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Continuum of Care or Minnesota Tribal Collaborative Certification Form SOAR Onetime Service Funding The Minnesota Department of Human Services (DHS) requests the following information for the SSI/SDI
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01
To fill out the continuum of care, follow these steps:
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Gather all necessary information about the person receiving care, including their medical history, current medications, and any specific needs or preferences they may have.
03
Start with the intake assessment, which typically includes basic details about the individual's demographics, living situation, and the reason for seeking care.
04
Move on to the comprehensive assessment, which involves a more thorough evaluation of the person's physical and mental health, functional abilities, social support, and overall well-being.
05
Based on the assessment findings, develop a care plan that outlines the specific services and interventions needed to address the person's needs and goals.
06
Continuously monitor and evaluate the person's progress, adjusting the care plan as necessary.
07
Complete all required documentation accurately and in a timely manner, ensuring all relevant information is recorded properly.
08
Communicate effectively with the person receiving care, their family members or caregivers, and other healthcare professionals involved in their treatment.
09
Follow all legal and ethical guidelines in providing continuum of care services.
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Regularly review and update the care plan to reflect any changes in the person's condition or needs.
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Collaborate with other healthcare providers, community resources, and support networks to ensure a holistic and coordinated approach to care.

Who needs continuum of care or?

01
The continuum of care is beneficial for various individuals who require ongoing healthcare support and services. This includes:
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- Elderly individuals who need assistance with daily activities, medication management, and monitoring of chronic conditions.
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- Individuals with disabilities who require specialized care, therapy, and support to enhance their quality of life and promote independence.
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- Patients transitioning from hospitals or other higher levels of care to their homes or community settings, ensuring a smooth and safe transition.
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- Individuals with complex medical conditions or multiple chronic illnesses who need coordinated care and management of their healthcare needs.
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- Individuals with mental health or substance abuse issues who benefit from comprehensive treatment programs and support services.
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- Individuals recovering from surgeries, accidents, or injuries who require rehabilitation, therapy, and ongoing healthcare monitoring.
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- Pregnant women and newborns who need prenatal and postnatal care, as well as guidance and support during the early stages of parenthood.
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- Individuals with terminal illnesses who require palliative care or hospice services to manage pain, provide comfort, and support end-of-life wishes.
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- Veterans, military personnel, and their families who may need specialized healthcare services and assistance reintegrating into civilian life.
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- Individuals at risk of homelessness or those facing housing instability who can benefit from supportive housing programs and wraparound services.
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Continuum of Care (CoC) is a community-based plan to organize and deliver housing and services to meet the specific needs of people who are experiencing homelessness.
Nonprofit organizations, local government agencies, and other entities that receive funding from the U.S. Department of Housing and Urban Development (HUD) to provide housing and services to homeless individuals and families are required to file Continuum of Care (CoC) applications.
Continuum of Care (CoC) applications can be filled out online through the HUD Exchange website. Applicants need to provide detailed information about the housing and services they provide, as well as the outcomes achieved.
The purpose of Continuum of Care (CoC) is to promote community-wide commitment to the goal of ending homelessness by providing funding for programs that help individuals and families secure stable housing.
Applicants are required to report information such as the number of people served, the types of services provided, program outcomes, and financial data.
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