# data[].attributes.body
BMI Intervention: CC will educate and connect EI to resources on meal planning. ----April Saxon, LBSW Rationale: Helps EI regain or maintain an appropriate weight. Promoting healthy lifestyles. ---April Saxon, LBSW Intervention: CC will encourage participation in general exercise. ----April Saxon, LBSW Rationale: To aid in facilitating in overall well-being and healthy lifestyle. ----April Saxon, LBSW Diabetes Intervention: CC will connect EI to Valentine’s for diabetic supplies. ----April Saxon, LBSW Rationale: To assist in providing adequate tools and supplies to monitor and document blood sugars. ---April Saxon, LBSW Intervention: CC will provide education about diabetes management and linkage to resources. ----April Saxon, LBSW Rationale: Reinforces learning about diabetes and provides key factors that may contribute to unstable blood sugars and how to obtain more stable blood sugar levels along with A1C<7. ---April Saxon, LBSW Behavioral Health Intervention: CC will assist EI in connect to behavioral health services for therapy and management of aggressive and impulsive behaviors. ---April Saxon, LBSW Rationale: Provides insight to diagnosis and assist EI with dealing with situations appropriately. Providing individualized coping skills and necessary lifestyle changes. ----April Saxon, LBSW Intervention: CC will encourage EI to take medication as prescribed and improve medication compliance. ---April Saxon, LBSW Rationale: Provides EI complete understanding of illness and need for medication treatment. Education is the key to promoting medication adherence. ---April Saxon, LBSW WC Visit Goal: EI will attend the annual well child visit scheduled for --- with ----Pediatrics. ---April Saxon, LBSW Intervention: CC will encourage, follow up, and monitor completing of the well child screening for preventative care. ----April Saxon, LBSW Rationale: EI will be screened, diagnosed, and treated for existing and potential health problems before they become permanent, lifelong disabilities. ----April Saxon, LBSW XXXXXXXXXX Incentive XXXXXXXXXDO NOT USE AS A GOAL Goal: EI will receive information on the EPSDT QIP gift card incentive offered over the next 90 days. ---April Saxon, LBSW Intervention: CC will educate on the EPSDT QIP incentive offered with completing the well child screening. ----April Saxon, LBSW Rationale: To ensure EI has yearly screening for optimal health outcomes. ---April Saxon, LBSW Link to Dental Care Goal: EI/guardian will choose a dental provider from a listing provided to them and schedule an appointment within the next 6 months. ---April Saxon, LBSW Intervention: CC will provide a dental provider listing and follow up to assist with scheduling an appointment if needed. ---April Saxon, LBSW Rationale: Promotes good oral health and hygiene in maintaining healthy teeth and gums. ---April Saxon, LBSW Have Documented BMI Goal: EI will receive nutritional and physical activity counseling along with a documented BMI at their Well Child appointment scheduled with ----Pediatrics. ---April Saxon, LBSW Intervention: CC will encourage EI receive nutritional and physical activity counseling along with documented BMI at their well child screening. ---April Saxon, LBSW Rationale: EI will be appropriately screened during the well child screening to reduce risk of childhood obesity. ----April Saxon, LBSW **Intervention: CC will follow up to ensure EI has documented BMI and nutritional counseling from well child screenings. ----April Saxon, LBSW Rationale: To identify any educational barriers and educate EI on a healthy diet and lifestyle to prevent potential issues. ---April Saxon, LBSW Speech Therapy Goal: EI/guardian will obtain referral and connection to speech therapy evaluation through the Clay Co Board of Education or Early Intervention over the next 6 months. ---April Saxon, LBSW Intervention: CC will connect EI with Clay County Board of Education or Early Intervention for further evaluation of speech and to receive therapy as needed. ----April Saxon, LBSW Rationale: Provides EI/guardian with services to enable EI to improve expressive language and communication skills with children and adults. ----April Saxon, LBSW ABA Therapy Goal: EI will obtain referral and connection to ABA services over the next 6 months. ---April Saxon, LBSW Intervention: CC will connect EI with ABA therapies to improve social skills, coping, and behavior management. ----April Saxon, LBSW Rationale: Provides EI/guardian with services to enable EI to improve social skills, coping, and behavior management and to improve quality of life. ----April Saxon, LBSW Early Intervention Goal: EI/guardian will obtain referral to Early Intervention for needed therapy over the next 6 months. ---April Saxon, LBSW Intervention: CC will follow up with Early Intervention to ensure all information has been received for EI to begin services and needed therapy. ----April Saxon, LBSW Rationale: Provides EI with the needed services in developing the foundation for learning and gives EI a greater chance for achieving to her best potential. ---April Saxon, LBSW Parents as Teachers Goal: EI will obtain referral to parenting resources over the next 6 months. ---April Saxon, LBSW Intervention: EI/guardian will learn about Parents as Teachers and be connected through referral process to address behavior concerns. -----April Saxon, LBSW Rationale: Provides EI/guardian with resources and skills needed to achieve positive behavior and increase positive change and behaviors with EI. ----April Saxon, LBSW Learn Benefits covered under Medicaid Goal: EI/guardian will demonstrate knowledge of benefits covered under Medicaid to include well child, dental, vision, and specialty care over the next 6 months. ----April Saxon, LBSW Intervention: CC will educate EI/guardian on benefits covered under Alabama Medicaid to include well child, dental, vision, and specialty care as well as NET assistance. ----April Saxon, LBSW Rationale: EI/guardian will increase knowledge of benefits covered to utilize appropriately to receive best management and care. ----April Saxon, LBSW Establish with PCP Goal: EI will choose a primary medical provider from a listing provided and schedule an appointment over the next 6 months. ----April Saxon, LBSW Intervention: CC will follow up with guardian regarding providers local to her and assist with scheduling an appointment to establish a medical home. ----April Saxon, LBSW Rationale: Provides EI with a medical home to avoid unnecessary ER visits and good management of benefits. ----April Saxon, LBSW

Care Plan Evaluation: Example: CC verified EI by date of birth and address confirmed. The encounter was completed telephonically with EI. EI was assessed for COVID. EI states they do not have COVID currently. EI reports they have not been exposed to COVID-19 within the last 2 weeks.

New Assessment Task Note: CC will attempt to follow up with EI monthly and work towards reaching the goals of the care plan. EI was agreeable.

