Date Discussed | Core Component | Data Element Name | Data Element Definition | Data Element Value Datatype / Format | Multiple Values (Y/N) | Comments / Discussion / Relevant Slide(s) | TEFT Grantee / Pilot Plan Element Mappings |
8/4/2016 | Risk | Identified Risk | An aspect of a person’s life, behavior, environmental exposure, an inborn or inherited characteristic, or barrier that increases the likelihood of a disease, condition or injury. | String / Free Text | Y | Identified Risk Slide | CO: Checkboxes + Comments field GA: Identified Areas of Risk MD: Risk Details MN: Identified risk and choice regarding services FEI: Risk Details |
8/4/2016 | Emergency Backup Plan | Emergency Backup Contact Phone Number | The phone number of the individual identified to provide necessary services and supports to the person in the event of an emergency. | Number / 111-111-1111 | Y | Emergency Backup Contact Phone Number Slide | CO: Contingency Plan MD: Phone Number MN: Phone Number FEI: Emergency Contact Phone Number |
8/4/2016 | Emergency Backup Plan | Emergency Backup Contact Name | The name of the individual identified to provide necessary services and supports to the person in the event of an emergency. | String / Free Text | Y | Emergency Backup Contact Name Slide | MD: Name MN: Key contact name FEI: Emergency Contact Name |
8/4/2016 | Emergency Backup Plan | Emergency Backup Contact Relationship Type | The relationship of the individual identified to provide necessary services and supports to the person in the event of an emergency. | String / Free Text | Y | Emergency Backup Contact Relationship Type Slide | CO: Contingency Plan MD: Relationship MN: Relationship FEI: Contact Type |
8/4/2016 | Emergency Backup Plan | Emergency Backup Plan Text | The free text description of how to address unforeseen events, emergency health events, problems with durable medical equipment, or unavailable staffing that put the person’s health and welfare at risk. | String / Free Text | Y | Emergency Backup Plan Text Slide | CO: Contingency Plan CT: Please describe your Emergency Backup Plan MD: Current Back-Up MN: Plan for unforeseen events, Plan for emergency health events, Plan for unavailable staffing that puts you at risk |
8/4/2016 | Goals & Strengths | Assessed Needs | The clinical or nonclinical support necessary for each service as identified through an assessment. | String / Free Text | Y | 7/28 the community decided to put this in the parking lot. On 8/4 it was revisited. Since most states did capture this information it was decided that this should be core. Assessed Needs Slides | CO: Things that NEED TO CHANGE KY: Is this service a result of a Service Needs Assessment outcome? MN: What are your strengths and needs? FEI: Clinical Needs and Support Needs that are Important For |
7/28/2016 | Beneficiary Demographics | Person Phone Number | The primary phone number of the person for whom the plan is for. | Number / 111-111-1111 | N | Person Phone Number Slide | CO: Phone KY: Phone Number MD: Primary Phone # MN: Phone Number FEI: Primary Phone # |
7/28/2016 | Goals & Strengths | Strengths | A favorable attribute of oneself, his/her support network, or environment as depicted by the person. | String / Free Text | Y | Strengths Slide | MD: Strength Detail MN: What are your strengths and needs?, Supports and strengths used to meet this need FEI: Strength Detail |
7/21/2016 | Goals & Strengths | Step or Action | A planned measurable step or action that needs to be taken to accomplish the goal identified by the person. | String / Free Text | Y | Step or Action Slide | CT: Strategies GA: Interventions, Outcome Notes KY: Objective MD: Steps/Actions MN: Support Needed FEI: Steps/Actions |
7/21/2016 7/14/2016 7/7/2016 | Goals & Strengths | Goal | A statement of a desired result that the person wants to achieve. | String / Free Text | Y | Definition was modified from the 7/7 description of: A defined outcome that a person wants to achieve. This new proposal was discussed and approved on the 7/21 call. Goal Slides Revised Definition of Goal Slide | CT: Goal CO: Personal Goal, Service Goal GA: Desired Outcome KY: Goal MD: Desired Goals MN: Goal FEI: Desired Goals, Service Goals Desired Outcomes |
