Haw. Code R. § 11-100.1-88 - Case management qualifications and services
(a) Case management services shall be
provided for each expanded ARCH resident to plan, locate, coordinate and
monitor comprehensive services to meet the individual resident's needs based on
a comprehensive assessment. Case management services shall be provided by a
registered nurse who:
(1) Possesses a
bachelor's degree in nursing and current license to practice in the State of
Hawaii; and
(2) Has at least two
years experience with client care coordination responsibilities and possesses
knowledge and skills pertaining to the long term care needs of the geriatric
population. The department may allow substitution of two additional years of
client care coordination experience for a bachelor's degree.
(b) When the care plan goal cannot
be met by the registered nurse, a social worker shall be available to the
resident and primary care giver for areas that include, but are not limited to,
counseling, access to community services, financial matters, and behavior
management. These services shall be provided by a social worker who:
(1) Possesses a master's degree in social
work and current license to practice in the State of Hawaii; and
(2) Has at least two years experience with
client care coordination responsibilities and possesses knowledge and skills
pertaining to the long term care needs of the geriatric population. The
department may allow substitution of two additional years of client care
coordination experience for a master's degree.
(c) Case management services for each
expanded ARCH resident shall be chosen by the resident, resident's family or
surrogate in collaboration with the primary care giver and physician or APRN.
The case manager shall:
(1) Conduct a
comprehensive assessment of the expanded ARCH resident prior to placement in an
expanded ARCH, which shall include, but not be limited to, physical, mental,
psychological, social and spiritual aspects;
(2) Develop an interim care plan for the
expanded ARCH resident within forty eight hours of admission to the expanded
ARCH and a care plan within seven days of admission. The care plan shall be
based on a comprehensive assessment of the expanded ARCH resident's needs and
shall address the medical, nursing, social, mental, behavioral, recreational,
dental, emergency care, nutritional, spiritual, rehabilitative needs of the
resident and any other specific need of the resident. This plan shall identify
all services to be provided to the expanded ARCH resident and shall include,
but not be limited to, treatment and medication orders of the expanded ARCH
resident's physician or APRN, measurable goals and outcomes for the expanded
ARCH resident; specific procedures for intervention or services required to
meet the expanded ARCH resident's needs; and the names of persons required to
perform interventions or services required by the expanded ARCH
resident;
(3) Review the care plan
monthly, or sooner as appropriate;
(4) Update the care plan as changes occur in
the expanded ARCH resident care needs, services and/or interventions;
(5) Promote continuity of care and
appropriate integration and utilization of services necessary to implement the
care plan;
(6) Coordinate care
giver training, hospital discharge, respite, home transfers and other services
as appropriate. Facilitate, advocate and mediate for expanded ARCH residents,
care givers and service providers to ensure linkages and provision of quality
care for the optimal function of the expanded ARCH resident;
(7) Arrange and participate in the expanded
ARCH resident's case conferences. Ensure that the expanded ARCH resident,
resident's family or surrogate, expanded ARCH resident's physician and the
primary care giver are represented at the case conferences;
(8) Have face-to-face contacts with the
expanded ARCH resident at least once every thirty days, with more frequent
contacts based on the resident's needs and the care giver's
capabilities;
(9) Provide ongoing
evaluation and monitoring of the expanded ARCH resident's status, care giver's
skills, competency and quality of services being provided;
(10) Conduct comprehensive reassessments of
the expanded ARCH resident every six months or sooner as appropriate;
(11) Make arrangements with a case manager
and/or registered nurse who meets the requirements of this subchapter (a) to
provide coverage in the event that the case manager takes leave or is unable to
provide services as required in this chapter; and
(12) Inform the department of any change in
quality of services being provided to the expanded ARCH resident.
Case management services shall be subject to all applicable state regulations.
(d) The department in collaboration with the
expanded ARCH resident family or surrogate may require a change in case
management services when it has been determined through review of resident
records, care plans and interventions that the case manager is unable to
provide adequate services as outlined in this subchapter.
(e) When a change in case management services
occurs, the new case manager shall perform a comprehensive reassessment of the
expanded ARCH resident, review the care plan and make necessary amendments. The
expanded ARCH resident, resident's family or surrogate, physician or APRN and
primary care giver shall be notified if a change in case management services is
contemplated.
Notes
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No prior version found.