why on-target assessments are a coordinator's secret weapon · 2019-08-22 · today...

Why On-Target Assessments are a Coordinator's Secret Weapon

American Association of Service Coordinators Conference8/11/19

Today you’ll…

• Learn why an on-target assessment can save you time, angst, and surprises later

• Discover the 5 most revealing questions that nobody ever asks• Uncover the assessment’s hidden gems that help you laser in on the

resident’s core issues• Develop a meaningful assessment template that you can implement

today• And more!

Hello!I’m Sara

Education and Experience…• Activity Therapist in Developmental Center• APSI Rep• Community Employment Coordinator• County Case Manager• Director of Vocational Rehabilitation• ICF/IDD Administrator/Director• Director of RFW Homes• Metropolitan Housing Director• Director of SSA• Managed Care Contract Manager -ODM• Section Chief HomeCare Waiver Clinical

Services –ODM• Created Ohio’s Private Duty Nursing Program

• Lead Medicaid Policy Developer DODD (Dep Director)

• ASI – FMS Services in Missouri and Georgia• Program Manager for Manager Care MITS• Director of Provider Oversight for HomeCare

Waiver – Public Consulting Group• Sara Sherman Consulting

• Nebraska Division of Developmental Disabilities

• Missouri Division of Developmental Disabilities

• Optum• University of Missouri Kansas City• Norwich Consulting• OPRA• Several Ohio Providers and County Boards

In Addition…

For all you do…

What’s the big deal about Assessments?

An On-Target Assessment…• Feeds the plan• Supplies data for the property wide profile• Drives contact with residents• Identifies the referrals to be executed• Determines the follow up contact with residents• Formulates the interdisciplinary team contribution• Defines the partnership with community based stakeholders• Identifies the resources that will comprise the databases• Drives service coordinators work priorities • Assists in maintaining professional boundaries• Defines the needed confidentiality agreements• Gives focus to the case notes• Helps residents see what is “in it for them”

The Role of a Service Coordinator

You provide the stability that supports the success of every other social service.

“It is nearly impossible for any other agency to be successful when people don’t have stable housing.”

Sara Sherman

What makes a housing service coordinator so important?

Service Coordinators ARE:Advocates on behalf of residentsFacilitors of wellness and other educational programsMotivators who empower residents to be as independent as possibleMonitors who follow up with services provided to residentsChampions who encourage residents to adhere to a healthy lifestyleEducators who provide trainings and assistance to residents and other property staffAdvisors who can assist residents with building support networks and consult with tenant organizations and resident management

Referral agents who connect residents to service providers who can meet their needsCommunity Partners to assist residents with accessing community-based services

www.hudexchange.info

Service coordinators ARE NOT:

• Direct service providers• Recreation or activity directors• Duplicators of existing community services• Distributors of medical aids, medications, or medical advice• Handlers of residents’ funds• Managers or leasing agents• Drivers of residents• Organizers or leaders of resident associations or councils• Powers of Attorney for residents or individuals who sign checks for

residentswww.hudexchange.info

You are not the DOER

You are the LINKER

And you…• Conduct comprehensive, non-clinical assessments of residents for wellness and

social needs;

• Help residents identify, access, and coordinate services (such as personal care services), including monitoring of services provided and follow up communication;

• Proactively develop and arranging educational preventative health programs and services for residents

• Develop and sustain partnerships with the Area Agency on Aging, the Aging & Disability Resource Connection, community-based supportive service providers and other community stakeholders, and

• Maintain an up-to-date resource directory with all local service providers

• Be part of the interdisciplinary team as applicablewww.hudexchange.info

That’s a tall order!

How do you keep it all straight?

Through the Secret Power of

an On-Target Assessment

What are the benefits of completing an assessment?

So now what?

How the process works

Individual

Assess

Plan

Implement

Evaluate

Individual

Assess

Plan

Implement

Evaluate

Illness

Room-mates

Behavior

Incidents

Family

Other

What you assess…

• Demographic Information• Financial Resources (earnings, benefits, support from family)• Sources of formal and Informal support• Employment status• Interests and hobbies• Existing social supports and networks• Health insurance status• Resident Reported physical, cognitive, and mental health conditions• Activities of Daily Living and Instrumental Activities of Daily Living (IADLs)• Unmet needs for supportive services and areas of vulnerability


Think…

• What is important TO the person, and what is important FOR the person

• Immediate needs, and longer term• Are they healthy and safe

Demographic Information

Who, What, Where:• Person’s age, birth date, address, phone• Person’s dependents and details• Emergency contacts• Who is important, why are they important, how do you reach them &

when• Who is missing, why, and is this a concern?

Financial Resources (earnings, benefits, support from family)

• Income and resources• From where• How much• How often• How are the bills paid• What is falling short

Sources of Formal and Informal Support

• Family • Friends• Other Social Service Agencies• Community Connections – Church, Co-workers, Meet-Ups, Clubs,

School, etc.• Other

Employment status

• Has a job• Wants a job• Wants another job• Needs help with job• Has daycare, needs daycare• Has transportation, needs transportation• Needs/wants additional job training or to go to school

Interests and hobbies

• Do they have interests and hobbies?• Do they want them?• Does a lack of interest/hobbies reflect need for depression screen?• Can they access their hobbies/interests?• Do they do these with friends?• Are there groups or organizations for these or similar

hobbies/interests that you can connect too?

