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Referring Procedures forPeople with Disabilities (PWDs) to

Integrated Home Care Services (IHCS) (Frail Cases)

Ms Lorensa Mak

Senior Social Work Officer (Elderly)

Social Welfare Department

21 and 22 July 2004

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(A) Initial Screening

(B) Referring Procedures

The procedures are to take effect on

16 August 2004

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(A) Initial Screening

• Before referring the PWDs for Minimum Data Set-Home Care (MDS-HC) assessment for admission to IHCS (frail cases), the responsible workers (RWs) of FSC/IFSC, MSSU or social workers (SWs) of rehabilitation service units / special schools should note the following criteria :

3 Criteria

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(A) Initial Screening (Cont’d)

• Confirm the PWDs are those suffering from severe level of physical disabilities, e.g. they are already waitlisted for or having the disability and care need levels equivalent to the eligibility criteria for the following residential services but are still living in the community:

− Hostel for Severely Physically Handicapped Persons (HSPH) 嚴重肢體傷殘人士宿舍 ; or

− Care and attention Home for Severely Disabled Persons (C&A/SD)嚴重殘疾人士護理院

(a) Eligible applicants

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• Explore whether the PWDs are in need of a service package provided by IHCS (frail cases), i.e. nursing care, personal care, rehabilitation services and home-making services, etc.

• The RWs or SWs should advise the PWDs or their carers to consider IHCS (ordinary cases) as an alternative service option if they are not in need of a service package provided by IHCS (frail cases)

(A) Initial Screening (Cont’d)(b) In need of comprehensive

service package

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• Confirm that the PWDs are not receiving or are ready to be discharged from any of the regular day services such as:

– sheltered workshop (SW);– day activity centre (DAC) or DAC service provide

d by home-based training and support (HBTS) teams;

– specialized HBTS service;– supported employment (SE);– day care services at C&A Home for Severely Dis

abled Persons; or– special schools, etc.

(A) Initial Screening (Cont’d)(c) Not regular day rehabilitation

services users

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• If the PWDs applying for IHCS (frail cases) are simultaneously being waitlisted for regular day rehabilitation services, they should withdraw their applications for IHCS (frail cases) once they are admitted to these services.

(A) Initial Screening (Cont’d)

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• The RWs or SWs concerned should explain to the applicants that their eligibility for IHCS (frail cases) is to be confirmed by the standardized care need assessment through the tool of Minimum Data Set- Home Care (MDS-HC).

(A) Initial Screening (Cont’d)

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(B) Referring Procedures

• After confirming the initial eligibility of PWDs, the RWs or SWs concerned may make referrals for assessment of eligibility to register in the Central Waiting List (CWL) by:

–completing LDS Form 1D ‘Arrangement of Standardized Care Need Assessment and Application for Integrated Home Care Services (Frail Cases) for PWD’ and

–forward to the Standardized Care Need Assessment Management Offices (Elderly Service) [SCNAMO(ES)] concerned.

(1) Application

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• To facilitate applications, the applicants should attach supporting documents, e.g. documentary proof of HDA, medical report/ discharge summary, psychological assessment report, occupational therapist report, physiotherapist report or special school report, etc., as appropriate.

• People with mental illness to be certified as mentally stable and free from aggressive / violent act in the past two months by medical practitioners.

(B) Referring Procedures (cont’d)

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• Upon receiving LDS Form 1D, the SCNAMO(ES) concerned will arrange its own accredited assessors to conduct and complete the assessment within 3 weeks.

(B) Referring Procedures (cont’d)

(2) Standardized Care Need Assessment

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• Upon confirmation of the applicants’ impairment at severe level according to the MDS-HC assessment, the SCNAMO(ES)s will:

– put the applicants on the waiting list of IHCS (frail cases) according to the assessment completion date;

– return the assessment result with the completed LDS Form 4D “Notification of Assessment Result for PWD” to RWs or SWs concerned for follow-up actions as appropriate, such as:

• explaining the assessment results to the applicants; and/or

• Referring the applicants to the accredited assessors concerned for further explanation of the assessment results, if required.

(B) Referring Procedures (cont’d)(3) Waitlisting for IHCS (frail cases)

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• For those applicants who are assessed to be at moderate level of impairment or below, the RWs or SWs concerned should continue to follow up the welfare plan of the applicant e.g. referring to IHCS (ordinary cases) or rehabilitation services as appropriate.

(B) Referring Procedures (cont’d)

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• For cases already waitlisted for IHCS (frail cases) under CWL, the RWs or SWs concerned should update the applicants’ data by forwarding LDS Form 7D “Up-dating Data on PWD Applicant and Reply to Offer of IHCS (Frail Cases)” to SCNAMO(ES)s concerned should there be a change of information of applicants, e.g.

– the residential addresses of the applicants

– withdraw the application due to admission to other services, deceased or hospitalization, etc.

(B) Referring Procedures (cont’d)

(4) Data up-dating

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• When there are expected vacancies in IHCS (frail cases), SCNAMO(ES)s concerned will issue LDS Form 11D “Offer of IHCS Placement to PWD” to RWs or SWs concerned.

