What is a Health Care Directive?

A Health Care Directive is one form of advance care planning. It is a way for you to communicate your decisions about your medical care to the people in your life. It is a written document used when you are unable to make your own decisions about your healthcare. It lists what types of medical care you want and do not want, and who you want to make decisions for you.

The process of creating a directive is just as important as the finished product. It aids you in thinking about your future and discussing this with the important people in your life. It is recommended to complete a directive when you are in good health; it is more difficult for you and others to make tough decisions when you are in crisis. Take your time and thoughtfully consider each aspect of your health.

Who should get a Health Care Directive?

While no one is required to have a Health Care Directive, it is highly recommended for everyone. If something happens to you and you do not have a directive, medical staff will not know what you want. Creating a directive is a legal way for everyone to make their wishes known.

What should I talk with the people in my life about?

Health care is complex. Many questions are not easy to answer. Directive templates have questions to get you started, and there is space to write your additional decisions. It is best to think of all possible scenarios, write them in your directive, and talk with your agent about them. There are documents in the resource section of this guide that can assist in this discussion. Depending on the directive template you use, it may include some of the following questions:

• What decisions do you want your agent to be able to make on your behalf?
• What types of treatment do you want? Are there any types of treatment you do not want?
• Do you want to receive medication for pain? How much?
• Do you want to be on life support? When would you want life support to be stopped?
• What would make you more comfortable in the hospital? Would you want a book read to you or music playing?
• Who do you want to be involved? Who do you want to visit you?
• Do you want to be an organ donor?
• What do you want your funeral to be like?

What is a Health Care Agent?

• A Health Care Agent is the person you choose to follow your Health Care Directive and make decisions for you if you become unable to do so. (You may also hear the terms “healthcare proxy” or “healthcare power of attorney” used.) It is recommended to talk with your agent about what you want for your healthcare and confirm they are able and willing to be your agent. They may have additional questions for you that you did not think you needed to answer. You can select a primary agent and an alternate agent in case the primary is unavailable.

Who should I choose to be my Agent?

Who you choose to be your agent varies depending on personal preferences. The person you choose to be your health care agent:

• Should follow what the directive says first, then make further decisions if your directive does not specify the choice they need to make. Be sure to choose someone who you believe would make the decisions you would want, not what they want.
• Could be a family member, significant other, friend, or anyone who knows you well.
• Should be someone you trust.
• Typically should not be a support staff, unless they will be in your life long term.

What kind of paperwork do I need to do?

There is not a specific form required for your Health Care Directive. There are several resources with templates at the end of this guide. A directive is valid as long as it meets certain requirements. It must:

• Include an agent and/or instructions about the health care choices you wish to make.
• Be dated and in writing.
• State your full legal name.
• Be signed by you or someone you authorize to sign for you.
• Have your signature witnessed by two people or notarized.

**The witness to your signature cannot be a hospital staff or your agent**

What do I do with it once I complete my Health Care Directive?

Talk with your agent, your doctor, and other people in your life so they know what you want. Make copies of the signed document. Keep one for yourself and give one to your agent(s), your doctor(s), your hospital(s), and your attorney if you chose to work with one. (You do not need an attorney to create a directive, but some people choose to use one.) Review this document yearly or after any event that might change your decisions.

Do I need a Health Care Directive if I have a guardian?

Everyone, regardless of guardianship, should have a Health Care Directive. If you are under guardianship (if it includes the medical power), your guardian can make medical decisions for you, so a Health Care Directive is not legally required.

However, completing a directive can give you more power and choice over what happens to you. You may want someone other than your guardian involved with your end of life decisions, and may have decisions about what you want your care to look like. In general, anyone who knows what they want for their health care and knows who they want to make decisions for them has the capacity to sign a directive.

Templates and Information

• Honoring Choices has free Advance Care Planning resources. Electronic Health Care Directive templates are available in eight languages. They have both a short form and a long form
  • www.metrodoctors.com/honoring-choices-mn 

• Minnesota Attorney General: This website answers frequently asked questions and has a free health care directive template.
  • www.ag.state.mn.us/consumer/handbooks/probate/CH6.asp

Information 

• Focus on the Future podcast episode 9: Health Care Directives with Honoring Choices Minnesota
  • www.arcminnesota.org/podcast/episode-9
• Minnesota Department of Health: Frequently Asked Questions about Health Care Directives
  • www.health.state.mn.us/facilities/regulation/infobulletins/advdir.html

