IDD Service Coordination

1. IDD Service Coordination And how to document!

2. What is MR Service Coordination? • It is defined as (TAC Title 40, Part 1, Chapter 2, Subchapter L): • Assistance in accessing medical, social, educational and other appropriate services and supports that will help and individual achieve a quality of life and community participation acceptable to the individual (and LAR on the individual’s behalf) as follows:

3. Crisis Prevention & Management • Linking and assisting the individual and LAR or actively involved person to secure services and supports that will enable them to prevent or manage a crisis • Key words: • LINKING and ASSISTING • SECURE SERVICES & SUPPORTS to PREVENT or MANAGE a CRISIS • Service Code: • 103 (with client – Type A Service) • 108 (with LAR/Collateral/Client – Type B Service – Any type of contact except correspondence)

4. Monitoring • Ensuring that the individual receives needed services, evaluating the effectiveness and adequacy of services, and determining if identified outcomes are meeting the individual’s needs and desires as indicated by the individual and LAR or actively involved person. • Key words/Phrases: • ENSURED…. EVALUATED EFFECTIVENESS OF… • EVALUATED ADEQUACY OF… • IDENTIFIED that ____ is meeting NEEDS or DESIRES • Service Code: • 103 (with client – Type A Service) • 108 (with LAR/Collateral/Client – Type B Service – Any type of contact except correspondence)

5. Assessment • Identifying the individual’s needs and the services and supports that address those needs as they relate to the nature of the individual’s presenting problem and disability • Key words/Phrases: • IDENTIFIED _____’s NEEDS as _________ • _____ NEEDS the following SERVICES and SUPPORTS based upon __________ … • Due to the following PROBLEM ____ , the TEAM agreed that _______ SERVICE will assist … • Service Code: • 103 (with client – Type A Service) • 108 (with LAR/Collateral/Client – Type B Service – Any type of contact except correspondence)

6. Service Planning and Coordination • Identifying, arranging, advocating, collaborating with other agencies and linking for the delivery of outcome-focused services and supports that address the individual’s needs and desires as indicated by the individual and LAR or actively involved person. YOUR TURN – • What Are The Key Words/Phrases?? • What Billing Codes Could Be Used? • What Services Could You Do For This?

7. Who can receive Service Coordination? • Person who is a open to IDD Services (has a diagnosis of Mental Retardation or PDD or a Related Condition as defined in the rules) • MUST HAVE: • Two (2) or more documented needs that require services and supports other than service coordination • Be in the process of enrolling in the • HCS program, or ICF/MR program, or TxHmL Program • Be seeking admission to a state supported living center • Be transitioning from an ICF/MR or state supported living center to community-based services other than an ICF/MR or Nursing Home

8. Need for Service Coordination • Service Coordination Evaluation Sheet • There is this wonderful form call the “Service Coordination Evaluation Sheet” that each MRA (mental retardation authority) must use to assess a person’s needs. • There is also an assessment tool called the “Discovery Tool”. That helps you find out more about the person you are providing services to, including their likes, dislikes and all kinds of things about them! • Based upon these assessments, the MRA must develop a plan of services and supports to meet the needs of the individual. • These and many other forms can be accessed at www.dads.state.tx.us

9. Speaking of forms… Every person served will have the following documents in their chart (this is not a comprehensive list): • DMR (diagnosis of “mental retardation”) * mental retardation is a legitimate diagnosis, however we now to use the term intellectual and/or developmental disability outside of referring to this assessment • Demographic form • Service Coordination Evaluation Sheet (annual) • Person Directed Plan (PDP) with Signature Sheet • Individual Plan of Care (IPC) *if HCS/TxHmL consumer • Comprehensive Assessment Tool (CAT) • Discovery Tool *if HCS/TxHmL consumer • Quarterly Reviews (completed by Service Coordinator) • Progress Notes completed by the Service Coordinator (these should all be electronic and only be in Anasazi now) • A whole bunch of consents and waivers (client rights, explanation of services, HIPAA rights, Assignment of Service Coordinator, DMR Waiver, Request for Services, Program Services/Options Preferences, etc…)

