service and support administration: the rule kelly miller and jean tuller
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Service and Support Administration: The Rule Kelly Miller and Jean Tuller Ohio, 2014. Why Are You Here? No, really, why are you here…. Share three reasons why you have stayed in the field. - PowerPoint PPT PresentationTRANSCRIPT
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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 ruleDecision 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 CoordinationResponsibilities:
• 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 informationon 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
forWhat’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 ConnectionsO’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 addressedInitial discoveryCommunication & 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 AddressedDiscovered in: Short name Describe How addressedHome & 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