1 Service and Support Administration: The Rule Kelly Miller and Jean Tuller Ohio, 2014

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Service and Support Administration: The Rule

Kelly Miller and Jean Tuller

Ohio, 2014

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Why Are You Here? No, really, why are you here…

• Share three reasons why you have stayed in the field.

• Where do you spend the majority of your day?

• What are you doing there?

• What do you think about that?

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What have we learned?• Too much emphasis on

paper and process

• Overly detailed monitoring plans

• Confused monitoring services and compliance of providers

• Believed we could not help individuals select a provider

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What’s different?

• Monitoring is individualized

• Responsibility of a team

• Natural supports important

• Person drives the supports

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What’s different?

• Ensures providers are trained on service plan

expectations

• Providers receive plan 15 days prior to implementation

• Outlines specific areas to assess

• Individual leads Person-Centered Planning process

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42 CFR 441.301

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Language from the rule

“Primary point of

coordination” instead

of “single point of

accountability”.

Team:

• People involved with

plan development or

implementation

• Guardian or

representative

• Specialists or

experts

• Anyone the

individual chooses

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Language from the rule

Decision Making Responsibility

• An individual cannot act as their own guardian (if guardianship has been deemed necessary)

• Addresses “best interest of the individual”

• It draws a bright line between representation and financial interest

• It affirms the primacy of “the individual's needs, desires and preferences.”

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Language from the rule

Provision of Service and Support Administration

Service and Support Administration provided to:

• Waiver recipients

• Individuals 3 years or older and eligible for county board services (if requested)

• Individuals residing in ICFDD (if requested)

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Language from the rule

Provision of Service and Support Administration

Service and support administration must be provided in accordance with the requirements of section 5126.15 of the Revised Code.

*There is no waiting list for service and support administration.

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Primary Point of Coordination

Responsibilities:

• Establish individual budget

• Objectively facilitate provider selection process

• Assist individual as necessary to resolve concerns/conflicts with providers

Language from the rule

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SSA Responsibilities:

Review and revise service plan at least annually and more often as needed.

Plans may need to be revised more often due to:

• Identified MUI/UI trends and patterns

• Change in living situation

• Change in medical condition

Language from the rule

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SSA Responsibilities:

Explain to waiver enrollees, including:

• Alternative services available

• Due process /appeal rights

• Free choice of provider/ provider selection process

• Freedom of choice (waiver vs. ICFDD)

• Services and supports funded by waivers

Language from the rule

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SSA Responsibilities:

Implement a continuous review process:

• Tailored to the individual

• Scope, type and frequency of reviews specified in service plan

• That ensures that service plans are developed in accordance with this Rule

Language from the rule

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Language from the ruleFrequency of continuous reviews may increase due to:

• Intense behavioral or medical needs

• Interruption of services more than 30 calendar days

• Crisis or multiple less serious but destabilizing events within a 3 month period

• Transition from ICFDD to community setting within past 12 months

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Language from the ruleFrequency of continuous reviews may increase due to:

• Transition to a new waiver provider in the past 12 months

• Individual’s provider is being suspended or revoked

• Request by the individual, guardian or adult identified by the individual

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Language from the ruleSSA needs to share the results of the continuous reviews with team members as appropriate.

If identified areas of non-compliance with waiver provider:

• County board conducts a provider compliance review or can request DODD to do so

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Primary Point of Coordination

The person we support

Assessment and Planning

Progress Notes

Monitor

Billing and Payment

Certify and license

providers

Eligibility and LOC

The Zen of DD-Everything is related to everything else.

Ohio’s ISP System

Gather person

centeredinformation

Discussand

makedecisions

Establish a budget

Keepthe planrelevant

Assessment

The

person and their circle

The ISP

Team

The ISP

Team

Anyone on ISP Team

IndividualService

Plan

IndividualService

PlanRevisions

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Assessments: Cuyahoga County Methodology Discovery of the person (assessment) is discussed as a

function of conversation. SA’s practice the art of

conversation to facilitate discovery – the challenge is to NOT

read down the list of questions in each topic area of the ISP

assessment but rather, to engage in conversation

and listen to

stories.

