D.C. Mun. Regs. tit. 22, r. 22-A2512

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 22-A2512 - COMPREHENSIVE CARE PLAN

2512.1

A Comprehensive Care Plan (CCP) is the document that drives the delivery of all services. The CCP shall be the plan that collates all the consumer's services and providers of service in order to reduce any instances of duplication of service, prioritize the consumer's goal(s) and monitor the progress of the goal(s) in the plan.

2512.2

The development of a CCP shall include:

(a) Active participation and partnership with the consumer;

(b) Risk factors identified from the completion of the comprehensive health assessment. The assessment includes a physical health, behavioral health, substance- use and socioeconomic assessment;

(c) The consumer's goals as identified by the comprehensive health assessment, prioritized and the timeframes and strategies for addressing each;

(d) The delineation of the specific roles and responsibilities of the members of the Health Home Team who are assisting the consumer in achieving his/her goals;

(e) The signature of all participants in the development of the CCP. The Nurse Care Manager or the Primary Care Liaison from the Health Home Team must participate in the care planning process and sign the plan; and

(f) All services the Health Home provider delivers to the consumer.

2512.3

The CCP shall be updated every one-hundred eighty (180) days or more often if the consumer's needs or acuity level changes.

2512.4

The CCP shall be developed in coordination with the consumer's healthcare providers. If the Health Home team develops the CCP, the MHRS Plan of Care, developed in accordance with Section 3411 of Chapter 34 of this title, shall be incorporated into the CCP. If the MHRS team develops the care plan the Health Home team will collaborate and participate in the care planning process to ensure the care plan is comprehensive.

D.C. Mun. Regs. tit. 22, r. 22-A2512

Final Rulemaking published at 63 DCR 849 (1/22/2016); amended by Final Rulemaking published at 66 DCR 5625 (5/3/2019); amended by Final Rulemaking published at 67 DCR 10674 (9/4/2020)