ESBD_515780_1778790246386_Attachment 05-VR2900 Diabetes Self-Management Education.pdf

VR2900 (02/23) Diabetes Self-Management Education Post-Training Assessment Page 1 of 4

Texas Workforce Commission Vocational Rehabilitation Services

Diabetes Self-Management Education Post-Training Assessment

Instructions

• Review previous visit.

• Summarize customer abilities in behaviors and use of adaptive equipment.

• Record customer statements and diabetes educator observations and comments.

• As appropriate, you may use the following abbreviations: NA for “not applicable”, ND for “not disclosed by customer”, or NE for “not evaluated”.

General Information Customer name:

TWS-VRS Case ID:

Counselor name:

Service authorization number:

Previous Visit

Date of previous visit:

What was the behavioral change goal from the previous visit?

Did the customer accomplish the behavioral change goal? Describe successes and barriers to change.

How did you evaluate the behavioral change goal (return demonstration, verbal feedback, etc.)?

What does the customer recall from the previous visit?

Was there anything that was difficult for the customer to implement?

Summarize customer’s abilities in the following behaviors:

Vocational Rehabilitation

Healthy Eating

Being Active

Monitoring

Taking Medications

Healthy Coping

Problem Solving

Reducing Risk

EXAMPLE

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Is the customer independent with the following adaptive aids? If not, please provide a reason the customer is not independent and the plan of action.

Adaptive Aid Yes No N/A Comment Count-a-Dose

Insulin Pen Magniguide Blood Glucose Meter Body Weight Scale Blood Pressure Meter Thermometer Other adaptive equipment purchased (Describe in comment)

Customer Statements What changes in your lifestyle have you made while completing the diabetes program?

What changes will be difficult to maintain?

Do you have the information you need to manage your diabetes at work? (VR customers only)

Final Observations, Comments, and Recommendations Does the customer have the skills to manage his or her health during intensive rehabilitation training programs (minitrainings, CCRC, etc.)?

Yes No Comment:

Observations, comments, and recommendations not covered previously:

Start time of visit: End time of visit:

Post assessment date: Total hours for post assessment:

Provider Signatures Diabetes Educator Signature (Required for all providers)

By signing below, I certify that:

• the above dates, times, and services are accurate;

• I personally facilitated all training, meeting all outcomes required for payment and documented the service, as prescribed in the VR-SFP and service authorization;

• Verification of the customer’s satisfaction and service delivery obtained as stated above;

• I maintain the staff qualifications required for an Evaluator as described in the VR-SFP or Service

Authorization; and

• I signed my signature and entered the date below.

Typed or Printed name:

Signature: (See VR-SFP 3 on Signatures)

X

Date Signed:

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Director (only required for Traditional-Bilateral Contractors) By signing below, I, the Director, certify that:

• I ensure that the services were provided by qualified staff, met all outcomes required for payment, and services were documented, as prescribed in the VR-SFP and service authorization;

• I maintain UNTWISE Director credential, as prescribed in VR-SFP;

• I signed my signature and entered the date below.

Typed or printed name:

Signature: (See VR-SFP 3 on Signatures)

X

Date Signed:

Select all that apply: UNTWISE Credentialed with ID:

VR3490-Waiver Proof Attached

VRS Use Only If any question below is answered no or if the report or supporting documentation is missing or incomplete, return the invoice to the provider with the VR3460. Make a case note to document the results of the review and the date VR3460 was sent to provider, when applicable.

Technical Review to Verify Provider Qualifications (Completed by any VR staff such as RA, CSC, VR Counselor)

Director’s Credential:

UNTWISE website or attached VR3490 verifies, for the dates of service, the director listed above:

maintained or waived the UNTWISE Director Credential did not hold a valid UNTWISE Director Credential

Verification of Service Delivery Technical Review (completed by any VR staff such as RA, CSC, VR Counselor) Verified that the report is accurately completed per form instructions Yes No Verified that the service(s) was provided within service date of SA and as stated in the VR Standards for Providers and/or the SA Yes No

When applicable, verify a copy of an approved VR3472 is attached to the report? NA Yes No Verified that this individual session was held for one hour. Yes No Verified that the form was submitted to VRS within 35 days of completion. Yes No Verified that the appropriate fee(s) was invoiced. Yes No Printed name of VR staff member making verification:

1. Date: 2. Date:

VR Counselor Review Verified that the form summarizes the customer abilities in behaviors and use of adaptive equipment.

Yes No

Verified the customer’s satisfaction with the training through signature on the form and/or by VR staff member contact with customer

Yes No

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By typing or printing your name, the VRC verifies:

• completion of the technical review,

• services provided met the customer’s individual needs,

• services provided met specifications in the VR-SFP and on the SA, and

• customer’s satisfaction with services received.

Approve to pay invoice Do not approve to pay invoice VR Counselor: Date: