Transition Planning and

Risk Assessments

Presented by:

Suzy Quinlan and Suzanne Huffman

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AGENDA
„ SPD Mission Statement
„ Case Manager’s Role in Risk Management
„ Transition Planning
„ Options and Requirements for assessing risks
„ Risk Assessment Tools & Identifying Risks
„ Implementing interventions to mitigate risks
„ What to do when risks cannot be mitigated
„ Risk section of the CAPS Client Details
„ STEPS - Benefits of using this program
„ Natural Supports
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 SPD Mission Statement
„ The SPD mission is to make it possible to
become independent, healthy and safe
„ SPD contributes to the DHS mission by
helping seniors and people with disabilities
of all ages achieve well-being through
opportunities for community living,
employment, family support and services
that promote independence, choice and
dignity
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Case Manager’s Role in Risk Mgmt
„ Identify individuals at risk
„ Identify what risk factors the individual has
„ Work with individual to eliminate or
minimize the risks
„ Monitor & continue to offer options over
time, to assist the individual in evaluating
risks and developing a plan

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Transition Planning – What is it?
„ Transitioning happens when:
„ Clients move from one care setting to another
„ Changes occur in the service plan
„ Services are closed
„ Services are reduced
„ Client accepts less than the assessed in-home
hours
„ The client chooses not to accept services
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 Transition Planning –
Why is it necessary?
„ To successfully move from one service setting to another
„ Identify available resources:
„ For individuals that need to transition into a new living situation
when services are closed
„ When SPD or a AAA can no longer offer the same level of
services
„ For individuals that are institutionalized, such as nursing
facilities – this is a CMS requirement
„ CMS waiver requirement to identify risks & to minimize
or eliminate risks
„ For individuals not receiving services, assist in eliminating
or reducing risks, such as for Risk Intervention services

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 Assessing Risks
„ Requirement:
„ Assessing and identifying risks
„ Work with individual to eliminate or reduce risks
„ Documenting risks in the Client Details RISK
section of CAPS
„ Options of tools to use for assessing Risks:
„ Risk Assessment Tools discussed in this Netlink
„ located on the CM Website
„ Risk Assessment Tool that your SPD/AAA local
office recommends
„ Assess and mitigate RISKS by directly entering
the info into the Client Details Risks section of
CAPS
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 Risk Assessment Tools
Case Management Website

„ Generic Risk Assessment Tool

„ Risk Assessment Tool Guidelines
„ Additional Requirements and Guidelines

„ NWSDS Client Risk Assessment tool

„ NWSDS Service Review, Client Monitoring
& Risk Assessment Policy
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I. Client Factors
1. Physical Functioning
2. Mental & Emotional Functioning
3. Cognitive Functioning
4. Behavioral Issues
5. Income/Financial Issues

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1. Physical Functioning
„ No Risk
„ Capable of all ADLs and IADLs

„ Low Risk
„ Minimal physical challenges, such as hearing
loss
„ Capable of completing most ADL and IADLs
„ Need for minimal ADL and IADL assistance

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Physical Functioning – continued….
„ Moderate Risk
„ Reduced physical abilities, such as:
„ Partial loss of hand or some arm movement
limitations
„ Requires use of assistive devices, such as a walker
or cane
„ Hands on assistance to ambulate

„ Capable of a few ADLs only

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Physical Functioning – continued….
„ High Risk
„ Severe physical capability
„ Bedridden
„ Chronic diseases
„ Severe physical challenges
„ Incapable of most or all ADLs and IADLs
„ Totally dependent on others

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2. Mental & Emotional Functioning
„ No Risk
„ No apparent mental or emotional limitations
observed or reported
„ Low Risk
„ Minimal mental or emotional challenges
„ Willing & cooperative to accept needed
assistance

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Mental & Emotional Functioning
– continued….

„ Moderate Risk
„ Exhibits some abnormal behaviors, such as
paranoid ideation, but is able maintain ADLs
„ Decompensating Mental & Emotional
functioning
„ Resistive to needed services
„ History of unstable depression

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Mental & Emotional Functioning
– continued….
„ High Risk
„ Developmental disability
„ Suicidal ideation
„ Depression
„ Hostile
„ Violent
„ Acting out
„ Expresses paranoid ideation
„ Withdrawn
„ Inappropriate laughter or crying
„ Refuses needed services
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3. Cognitive Functioning
„ No Risk
„ No apparent Cognitive impairment
„ No observed or reported cognitive issues,
such as confusion & memory issues
„ Low Risk
„ Mild forgetfulness, but remembers to pay rent
& utilities
„ Anxiety over forgetfulness
„ Willing to accept services
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Cognitive Functioning – continued….
„ Moderate Risk
„ Periodic confusion
„ Impaired reasoning
„ Inappropriate answers to some questions
„ Sometimes forgets to pay rent & utilities
„ Resists offers of guidance, won’t use public
transportation or give up driving