7/7/2016 | Beneficiary Demographics | Person Identifier | One or more character(s) used to identify the person for whom the plan is for. This may be the Medicaid ID number when applicable. | String / Free Text | N | Person Identifier Slide | CO: SSN CT: Medicaid # GA: Client Social Security Number, Client Medicaid # KY: Social Security Number, MAID# MN: MA# FEI: Medicaid # |
7/7/2016 | Beneficiary Demographics | Person Identifier Type | The type of unique identifier used to identify the person for whom the plan is for. May include State ID, Medicaid Number, Social Security number. | String / Free Text | N | This element is slated to be used in conjunction with Person Identifier. Person Identifier Type Slide | CO: SSN CT: Medicaid # GA: Client Social Security Number, Client Medicaid # KY: Social Security Number, MAID# MN: MA# FEI: Medicaid # |
7/7/2016 | Beneficiary Demographics | Person Address | The address of the person for whom the plan is for. | String / Street Address, City, State, Zip Code, County | N | Person Address Slide | CO: Street Address, City, State, Zip Code, County KY: Address Line 1, Address Line 2, City, State, Zip Code, Zip +4, KY County/ Out of State MD: Current Address, Street Number, Apt number, City, State, Zip MN: Address, City, State, Zip Code, COR FEI: Address, County, Street Number, Apt number, City, State, Zip |
6/23/2016 | Beneficiary Demographics | Date of Birth | The birth date of the person for whom the plan is for. | Date / MM/DD/YYYY | N | Person Date of Birth Slide | CO: DOB KY: Date of Birth MD: DOB MN: Date of Birth |
6/23/2016 | Beneficiary Demographics | Person Name | The name of the person for whom the plan is for. | String / First Name, MI, Last Name | N | NOTE: Person Name is a Common Clinical Dataset element. Person Name Slide | CO: First Name MI Last Name CT: Name GA: Client Name KY: First Name MI Last Name MD: Client Name MN: First Name MI Last Name FEI: Person's Name |
6/23/2016 | Service Information | Service Comment | Additional information related to the service being provided. | String / Free Text | N | This is notated as an optional element since it is not expected or required for a comment to be entered for each service. This field could capture additional information of the frequency of the service, how the client wants the service delivered and only used when the comment provides additional detail of the service not already handled by another element. Service Comment Slide | GA: Service Notes KY: Non-Waiver Service Comments MN: Comments; Support Instructions FEI: Comments |
6/16/2016 | Service Information | Service Funding Source | The source of payment for the service. | String / Free Text | Y | Service Funding Source Slide | CO: Funding Source KY: Source of Payment MN: Payer |
6/16/2016 | Service Information | Total Plan Cost of Service | The total cost of a service for the plan. | Number / $ | N | Service Cost Slide | CT: Section Total Cost KY: Service Subtotal MD: Annual Cost MN: Plan Total FEI: Annual |
6/16/2016 | Service Information | Service Rate per Unit | The rate of one unit for a service. | Number / $ | N | Service Rate Slide | CT: Medicaid Unit Cost of Service per Hour or Unit, Rate KY: Rate per Unit, PDS Rate per Units MD: Rate MN: Rate/Unit FEI: Rate |
6/16/2016 | Service Information | Service End Date | The end date of the service being provided. | Date / MM/DD/YYYY | N | Each service has a start and end date. These dates may or may not align with the start and end date of the service plan itself. Service Start and End Date Slide | CO: Service End Date GA: Service End Date KY: Service End Date, PDS Service Actual End Date MD: Frequency MN: Time Period FEI: Frequency |
6/16/2016 | Service Information | Service Start Date | The start date of the service being provided. | Date / MM/DD/YYYY | N | Each service has a start and end date. These dates may or may not align with the start and end date of the service plan itself. Service Start and End Date Slide | CO: Service Start Date GA: Service Begin Date KY: Service Start Date, PDS Service Actual Start Date MD: Frequency MN: Time Period FEI: Frequency |
6/16/2016 | Service Information | Service Total Units | The total number of units for each service for the duration of the plan. | Number / Numeric | N | This is the total number of units authorized per service. It is important for the beneficiary to know how much they started with, that way they can manage their services appropriately. Service Total Units Slide | CO: Total Units KY: PDS Total Units, Utilized Units |
