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									Texas Department of Aging                           Medically Dependent Children Program                                                 Form 2410
and Disability Services                                                                                                                October 2008
                                   Medical-Social Assessment and Individual Plan of Care
Individual Information
Name                                                                                         IPC Period (From – To)
                                                                                                       /    /       –           /     /
1. Date of Birth                               2. Medicaid No.                               3. Social Security No.

4. Primary Caregiver(s)                                                                      5. Caregiver’s Area Code and Telephone No.

6. Relationship to Applicant/Consumer                             7. MN-AED                  8. RUG                       9. Date TMHP-MN

10. IPC Submission            11. Name of Applicant’s/Consumer’s Physician                   12. Physician’s Area Code and Telephone No.
      Initial    Annual
13. Physician’s Address                                                                      14. City                     15. State       16. ZIP

17. Initial Case Only — Indicate the applicant’s location at start of eligibility determination:
        Hospital      NF       Home          Other:

Part I — Medical Assessment (to be completed by MDCP nurse) Mark                        box if additional pages of health information are attached.
18. The following medical information was obtained from:
   Family       Physician       Other:
19. Diagnosis:
19a(Primary)-                                                                 19d-
19b-                                                                          19e-
19c-                                                                          19f-
20. Ventilator:     Yes       No    If Yes, briefly describe type and frequency of use:

21a. Give dates and reasons for any hospitalizations within the past 12 months:

21b. List recent acute illnesses requiring physician evaluation/treatment/interventions:

21c. List any planned/potential inpatient or outpatient hospitalizations within the next six months:

22a. Health Information:

22b. Describe current treatments:

22c. Describe medical equipment/assistive devices in use or needed:

22d. Prognosis, if known:

22e. Allergies:

23. Caregivers: Does the primary caregiver state that he/she is able to care for the applicant/consumer? ....................       Yes       No
24. Does the primary caregiver state that he/she is able to provide consumer-specific training to providers? ...............        Yes        No
25. Short-term Goals (consult with case manager):

26. Long-term Goals (consult with case manager):

Signature — MDCP Nurse                                            Date                       Region               Area Code and Telephone No.
                                                                                                                                  Form 2410
                                                                                                                              Page 2/10-2008

Name                                                                                         IPC Period (From – To)
                                                                                                      /    /          –   /    /
Part II A — Social Assessment (to be completed by the case manager)
Describe the family’s home and community factors that contribute to the applicant’s/consumer’s care at home. Include any relevant
socioeconomic, psychological or health-related issues affecting the applicant’s/consumer’s care. Address health status of all primary
caregivers. Attach additional pages, if necessary.
27. Applicant’s/Consumer’s Functioning (physical, emotional, cognitive, behavioral):

28. Household Member(s)/Relationship to Applicant/Consumer and Ages:

29. Abilities/Limitations to Provide Care of:
29a. Primary Caregiver(s):

29b. Others in Household:

30. Family Relationship/Dynamics:

31a. Financial Resources/Limitations (include HIPP):

31b. Caregivers’ Work Schedules:

32. Community Resources:

33. School District Services:
       a. Date of latest Admission, Review and Dismissal (ARD) meeting:                  /      /
       b.   Homebound Education:                Hours per Day             Check here if home-schooled by choice.
       c.   Attends Public School:              Hours per Day Type:       Regular        Special Ed.       Other (specify):
       d.   School Transportation Provided by:             Family      School Dist.     Other (specify):
34. Other Inclusion Activities:

35. Permanency Plans:

36. Special Needs/Considerations (not described above that impact applicant’s/consumer’s care):

37. Describe any safety or environmental health hazards:                     38. Actions/recommendations:
       a.    None observed                                                    a.      None required
       b.    Electrical/structural:                                           b.
       c.    Other:                                                            c.

