medical care

Assistance with daily (or routine) problem solving

Non-medical transportation

Social opportunities

Other, describe:____

Proposing a multi-select of assessed

needs. Need to discuss with

automation team.

Less than once a month

About once a month

About once a week

3-4 times a week

Once a day

2 or more times/day < continuously

Continuously

As needed

What I should do if the support does not show up:________________________________________

Support source responsible for

arranging back-up

Who else can help, how they can help, and any other concerns I have if my other supports are not available (optional if support responsible for

arranging back-up):_______________________________________

Yes, describe:_______

No

Yes

No

If “No”: ➢ Why will care end:__ ➢ When will care

end:__

Yes, describe:_____________

No

5. Other sources of paid support- Are there any other potential sources of paid supports beyond what was identified in during the assessment? Yes No (Skip to 6)

Support Source Name/ Agency

Contact Information

Assessed Needs Support is

Assisting With

Amount, Duration, And Frequency of

Support

Back-up Planning Guidance for

Supports

Other Considerations

Individual/agency is:

Preferred

Phone #:


assessed needs. Need to discuss

Text What I should do if the support does not show up:______________

Text Text

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Regular support

Back-up support

Preferred

email:

with automation team.

Support source responsible for arranging back-up

Who else can help, how they can help, and any other concerns I have if my other supports are not available (optional if support responsible for arranging back-up):_________________

Additional support sources can be added within the automated system.

6. Voluntary Support Calendar- The Support Calendar is a voluntary spreadsheet that will allow me to plan the type and amount of support that I will need during different weeks. For example, I may need a different level of support during a work week than I do during a holiday or vacation week.

Support Calendar was completed:

Yes No

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7. Medicaid HCBS waiver and State Plan services to be Authorized- The following services will be authorized to help me

achieve my goals. Update all support sources previously discussed prior to completing this item.

Funding Stream

Service Unit Type # of Units

Unit Rate Start End Assessed

Need Guidance

to workers Skills

Building

Provider Agency

Populate from Waiver/

State Plan selected in Section 10

Dropdown tailored to funding stream selected

Fixed field based on

service option selected in Column 2

Fixed field based on

service option selected in Column 2

Select items from Assessment

Outputs

☐

Dropdown w/ TBD Option

Populate from Waiver/

State Plan selected in Section 10

☐


Total Cost of Services:

Additional services can be added within the automated system.

8. I have been informed that:

I have a choice of available long-term services and supports;

I have the right to select among qualified providers;

I can change providers at any time;

A provider has the right to accept or deny my request for services

9. I have been given a list of qualified providers or provided with directions on how to access this list.

Yes, given a list of providers during the meeting

Yes, provided directions on how to access a list of providers. How to access this list (e.g., website, mail):______________

(Skip to Item 11)

No (Skip to Item 11)

10. I had enough providers to choose from.


Items 11-14 are for Reassessment Only 11. I want to change providers. [Required for re-assessment, change in provider, or request for additional services]

Yes No (Skip to Item 15)

I want to change the following providers:

Commented [AC7]: Automated system should allow for autocalculation

Commented [AC8]: Lori to confirm how Plan would flow if only provider or service change is requested. Is entire Plan supposed to be revised?

16 | P a g e

12. I have selected a new provider during this meeting.

Yes for all providers I wanted to change (Skip to Item 15)

Yes for some providers I wanted to change, identify remaining providers:_____

No 13. My case manager’s plan for helping me find a new provider:

14. Target date for finding a new provider:_________ 15. I have selected CDASS or IHSS as one of my services.

Yes, and this is my initial enrollment in participant directed programs

Yes, and I have previously been enrolled in participant directed programs (Skip to Item 19)


Items 16-18 are For Initial Selection of CDASS or IHSS Only

16. When I manage people who are paid to help me, this is how I would do the following: [Ask authorized representative if one has been identified. Record brief summary in the boxes below. Emphasize that it is okay to be uncertain about how to address these tasks – the individual and/or authorized representative will receive training on how to perform tasks.] A. Find/select workers to hire

B. Train workers

C. Give workers directions

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D. Deal with a worker who is not doing her/his job well

E. Dismiss a worker who is not meeting my needs

F. Manage my service budget (Ask only if CDASS is selected)

17. I can self-direct my services:

With very little or no support

With support, describe: ______________

If another person acts as an authorized representative: Representative name:__________________ Relationship to me:____________________

I have decided not to self-direct my services- Update service selection in item 7 and response to item 15 to reflect this decision

18. I would like the following training to help me direct my supports and/or manage my budget (if applicable):

19. For Reassessment Only- I need to change or update the provider who helps me with my participant directed program.

No (Skip to Section 12) Yes, identify change/update needed:____________________

20. I would like to select the following FMS agency (ask only if CDASS selected) – Drop down list of agencies (Includes TBD option)

