You Are the Keystone for Individuals and Families...You Are the Keystone for Individuals and Families Now let’s use the ISP process to illustrate the roles of locate, coordinate,

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You Are the Keystone for Individuals and Families

This webcast includes spoken narration.

To adjust the volume, use the controls at the bottom of the screen. While viewing this webcast, there is a pause and reverse button that can be used throughout the presentation.

The written version of the narration appears to the right of the screen.

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Certificates of Achievement will be available to Supports Coordinators after completing all course requirements. Please view and then save or print your certificate in order to receive credit for this course.

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Hello, my name is Nancy Thaler and I am the Deputy Secretary for the Office of Developmental Programs. Welcome to your new job and your new role.

Your new job is to be a Support Coordinator. And as a Support Coordinator, you will have job responsibilities that are related to working within the service system to help every person and their family get the services and supports that they need.

But you have a new role, and that role is to help people have an everyday life. That means helping them find their voice, helping them dream dreams, plan for their future, build relationships, and be part of their community. And in doing that, you will make the world a better place because it will be a world in which everybody belongs.

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Hello, my name is Dave Maloney with The Columbus Organization and I will be the narrator throughout this webcast. The Columbus Organization is the vendor selected by the Office of Developmental Programs (ODP) to assist in the training of Supports Coordinators. I’d like to welcome you to your new job as a Supports Coordinator! I hope you find your work even more rewarding than you anticipated it would be.

The focus of this webcast is about how the system is organized. The title of the webcast is You Are the Keystone for Individuals and Families. Your relationship with the people you support is a foundation for the system. You will have a critical role in supporting individuals and families through locating, coordinating, and monitoring services. Other organizations and governmental agencies will also have a role in helping people you support to achieve an everyday life. Through oversight, administration, and policy, ODP will be central to all the roles you will play in supporting individuals and families.

The Mission of the Office of Developmental Programs is to support Pennsylvanians with intellectual and developmental disabilities to achieve greater independence, choice, and opportunity in their lives.

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During this webcast, you will:

* Learn how the Everyday Lives Values influence the Supports Coordinator’s work.

* Learn about the Supports Coordination (SC) roles of locating, coordinating, and monitoring.

* Learn about the role of the Office of Developmental Programs (ODP) in the delivery of services to individuals and families.

* Learn how the ODP service system fits within the larger context of other state agencies and federal government services.

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Building a trusting relationship is a key to supporting people to find an everyday life.

Leroy and his Supports Coordinator Tiffany have known each other for many years and have a great deal of trust in each other. Tiffany and others who know Leroy are able to say lots of things they like and admire about him. Leroy loves animals. He’s kind, always has a smile for everyone, and loves to tease and make people laugh. He’s a great storyteller. He has a unique perspective on how things have changed over the years. Leroy lived in an institution for some years and shares what he’s learned with others.

Now, Leroy lives with two friends he has known for years. He has a rich, full life in the community. An Everyday Life.

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In 2016, ODP gathered individuals, families, counties, supports coordination organizations, providers, and other stakeholders and formed the Information Sharing and Advisory Committee, or ISAC. The ISAC developed Everyday Lives: Values in Action, which includes what is valued by individuals and valued by families. The ISAC developed specific recommendations designed to improve how we help people to live an everyday life based on what people with an Intellectual Disability or Autism Spectrum Disorders, and their families say is important to them.

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This quote is one way to think about Everyday Lives.

“Our goal should be clear. We are seeking nothing less than a life surrounded by the richness and diversity of community. A collective life. A common life. An everyday life. “

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Everyday Lives: Values in Action is closely related to another foundational approach in supporting practices to help identify a person's unique strengths and needs: person‐centered thinking and planning, or PCT. PCT is the foundational tool the SC uses to ensure the person has a good life.

There’s training specific to PCT available on the MyODP Training and Resource Center,located in the category called "Foundations of Person Centered Thinking". Included among the PCT tools available for you are resources to help you create a relationship with the individual you support.

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One way relationships form is by learning what we appreciate about each other. In person‐centered thinking, “like and admire" identifies what you and others like about the person you support.