10. Forms that are VERY Important to Complete/Update at least Annually • Consumer Demographic Form – This form should be updated in Anasazi any time that there are changes to a person’s address, phone number, primary caregiver, etc… • Contact Form: HCS and TxHmL has a form called “contact form” that must also be done and copies have to be given to consumer, primary care giver/LAR, and provider! VERY Important to do annually!! • Financial Assessment – This form should be completed/ updated at admission, annually and upon any changes to a person’s income or insurance benefits. It is now in Anasazi under initial and annual paperwork. There are two sections to this form and both sections must be completed! One section is the financial assessment and the other is the section that the consumer signs off on allowing us to bill them or their insurance company for services. • Rights Forms (received the rights booklet) – you will learn that there are many rights booklets and people have to get the correct ones! :0) VERY Important to do annually!! • Authorization(s) for Disclosure – These forms allow us to talk to other people in the person’s life. If the person is over 18 and doesn’t have a guardian, we must have consent to discuss their case with other people – including their parents/primary caregivers. DADS requires us to use their forms. It can be found in the IDD records room or at http://www.dads.state.tx.us/forms/search.aspsearch for form 8502 or 8502-S (Spanish) There are other DADS forms at this site, if needed, such as the “contact form” “Rights forms” all kinds of forms! 

11. What do Service Coordinators Do??? You are the “superhuman” of the team! Besides being the #1 contact for the person served, family and team • You write the Person Directed Plan • Follow-up to make sure the person is satisfied with the services & supports they are getting • Figure out if the person has other needs and get’s them “linked up” with those services & supports • You are the person’s advocate • You empower people to make their own decisions and work towards meeting their outcomes

12. PDP Writing Basics PDP writing is something that cannot be taught in a power point (okay, it can, but it would be one long, tedious presentation – longer than this one!) HINTS: • Ask the person served if the provider can attend the PDP meeting! Why? Because the provider is the person/agency that will be carrying out the plan! • Ask the person served if they have any family members or friends they want to attend the PDP meeting. Why?Because this is a perfect opportunity to get your written authorization for disclosures.

13. PDP Writing Basics, con’t… 3) Outcome/Purpose – This is what the person wants from services. This can be very specific or very general. There could be just one broad outcome or multiple outcomes. For each outcome/purpose the team will need to come up with strategies for the individual to reach/achieve those outcomes. Some outcome examples (not a complete list!) • Choose where to live (SHL? foster companion? residential?) • Choose who helps them at home (foster companion? residential support? SHL?) • To get a job at a store (supported employment?) • Learn how to cook meals for myself and my friends. (Day Hab? SHL?) • Make choices about what to do in their free time (SHL?) • Make own decisions or choices about daily schedule (SHL? Day Hab? SE?) • Choose what to do/how to spend own money (SHL? Day Hab?) • Learn how to do things in the home so I can move out some day (SHL? Day Hab?) • Learn how to make more friends and socialize more (SHL? Day Hab?) • Be healthier (nursing? dental? dietary services?) • Get time away from my family every once in a while (respite?) • Get what I need to walk better (adaptive aids? )

14. Person Directed Planning • The Texas Department of Aging and Disability Services (DADS) has standardized the PDP document. • Strengths with standardized PDP: • Consistency – ensures each area of need is reviewed for every individual • Provides a structure for staff to make sure that they address consumer’s strengths, capabilities, areas of need and outcomes or desires. • Provides choice from consumer to include who they want involved in their planning process • Clearly identifies who the person’s community supports are • Challenges with standardized PDP: • Can become routine for SC and plans could look the same from person to person • Process to develop plan can be long when not familiar with the plan format or when the person has limited community/family supports • Discovery tool process can take a lot of time, you need to talk to the person, the primary care giver, and even the provider(s) of services (like direct care staff). Sometimes the people we serve feel that this takes too long and is too much information about them. • Easy to “cut and paste” resulting in not really updating or individualizing. • Doesn’t automatically link to IPC – this can result in oversight in listing everything in one or the other documents (not matching up waiver and non-waiver services) • Challenges with Statewide Implementation: • Multiple changes in several years – staff learn one process, then changes happen and have to learn new process. HCS and TxHmL don’t have the same PDP format.