# data[].attributes.body
Intervention and Rationale Examples Asthma Intervention: CC will provide education on short acting and long acting medication and compliance. ---April Saxon, LBSW Rationale: Provides information that will improve EI knowledge and assist in prevention of asthma attacks and increase medication compliance. ----April Saxon, LBSW

Intervention: CC will provide education on correct usage of Metered dose inhaler (MDI) and spacer. ----April Saxon, LBSW

Rationale: Helps promote correct use of spacer by slow, deep inhalation and breathe holding after inhalation help promote effectiveness of medication. -----April Saxon, LBSW

Intervention: CC will educate and encourage EI to avoid triggers. ---April Saxon, LBSW

Rationale: Understanding triggers can lessen frequency of asthma attacks and improve EI quality of life. ----April Saxon, LBSW Connection to SPECIALTY CARE Goal: EI will attend ------ within the next 6 months to manage ----diagnoses. ----April Saxon, LBSW

Intervention: EI will schedule-----appointment by follow up with CC next month. -----April Saxon, LBSW

CC will assist EI with scheduling -----appointment by follow up with CC next month. ---April Saxon, LBSW

CC will provide appointment reminders via text message prior to scheduled -----appointment. ----April Saxon, LBSW

Rationale: EI reports difficulty remembering appointments dates/times so CC providing a reminder will increase the likelihood of EI attending appointment as scheduled. ----April Saxon, LBSW Long Range Planning Goal: EI/guardian will demonstrate improved knowledge and referred to long term planning for EI over the next 6 months. ----April Saxon, LBSW

Intervention: CC will educate EI/guardian on waiver programs that will increase independence and help EI to remain home and increase quality of life. CC will connect and refer to programs as needed. ---April Saxon, LBSW

Rationale: By providing resources and programs available to EI for utilization will help increase independent lifestyle and increase quality outcomes. ---April Saxon, LBSW Medication Fill Plan Goal: EI will initiate use of medication fill plan over the next 6 months to improve medication compliance and decrease/eliminate out of pocket medication cost. ---April Saxon, LBSW

Intervention: CC will connect EI with MCA PharmD to provide fill plan. ---April Saxon, LBSW

Rationale: PharmD can create and provide a fill plan for EI to use to schedule when medications are filled in order to decrease/eliminate issues of EI having to choose to pay out of pocket or not refill medications. This should help increase medication compliance. ---April Saxon, LBSW Surgery FU Goal: EI will attend surgery appointment within 2 weeks of hospital discharge to follow up with provider post-op. ---April Saxon, LBSW

Intervention: CC will provide appointment reminder prior to scheduled surgery appointment. ---April Saxon, LBSW

Rationale: Providing appointment reminders will decrease the chance of EI forgetting about the appointment and no-showing. This will increase the likelihood of EI making appointment within 2 weeks of discharge and not having to reschedule. ----April Saxon, LBSW Cardiovascular Disease Intervention: CC will educate EI on HTN and how it effects on the heart, blood vessels, kidneys and brain. ----April Saxon, LBSW

Rationale: Provides information on blood pressure and improves EI’s knowledge of causative factors and informs EI that HTN can exist without symptoms and enable EI to continue treatment even when feeling well. ----April Saxon, LBSW

Intervention: CC will encourage medication compliance. ---April Saxon, LBSW

Rationale: Promotes cooperation in taking medication and improves knowledge of consequences of inadequate compliance. Therefore, assisting EI’s health maintenance. ---April Saxon, LBSW

Intervention: CC will connect EI to remote patient monitoring program. ---April Saxon, LBSW

Rationale: Self-monitoring of BP offers reassurance to EI. Visualization of BP help promote early detection of any changes in blood pressure. ----April Saxon, LBSW

Intervention: CC will connect EI to smoking cessation resource (QUITNOW). ---April Saxon, LBSW

Rationale: Provides an avenue to prepare and plan to quit smoking and eliminate tobacco. ---April Saxon, LBSW Community Resources Goal: EI/guardian will utilize {community resource} for financial assistance over the next 6 months. ----April Saxon, LBSW

Intervention: CC will connect EI to community resources for financial assistance. ---April Saxon, LBSW

Rationale: Provides services that may be helpful in EI’s efforts in initiating and maintaining healthy lifestyles. ---April Saxon, LBSW

Goal: EI/guardian will demonstrate improved knowledge of transportation resources such as KidOne and NET assistance over the next 6 months. ---April Saxon, LBSW

Intervention: CC will provide education both verbal and written to EI/guardian on requesting NET assistance successfully. ---April Saxon, LBSW

Rationale: Provides EI with transportation reimbursement for appointments and increases access to medical care and appointment compliance. ---April Saxon, LBSW

Intervention: CC will connect EI to community resources for financial assistance and connect with possible insurance opportunities in the event family doesn't qualify for continued coverage under Medicaid. ---April Saxon, LBSW

Rationale: Provides services that may be helpful in EI’s efforts in initiating and maintaining healthy lifestyles and ensure continued insurance opportunities for family. ---April Saxon, LBSW Transportation Goal: EI/guardian will demonstrate knowledge on how to utilize NET transportation assistance over the next 6 months. ---April Saxon, LBSW

Intervention: CC will assist with connecting EI to public transportation assistance and educate on NET. ---April Saxon, LBSW

Rationale: Provides safe and reliable means of transportation and increases access to medical care and appointment compliance. ---April Saxon, LBSW

Intervention: CC will provide education to EI both verbal and written on requesting NET assistance successfully. ---April Saxon, LBSW

Rationale: Provides EI with transportation reimbursement for appointments and increases access to medical care and appointment compliance. ----April Saxon, LBSW

Intervention: CC will assist with connecting EI to public transportation, KidOne, and educate on NET. ---April Saxon, LBSW

Rationale: Provides safe and reliable means of transportation and increases access to medical care and appointment compliance and decreases likelihood of missing appointments or having to reschedule. ---April Saxon, LBSW Receive Medically Appropriate Care: Intervention: CC will empower Guardian to schedule EI's yearly follow up with cardiology by follow up with CC next month. -----April Saxon, LBSW

Rationale: Guardian reports difficulty remembering appointments dates/times so CC providing a reminder will increase the likelihood of EI attending appointment as scheduled. ----April Saxon, LBSW : Demonstrate improved Knowledge Intervention: CC will encourage EI to take medication as prescribed for medication compliance and control of -----condition. ---April Saxon, LBSW

Rationale: Provides EI complete understanding of ----condition and need for medication treatment. Education is the key to promoting medication adherence. ---April Saxon, LBSW Heart Failure Intervention: CC will connect EI to Remote Monitoring. ---April Saxon, LBSW Rationale: Providing tools to monitor and document fluid increase and loss. Involving EI in therapy regimen at home. This may enhance sense of control and cooperation with restrictions. -----April Saxon, LBSW

Intervention: CC to educate EI on heart failure and normal function of the heart and importance for medication compliance. ----April Saxon, LBSW

Rationale: Increase EI knowledge of disease process and expectations. This may reinforce adherence to prescribed medication regimen. ---April Saxon, LBSW Substance Abuse Intervention: CC will connect EI to ROSS peer support. ---April Saxon, LBSW

Rationale: Provides support and connection to systems necessary to manage sobriety and drug free lifestyles. ----April Saxon, LBSW

Intervention: CC will provide education on importance of medication compliance along with coping skills. ----April Saxon, LBSW