Then, record

information

on the

assessment

template.

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AssessmentsImportant

to/Important for

Risk Management

Employment FIRST

Working and not working

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Important to/Important

for• Gives people a structure to works towards a balance

between what’s important to someone and what’s important for them

• Useful for thinking through a situation before deciding what happens next.

Important to Important for2 4

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Important to/Important

for

What’s important to…

What’s important for…

What do we need to learn/know

Important to Important for2 4

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Important to/Important

for

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Risk Management

• Do I have adequate health care?

• Do staff know how to support my health and safety?

• Are my home and work place safe, secure, clean and well maintained? If I own or rent a home, have decisions about safety features been informed and freely made?

• Are my belongings secured at home and at work?

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Risk Management

• Can I get help in emergencies or dangerous situations? Do I need education and supports in this area?

• Do I know how to report mistreatment? Are education and supports necessary to assist with this?

• Are there safeguards to ensure that I am free from abuse, neglect and mistreatment?

• Do I manage my own finances? Do I need education and supports in this area? If I cannot manage my own finances, are there safeguards to protect my resources?

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Risk Management

Are you reviewing the person’s health and welfare

for risk of:

• Aspiration/choking?

• Dehydration?

• Constipation?

• Seizures?

• Specific health and medical concerns (e.g.,

diabetes, complications associated with a

feeding tube, unable to clearly report pain,

injuries due to falling)?

• Behavioral issues and supervision needs

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Employment FIRST

• Where do I spend my weekdays?

• Would I like a greater variety of activities?

• What new skills would I like to master?

• Do I like the people

I work with or spend

my time with during

the day?

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Employment FIRST

• Would I like a job or a different job?

• What am I proud of at work?

• What do I enjoy doing?

• What have I

accomplished?

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Working and not working

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Working and not working

Working and not working

• Analyzes issues across multiple perspectives

• Picture of how things are right now

• Excellent for pinpoint problem solving before planning next steps

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The assessment shall identify supports that promote:

• Rights

• Self-determination

• Physical well-being

• Emotional well-being

• Material well-being

• Personal development

• Interpersonal relationships

• Social inclusion and community participation

This conversation guide is intended to provide the foundation for

Discovery when someone is seeking support from a County

Developmental Disability Service Board in Ohio’s Region V.

The questions included are intended

to contribute to the identification

of current areas of the person’s

life that are important TO and

important FOR the person.

This guide is the beginning of

the discovery process. Further

exploration and discussion are

necessary when a specific area is

identified as a potential area of

needed or desired support.

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From the Imagine Discovery Guide

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Person-Centered Planning

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The Intention of Person-Centered Planning

• Improve the social status of people with disabilities

• Enhance the perception held of people with disabilities

• Expand the network of allies and associations in people’s lives

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Core Values The Cuyahoga County Community and Medicaid Services Department

• Respect

• Positive

Attitude

• Commitment

• Flexibility

• Integrity

• Professionali

sm

Reflecting Assessment

Results

Address Identifie

d Risk

s

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Person-Centered Planning

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Integrating Assessment into the ISP

For each topic, discuss the person’s preferences and decide:

• What does this person want to develop and/or change?

• Are there any obstacles to address?

• Does the person indicate an interest in pursuing other available services, providers, and/or staff?

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Integrating Assessment into the ISP

For each topic, discuss the person’s preferences and decide:

• Are there opportunities to enhance the person’s independence, integration, and productivity?

• Are there differences between what this person and the team want to develop and/or change?

• Does the person choose a recurring or one-time support?

• Is an action plan needed?

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One Page Profile

Person’s Name: _______________________This information comes from the person’s perspective.