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Cognitive Functioning – continued….
„ High Risk
„ Considerable or severe confusion
„ Disoriented to person, place or time
„ Forgets to pay rent & utilities
„ Incapable of preparing meals & forgets to eat
„ Deny confusion
„ Refuses needed services

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4. Behavioral Issues
„ No Risk
„ No apparent problems with behaviors
„ No indication or known substance or alcohol
abuse problems
„ Low Risk
„ Minor problem behaviors
„ History of substance or alcohol abuse, but no
current abuse
„ Willing to accept assistance
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Behavioral Issues – continued….
„ Moderate Risk
„ Moderate problem behaviors, such as
„ Taking medications intermittently or choosing not
to follow medical recommendations
„ Failure to make or keep doctor’s appointment

„ Occasional substance or alcohol abuse problems

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Behavioral Issues – continued….
„ High Risk
„ Severe problem behaviors that place
individual at risk, such as
„ Wandering
„ Current substance or alcohol abuse/addiction

„ Making Life-threatening medical choices

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5. Income/Financial Issues
„ No Risk
„ Adequate income to provide for necessities
„ Financially independent
„ Low Risk
„ Adequate income for necessities only
„ Financial dependence upon others for
emergency expenses, etc.

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Income/Financial Issues – continued….
„ Moderate Risk
„ Major financial dependence on others
„ Barely able to provide for life’s necessities
„ Sometimes must choose between necessities,
such as medicine or food
„ History of financial exploitation

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Income/Financial Issues – continued….
„ High Risk
„ Totally dependent upon others financially
or
„ Has adequate income but unable or unwilling
to provide for life’s necessities

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II. Environmental Factors
6. Safety/Cleanliness of Residence/Facility
7. Service plan meets individual’s Physical
& Medical need
8. In-Home Service Plan meets
individual’s Mental/ Emotional/
Behavioral needs

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6. Safety/Cleanliness of Residence/ Fac..
„ No Risk
„ Structure appears sound and sanitary
„ No major repairs needed
„ No exposed trash or odor
„ No threat of eviction
„ Low Risk
„ Sound structure but old & needs some repairs, such
as painting
„ Utilities operative
„ Sanitary, but undesirable housekeeping standards,
such as odor from trash, thick dust, etc…
„ Threat of eviction
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Safety/Cleanliness of Residence/Fac…
- continued….
„ Moderate Risk
„ Deteriorating structure
„ Safety problems posing a degree of risk
„ Unsanitary conditions
„ Animal droppings or pest infestation or
undisposed garbage
„ Interruption of utilities
„ Access issues, such as steep stairs
„ Threat of eviction

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Safety/Cleanliness of Residence/Fac…
- continued….

„ High Risk
„ Unsound or condemned structure
„ Serious health risks, such as severe
pest/rodent infestation
„ Human and/or pet waste present
„ Utilities terminated or inoperative
„ Residence poses problems that place the
individual at immediate high risk, such as no
heat or water, caved-in ceiling
„ Eviction in progress
„ Homeless
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7. Service plan meets individual’s
Physical & Medical needs
„ No Risk
„ Service plan meets all of client’s medical and
physical needs and
„ Client accepts care/services
„ Low Risk
„ Some minor or occasional issues with
care/service provisions, but client’s basic
medical/physical needs are met
„ No threat of eviction based on a lack of
service assistance
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Service plan meets individual’s Physical
& Medical need – continued….

„ Moderate Risk
„ Service plan fails to meet some medical or
physical needs or
„ Refuses some needed care, but risk to
individual’s health is not serious or imminent

„ Threat of eviction

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Service plan meets individual’s Physical
& Medical need – continued….

„ High Risk
„ Client at serious or imminent risk due to
inadequacy of in-home or facility services
meeting critical needs
or
„ Client refuses critical physical or medical
care

„ Eviction in progress due to lack of physical or

medical care

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8. Care Plan Meets Mental/Emotional/
Behavior Needs
„ No Risk
„ Service plan meets all mental/ emotional/
behavioral needs and
„ Individual accepts services

„ Low Risk
„ Some minor or occasional issues with service
provisions, but individual’s basic mental/
emotional/ behavioral needs are met
„ No threat of eviction
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Care Plan Meets Mental/Emotional/
Behavior Needs – continued….
„ Moderate Risk
„ Service plan fails to meet some mental,
emotional or behavioral needs or
„ Individual refuses some needed care, but risk
to client’s health is not serious or imminent

„ Threat of eviction

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Care Plan Meets Mental/Emotional/
Behavior Needs – continued….
„ High Risk
„ Individual is at serious or imminent risk, due
to inadequacy of in-home or facility
care/services because of critical emotional/
behavioral needs or problems
„ Client refuses critical services
„ Eviction in progress/behavioral.

