The Patient Qualification Form is a crucial tool designed to determine eligibility for Long Term Care Pharmacy at Home services. This form ensures that patients meet all necessary criteria to receive comprehensive and compliant care in their home setting. Below is a step-by-step guide on how to properly fill out and utilize this form:

Detailed Guide to Utilizing the Patient Qualification Form for LTC at Home Services

The Patient Qualification Form is crucial for assessing eligibility for Long Term Care at Home Pharmacy services. It captures essential information to ensure patients receive appropriate care in their home setting. Follow these detailed steps to ensure accurate completion and utilization of the form:

Initial Information

• Patient’s Details:
  Start by entering the patient’s full name and date of birth at the top of the form. This ensures that the form is matched correctly to the patient’s medical and pharmacy records.
• Completing the Form: Indicate the name and title of the healthcare professional filling out the form. Eligible providers include:
  • RPh (Registered Pharmacists)
  • Pharm. D (Doctors of Pharmacy)
  • CPhT (Certified Pharmacy Technicians)
  • MD (Medical Doctors)
  • DO (Doctors of Osteopathic Medicine)
  • NP (Nurse Practitioners)
  • LPN (Licensed Practical Nurses)
  • MSW (Master of Social Work)
  • CHW (Community Health Workers)
  • RN (Registered Nurses)
  • CM (Case Managers)
  • BHS (Behavioral Health Specialists)

Section 1: Qualification via Waiver, Qualifying Program, or Discharge Status

• 1A: Check if the patient is currently in or qualifies for a Home & Community-Based Services (HCBS) program or other qualifying waiver programs. A ‘yes’ response qualifies the patient; to document the program details.
  • Pro Tip: Document the program details in the patient profile.
• 1B: Determine if the patient has been discharged from a long-term care facility within the past 6 months. A ‘yes’ response here also qualifies the patient. Record the discharge date and the name of the facility.
  • Pro Tip: Record the discharge date and the name of the facility in the patient profile. Keep a record of any discharge paperwork in the patient profile.

If a patient has 1A or 1B checked, they qualify for Long Term Care Pharmacy at Home Services. Continue to document the patient needs in Section 2 for care documentation.

If a patient does not have 1A or 1B checked, they may qualify for Long Term Care Pharmacy at Home Services due to their specific health detriments. Continue to evaluate the patient in Section 2.

Section 2: Qualification via Patient Status

This step assesses patient functionality and health conditions to determine their eligibility for Long Term Care at Home services.

• 2A: ADL and IADL Assessment
  • Source of ADL and IADL List: The list of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) used in this form is based on standards published by the National Institute of Health, specifically the National Library of Medicine. These activities are widely recognized benchmarks used to assess an individual’s ability to manage everyday tasks and, thus, their potential need for additional support at home.
  • Documentation: Assess and check off each activity the patient can or cannot perform independently, such as cooking, bathing, dressing, grooming, and managing medications. Document each assessed activity and the patient’s capability level. If the patient has two or more barriers, they may qualify for further services.
    • If the patient has 2 or more barriers, continue to 2B;
    • If the patient has 1 or fewer barriers, STOP. The patient does NOT qualify for Long Term Care at Home Pharmacy Services.
  • 2B: Chronic Disease Evaluation
    • Source of Chronic Disease List: The chronic conditions listed are derived from the Centers for Medicare & Medicaid Services (CMS) Prevalence and Medicare Utilization Chronic Condition data. Additionally, these conditions align with the CMS Chronic Conditions Special Needs Plans Chronic Disease list, ensuring relevance and compliance with current medical standards for long-term care.
    • Documentation: Evaluate the patient’s health by checking for the presence of three or more chronic diseases from the provided list.
      • Tip: In the patient’s profile, document the conditions and provide an overview of each diagnosed condition.
      • If three or more conditions are checked, the patient qualifies under this criterion, continue to 2C;
      • If 2 or fewer conditions are checked, STOP. The patient does NOT qualify for Long Term Care at Home Pharmacy Services.
  • 2C: Confirm the number of medications the patient is taking.
    • If the patient is on multiple medications for their chronic conditions, indicate ‘yes’ and write in the medications. This step is crucial for understanding the patient’s medication management needs.
      • Note: These medications MUST be prescribed maintenance medications for the chronic conditions that were listed in 2B
      • If the patient is taking prescribed maintenance medications for their chronic conditions, continue to 2D;
      • If the patient is not taking prescribed maintenance medications for their chronic conditions, STOP. The patient does NOT qualify for Long Term Care at Home Pharmacy Services.
  • 2D: Assess mobility.
    • If the patient has limited mobility that makes leaving the home independently difficult, check ‘yes.’
      • Limited Mobility refers to a person’s reduced ability to move freely and independently, often due to physical or neurological conditions. For example, Mr. Smith has chronic conditions and struggles to navigate without assistance, making it difficult for him to leave his home safely. He cannot drive or use public transport without his caregiver, and there is a high risk of injury if he tries to do so alone. Because of these challenges, Mr. Smith qualifies for LTC Pharmacy at Home services that accommodate his limited mobility. This ensures he receives the necessary support while remaining safely in his home environment.
        • Note: Document and describe the mobility issues in the patient’s profile.
        • If the patient has limited mobility that makes leaving the home independently difficult, along with meeting the qualifications in 2A, 2B, and 2C, the patient DOES qualify for Long Term Care at Home Pharmacy Services. Continue to Section 3.
        • If the patient does not meet the limited mobility barrier, STOP. The patient does NOT qualify for Long Term Care at Home Pharmacy Services.
        • If a patient has all four of the following:
          • 2 or more barriers of Activities of Daily Living/Instrumental Activities of Daily Living
          • 3 or More Chronic Diseases
          • Is on Multiple Medications for the Chronic Diseases Listed
          • Has limited mobility that makes leaving the home independently difficult

          They qualify for Long Term Care Pharmacy at Home Services. Go forward and complete Section 3.

Section 3: Pharmacist Attestation

• Once all sections are completed, the pharmacist at the dispensing Long Term Care at Home Pharmacy location should review the information for accuracy and completeness, then:
  • Complete the pharmacy information;
  • Sign the form to attest that the information is correct and that an onboarding assessment has been conducted;
  • Agree to review the patient’s profile every six months to confirm ongoing eligibility for LTC at Home services.
  • Document the date of completion and include the pharmacist’s NPI and signature.

Download the Form

For pharmacies looking to implement this qualification process:

Download Patient Qualification Form