15. PDP Writing Basics, con’t… Implementation Strategies (IP) – Okay…this is the “Provider’s side of the House” but you still need to know and understand it! • Need to be individualized • Need to be measurable (you need to be able to evaluate the progress) • Each outcome needs at least one strategy – some will have many – it may take many steps to reach an outcome (remember, it took many steps for you to become a Service Coordinator – which was one of your “outcomes”). • Example: Each step to reach a person’s outcome should be based upon what others have observed, what the various assessment have determined they can do with and without prompts/assistance/ independently, what barriers may be hindering their achievement, etc… so, “learning how to do things by myself at home” may first start out with learning the basics such as “learning hot and cold water/adjust water temperature” first before they learn how to take a bath on their own may be one of many strategies to reach the outcome of: doing things by themselves at home.

16. PDP Writing Basics, con’t… Outcome Oriented and Observable/Measurable WHAT??? YUP, still IP stuff but…you still need to know and understand it! Remember these key points: When you review the strategies, you should be able to tell whether or not an action or event has occurred. (you should be able to say “yes, Suzie learned to adjust the water temperature in the shower safely so she doesn’t need her mom to do it) Observable means that the action or event can be detected by using one or more of the five senses: sight, touch, hearing, taste or smell. Measurable means that you can calculate progress and know if the person accomplished the “task” and how many times. This will end up being the Implementation Strategy: Objective: Suzie will adjust the water temperature to warm with three verbal prompts, 4 out of 5 days a week for six (6) consecutive months. observable Measurable Outcome oriented

17. PDP and the IPCIPC’s are for HCS and TxHmL Participants Based upon the PDP Outcome the IPC is Developed. For every outcome there must be an “identified service” on the IPC. Not all of the “identified services” are going to be “waiver” services provided by the HCS or TxHmL program. For example: Bob may have the following outcomes (shortened for space)

18. IPC Waiver Services • These are listed on the IPC’s. They will listed as services such as the following (partial list): • Adaptive aids • Audiology • Foster/Companion Care • Dental • Nursing • Supported Home Living (SHL) • Behavioral Support • Day Habilitation • Etc… • Each one of these services will require: Authorized Units, Unit Rate, Estimated Annual Cost

19. IPC Non-Waiver Services provided by family and other funding sources • These services must be listed on the second page of the IPC. Any “non-waiver” service that is provided by a community provider or family, that is mentioned in the PDP, must be listed on the plan. • For example, if Bob’s mom provides transportation to and from medical appointments and recreational activities this must be listed. Also, if mom is representative payee – her managing finances must be listed. • If Bob see’s a private doctor and dentist – they must be listed • The Bob gets food stamps, medications from a pharmacy and has a supervisor from his volunteer job – they all must be listed if they are mentioned in the PDP (and they should be mentioned, as they are very important to who Bob is)

20. Other Non-Waiver Services • School District Services • Medical Services (Doctors, Dentists) • Therapists – (that aren’t being billed through waiver program) • Family transportation assistance • Assistive Technology “assessment part” – adaptive aids will fall under waiver • Home health services • Community transportation • Food stamps • WIC • Food bank • Pharmacies • Texas health Steps • Other community services that aren’t paid for through waiver program funding

21. Service Coordination Contact Notes • Based upon the discovery tool and PDP, you will determine the frequency of contacts needed for each individual served. • With most of the people we serve, they will have a moderate to intensive need for service coordination.(will have 2 or more unmet outcomes) • Basically, this will mean that you need to maintain contact with the person to follow-up on the unmet outcomes at least once a month and also document (face-to-face) • You will also need to document your “other” contacts during the month with “collaterals” or with the person served.