• Go Wish: An interactive online tool to help prioritize what is most important to you.
  • www.gowish.org

• Five Wishes: A website with resources to help guide the conversation about your health care wishes.
  • www.fivewishes.org

• A letter to my doctor: A tool that helps people with disabilities describe how and when they want help making health care decisions.
  • www.thearc.org/wp-content/uploads/2019/08/Making-My-Own-Health-Care-Decisions–A-Letter-for-to-My-Doctors.pdf

• Arc Guide to Guardianship: A document that talks about how to support people in making choices. It discusses alternatives to guardianship and guardianship.
  • www.arcminnesota.org/resource/arc-guide-to-guardianship/

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For further information or advocacy services, contact The Arc Minnesota at 952.920.0855 or toll-free at 833.450.1494 or visit www.arcminnesota.org. (Please note: This document is not legal advice, and should not be construed as such. Thus, no information herein should replace the sound advice of an attorney.)

All rights reserved (c) 2019 The Arc Minnesota

September 2019

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The Arc pab tau leej twg?

Cov tib neeg uas loj hlob qeeb thiab laj lim qeeb thiab lawv tsev neeg nyob hauv Minnesota.

The Arc pab tau li cas?

Ua ntaub ntawv rau cov kev pab cuam them nqi kho mob xws li Medical Assistance tsis yooj yim. The Arc muaj ntaub ntawv los qhia thiab pab koj xaiv qhov kev pab cuam them nqi kho mob raws li koj kev xav. Koj yeej tham nrog ib tus kws thoob tswv yim tau thiab. Nws yuav pab qhia los xa ib tsab ntawv los piav txog yog mus ua cov ntaub ntawv mus ua li cas.

Cov kws thoob tswv yim uas paub txog ntaub ntawv kho mob nram The Arc paub teb cov nqe lus nug txog:

• MNsure (MNsure yog ib qhov chaw ua luam uas Minnesota cov tib neeg yos yuav tau, muab piv rau lwm qhov thiab xaiv qhov kev pab them nqi kho mob ua tau raws li koj cov kev xav)
• Lwm yam kev pab cuam them nqi kho mob rau cov tib neeg uas muaj kev tsis taus xws li hu uas Tax Equity an Fiscal Responsibility (MA-TEFRA), Medical Assistance rau cov tib neeg uas muaj kev tsis taus uas lawv ua hauj lwm (MA-EPD) thiab Special Needs Basic Care (SNBC)
• Tus nqi niam txiv ntawm MA-TEFRA
• Cov nqi kho mob Medical Assistance pab them
• Kev pab them nqi kho mob uas luag ua tswv rau (private insurance) ua hauj lwm li cas nrog Medical Assistance
• Ua ntaub ntawv kho mob yog mus ua li cas
• Pab rov qab ua ntaub ntawv kho mob dua

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ACA:         Affordable Care Act

