Commonwealth Care Alliance Individual Preference Plan (IPP)

Commonwealth Care Alliance Individual Preference Plan (IPP):

Date: ______

Member Name: ______DOB:______

Is (Name to be filled in)still your personal care attendant (PCA)?

YesNo (If not, who is new PCA? ______)

How often does he/she help you (with your needs)?

DailyMon-Fri3-4 days/weekonce/weekOther

Do you think he/she understands your needs?YesNo

Do you think he/she knows how to respond to them?YesNo

Do you have any additionalneeds or concerns that you would like your PCA to meet? If so, what are they?

Do you have any informal support or informal caregivers other than your PCA(s)?

Name(s): ______

Phone Number:______

Relation:______

What does (informal support/informal caregiver) help you with? ______

Do you have acurrent:

Health Care Proxy YesNo Who?

Power of Attorney YesNoWho?

Legal Guardian YesNoWho?

Conservator YesNoWho?

Rate Payee YesNoWho?

Surrogate YesNoWho?

PCA Care Plan

Do you have a copy of the PCA Care Plan prepared by your primary care team?

Yes No If No, Would you like a copy? YesNo

Are you able to understand the PCA Care Plan prepared by your primary care team?

Yes No

If not, would you like help in following or understanding it? ______

Do you have a PCA schedule with specific tasks for the PCA? YesNo

If not, would you like to do a PCA schedule? YesNo(See sample form)

Do you have any specific concerns regarding your PCA? Yes No

__Not doing tasks __Coming late __Not communicating effectively __Other(s)

(E.g. changing work schedule without consulting with me; bringing child or friends to work)

If yes, do you want help?YesNo

If yes,what issues would you like assistance with? ______

What type of assistance? ______

Training/Skill Development Interest

Are you interested in having your PCA(s) receive more training and skill development?

YesNoIf so, what would you be interested in your PCA(s) learning more about?

First AidCPR MedicationsActivities of Daily Living

Home Safety NutritionMental Health Mobility

Communication and Listening Skills Quality of Life

Computer Classes Protective Services Fraud

Confidentiality Universal Precautions ESOL

Fundamentals of Care Working with the primary care team

If you are not interested in having your PCA learn more about any of the subjects listed above, please let us understand why: ______

If your PCA attended any of these training opportunities, would you need coverage to assist you during those hours? Yes• No•

How much time:______

IndividualizedTraining specific to your own needs:

1.Does your PCA help you with any of these daily activities?

Bathing or showering? ______

Dressing? ______

Toileting? ______

Washing up? ______

Getting in and out of bed? ______

Walking? ______

Eating? ______

Would you like us to help you teach your PCA to do any of these tasks better?

Yes  Which ones? ______

No 

2.Does your PCA help you with any of these additional activities?

Shopping? ______

Cleaning or doing laundry? ______

Cooking or preparing food? ______

Paying bills? ______

Taking your medications? ______

Getting around town? ______

Talking on the telephone or using a computer? ______

Would you like us to help you teach your PCA to do any of these tasks better?

Yes  Which ones? ______

No 

Would you be interested in attending any of thesetrainings with your PCA:

Yes No

If so, which trainings?

First AidCPRMedications reconciliationNutrition

 Home SafetyDiabetes Activities of Daily Living Mobility

Mental Health Communication and Listening Skills

Quality of Life Computer Classes Protective Services

Fraud Confidentiality Universal Precautions

ESOL Fundamentals of Care

Working with the primary care team

Other:______

Would you be interested in attending any of CCA’s workshops on chronic illness? Yes No

Chronic Disease Self Management/Tomando?YesNo

Diabetes management?YesNo

Would you be interested in having your PCA attend as well?Yes No

Communication with Care Team

Would you feel comfortable with your PCA communicating directly with your CCA primary care team/care manager?Yes No Only under certain circumstances

If yes, what types of issues are you comfortable with your PCA communicating about?

Health issues/concernsMedications Follow up appointments

PCA payments Health Care Proxy Emergency Only

Conflict resolutionOther(s)______

All of the above

If yes, would you be comfortable withyour PCA communicating with yourprimary care team only when you are present?Yes No

If only under certain circumstances, what circumstances would you feel comfortable withyour PCA communicating with your Commonwealth Care Alliance Team about?

Health issues/concernsMedications Follow up appointments

PCA payments Health Care ProxyEmergency Only

Conflict resolutionOther(s) ______

Does your PCA currently talk with members of your primary care team/your Care Manager? If so, what is the usual topic of this communication?

If yes, are you usually there during these talks?

If no, would you like to be there?

Either way, are you comfortable with your PCA talking to your Care Manager when you are not there to listen?

Would you be interested inhaving an opportunity to talk with your primary care team about your goals & concerns?

YesNoIf yes, how often?______

Who wouldyou like present at this discussion?PCA RN GSSC Surrogate

MA LPN PCA Project Coordinator NP MD

None of the above Other(s)______

Individual Preference Plan (Action Plan)

Name of Consumer:______

1)My top goal is:______

______

2)Why is this accomplishment important to you? ______

3)How are you preparing to accomplish this goal?

______

4)Who is helping you with this accomplishment and how he/she helping you?

______

Rev01-04-13/DL