Complete this page based on communicating directly with the person. If additional information is needed, include information from people who have direct knowledge of the person’s perspective.

What people admire most about me:

What is most important to me:

How to best support me:

(Thanks to Clark County)

Placeholder for picture

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7. Preferences & Priorities(What makes a good day/good life?)

1. Strengths & Talents(Things we appreciate and value)

2. Interests & Hobbies(What are favorite things or dislikes? Goals? Skills?)

3. Vocation/Living(Work interests? Volunteering? Daily living skills/pre-vocation?)

4. Fears & Obstacles(What are barriers to success?)

5. Supports Needed/Desired (Do’ and Don’ts)

6. Community Connections(What resources in the community will help reach success?)

_______________________’s Profile

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Some areas to consider

• Life in Current Living Arrangements

• Life in the Community and Social Activities

• Life at Work

• Life at Day Supports

• School and Life-Long Learning

• Health and Wellness

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Some areas to consider

• Financial Life

• Protection and Advocacy

• Cultural Considerations

• Behavioral Health

• Mental Health

• Transportation

• Assistive Technology

• Environmental Modifications

Reflecting Assessment

Results

Address Identifie

d Risk

s

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Person-Centered Planning

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The most basic of the Medicaid Basic Assurances

• Adequacy of current supports

• Unmet needs

• Relationships with medical professionals

• Physical fitness

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The most basic of the Medicaid Basic Assurances

• Nutrition

• Dental care

• Behavioral supports

• Mental health

• Advance directives

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Outcomes• M

y health does not interfere with my participation in the community

Goals• I

remain seizure free

Action steps1. I see a neurologist twice a year

2. My medication blood levels are

taken monthly and acted upon if

necessary

Health and Welfare in John’s life

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Outcomes• H

ealthy activities are a part of my life

Goals• I

learn to dance

Action steps1. I take dance classes

2. I go out dancing with friends

Health and Welfare in LaToya’s life

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Outcomes• I

am fit

Goals• I

weigh 12 pounds less

Action steps1. I join a fitness club2. I find a substitute for sugared soda

and ice cream drinks and identify

other foods that I need to substitute3. I track my weight weekly

Health and Welfare in Bill’s life

Reflecting Assessment

Results

Address Identifie

d Risk

s

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Person-Centered Planning

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Outcomes• I

work in my community

Goals• I

work at Wal-Mart as a greeter

Action steps1. I pick out attractive, age-

appropriate clothing2. I shake hands and say “Hi” to

people as they come through the

door

Employment in William’s Life

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Outcomes• I

become a cashier at a store in my neighborhood

Goals• I

work at Marc’s

Action steps1. I learn how to operate a cash register2. I learn how to handle a rude or

difficult customer3. I learn how to ask for a break if I am

having a hard moment

Employment in Anna’s Life

Reflecting Assessment

Results

Address Identifie

d Risk

s

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Person-Centered Planning

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Support Community ConnectionsAcknowledgements to Carol Blessing and Michael

Kendrick

Citizenship is a multi-dimensional concept equated with community participation, group identity, public practice and responsibility.

• Attained through access to community, self- determination, participation and the opportunity to make contributions that are welcomed and productive

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Support Community ConnectionsAcknowledgements to Carol Blessing and Michael

Kendrick

Citizenship is a multi-dimensional concept equated with community participation, group identity, public practice and responsibility.

Three dimensions

of citizenship:

• Social

• Political

• Legal

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Support Community Connections

O’Brien’s Valued Outcomes

• Community Presence

• Choice

• Respect

• Community Participation

• Competence

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Example of Community Connections Outcome

(Thanks to Licking County)

Outcome Linda gets out of her house more in order to experience new things and enhance her quality of life.

Important To/Important For Linda will have opportunities to do fun things while receiving the necessary supports from her provider to maintain her health and well-being.

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Example of Community Connections Outcome

Thanks again to Licking County!