22. Collateral Contacts… That means your phone contacts with “mom” “dad” “primary care giver” “food stamp office” “local church to see if they have food available” “local housing authority” “probation office to coordinate services” “fire department for smoke detectors” etc…

23. HOW to BILL? • 103’s (A contacts) Service Coordination FACE-to-FACE contacts with the CLIENT Meetings with the client to do the BIG 4 • ASSESSMENT • SERVICE PLANNING & COORDINATION • MONITORING • CRISIS PREVENTION & MANAGEMENT

24. SC Contact Note 1. Who received the service 2. Whatservice they received 3. When they received it 4. How long they received the service 5. Where the service was provided 6. Reason for contact 7. Progress and status towards outcomes 8. New Need(s) Identified? ___ No ___ Yes If yes, what? _ 9. Pertinent information: 10. Next scheduled appointment: 11. Who provided the service

25. The Basics of a SC Note The basics of the note are buttons to push in Anasazi. You get to check off the who, what, when, how long, where. Sounds easy, right? Right! 1. Who received the service. If you provided the service to the person served, check “Client”; if it was the person served (they are an adult) and their primary caregiver – check “Client and Primary Care Giver”; if it is the person served (they are a child) and their parent/guardian check “Client and LAR/Guardian”; etc… Just don’t forget to check the correct option – because when the person reading the note (the auditor, the payor – such as Medicaid, or even the person served) reads the content and you wrote that you met with “Bob and his sister” but you only checked off “client” in the billing section, you just made the note non-billable.

26. The Basics, con’t… 2. What service they received. This is where you choose the “IDD Service Coordination” code and decide whether or not this is your “A” contact or one of your “B” contacts in Anasazi. Remember! You are to have one (1) primary contact a month with the person served a month. This is your “A” contact. This contact should be where you meet “Face to Face” with the person and find out whether or not they are satisfied with services, if they are making any progress towards their goals, if they have any needs, follow-up on things, link & refer, etc… (more details to come!) Your “B” contacts should be at least three (3) a month and can be with the person served or with other people/providers in the person’s life (more details to come!)

27. The Basics, con’t… • When they received the service. This is the date that you provided the service. • How long they received the service.This is your start time and stop time for the service. You are not to include any travel time to get to/from the service. You cannot bill for services if you are transporting (e.g. person needed a ride home, so you drove them home and talked to them the whole way home about how they are doing – this is NOT billable). • Where they received the service. This is fairly simple – you get to choose “home” “office” “other” “school” etc… If you choose “other” or “school” you must specify in the note where exactly you provided the service. For example: “other” could be “at boyfriends house” “at grandmother’s home” or “school” should be specific such as “Oak Park Elementary School” “George West High School”

28. “Nitty Gritty” of SC Notes 6. Reason for Contact: This is where you put down a brief statement of the purpose of the contact. Some reasons for a strong service coordination contact can be: • Assessment – identifying the person’s needs and the services and supports to meet those needs (as they relate to their intellectual disability). • Service planning and coordination – identifying, arranging, advocating, collaborating with other agencies and linking for the delivery of outcome-focused services and supports that address the individual’s needs and desires • Monitoring – ensuring that the person is receiving the needed services, evaluating the effectiveness & adequacy of the services, and determining if identified outcomes are meeting the individual’s needs and desires • Crisis prevention and management – linking and assisting the person to secure services and supports that will prevent or manage a crisis DADS Service Coordination (Data Verification Manual) RO 14)

29. “Nitty Gritty” con’t… 7. Progress and status towards outcomes: This part of the note will be unique, based upon what the reason for the contact is. The most important part of this section is to tie the progress and status back to the reason for the contact! For Example: Assessment: Met with Suzie to assess her current needs and desires re: Day Hab services. Told her Tom had called stating she had met her homemaking objectives of preparing her own sandwich for lunch. We reviewed assessment tool and asked Suzie what she wanted to learn. Suzie said she wants to cook pot roast at home.

