Behavioral Health Standard 5.H – Medically Complex (MC)


The program description of services available for this population includes the following, as applicable:

a. Medical acuity issues

b. Medical stability issues

c. Psychological issues

d. Behavioral issues

e. Activity limitations

f. Participation restrictions

g. Long-term planning criteria

h. Intended discharge environments

i. Environmental modifications

j. Adaptive equipment

k. Respite

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The program collaborates with:

a. Healthcare providers who provide specialized medical, psychological/behavioral, and other therapeutic care to the person served

b. Other providers who provide specialized care to the person served

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Services are managed by an individual who has:

a. The education, training, and experience needed to meet the needs of persons with medically complex needs

b. The competencies needed to manage the services

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The program informs the primary care physician(s) of the progress of each person served toward his or her individual goals regarding:

a. Assessments

b. Significant changes

c. Discharge/transition

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The service delivery team includes specialists, as appropriate.

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Personnel demonstrate competences in the following areas:

a. Developmental stages

b. Physical impairments

c. Behavioral needs

d. Day-to-day needs

e. Grief and end-of-life support concerns

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The program promotes a positive, therapeutic approach to behavior management, as applicable, that addresses:

a. Instruction and guidance to the person regarding desired behaviors that:

  1.  Build on current strengths
  2.  Promote resiliency

b. Environmental factors to enhance the desired behaviors of the person

c. Environmental modifications

d. Use of medications

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As appropriate to the scope of the program, end-of-life planning:

a. Is directed by the wishes/desires of the person served and/or legal guardian

b. Includes advocacy of hospice, palliative care, or other end-of-life choices as needed

c. Includes spiritual or religious elements, if desired by the person served and/or legal guardian

d. Includes the guidance of a medical professional, if desired by the person served and/or legal guardian

e. Is communicated to applicable service providers in the required format, if applicable

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The program has a written philosophy of health and wellness for the persons served that:

a. Is designed to:

  1.  Meet their interests
  2.  Align with their cognitive capabilities
  3.  Reflect their choices
  4.  Promote their personal growth
  5.  Enhance their self-image
  6.  Improve or maintain their functional levels whenever possible

b. Is implemented to:

  1.  Address:
    1. Function
    2. Quality of life
  2.  Promote healthy aging and wellbeing

c. Addresses aging in place

d. Is shared with:

  1.  The persons served
  2.  Families/support systems
  3.  Personnel
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The primary assessment for each person served in the program includes the identification of:

a. Presenting health risks

b. Health goals

c. Expected health benefits

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Based on the initial and ongoing assessments, the person-centered plan of care addresses needs in the following areas, as appropriate:

a. Adjustment of the person to activity limitations

b. Adjustment of the family to activity limitations

c. Advance directives

d. Assistive technology

e. Bereavement

f. Communication

g. Community reintegration

h. Environmental modifications

i. Growth and development

j. Sexuality

k. Wellness

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The person-centered plan of care:

a. Specifically addresses how services will be provided in a manner that ensures the safety of the person served

b. Identifies the services provided by skilled healthcare providers

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Wellness for the person served is promoted through activities that:

a. Are purposeful

b. Include daily:

  1.  Structured activities
  2.  Unstructured activities

c. Are designed to:

  1.  Meet their interests
  2.  Align with their cognitive capabilities
  3.  Reflect their choices
  4.  Promote their personal growth
  5.  Enhance their self-image
  6.  Improve or maintain their functional levels whenever possible

d. Allow for group interaction

e. Allow for autonomy, as applicable

f. Include opportunities for community integration

g. Are evident in the person-centered plan for each person served

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The environment where services are provided addresses the behavioral and cognitive needs of the person served in terms of:

a. Agitation

b. Cueing

c. Distractibility

d. Elopement risks

e. Equipment safety

f. Level of responsiveness

g. Orientation

h. Physical safety

i. Physically aggressive behaviors

j. Self-injurious behaviors

k. Sexual behaviors

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The environment where services are provided supports:

a. Wellness activities

b. Initiation of the wellness/health services

c. Transition from the wellness/health services

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When applicable, the living environment provided for the person served is:

a. Developed based on input from the person served and family/guardian

b. Modified as needed based on input from the person served and family/guardian

c. Inclusive

d. Integrated into the community

e. Physically supportive to meet the needs of the persons living in the residence

f. Psychologically supportive to meet the:

  1.  Emotional needs of the person served
  2.  Social needs of the person served
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When applicable, individual possessions and decorations reflecting the choices by the person served are evident in his or her living environment.

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As appropriate based on scheduling, the program provides:

a. Daily access to at least three nutritious meals (or equivalent per doctor/dietician) or enteral feedings in a program that provides 24-hour care

b. Access to snacks consistent with personal choice and timing, unless contraindicated by the person-centered plan or medical condition

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The education and training program for the person served:

a. Is:

  1.  Developmentally appropriate
  2.  Age appropriate

b. Includes:

  1.  Knowledge of:
    1. Ability
    2. Activity
    3. Participation
  2.  Ability to describe and discuss any activity limitations in an age-appropriate fashion
  3.  Conflict resolution
  4.  Negotiation skills
  5.  Assertiveness training
  6.  Advocacy training
  7.  Preparation for adolescence/adulthood
  8.  Outcomes of decisions
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When a person served dies, opportunities are provided to other persons in the program, family/support systems, and personnel to:

a. Express grief and remembrance

b. Develop and participate in:

  1.  Memorial services
  2.  Memorial rituals
  3.  Other forms of grief expression, as desired
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