The SC must be a strong and effective team leader. After the participant has selected all service providers, the SC organizes the team to provide individualized services for the participant. The SC needs to coordinate communication among all team members, including the participant. This becomes especially important when cognitive deficits affect the participant's memory. Maintaining good communication contributes towards effective coordination of services to support the participant in the community.
Team Meetings are scheduled based on the service needs of the participant but must be held at a minimum of every six (6) months when the RSP is being developed. A new waiver participant may benefit from monthly meetings initially with the entire team.
The SC coordinates and facilitates the Team Meeting. The participant, his/her legal guardian if applicable, and all waiver service providers for the individual must attend each Team Meeting. (Exceptions to Team Meeting attendance may be made at the discretion of the SC for providers of Assistive Technology (AT), Community Transition Services (CTS), Congregate and Home Delivered Meals, Environmental Modifications(E-mods), Moving Assistance, Home Visits by Medical Personnel, and Respite Services. Failure to attend may jeopardize the ability of the waiver provider to continue to provide waiver services. Providers of essential non-waiver services and anyone identified in the Plan for Protective Oversight should also be invited to Team Meetings. Other potential members of the Team Meeting include advocates, family members, local department of social services staff, etc. If the waiver participant is receiving the same service from different waiver providers, both providers should attend the Team Meeting.
The SC is responsible for facilitating effective communication between the participant and all service providers. To assure services are provided in the most integrated and efficient manner, it is necessary for providers to attend regularly scheduled Team Meetings to discuss progress toward the participant's goals, identify any impediments to achieving projected milestones and address any issues affecting the participant. Regularly scheduled Team Meetings with the participant and service providers are an essential part of assuring the participant's health and welfare.
Team meetings are scheduled by the SC six (6) weeks prior to the end of the most recently approved SP period and/or on an as needed basis. Prior to or at the time of the Team Meeting, all waiver providers required to submit an updated ISR must do so to assure the development of the RSP. Timely submission of Individualized Service Reports (ISR) (refer to Appendix C - form C.16) is imperative to maintain continuity of services to the participant. In addition, the SC may need to obtain information from non-waiver providers or other parties prior to the meeting. The RRDS may consult with the SC to determine if Team Meetings are being used appropriately.
On limited occasions, service providers may indicate the need to meet without the participant (e.g. the participant's behavior or other factors jeopardize the participant's ability to remain in the community). The SC is responsible for informing the RRDS of the team's interest in holding a meeting without the participant. Following the meeting, the SC and other members of the team must meet with the participant to explain the results of the meeting. This exception does not apply when the team is meeting to develop a RSP.
Team Meetings must be documented in the SP by the SC. Participation in Team Meetings must be documented in the notes of each active waiver service provider, including date, time and location, and projected activities (refer to Section VII - Record Keeping).
In addition, the SC completes the Team Meeting Summary form (refer to Appendix C - form C.17 which includes:
- Date, time and location of Team meeting;
- Participant's (or designated representative's) input and comments;
- Issues Addressed;
- Recommendations for changes in the Service Plan (e.g. addition, decrease, increase or discontinuation of service(s));
- Who was in attendance; and
- Submission and acceptance of all required ISRs or documentation of reasons for any delay or resubmission.
The SC distributes a copy of the completed Team Meeting Summary to all active waiver service providers for review and acceptance. A final copy is then provided to the participant. Any concerns regarding the content of the Team Meeting Summary should be directed to the SC. All active waiver service providers must maintain a copy of the Team Meeting Summary in the participant's record.
Team Meetings may not be used by the SC for required face-to-face visits.
Team Meetings are organized and facilitated by the SC as part of his/her responsibility to oversee services. Reimbursement for this activity is included in the monthly rate for Service Coordination. All other waiver service providers participating in a Team Meeting will be reimbursed at the usual rate for their service (e.g. Community Integration Counseling (CIC) will be able to bill as a face-to-face session with the participant).