Core ResponsibilitiesPlan more activities for Linda to do outside of her house. Assist Linda in engaging in those activities and arrange transportation.

Be Creative/Use Judgment Give Linda opportunities to try new and different things, to do things with roommates and by herself with provider. Observe Linda’s reaction to activities in an effort to determine what she enjoys and what she doesn’t.

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Outcomes• I

am a member of my community

Goals• I

volunteer at a soup kitchen

Action steps1. I learn to serve food 2. I learn good hygiene around food3. I learn the names of foods4. I am supported to find a soup kitchen

where I can work

Community Connections in Sam’s Life

Reflecting Assessment

Results

Address Identifie

d Risk

s

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Person-Centered Planning

"Being able to say when, how and who has been very important to my self-esteem…

 …People with disabilities are able to direct their own supports and should be given every

opportunity to do so."

Bernadette Thompson, North Carolina

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Outcomes• I

exercise my rights

Goals• I

vote

Action steps1. I learn what voting means2. I practice at a voting machine3. I vote in local elections

Self-Advocacy in Steve’s Life

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Outcomes• I

make big decisions in my life

Goals• I

plan my own daily schedule

Action steps1. I learn the concepts of “before” and “after”2. I cut out pictures of my daily activities

from magazines3. I paste the pictures on cardboard and

hang it in my bedroom4. I tell staff what I am going to do

Self-Advocacy in Gina’s Life

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Outcomes• I

speak up for myself and others

Goals• I

participate in a County Board workgroup

Action steps1. I talk to the Superintendent about joining a workgroup2. I select the workgroup that is most interesting to me. 3. I get support from staff to attend the workgroup.

Self-Advocacy in Barb’s Life

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Outcomes• I

learn to advocate for myself

Goals• I

will join People First!

Action steps1. I call People First to find out when

their next meeting is2. Staff assist me to attend a meeting

3. I talk with staff about my response to

the meeting and plans to attend again

Self-Advocacy in Jackie’s Life

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Outcomes• I

direct my own planning process

Goals• I

run my next ISP

Action steps1. I work with my SSA to identify where I want my meeting and who I want to invite2. I work with my SSA to make an agenda to help me direct the meeting. 3. I bake cookies for the meeting.4. I host the meeting.

Self-Advocacy in Kerry’s Life

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Outcomes• I

communicate what I want

Goals• I

learn to point

Action steps1. I choose between two things

(one I like and one I don’t)

Self-Advocacy in Karen’s Life

Reflecting Assessment

Results

Address Identifie

d Risk

s

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Person-Centered Planning

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Action Planning

• Why does a change need to happen?

• What are the challenges to meeting the desired outcome?

• How will the person benefit from this change?

• What is happening or not happening that needs to be different and why?

• What needs to be enhanced and why?

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Action Planning

• What is the meaningful change expected in this person’s life?

• How will person’s life be different/better because of this action plan?

• What do team members hope to see when this plan is completed?

• What does the person want to accomplish, learn or have?

Reflecting Assessment

Results

Address Identifie

d Risk

s

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Person-Centered Planning

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Risks: Important to / Important for

What is important TO a person includes what makes them happy, content, fulfilled and/or comforted.

• It is learned by listening to what people are saying with words and/or behavior

• When words and behavior are in conflict, listen to the behavior

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Risks: Important to / Important for

What is important FOR a person includes issues of health and safety.

• Physical health and safety, including wellness and prevention

• Emotional health and safety, including support needed

• What others see as important to help the person be a valued member of their community

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Risks: Important to / Important for

Balancing important TO and important FOR

• It isn’t either / or

• Address important FOR with pieces of important TO

• Without an important TO “hook”, our only option is

coercion

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Quick Summary: Risks/ How Addressed (Thanks to Licking County)

Discovered in: Short name Describe How addressed

Initial discovery

Communication & learning

Relationships

Day to day life Calorie and fluid intake

Joe has been known to exceed his calorie and fluid restriction. Excess

weight causes an increase in issues/pain in his feet. Excess fluid aggravates his sodium deficiency,

which can result in seizures or coma.

