1300, Overview of Service Delivery System

Revision 10-0; Effective June 1, 2010

June 1, 2010, brings major changes to the Home and Community-based Services (HCS) service delivery system. The purpose of this section is to introduce program providers and Local Authorities to what HCS services will look like in the future. The success of HCS services will depend on individuals, their legally authorized representatives (LARs) and family members, the program providers, Local Authorities and Department of Aging and Disability Services (DADS) staff understanding the concepts behind the new system and developing the relationships that will support individuals in the HCS Program.

For the individuals who receive services, their LARs and family members: The transition from an Individual Service Plan (ISP) to a Person-Directed Plan (PDP) will require that personal outcomes be communicated to the service planning team (SPT). In the past, the interdisciplinary team, which included the individual, the LAR and often family members of the individual, decided what would be included in the ISP. The PDP will place even more emphasis on the results the individual desires from services and supports. Development of an effective PDP is dependent on the SPT knowing what is important to and for the individual who is receiving HCS services. Communication between the individual, the LAR, the individual’s family and the Local Authority service coordinator is critical to the development of a PDP that is meaningful for the individual. It is important that the SPT act not only on preferences that are communicated through words, but also on those preferences that are communicated through body language and maladaptive behaviors. Identifying natural supports and their roles and limits in supporting an individual is essential when linking an individual to HCS services and non-HCS services. Communication is also needed from individuals, their LARs and family members to determine whether the services being delivered are meeting the individual’s needs and preferences or whether revisions are necessary.

For the Local Authorities: Delivery of effective service coordination requires commitment to the individual who receives HCS services and to the collaboration with HCS and non-HCS service providers. A concerted effort must be made to get to know the individual and their natural supports very well. Collecting information from HCS and non-HCS service providers is essential in developing a PDP that is meaningful and will result in the desired outcomes. The ability to recognize service needs, to communicate the service needs to natural supports and HCS and non-HCS service providers, to link the individual to available resources, and to analyze the effectiveness of service delivery is essential to successful service coordination.

Service coordinators must also have extensive knowledge of non-HCS service resources to develop a PDP and to determine what HCS services need to be purchased on behalf of an individual. Knowledge of the HCS Program Billing Guidelines (PDF) is critical in order to ensure that the services being purchased from the HCS program provider can be reimbursed.

For the HCS program providers: Eliminating the case management function from the array of services offered by the HCS program provider will likely require many changes to the program provider’s organizational structure. Most program providers assigned case management duties that exceeded HCS rule requirements. However, many of the case management functions that previously were defined in rule, including coordinating the development and implementation of the service plan, coordinating and monitoring the delivery of HCS and non-HCS services, integrating various aspects of services delivered through HCS and non-HCS services, recording progress and lack of progress, record-keeping, and developing a pre-discharge plan, are now the responsibility of the Local Authority service coordinator. The program provider will need to perform some parallel functions to ensure that services are effective and that individuals are healthy, safe and satisfied with their services. For example, the program provider is responsible for developing the Implementation Plan (IP) that describes specifically how the program provider’s services will achieve the assigned desired outcomes. In addition, program providers will be responsible for supervising their employees and contracted staff to ensure that they are following the IP and that progress or lack of progress is documented. If an individual receives foster/companion care, Supervised Living or Residential Support Services and possibly Supported Home Living or Respite, it is probable that the program provider’s staff will communicate and collaborate with the non-HCS service provider to integrate various aspects of service delivery. The program provider will be required to maintain a record that contains documentation relevant to the delivery of the program provider’s HCS services.

In cases in which the program provider provides foster/companion care, Supervised Living or Residential Support Services, the program provider must be able to respond to emergency situations 24 hours per day, seven days per week. The program provider may also be required to provide emergency services to an individual who lives in their own home or family home, as documented in the PDP. In the event that an unanticipated emergency arises and emergency services not included in the individual’s IPC are required, it is expected that the program provider will be responsive to that emergency and that units are added to the IPC later (if necessary) to allow reimbursement to the provider.

Program providers are encouraged to maintain frequent communication with the individuals to whom they provide services, as well as LARs and family members, to evaluate their satisfaction and to determine if changes are needed to the IP. Since case management is no longer included in the program provider’s array of HCS services, it is critical to develop effective communication systems among program provider staff and that staff know when and how to contact the individual’s service coordinator.

For DADS employees: DADS staff must prepare for these changes in the service delivery system. All DADS staff who serve individuals who receive HCS services must be knowledgeable of how the elimination of the case management function from the program provider’s array of services and the assignment of Local Authority service coordination to individuals receiving HCS services will affect the way they perform their jobs. These DADS staff must understand the concepts of person-directed planning and how to promote the acquisition of outcomes. New monitoring processes and tools will be used by the following DADS areas:

  • Access and Intake – Local Authority Section, Contract Accountability and Oversight Unit; Utilization Management and Review, IDD Waivers, Program Enrollment and UR; and Billing and Fiscal Monitoring
  • Regulatory Services – Waiver Survey and Certification

Click here for a table describing many of the major changes that result from the removal of case management services from the program providers’ service array and the performance of service coordination by the Local Authorities.