Attachment D CALIFORNIA CHILDREN’S SERVICES ADOLESCENT TRANSITION CONFERENCE (ATC) ADOLESCENT TRANSITION HEALTH CARE PLAN
NAME: _________________________________________ BIRTHDATE:____________________ DIAGNOSIS: ___________________________________________ CCS# ___________________
Primary Care Physician/Medical Home Name: Address: Other case managing agency (s) Therapist yes no Caseworker:____________ (County Name): yes no IHO: yes no IEP: Attendance:___________ yes no School District: Residence:____________ Current Authorizations Provider:___________________ Service: ___________________ Provider:___________________ Service: ___________________ Provider:___________________ Service: ___________________ Dates:______________ Dates:______________ Dates:______________ Dates:______________ Dates:______________ Dates:______________
16 yrs. ATC date__________ 18 yrs. ATC date__________ 20 yrs. ATC date__________
Dentist: Healthcare Coverage Medi-Cal __________________________ CCS Only __________________________ Healthy Families Private Insurance: coverage type: HMO________ PPO________ Other ______ No insurance Primary Care Physician/Medical Home Name: Address:
Dentist: Healthcare Coverage Medi-Cal ____________________________ CCS Only ___________________________ Healthy Families Private Insurance: coverage type: HMO________ PPO________ Other ______ No insurance Primary Care Physician/Medical Home Name: Address:
Other case managing agency (s) Therapist yes no Caseworker:____________ (County Name): yes no IHO: yes no IEP: Attendance:___________ yes no School District: Residence:____________ Current Authorizations Provider:___________________ Service: ___________________ Provider:___________________ Service: ___________________ Provider:___________________ Service: ___________________ Dates:______________ Dates:______________ Dates:______________ Dates:______________ Dates:______________ Dates:______________
Dentist: Healthcare Coverage Medi-Cal __________________________ CCS Only __________________________ Healthy Families Private Insurance: coverage type: HMO________ PPO________ Other ______ No insurance
Other case managing agency (s) Therapist yes no Caseworker:____________ (County Name): yes no IHO: yes no IEP: Attendance:___________ yes no School District: Residence:____________ Current Authorizations Provider:___________________ Dates:______________ Service: ___________________ Dates:______________ Provider:___________________ Dates:______________ Service: ___________________ Dates:______________ Provider:___________________ Dates:______________ Service: ___________________ Dates:______________
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Attachment D CALIFORNIA CHILDREN’S SERVICES ADOLESCENT TRANSITION CONFERENCE (ATC) ADOLESCENT TRANSITION HEALTH CARE PLAN
Medical Services
Medical Specialists currently involved: Orthopedist Neuro GI Pulmon Opthalm Urol Genetics Other______________ Will current specialists continue care after discharge from CCS program and accept patient’s mode of funding? Patient/caregiver have provided signed consent for release of latest Medical Therapy Conference dictation, therapy assessment/plan and all x-rays from unit (final transition) Medical Home/Primary Care Physician/Medical Therapy Conference Do you have a current Medical Home or PCP who can provide care following your discharge from CCS regarding important needs such as overall medical care, supplies and medication? Behavior/personality/attitude changes/concerns noted and referred to Social Work, Medical Home or PCP for follow up as needed. Sex education (sexuality, birth control, etc.): referral to Medical Home or PCP for follow up as needed. Substance abuse: referral to Medical Home or PCP for follow up as needed. General Equipment Information Therapist Home visit completed if needed Patient has braces or splints: ______________________________ Patient has DME vendor and Orthotist information Durable Medical Equipment – Rehab Therapist Purchase Date Wheelchair: manual Wheelchair: power Walker/crutches Braces Toileting equipment Bath equipment ADL equipment (e.g., dressing, grooming) Feeding equipment Communication device Hospital bed Ramps Lift Durable Medical Equipment – Medical Purchase Date Ventilator O2 Supplies Apnea Monitor Trach. Supplies Other:
16 yrs.
yes yes yes no no no
18 yrs.
yes yes yes no no no
20 yrs.
yes yes yes no no no
yes
no
yes
no
yes
no
yes yes yes
no no no
yes yes yes
no no no
yes yes yes
no no no
16 yrs.
yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no no no no no no no no no no no no
18 yrs.
yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no no no no no no no no no no no no
20 yrs.
yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no no no no no no no no no no no no
16 yrs.
18 yrs.
20 yrs.
16 yrs.
18 yrs.
20 yrs.
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Attachment D CALIFORNIA CHILDREN’S SERVICES ADOLESCENT TRANSITION CONFERENCE (ATC) ADOLESCENT TRANSITION HEALTH CARE PLAN
Indicate N/A if item is not applicable to patient Funding Social Worker 16 yrs.
yes yes no no
18 yrs.
yes yes no no
20 yrs.
yes yes no no
Patient has been advised to apply for SSI If patient does not qualify for SSI, alternative means of funding and/or coverage by certain community agency’s (e.g., Regional Center, Charities) services have been discussed for expenses such as medical services, supplies, equipment and equipment repairs
Resources
Social Worker
16 yrs.
yes yes yes yes yes yes no no no no no no
18 yrs.
yes yes yes yes yes yes no no no no no no
20 yrs.
yes yes yes yes yes yes no no no no no no
Does family need help or have questions about: Guardianship/Conservatorship Living Situation/Respite care Mental Health In-Home Supportive Services, (IHSS), In Home Operations (IHO) Recreational/Social activities Transportation Resources
MTP use only
Age 16 Date: Participant Patient: ________________________________ Therapist: _______________________ Parent: ________________________________ Nurse Case Manager: _____________ Physician: ______________________________ Social Worker: ___________________ Other: _________________________________ Other: __________________________ Information provided by:
MTP use only
Age 18 Date: Participant Patient: ________________________________ Therapist: _______________________ Parent: ________________________________ Nurse Case Manager: _____________ Physician: ______________________________ Social Worker: ___________________ Other: _________________________________ Other: __________________________ Information provided by:
MTP use only
Age 20 Date: Participant Patient: ________________________________ Therapist: _______________________ Parent: ________________________________ Nurse Case Manager: _____________ Physician: ______________________________ Social Worker: ___________________ Other: _________________________________ Other: __________________________ Information provided by:
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