6/16/2016 | Service Information | Service Unit Value | The numerical quantity of the service unit being provided for a frequency. | Number / Numeric (needs to accommodate fractions) | N | This element is slated to be used in conjunction with Service Frequency Type and Unit of Service Type elements to form a full description of how often a service is provided. For example, a service being provided 7 units per week, the Service Unit Value = "7". For a service being provided 8 hours a day, the Service Unit Value = "8". For a service being provided 1/4 hour per day, the Service Unit Value = "1/4". Service Unit Value Slide | Includes element values from all Grantees (CO, CT, GA, KY, MD, MN, FEI) |
6/16/2016 | Service Information | Unit of Service Type | A named quantity in terms of which services are measured or specified, used as a standard measurement of like services. Values include: unit(s), minute(s), hour(s), day(s), week(s), month(s), meal(s), mile(s), visit(s)/session(s), installation(s), none, other (free text). | String / List of Values | N | This element is slated to be used in conjunction with Service Frequency Type and Service Unit Frequency Value elements to form a full description of how often a service is provided. For example, a service being provided 7 units per week, the Unit of Service Type = "units". For a service being provided 8 hours a day, the Unit of Service Type = "hours". Unit of Service Type Slide | Includes element values from all Grantees (CO, CT, GA, KY, MD, MN, FEI) |
6/16/2016 | Service Information | Service Frequency Type | How often a service is provided. Values include: Day, Week, Month, Annual, One Time Only, Other (free text). | String / List of Values | N | This element is slated to be used in conjunction with Unit of Service Type and Service Unit Frequency Value elements to form a full description of how often a service is provided. For example, a service being provided 7 units per week, the Service Frequency Type = "week". For a service being provided 8 hours a day, the Service Frequency Type = "day". Service Frequency Type Slide | CO: Frequency KY: Service Frequency, Total Prior Authorized Frequency, Total NOT Approved Frequency, PDS Service Frequency, Non-Waiver Frequency MD: Frequency Type MN: Frequency |
6/16/2016 | Service Provider Name and Other Identifiers | Support Planner Phone Number | The phone number of the support planner. | Number / 111-111-1111 | Y | This element could accompany the Support Planner Signature elements set (signature, printed name, date) that is already included as a core element. The "name" elements below map to the Support Planner Signature Printed Name element already included as a core element. Support Planner Phone Number Slide | CO: Case Manager Name, Case Manager Phone GA: Care Coordinator Name, Care Coordinator Phone Number KY: Case Manager First name, MI, Last Name MN: Case Manager/Care Coordinator Name, Case Manager/Care Coordinator Phone Number FEI: Case Manager Name, Case Manager Phone |
6/9/2016 | Service Provider Name and Other Identifiers | Service Provider Phone Number | The phone number of the service provider. | Number / 111-111-1111 | N | It was agreed that the beneficiary or support planner needs to decide when they want a phone number displayed for a service provider. It may only be needed or beneficial to have for certain service providers. Service Provider Phone Numbers Slide | GA: Provider Site Phone KY: PDS Provider Primary Phone Number, Non-Waiver Provider Primary Phone Number, CDO Representative Information |
6/9/2016 6/2/2016 | Service Provider Name and Other Identifiers | Service Provider Name | The name of the organization/agency or individual plus the relationship of the person providing the service. | String / Organization/Agency Name OR Individual Provider First Name Last Name + Relationship | N | For paid services use organization/agency name, for unpaid services use the individual’s first name, last name and relationship to the person receiving the service. Service Provider Name Slides Service Provider Contact Information Slides | CO: Provider (CO) CT: PCA Name, Name of the Support and Planning Coach KY: PDS Employee Name, Provider Name, PDS Provider Name, Non-Waiver Provider Name MD: Provider Name MN: Provider FEI: Provider Name |