Rationale: To provide knowledge of medication and coping skills to aid in necessary successful life changes. ----April Saxon, LBSW COPD Intervention: CC will educate EI on diagnoses and medication use. ---April Saxon, LBSW

Rationale: Provides improved knowledge of disease and promotes participation in treatment plan, allowing EI to make informed choices. Proper administration of drug enhances delivery and effectiveness of medications. ----April Saxon, LBSW

Intervention: CC will connect EI to smoking cessation program. ---April Saxon, LBSW

Rationale: Cessation of smoking may slow or halt the progression of COPD. ---April Saxon, LBSW

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General
Chart Note:
Consent for services was explained to the EI, signed by the EI, and copy was provided. CC also reviewed and provided EI with copies of the HIPPA/Confidentiality and Rights and Responsibilities. EI was provided information on how to request CC services for the future. ---April Saxon, LBSW

Other-General Consent:
CC uploaded general consent form to RMEDE. ---April Saxon, LBSW

Community Resource:
CC reviewed benefits covered under Medicaid to include importance for seeking care from provider over presenting to the ER unless in a true emergency.  CC reviewed wellness benefits and screenings covered and frequency for screenings.  CC discussed number of allowed provider visits and discussed ways to keep track and better manage allotted visits.  CC educated EI on how to request and access NET assistance through both verbal and written information.  CC educated on community resources through local churches and food banks within the community.  Education provided on Community Action for utility assistance.   CC also directed EI to the 211 resource line for added support if needed. ----April Saxon, LBSW 

PCP Notification:
Provider notified of EI enrollment to CC services with My Care Alabama through secure patient portal. ----April Saxon, LBSW

ASSESSMENT & Task Notes:
A0005 - Correspondence with PCP
Description: Provider notified of EI enrollment to CC services with My Care Alabama through secure patient portal. ----April Saxon, LBSW
Interventions: Education, Education, Education
 April Saxon  0
 Date Documented: Dec 02, 2022
 Date of Service: Dec 01, 2022

A0007 - Medication List
Description: Medication list obtained from EI during provider visit. EI was being seen for a follow up sick visit. EI was able to provide medications which was compared to RMEDE claims data and the secure patient portal. CC encouraged taking medications as directed with timely refills. EI declined smoking cessation at this time. EI has diagnoses of prediabetes and CC will continue to educate her on healthy diet and exercise along with medication compliance to keep condition from worsening. Medication reconciliation submitted to pharmacy for review. ----April Saxon, LBSW
Interventions: Education, Education, Education
 April Saxon  0
 Date Documented: Dec 02, 2022
 Date of Service: Dec 01, 2022

G0007 - Community Resource Assistance
Description: CC reviewed benefits covered under Medicaid to include importance for seeking care from provider over presenting to the ER unless in a true emergency. CC reviewed wellness benefits and screenings covered and frequency for screenings. CC discussed number of allowed provider visits and discussed ways to keep track and better manage allotted visits. CC educated EI on how to request and access NET assistance through both verbal and written information. CC educated on community resources through local churches and food banks within the community. Education provided on Community Action for utility assistance. CC also directed EI to the 211 resource line for added support if needed. CC urged medication compliance and timely refills. CC educated on healthy diet to keep blood sugars stable as well as the importance for monitoring A1C every 3 months to ensure her level remains <7. ----April Saxon, LBSW
Interventions: Education, Education, Education
 April Saxon  0
 Date Documented: Dec 02, 2022
 Date of Service: Dec 01, 2022

G0001 - Face to Face Assessment / Reassessment
Description: The initial assessment was completed with EI during p virovidersit. EI was verified by date of birth and address verified. EI is a 53 year old female living in the Ashland area. EI reports she is new to Medicaid and receiving SSI income. EI receives food stamps in the home and has reliable transportation. EI has past medical history of fibromyalgia, is a prediabetic, high cholesterol, anxiety, acid reflux, and weak bones. EI is established with Ashland Family Practice and is current with her CCS and mammogram. EI is also established with vision care. EI states her A1C was completed in October, and she was at 5.7. States she was started on a weekly injection to help control her blood sugar. EI states she was also sent to have a pulmonary nodule checked in her lung, but results were fine and will repeat it yearly. CC educated EI on smoking cessation programs, but EI declined referral at this time but agreed to consider. EI reports good knowledge of her conditions and denies needing additional information except for prediabetes. EI is agreeable for CC to attempt monthly follow up in working toward meeting goals of the care plan. CC and EI set up goals together to meet the needs of EI at this time. EI will receive information on medications to assist with keeping blood sugars well managed over the next 6 months; EI will receive information on NET assistance for transportation reimbursement over the next 6 months; EI will receive information on covered services under Medicaid over the next 6 months. ----April Saxon, LBSW
Interventions: Education, Education, Education
 April Saxon  0
 Date Documented: Dec 02, 2022
 Date of Service: Dec 01, 2022

A0003 - Chart Note
Description: Consent for services was explained to the EI, signed by the EI, and copy was provided. CC also reviewed and provided EI with copies of the HIPPA/Confidentiality and Rights and Responsibilities. EI was provided information on how to request CC services for the future. ---April Saxon, LBSW
Interventions: Education, Education, Education
 April Saxon  0
 Date Documented: Dec 01, 2022
 Date of Service: Dec 01, 2022

Other - Receipt of Referral; face to face
Description: Referral received on this EI through provider referral. Medicaid is verified active for December via the Alabama Medicaid Web Portal. Claims and medication data reviewed in RMEDE. EI was later seen with and verified by date of birth and address. CC introduced program and offered CC services. EI was receptive for CC to proceed with screening and assessments. ----April Saxon, LBSW

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EPSDT Chart Note: Consent for services was explained to the EI's guardian, signed by the guardian, and copy was provided. CC also reviewed and provided guardian with copies of the HIPPA/Confidentiality and Rights and Responsibilities. guardian was provided information on how to request CC services for the future. ---April Saxon, LBSW

