The Q

 

Quality Services for Independent Living 

Service Coordination Job Description

Definition

The Service Coordinator assists the prospective participant to become a waiver participant and coordinates and monitors the provision of all services in the Service Plan. Services may include Medicaid State Plan services, non-Medicaid federal, state and locally funded services, as well as educational, vocational, social, and medical services. The goal is to increase the participant’s independence, productivity and integration into the community while maintaining the health and welfare of the individual.

Roles and Responsibilities

The participant is the primary decision-maker in the development of goals, and selection of supports and individual service providers. The Service Coordinator is responsible for assuring that the Service Plan is implemented appropriately and supporting the participant to become an effective self-advocate and problem solver. Together they work to develop and implement the Service Plan, which reflects the participant’s goals. The Service Coordinator assists the participant in the development, implementation and monitoring of all services in the Service Plan. Additionally, the Service Coordinator must initiate and oversee the assessment and reassessment of the participant’s level of care and on-going review of the Service Plan.

Questions that a Service Coordinator should explore with the participant include:

• What are the participant’s goals?

• What can be done to help the participant fulfill his goals?

• How can the participant be assisted to become a member of the community?

• What can be done to assist the participant to be more independent?

The Service Coordinator must also be an effective advocate for the participant, ensure that the participant is receiving appropriate and adequate services from providers and maintain quality assurance.

Service Coordination has two basic components: Initial and Ongoing Service Coordination.

Initial Service Coordination encompasses those activities involved in developing the individual’s Application Packet. After the individual selects a Service Coordinator, it is the

Service Coordinator’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 potential participant. Information from community services and medical facilities including information from a discharging facility should be obtained.

In assisting the individual to develop the Initial Service Plan, the Service Coordinator should look to sources of support – informal caregivers (family, friends, neighbors, etc.), non-Medicaid services, such as VESID, 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.

Another important task of the Service Coordinator is to assist the participant in locating a place to live in the community. The HCBS/TBI waiver supports the individual’s right to choose where to live and to have access to generic affordable and accessible housing. The Service Coordinator must complete a Housing Standards Checklist for waiver participants receiving a HCBS/TBI Housing subsidy with the Initial Service Plan and annually in accordance with HCBS/TBI Housing Guidelines.

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 Individual Residential Alternative or Adult Home). The Service Coordinator may assist the waiver participant and other supports to secure housing. In the RRDC regions of New York City, Hudson Valley and Long Island, assistance in locating housing is done by an agency under contract with DOH. Technical assistance to the Service Coordinator about housing issues is available through the RRDS.

Ongoing Service Coordination begins as soon as the individual is approved to become a waiver participant. The Service Coordinator is responsible for the timely and effective implementation of the approved Service Plan. The Service Coordinator is responsible for assuring that there is adequate coordination, effective communication, and maximum cooperation between all sources of support and services for the participant.

The ultimate responsibility for assuring that the Service Plan is appropriately implemented rests with the Service Coordinator.

A Service Coordinator must be knowledgeable about all waiver services, Medicaid State Plan Services, and 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 Service Coordinator’s ability to make use of these informal supports is essential, and offers the Service Coordinator and other providers the greatest opportunity for creativity.

The Service Coordinator will also be responsible for:

1. Formally reviewing, updating and submitting timely Service Plans (ISP, RSP, and addendum) to the RRDS for review(refer to the Service Plan section of this Manual for specific information on Service Plan responsibilities);

2. Organizing and facilitating Team Meetings;

3. Maintaining records for at least seven years after termination of waiver services;

4. Assuring that the PRI/SCREEN is completed:

a. at least every twelve months; or

b. whenever the participant experiences a significant improvement in his/her ability to function independently in the community.

5. Maintaining records of all waiver services as described in the Manual section on Record Keeping

6. Assuring that all waiver service providers and the participant receive a current copy of the most recently approved Service Plan;

7. Maintaining knowledge of all approved waiver service providers in their region; and

8. Conducting face-to-face visits at least one time per month or as described in the service plan.

9. Conducting in-home visits with the participant no less than once a quarter.

Although the Service Coordinator may be an employee of a provider agency, the Service Coordinator must always act as a neutral advocate in assisting the participant with the selection of providers.

Ratio of Waiver Participants to Service Coordinator

Full time Service Coordinators for HCBS/TBI waiver participants may not exceed a caseload of seventeen (17) waiver participants.

Service Coordinators providing services to HCBS/TBI waiver participants on less than a full time basis must limit their caseload proportionately. For example, a Service Coordinator working 50 percent may not exceed a caseload of eight (8) HCBS/TBI waiver participants.

E-mail your resume at: [email protected]




COMMUNITY INTEGRATION COUNSELORS NEEDED - LI/NYC

Definition:

Community Integration Counseling (CIC) is an individually designed service intended to assist waiver participants who are experiencing significant problems managing the emotional responses inherent in adjusting to a significant physical or cognitive disability while living in the community. It is a counseling service provided to the waiver participant who is coping with altered abilities and skills, a revision of long term expectations, or changes in roles in relation to significant others. This service is primarily provided in the provider’s office or the waiver participant’s home. It is available to waiver participants and/or anyone involved in an ongoing significant relationship with the waiver participant when the issues to be discussed relates directly to the waiver participant. It is expected that CIC will be conducted on a short-term basis. The need for CIC could occur at the time of transition from a nursing home or at various times during the participant’s involvement in the NHTD waiver. While CIC Services are primarily provided in a one-to-one session to either the waiver participant or a person involved in an ongoing relationship with the participant, there are times when it is appropriate to provide this service to the waiver participant or other in a family counseling or group counseling setting.

Regarding client confidentiality, the sharing of information obtained during a CIC session can only be disclosed in accordance with federal standards and accepted professional standards regarding client confidentiality.

A CIC must be a:

  • 1. Licensed Psychiatrist - Licensed by the NYS Education Department;
  1. Licensed Psychologist - Licensed by the NYS Education Department;
  2. Master of Social Work;
  3. Master of Psychology;
  4. Mental Health Practitioner - Licensed by the NYS Education Department;
  5. Certified Rehabilitation Counselor - Certified by the Commission on Rehabilitation Counselor Certification; or
  6. Certified Special Education Teacher - Certified by the NYS Education Department.

Each of these individuals must have, at a minimum, two years of experience providing adjustment related counseling to individuals and/or seniors with physical and/or cognitive disabilities and their families. A significant portion of the provider’s time which represents this experience must have been spent providing counseling to individuals with disabilities and/or seniors and their families in order to be considered qualifying experience.

Individuals listed in a) may supervise the following individuals to perform CIC services:

  • 1. Licensed Psychiatrist - Licensed by the NYS Education Department;
  1. Licensed Psychologist - Licensed by the NYS Education Department;
  2. Master of Social Work;
  3. Master of Psychology;
  4. Mental Health Practitioner - Licensed by the NYS Education Department;
  5. Certified Rehabilitation Counselor - Certified by the Commission on Rehabilitation Counselor Certification; or
  6. Certified Special Education Teacher - Certified by the NYS Education Department.

Individuals in section b) may have less than two years of experience providing adjustment related counseling to individuals and/or seniors with physical, cognitive, developmental or psychiatric disabilities.

Supervisors are responsible for providing ongoing supervision and training to staff. Supervision must occur no less than once a month when reviewing the caseload and must be more frequent when there is a new participant, a new provider or there has been a significant change in the participant’s emotional, psychiatric or life situation.

***This is a flexible opportunity for people looking to pick up a few hours per week. Not a full time job. $35.00/hour.

Higher rate considered for fluent bilingual counselors. Spanish needed.

E-mail your resume at: [email protected]




INDEPENDENT LIVING SKILLS TRAINING SERVICES

JOB DESCRIPTION

Independent Living Skills Training Services (ILST) are individually designed to improve or maintain the ability of the waiver participant to live as independently as possible in the community. ILST assists in recovering skills that have decreased as a result of onset of disability. Also, ILST will primarily be targeted to those individuals with progressive illnesses to maintain essential skills. ILST may be provided in the waiver participant's home and in the community. This service will primarily be provided on an individual basis.

Responsibilities: The ILST staff conducts a comprehensive functional assessment of the waiver participant, identifying the participant's strengths and weaknesses in performing ADL and IADL related to his/her established goals.

The ILST staff uses the results of the assessment to develop an ILST Detailed Plan. The Detailed Plan will identify milestones to be met during the six (6) month period. The assessment must also include a determination of the participant's best manner of learning new skills and responses to various interventions. This comprehensive and functional assessment must be conducted at least annually from the date of the last assessment.

The ILST staff provides assessment, training, and supervision of an individual with self-care, medication management, task completion, communication skills, interpersonal skills, socialization, sensory/motor skills, mobility, and community transportation skills, reduction/elimination of maladaptive behaviors, problem solving skills, money management, pre-vocational skills and skills to maintain a household.

ILST services must be provided in the environment and situation that will result in the greatest positive outcome for the waiver participant. It is expected that this service will be provided in the waiver participant's environment.