30. Another example… Monitoring: Met with George and his mom at his house to monitor his progress towards his outcomes. George mostly shook his head “yes” to every question asked. Asked both George and his mom if they were satisfied with the services provided at the day hab and if he is progressing on his training. Mom said that George comes home happy most of the time. She stated that he brings home his papers that he works on. George got up and brought back some papers with drawings on them. Mom reported that she couldn’t take George to the dentist and hasn’t rescheduled. Asked if Community Supports needed to take him. Mom stated she would do it. She got refills of his meds from CVS pharmacy last week and will take him to see doctor next week. Mom said she is still rep payee for George’s SSI and food stamps. Mom packs George’s lunch because he likes to take his lunch box to “school” as she calls it. George continued to carry his lunch box and backpack everywhere he goes.

31. “Nitty Gritty” con’t… 8. New Need(s) Identified? ___ No ___ Yes If yes, what? _ This is a new section in the SC Template. The purpose of this is to highlight any new needs that may have arisen in the contact that might otherwise get lost within the content of a “narrative” type note. Examples: New Need(s) Identified? ___ No _X__ Yes If yes, what? Jenny has a rash on her right arm. Nurse contacted. Community Supports to take to Dr. at 3 pm today. New Need(s) Identified? ___ No _X__ Yes If yes, what? Suzie wants to learn to cook a pot roast – team meeting scheduled for next Wednesday. New Need(s) Identified?_X__ No ___ Yes If yes, what? New Need(s) Identified?___ No __X_ Yes If yes, what? Ralph needs his bike repaired or new bike to get around town.

32. “Nitty Gritty” con’t… 9. Pertinent information: Yes! Another new section of the progress note template! This is for ‘other information’ that may not be “new needs” but is still very important to the person’s case. Examples: Pertinent Information: George still needs to go to dentist. Pertinent Information: Jenny went camping this past weekend Pertinent Information: George’s mom has applied to become guardian Pertinent Information: Suzie is afraid that her mom won’t let her cook at home. Pertinent Information: Ralph’s bike broke this past weekend.

33. “Nitty Gritty” con’t… 10. Next scheduled appointment: • This is to prompt you to document your scheduled appointments. • This does not mean that you will not have other documentation in between these scheduled appointments however, it does help the people served know when you might be coming to see them the next time. • This is just respectful. Most people do not like people just dropping in on them. People like things scheduled. A lot of people like routine. Try to schedule your monthly visits on the same day and time each month (e.g. the first Thursday of the month at 3:00 pm) 11. Who provided the service • Most of your notes are going to be “Electronically Signed” as we have moved to the Electronic Medical Record (EMR). • Make sure that your signature has your credentials after it – your credentials should be “S.C.” for Service Coordinator, not your B.S., B.A., M.S., M.A. or QMRP!

34. Example.Without any billing information, of course… Reason for Contact: Monitoring Progress and status towards outcomes: Steve states he enjoys Day Hab. He continues to practice computers and cooking with some improvement. Community Supports takes him shopping for groceries once a week, comes over daily to help him cook dinner and make sure he takes his medicine. He says “Barb” is nice, but “Kate” wants him to “eat good food” like vegetables and tells him he drinks too much soda. He says they both help him cook and he cooks his own meals too (progress noted as cooking food on own). He says he doesn’t see nurse, that “Barb” does his box (pill box). Steve said he went to “that doctor” last week that gives him the pills (psychiatrist) and he said he was doing good, progress noted as he is smiling and not exhibiting signs of depression. He’s mad because the pharmacy makes him pay for his pills (has co-pay of $3 each). He says he doesn’t have to go to dentist for a long time, now that he has new teeth (dentures). New Need(s) Identified? ___ No _X__ Yes If yes, what? How to clean dentures as part of DLS - Community Supports Pertinent information: Nurse’s name is “Barb” Next scheduled appointment: next month – 1st Wed of month after day hab __Jane Smith, SC_________ __7/18/12______________