6/2/2016 | Name of Service Provided | Service Name | Identifies the services provided to an individual. | Text / display name, code, modifier | Y | Name of Service Provided Slide | CO: Service CT: Available Service GA: Waiver Services, Service Type KY: Service Name MD: POS Service MN: Service FEI: Service |
5/26/2016 | Service Provider Preferences | Person Service Provider Choice Indicator | States whether or not the person was offered a choice of providers and made an informed choice in selecting the provider for each service. | Boolean / Yes, No | N | Person Service Provider Choice Indicator Slide | CO: Client has been offered or given a resource list of qualified providers, Client has been informed of the availability and right to select among qualified providers, Client has been informed of his/her right to change providers at any time, Client has been informed that providers have the right to accept or deny the request for services, Client has been informed of any potential conflict of interest KY: I certify that I have made an informed choice when selecting the providers/employees to provide each service, The Individual understands that under the waiver programs, they may request services from any Medicaid provider qualified to provide the service and that a listing of currently enrolled Medicaid providers may be obtained from Medicaid Services MN: I was offered a choice of providers for services I am receiving. (Yes/No), I agree with the services, supports, and providers in my plan. (Yes/No) FEI: As the person this Plan of Services and Supports is being developed for, I agree that by signing this I was presented with all of my service options under this program. I also acknowledge that for the services selected, I was provided with all of the available providers of those services and authorize that I have selected the providers listed in this Plan of Services and Supports. |
5/26/2016 | Service Preferences | Person Service Agreement Indicator | States whether or not the person was given a choice of services and participated in the selection of and agrees to the services outlined in the plan. | Boolean / Yes, No | N | Person Service Agreement Indicator | CO: I have participated in the development of this plan and I agree with the services outlined., Client/Guardian indicates that he/she is in agreement with the information in the Service Plan and agrees to receive services accordingly., Client has been informed of his/her choice of available long term care programs and services CT: If you are not interested in services in this section initial here: KY: This is to certify that Individual/Legal Representative have been informed of waiver services. Consideration for waiver program as an alternative to institutional placement is requested. MN: I was given choices of different types of services that could meet my assessed needs. (Yes/No), I agree with the services, supports, and providers in my plan. (Yes/No) FEI: As the person this Plan of Services and Supports is being developed for, I agree that by signing this I was presented with all of my service options under this program. I also acknowledge that for the services selected, I was provided with all of the available providers of those services and authorize that I have selected the providers listed in this Plan of Services and Supports. |
5/19/2016 5/12/2016 | Financial Information: Funding / Source of Payment | Plan Funding Source | The source(s) of payment for the plan. | String / Text | Y | Continued discussion from 5/12. The community agreed that this should be a core element. It was decided that the list of values will vary by state and implementation. The funding source at the specific service level (e.g., Funding Source (CO)) will be addressed when we discuss service-specific elements in a few weeks. Funding-Source of Payment Slide | KY: Source of Payment MN: Funding the Plan |
5/19/2016 | Plan Signatures | Support Planner Signature Date | The date the support planner signed the plan. | Date / MM/DD/YYYY | N | Every signature type on the plan will be accompanied by a date. Support Planner Signature Date Slide | CO: Signature of Case Manager Date CT: Universal Case Manager approval date KY: Case Manager E-Signature Date MD: Signature Date MN: Signature of Person Who Developed This Plan Date FEI: Signature Date |
