Building a Person-Centered Plan of Care: Supporting Quality Plan Development and Implementation

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Medically Fragile 0-5 years old HCBS/LOC Functional Algorithm
A child meets "medically fragile" if he/she meets: At least one "3" on Criterion 1 OR At least TWO "2" or "3" on Criterion 2 AND At least a "2" or "3" on Criterion 3 (such that in the absence of well-trained caregiver or medical personnel that this child's care due to physical disability would be provided in a skilled alternate setting, i.e., hospital, nursing home)
Criterion 1.
Medical Health Module Life Threatening Chronicity Intensity of Treatment	Child Development Positioning Transferring
Criterion 2.
Medical Health Module Life Threatening Chronicity Intensity of Treatment	Child Development Eating Mobility Positioning Transferring Elimination
Criterion 3.
Medical Health Module: Impairment in Functioning

Medically Fragile 6-21 years old HCBS/LOC Functional Algorithm
A child meets "medically fragile" if he/she meets: At least one "3" on Criterion 1 OR At least TWO "2" or "3" on Criterion 2 AND At least a "2" or "3" on Criterion 3 (such that in the absence of well-trained caregiver or medical personnel that this child's care due to physical disability would be provided in a skilled alternate setting, i.e., hospital, nursing home)
Criterion 1.
Medical Health Module Life Threatening Chronicity Intensity of Treatment	Self-Care Activities of Daily Living Module Positioning Transferring
Criterion 2.
Medical Health Module Life Threatening Chronicity Intensity of Treatment	Self-Care Activities of Daily Living Module Eating Toileting Mobility Positioning Transferring
Criterion 3.
Medical Health Module Impairment in Functioning

Serious Emotional Disturbance (SED) 0-5 years old HCBS/LOC Functional Algorithm
A child meets "SED" if he/she meets: At least ONE "3" on Criterion 1.1 OR Criterion 1.2; OR At least ONE "2" on Criterion 1.1 AND at least ONE "2" on Criterion 1.2; OR At least TWO "2" on Criterion 1.2 AND At least ONE "3" OR "2" on Criterion 2 items within TWO or more of these five domains Caregivers Resources & Needs Child Strengths Child Needs and Functioning Risk Behaviors Preschool/Childcare Functioning
Criterion 1.1
Behavioral Health Module Attention/Concentration Impulsivity/Hyperactivity Anger Control	Child Development Agitation Sensory Reactivity Emotional Control Frustration Tolerance Temperament
Criterion 1.2
Trauma Symptoms Module Traumatic Grief Re-experiencing Hyperarousal Avoidance Numbing Dissociation Emotional and/or Physical Dysregulation	Behavioral Health Module Depression Anxiety Oppositional Behavior Pica Risk Behaviors Self-Harm
Criterion 2.
Caregivers Resources & Needs Caregiver 1 Problem Solving Parenting Stress Care/Treatment Involvement Caregiver 2 Problem Solving Parenting Stress Care/Treatment Involvement Caregiver 3 Problem Solving Parenting Stress Care/Treatment Involvement Caregiver 4 Problem Solving Parenting Stress Care/Treatment Involvement	Child Strengths Interpersonal Relationship Stability Child Needs & Functioning Attachment Difficulties Living Situation Social and Emotional Functioning<.li> Risk Behaviors Aggressive Behavior Fire Setting Intentional Misbehavior Preschool/Childcare Functioning Preschool/Childcare Behavior Preschool/Childcare Attendance

Serious Emotional Disturbance (SED) 6-21 years old HCBS/LOC Functional Algorithm
A child meets "SED" if he/she meets: At least ONE "3" on Criterion 1.1 OR Criterion 1.2; OR At least ONE "2" on Criterion 1.1 AND at least ONE "2" on Criterion 1.2; OR At least TWO "2" on Criterion 1.2 AND At least ONE "3" OR "2" on Criterion 2 items within TWO or more of these five domains A - Caregivers Resources & Needs B - Child/Youth Strengths C - Child/Youth Needs & Functioning D - School/Academic Functioning E - Risk Behaviors
Criterion 1.1
Behavioral Health Module Attention/Concentration Impulsivity/Hyperactivity Anger Control
Criterion 1.2
Trauma Symptoms Module Traumatic Grief Re-experiencing Hyperarousal Avoidance Numbing Dissociation Emotional and/or Physical Dysregulation	Behavioral Health Module Psychosis Depression Anxiety Oppositional Behavior Conduct Emotional Control Attachment Difficulties Risk Behaviors Suicide Risk Non-Suicidal Self-Injurious Behavior Other Self-Harm (Recklessness) Danger to Others
Criterion 2.
Caregivers Resources & Needs Caregiver 1 Problem Solving Parenting Stress Care/Treatment Involvement Caregiver 2 Problem Solving Parenting Stress Care/Treatment Involvement Caregiver 3 Problem Solving Parenting Stress Care/Treatment Involvement Caregiver 4 Problem Solving Parenting Stress Care/Treatment Involvement	Child/Youth Strengths Social Relationships with Adults Relationship Stability Child/Youth Needs and Functioning Living Situation Decision-Making School/ Academic Functioning School Behavior School Attendance Risk Behaviors Fire Setting Sexually Reactive Behavior Sexual Aggression Delinquent Behavior Bullying Runaway Intentional Misbehavior Eating Disturbance

Published 2018, Updated 2025