The ILST staff assists a participant in returning to, or expanding the waiver participant's involvement in meaningful activities, such as paid or unpaid (volunteer) employment. The use of ILST for vocational purposes must occur only after it is clear that the waiver participant is not eligible for these services through either the Vocational and Educational Services for Individuals with Disabilities (VESID) or the Commission for the Blind and Visually Handicapped (CBVH); that VESID and CBVH services have been exhausted; or the activity is not covered by VESID or CBVH services.

The ILST staff will train the waiver participant's informal/natural supports, paid staff and waiver providers to provide the type and level of supports that allows the waiver participant to act and become as independent as possible in ADLs and IADLs.

Qualifications:

ILST may be provided by any not-for-profit or for profit health and human services agency.

An ILST must be a:


    1. Registered Occupational Therapist - licensed by the NYS Education Department;
    2. Registered Physical Therapist - licensed by the NYS Education Department;
    3. Licensed Speech-Language Pathologist - licensed by the NYS Education Department;
    4. Registered Professional Nurse - licensed by the NYS Education Department;
    5. Certified Special Education Teacher - certified by the NYS Education Department;
    6. Certified Rehabilitation Counselor - certified by the Commission on Rehabilitation Counselor Certification;
    7. Master of Social Work; or
    8. Master of Psychology.

These individuals must have, at a minimum, one (1) year of experience completing functionally based assessments, developing a comprehensive treatment plan and teaching individuals with disabilities and/or seniors to be more functionally independent; OR

  1. An individual with a Bachelor's degree and two (2) years of experience completing functionally based assessments, developing a comprehensive treatment plan and teaching individuals with disabilities and/or seniors to be more functionally independent; OR
  2. An individual with a High School Diploma and three (3) years experience completing functionally based assessments, developing a comprehensive treatment plan and teaching individuals with disabilities and/or seniors to be more functionally independent.
E-mail your resume at: [email protected]


POSITIVE BEHAVIORAL INTERVENTIONS AND SUPPORTS JOB DESCRIPTION

Positive Behavioral Interventions and Supports (PBIS) services are individually designed and are provided to waiver participants who have significant behavioral difficulties that jeopardize their ability to remain in the community of choice due to inappropriate responses to events in their environment. The PBIS should be provided in the situation where the significant maladaptive behavior occurs.

Responsibilities:

The PBIS staff develops a comprehensive assessment of the individual's behavior (in the context of their medical diagnosis and disease progression as determined by the appropriate health or mental health professional), skills and abilities, existing and potential natural and paid supports and the environment.

The PBIS staff is responsible for the development and implementation of a holistic structured behavioral treatment plan (Detailed Plan) including specific realistic goals which can also be utilized by other providers and natural supports. The primary focus of the PBIS Detailed Plan is to decrease the intensity and/or frequency of the targeted behaviors and to teach safer or more socially appropriate behaviors. None of these activities shall fall within the scope of the practice of mental health counseling set forth in Article 163 of the NYS Education Law.

The PBIS staff may provide training for family, natural supports and other providers so they can effectively use the basic principles of the behavioral plan.

The PBIS staff provides regular reassessments of the effectiveness of the behavioral treatment plan, making adjustments to the plan as needed.

PBIS services must be provided in the environment and situation that will result in the greatest positive outcome for the waiver participant. It is expected that this service will be provided in the waiver participant's environment.

PBIS services may be provided by any not-for-profit or for profit health and human services agency. The two key positions in PBIS service are the Program Director and the Behavioral Specialist. Each PBIS provider must employ a Program Director.

The Program Director is responsible for assessing the waiver participant and developing the PBIS plan for each waiver participant. The Director may work as a Behavioral Specialist or may provide ongoing supervision to a Behavioral Specialist who will implement the plan.

Qualifications:

The Behavioral Specialist is responsible for implementation of the Detailed Plan under the direction of the Program Director and must be a:

  1. Person with a Bachelor's Degree;
  2. Licensed Practical Nurse licensed by the NYS Education Department;
  3. Certified Occupational Therapy Assistant, certified by the NYS Education Department; or
  4. Physical Therapy Assistant, certified by the NYS Education Department.

The Behavioral Specialist must have at least one year of experience working with individuals and/or seniors with disabilities or behavioral difficulties. The Behavioral Specialist must successfully complete forty (40) hours training in behavioral analysis, and crisis intervention techniques which is provided by the Positive Behavioral Interventions and Supports Program. Until the Behavioral Specialist successfully completes the forty (40) hours of training, the PBIS provider may not bill for the Behavioral Specialist's time. The Behavioral Specialist must be supervised by the Program Director. The Program Director will provide ongoing training and supervision to the Behavioral Specialist.

Supervision must occur no less than biweekly to review the caseload and must be more frequent when there is a new participant, new provider or when significant behavioral issues arise.

E-mail your resume at: [email protected]