ACO:         Accountable Care Organization

ADA:         Americans with Disabilities Act

ADL:        Activities of Daily Living

AFC:        Adult Foster Care

AGI:         Adjusted Gross Income

ARMHS:    Adult Rehabilitative Mental Health Services

ASD:        Autism Spectrum Disorder

AT:          Assistive Technology

BI:           Brain Injury

CAC:        Community Alternative Care

CADI:       Community Access for Disability Inclusion

CDCS:      Consumer Directed Community Supports

CEHI:       Cost Effective Health Insurance

CEP:        Common Entry Point

CFC:        Corporate Foster Care

CFR:        County of Financial Responsibility

CFSS:       Community First Services and Supports

CHIP:       Children’s Health Insurance Program

CMS:        Centers for Medicare and Medicaid Services

COBRA:    Consolidated Omnibus Budget Reconciliation Act

COLA:      Cost Of Living Adjustment

CSG:        Consumer Support Grant

CSP:         Community Support Plan

CSSP:       Coordinated Service and Support Plan

CTSS:       Children’s Therapeutic Services and Supports

DD:          Developmental Disabilities

DEED:      Department of Economic and Employment Services

DHS:        Department of Human Services

DTH:       Day Training and Habilitation

DME:       Durable Medical Equipment

DWRS:     Disability Waiver Rate Setting

EIDBI:      Early Intensive Developmental and Behavioral Intervention

ELP:        Essential Lifestyle Planning

EOB:       Explanation of Benefits

EOMB:     Explanation of Medical Benefits

FASD:      Fetal Alcohol Spectrum Disorder

FFS:        Fee For Service

FPL:       Federal Poverty Level

FSA:       Flexible Spending Account

FSE:       Fiscal Support Entity

FMS:       Financial Management Service

FMLA:     Family and Medical Leave Act

FSG:       Family Support Grant

GA:         General Assistance

GRH:       Group Residential Housing

HAC:       Housing Access Coordination

HAS:        Housing Access Services

HCAPP:    Health Care Application

HCBS:      Home and Community Based Services

HHA:       Home Health Aide

HHS:       Health and Human Services

HIPAA:    Health Insurance Portability and Accountability Act

HMO:      Health Maintenance Organization

HRA:       Health Reimbursement Account

HSA:        Health Savings Account

I/DD:       Intellectual and Developmental Disabilities

IADL:       Instrumental Activities of Daily Living

ICF/DD:   Intermediate Care Facility/Developmental Disability

IHO:        Individualized Housing Options

ISP:          Individual Service Plan

LOC:         Level of Care

LTC:          Long Term Care

LTCC:        Long Term Care Consultation

LTSS:         Long Term Care Services and Supports

MA:           Medical Assistance/Medicaid

MA-EPD:     Medical Assistance for Employed Persons with Disabilities

MA-TEFRA: Medical Assistance- Tax Equity and Fiscal Responsibility Act

MAGI:        Modified Adjusted Gross Income

MAPS:       Making Action Plans/McGill Action Planning System

MCO:        Managed Care Organization

MCRE:      MinnesotaCare

MDH:       Minnesota Department of Health

METO:      Minnesota Extended Treatment Options

MHCP:     Minnesota Health Care Programs

MSOCS:   Minnesota State Operated Community Services

MSA:       Minnesota Supplemental Aid

NF:         Nursing Facility

OCR:       Office of Civil Rights

OIO:        Olmstead Implementation Office

OT:         Occupational Therapy

PATH:     Planning Alternative Tomorrows with Hope

PASS:      Plan to Achieve Self Support

PCA:       Personal Care Assistance

PCP:       Person Centered Planning

PCPO:     Personal Care Provider Organization

PCT:       Person Centered Thinking

PDN:       Private Duty Nursing

PFP:        Personal Futures Planning

PHN:       Public Health Nurse

PMAP:     Prepaid Medical Assistance Plan

PT:         Physical Therapy

QA:         Quality Assurance

QP:          Qualified Professional

RC:          Related Condition

RSDI:        Retirement, Survivors, Disability Insurance

SES:         Supportive Employment Services

SILS:        Semi-Independent Living Services

SLS:         Supportive Living Services

SMRT:      State Medical Review Team

SNAP:      Supplemental Nutrition Assistance Program

SNBC:      Special Needs Basic Care

SNF:       Skilled Nursing Facility

SNT:       Special/Supplemental Needs Trust

SNV:       Skilled Nursing Visits

SSA:       Social Security Administration

SSDI:      Social Security Disability Insurance

SSI:        Supplemental Security Income

SSN:      Social Security Number

TBI:       Traumatic Brain Injury

TCM:      Targeted Case Management

VR:        Vocational Rehabilitation

VA:         Vulnerable Adult

WIC:       Women, Infants and Children

WIOA:    Workforce Innovation and Opportunity Act

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For further information or advocacy services, contact The Arc Minnesota at 952-920-0855 or toll-free at 833.450.1494 or visit www.arcminnesota.org. (Please note: This document is not legal advice, and should not be construed as such. Thus, no information herein should replace the sound advice of an attorney.)

All rights reserved (c) 2019 The Arc Minnesota

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Cost Effective Coverage

Cost effective coverage is private health coverage for which the amount paid for premiums, co-pays, deductibles and other costs is likely to be less than what MA would pay for a similar set of services.

Private healthcare coverage could include, but isn’t limited to:

• Group healthcare coverage (for eligible employees through their employer)
• Health insurance purchased by the individual
• COBRA (Consolidated Omnibus Budget Reconciliation Act)*
• Medicare (Part A & Part B)
• TRICARE (insurance for military personnel & their families)

Adults applying for themselves who are eligible for health insurance through their employer must cooperate by enrolling in the plan and stay enrolled when the employer is determined to be cost effective or they may lose MA coverage.

Process

Applicants looking for MA, MinnesotaCare or a Qualified Health Plan complete an online MNsure application (www.mnsure.org) or a paper MNsure application.

