Standards for private organizations

2020 Edition

Integrated Care; Health Homes (ICHH) 5: Care Planning and Monitoring

The person and his or her family participate in the development and ongoing monitoring of a care plan that is the basis for delivery of appropriate services and support.
2020 Edition

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Purpose

Adults and children who receive integrated care experience improved health care quality, an improved client care experience, and improved clinical and non-clinical outcomes.
1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • In a few instances, client or staff signatures are missing and/or not dated; or
  • With few exceptions, staff work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc.; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • In several instances, client or staff signatures are missing and/or not dated; or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some clients is clearly inappropriate; or
  • Service planning is often done without full client participation; or
  • Appropriate family involvement is not documented; or  
  • Documentation is routinely incomplete and/or missing; or
  • Individual staff members work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc., but this is the exception.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.  
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Service planning and monitoring procedures 
No On-Site Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

ICHH 5.01

An assessment-based care plan is developed in a timely manner with the full participation of the individual and his or her family and includes: 
  1. the person's behavioral health, physical health, and community and social support service needs and goals, including basic needs when applicable; 
  2. steps for working toward achievement of desired goals including timeframes where appropriate;
  3. services and supports to be provided, and by whom; 
  4. possibilities for maintaining and strengthening family relationships and other informal social networks;
  5. agreed upon timelines for conducting regular case reviews; and 
  6. documentation of the individual’s or family’s involvement in care planning.

ICHH 5.02

The care coordinator and the care planning team actively review the case according to established timelines to assess:
  1. continued accuracy of the assessment;
  2. care plan implementation;
  3. the person’s continued engagement in his or her treatment;
  4. the person’s progress toward achieving goals and desired outcomes; and
  5. the continuing appropriateness of agreed upon service goals.

Interpretation

Timeframes for the review should be defined by the person and the care coordinator and take into consideration the issues and needs of the person and the frequency and intensity of services provided. Traumatic events or other significant life changes such as changes in housing, disclosure of abuse, hospitalization, or contact with the criminal justice system should trigger an immediate review of the case.

ICHH 5.03

The care coordinator, the individual, and his or her family:
  1. regularly review progress toward achievement of agreed upon goals; and  
  2. sign revisions to service goals and plans.