ASSESSMENT FOR DETERMINATION OF CARE FOR MEDICALLY

FRAGILE CHILDREN IN FOSTER CARE
Michigan Department of Human Services
Case Name	Log Number
Case Number	County	District	Section	Unit	Last Assessment/Level/Date
Date of Birth	Begin Date	End Date
Foster Home Name
Legal Status	Permanency Goal
This form is used when a child has a documented medical condition which threatens health, life or independent functioning. Documentation of the medical condition must be in the case file.
A foster care provider or supervising agency/DHS staff may initiate a request for review of a DOC at any time. The request must be done in writing. Action must be taken within 30 days of the receipt of the request.

If the foster care provider or the agency disagrees with the level of care determination, an administrative review process may be initiated within 30 calendar days of the decision. See FOM 903-3.

When a DOC supplement is due to a physical or mental disability screen the youth for SSI eligibility: see FOM 902-10 SSI Benefits Determination.
Section I -	If at least 2 of the following characteristics or care needs are checked in section 1A and/or 1B the youth qualifies for a Level I DOC.
If 3 or more Items in Section 1A and/or 1B are checked go to Section II.
1A.	PHYSICAL or MEDICAL IMPAIRMENTS
1.
Any physical or medical impairment or combination of impairments requiring an average of at least ½ to 1 hour of daily medically prescribed therapy or procedures performed by the foster parents (i.e. respiratory, bowel or skin treatments, shunt monitoring, burn care, orthopedic braces, percussion, suctioning, range of motion, medication, failure to thrive).
2.
Colostomy care.
3.
Ileostomy care.
4.
Daily injections (i.e. insulin, allergies).
5.
Feeding problems requiring an additional 30 minutes of preparation or feeding time (i.e. difficulty swallowing, cleft pallet, nasal difficulties, tongue thrust).
6.
Special diet (i.e. diabetic, asthmatic, allergy, mild Cystic Fibrosis, and/or need for special formulas, additives).
7.
Hearing problems requiring encouragement and monitoring (i.e. hearing-aid use).
8.
Vision problems requiring encouragement, visual exercises, patching.
9.
Sporadically active infectious diseases requiring sterile procedures when active, such as Herpes-type viruses.
10.
Out-of-home bi-weekly or weekly therapy or medical appointments (i.e. PT, OT, ST, etc.), or medical training involving the foster parents.
11.
In-home therapy (i.e. PT, OT, ST). Every two weeks nursing, or teacher appointments requiring foster parent involvement.
1B.	BEHAVIORAL or EMOTIONAL PROBLEMS
1.
Weekly counseling or therapy appointments requiring monthly foster parent participation and/or every two weeks schedule of foster parent programming (i.e. behavior charts, etc.) for problems such as depression, hyperactivity, encopresis, enuresis, eating disorders, night trauma.
2.
Special Education (EI, LD, TMI, EMI) requiring monthly school contact and/or up to ½ hour of daily foster parent programming.
3.
Regular Education requiring every two weeks to weekly school contact (i.e. meetings, teacher conferences to monitor attendance, behavior).
4.
Documented supervision or attention needed to prevent the child from causing minor injury to self, others, or property – including clothing, glasses.
5.
Documented increased attention needs which prevent or interfere with therapy or sleep (i.e. child wakes up 3-4 times a night, intolerance of tactile stimulation).
Foster Parent Activities for any item checked.
Section II – If any 1 characteristic or care need is checked in Section 2A the youth qualifies for Level II DOC.
If any two items are checked in Section 2B or 2C the youth qualifies for a level II DOC.
If only 1 item in section 2B or 2C is checked and none in section 2A the youth qualifies for a level I DOC.
If 3 or more Items are checked in Section II, go to Section III.
If 3 or more Items are checked in Section I and none in Section II the youth qualifies for a level I.
2A.	AT RISK PHYSICAL or MEDICAL IMPAIRMENTS
1.
Seizures uncontrolled by medication, requiring hospitalization 3-4 times per year.
2.
Heart monitor (i.e. for apnea and to prevent Sudden Infant Death Syndrome).
3.
Oxygen while sleeping (for Broncho Pulmonary Dysplasia).
4.
Tube feedings.
5.
Severe heart problems, such as ‘blue baby”.
6.
Respiratory problems (asthma or allergies) requiring major dietary and/or environmental restrictions. Examples include no pets, no carpeting or overstuffed furniture, no smoking, no perfume or heavy scents, daily vacuuming and dusting with wet cloth, the use of allergy-proof bedding or allergy-proof covers on pillows and bedding and the use of an air purifier and/or air conditioner.
7.
Chemotherapy.
8.
Body cast (Spica cast).
9.
Other activities, specify:
2B.	PHYSICAL or MEDICAL IMPAIRMENTS
1.
Any physical or medical impairment or combination of impairments requiring an average of at least 1 to 2 hours of daily medically prescribed therapy or procedures performed by the foster parents (i.e. respiratory, bowel or skin treatments, shunt monitoring, burn care, orthopedic braces, percussion, suctioning, range of motion, medications, failure to thrive, etc.).
2.
Legal blindness in both eyes or severe vision impairments requiring exercises, minor environmental modifications.
3.
Hearing impairment requiring foster parent to know sign language and encourage and monitor hearing-aid or auditory-training device use.
4.
Twice weekly out-of-home therapy or medical appointments (i.e. PT, OT, ST, etc.) requiring foster parent involvement.
5.
Twice weekly in-home therapy (i.e. PT, OT, ST, etc.), nursing or teacher appointments, requiring foster parent involvement.
6.
Child age two or over weighing 20 to 30 pounds with mobility impairments causing partial dependence, requiring assistance in transfer from wheelchair to bed, chairs.
2C.	BEHAVIORAL or EMOTIONAL PROBLEMS
1.
Weekly therapy or counseling appointments requiring bi-weekly to weekly foster parent participation and/or a daily schedule of foster parent programming for problems such as depression, hyperactivity, encopresis, enuresis, eating disorders, night traumas, etc.
2.
Special Education (EI, LD, TMI, EMI, SMI) requiring school contact every two weeks and/or up to one hour per day in-home foster parent programming.
3.
Documented supervision and attention needs in daily hygiene skills in excess of age-appropriate developmental levels (i.e. bathing, clothing, feeding) for children to monitor age five or over who are not in regular therapy.
Foster Parent Activities for any item checked.
Section III – If any one or two of the following characteristics and/or care needs are checked the youth qualifies for a level III DOC.

If three or more are checked, complete Section IV with additional documentation/justification for a level IV DOC (negotiated rate).
3A.	PHYSICAL or MEDICAL IMPAIRMENTS
1.
Any physical or medical impairment or combination of impairments requiring an average of 3 or more hours of daily prescribed therapy or procedures performed by the foster parents (i.e. for respiratory, bowel or skin treatments, shunt monitoring, burn care, orthopedic braces, percussion, suctioning, range of motion, medication, failure to thrive).
2.
Any life-threatening medical needs or conditions.
a.
Oxygen 24 hours per day (for BPD, etc.)
b.
Tracheotomy.
c.
Hemophilia.
d.
Respiratory problems (asthma or allergies) requiring a complete sterile environment. In addition to all the examples listed in Section II, the child is not able to be in public settings. Anyone interacting with the child must wash his/her hands and wear a gown and mask.
e.
Other, specify
3.
Seizures uncontrolled by medication, occurring daily or more often.
4.
Child age two or over weighing 31 pounds or more with mobility impairments causing partial dependence, requiring assistance in transfer from wheelchair to bed, chairs, etc.
5.
Child age two or over weighing 20 pounds or more who is totally dependent, without use of own limbs for mobility.
6.
Child age four or over without self-care skills (i.e. cannot dress, feed, or bathe self) requiring total care due to physical impairments.
7.
Child age four or over who is more than 50% behind age level in more than 3 areas of development due to physical impairments.
8.
Child age four or over without self-care skills (i.e. cannot dress, feed or bathe self) requiring total care due to mental retardation or emotional impairments.
9.
Child age four or over who is more than 50% behind age level in more than 3 areas of development due to mental retardation or emotional impairments.
10.
Child who is totally blind requiring mobility training and/or major environmental modifications.
11.
Child with major behavior problems that may or may not be due to physical impairment (i.e. self-stimulating, head banging, removes medical apparatus at least 3 times a week); refusal to comply with medical procedures (i.e. taking meds at prescribed times).
12.
Any active, chronic infectious disease requiring complete sterile procedures.
Foster Parent Activities for any item checked.
Section IV – This section is required for Level IV requests.

4A.	Document the current DOC Status, and why/how the scenario has changed, or necessitates an increase in level.
4B.	Document the extraordinary behaviors and needs of the child.
4C.	Explain how the reimbursement amount was determined. Document the extraordinary care, activities and supervision required by the foster parent. Include a list of specific activities, and time required for each activity, for the foster parent to meet the child’s needs.
4D.	List/describe any other services and payments being provided for the child’s care (i.e. assisted care, nursing services, day care, counseling/therapy, etc.).
4E.	Attach the current DHS-626, pending 626 for Level IV DOC (with the County Director’s Signature), and ISP/USP/PWSP.

Attach any additional supporting documents: (i.e. medical reports/records, therapy reports, IEP’s, etc.).

Please ensure that all required signatures and dates have been obtained on all documents: foster parents, services specialist, services supervisor and county director.

Once completed submit packet to:

Field Operations Administration

235 S. Grand Ave., Suite 415

P.O. Box 30037

Lansing, MI 48909

Case Name	Log Number
5.
Level I	$8.00		Age Appropriate Rate
5A $
Level II	$13.00
Determination of Care

(if appropriate)
5B $
Level III	$18.00
Level IV	approved rate
TOTAL FOSTER PARENT RATE (5A + 5B):
5C $
Begin Date	End Date	ADMINISTRATIVE RATE:

(if appropriate)
5D $
Approval not to exceed 6 months	TOTAL PER DIEM RATE (4C + 4D): $
Due to the foster parent’s extensive activities a level IV exception is being requested.
Initial
Renewal
Approved
Escalation
Descalation
Denied
If denied, reason why:
SIGNATURES: Supplements above a level III DOC require additional documentation/justification (see FOM 903-3).
Direct Service Worker Signature	Date	Foster Parent Signature	Date
Direct Service Supervisor Signature (Required for all levels)	Date
DHS Monitor Signature (Required for all levels)	Date	DHS County Director Signature (Required for Level III & IV)	Date
DHS Monitor Supervisor Signature	Date	Field Operations Director or designee Signature (Required for Level IV)	Date
Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.	AUTHORITY: PA 280 of 1939

COMPLETION: Is required by policy.

CONSEQUENCE: Correct reimbursement may not be received by the foster parent.

DHS-1945 (Rev. 8-11) Previous edition obsolete. MS Word	1

DHS-1945, Assessment for Determination of Care for Medically Fragile Children in Foster Care

Technical Services

2016-01-16

Michael Turner

Michigan Department of Human Services