Receipt of Referral from PCP: Referral received on EI through primary care provider. Medicaid is verified active for January via the Alabama Medicaid Web Portal. Claims and medication data reviewed in RMEDE. EI was seen with her mom program introduced. EI was verified by date of birth and address. Guardian was receptive for CC to proceed with screening and assessment. ---April Saxon, LBSW Other: Consent Task Note: CC uploaded general consent form to RMEDE. ---April Saxon, LBSW Community Resource: FU Appt: CC provided both verbal and written instructions on how to request and access NET assistance. CC encouraged calling appointments in before attending them to ensure eligibility. CC also reviewed KidOne and other public means for transportation but guardian states she has a reliable vehicle. CC urged importance for remaining current with screenings and immunization services and reviewed the screening schedule with guardian. CC reviewed importance for attending EI's allergy testing appointment scheduled for 12/02/2022. Guardian reports no barriers to keeping this appointment and is ready to learn what all EI is allergic to. Guardian voiced having a text reminder will be helpful as well. CC further educated on giving medication as prescribed until more can be learned about his allergies. Advised guardian to contact CC as needed. ----April Saxon, LBSW ADHD: CC provided both verbal and written instructions on how to request and access NET assistance. CC encouraged calling appointments in before attending them to ensure eligibility. CC also reviewed KidOne and other public means for transportation but guardian states she has a reliable vehicle. CC urged importance for remaining current with screenings and immunization services and reviewed the screening schedule with guardian. CC reviewed importance for giving medications for ADHD as prescribed and refilling timely. Encouraged guardian to explain to PCP what's working and what is not and keep track of any changes with mood or behaviors to address at follow up appointments. EI is also taking a daily allergy medication for seasonal allergies and CC encouraged giving this daily to keep symptoms well controlled. EI is awaiting an appointment with Sparks clinic for further evaluation for possible Autism and states a text reminder will be helpful once appointment is obtained. Advised guardian to contact CC as needed. ----April Saxon, LBSW CC provided both verbal and written instructions on how to request and access NET assistance. CC encouraged calling appointments in before attending them to ensure eligibility. CC also reviewed KidOne and other public means for transportation but guardian states she has a reliable vehicle. CC urged importance for remaining current with screenings and immunization services and reviewed the screening schedule with guardian. CC reviewed importance for giving medications for ADHD as prescribed and refilling timely. Guardian states EI is doing well on his medications at this time and denies need for additional education. Encouraged guardian to note any changes with mood or behaviors to address at follow up appointments with PCP. Advised guardian to contact CC as needed. ----April Saxon, LBSW Benefit & Resource Information: CC provided both verbal and written instructions on how to request and access NET assistance. CC encouraged calling appointments in before attending them to ensure eligibility. CC also reviewed KidOne and other public means for transportation but guardian states she has a reliable vehicle. CC urged importance for remaining current with screenings and immunization services and reviewed the screening schedule with guardian. CC reviewed WIC services and eligibility requirements and encouraged guardian to seek appointment for EI if needed. Advised guardian to contact CC as needed. ----April Saxon, LBSW PCP Notification: Phone call placed to PCP and spoke with Nina regarding EI enrollment to CC services with MyCare Alabama. Reviewed goals and education being provided and advised provider contact CC if needed. ----April Saxon, LBSW PCP notified of EI enrollment to CC services with MyCare Alabama through secure patient portal. ----April Saxon, LBSW G0009 - Professional Encounter with PCP Description: Phone call placed to PCP and spoke with Nina regarding EI enrollment to CC services with MyCare Alabama. Reviewed goals and education being provided and advised provider contact CC if needed. ----April Saxon, LBSW Interventions: Follow-up/Monitor, Education, Education April Saxon 0 Date Documented: Nov 18, 2022 Date of Service: Nov 16, 2022 A0007 - Medication List Description: Medication list was obtained with guardian during initial assessment. Guardian voiced no current medications at this time. States EI is treated for occasional illness and CC educated guardian on the importance for completing all antibiotics when prescribed and to follow up with PCP as needed and limit ER use to true emergencies only. Medication reconciliation submitted to pharmacy for review. ----April Saxon, LBSW Interventions: Follow-up/Monitor, Education, Education April Saxon 0 Date Documented: Nov 18, 2022 Date of Service: Nov 16, 2022 G0007 - Community Resource Assistance Description: CC provided both verbal and written instructions on how to request and access NET assistance. CC encouraged calling appointments in before attending them to ensure eligibility. CC also reviewed KidOne and other public means for transportation but guardian states she has a reliable vehicle. CC urged importance for remaining current with screenings as EI is currently past due. Guardian was agreeable to schedule an appointment with PCP. CC offered to assist with scheduling if needed. CC further educated on the benefits for completing screenings for preventative care and early detection. Advised guardian to contact CC as needed. ----April Saxon, LBSW Interventions: Follow-up/Monitor, Education, Education April Saxon 0 Date Documented: Nov 18, 2022 Date of Service: Nov 16, 2022 G0001 - Face to Face Assessment / Reassessment Description: The initial assessment was completed with guardian at location of choice, Annie Awbrey Public Library. EI was identified by date of birth and address. EI is a 13 year old who mom requested a review of services for. It was identified that EI is needing to have a well child screening and CC further discussed and educated on the benefits for completing screening as well as frequency for screenings. Guardian voiced she will schedule EI an appointment with PCP soon. EI is well linked with vision and dental care. No past medical history reported except for occasional illness. EI lives with his mom and sibling in a safe home environment. Child support is received, and family receives EBT. Mom provides transportation and states NET will be helpful for transportation reimbursement. Guardian is agreeable for CC to attempt monthly follow up in working toward meeting goals of the care plan. CC and EI's guardian set up goals together to meet the needs of EI at this time. EI will receive information on well child screenings over the next 6 months; EI/guardian will receive information on benefits covered under Medicaid over the next 6 months; EI/guardian will receive information on NET assistance over the next 6 months. ----April Saxon, LBSW Interventions: Follow-up/Monitor, Education, Education April Saxon 0 Date Documented: Nov 18, 2022 Date of Service: Nov 16, 2022 Other - General Consent Description: CC uploaded GCC form to RMEDE. ---April Saxon, LBSW Interventions: Follow-up/Monitor, Education April Saxon 0 Date Documented: Nov 18, 2022 Date of Service: Nov 16, 2022 A0003 - Chart Note Description: Consent for services was explained to the EI's guardian, signed by the guardian, and copy was provided. CC also reviewed and provided guardian with copies of the HIPPA/Confidentiality and Rights and Responsibilities. guardian was provided information on how to request CC services for the future. ---April Saxon, LBSW Interventions: Follow-up/Monitor, Education, Education April Saxon 0 Date Documented: Nov 18, 2022 Date of Service: Nov 16, 2022 Other - Receipt of Referral; face to face Description: Guardian requested referral on EI while enrolling herself to CC services for a review of benefits and covered services. EI was identified by date of birth and address. Medicaid is verified active for November via the Alabama Medicaid Web Portal. Claims and medication data reviewed in RMEDE. Guardian is receptive for CC to proceed with screening and assessments. ----April Saxon, LBSW PCP REFERRAL: Referral received on this EI through PCP. Medicaid is verified active for December via the Alabama Medicaid Web Portal. Claims and medication data reviewed in RMEDE. EI was later seen with guardian and CC introduced program and services offered. Guardian was receptive for CC to proceed with the screening and assessment. ----April Saxon, LBSW

# data[].attributes.body
Other: General Consent Task Note:

Provider Notification Task Note:

Medication Task Note:

Community Resource Task Note: CC reviewed educational materials regarding sickle cell disease and tips for healthy living with guardian. Guardian is very knowledgeable of the disease and reports going through classes at Children's when EI was diagnoses at a young age. Guardian reports EI has had maybe 3 ER visits within the last year and maybe 1 was considered an inpatient due to being overnight. States EI does have crisis episodes but is on daily treatment. CC encouraged appointment compliance with specialty care. Guardian reports a recent visit and will return in about 3 months for his next visit. She agreed to keep CC updated with appointment details. CC was able to provide verbal and written information on requesting NET assistance for transportation reimbursement. Guardian states this could be helpful to them in going to Birmingham for his specialty care and dental appointments and voiced appreciation for explaining the process. Advised guardian to contact CC as needed. ----April Saxon, LBSW

ASSESSMENT & Task Note: The initial assessment was completed with EI's guardian at her workplace, American Tax, Talladega, AL. EI is identified by date of birth and address and CC was given permission by EI to speak with guardian. EI is a 15 year old male with past medical history of Sickle Cell Disease and mild asthma. EI has a primary care provider, Dr. Dela Cruz and is also connected with Children's of Alabama Clinic 8 with Dr. L. Hilliard, Hematologist in managing Sickle Cell Disease. EI is also being seen for dental care at Children's as well. EI lives in a safe home environment with his mom and grandmother. Grandmother provides transportation to all of EI's appointments and reports transportation is reliable. Guardian was not aware of NET assistance and is agreeable to receive education on this. EI is on the track team and coaches are well aware of EI's condition and monitors him closely. EI does have a history of mild asthma, but guardian states he rarely has a flare up with it. States it is mainly when he gets ill with a cold or upper respiratory infection. States EI does not require daily treatment and inhaler is given only if needed. States no additional education is needed regarding asthma. Ei is supported financially by his mom and grandmother. Reports having a good relationship with his father, and he does provide as needed for EI. They do not qualify for EBT. Guardian is agreeable for CC to attempt monthly follow up in working toward meeting goals of the care plan. CC and EI's guardian set up goals together to meet the needs of EI at this time. EI/guardian will increase knowledge of sickle cell disease over the next 6 months; EI/guardian will receive information on NET assistance over the next 6 months; EI will attend follow up appointment for SCD as scheduled over the next 6 months. ----April Saxon, LBSW

OTHER_Sickle Cell Disease

GOAL: EI/guardian will increase knowledge of sickle cell disease over the next 6 months. ---April Saxon, LBSW Intervention: CC will educate on Sickle Cell Disease. ----April Saxon, LBSW

Rationale: Provides EI with needed education regarding sickle cell disease which may help to reduce crisis episodes and ER visits. ----April Saxon, LBSW Transportation goal: EI/guardian will receive information on community resources such as NET assistance over the next 6 months. ---April Saxon, LBSW

Intervention: CC will provide education both verbal and written to EI/guardian on requesting NET assistance successfully. ---April Saxon, LBSW

Rationale: Provides EI with transportation reimbursement for appointments and increases access to medical care and appointment compliance. ---April Saxon, LBSW Attend appointment goal GOAL: EI will attend follow up appointment for Sickle Cell Disease as scheduled over the next 6 months. ----April Saxon, LBSW

Intervention: CC will monitor and encourage attending follow up appointments as scheduled in managing sickle cell disease. ----April Saxon, LBSW

Rationale: Provides EI with needed follow up and which will lead to medication compliance and possible reduction of crisis episodes and improve quality of life. -----April Saxon, LBSW

# data[].attributes.body
Referral:
Received referral for care coordination from EI's PCP. CC verified EIs Medicaid active for 3.2024 and assigned with the My Care Alabama East ACHN via AL Medicaid Portal. Eligibility report uploaded into EIs REMEDE. Initial screening completed. ---Lisa Johnson, LBSW

Phone Call to Schedule Initial:
Phone call to EI's caregiver to schedule initial assessment visit. Visit scheduled for 3.11.2024. ----Lisa Johnson, LBSW

Consent for Services:
EI consented to services. CC and EI reviewed the consent form, HIPAA Confidentiality Agreement, and patients’ rights and responsibilities. EI was notified of the right to request services in the future. ----Lisa Johnson, LBSW

Community Resources:
CC provided education on Medicaid benefits, screenings covered for preventative services. Reviewed community resources available in the area as well as educated caregiver on NET assistance offered through the Alabama Medicaid agency and how to request and access services if needed. -----Lisa Johnson, LBSW

Safety Needs/Concerns for Psychosocial:
No safety needs identified. CC and EI developed goals together to meet EI's needs. EI will establish with a PCP. EI will obtain medication refills as prescribed. EI will demonstrate understanding of how to use food assistance by recalling the steps for application.

No safety concerns identified.  Caregiver and CC identified goals together to meet EI’s needs. Caregiver will be verbalize understanding of the importance of well child visits and weight checks for the first 15 months of life. Ei will gain weight appropriately, according to pediatrician recommendations. Caregiver will utilize NET for transportation assistance.

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Documentation Examples – General 

Social Issues: Initial assessment was completed with the patient in her home. Patient was admitted to Gadsden Regional Medical Center with heart failure on 10/1/2019 and discharged on 10/6/2019. Patient is a 65 year old female who lives in a house alone. Patient receives an income of $771/month in SSI benefits and $150/month in food assistance. She states she has reliable transportation. Patient states she has a past medical history of: diabetes, and hypertension. 

Safety Concerns/Needs Identified: No safety concerns identified at present time. RN and EI set up goals together in order to meet the needs of the patient at this time - EI will schedule a follow-up appointment with her PCP;  EI will attend appointment with an endocrinologist;  EI will be linked with bio-monitoring for a glucometer, blood pressure monitor, and scale; EI will receive education on community resources, medications, and diagnoses.

Face to Face Assessment/Reassessment: CC completed initial assessment with the EI in her home. EI called the PCP during the assessment and scheduled an appointment for 10/30/19 at 11 am. RN made a referral with the bio-monitoring nurse M. Waker, RN. EI had no other concerns or questions at the present time. 