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Relationship building starts with understanding how the other person communicates. Communication tools help you understand when spoken language doesn't work. Remember that both words and actions tell us what support to give: behavior is communication.

Everyday Lives Values in Action provides vision and recommendations for the system to act in ways that promote hopes and dreams. The SC plays the most important role in knowing the person, in facilitating how we as a service system can assist the person in achieving their everyday life, and in being an advocate for the person receiving support.

There are many resources to learn about Everyday Lives and person‐centered thinking, including resources on the MyODP Training and Resource Center. Your supervisor can tell you more.

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The Individual Support Plan (ISP), at its most basic level, is developed to outline services and supports needed by the person you support. This plan is collaboratively developed by you, the person you support, others who the person would like to participate in the team meeting, and support professionals who provide services to the person.

The ISP documents the services and supports for the individual as determined by the individual and their chosen team members. It gives a complete picture of what is important to the person balanced with everything that needs to happen to make sure he or she is healthy and safe.

A well‐developed ISP is a living document. It provides a lot of information about the person over time, but it’s clear that it’s been reviewed and updated as the person’s life changes.

The SC has an important responsibility to complete the PUNS (Prioritization of Urgency of Need for Services) and other assessments. The PUNS helps to determine what services and supports are needed and approximately when they will be needed. The PUNS facilitates determining how urgently someone needs supports and services. Additional assessments such as the Supports Intensity Scale (SIS™), PA Supplement, and others are also required by ODP and integral to the services and supports planning process.

Resources available within the MyODP Training and Resource Center will help clarify the differences in practice for services overseen by the Bureau of Autism Services.

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Keeping in mind that the basis is always the relationships among the individual, family, and Supports Coordinator, an SC’s job is to locate and coordinate supports and services and monitor them for the individual receiving support. The quality of this work, supported by your Supports Coordination Organization or SCO, is of vital importance to ODP, which regularly qualifies each SCO.

The SC’s roles are: * Locate: Link, arrange for, and obtain needed services including medical, social, habilitation, education, or other community services the individual needs to live at home or in the community.

* Coordinate: Interconnecting services and supports and developing ISPs with the individual and their planning team, and updating the ISP annually and as needed based on the individual’s needs. Provide ongoing management of services and supports stipulated in the ISP in cooperation with the individual, family, and providers of service.

* Monitor: Establish and implement a means to assure the individual is receiving the appropriate quality, type, duration, and frequency of services and supports outlined in the ISP.

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Now let’s use the ISP process to illustrate the roles of locate, coordinate, and monitor.

In ISP development, the team may discuss the need for a new service or support. Let’s say the SC takes responsibility to make the referral to an agency after the ISP meeting. He or she would then be performing the role of locating services.

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An important part of the ISP process and supports coordination in general is discussion of how all those involved will work in harmony, avoid overlaps in the support they offer, and overcome barriers to service.

When the SC is facilitating the team to develop a plan that is collaborative and integrated, he or she is performing the role of coordination.

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Monitoring means contacting the individual, family, and team to ensure the ISP is being implemented as written and services and supports are provided as described. It can be informal – checking in to see how things are going – or formal, such as a structured process of regular contact with those receiving services. Supports Coordinators must also monitor the health and safety of the individual, take action if there are concerns, and ask the individual and family if they are satisfied with the services.

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Let’s discuss ODP’s role in the system. In our state, the Department of Human Services (DHS) provides many services to support Pennsylvanians in need of financial or medical support and home and community services for people with physical disabilities. Within DHS, the Office of Developmental Programs (ODP) administers programs for people with an Intellectual Disability and/or Autism Spectrum Disorder.

ODP is responsible for more than promoting a vision. Either through direct action or through delegation to partners, ODP is the authority responsible for regulation, policy, procedure, and practice to ensure quality throughout the system that supports individuals and families.

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The majority of ODP services are provided through Medicaid Waiver programs. Waiver means that certain federal Medicaid regulations are waived for services provided in the home and community that previously were only available in an institution.

ODP is responsible for these programs for individuals with an Intellectual Disability (ID) and/or Autism Spectrum Disorders:

* The Consolidated Waiver. This Waiver does not have a set cap on funding per individual.* The Person/Family Directed Supports Waiver. The P/FDS Waiver has an annual cap of $33,000 per individual.* The Community Living Waiver has an annual cap of $70,000 per individual. * The Adult Autism Waiver (AAW) provides specific services for eligible individuals statewide.* The Adult Community Autism Program (ACAP) provides services in some counties, operated within a managed care model.