Provider encourages calorie and fluid limits

EmploymentFinance Too generous Joe can easily be talked into giving

money and gifts to others (especially women) even if it means he doesn’t

have money for himself.

Provider counsels regarding asserting himself and

monitor to ensure he isn’t taken advantage of. They

also ask that his family sign a loan agreement to document

any money they “borrow” with terms regarding

payback.

Getting around

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Quick Summary: Risks/ How Addressed

Discovered in: Short name Describe How addressed

Home & HousingHealth & Wellness

Self-injurious behavior & grass/pollen allergies

-Joe has a long history of self-injurious behavior, including episodes of hitting, slapping or poking himself in the leg, stomach or face repeatedly. He will also dip her finger in her food and poke or rub his eyes.

-Joe suffers from severe allergies to grasses and pollen, which cause itching and a rash, especially to his face.

-Whenever possible, engage Joe in activities to eliminate opportunities for self-injurious behaviors. Activities include looking at magazines, blowing bubbles, etc. -Praise Joe for his positive behavior when he is interacting appropriately with his environment.- Staff will assure Joe has a pad or blanket to sit on while outside to limit exposure to grass. Staff will attempt to direct him inside every 15-20 min. to break up his time in the grass.

Community Membership

Informal Supports

AlternativesEfficiencyEconomy

Quality

The SSA Rule Calls for A New Framework for Planning

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Do this ISP and support documents reflect…?

• How I exercise control over my life?

• What makes me happy?

• My hopes and dreams?

• Being with people I like?

• Where and how I want to live?

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• My cultural, spiritual , family

traditions?

• What I need to be safe?

• How I contribute to my community?

• New things I want to learn?

Do this ISP and support documents reflect…?

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• Where I want to work, what I’m

doing at work and how much I want

to work?

• The supports I need?

• How I want to handle my money?

Do this ISP and support documents reflect…?

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Independence: Having control and choice over one’s

own life.

Integration: Living near and using the same community

resources and participating in the same activities as, and

together with, people without disabilities.

Productivity: Engaging in work that contributes to a

household or community; or engaging in income-producing

work that is measured through improvements in income

level, employment status or job advancement.   

The Developmental Disabilities Assistance

and Bill of Rights Act of 2000

Do this ISP and support documents reflect…?

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Thoughts on progress notes

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Thoughts on progress notes

Why?

• Federal and state requirement

• Demonstrate that a service has been provided

• Formal record of service history

• Formal record of ongoing service planning

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Thoughts on progress notes

Why?

• Continuity of care

• It’s how we get paid

• We are telling the story of a person’s life and describing what we did to support that person

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Thoughts on progress notes

What?

• Who was involved in the encounter?

• Am I acting on

information provided?

• Am I monitoring by assessing the situation and developing a plan?

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Thoughts on progress notes

What?

• Am I communicating with team members to clarify an issue?

• Following a review of incident reports, am I providing relevant follow up, based on my assessment of the situation and identified needs?

• Whenever possible, tie progress note entries to the ISP

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• Arrange for assessments to determine eligibility

• Develop goals in ISPs

• Refer

• Link

• Monitor

• Follow-up

• Conduct individual QA reviews

• Review trends and patterns

• Coordinate

• Communicate

Specific Billable Language

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Successful SSA Units

have:

• Internal systems

that provide IP

oversight

• Monitoring

oversight supports

for SSAs

• Build-on Skills

• Determine

manageable case

loads

• Assist in problem

solving

We all have a hungry heart, and one of the

things we hunger for is happiness. So as

much as I possibly could, I stayed where I

was happy. I spent a great deal of time in my

younger years just writing and reading,

walking around the woods in Ohio, where I

grew up.

- Mary Oliver