35. So, what will a SC Progress Note Look Like? Billing Info will be the same (hey, it is Anasazi!)– you know, the basics: client name, date of service, start time, stop time, etc… Reason for Contact: Progress and status towards outcomes: New Need(s) Identified? ___ No ___ Yes If yes, what? Pertinent information: Next scheduled appointment: __signature, title______________ ___ date___

36. Key Words & Phrases • When providing Service Coordination make sure you use some “key words” and “phrases” in your notes such as… • Linked • Identified • Arranged • Advocated • Monitored • Evaluated the effectiveness • Determined that ___ outcome is/is not being met • ____ is receiving ____ service as identified in plan and this service is/is not meeting current needs • Helped secure ______ crisis services by _______ to ____ • Coordinated _______ as current need was _________

37. What you can’t do as a 103 • NO TRANSPORTATION • Services with other people (family members, LARS, collaterals such as law enforcement, probation, food bank, etc…) • Telephone contacts • Going to house but no one is home and recording it as a 1 minute f-to-f contact (record it as a 103 NO SHOW)

38. Documenting Collateral Contacts • 108’s are where to document legitimate collateral contacts or “B” contacts. • What are legitimate collateral contacts? They are contacts with family members and services/supports in the community in which you are providing “Service Coordination” (the big 4) • ASSESSMENT • SERVICE PLANNING & COORDINATION • MONITORING • CRISIS PREVENTION & MANAGEMENT

39. 108’s continued • You can also document your telephone contacts with the consumer, IF they are actual Service Coordination • ASSESSMENT • SERVICE PLANNING & COORDINATION • MONITORING • CRISIS PREVENTION & MANAGEMENT

40. What if the contact IS NOT Service Coordination? • If your contact ends up being “informational” and thus NOT BILLABLE • Use a 102 billing code • For Example… • Susie Client calls you up crying to tell you that she is having problems with Josie (another client) at the Day Hab. She says that she and Josie like the same guy (which has gone on for years). You talk to Susie about relationships and how to try to get along with Josie. She finally calms down after a ½ hour. You document this, as this is part of Susie’s depressive cycle, but it is just informational at this time.

41. What is this an Example of?103 or 108 or 102 Reason for contact: Monitoring Progress and status towards outcomes: Medical/dental: Bob went to the dentist this month but did not get the examination because he couldn’t sit still. Bob is still seeing Dr. Smith for seizure disorder, next appt in 2 mo after Depakote levels drawn. School issues: Bob nodded his head yes when asked if he is doing well in school. Mom reports that he has issue of grabbing girls. School is wanting to put him in a different class. Mom and Bob don’t want this. New Need(s) Identified? ___No _X_ Yes If yes, what? Referrals to dentists who take Medicaid and treat people with unique needs. ARD to address challenges in the classroom. Pertinent Information: Mom will call school to set up ARD and advise SC of meeting date/time to assist with advocating. Mom requested specialist in dental care. SC to call mom with dentist info. Next scheduled appointment: Mom to call with ARD date/time.

42. What is this an Example of?103 or 108 or 102 Reason for Contact: Service planning & coordination Progress and status towards outcomes: Tx team met to arrange for additional behavioral support services for John based upon continued issues at Day Hab. Day Hab staff and Psychologist noted that John has been slapping at anyone who walks by him for the last two months. Tracking of behaviors indicates this behavior occurs on random dates and at random times. There are no precipitating triggers that can be found. Health reasons ruled out. Team agreed to implement a behavioral support plan. See IDT dated this date for details. New Need(s) Identified? ___No _X_ Yes If yes, what? Training for all Day Hab staff by psychologist on BSP Pertinent Information: Mom states that John does this at church, too. Next scheduled appointment: Team: 3 months to review progress.

43. What is this an Example of?103 or 108 or 102 • Hollie’s mom called to tell SC that Hollie has been wanting to visit her in Dallas. Mom would like SC to arrange for bus ride up to Dallas from Corpus Christi. She feels that Hollie can ride the bus alone, as she has done it before. SC informed mom that she did not feel that this was a safe option. Mom insists that it is and that if she has to she will pull Hollie out of the program and move her to Dallas. SC will arrange to send Hollie home for the upcoming holiday weekend, by bus.