ODP oversees Targeted Service Management (TSM), an optional state plan case management service for individuals who are MA eligible but not enrolled in a waiver program.

ODP also operates state centers, which are Intermediate Care Facilities for people with an Intellectual Disability (ICFs/ID). There are also community ICFs/ID operated by private agencies within the community. These facilities are usually much smaller, often eight‐bed sites.

In addition to the waivers, counties have access to some state‐only monies called base funds.

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Let’s fill in more of the picture of the system.

As you think about the work you’ll be doing as a Supports Coordinator, you can imagine there will be a lot of interaction with service providers. Providers are another vital piece in the support of individuals and families. ODP regularly qualifies agencies to provide services and supports for individuals with an Intellectual Disability and/or Autism Spectrum Disorder.

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Remember the person‐centered perspective and Everyday Lives Values we’ve talked about throughout this webcast. Service selection begins with learning what is important to the person you support, what supports are necessary, and how the individual wants support to be offered.

As the individual chooses providers willing to help in his or her daily life, the SC provides guidance, information, and support without influencing the individual's choice among providers.

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The process of service choice and selection may lead to the ability of the individual to access opportunities in the community as well as access agencies qualified by ODP to provide services.

You will over time need to become familiar with resources available in the communities in which the people you support live.

Supports can also include family, friends, or others that the individual knows.

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ODP Providers that hire their own employees to deliver service and are responsible for all aspects of service delivery are considered traditional providers. When individuals and families choose to have greater control over managing their services, including decisions like hiring their own staff or referring prospective employees for hiring, this is called the Participant Directed Service Model. ODP has two types of Participant Directed Service models: Agency with Choice and the Vendor Fiscal/Employer Agency model.

The more traditional provider model and participant‐directed service model are not mutually exclusive. Some individuals and families use one or the other, while others feel a combination of both works best for them.

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There are some important points to keep in mind when individuals and families are making choices about services and supports:

* The individual leads the team and the SC is the facilitator of the team. The SC’s role is to assist the individual and family to seek out and make choices of services and providers that would be appropriate to meet their needs.

* The individual you support always has the right to choose among willing and qualified providers. It is an ongoing discussion as to whether the agency meets their needs or if they are satisfied with the supports and services they are receiving.

* Providers in the ODP system must be qualified by the Administrative Entity (AE) or Bureau of Autism Services (BAS) based upon qualifying criteria established by ODP.

* Providers who are willing and selected by an individual and family must agree to provide the service as outlined in the ISP, including support for health and safety.

You’ll learn more about the specifics of provider choice, authorization, and community services as you gain experience. Links to information about ODP providers are located on MyODP Training and Resource Center.

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Let’s fill in another piece of the picture of the system.

At the beginning of the webcast, I talked about ODP’s responsibility for management of the statewide program and how it delegates certain responsibilities to partners. The Administrative Entity (AE) reviews and authorizes ISPs and works with the team to ensure the individual’s health and safety. The AE is a key external partner in the support of individuals and families. ODP maintains operating agreements with each AE to support the provision of quality services. For the Adult Autism Waiver, the Bureau of Autism Services (BAS) reviews and authorizes plans.

When AEs and the BAS review plans, they pay attention to the content to see if it fully describes who the individual is as well as if the plan conforms to ODP policies and procedures.

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AEs and BAS are also responsible to be aware of individuals waiting for services and to work with ODP to manage the waiting list. ODP is tasked with managing the waivers within a specific numerical capacity of individuals as designated by the federal government. ODP delegates to the AEs the responsibility of assigning and ensuring individuals’ needs are being met appropriately by waiver funding. One tool for doing this is the PUNS process, mentioned earlier. The PUNS process is the method that keeps ODP and AEs aware of the needs and circumstances of those waiting for services and facilitates planning for future needs.

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ODP delegates responsibility to AEs to register individuals and determine eligibility for services. Both BAS and AEs are responsible to ensure that individuals registered are given a choice of Supports Coordination Organizations, or SCOs.