Community Resource Assistance: 10/1/2019 - CC provide the patient with education on Medicaid NET, and resources for food assistance in the EIs community. CC provide the patient with a printed list of resources. S. Kelley, RN 

Consent (chart note): 10/1/19 - Consent for services was explained to the EI, signed by the EI, and a copy was provided. EI was provided information on how to request care coordination services for any future needs. S. Kelley, RN

Face to Face In home Visit: 11/1/19 - CC completed initial assessment with EI in her home. CC assisted EI in contacting PCP to schedule appointment - EI will be seen by Dr. Harris 11/5/19 at 1pm. CC also provided diabetic, and heart failure education. EI verbalized understanding of education. S. Kelley, RN

Face to Face Non Home Visit: 11/1/19 - CC completed initial assessment with EI at Jack’s per the EI’s request. CC assisted EI in contacting PCP to schedule appointment - EI will be seen by Dr. Harris 11/5/19 at 1pm. CC also provided diabetic, and heart failure education. EI verbalized understanding of education. S. Kelley, RN

Medication List Task: Medication list was collected during the initial assessment using the medication bottles and compared to the RMEDE claims data. Patient stated she takes the medications as prescribed; EI notes that she only takes half of the dose of insulin prescribed because she is afraid of her blood sugar dropping too low – CC provide education on the importance of taking medications as prescribed, and EI and CC discussed the signs and symptoms of hypoglycemia. EI reports a HgA1C of 10%. Medication reconciliation has been requested. S. Kelley, RN (report any discrepancies in this note)

Medication Reconciliation Follow Up: 10/15/19 – CC reviewed the medication reconciliation note that was prepared by the pharmacy. RN and patient discussed via phone the medication duplication that was reported on abc med and xyz medication – EI states she will ask her PCP about the medications during her appointment that is scheduled for 10/16/2019 at 1pm. CC notified patient that the pharmacy states the PCP will need to submit a PA for xyz medication. S. Kelley, RN 

MCT Task: 10/15/2019 – CC spoke with the EIs PCP regarding the EIs current care plan. CC discussed that we were providing care coordination services. CC notified PCP of the referral that was made for bio-monitoring – PCP also recommended additional education be provided on heart failure management since it is a new diagnosis. CC discussed the possibility of an endocrinology referral to assist in diabetic management – PCP agreed and states he will refer the EI to a endocrinologist. PCP had no other recommendations or concerns at the present time. S. Kelley, RN 

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Medication list was collected during the initial assessment using information provided by the EI and compared to the RMEDE claims data. EI reports she takes her medication as prescribed. The CC educated the EI that she should take ibuprofen with food to avoid any gi upset if this is prescribed upon d/c from hospital. The CC educated the EI that oxycodone/a pap may make her drowsy and to not drive while taking this medication if this medication is prescribed upon d/c from hospital. In addition to drowsiness, pain medication has a high chance of constipation especially after delivery. EI should drink plenty of fluids while taking and report any significant bowel changes to doctor. CC provided education on the importance of taking medication as prescribed. Medication reconciliation has been requested. ——-Pam Anderson, LBSW

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CC provided education on Medicaid benefits; screenings covered for preventative services. Reviewed community resources available in the area as well as educated guardians on NET assistance offered through the Alabama Medicaid agency and how to request and access services if needed. Encouragement provided. ——-Pam Anderson, LBSW

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GOAL: EI will attend postpartum visit with CC within 30 - 45 days of delivery to address postpartum care, needs and any other concerns. ------Pam Anderson, LBSW

Intervention: Care Coordinator will follow up with EI to ensure that all post-partum needs are met and knowledge of any post-partum appointments with DHCP. ------- Pam Anderson, LBSW

Rationale: Receiving postpartum care ensures the body is healing well and no complications have developed. ----------- Pam Anderson, LBSW

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GOAL:     Caregiver to be knowledgeable of in-home resources to aide in education and services within the next 90 days. ------Pam Anderson, LBSW

Intervention:  CC to refer the EI/Caregiver to in home services with Parents as Teachers to provide support with EI's care and education. ----Pam Anderson, LBSW

Rationale: In order for the EI's Mother to receive support within home needs the mother needs to be aware of available services. -------Pam Anderson, LBSW

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Multiple attempts made to contact the EI for follow-up without success. Care Coordinator requested Attempt to Contact Letter to be mailed through our automated letter process in SharePoint. Letter will be generated and mailed out with the upcoming mail cycle. ------Pam Anderson, LBSW

Multiple attempts made to contact the EI for follow-up without success. Care Coordinator requested Attempt to Contact Letter was mailed through our automated letter process in SharePoint. Letter was generated and mailed out with the upcoming mail cycle. No response has been received from the EI and therefore the CC will close the case.  --------- Pam Anderson, LBSW

Multiple attempts have been made to contact the EI regarding the referral without any results. Care Coordinator requested Attempt to Contact Letter to be mailed through our automated letter process in SharePoint. Letter will be generated and mailed out with the upcoming mail cycle.  CC will therefore close the case. -------Pam Anderson, LBSW

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No safety issues noted.  EI to demonstrate understanding of importance of being compliant with all scheduled medical appointments and medication.  EI to have understanding of community resources along with the NET program.

No safety issues noted.  EI's Mother to verbalize understanding of the schedule for immunizations and screening, along with information regarding Child Care resources.   The EI's Mother to verbalize understanding of community resources, NET, EBT and WIC.

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Ei to be seen by the Pediatrician within 5 days of discharge from hospital after birth.  -------------- Pam Anderson, LBSW

CC to educate the Mother on the importance of contact with the Pediatrician after delivery to ensure health of the baby.   —- Pam Anderson, LBSW

Early intervention with any medical issues with ensuring proper medical care and intervention. --------Pam Anderson, LBSW

GOALS:  EI’s Mother will attend all medical appointments with the EI’s Pediatrician to ensure understanding the importance of compliance with medical appointments and immunizations for the EI within the next 90 days. -------Pam Anderson, LBSW

Intervention:  CC to educate the Mother on the importance of compliance with medical appointments for monitoring and immunizations for the EI along with the schedule for immunizations. -----Pam Anderson, LBSW

Rationale:  In order to ensure prompt medical monitoring and ensure attention to any early intervention the Mother needs to be compliant with medical appointments. --------Pam Anderson, LBSW

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Ei will attend follow up apt with OB/GYN scheduled for the 6 weeks post-partum appointment.  -------------- Pam Anderson, LBSW

CC to educate the EI on the importance of compliance with medical treatment and appointments.  —- Pam Anderson, LBSW

In order for the EI to receive appropriate medical care and intervention, monitoring of medical care is necessary. --------Pam Anderson, LBSW

GOALS:  EI’s Mother will attend all medical appointments with the EI’s Pediatrician to ensure understanding the importance of compliance with medical appointments and immunizations for the EI within the next 90 days. -------Pam Anderson, LBSW

Intervention:  CC to educate the Mother on the importance of compliance with medical appointments for monitoring and immunizations for the EI along with the schedule for immunizations. -----Pam Anderson, LBSW

Rationale:  In order to ensure prompt medical monitoring and ensure attention to any early intervention the Mother needs to be compliant with medical appointments. --------Pam Anderson, LBSW

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Goal: EI will be educated on safe sleep practices and Sudden Infant Death Syndrome within 90 days to improve knowledge on safe sleep practices and Sudden Infant Death Syndrome. -----Pam Anderson, LBSW

Intervention: Care Coordinator will educate EI on safe sleep practices and Sudden Infant Death Syndrome. No blankets, pillows, or anything in the bed with infant; back to sleep; do not co-sleep with infant. ----------- Pam Anderson, LBSW

