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South Country Health Alliance | Nursing Home: Comprehensive Health Assessment

Nursing Home: Comprehensive Health Assessment

Comprehensive Health Assessment

Review the member’s MDS assessment within the first 30 days of enrollment and annually thereafter. Document the member’s main health concerns on the Nursing Facility Health Risk Assessment and Care Plan in CCM.

INSTRUCTIONS – Nursing Facility Health Risk Assessment and Care Plan in CCM

If a SCHA member is moving into a nursing home, determine if the stay is going to be short-term (fewer than 90 days) or long-term (more than than 90 days).

  • If the member will be having a short-term stay and will be transitioning out of the nursing home, refer the member for Relocation Service Coordination/Care Transition services. Follow up to assure that services are provided.
  • If the member is going to stay long-term in the nursing home, the MDS must be reviewed within the first 60 days of admission or upon the member’s reassessment date, whichever is determined to be sooner.