Signature —Case Manager                                         Date                         Region            Area Code and Telephone No.
                                                                                                                                   Form 2410
                                                                                                                               Page 3/10-2008

Name                                                                                      IPC Period (From – To)
                                                                                                      /     /       –     /     /
39. – 40. Part II B — MDCP Schedule Planning Grid — Schedule must reflect plan for use of MDCP hours
Scheduling codes are listed in ( ) below. Note: Providers may deliver services overnight, but may not bill for hours during which the
nurse or attendant was asleep.
                                Week 1                                                                     Week 2
   Time        Sun       Mon     Tues Wed         Thurs    Fri      Sat         Time    Sun     Mon       Tues Wed Thurs       Fri     Sat
12 mid                                                                      12 mid
1 am                                                                        1 am
2 am                                                                        2 am
3 am                                                                        3 am
4 am                                                                        4 am
5 am                                                                        5 am
6 am                                                                        6 am
7 am                                                                        7 am
8 am                                                                        8 am
9 am                                                                        9 am
10 am                                                                       10 am
11 am                                                                       11 am
12 noon                                                                     12 noon
1 pm                                                                        1 pm
2 pm                                                                        2 pm
3 pm                                                                        3 pm
4 pm                                                                        4 pm
5 pm                                                                        5 pm
6 pm                                                                        6 pm
7 pm                                                                        7 pm
8 pm                                                                        8 pm
9 pm                                                                        9 pm
10 pm                                                                       10 pm
11 pm                                                                       11 pm
41. Total Child Care Hours (parent at work, school or job training) Needed Per Week:
42. Private Insurance (I) (hours/week)                                          43. Non-Waiver Services
a. Nursing                                                                hrs a. School (S)                                             hrs
b. PT, OT or Speech Therapy                                               hrs b. Personal Care Services (PCS)                           hrs

44. Medicaid: (CCP) and/or Home Health (HH) (hours/week)                        45. Services Provided by Family (hours/week)
a. CCP Private Duty Nursing                                               hrs a. Hands-on Skilled/Personal Care (P)                     hrs
b. PT, OT or Speech Therapy                                               hrs b. General Supervision (P)                                hrs
c. Home Health Services                                                   hrs c. Paid Child Care (CC)                                   hrs

46. MDCP Services (hours/week) Specify provider type – nurse (N) or attendant (ATT)
a. Respite Care (R or FR)                  N or      ATT                  hrs
b. Adjunct Supports (A or FA)              N or      ATT                  hrs

Signature — Case Manager                                   Date                        Region               Area Code and Telephone No.

Applicant’s/Consumer’s/Caregiver’s Name (Type or Print)           Applicant’s/Consumer’s/Caregiver’s Signature          Date
                                                                                                                                  Form 2410
                                                                                                                              Page 4/10-2008

Name                                                                                   IPC Period (From – To)
                                                                                               /     /          –     /       /

Part II C — Individual Plan of Care Summary
47. MDCP Services
                                                      Yes        No   Comments:
47a. Respite
47b. Adjunct Support Services
     – Child Care
     – Independent Living
     – Post Secondary Ed
47c. Adaptive Aids
47d. Minor Home Modifications
47e. Financial Management Services
47f. Transition Assistance Services
48. Difficulty finding provider of choice:      Yes         No
49. If Yes, describe:
50. Services/Equipment Requested from Other Agencies: Each item must be addressed on Item 51 below (contact/follow-up
50a. Service/Equipment Requested                 50b. Agency Providing Service               50c. Date Requested          50d. Status

51. Case Manager Contact/Follow-up Schedule (must include a face-to-face visit at a minimum of every six months).
51a. Purpose of Contact                      51b. Time Frame or Date of Contact            51c. Method of Contact
   Plan Revisions/Changes                      At Consumer’s/Family’s Request                 By Telephone          By Mail
   All Initial Plans: (Confirm services
                                               30 Days from Plan Start Date                   By Telephone
started as planned.)

