DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA) Enhanced Case Management Referral Consideration CLIENT’S NAME AGE ADSA ID NUMBER CRM NAME ECMP CARE ASSESSMENT DATE TRIGGERED REFERRAL? No Yes REPORTING UNIT / OFFICE CRM SUPERVISOR Does client live with paid caregiver No (not eligible) Name of paid caregiver: OR is client largely dependent on a Yes (continue) paid caregiver in home? Is the client always able to No Who is designated to supervise the paid caregiver? supervise caregiver? (CARE Yes Decision making screen) Does client have communication No Comments: barriers and few community Yes contacts? Does client have additional paid or No Waiver: unpaid services that would provide Yes additional oversight in the person’s List authorized services in PCSP: home? Are there Adult Protective Services No Comments (enter dates / results): (APS) or Child Protective Services Yes (CPS) referrals in the past year? Are there concerns about the home No Comments: environment that may jeopardize Yes the client’s health and safety or quality of care? Does the client have a Person No Comments: Centered Goal identified in the Yes Finalized Plan? Provide additional information Comments: the client challenging behaviors, medical concerns, unresolved issues, etc.), and/or provider concerns (contract, training, quality of care).
DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA) Enhanced Case Management Referral Consideration CLIENT’S NAME AGE ADSA ID NUMBER CRM NAME ECMP CARE ASSESSMENT TRIGGERED REFERRAL? No Yes DATE REPORTING UNIT / OFFICE CRM SUPERVISOR Does client live with paid caregiver OR is client largely dependent on a paid caregiver in home? No (not eligible) Yes (continue) Name of paid caregiver: Is the client always able to supervise caregiver? (CARE Decision making screen) No Yes Who is designated to supervise the paid caregiver? Does client have communication barriers and few community contacts? No Yes Comments: Does client have additional paid or unpaid services that would provide additional oversight in the person’s home? No Yes Waiver: List authorized services in PCSP: Are there Adult Protective Services (APS) or Child Protective Services (CPS) referrals in the past year? No Yes Comments (enter dates / results): Are there concerns about the home environment that may jeopardize the client’s health and safety or quality of care? No Yes Comments: Does the client have a Person Centered Goal identified in the Finalized Plan? No Yes Comments: Provide additional information the client challenging behaviors, medical concerns, unresolved issues, etc.), and/or provider concerns (contract, training, quality of care). Comments:
11-121.docx