Rationale: Improved knowledge on safe sleep practices may reduce the risk of Sudden Infant Death Syndrome. ------ Pam Anderson, LBSW

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GOAL:   Ei will choose the appropriate medical physician from list provided to them and schedule initial visit within the next 90 days. --------- Pam Anderson, LBSW

INTERVENTION:    CC will educate the Mother on process needed to ensure medical coverage for the EI throughout the calendar year. -------Pam Anderson, LBSW

RATIONALE:  Full understanding of the process to ensure insurance coverage exceeding the 14 Medicaid days will be beneficial to the EI's Mother. -------- Pam Anderson, LBSW

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Goal:  Ei will choose PCP rom list provided to them and schedule initial visit within the next 90 days--------- Pam Anderson, LBSW

.Intervention:  CC will follow up with EI regarding providers local to her and assist with scheduling an appointment to establish a medical home. ----Pam Anderson, LBSW

Rationale:  Provides EI with a medical home to avoid unnecessary ER visits and good management of benefits. ----Pam Anderson, LBSW

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Goal:  EI/guardian will learn benefits covered under Medicaid to include well child, dental, vision, and specialty care over the next 6 months. ----Pam Anderson, LBSW

Intervention:  CC will educate EI/guardian on benefits covered under Alabama Medicaid to include well child, dental, vision, and specialty care as well as NET assistance. --- Pam Anderson, LBSW

Rationale:  EI/guardian will increase knowledge of benefits covered to utilize appropriately to receive best management and care. ----Pam Anderson, LBSW

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Goal:  EI will receive nutritional and physical activity counseling along with a documented BMI at their Well Child appointment scheduled with ----Pediatrics. ---Pam Anderson, LBSW

Intervention:  CC will encourage EI receive nutritional and physical activity counseling along with documented BMI at their well child screening. ---Pam Anderson, LBSW

Rationale:  EI will be appropriately screened during the well child screening to reduce risk of childhood obesity. ----Pam Anderson, LBSW

**Intervention:  CC will follow up to ensure EI has documented BMI and nutritional counseling from well child screenings. ----Pam Anderson, LBSW

Rationale:  To identify any educational barriers and educate EI on a healthy diet and lifestyle to prevent potential issues. ---Pam Anderson, LBSW

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Goal:  EI will attend the annual well child screening by her PCP within the next 90 days. ---Pam Anderson, LBSW

Intervention:  CC will encourage, follow up, and monitor completing of the well child screening for preventative care. ----Pam Anderson, LBSW

Rationale:  EI will be screened, diagnosed, and treated for existing and potential health problems before they become permanent, lifelong disabilities. ----Pam Anderson, LBSW

GOAL:  EI/Caregiver to ensure the completion of the —- year Child Health Screening within the next 90 days in order to screen for potential health problems, diagnosis and treatment. —Pam Anderson, LBSW

INTERVENTION: CC to provide education regarding the upcoming ——- year Child Health Screening appointment and importance of compliance and benefits of yearly screening. ---------- Pam Anderson, LBSW

RATIONALE: Well Child Checkup is helpful to identify actual or potential health problems to screen, diagnose and treat problems before they potentially become permanent, lifelong disabilities. ——- Pam Anderson, LBSW

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Goal:  Ei will choose dentist from list provided to them and schedule initial visit within the next 90 days. --------- Pam Anderson, LBSW

Intervention:  CC will follow up and assist with linking EI to needed dental care. ---Pam Anderson, LBSW

Rationale:  Promotes good oral health and hygiene in maintaining healthy teeth and gums. ---Pam Anderson, LBSW

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Goal:  EI/Caregiver will have contact numbers available for Behavioral Health Services in order to receive appropriate treatment within the next 90 days. ----------Pam Anderson, LBSW

Intervention:  CC will assist EI in linkage to behavioral health services for therapy and management of aggressive and impulsive behaviors. ---Pam Anderson, LBSW

Rationale:  Provides insight to diagnosis and assist EI with dealing with situations appropriately.  Providing individualized coping skills and necessary lifestyle changes. ----Pam Anderson, LBSW

Rationale:  Provides EI complete understanding of illness and need for medication treatment.  Education is the key to promoting medication adherence. ---Pam Anderson, LBSW

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Intervention:  CC will educate EI on Valentine DME which would help provide diabetic supplies to ensure regular monitoring of blood sugar within the next 90 days. ----Pam Anderson, LBSW

Rationale:  To assist in providing adequate tools and supplies to monitor and document blood sugars. ---Pam Anderson, LBSW

Intervention:  CC will provide education about diabetes management and linkage to resources. ---- Pam Anderson, LBSW

Rationale:  Reinforces learning about diabetes and provides key factors that may contribute to unstable blood sugars and how to obtain more stable blood sugar levels along with A1C<7. --- Pam Anderson, LBSW

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Intervention:  CC will educate and link EI to resources on meal planning, nutritional education and exercise within the next 6 months. ----Pam Anderson, LBSW

Rationale:  Helps EI regain or maintain an appropriate weight, increase life style activity and educate the EI in order to promote healthy lifestyle. ---Pam Anderson, LBSW

Intervention:  CC will encourage participation in general exercise, weight loss program, and receive needed exercise. ----Pam Anderson, LBSW

Rationale:  To aid in facilitating in overall well-being and healthy lifestyle. --- Pam Anderson, LBSW

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Intervention:  CC will educate EI on diagnoses and medication use. ---Pam Anderson, LBSW

Rationale:  Provides improved knowledge of disease and promotes participation in treatment plan, allowing EI to make informed choices.  Proper administration of drug enhances delivery and effectiveness of medications. ----Pam Anderson, LBSW

Intervention:  CC will link EI to smoking cessation program. ---Pam Anderson, LBSW

Rationale:  Cessation of smoking may slow or halt the progression of COPD. ---Pam Anderson, LBSW

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Intervention:  CC will link EI to ROSS peer support. ---Pam Anderson, LBSW

Rationale:  Provides support and linkage to systems necessary to manage sobriety and drug free lifestyles. ----Pam Anderson, LBSW

Intervention:  CC will provide education on importance of medication compliance along with coping skills. ----Pam Anderson, LBSW

Rationale:  To provide knowledge of medication and coping skills to aid in necessary successful life changes. ----Pam Anderson, LBSW

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Goal:  EI/Caregiver to become knowledgeable of services available to ensure appropriate treatment and evaluation for Autism within the next 6 months.   -----Pam Anderson, LBSW

Intervention – CC will assist EI in linkage to behavioral services for testing and assessment for Autism ---Pam Anderson, LBSW

Rationale:  Provides insight to Autism and Autism spectrum diagnosis and assist EI with dealing with situations appropriately. Providing individualized coping skills and necessary lifestyle changes to achieve desired behaviors. ----- Pam Anderson, LBSW

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Intervention:  CC will link EI to Remote Monitoring. ---Pam Anderson, LBSW