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III. Support Factors
9. Adequacy/Availability of Informal
Support
10. Access to Needed Care/Services, such as
Medical, MH, Transportation, Telephone,
Emergency Response System, etc…

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9. Adequacy/Availability of Nat Support
„ No Risk
„ Family, friends or other supports are actively
involved to assist, and client accepts
assistance

„ Low Risk
„ Family, friends or other supports are
concerned but provide only limited assistance

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Adequacy/Availability of Nat. Support
– continued….

„ Moderate Risk
„ Family, friends or other supports are:
„ Unreliable
„ Provide little or no help

„ Express good intentions but rarely follow through

„ Physically unable to provide assistance, although

would like to be involved

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Adequacy/Availability of Nat. Support
– continued….

„ High Risk
„ Family, friends or other supports:
„ Interfere with individual’s needs being met
„ Are abusive/neglectful

„ Are estranged

„ Individual has no known family, friends or other

supports

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10. Access to needed Services
„ No Risk
„ No formal services needed or
„ Has unimpeded access to all needed services

„ Low Risk
„ No physician/MH care, but no apparent
medical / mental health needs
„ Generally willing to seek services
„ Transportation problematic but available
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Access to needed Services
– continued….

„ Moderate Risk
„ Has medical / mental health needs but does
not have or cannot access assistance for it
„ Transportation problematic
„ Limited access to phone or other methods of
summoning help
„ Somewhat resistant to needed service

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Access to needed Services
– continued….

„ High Risk
„ Has significant medical / mental health needs
but receives no care, or refuses available care
„ Transportation unavailable or client refuses to
use it
„ No phone or is too confused to use it
„ No Emergency Response System (ERS) or
refuses to use it

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 Implementing Risk Interventions
For the three areas of identified Risk Factors:
„ Client Factors
„ Environmental Factors
„ Support Factors

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 Implementing Interventions based
on the Risk Assessment Tool
„ Risk Assessment Tool Guidelines
„ Use your professional judgment & common sense:
„ Frequency & type of contact
„ Reducing or Eliminating risk factors for Low, Moderate
or High Risk Individuals
„ Tool is not a requirement
„ Guidelines for using the tool is not a requirement
„ Risks section of Client Details is a requirement

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 Case Manager’s Role in
Risk Intervention
„ Minimize or eliminate risk
„ Offer choices and options
„ Evaluate and Identify Natural Supports
„ Refer to community resources or programs available
„ Home Delivered Meals
„ Adult Day Services
„ Emergency Response System
„ Community Health Support services, previously called CRN
„ ADRC-Aging & Disability Resource Connection website
„ www.ADRCofOregon.org
„ Monitor and continue to offer options over time

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Aging & Disability Resource of Oregon
ARDC website has information:
„ FAQ about ARDC
„ Self-assessment of needs
„ Learn about Community Services & Resources
„ Get connected to Services
„ Find Oregon’s Licensed Facilities
„ Local Assistance and Help
„ Other Resources, such as CMS or other agency
info

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Risks that cannot be mitigated
„ Continue periodic monitoring
„ Continue to offer interventions and
solutions to minimize the risk
„ Discuss the risks with the individual
„ Document in CAPS Client Details – Risk
section:
„ The individual’s ability to understand & accept or
decline any plan or intervention
„ Document which items the individual accepted &
refused
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 Risks - Client Details
Plan/Comments

„ Plan/Comments are used:

„ There is a risk, but no appropriate selection
„ To document the Facility’s Responsibility to
reduce risk factors
„ Next slide has additional reasons

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 Risks - Client Details
Plan/Comments … continued
„ Identify risks needing clarification
„ Identify how each risk is or is not going to be resolved
„ Explain solutions offered to minimize the risk
„ After the risk has been discussed with the individual,
document the individual’s ability to understand and
accept or decline any plan or intervention
„ Document which items the individual accepted and refused
„ Enter the name, address & phone number of person that is
assisting with the risk and how this person will assist the
individual
„ Used for CAPS2 Emergency Concerns Report – next slide
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 CAPS2
Emergency Concerns Report
„ Risk section of CAPS Client Details
„ Must select Power Outage, Natural Disaster/
Extreme Weather:
„ Only 3 selections that carry over to the report
„ Only select if the individual needs prompt response
„ Develop contingency plan for in-home plans
„ CBC or nursing Facilities are responsible to
develop contingency plans for emergencies
„ Document in the CAPS Risks Plan/Comments
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Addl Requirements & Guidelines
continued from previous slide

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STEPS to SUCCESS
with your
Homecare Worker

Presented by: Suzanne Huffman

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Do you want your
clients to manage
in-home services
more independently?