Existing social supports and networks

• Does the person have social supports and networks?• Do they want them?• Does the lack of having them indicate that a depression or other

screen is necessary?• Are the social supports and networks meeting the individual’s needs?• Does the person feel safe, accepted, have sufficient and meaningful

contact, etc.?• Do they want to go to church, senior activities, connect with peers?

Health insurance status

• Does the person have health insurance?• Do they need health insurance?• Do they need help finding or interacting with their insurance?• Do they understand their insurance, what it covers, and how to use

it?• Who helps with health decisions? Is there POA or a Guardian?• Do they have advanced directives, are they an organ donor, etc.?

Resident Reported physical, cognitive, and mental health conditions• How are things?• Where do they struggle? • What is going really well?• What do they want to change? • How much education have they completed? • How’s their health? • Who helps with decision making? • Do they take medications? Can they pay for them? Can they pick them up? • Do they have a doc, a dentist?• How does it feel to go through their day? • Do they sleep well? • Are they hungry?• Do they have sufficient clothing, food, cleaning supplies, access to stores, resources, etc.• What are their concerns?

Activities of Daily Living

• Bathing or showering• Dressing• Getting in and out of bed or a chair (Transferring) • Walking (Mobility) • Using the toilet – includes clean up• Eating – includes cutting food, feeding self

Cms.org

Instrumental Activities of Daily Living (IADLs)

These skills reflect life independence:• Preparing meals – includes planning meals• Managing money• Shopping for groceries or personal items• Performing light or heavy housework• Using a telephone

Cms.org

What you’re looking for with ADLs & IADLs:

• Are they independent?• Could they be independent, or more independent with adaptive

equipment? (OT eval/PT eval? Technology?)• Are they at risk for falls/injuries, victimization, exploitation, choking,

hunger, illness, etc.

Unmet needs for supportive services and areas of vulnerability

• Ask clarifying questions• Ask “Is there something I didn’t ask you, that I should know?”• Discuss barriers to dreaming big• Ask again (assess again) after urgent matters are addressed• Ask again after a more trusting relationship has been developed• When you see something, or think you see something - ASK

How to assess?

• Be conversational • Ask open ended questions• Be patient – give time to think• Re-ask the question in different ways• Use reflective listening • Verify that you understand, and verify that they understand• Build relationship

Form

Demographics

Name Address

DOB Phone

Emergency Contact Phone

Health Insurance SSN

FinancialIncome and Resources Food stamps: $125

SSI: $700Railroad: $200Housing VoucherMedicaid Card

Shortcomings Runs out of food stampsDoesn’t have a budgetNeeds help with annual appointmentNo checking accountDoesn’t have HEAPNo phone

Current bills Electric $100/monthFood $300Rent: Covered

Notes:Check on HEAP; Sign up for County Extension Food Planning Session; refer to county Get a Phone Program; Sign up for senior phone programIs very concerned about running out of money at the end of the monthSometimes gets money from daughter – follow up with daughter

5 6 Questions No One Asks

1. If you could be granted one wish, what would it be?2. If you could prevent one thing from changing in your life what

would it be?3. If you could change just one thing from your past what would it be?4. What is your greatest source of pride?5. How do you hope to be remembered?6. How can you best help other people?

What does it mean to “Get to Know Your Residents”?

“Relationship Building” sounds great!

But…

We know we need:Professional BoundariesNo Conflict of Interests

What does “Relationship Building” really mean, and how do you know you are

doing it right?

The term “Relationship Building” is:• Broad• Never ending• Overwhelming• Hard to define success• Can cross a line• Adds a lot of pressure• Takes a lot of time

Find someone you don’t know really well…and get to know them. Take 10 minutes.

How did it go?• What is the difference between what you just

experienced and when you go to the doctor and the doctor gets to know you?

• What do you want from your doc…what do your people need and want from you?

Goal of personal relationship building:• Make a friend• Become/find a personal support• Share common ground: values, dreams, pursuits, past

times, interests• Spend time together personally• Deeply share feelings, experiences, secrets, dreams, pain

The goal of support coordinator relationship building is to:• To get enough information to do your job

• Show people they can depend on you to do your job well

Why boundaries are important

• Objectivity • Safety• Keeps the focus on the person’s independence• Builds trust • Prevents abuse/neglect

How does an SC ‘get to know someone’ and ‘build that relationship’?• Build your own dependability and credibility reputation • Be aware of Culture• Know your own biases and correct for them – Don’t display your bias• Develop your support coordinator skills through professional

development• Look and Speak the part• Follow through• Know the services and funding that are available• Solve problems• Be the system expert (seek answers and follow up [even when you

don’t have the answers])

The process is fluid…

Sometimes like this…

Individual

Assess

Plan

Implement

Evaluate

Review:

• Reassess and change the plan whenever is necessary• Assessment is a constant process• New information comes up, people change their minds• Get to know your residents in the way that makes you an effective SC• Know the regs• Follow through• Use a form that does the job• Trust yourself

Remember…

Feed a person a fish and she eats for a dayTeach a person to fish and she eats for a

lifetimeChinese proverb

You are teaching people to fish…

Questions:

[email protected]

mailto:[email protected]

why on-target assessments are a coordinator's secret weapon · 2019-08-22 · today...

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