5/19/2016 | Plan Signatures | Guardian / Legal Representative Signature Date | The date the guardian/legal representative signed the plan. | Date / MM/DD/YYYY | N | Every signature type on the plan will be accompanied by a date. Guardian - Legal Representative Signature Date Slide | CO: Signature of Legal Guardian Date MN: Signature of Person or Guardian / Legal Representative Date |
5/19/2016 | Plan Signatures | Person Signature Date | The date the person signed the plan. | Date / MM/DD/YYYY | N | Every signature type on the plan will be accompanied by a date. Person Signature Date Slide | CO: Signature of Client Date CT: Participant signature date KY: Individual E-Signature Date MD: Signature Date MN: Signature of Person or Guardian / Legal Representative Date FEI: Signature Date |
5/12/2016 | Financial Information | Total Plan Budget | The total allotment of funds for a plan. | Number / $ | N | Grantees agreed that Total Plan Budget should be a core element. Each implementation will arrive at that total budget amount from calculating "miscellaneous budget elements". Total Plan Budget Slide | CT: Total Budget Allocation, For individuals that used a paid Support and Planning Coach to assist with care planning, enter the authorized total KY: Total Prior Authorized Amount |
5/12/2016 | Financial Information | Total Plan Cost | The total cost of all services and supports for a plan. | Number / $ | N | Total Plan Cost Slide | CT: Sections 1-4 Total (plus totals from non-CFC services) KY: Total Prior Authorized Amount MD: Total POS Cost MN: Total Plan Cost FEI: Total PSS Cost |
5/12/2016 5/5/2016 | Plan Signatures | Person Printed Name | The printed or typed name of the person | String / Free Text | N | Printed Name Slides | MD: Signature Printed Name FEI: Signature Name |
5/12/2016 5/5/2016 | Plan Signatures | Guardian / Legal Representative Printed Name | The printed or typed name of the guardian/legal representative. | String / Free Text | Y | Printed Name Slides | MD: Signature Printed Name FEI: Signature Name |
5/12/2016 5/5/2016 | Plan Signatures | Support Planner Printed Name | The printed or typed name of the support planner. | String / Free Text | N | Printed Name Slides | MD: Signature Printed Name FEI: Signature Name |
5/5/2016 | Plan Signatures | Person Signature | The handwritten depiction of the person's name as proof of identity and intent for the plan. | String / Signature | N | Conforms to person-centered planning guidance regulations. Outstanding Question: What does Georgia capture? Plan Signatures Slide | CO: Client Signature CT: Participant Signature KY: Individual's Signature MD: Client Signature MN: Signature of Person or Guardian/Legal Representative FEI: Person Signature |
5/5/2016 | Plan Signatures | Guardian / Legal Representative Signature | The handwritten depiction of the guardian or legal representative's name as proof of identity and intent for the plan. | String / Signature | Y | Plan Signatures Slide | CO: Legal Guardian MN: Signature of Person or Guardian/Legal Representative, Other Signature |
5/5/2016 | Plan Signatures | Support Planner Signature | The handwritten depiction of the support planner's name as proof of identity and intent for the plan. | String / Signature | N | Plan Signatures Slide | CO: Case Manager Signature CT: Universal Case Manager Signature GA: Care Coordinator Signature KY: Case Manager Signature MD: Support Planner Signature MN: Signature of Person Who Developed This Plan FEI: Case Manager Signature |
4/28/2016 | Program Type | Program Name | The state-administered Medicaid funding source in which the person is enrolled. | String / Free Text | Y | Core element for the eLTSS Plan, but each implementation will have a different list of values specific to their state/pilot. Program Name Slides | CO: HCBS Waiver Program / Program GA: Recommendation KY: Program MD: Program Type MN: Program FEI: Person is Enrolled In |
4/21/2016 | eLTSS Plan Period / Plan Effective Dates | Plan Effective Date | The date upon which the plan comes into effect. | Interval of Dates / MM/DD/YYYY -MM/DD/YYYY | N | Start date is required, end date is optional. Plan Effective Date Slide | CT: Care Plan Effective Date GA: Care Plan Period KY: Proposed Start Date, Level of Care End Date MD: POS Effective Date MN: Time Period Covered by the CSSP Start Date, Time Period Covered by the CSSP Start Date FEI: Effective Date |