In-Home Supportive Services (IHSS) Program

Accompaniment to Medical Appointments

Welfare and Institutions Code section 12300(b) specifies that, “Supportive services shall include… accompaniment by a provider when needed during necessary travel to health-related appointments or to alternative resource sites...”

Manual of Policy and Procedures section 30-757.15 states, “Assistance by the provider is available for transportation when the recipient's presence is required at the destination and such assistance is necessary to accomplish the travel, limited to:

.151 Transportation to and from appointments with physicians,dentists and other health practitioners.

.152 Transportation necessary for fitting health relatedappliances/devices and special clothing.

.153 Transportation under .151 and .152 above shall beauthorized only after social service staff has determined thatMedi-Cal will not provide transportation in the specific case.

.154 Transportation to the site where alternative resourcesprovide in-home supportive services to the recipient in lieu ofIHSS.”

Accompaniment to Medical Appointments is not intended for the purpose of transportation; rather, it may be authorized only when the recipient needs assistance with specific IHSS tasks during transportation to/from or at the destination.

Time authorized for accompaniment does not include time to perform the specific IHSS tasks the recipient needs assistance with during

In-Home Supportive Services (IHSS) Program

Accompaniment to Medical Appointments

transportation. Time for those tasks would be authorized in the specific service category in which assistance is needed.

For example, a recipient needs his/her provider’s assistance toget from the car to the dentist’s office: The time traveling to andfrom the dental appointment would be authorized under theAccompaniment category; the time required to assist therecipient to/from the car to the dentist’s office would beauthorized under the Ambulation category.

FLSA regulations (29 Code of Federal Regulations 785.15 & 785.16) define two different types of wait time:

“engaged to wait,” and “waiting to be engaged”

“engaged to wait” means unpredictable periods of time, usually of short duration, during which the employee is unable to use the time effectively for his own purposes. Waiting is an integral part of the job; the wait time belongs to and is controlled by the employer. A period of time that is not sufficient to allow the individual to effectively use the time on his/her own may also be considered time “engaged to wait.” Employees must be compensated for time when they are considered “engaged to wait.”

Examples of the definition “engaged to wait” are: When a provider accompanies his/her recipient to a medical

appointment of unknown duration and the provider is requiredto remain at the doctor’s office because at any moment he/shemay be called upon to assist the recipient with returninghome.

Other wait periods of short duration, such as standing in lineat a grocery store or pharmacy, or waiting for clothes to finish

In-Home Supportive Services (IHSS) Program

Accompaniment to Medical Appointments

wash/dry cycles at a coin-operated laundry facility (Laundromat). This time would be included in the time authorized under the appropriate service category, i.e., Food Shopping, Shopping/Other Errands, and Laundry.

“waiting to be engaged” means periods during which the employee is completely relieved from duty and which are long enough to enable him to use the time effectively for his own purposes. These waiting periods are not considered hours worked. The employee must be informed in advance that he/she may leave the job and that he/she will not have to return to work until a specified time. Under such circumstances, the provider would not be

considered “engaged in wait” and would not be compensated for the time unless he/she was using the time to complete other authorized services for the recipient, e.g., Shopping/Errands.

An example of the definition “waiting to be engaged” is: A provider accompanies his/her recipient to a physical therapy

appointment that is scheduled to last for a specified period oftime. The provider is not required to remain on the premises butmust return at a designated time to retrieve the recipient.Additionally, the amount of time of the appointment is sufficientfor the provider to effectively engage in personal activities, eitheron the premises or not, such as reading a book, etc.

OVERTIME ASSISTANCE UNIT REFERRAL

Date:

IHSS Social Worker: Telephone Number:

IHSS Social Work Supervisor:

Case Name: CMIPS II Case Number:

PLEASE ASSIST WITH THE FOLLOWING REQUEST(S)

Accompaniment to medical appointments must not be authorized simply to fill the recipient’s need for transportation. Medical Accompaniment must only be authorized when the recipient needs assistance with specific IHSS tasks during transportation, and at the destination. The referral form must be submitted by FAX to (858) 505-6683 or through County Mail to mail stop O-434.

NON-EMERGENCY MEDICAL TRANSPORTATION SERVICES: Verify that non-emergency medical transportation services are not received through the Medi-Cal program.