Applicants with certified disabilities looking for disability-based MA, MA for Employed Persons with Disabilities (MA-EPD) or help paying Medicare costs complete an Application for Certain Populations (DHS 3876) and return it to their county of residence along with required proofs that are listed on the application.

Applicants must provide information about other coverage that they are enrolled in or have available to them. Applicants note the policyholder’s name, policy number, insurance company name, type of insurance (i.e. medical, vision, dental), start/end dates and any family members covered by the policy. Applicants also need to submit copies (front and back) of health insurance cards with their application.

When the county financial worker processes the healthcare application, they make a referral to that county’s Cost Effective unit for follow up. A Cost Effective worker sends the applicant a notice and packet of information to complete and return. Applicants return completed

forms to their county’s Cost Effective unit. They may be asked to send copies of Explanations of Benefits (EOBs) or other information to their county as well.

Applicants may receive the forms listed below or they may receive other forms their county agency uses for the cost effective determination process.

• If the applicant’s private insurance coverage is through their or a family member’s employer, they receive DHS 3767 “Request for Group Health Plan Information.”
• If the applicant or their family member purchased a private insurance policy from an insurance company or through MNsure, they receive DHS 3767B “Request for Individual Health Plan Information.”

Applicants may call their county’s Cost Effective unit with questions about filling out the forms.

Once the county Cost Effective unit receives the forms and processes them, the applicant will be notified by mail if their private insurance policy has been determined “cost effective” or not.

• If the insurance is determined to be cost effective the applicant:
  • must stay enrolled in the private insurance policy. It pays first, and MA pays second (MA may cover services the private insurance policy does not).
  • will be reimbursed for the applicant’s private insurance premium cost or may have premium paid directly to the employer or insurance provider.
  • will have their private insurance deductible, co-pays and co-insurance covered by MA.
  • will have “straight” / “Fee for Service” MA coverage.
• If the insurance is determined to be not cost effective the applicant:
  • may drop their private insurance coverage and stay enrolled in MA only.
  • will not be reimbursed for any private insurance costs.
  • may appeal the decision. The notice the county mails has important appeal information and timelines.

Enrollees should call their financial worker when their private insurance changes.

Resources

*http://www.health.state.mn.us/hmo/cobra.htm

Minnesota Health Care Programs Eligibility Policy Manual “Cost Effective Insurance”

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For further information or advocacy services, contact The Arc Minnesota at 952-920-0855 or toll-free at 833.450.1494 or visit www.arcminnesota.org. (Please note: This document is not legal advice, and should not be construed as such. Thus, no information herein should replace the sound advice of an attorney.)

All rights reserved (c) 2019 The Arc Minnesota

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Stress manifests in a variety of ways, like feeling tired or overwhelmed. It may cause you to lose interest in activities you once enjoyed. Each caregiver copes with stressors in different ways.

This guide is an overview of ideas that may help you address stressors in your life.

ASKING FOR HELP

Receiving help can be a great aid when you feel overwhelmed. Asking for help from family and friends can be difficult for most. Yet, people often want to help, but are not sure how. Here are some tips for asking for help:

• Create a list of family and friends who you feel may want to help. Think about that individual’s interests and abilities. Ask them to meet with you one-to-one to discuss areas of support.
• Write down a list of activities that you would be willing to ask others to assist you with such as:
• Meal planning
• Grocery shopping
• Transportation to appointments
• Laundry
• Having someone stay with the individual you are caring for
• Use “I” statements to ask for assistance. For example: “I haven’t been able to cook recently and I would love to make this dish. It’s difficult to cook and care for . Would you be able to spend time with while I cook? Then, we can share the meal together.”
  • If they turn down your request, try not to get discouraged! If the individual seems hesitant you could say, “You can think about it and get back to me.”

BREATHING TECHNIQUES

Sometimes, family and friends aren’t available during high stress times. There are other options available to you. The following are breathing techniques for slowing down your body and mind during a stressful moment.

1. THE MEASURED BREATH

• You can sit or stand, but be sure to soften up a little before you begin. Make sure your hands are relaxed, and your knees are soft.
• Drop your shoulders and let your jaw relax.
• Now breathe in slowly through your nose and count to four, keep your shoulders down and allow your stomach to expand as you breathe in.
• Hold the breath for a moment.
• Now release your breath slowly and smoothly as you count to seven.
• Repeat for a couple of minutes.

