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Effective: 4/22/2025

C7.23 Individual Health Plan for the Medically Complex Child

Legal Authority

Introduction

​​​​​​​​​​The individual health plan (IHP) meeting was established to assess the ongoing needs of the medically complex child. A review of the IHP is completed every three (3) months within the region. The SSW, regional nurse consultant, managed care organization (MCO) nurses, care providers, and others involved in the child’s medical care should attend this meeting. The IHP is to be updated every six (6) months.

The regional nurse consultant may utilize the DPP-104C Medically Complex Monthly Report in preparation and development of the child’s IHP.

During the initial IHP meeting and once every six (6) months thereafter, the medically complex service team:

  • ​Develops an IHP; 
  • ​Reviews current medical services and medical providers; 
  • Incorporates the current and potential medical and rehabilitative needs of the child, and awareness of the long-term needs of the child into the child’s care and treatment; 
  • Identifies additional services to meet the child’s needs; 
  • Discusses transition planning when applicable; and 
  • Assesses whether the child’s needs continue to warrant a medically complex designation. 



Practice Guidance

The regional nurse consultant:

  • Coordinates with the MCO nurse case manager to schedule and complete an IHP meeting within thirty (30) calendar days of the child's designation as medically complex; 
  • Coordinates with the MCO nurse case manager to invite the members of the medically complex service team including, but not limited to the following people, to assist with the child’s planning: 
    • MCO case manager; 
    • ​Birth parents; 
    • Foster/adoptive parents and either the recruitment and certification (R&C) worker or private agency staff, as applicable;
    • Medical providers; 
    • Service providers; 
    • SSW; 
    • FSOS; 
    • Medical Support Section; 
    • Any other supportive family member; and
    • Any other member of the child's care team.  
  • Requests written recommendations before the meeting and documents oral information provided by the team members in the child’s case record, all of which are considered at the IHP meeting if a team member is unable to attend; 
  • Contacts the child’s physicians to receive a current report on the child’s medical status (e.g. medications, treatment, etc.) and to request medical records from the previous six (6) months if this information is not already known or available from other members of the child's care team included in the IHP; 
  • Completes the medically complex child’s DPP-104B Individual Health Plan and distributes the signed copies to all team members, including the Medical Support Section of the Department of Protection and Permanency (DPP) following the initial IHP meeting and every six (6) months thereafter; 
  • Schedules additional IHP meetings once every six (6) months and the team: 
    • Reviews the plan to ensure that it meets the child's current needs; and 
    • Re-evaluates the child's continued medically complex status; 
  • Contacts the Medical Support Section to advise of the medically complex service team's recommendation that the child may no longer require a medically complex designation. 
  • The medical support section makes the final decision on the removal of the designation and notifies the regional nurse consultant.  
  • If a decision is reached to discontinue medically complex status, the team makes recommendations regarding the child’s future placement options and aftercare planning. 
  • If the foster/adoptive home parent agrees to provide continued care of the child, the child can remain in the same placement.

Procedure

​The SSW:

  1. Assists the regional CCSHCN nurse consultant and MCO case manager in inviting participants to the IHP meeting; 
  2. Attends and participates in the IHP meeting; 
  3. Uploads a copy of the IHP into the electronic file;  and
  4. If the SSW cannot attend the IHP meeting, the FSOS attends in the worker’s place; and if the FSOS is unable to attend, a representative from the regional office attends.

Contingencies and Clarifications

  • For out-of-state placements, the SSW and regional nurse consultant obtain​ medical records from the current providers to document the plan of care in place within the state where the child resides. These records should be uploaded into TWIST to serve as a care plan. 

Documents

Revisions

4/22/2025

The individual health plan (IHP) meeting was established to assess the ongoing needs of the medically complex child. A review of the IHP is completed every three (3) months within the region. The medically complex liaison, Commission for Children with Special Health Care Needs (CCSHCN) nurse, SSW, regional nurse consultant, managed care organization (MCO) nurses, care providers, and others who are involved in the child’s medical care should attend this meeting. The IHP is to be updated every six (6) months.
The regional CCSHCN nurse consultant:

  • Coordinates with the MCO nurse case manager to schedule and complete an IHP meeting within thirty (30) calendar days of the child's designation as medically complex; 
  • Coordinates with the MCO nurse case manager to invite the members of the medically complex service team including, but not limited to the following people, to assist with the child’s planning: 
  • FSOS; 
  • Medically complex liaison; 
  • Medical Support Section; and 
  • Any other supportive appropriate family member.; and 
  • Any other member of the child's care team. 

  • Contacts the child’s physicians to receive a current verbal report on the child’s medical status (e.g. medications, treatment, etc.) and to request medical records from the previous six (6) months if this information is not already known or available from other members of the child's care team included in the IHP; 
  • Completes the medically complex child’s DPP-104B Individual Health Plan and distributes the signed copies to all team members, including the Medical Support Section of the Department of Protection and Permanency (DPP) following the initial IHP meeting and every six (6) months thereafter; Reviews the IHP every three (3) months with the team; 
  • Contacts the Medical Support Section to advise of the medically complex service team's recommendation if it is determined that the child may no longer require a medically complex designation. 
  • The medical support section makes the final decision on the removal of the designation and notifies the regional nurse consultant. CCSHCN nurse and medically complex liaison. 
​​3.  Uploads a ​Places one copy of the IHP in the request and/or agency case ​electronic file; If the SSW cannot attend the IHP meeting, the FSOS attends in the worker’s place; and 
4.  If the FSOS is unable to attend, a representative from the regional office attends.​


  • For out-of-state placements the SSW and medically complex liaison regional nurse consultant obtains medical records from the current providers to document the plan of care in place within the state where the child resides. These records should be uploaded into TWIST to serve as a care plan. conduct: The initial IHP within thirty (30) days of the designation; and 

  • An IHP meeting during the annual face-to-face visit in the placement setting (refer to SOP 4.24 SSW’s Ongoing Conta​ct with the Birth Family and Child, Including the Medically Complex Child). 
  • For children who are placed with a relative and/or out of state, the medically complex liaison completes the IHP.​