21. I would like to select the following IHSS agency (ask only if IHSS selected) – Drop down list of agencies (Includes TBD option)

12. PROVISIONS FOR TEMPORARY INCREASE IN SERVICES

1. My plan will include the ability to temporarily increase services:


Items 2-6 may be completed for additional scenarios in the automated system 2. Description of circumstances that may result in need to temporarily increase services:

3. Voluntary Support Calendar- The Support Calendar is a voluntary spreadsheet that will allow me to plan the type and amount of support that I will need during different weeks. For example, I may need a different level of support during a work week than I do during a holiday or vacation week. If support calendar was previously completed, update as necessary based on potential temporary service needs.

18 | P a g e

Support Calendar was completed:

Yes No

4. Medicaid HCBS waiver and State Plan services to be Authorized on a Temporary Basis

Funding Stream

Service Unit Type

# of Units

Unit Rate

Assessed Need

Guidance to workers

Skills Building

Provider Agency

Populate from

Waiver/ State Plan

selected in Section

10

Dropdown tailored to funding stream selected

Fixed field

based on service option

selected in

Column 2

Fixed field

based on service option

selected in

Column 2

Select items from Assessment

Outputs

☐


☐


Total Cost of Services:

Additional services can be added within the automated system.

5. Describe any changes that will occur to the type, duration, frequency, or level of other supports included in the Support Plan if the temporary increase is implemented.

6. Process for implementing the temporary increase:

13. REFERRALS

Referral Agency

Reason for referral

Who will follow-up

Contact Information for Referral

Additional referrals can be added within the automated system.

14. BACK-UP PLANS

1. Planning back-up supports- What should occur if my support source does not show up. Update if authorized services/supports changed the type or amount of back-up previously documented

Support Source

Support source

responsible for

arranging back-up

What I should do if the support

does not show up

Who else can help, how they can help, and any other

concerns I have if my other supports are not available

(optional if support

19 | P a g e

responsible for arranging back-up)

Paid Supports

Auto-populate from 11.3-4

☐

☐

Unpaid Supports

Auto-populate from items 1-2 in Section 11

☐

☐

Medicaid Waiver/State Plan Supports

Auto-populate from provider name in item 7 in Section 11

☐

☐

2. Contact Information for My Back-up Supports- Contact information for people and

agencies listed above:

Name Phone Number to

Call Phone Number to

Text Email Address

Auto-populate from supports identified as “back-up” in Section 11




Additional back-up supports can be added within the automated system.

15. DISASTER RELOCATION PLANNING

1. I would like to develop a Disaster Relocation Plan or provide information about my current

Disaster Relocation Plan.


2. My provider has or will develop a Safety Plan for me and/or my information has been entered into or will be entered into a provider or other system for safety and disaster response used by first responders in my area, such as Smart911: Not entered (Skip to 3) Developed by provider (Skip to Section 16) Entered into response system, date of last update:_______________ Will be entered into response system, date information will be entered:____________

a. Name of system:___________________ b. Weblink for system:_________________

(Skip to Section 16 if response other than “Not Entered” was selected)

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3. Emergency Contacts and Relocation Sites- If I need to move to another location in an emergency, these individuals/organizations should be contacted. I have also ranked my preferences for where I should be relocated.

Name/

Organization (Order should reflect priority

of individuals to contact)

Relationship Primary Phone

Number

Secondary Phone

Number

Options for

Relocation (Rank your preference)

Address (Enter only if

site is a relocation option)

1 Click or tap here to enter text.

Click or tap here to enter text.



Choose an item.


2 Click or tap here to enter text.




Choose an item.


4. If I need to relocate because of an emergency, this is what I will need to take:

Medication & Equipment to Take

Information to Take Special Instructions to

Share

Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter

text.

16. MINIMIZING MY RISKS

1. I depend on medical devices that require electricity.

No (Skip to Item 4) Yes

2. I have applied for an energy assistance program.

No (Discuss whether participant would like more information) Yes

3. I have a back-up generator.

No

Yes, my provider is responsible for making sure I have electricity (Skip to Item 4) Yes, I have a back-up generator (Skip to Item 3b)

a. I need to get a back-up generator.

No, do not want one. Why not:_________________ (Skip to Item 4)

Yes, but cannot get one due to systemic barriers or other issues:_____ (Skip to Item 4)

Yes, plan for obtaining back-up generator:____________________ (Skip to Item 3e)

b. The back-up generator is activated by:___________ c. The last time the generator was tested to see if it was working:___/___/_____ d. My primary and back-up caregivers are trained on how to activate the back-up generator.

