Department for Community Based Services

Standards of Practice Online Manual

4.27.1 Individual Health Plan for the Medically Complex Child

Cabinet for Health and Family Services

Department for Community Based Services
Division of Protection and Permanency
Standards of Practice Online Manual
Chapter:
Chapter 4-Out of Home Care Services (OOHC)
Effective:
11/18/2015
Section:
4.27.1 Individual Health Plan for the Medically Complex Child
Version:
5

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Legal Authority/Introduction

LEGAL AUTHORITY:

  • N/A

The individual health plan (IHP) meeting was established to assess the ongoing needs of the medically complex child.  A review of the IHP is completed every three (3) months within the region.  The medically complex liaison, Commission for Children with Special Health Care Needs (CCSHCN) nurse, care providers and others who are involved in the child’s medical care should attend this meeting.  The IHP is to be updated every six (6) months. 

The CCSHCN nurse may utilize the DPP-104C Medically Complex Monthly Report in preparation and development of the child’s IHP.

During the initial IHP meeting and once every six (6) months thereafter, the medically complex service team:

  • Develops an IHP;
  • Reviews current medical services and medical providers;
  • Incorporates the current and potential medical and rehabilitative needs of the child, and awareness of long-term needs of the child into the child’s care and treatment;
  • Identifies additional services to meet the child’s needs;
  • Discusses transition planning when applicable; and
  • Assesses whether the child’s needs continue to warrant a medically complex designation.

Procedure

The SSW: 

  1. Assists the CCSHCN nurse in inviting participants to the IHP meeting;
  2. Attends and participates in the IHP meeting; and
  3. Places one copy of the IHP in the request and/or agency case file.
  4. If the SSW cannot attend the IHP meeting, the FSOS attends in the worker’s place; and if the FSOS is unable to attend, a representative from regional office attends.

Contingencies and Clarifications

For out of state placements the SSW and medically complex liaison conduct:

  1. The initial IHP within thirty (30) days of the designation; and
  2. An IHP meeting during the annual face to face visit in the placement setting (refer to SOP 4.24 SSW’s Ongoing Contact with the Birth Family and Child, Including the Medically Complex Child).
  3. For children who are placed with a relative and/or out of state, the medically complex liaison completes the IHP.

Practice Guidance

The CCSHCN nurse:

  • Schedules and completes an initial individual health plan (IHP) meeting within thirty (30) calendar days of the child's designation as medically complex;
  • Invites the members of the medically complex service team including, but not limited to the following people, to assist with the child’s planning:
    • MCO case manager;
    • Birth parents;
    • Foster/Adoptive parents and either the R&C worker or private agency staff, as applicable;
    • Medical providers;
    • Service providers;
    • SSW;
    • FSOS;
    • Medically complex liaison;
    • Medical Support Section; and
    • Any other appropriate family member;
  • Requests written recommendations prior to the meeting and documents oral information provided by the team members in the child’s case record, all of which are considered at the IHP meeting if a team member is unable to attend;
  • Contacts the child’s physicians to receive a current verbal report on the child’s medical status (e.g. medications, treatment, etc.) and to request medical records from the previous six (6) months;
  • Completes the medically complex child’s DPP-104B Individual Health Plan and distributes the signed copies to all team members, including the Medical Support Section of Protection and Permanency (P&P) following the initial IHP meeting and every six (6) months thereafter;
  • Reviews the IHP every three (3) months with the team;
  • Schedules additional IHP meetings once every six (6) months and the team:
    • Reviews the plan to ensure that it meets the child's current needs; and  
    • Re-evaluates the child's continued medically complex status;
  • Contacts the Medical Support Section if it is determined that the child may no longer require a medically complex designation. 
  • The medical support section makes the final decision on the removal of the designation and notifies the CCSHCN nurse and medically complex liaison.
  • If a decision is reached to discontinue medically complex status, the team makes recommendations regarding the child’s future placement options and aftercare planning. 
  • If the foster/adoptive home parent is agreeable to providing continued care of the child, the child can remain in the same placement.
 

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