Rationale:  Providing tools to monitor and document fluid increase and loss.  Involving EI in therapy regimen at home.  This may enhance sense of control and cooperation with restrictions. -----Pam Anderson, LBSW

Intervention:  CC to educate EI on heart failure and normal function of the heart and importance for   medication compliance. ----Pam Anderson, LBSW

Rationale:  Increase EI knowledge of disease process and expectations.   This may reinforce adherence to prescribed medication regimen. ---Pam Anderson, LBSW

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Goal:  EI’s Caregiver to be educated on the disease process and treatment plan to ensure appropriate medical care. ----------- Pam Anderson, LBSW

Intervention:  CC will educate the EI’s Parents on the disease process and treatment plan in order to control seizures. ---Pam Anderson, LBSW

Rationale:  Provide EI’s Parents with complete understanding of seizures and need for medication treatment and monitoring. Education is the key to promoting medical adherence. ---Pam Anderson, LBSW

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Goal:  Mother will demonstrate improved knowledge of transportation resources available to her such as Kid 1 and NET within the next 30 days. ------------- Pam Anderson, LBSW

Intervention:  CC will assist with linking EI to public transportation assistance and educate on NET. ---Pam Anderson, LBSW

Rationale:  Provides safe and reliable means of transportation and increases access to medical care and appointment compliance. ---Pam Anderson, LBSW

Intervention:  CC will provide education to EI on requesting NET assistance successfully. ---Pam Anderson, LBSW

Rationale:  Provides EI with transportation reimbursement for appointments and increases access to medical care and appointment compliance. ----Pam Anderson, LBSW

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Intervention:  CC will link EI to community resources for financial assistance. ---Pam Anderson, LBSW

Rationale:  Provides services that may be helpful in EI’s efforts in initiating and maintaining healthy lifestyles. ---Pam Anderson, LBSW

Goal:  EI/EI's caregiver will utilize [community resource] for financial assistance, Childcare services and NET within the next 3 months.  ----------Pam Anderson, LBSW

Intervention:  CC will provide education to EI/guardian on requesting NET, Childcare Services and 211 assistances successfully. ---Pam Anderson, LBSW

Rationale:  EI/Caregiver knowledge of community resources, Childcare services and NET, which would benefit household to meet needs. -----------Pam Anderson, LBSW

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Goal:  EI will verbalize understanding of the Smoking Cessation services available and verbalize her understanding of benefits within the next 90 days. -------Pam Anderson, LBSW

Intervention:  CC will link EI to smoking cessation resource (QUITNOW) and provide application to use to enroll in program.  ---Pam Anderson, LBSW

Rationale:  Provides an avenue to prepare and plan to quit smoking and eliminate tobacco. ---Pam Anderson, LBSW

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Intervention:  CC will educate EI on HTN and how it effects on the heart, blood vessels, kidneys and brain. ----Pam Anderson, LBSW

Rationale:  Provides information on blood pressure and improves EI’s knowledge of causative factors and informs EI that HTN can exist without symptoms and enable EI to continue treatment even when feeling well. ----Pam Anderson, LBSW

Intervention:  CC will encourage medication compliance. ---Pam Anderson, LBSW

Rationale:  Promotes cooperation in taking medication and improves knowledge of consequences of inadequate compliance.  Therefore, assisting EI’s health maintenance. ---Pam Anderson, LBSW

Intervention:  CC will link EI to remote patient monitoring program. ---Pam Anderson, LBSW

Rationale:  Self-monitoring of BP offers reassurance to EI.  Visualization of BP help promote early detection of any changes in blood pressure. ----Pam Anderson, LBSW

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GOAL: EI to verbalize understanding the importance of being compliant with all prescribed medication within the next 90 days. ——-Pam Anderson, LBSW

Intervention: CC to educate the EI on the importance of being compliant with all prescribed medication. ----- Pam Anderson, LBSW

RATIONALE: Ensures cooperation in taking medications and improves knowledge of consequences of on noncompliance, which assist EI health maintenance. ——-Pam Anderson, LBSW

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Goal:  EI will attend surgery appointment within 2 weeks of hospital discharge to follow up with provider post-op. ---Pam Anderson, LBSW

Intervention:  CC will provide appointment reminder prior to scheduled surgery appointment. --- Pam Anderson, LBSW

Rationale:   Providing appointment reminders will decrease the chance of EI forgetting about the appointment and no-showing.  This will increase the likelihood of EI making appointment within 2 weeks of discharge and not having to reschedule. ----Pam Anderson, LBSW

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Goal:  EI will initiate use of medication fill plan over the next 6 months to improve medication compliance and decrease/eliminate out of pocket medication cost. ---Pam Anderson, LBSW

Intervention:  CC will link EI with MCA PharmD to provide fill plan. ---Pam Anderson, LBSW

Rationale:  Pharm can create and provide a fill plan for EI to use to schedule when medications are filled in order to decrease/eliminate issues of EI having to choose to pay out of pocket or not refill medications.  This should help increase medication compliance. --- Pam Anderson, LBSW

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Goal:  EI/guardian will receive information and linkage to long term planning for EI over the next 6 months. ----Pam Anderson, LBSW

Intervention:  CC will educate EI/guardian on waiver programs that will increase independence and help EI to remain home and increase quality of life.  CC will link and refer to programs as needed. ---Pam Anderson, LBSW

Rationale:  By providing resources and programs available to EI for utilization will help increase independent lifestyle and increase quality outcomes. -------Pam Anderson, LBSW

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Goal:  EI will attend/receive linkage to ------ within the next 6 months to manage ----diagnoses. --- Pam Anderson, LBSW

Intervention:  EI will schedule-----appointment by follow up with CC next month. -----Pam Anderson, LBSW

CC will assist EI with scheduling -----appointment by follow up with CC next month. -----Pam Anderson, LBSW

CC will provide appointment reminders via text message prior to scheduled -----appointment. ----Pam Anderson, LBSW

Rationale: EI reports difficulty remembering appointments dates/times so CC providing a reminder will increase the likelihood of EI attending appointment as scheduled. ----Pam Anderson, LBSW

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Intervention: CC will provide education on short acting and long acting medication and compliance. ---Pam Anderson, LBSW

Rationale: Provides information that will improve EI knowledge and assist in prevention of asthma attacks and increase medication compliance. ----Pam Anderson, LBSW

Intervention:  CC will provide education on correct usage of Metered dose inhaler (MDI) and spacer. ----Pam Anderson, LBSW

Rationale:  Helps promote correct use of spacer by slow, deep inhalation and breathe holding after inhalation help promote effectiveness of medication. -----Pam Anderson, LBSW

Intervention:  CC will educate and encourage EI to avoid triggers. ---Pam Anderson, LBSW

Rationale:  Understanding triggers can lessen frequency of asthma attacks and improve EI quality of life. ----Pam Anderson, LBSW