• DHCS 6247 – Authorization for Release of Protected Health Information

Attached IHSS WebTop Not on File

Indicate Reason Verification is Required:

MEDICAL ACCOMPANIMENT AND WAIT TIME: Medical Accompaniment and wait time can be verified at the discretion of the IHSS Social Worker or IHSS Social Work Supervisor. Verification is not required in order to authorize the service, unless the wait time exceeds one hour per visit.

Verify Medical Accompaniment and Wait Time Calculate Medical Appointment and Wait Time

• 12-21C – Medication and Physician Information Attached IHSS WebTop Not on File

EXTRAORDINARY CIRCUMSTANCE EXEMPTION (EXEMPTION 2) Process request for exemption. The form APD 005 – Exemption from Workweek Limits for Extraordinary

Circumstances Referral Justification must be included with referral. OTHER: COMMENTS:

12-36B HHSA (06/16) DO NOT SCAN THIS FORM

OVERTIME ASSISTANCE UNIT REFERRAL

OVERTIME ASSISTANCE UNIT RESPONSE

Status: Request Completed Unable to Process Request Other: _______________________________

Name of OA Social Worker: Date:

Comments:

Forms Scanned to WebTop: SOC 2274 – Accompaniment to Medical Appointment Form 12-21C – IHSS Medication and Physician Information APD 005 – Exemption from Workweek Limits for Extraordinary Circumstances Referral Justification Other: ________________________________________________________________________

________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

12-36B HHSA (06/16) DO NOT SCAN THIS FORM

STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES PRIVACY OFFICE

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

I, , hereby authorize to (Name of patient) (Name of person or facility which has information)

release the following health information:

To:

(Name and title or facility name to receive health information)

(Street address, city, state, ZIP code) (Telephone number) (Fax number)

For the following purposes:

This authorization is in effect until (date or event), when it expires.

I understand that by signing this authorization: • I authorize the use or disclosure of my individually identifiable health information as

described above for the purpose listed.• I have the right to withdraw permission for the release of my information. If I sign this

authorization to use or disclose information, I can revoke that authorization at any time.The revocation must be made in writing and will not affect information that has alreadybeen used or disclosed.

• I have the right to receive a copy of this authorization.• I am signing this authorization voluntarily and treatment, payment, or my eligibility for

benefits will not be affected if I do not sign this authorization.• I further understand that a person to whom records and information are disclosed pursuant

to this authorization may not further use or disclose the medical information unless anotherauthorization is obtained from me or unless such disclosure is specifically required orpermitted by law.

Signed by Patient: Date

Or Signed by Personal Representative: _____________________________________________________ On Behalf of _____________________________________________________

Name of Patient

Date

IDENTIFYING INFORMATION

COPY OF IDENTIFICATION ATTACHED

TYPE (CA DRIVER’S LICENSE, CA DMV

IDENTIFICATION CARD, BIRTH CERTIFICATE, BENEFITS IDENTIFICATION CARD, MANAGED CARE CARD, STATE OR FEDERAL EMPLOYEE ID CARD)

NUMBER

IF NO IDENTIFICATION IS ATTACHED, YOUR SIGNATURE MUST BE NOTARIZED.

NOTARIZED BY

ON (DATE)

NOTARY PUBLIC NUMBER

NOT OFFICIAL UNLESS STAMPED BY NOTARY PUBLIC

PERSONAL REPRESENTATIVE INFORMATION

PATIENT?WHAT LEGAL AUTHORITY DO YOU HAVE TO MAKE MEDICAL DECISIONS FOR THE

CONSERVATOR PARENT

GUARDIAN EXECUTOR OF WILL

OTHER MEDICAL POWER OF ATTORNEY

NOTE: ATTACHING LEGAL DOCUMENTATION IS REQUIRED TO VERIFY THAT YOU ARE THE PARENT, CONSERVATOR, GUARDIAN, EXECUTOR OF A DECEDENT’S WILL, OR HAVE MEDICAL DECISION-MAKING AUTHORITY FOR THE INDIVIDUAL.