2. THE BUMBLE BEE BREATH

• Relax your shoulders
• Close your throat slightly so you can hear your breath when you breathe in
• Cover your ears with your thumbs and your eyes with your fingers
• Keep your lips closed but lightly and your teeth slightly apart with your jaw relaxed and breathe out slowly making a long, low humming sound
• Make your exhalation long and smooth
• Repeat 5-10 times
• Then sit with long slow breaths for a couple of minutes and enjoy the peace.

3. BELLY BREATHING FOR RELAXATION

• Breathe in slowly and deeply through your nose. Make sure your shoulders are down and relaxed. In this exercise, your stomach should expand, but your chest should rise very little. So, if you want, you can place one hand on your stomach and the other on your chest so you can feel how you are breathing.
• Exhale slowly through your mouth. As you blow air out, purse your lips slightly, but keep tongue and jaw relaxed. You may hear a soft “whooshing” sound as you exhale. That’s good, listen for that sound every time your practice and learn to value it as the sound of relaxation.
• Repeat this breathing exercise for several minutes. Make your outgoing breath as long and smooth as you can. The out breath is the key to relaxation so give it your full attention and practice breathing out in a long slow controlled breath and you will quickly feel the benefit.

Self-Care Activities 

• Ask yourself what is important to you and what you like to do
• Consider things you used to enjoy, but haven’t don’t in a while
• Journaling
• Exercising
• Getting enough sleep
• Eating healthy food
• Engage in activities that help you create meaning, such as praying or meditating
• Utilize respite resources

References:
3 Anxiety Breathing Techniques You Can Practice Anywhere

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For further information or advocacy services, contact The Arc Minnesota at 952-920-0855 or toll-free at 833.450.1494 or visit www.arcminnesota.org. (Please note: This document is not legal advice, and should not be construed as such. Thus, no information herein should replace the sound advice of an attorney.)

All rights reserved (c) 2019 The Arc Minnesota

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An Individualized Healthcare Plan (IHP) is used when you need healthcare services at school. An IHP can be simple or detailed. An IHP must be signed and dated. The school district creates an IHP to meet your needs as a student.

Determining Need For and Creating an IHP

If you have an Individualized Education Program (IEP), your health and safety needs might be addressed in that document. If they are not, you will need an IHP. You do not need to have an IEP to have an IHP.

The creation of your IHP should include the IEP team, if you have one. It should also include a district representative and parents, staff, or others. A nurse licensed from the Board of Teaching must oversee school nursing services.

If an Individualized Healthcare Plan is necessary, the following information should be considered:

• Medical diagnosis
• Treatments during and outside of school day
• Medications
• Frequent absences due to illness and/or hospitalizations
• School day schedule adjustments
• Specific health care needs (lifting, positioning, feeding, etc.)

A licensed medical provider must provide:

• An order for special healthcare services to be performed at school
• Information about specialized healthcare procedures and administration of medications
• A parent’s signature

An IHP Includes:

• Medical condition and brief medical history
• Primary and specialist healthcare provider(s)
• Procedure(s) to be performed
• Medication(s) and possible side effects
• Special equipment
• Physical limitations (if any)
• Checklist of medication administration
• Healthcare needs at school
• Precautions, reactions, and/or interventions
• Daily log charts of healthcare records
• Healthcare goals and actions may also be included

Staff training should include:

• A plan for how Licensed School Nurse will assign staff
• List of qualified staff
• How to administer medications and provide healthcare procedures
• Training schedule

Additional plans to ensure your health and safety may be necessary. This may include:

• Emergency Procedures and Safety Plans:
  • Summary of medical information
  • Emergency names, places, and numbers
  • How to respond if an emergency occurs
• Transportation Plan
• Outline issues and procedures
• Share plans with the bus driver, transportation aide, and substitute

All plans should be noted and attached to the IEP if applicable. Staff working directly with the student must have access to these plans. Decide which staff will have access to specific (or all) IHP information.

Resources

Arc Guide to Medication Administration

Minn. Rule 121A.21 School Health Services

Download PDF: Arc Guide to An Individualized Health Care Plan

For more information or advocacy services, contact The Arc Minnesota at 833.450.1494 or visit www.arcminnesota.org. (Please note: This document is not legal advice. No information should replace the advice of an attorney.)

All rights reserved (c) 2020 The Arc Minnesota. Document updated June 2020.

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