OT/PT Dept Awaiting Service to Active

1. Page 1 Jan 2010 Start HERE Check with other OSNS programs about their involvement with the family If unable to contact, call referral source. If still unable to contact after writing letter, discharge. Let other OSNS programs know you were unable to contact. OT/PT DeptAwaiting Service to Active If there is no intake on file, go to page 4, then come back here If we have consent for outside agencies (eg IDP), check with them about their involvement with the family Complete Initial Needs Assessment within 90 days (if you did not see the child, skip this) Casenote in ACTIVE while you try to contact the family, and until you are finished the assessment On the day you first try to call the family, discharge from AWAITING SERVICE, re-admit to ACTIVE Contact family to set appointment Write report within 3 months of initial contact Determine how frequently you plan to see the child If < every 3 months, then discharge from ACTIVE, (you will be cued to enter a discharge Needs Assessment). & re-admit to MONITORING If > every 3 months, leave in ACTIVE Discharge from services See Page 3 • Provide Intervention. • Casenote all contact within three working days • Create goals with family. Review at least every 6 months • Update Needs Assessment at least every 6 months. • Write full progress report at least every 12 months See Page 4 See Page 5 See Page 6

2. Page 2 Jan 2010 Start HERE Check with other OSNS programs about their involvement with the family OT/PT DeptAwaiting Service to Consultation Complete Initial Needs Assessment within 90 days (if you did not see the child, or discharged right away, skip this) If there is no intake on file, go to page 5, then come back here If we have consent for outside agencies (eg IDP), check with them about their involvement with the family If unable to contact, call referral source. If still unable to contact after writing letter, discharge. Let other OSNS programs know you were unable to contact. Casenote in CONSULT until you are finished your involvement Leave child in CONSULT when you are finished your involvement On the day you first contact the family, discharge from AWAITING SERVICE, re-admit to CONSULTATION Contact family to set appointment Guidelines & Paperwork Use 1-3 visits to complete your screening/ consultation • Provide family with: • Short letter/report summarizing • observations and recommendations • Home programming suggestions • Who to call with questions • Provide a list of groups we run that their • child might be appropriate for (including • Summer Program) Important to explain to parents that this is not service. Child is still on waitlist. We want them to understand that true therapy service is much more detailed and comprehensive and intensive. We are just trying to do the best we can with our waitlist. Generally don’t use standardized assessments – just a screening opportunity. If you really don’t feel you see the whole picture, you can use an assessment to help. Chart your detailed observations in CONSULT case notes. See Page 3 These children can be seen by TSW if that seems appropriate. Make Internal Referral If no concerns, discharge from services and let other team members know See Page 4 Update consent forms if things have changed since intake. See Page 5 See Page 6

3. Page 3 Jan 2010 OT/PT DeptHOMES – Discharge & Re-admit Discharge Re-Admit From the HOMES Main page From the HOMES casenote page (of the current OT/PT program of the client) From the HOMES Main page Choose ‘Readmit a Client & Student’ under “Case Demographics” Choose ‘Discharge, Closure, or Transfer Report’ under “Case And Outcome Management” Choose ‘discharge’ from File Folder drop down menu Click on the drop down envelope to the right of 1. Client/Student. Type in client name and click ‘Search’. Choose correct program. Complete the fields in blue (date, discharge date etc) Type in client name and click ‘Search’. Choose correct client. Complete the fields in blue (date, discharge date etc) • For moving between • OT/PT programs: • Next Step Program • N/A Complete the fields in blue • For moving between • OT/PT programs: • Next Step Program • N/A 3. Choose the OT/PT program you are admitting the child to 5. Select the MOST RECENT ‘Intake and Case management’ Program 7. Do NOT “Check All”

4. Page 4 Jan 2010 OT/PT DeptHOMES - Needs Assessments (NA) First time Needs Assessment in this HOMES program Repeat Needs Assessment within same program Discharge Needs Assessment (either to move to new program or to discharge altogether) Open client in HOMES under the program he is currently enrolled in. In the ‘File Folder’ tab, choose Initial Assessment Open client in HOMES under the program he is currently enrolled in. In the ‘File Folder’ tab, choose ‘Progress and Updated Service Plan’ When you choose “Discharge” from the file folder tab, you will be cued to enter a discharge NA Rate the needs appropriately, then SAVE. If child has just transferred from another program this initial NA should be the same as the D/C NA in previous program Rate the needs appropriately then SAVE Rate the needs appropriately, then SAVE. PRINT: click Reports tab at the top. Then choose “Interim Outcome Reports”. Choose “Pre to Interim Post”. Right click to print. PRINT: click Reports tab at the top. Then choose “Outcome Reports”. Choose “Pre to Post Program Needs Assessment”. Right click to print PRINT: click Reports tab at the top. Then choose “Program Needs Assessment”. Right click to print What if I want to add a new Need when it is identified during one of the Repeat NAs? Without changing the date, enter the new need in this NA and rate it as you see it today It will then appear on all the subsequent NAs until today’s. That’s okay. It is not counted in outcomes until it changes. When you want to re-rate it during the next NA, it will be there to record a change Go back to the Initial NA in the CURRENT OT/PT program

5. Page 5 Jan 2010 OT/PT DeptHOMES – Discharge Forever When discharging a child from OT/PT Department (not just between programs) Complete final needs assessment If applicable 2) will automatically come up. Enter 1-2 sentences to state reason for discharge. Click “Save and continue to list” On “Needs and Issues Addressed” page, choose “Program Measures” (top left side) then “Program Report Comments” Choose “Reports” from top line Click “case reports” Click “Discharge Report (Standard Version)” Choose “Add All” on bottom right side under check boxes Report will be on the screen. Right click and print. Sign and include in your discharge file. 1), 2), 3), on left side are now blue. Choose 1) and enter 1-2 sentences to summarize your services. Then click “Save and continue to list”

6. Page 6 Jan 2010 OT/PT DeptSeeing a Child When No Intake is on File If there is no intake on file, it is your job to complete one with the family. This happens most often with the infants who are referred. Don’t worry about getting all the paperwork done on the first visit. You can interact with the child and develop a rapport with him. Keep the paperwork for the end of the visit, or even the next one. Most of one visit will be dedicated to sharing info about OSNS with the family, gathering intake information, and getting consents signed Once the paperwork is done, put the intake form, and the two consents in the Receptionist’s box. • On your first visit, take: • Intake form • Consent to Release Information • Consent to Service Agreement • Parent Handbook • Brochure In the Main file, on the pink sheet at the front, fill in the bottom three lines (parent handbook, intake and consents) and initial. Now go back to Page 1 • When completing forms with • parents/guardians, be sure to • Review complaint process • Explain parent rights • Read each bullet of Consent • to Service agreement If you feel the child is older, or the family circumstances would benefit from having the Family Resource Worker complete the intake, feel free to make that request. Young infants don’t usually require a lot of time to gather info, but older ones (or complicated ones) do and then the FRW can be called upon.