   Annual Reassessment                         Before Start of Next Plan Year                 Six-Month Face-to-Face Visit

Signature —Case Manager                            Date                       Region           Area Code and Telephone No.
                                                                                                                                               Form 2410
                                                                                                                                           Page 5/10-2008

Name                                                                                 IPC Period (From – To)
                                                                                                      /       /         –          /   /

Part III — MDCP Applicant/Consumer Plan of Care/Budget Worksheet
52. IPC:        Initial      Annual
53. RUG:                                                         Maximum Annual Cost Limit: $
54. SSI Eligible:           Yes        No                    54a. Date Verified:
55a. Non SSI Applicant/Consumers – Disability Determination Date                         /       /

55b. Latest Medical Eligibility Date                                                     /       /

56. Respite (R)/Adjunct Support Services (A):            Child Care           Independent Living          Post Secondary Ed
a. R, A, FR                                          e. Hours/      f. No. of      g. Total No. of   h. Rate per
            b. From Date c. To Date d. Provider Type            X               =                  @             =          i. Cost
   or FA                                               Week          Weeks             Hours            Hour
                                                                     X               =                    @                  =
                                                                     X               =                    @                  =
                                                                     X               =                    @                  =
                                                                     X               =                    @                  =
                                                                     X               =                    @                  =
                                                                     X               =                    @                  =
                                                                     X               =                    @                  =
                                                                     X               =                    @                  =
                                                                                                                  56 j. Total 1:
57. Minor Home Modifications
                                   a. Type of Modification                                                          b. Estimated Cost

                                                  c. Total Amount This Request = Subtotal
                                          d. Previous Expenditures for Home Modifications
e. Add c (Subtotal) + d =                                 – $7500 lifetime service limit.
   If less than $7500, continue. If total is more than $7500, revise plan.
f. Add specification fee, if applicable. Fee is not included in the lifetime service limit.
                                                                                    Total 2:
g. Home Modification Maintenance/Repair: may not exceed $300/year –
   not included in lifetime service limit =                                         Total 3:
58. Adaptive Aids
                                                                                                                   b. Estimated Cost
                                   a. Type of Adaptive Aid
                                                                                                     (Total 4 may not exceed $4000 per IPC period)

                                                                                   c. Total 4:
59. Add Totals 1 + 2 + 3 + 4 = Grand Total (must not exceed annual cost limit)
If this total is below the maximum cost limit, note that the full maximum cost limit remains available should the consumer require any
plan changes during the plan year.

Signature —Case Manager                                 Date                          Region              Area Code and Telephone No.
                                                                                                                                    Form 2410
                                                                                                                                Page 6/10-2008

Name                                                                           IPC Period (From – To)
                                                                                              /     /        –       /     /
60. Name of Primary Caregiver                                                  61. Relationship to Applicant/Consumer

Part IV — Individual Plan of Care – Signature/Approval
62.    Applicant’s/Consumer’s/Caregiver’s Approval:
           DADS offers a number of services and provider types in MDCP from which families may choose. Your signature on this
            plan is required in order to authorize services. However, your signature on this form in no way affects your right to request
            a fair hearing if you disagree with this plan of care.
           You have the right to make a change in the plan of care before the end of the plan year. You can choose to authorize the
            case manager to make such changes on your verbal instruction or you may choose to have any changes you request
            signed before they are made final. Your choice in no way affects your right to request a fair hearing. (If you make no
            choice, all changes you request will require your signature.) You will receive copies of any plan changes made during the
            IPC period.
           I understand that this plan of care is an alternative to institutional services, and that my signature is required for services to
            be authorized. I understand that my signature does not affect my right to a fair hearing if I disagree with this plan. I also
            understand that I may make changes in the plan before the end of the IPC period by contacting my case manager, and
                   I want to be allowed to authorize changes to the Applicant/Consumer Plan of Care verbally to the case manager.
                   I understand that I will be provided with a copy of the revised plan.
                   I want DADS to require my signature to make changes to the Individual Plan of Care.
Applicant’s/Consumer’s/Caregiver’s Name (Type or Print)           Applicant’s/Consumer’s/Caregiver’s Signature           Date

63.    Case Manager:
       This plan was developed in collaboration with the applicant/consumer and/or primary caregiver(s). I have reviewed the rights
       and responsibilities with the applicant/consumer/caregiver. I also have informed them that they have the right to make changes
       in the Individual Plan of Care before the end of the period and may do so by contacting me.
Case Manager Name (Type or Print)                                 Case Manager Signature                                 Date

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