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The relationships among SCOs, AEs, and BAS are collaborative. By that, I mean that AEs and the BAS depend on SCOs to keep them updated regarding the needs of individuals and families, offer information to prioritize those who are on the waiting list, collaboratively address needs, ultimately ensuring the health and safety of the individuals the AE, SCO, and BAS serve.

Resources available within the MyODP Training and Resource Center will help clarify the differences in practice for services overseen by the Bureau of Autism Services.

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To complete the picture of how our system is constructed, we now need to take a broader view, beyond the Office of Developmental Programs, to other state and federal agencies.

The Office of Medical Assistance Programs (OMAP) within the Department of Human Services (DHS) is responsible for the administration of Medicaid, the funding source for waiver programs. Eligibility for Medicaid includes an examination of the individual’s financial resources, which is determined by a separate office within DHS, the Office of Income Maintenance, or OIM. OIM operates through local County Assistance Offices (CAOs). AEs and SCs work with the local CAO on confirmation of eligibility for Medicaid Waiver Programs.

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Other DHS Offices collaborate on supporting individuals with Intellectual Disability and/or Autism Spectrum Disorders. For example, the Office of Mental Health and Substance Abuse Services (OMHSAS) can be a vital resource when someone has multiple diagnoses: Intellectual Disability, Autism, and a mental health diagnosis or substance abuse issue.

The Office of Long‐Term Living (OLTL) serves people with physical disabilities as well as the population of individuals who are aged and can be a resource for people with Intellectual Disability and/or Autism Spectrum Disorders.

The Office of Children, Youth, and Families (OCYF) collaborates with ODP when children and families require support from both Offices.

It’s important for SCs to learn about other specific programs DHS administers and the rules that govern them. For example, when services can be paid through Early Periodic Screening, Diagnosis, and Treatment (EPSDT), those services cannot be authorized on the ISP as a waiver‐funded service.

You’ll learn more about specific programs and the rules of each as you gain experience. The DHS website can be useful in learning about specific programs.

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A priority for ODP is to promote competitive, integrated employment as often as possible when it aligns with individuals’ desired outcomes. The Office of Vocational Rehabilitation (OVR), part of the Pennsylvania Department of Labor and Industry, is an active partner with ODP in providing guidance and support to help individuals with an Intellectual Disability and/or Autism achieve the goal of working in the community.

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Most individuals served by ODP are also receiving federal Social Security or Social Security Disability Insurance. Supports Coordinators are expected to become familiar with how these federal programs operate and the impact benefits may have on other services the individual is receiving.

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The Federal Centers for Medicaid and Medicare Services (CMS) provides funding and oversight for many of the programs and services we’ve discussed in this webcast, especially Medicaid Waiver programs. CMS expects states to offer individuals choice of waiver services in integrated community settings (regulations clarify the characteristics of services that are considered community‐based and those that are not), and that health and safety are ensured for the people receiving services and supports.

CMS also expects states to promote choice and self‐determination when people receive services in the home and community. And in this respect, we’ve come full circle to where we began the webcast. The values of a person‐centered approach, an everyday life in the community, and choice and inclusion are not only the basis for a strong relationship between an individual and a Supports Coordinator. They are also the values that pervade the entire system, including the federal programs that fund and oversee services within Pennsylvania.

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Here’s an example of how these expectations influence the system:

In 2014, CMS issued guidance that people should receive services in the community, not in segregated settings. This means that people are not just present in the community, but that they are known, they are recognized and welcomed, missed when they’re absent. They are a part of the everyday life of their community just like everyone else.

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When Deputy Secretary Thaler introduced this webcast, she said that your role is to help people find their voice, reach their dreams, and be part of their communities. Our system is founded on those essential values that will help everybody belong.

I hope you look forward to your role in making that happen!

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This webcast has been developed and produced by The Columbus Organization on behalf of the Pennsylvania Department of Human Services, Office of Developmental Programs.

Thank you for participating in this lesson.

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Documents

You Are the Keystone for Individuals and Families...You Are the Keystone for Individuals and Families Now let’s use the ISP process to illustrate the roles of locate, coordinate,