Types of Service Coordination

Service Coordination has two basic components:

  1. Initial; and
  2. Intensive

1. Initial Service Coordination

This component has three types of Service Coordination available to the waiver applicant:

  • Initial Service Coordination Diversion - This type of Service Coordination is provided to individuals who are new to the waiver and presently living in the community. This will occur only once per waiver enrollment.
  • Initial Service Coordination Transition - This type of Service Coordination is provided to individuals who are new to the waiver and presently living in a nursing home for less than six months. This will occur only once per waiver enrollment.
  • Initial Service Coordination Transition - This type of Service Coordination is provided to individuals who are new to the waiver and presently living in a nursing home for six months or more. This will occur only once per waiver enrollment.

Initial Service Coordination encompasses those activities involved in developing the individual's Application Packet. After the individual selects a SC, it is the SC's responsibility to gain a full understanding of who this person is now, his/her life experiences, and his/her goals for the future. It is essential to interview those individuals who are of primary importance to the applicant. Information from community services and medical facilities/practitioners providing services to the individual including information from a discharging facility should be obtained.

In assisting the individual to develop the ISP (refer to Appendix C - form C.1), the SC should look to sources of support - informal caregivers (family, friends, neighbors, etc.), non-Medicaid federal and state funded services, such as VESID, Medicare and other third party payers and Medicaid funded services (physician, personal care, nursing, etc). The waiver services are designed to complement other available supports and services available to Medicaid recipients. Waiver services can be substituted for Medicaid State Plan services when there are greater efficiencies, such as the use of Congregate and Home Delivered Meals in lieu of a personal care assistant preparing a meal.

Another important task of the SC is to assist the participant in locating a place to live in the community. The NHTD waiver supports the individual's right to choose where to live and to have access to integrated and accessible housing that falls within the individual's economic means.

There are no certified residences specifically/directly associated with the waiver; participants may live with up to three (3) other non-related individuals, unless they are in a living situation which is certified or licensed by the State (e.g. an Office of Mental Hygiene supported Residential Program for Adults or an Adult Care Facility). The SC is to assist the waiver participant to secure housing.

2. Intensive Service Coordination

This component has one type of Service Coordination available to the waiver applicant:

  • Intensive Service Coordination - This type of Service Coordination is provided to participants on an ongoing basis.

Intensive Service Coordination is ongoing and begins after the individual is approved to become a waiver participant and has been issued a Notice of Decision (NOD). The SC is responsible for the timely and effective implementation of the approved SP. The SC is responsible for assuring that there is adequate coordination, effective communication, and maximum cooperation between all sources of support and services for the participant.

During the first six (6) months of the ISP, the SC will conduct face-to-face meetings with the waiver participant at least monthly to provide closer monitoring of the participant's health and welfare needs as he/she adjusts to the waiver program. It is expected that at least one of these visits will be conducted in the participant's home. In addition, these meetings can provide monitoring opportunities for the SC to assure that all approved services are being provided. Thereafter, the SC will conduct face-to-face meetings with the waiver participant as determined through discussion with the participant and as authorized in the SP. These meetings must occur, at a minimum, once every six (6) months. The SC will assure that the participant is aware that he/she may contact the SC if issues/problems occur.

The ultimate responsibility for assuring that the SP is appropriately implemented rests with the SC.

A SC must be knowledgeable about all waiver services, Medicaid State Plan Services, and available non-Medicaid services. Informal supports are often a crucial factor if the participant is to live a satisfying life and remain in the community. The SC's ability to make use of these informal supports is essential, and offers the SC and other providers the greatest opportunity for creativity. In addition, the SC must be knowledgeable of the processes necessary to obtain needed referrals/orders, assessments and approvals for non-waiver service.

The SC will also be responsible for:

  1. Formally reviewing, updating and submitting all SPs to the Regional Resource Development Specialist (RRDS) for review in a timely manner (refer to Section V - The Service Plan);
  2. Assuring that Team Meetings are held at least six (6) weeks prior to the end of the most recently approved SP period and/or on an as needed basis;
  3. Providing all waiver providers, the participant and others, as appropriate, with written summaries of the Team Meetings (refer to page 8 for more information on Team Meetings);
  4. Maintaining records for at least six (6) years after termination of waiver services;
  5. Maintaining a tracking system for level of care evaluations and assuring that the PRI and SCREEN (refer to Appendix F) is completed:
    1. at least every twelve months; or
    2. when the participant experiences a significant improvement in his/her ability to function independently in the community;
  6. Assuring that a signed Release of Information is obtained to disclose the ISP, Addendum or RSP and other documents generated in the provision of service to the participant. This information with be shared as needed with waiver service providers and others as directed by the participant;
  7. Maintaining knowledge of all approved waiver service providers in their
  8. Conducting face-to-face meetings with the participant and at a minimum:
    1. Review the SP with the participant to determine if the services are meeting the participant's needs;
    2. Discuss the provision of services with the participant to determine the participant's level of satisfaction with the services he or she is receiving; and
    3. Review the Service Coordination Detailed Plan with the participant to discuss the participant's progress towards meeting his or her goals.
  9. Conducting in-home visits with the waiver participant at least once every six (6) months, prior to the development of the Service Plan;
  10. Reviewing all NODs with the participant and assuring that the participant understands his/her rights to an Informal Conference and/or Fair Hearing;
  11. Ensuring that the participant understands and signs the Waiver Participant's Rights and Responsibilities (refer to Appendix C - form C. 5) annually;
  12. Assuring that the participant is provided with information regarding abuse/neglect prevention and how to report any incidents of abuse/neglect if it does occur;
  13. Working with the participant to develop and maintain a Detailed Plan for Service Coordination which includes coordination of team in the provision of services, and overall activities and goals of the SC;
  14. Documenting all visits, contacts, meetings, etc. involving the participant in the SC's record;
  15. Working with the participant on a safe discharge/discontinuation plan if he/she is leaving the NHTD waiver. In many cases, this will include collaboration with Local Department of Social Services (LDSS) to establish alternative services; and
  16. Administering the Quality of Life (QoL) Survey for applicants who have resided in a nursing home for at least six (6) months prior to transitioning into the community. The QoL Survey must be administered within two (2) weeks of the anticipated discharge of the individual from the nursing home.

Although the SC is an employee of a provider agency, the SC must always act as the participant's advocate and provide unbiased assistance to the participant with the selection of providers.

Ratio of Waiver Participants to SC:

  • Full time SC for NHTD waiver participants may not exceed a caseload of twenty (20) waiver participants.
  • SCs providing services to NHTD waiver participants on less than a full time basis must limit their caseload proportionately. For example, a SC working 50 percent may not exceed a caseload of ten (10) waiver participants.