Monitoring is a critical part of a service coordinator’s relationship with members and residents. Thank you all for sharing tips on how you continuously engage with clients over time. It would be terrific to generate a list of helpful probing questions to aid in the ongoing assessment of how members/residents are doing in the monitoring phase. Please comment!
Tag Archives | Case Management
Sample ISP
By admin on April 16, 2013 in Initial Service Plan Templates, Reference Information, Templates for Documentation
Hi All,
This was a group activity during new SC orientation. The group produced a sample Initial Service Plan that Alexa typed up. See attached!
Initial Service Plan
SC met with member in the office requesting assistance with grooming, transportation, and emergency food assistance. Confidentiality forms and consent to release information forms were signed by member.
Intake, ADL, and individual, assessments were completed in the office, as member felt more comfortable meeting in this venue. Member requires assistance with the following ADLs: grooming (fixing hair) and transportation. Member’s daughter typically assists with these needs, but daughter is out of town at this time. Member is considered at risk based on this assessment.
1) SC will support member with identifying resources for assistance with grooming within 1 week.
- Member will identify other family members who may be able to assist with her grooming.
2) SC will support member with identifying and coordinating emergency food assistance within 1 day.
3) SC and member will discuss and identify resources for transportation to assist with grocery shopping within 1 week.
4) SC will assist member with obtaining a replacement Bridge Card within 1 week.
- SC will provide member with contact information to request a replacement card.
5) Next SC appointment is scheduled Tuesday.
6) SC will continue to monitor and assess member’s needs every 30 days, or as needed.
A.L. 3/13/13
Reoffering SC Services
Hi All,
I’m posting this now, because we are approaching the “first year” anniversary of a large number of SCs. Congrats all!
This also means that a number of you have reached the point (365 days – or one year) when you need to re-explain and re-offer your SC services to members/residents who declined SC services at this time last year.
So, what does this entail?
Case management procedures explain that you do need to personally offer your services to members/residents once a year. A personal offer means that you specifically explained your services and offered them to an individual member/resident. This can be in the form of a direct, face-to-face conversation in your office, their apartment, or in a discrete location in the common areas; or this can be a personalized letter (clipped to door – if approved in your Co-op/Village), “snail-mailed” via USPS, or otherwise delivered; a voicemail message if you have access to a telephone number; or a comparable direct offer. If the member tells you in person, over the phone, on your voice mail, or in writing that they are either accepting or declining your services, you are done! The “ask” is complete and you either proceed with an intake, assessement, and Initial Service Plan for the member/resident, or you note in your Progress Notes the method of offering your services, the method in which they declined, and the the next step is that you will reoffer services again in another year (unless they come to you first).
If there is no answer to your initial inquiry, you need to reoffer your services up to 3 discreet times. Each must be recorded in your Progress Notes. If a member/resident does not answer your inquiry after 3 offers, you can consider it to be a “no” and that they are declining your services. Please note this in your Progress Notes and your next step will be reoffering your services in another year.
Possible tips:
– Let your Co-op Leadership Team (or Village Administrator) know that it is a time of year that you are re-offering your services to members/residents. Explain the process. Also explain that if members/residents report feeling badgered or pressured by multiple inquiries, they simply need to respond yes or no to the SC and the process will be finalized without additional inquiries for another year.
– Announce during your scheduled educational workshop that this effort is in progress.
– Hold another “meet and greet”.
This is a great topic for a SC Conference Call to share what is working (and isn’t) at your site.
Enjoy this opportunity to reintroduce yourself to members/residents you don’t see as often, may have been initially uneasy about the SC program, or have experienced life changes in the past year that have made them ready to consider working with you.
Non-participants
Question:
It’s getting to be about time to start offering members services again. If a member signed a nonparticipation form in 2012, do we have to ask them if they will sign the form again?
Answer from Cheryl:
No. I think you just ask them if they want services and if they say no just put
it in the PNs for the limited file the person has. C
Monitoring Residents/Members – Helpful Hints
Based on questions and feedback from SCs and audit staff, here are some helpful hints for monitoring clients:
1. The SC should monitor frail and at risk clients a minimum of every 30 days (note that this is more specific than “monthly”).
2. The SC should monitor all other clients a minimum of every 90 days (note that this is more specific than “quarterly”).
3. Monitoring must include direct, individualized contact. Hence, a group service log and progress note indicating that the client attended an educational workshop hosted by the SC is not sufficient. However, the SC can talk with the client individually at the event and note that direct contact in the PN, which could be considered a form of monitoring (as long a the client didn’t have follow-up needs that constituted more intensive monitoring).
4. I recommend that if you follow up with a client one month at an event (such as an educational workshop or Focus Hope delivery) or via phone, that the next month be an in-home or in-office visit.
5. Monitoring must indicate progress towards goals the client’s Initial or Updated Service Plan.
Changes to Case Management Procedures
Cheryl, Rachel and Brenda had the opportunity to discuss some of the issues that we have heard the service coordinators are encountering that impact our case management procedures. After discussion, we are going to revise our case management procedures as follows:
1) When attempting to offer services to residents/members that are either new or annually, three separate documented attempts without response will constitute a “refusal” of services. This means that you need to attempt three different types of direct contact with the resident/member and document each attempt. Only after that third unsuccessful attempt is it considered a refusal. Seperate direct attempts include telephone messages, notes under the door, or direct mailing. Once these three attempts have been made and the resident/member does not respond to you then you can document that the resident does not want services at this time in your progress notes.
2) The “Non-Participation Form” will ONLY be used when a specific service is offered and declined. The form does not need to be signed by the resident/member when you are simply offering the services of the Service Coordinator, when they are new or annually, and they decline. A specific service would be a service that is specifically being offered to the resident because of a referral from management, the FCRC, or something that the Service Coordinator deems as being an imminent/emergent need that the resident refuses. The specific service being offered can be detailed in the “comments” box. A resident/member can sign a “Non-Participation Form” and still be considered an “active client” of the Service Coordinator, still receiving OTHER services, but refuses a specific service.
3) Group Add Service Logs and Progress Notes are to be completed for ALL residents regardless of client status. Therefore, any resident that attends an educational session will be included on the group add on the Service Logs and Progress Notes.
4) Service Logs should be used on any contact with the resident/member and the Service Coordinator needs to utilize the “subcategory” when identifying the type of service provided. We are asking that all Service Coordinators make a concentrated effort to eliminate “Other” as an option and that you specifically categorize your interactions.
All of these updates go into effect today. Should you have any questions, please do not hesitate to contact us.
Hannan Service Center September Intake Schedule
Hannan Zena Baum Service Center Intake Responsibility and student schedule – September 2012
See attached.