AFC Member Lifecycle Workflow

Complete process flow with associated forms at each phase

Actors/Roles
Forms (has PDF)
Forms (PROPOSED)
Outputs/Decisions
External (Doctor/Insurance)

1. REFERRAL

1-7 days
referral_received

Actors

👤 Office Staff
👤 Care Manager

Forms (Section 1)

📄 Referral Form
📄 Insurance Verification

Outputs

✓ referral_accepted
✗ referral_declined
â–ŧ

2. PRE-ADMISSION

1-14 days
pre_admission

Actors

👩‍⚕ī¸ RN
👤 Care Manager
👤 Office Staff

Forms (Sections 1, 4, 5, 6)

📄 Member Application
📄 Psychosocial Assessment
📄 Pre-Admission Meeting
📄 Pre-Admission Assessment
📄 Home Assessment
📄 Home Alone Assessment
📄 TB Screening
📄 Medical Sheet
→ Send to Doctor
📄 Request to Physician
← Receive from Doctor
đŸ“Ĩ Medical Records / Physical

Outputs

✓ Eligible (Level I/II)
✗ not_eligible
â–ŧ

3. PRIOR AUTH

3-14 days
pa_pending

Actors

👩‍⚕ī¸ RN
👤 Office Staff

Forms (Sections 2, 5)

📄 MDS-HC Assessment
📄 MD Consultation Report
← From Doctor (required for PA)
đŸ“Ĩ Face-to-Face Encounter
→ Submit to Insurance
📄 MassHealth PA Form

From Insurance

đŸ“Ĩ Approval Letter + Auth #
đŸ“Ĩ OR Denial Letter

Status

✓ pa_approved
✗ pa_denied
â–ŧ

4. ADMISSION

Day 1-30
admitted

Actors

👩‍⚕ī¸ RN
👤 Care Manager
đŸ‘Ĩ Member
🏠 Caregiver

Forms (Sections 1, 3, 5, 8)

📄 Client ID/Photo/SSN
📄 Consent for Services
📄 HIPAA Acknowledgment
📄 Rights & Responsibilities
📄 AFC Funding Agreement
📄 Grievance & Appeal Rights
📄 5-Day Care Plan ⚠ī¸
📄 30-Day Care Plan ⚠ī¸
📄 Care Plan Task Sheet
📄 Fire Exit Plan
📄 Emergency Action Plan
📄 Evacuation Plan

Outputs

⚠ī¸ 5-Day Plan (Day 1-5)
⚠ī¸ 30-Day Plan (Day 6-30)
✓ Binder Sections 1-8 Complete
â–ŧ

5. ONGOING CARE

Continuous
active

Actors

🏠 Caregiver (Daily)
👩‍⚕ī¸ RN (Weekly-Monthly)
👤 Care Manager (Monthly)

Forms (Sections 7, 10, 11)

📄 Caregiver Daily Log
📄 Care Plan Task Sheet
📄 Nursing Notes
📄 Caseworker Notes
📄 Home Safety Check
📄 Medication List

Requirements

📅 Daily logs kept
📅 30-day log review
â–ŧ

6. REASSESSMENTS

6mo / 12mo
active

Actors

👩‍⚕ī¸ RN
👤 Care Manager
đŸ‘Ĩ MDT

Forms (Sections 2, 4, 5, 6, 8)

📄 Semi-Annual Care Plan
📄 Annual Care Plan
📄 Annual MDS-HC
📄 Annual Home Assessment
📄 Fire Drill (Apr/Oct)
📄 TB Screening (2yr)
← From Doctor (for PA renewal)
đŸ“Ĩ Face-to-Face Encounter

Outputs

→ Send to PCP
📤 6-mo Health Status Report
→ Submit to Insurance
📤 12-mo PA Renewal Request
â–ŧ

7. EVENTS

As Needed
varies

Triggers

🚨 Incident
đŸĨ Hospitalization
📈 Level Change
👤 Caregiver Change

Forms (Sections 5, 9, 10, 12)

📄 Incident Report
📄 ER Sheet
📄 Hospital Tracking
📄 Level Change Care Plan
📄 Alternate Caregiver Request
📄 Missing Person Protocol

Outcomes

↩ī¸ Return to active
→ Discharge
â–ŧ

8. DISCHARGE

Variable
discharged

Reasons

👤 Member Choice
đŸĨ Higher Level of Care
📍 Moved
✝ī¸ Death

Forms (Section 9)

📄 Discharge/Transition Plan
📄 Discharge Care Plan
📄 Post Discharge Status
📄 Transfer Form

Notifications

📧 Payer (PA termination)
📧 PCP
📧 Family

⚠ī¸ = Compliance Deadline | Generated for TopAid AFC v3

Official MassHealth Forms: PCP Order Form | Intake/Transfer Form