44. What is this an Example of?103 or 108 or 102 • Jim’s mom called to inform SC that Jim wants to get a job at the farm next to them. Dad already works there as a ranch hand. Mom wants to know if this is possible and if it would affect SSI. Informed mom that Jim has Employment Assistance on plan. Will arrange for Empl. Coord. to meet w/Jim. Obtained info on farm owner and sent info to E.C. to ensure identified needs and desires of Jim are addressed.

45. What is this an Example of?103 or 108 or 102 Reason for Contact: Assessment Progress and status towards outcomes: Tammy came to office stating that she wants to move out of parent’s home. Tammy and I discussed what she needed to do to prepare to live on own. We went over budget and assessed her ability to live independently by making a list of not only what it took financially, but other things she needed to learn to do (e.g. how to do own laundry, cook, wash dishes, what to do in an emergency, etc…). New Need(s) Identified? ___No _X_ Yes If yes, what? Additional training to help Tammy reach her independent living goals and advocacy to help her communicate desires to parents. Pertinent Information: Tammy has not told her parents she wants to move out. Next scheduled appointment: Next Tuesday after Day Hab at her home.

46. What is this an Example of?103 or 108 or 102 Reason for Contact: Monitoring Progress and status towards outcomes: Went to Chuck’s house for scheduled home visit. Chuck’s sister-in-law said that Chuck was out picking up cans. She was uncertain when he would be home. New Need(s) Identified? __X_No __ Yes If yes, what? Pertinent Information: She did say that he was enjoying going to Day Hab, still picking up cans for extra money and rides his bike all over town. She will have him call me. Next scheduled appointment: Not scheduled at this time

47. What is this an Example of?103 or 108 or 102 Reason for Contact: Monitoring Progress and status towards outcomes: Met with Jacob at the school. Jacob was working on counting when I got there. When he finished he told me that he was going to graduate this year (his teacher shook her head “no”). He said that he was going to be a race car driver and get married to Selena Gomez (the actress). When asked, Jacob told me that he liked going to school, but he was 18 now which means that he should graduate like his brother did and get his license. He would get loud if asked about anything other than graduating, getting license and getting married (would not discuss respite or Saturday out program). New Need(s) Identified? ___No _X_ Yes If yes, what? ARD to address continuation of school and disrupting class. Pertinent Information: His teacher pulled me aside and stated that they are increasingly having more difficulty redirecting him from his unrealistic expectations, especially the “Selena Gomez” getting married thing. She stated she has spoken with both parents and they said “he will grow out of it” but he has been very disruptive to class activities. Next scheduled appointment: Next Thursday 2:00 pm at school

48. So, what should a Service Coordinator do??? • A Service Coordinator should • Assess and identify the needs of the person served • Identify the services and supports that address the person’s needs as they relate to the person’s presenting problem and disablity • Develop a service plan based upon the person’s needs and desires (remember, a person may need to learn how to do something but not want to learn how to do it)

49. So, what should a Service Coordinator do??? • Arrange for services and supports e.g. if they need transportation and can’t communicate clearly what/when they need it, you call the care giver to ensure that they will get there OR if they have respite on plan and need this service, you call the respite provider to arrange this service • Advocate for services and supports – e.g. they are in school and both child/parents need someone to advocate for integrated classroom or behavioral intervention; advocating for understanding at housing authority when client didn’t understand rules regarding laundry area usage at night

50. So, what should a Service Coordinator do??? • Collaborating with other agencies – e.g. working with client and housing authority to post both written signs and picture signs in laundry room for people who don’t read so tennis shoes don’t get put in dryer again and dent the dryer. • Linking – e.g. linking and referring client to local church for “Angel Ministries monthly discounted food” program; linking and referring client and mother to Alice Counseling Center for family therapy to help problem resolution counseling