The person receiving services and their support team work together to balance what is important to and what is important for their physical health needs and wants. 
The development of the Support Plan reflects what services and supports are offered by extracting physical and mental health information from their existing support plans (i.e., Coordinated Service and Support Plan, Individual Service Plan, and Person Centered Plan, if available) and what services and supports are offered, as well as how, when, and by whom the services will be provided. 


1.    Access to Health Services

a.    The manager assists with or coordinates health service appointments using a tracking system which is maintained at the site
b.    The manager is responsible for the supervision of or assists the person in scheduling, attending, and documenting health related appointments as designated in the support plan.
c.    The manager is responsible for training the employees on the appropriate referral form needed for the health care provider and that all orders are implemented.
d.    Each person has the choice of which health care providers they desire to use.
e.    Each person will participate in the planning of their health care whenever possible.

2.    Health care appointments

a.    To maintain an optimal general level of health for each individual person’s physical and/or mental health diagnosis
b.    To maximize functioning, prevent disability; and promote optimal development of each person
c.    Managers will work to maintain a health care appointment tracking system.  For each person.  The tracking will include:

i.    A list of specific health care providers
ii.    Referral forms
iii.    Medication History Log 
iv.    Appointment Summary
v.    A calendar system 
vi.    display recommended frequency of appointments
vii.    the date of the last appointment
viii.    the date of any future scheduled and/or needed follow up appointments
d.    A physical examination should occur annually to:
i.    Obtain preventative health care screenings
ii.    Review medication and treatment orders
iii.    Review the use of standing order/over the counter medications
iv.    Evaluation progress and outcomes of treatment goals
v.    Determine further treatment planning

e.    A dental examination is recommended at a minimum every 6 months (or according to the person’s insurance carrier) to provide for:

i.    Examination and diagnosis
ii.    Restoration
iii.    Cleaning
iv.    Preventative screenings as prescribed
v.    X-rays 
vi.    Maintenance of dental health

f.    All other necessary appointments will occur as needed

i.    Vision
ii.    Hearing
iii.    Podiatry
iv.    Neurology
v.    Psychiatry
vi.    Other

3.    Monitoring Health

a.    When employee believes a medical emergency may be life threatening, they will call 911, or they will call the mental health crisis intervention team when the person is experiencing a mental health crisis
b.    The person’s health conditions are monitored according to written instructions from a health care provider and are documented on the Health Needs Record form.

i.    The Health Needs Record is completed at intake, 45 day meeting, annually, and as needed if there is a change in the person’s health condition

c.    Employee documents any changes in the person’s health in the Health Care Progress Notes (HPNs) and report changes to the manager before leaving their shift
d.    The manager notifies the health care provider of the changes within 24 hours or sooner depending on the severity of the changes.
e.    The manager notifies the person, person’s legal representative, if any, and case manager within 24 hours of changes in the person’s physical and mental health if they affect the health service needs assigned in the coordinated service and support plan (Support Plan) or the support plan.
i.    The notification is documented on a Health Needs Change Notice form
f.    Consistent coordination and communication to all involved in the care of the person
g.    Mains’l Services will provide a team approach for Health Care Quality Assurance to identify improvement needs in health care documentation, health care training and related processes.
h.    A Mains’l Services Therapist/Behavioral Specialist and/or a Nurse will be involved with providing recommendations in physical or mental health care when the likelihood of a change in condition requires a skilled assessment to identify a need for possible modification, treatment or initiation of additional medical services

i.    Acute and chronic conditions
ii.    Diabetes and insulin injection process
iii.    Other injection needs
iv.    Feeding tubes
v.    Oxygen and breathing assessments
vi.    Other skilled needs as identified

4.    Medical Equipment

a.    Orders for the medical equipment are filed in the person’s medical file
b.    An employee is trained on the safe and correct operation of medical equipment used by the person to sustain life or to monitor a medical condition that could become life-threatening without proper use of the medical equipment; including but not limited to ventilators, feeding tubes, or endotracheal tubes.

i.    The training is provided by a licensed health care professional or a manufacturer’s representative, who does an observed skill assessment as part of the training to ensure that the employee person demonstrated the ability to safely and correctly operate the equipment according to the treatment orders and the manufacturer’s instructions.
ii.    Training is documented on the “Training in Use of Medical Equipment Used to Sustain Life” form and filed at the site

5.    Mobility and Transfers Equipment

a.    Employee is trained on the safe and correct operation of equipment used for mobility and transfers such as mechanical lifts, van lifts, power wheelchairs, chair elevator lifts, standard wheelchairs and transfer equipment for showering/bathing.

i.    The training is provided by the manager, support coordinator or designated employee who does an observed skill assessment, as part of the training to ensure employee demonstrate the ability to safely and correctly transfer a person using the equipment
ii.    Training is documented, by the manager, support coordinator or designated employee on the “Training in Use of Equipment for Mobility and Transfer” form and filed in the medical book.

b.    A written procedure for each piece of equipment is available for employee to reference