No, plans for training and/or reasons why some people will not be trained:__________

Yes

e. Plan if back-up generator is not available or cannot be used:

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4. Activities for which there are unmet needs:

Activities to Fulfill Goals- Populate from Section 6

Challenges to Fulfilling Goals- Populate from Section 6

Activities to Meet Health and Safety Issues- Populate from Item 7.3

Challenges to Meeting Health and Safety Issues- Populate from Item 7.3

5. Assessed needs not attached to a support source, Medicaid service, or unmet need- Prepopulate:

6. Health and/or safety issues I choose not to address:

Description of Health and/or Safety Issue- Populate from Item 7.2

Why I Do Not Want to Address Health and/or Safety Issue- Populate from Item

7.2

7. Summary of Health and/or safety risks related to medical/health conditions:

No risks (Skip to 8) Risks adequately described in items 1 through 6 (Skip to 8)

Additional risks, describe:

8. Summary of Health and/or safety risks related to behaviors:

No risks (Skip to 9) Risks adequately described in item 1 through 6 (Skip to 9)


9. Summary of Health and/or safety risks related to environment or other issues:

No risks (Skip to 10) Risks adequately described in item 1 through 6 (Skip to 10)


10. Plans for reducing risks:

11. Have changes been made to services or guidance to workers in Sections 6,7, 10 and/or 11 to reduce risks?

No

Yes, describe changes:

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12. Summary of remaining risks:

13. ☐ I understand and am willing to accept those risks

14. ☐ My legal representative understands and is willing to accept those risks (if applicable)

17. MODIFICATION OF RIGHTS/SETTINGS EXCEPTION

1. Were emergency control procedures used since the last assessment?

No (Skip to 3) Yes

2. Are actions being taken to prevent the need for continued use of emergency control procedures?

No, describe why not:

Yes, describe actions:

3. I will be in a setting in which certain actions must be taken before my rights are modified: No (Skip to Section 18) Yes

4. Reasons for the modification:

Modification #

Observable and measurable description of behavior or

other issue to be changed or improved

Assessment item(s) that

demonstrate why issue has been

targeted

Efforts to use positive interventions and less intrusive alternatives

as an alternative

1 Text Text box Text box

2 ☐ Same text As Above

If not checked, Text Field

☐ Same text As

Above


☐ Same text As Above

If not checked, Text

Field

5. Types of modifications:

Modification #

Classification of modification:

Plans for putting

modification in place

Informed consent has

been documented

for mod.

Plans for making sure

staff understand when and how to put

the modification

in place

Providers to implement

modification

Commented [AC9]: For automation- 17.4-6 should be dynamic tables, with 5-6 mirroring the number of modifications entered in 4.

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1

Safety Control Procedures

Access to the greater community

Choice of Setting

Right to Privacy

Independent decision-making, initiative or autonomy

Choice of services and who provides them

Access to personal possessions

Access to dangerous objects or hazardous materials

Access to specific areas in living space

A unit lockable by the individual

Choice of roommates

Freedom to furnish or decorate sleeping or living units

Freedom and support to control own schedules and activities

Access to food at any time

Choice of visitors at any time

Access to media and Internet

Other:_____________________

Text box ☐ Text box

Checkboxes for all providers identified in authorized

services in item 11.7

2

Safety Control Procedures

Access to the greater community

Choice of Setting

Right to Privacy

Independent decision-making, initiative or autonomy

Choice of services and who provides them

Access to dangerous objects or hazardous materials

Access to personal possessions

Access to specific areas in living space

A unit lockable by the individual

Choice of roommates

Freedom to furnish or decorate sleeping or living units

Freedom and support to control own schedules and activities

Access to food at any time

Choice of visitors at any time

Access to media and Internet

Other:_____________________

☐ Same text

As Above

If not

checked, Text

Field

☐

☐ Same text

As Above

If not

checked, Text

Field

Checkboxes for all providers identified in authorized

services in item 11.7

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6. Plans for monitoring and removing modifications:

Modifications #

Who will

monitor

How will effectiveness be measured

What data will

be collected

Changes necessary to remove

modification

Timeline for reviewing whether modification is still

necessary

1 Text box Text box Text box Text box Text box

2

☐ Same

text As Above

If not

checked, Text Field

☐ Same text

As Above


Field

☐ Same

text As Above

If not

checked, Text Field

☐ Same text

As Above


Field

☐ Same text As

Above


7. I have questions or concerns about the rights modifications process. No Yes, document concerns and discussion:

8. Human Rights Committee (HRC) review necessary? Autopopulate based on whether adult in an IDD waiver in 11.7.


Yes, because: Of a rights modification Of a restrictive procedure Use of psychotropic medication 1) administered by a paid support and/or 2) receiving

residential habilitation 9. HRC Review Status/Outcome

To be submitted (Skip to Section 18)

Submitted, awaiting review (Skip to Section 18)