• The allocation of placement is based on the assessment completion date of MDS-HC of the applicants for IHCS (frail cases).

• Unless there is a change in the condition or the impairment level of the applicants, re-assessment for PWDs is normally not required even if the MDS-HC assessment results exceed the validity period of 12 months.

(B) Referring Procedures (cont’d)

(5) Offer of placement

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• RWs or SWs concerned are required to confirm applicants’ acceptance of the offer of placement or otherwise within 3 weeks from the date of offer of placement by submitting LDS Form 7D to SCNAMO(ES)s concerned.

• If LDS Form 7D is submitted to decline the offer, SCNAMO(ES) concerned will issue LDS Form 9D “Confirmation of Closing of Application for PWD” to the RWs or SWs concerned for confirmation.

(B) Referring Procedures (cont’d)

(6) Confirmation of acceptance

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• RWs or SWs should inform the applicants that once they are admitted to the IHCS (frail cases), any day services they may be receiving including specialized HBTS or IHCS (ordinary cases) will be terminated.

• Nevertheless, while receiving IHCS (frail cases), the applicants can still receive HBTS (home-based training cases), day and residential respite services from rehabilitation service units as necessary.

(B) Referring Procedures (cont’d)

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• The applicants may continue waitlisting for other day rehabilitation services while receiving IHCS (frail cases).

• But, they should withdraw receiving the IHCS (frail cases) once the day rehabilitations service is available.

(B) Referring Procedures (cont’d)

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• For applicants who are already using IHCS (ordinary cases) and change to waitlist for IHCS (frail cases), their RWs or SWs should notify them that it may not be the same IHCS team that will provide frail case services to them.

(B) Referring Procedures (cont’d)

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• If the applicants accept the offer of placement and when vacancies are available, SCNAMO(ES)s concerned will forward LDS Form 15D “Referral for Admission to IHCS for PWD” together with the MDS-HC assessment results to the service providers of IHCS

• A copy of LDS Form 15D to the RWs or SWs concerned for reference.

(B) Referring Procedures (cont’d)

(7) Service admission

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• After receiving LDS Form 15D, the service providers of IHCS are required to admit the applicants and develop initial care plans with reference to MDS-HC assessment results and CAPs triggered as soon as possible.

• They should notify the applicants and RWs or SWs about the dates of admission direct and return LDS Form 17D “Result of IHCS (Frail Cases) Admission for PWD” to SCNAMO(ES)s concerned, with a copy of RWs or SWs concerned, upon admission of the applicants.

(B) Referring Procedures (cont’d)

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• To facilitate the development of care plan and service provision by IHCS operators to the PWDs, the RWs or SWs concerned should encourage the carers of PWDs to be present on-the-spot as far as possible.

(B) Referring Procedures (cont’d)

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(B) Referring Procedures (cont’d)

(8) Discharge• Service users will be discharged from IHCS (frail cases) under the following circumstances:

– self-withdrawal;

– away from service for more than 30 days (e.g. as a result of long-term hospitalization);

– availability of other support services;

– no longer in need of a comprehensive package service of IHCS (frail cases); or

– death, etc

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• If service users are discharged from IHCS (frail cases), service providers should inform SCNAMO(ES)s concerned by submitting LDS Form 24D “Notification of Discharge of PWD / Request for Referral” within 2 working days after discharge of the service users.

(B) Referring Procedures (cont’d)

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Direct Re-entry to IHCS (Frail Cases)

• For service users who are away from the service for 90 days or less due to justifiable reasons, e.g.:

– temporary availability of support network;

– service user is away from Hong Kong for a short trip, etc

direct re-entry on a priority basis can be arranged.

• In case there are two or more cases requesting re-entry arrangement to IHCS (frail cases), ‘first-come-first-served’ principle should apply.

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Direct Re-entry to IHCS (Frail Cases)

• The RWs or SWs should:

– check with SCNAMO(ES)s concerned the service users’ status in the CWL; and

– Submit LDS Form 23D “Notification of Re-entry of PWD” to SCNAMO(ES)s concerned if status in the CWL is confirmed

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Direct Re-entry to IHCS (Frail Cases) (Cont’d)

• SCNAMO(ES)s concerned will then:

(a) allocate placements by giving priority to the service users over other applicants on the waiting list; and

(b) when vacancies are available, issue LDS Form 16D “Referral for Re-admission to IHCS (Frail Cases) for PWD to the service providers of IHCS, with a copy to RWs or SWs concerned for re-admission of the applicants.

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Direct Re-entry to IHCS (Frail Cases) (Cont’d)

• For service users who are away from the service for more than 90 days, no direct re-entry will be considered.

• Service users should go through the normal application procedures as stated above if they are in need of the service.

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Mediation Mechanism• If the applicants, their authorized persons or the

service providers disagree with MDS-HC assessment results, they can raise their concerns with SCNAMO(ES)s concerned in writing.

• SCNAMO(ES)s concerned will take part in mediation including liaison with related parties, re-examination and/or explanation of the MDS-HC assessments to the applicants, etc.

• Application will be suspended once the mediation is initiated.

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Thank You