Case Name:

Social Worker:

TOTAL TIME TOTAL WAIT TIMEOFFICE ADDRESS ROUND TRIP PER APPOINTMENT TOTAL TIME

(HH:MM) (HH:MM) (HH:MM)Example: Dr. John Smith/ Cardiologist

5500 Overland Ave., Ste. 450San Diego, CA 92123 (000) 000-0000 (000) 000-0000 6 0:40 1:00 10:00

0:00

0:00

0:00

0:00

0:00

0:00

0:00

0:00

0:00

0:000:00

*Service Task:

*Frequency: Weekly 0:00

*Quantity: 1

*Required CMIPS II Fields

During your scheduled home visit, your Social Worker will need information related to your medications and doctors. Please provide the information requested below, or have it available for the Social Worker on the day of the home visit. Please make sure that you have all medication bottles available so the Social Worker can confirm the information provided.

CMIPS II Case Number:

Assessment Date:

*Duration (HH:MM):

Accompaniment to Medical Appointments and Wait TimeCMIPS II SERVICE EVIDENCE ENTRY

TOTAL NEED FOR ACCOMPANIMENT TO MEDICAL APPOINTMENTS:

PHYSICIAN'S NAME AND SPECIALTY

TELEPHONE NUMBER

FAX NUMBER

FREQUENCY PER YEAR

In-Home Supportive Services Disaster Preparedness Worksheet

Disaster preparedness codes must be evaluated at intake and reassessment, information in CMIPS II updated accordingly. Recipient: Date: Case Number: SW: Section I – Disaster Contact Check the appropriate factor(s) below in determining if an IHSS recipient will require contact by IHSS or emergency response personnel.

Socially isolated, no live-in provider, family member or responsible person lives nearby, AND:

Functional Index Score (FI) is 2.75 or higher and is Severely Impaired (SI) or bedfast. Relies heavily, or completely on IHSS for needs (close to maximum hours) Ranks 4 or higher in meal preparation, transfer, eating, bowel and bladder care. Is blind or significantly visually impaired Ranks 5 or 6 in respiration Is heavily medicated or a substance abuser Other

Use Code “A”, “”B, or “C” in “Degree of Contact” field.

Not socially isolated, has live-in provider, family member or responsible person(s) available. Use Code “Z” in “Degree of Contact” field.

Field in CMIPS II Code Degree of Contact Special Impairment Life Support Supply Need

Extreme Weather Transfer the identified codes to CMIPS II

In-Home Supportive Services Disaster Code Definitions

Section - II IHSS Disaster Preparedness Codes and Evaluation Guidelines The IHSS recipient’s support network and environment are the primary factors in determining his/her response need after a disaster. These include:

• The quality and availability of the recipient’s support system • The recipient’s access to adequate transportation • Whether or not the recipient lives in a geographically isolated area

Degree of Contact

Special Impairment

Life Support Supply

Need

Extreme Weather

A-Critical (within 24 hours) B-Urgent (within 48 hours) C-Moderate (within 72 hours) Z-None

A-Severely Disabled or Bedfast B-Relies on IHSS for needs C-Functional Rank 4 (substantial assistance) D-Functional Rank 5 (must have assistance) E-Heavy Medication F-Blind G-Deaf H-Lacks Transportation I-Lives in isolated area J- Receives Protective Supervision (non self-directing, mentally impaired/confused, need for 24-hour care) Z-No Special Impairments

A-Respirator B-Oxygen C-Insulin D-Life Support Medications E-Dialysis F-Paramedical Services Z-None

A-Extreme Cold B-Extreme Heat C-Extreme Heat and Cold Z-No contact required

General Functional Ranking The following are general regulatory standards that apply to all functions. Rank 1: Independent: Able to perform function without human assistance although the recipient may have difficulty in performing the function, but the completion of the function, with or without a device or mobility aid, poses no substantial risk to their safety. Rank 2: Able to perform a function, but needs verbal assistance such as reminding, guidance, or encouragement. Rank 3: Can perform the function with some human assistance, including, but not limited to, direct physical assistance from a provider. Rank 4: Can perform a function but only with substantial human assistance. Rank 5: Cannot perform the function with or without human assistance. Rank 6: Paramedical Services needed. Functional Index System generated number between 1 and 5 which indicates the relative need of a recipient for IHSS. Individual scores from Functional Limitations are weighted to provide the functional index ranking for each recipient (the higher the ranking, the greater the need).