Review completed 10. HRC review outcome and recommendations:

18. ADVANCE DIRECTIVES

For participants <18 years old, start with Item 2. 1. Participant has someone who assists with or is legally authorized to make decisions (e.g., POA,

DPOA, legal guardian, etc.):

No [Skip to Item 5] Yes

2. Name of individual(s) or agency(ies) assisting or authorized in making decisions: _______________________________________________________________________________

3. Is this individual a legal guardian?

No

Yes, limited guardianship. Describe:_____________________________________________

Yes, full guardianship

25 | P a g e

[If Yes, skip to Item 5] 4. Decision making capacity:

Trustee

Representative Payee

Legally Authorized Representative

Responsible Party

Conservator

Power of Attorney (POA)

Surrogate Decision-maker for health care decisions (DPOA)

Other parent

Partner of parent

Stepparent with no legal authority

Family

Friend

Advocate

Other:_______________________

5. I have established advance healthcare directives.

No [Skip to Item 8] Yes

If yes, type of advance healthcare directive: Durable power of attorney

Health care advocate

Advance directives concerning care (e.g., DNR, extraordinary measures, etc.)

Physician Orders for Life-Sustaining Treatment (POLST)

5 Wishes

Other

6. My advance healthcare directives are located:_____________________________ 7. Sharing directives with my doctor, healthcare/service provider, and/or family/friends.

Already shared with everyone I want

Choose not to share

Want to share. Who I need to share with and who will share it:____________________

8. I would like assistance to establish or update advance healthcare directives.

Yes, establish Yes, update No

If yes, I want assistance with developing/updating: Durable power of attorney

Health care advocate

Advance directives concerning care (e.g., DNR, extraordinary measures, etc.)

Physician Orders for Life-Sustaining Treatment (POLST)

5 Wishes

Other

9. The following person will help me develop, update, and/or share my advance directives. Name of Person: Relationship: Contact Information: Development, updates, and/or sharing will occur by:__________

19. CASE MANAGEMENT MONITORING

1. Minimum monitoring my case manager is required to do:

Quarterly face-to-face (IDD waivers)

Quarterly phone (other waivers)

☐ I understand these requirements

Commented [AC10]: For automation: Populate based on waiver selected in Section 11.

Page 26 of 27


2. I would prefer that my case manager check in with me:

The minimum amount required

More than the minimum, describe:

3. My preferences for how my case manager contacts me (rank preferences, put N/A if do not have):

__ In person __ By telephone __ By email

__ By text __ Other, describe:_____________

4. When I meet with my case manager in person, I would prefer these meetings happen at: My home Other location(s) where services are

being delivered:_________________ 5. If something important occurs, such as a change to my service eligibility or a support worker will

not show up, I would prefer that the following people also be notified:

No one

The following people:

Person 1’s Name:______________________________________ Phone number:______ Primary email:______ Primary text number:________


Additional individuals may be added in the automated version 6. My case manager should contact me or my legal representative prior to responding to questions

from the following people/entities:

No one

Any individual or entity for whom previous authorization has not been given

The following people:



7. Other things I would prefer that my case manager do or not do when monitoring my plan or

services:

20. COMMENTS, GUIDANCE, AND CONCERNS FROM MEMBERS OF MY TEAM

1. Comments, guidance, and concerns about services, supports, next steps, or other areas of the Plan. If no comment, enter “None”. If there is no representative of the category, enter “N/A”.

a. case manager

☐ case manager attests that the services and supports included in this Plan are

related to an assessed need or a personal goal. b. Agency Representative. Identify agency: Click or tap here to enter text.

Page 27 of 27


c. Agency Representative. Identify agency: Click or tap here to enter text.

d. Other Support. Identify name and relationship: Click or tap here to enter text.

e. Other Support. Identify name and relationship: Click or tap here to enter text.

f. Other Support. Identify name and relationship: Click or tap here to enter text.

2. Summary of changes to the plan to address team members’ comments, guidance, or concerns:

3. Parent, Guardian, or Legal Representative comments, guidance and concerns (If applicable)

4. Summary of the changes to the plan to be taken to address parent, guardian, or legal representative’s comments, guidance, or concerns:

5. My comments, guidance and concerns

6. Summary of the changes to the plan to address my comments, guidance, or concerns:

7. I led the creation of my Support Plan as much as I wanted and am capable of.


8. My representative believes that he/she was able to play a leading role in creating my Support Plan.


Not applicable

9. Date all providers signed off on services:_______________

10. Date participant considers plan as final:_______________

Documents

Support Plan Plan.pdfPage 2 of 27 Colorado Assessment Process Restructuring Initiative: Draft Support Plan (3-30-18) Texting/Email/Social Media Electronic Device Other:_____ 2. SUPPORT