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 STEPS Benefits Case
Managers…
♦ Clients better understand employer
role and responsibilities
♦ Fewer calls about homecare worker
(HCW) issues
♦ Decreased HCW turnover
♦ Follow-up and collaboration

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STEPS Benefits Consumer-Employers…
 Learn and improve employer skills
 Gain confidence in ability to hire and
supervise HCWs
 Feel ownership of process
 Assume control over and responsibility
for quality of services and daily life
♦ Access CIL information and referral and
other services

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The guiding principle of
STEPS:

Choice
+ Responsibility
Empowerment

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 CONSUMER
CHOICE RESPONSIBLITIES
‹ Hiring homecare ‹ Client-Employed Provider
worker Program Participation
‹ Daily schedule Agreement (SDS 0737)
‹ Priorities ‹ Communicating
‹ Budgeting service expectations
hours ‹ Maintaining appropriate
‹ How and when boundaries
authorized services ‹ Planning for home safety
will be provided and emergencies

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 How STEPS Promotes Success
 Reviewing rights and responsibilities
 Encouraging informed choices
 Providing written guides and forms,
including job descriptions,
employment agreements, and
more…

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What does the STEPS curriculum
include?
 Understanding the Service Plan and Task List
 Creating job descriptions
 Locating employees
 Interviewing and completing reference checks
 Selecting the best Homecare Worker for the job
 Creating an Employment Agreement
 Training, supervising and communicating
effectively with employees
 Ensuring that work is performed satisfactorily…

63
Curriculum, continued
 Maintaining employment records
 Scheduling and tracking authorized hours
worked
 Approving paid leave and unexpected absences
 Recognizing, discussing and attempting to
correct any employee performance deficiencies
 Discharging unsatisfactory workers
 Developing a backup plan for coverage of
services
 Making the home a safe place for consumer-
employers and employees
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STEPS Tools For
Day-to-day
Management

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 Services and Tasks Worksheet
Services Tasks (describe the routine you like?
1.

Time – How long will it take?

2.

3.

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 DAILY TASK CHECKLIST

Date Task Done

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 Homecare Worker Daily Sign-In Sheet
Date HCW Time in Time out Daily Employee Employer
Name Hours Initials Initials

68
 What
case managers
say about
STEPS…
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STEPS helps my clients:

 understand their true role

 be better employers
 gain knowledge
 be more specific about
how they want things done.

70
My clients have learned about:
 their rights and responsibilities
 how to interact with the HCW
 how to communicate needs in a
forthright and non-apologetic way
 how to direct their own services
 how to get started on their own safety
plan.

71
 The program helps clients who:

 habitually make
questionable
decisions about
hiring/firing HCWs
 are taking direction
from workers rather
than the other way
around.

72
Who benefits
most from
STEPS?
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 Clients who are new to in-home
services
 Designated representatives
 Frequent callers
 Those who employ family
members or friends

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Refer clients when…
 the service plan changes
 there is frequent HCW turnover
 things are going well!

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 How is STEPS provided?

 Workshops
 One-to-one sessions
 Optional “Guide-on-the-
Side” follow-up

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Workshop Scheduling
 Provide contact information to
Center for Independent Living
 The STEPS Coordinator will…
9 arrange one or more workshops
9 contact consumer-employers
9 follow up with you as needed

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Workshop Mailing: Brochure and “Ticket”

FREE WORKSHOP ~ LUNCHEON

$25 GIFTCARD ~ HANDBOOK
ADDITIONAL SUPPORT IF NEEDED

Tuesday, March 29, 2011 ~ 11AM - 2PM

County Senior Center
Space is limited! Please register one week in advance
by calling (503) 555-1212 or talking with Mary.
See brochure for gift card eligibility information. In-home consultations are
available for those unable to attend.
STEPS is presented by your area Center for Independent Living in partnership with your case
manager’s office.

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 Individual Referrals
 Visit www.oregon.gov/DHS/STEPS
 Click STEPS locations at bottom of page, then:
• Call Coordinator (numbers are in Contact list by county) OR
• Download Referral Form to fax or email
STEPS to SUCCESS with Your Homecare Worker
Referral Form
Case Manager Information

Name:
Branch:
Phone Number:
Fax Number:
Email:
Yes No
Do you wish to receive a progress update?
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 A STEPS Specialist will…
1. prepare a list of HCWs, if needed
2. meet with client and/or representative
3. stress employer responsibilities and
how to use the task list
4. provide feedback to you on consumer-
employer’s progress
5. schedule follow-up appointments as
needed

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 Take the first STEPS…

Contact your area

Specialist to
schedule a
workshop or make
an individual
referral.
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QUESTIONS ?

82
Natural Supports

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Evaluating Natural Supports in
new and long-standing cases:
„ Emphasis on good assessment of natural
supports at the initial intake
„ Must evaluate natural supports on-going:
„ May not be any new natural supports
„ Natural support may no longer be available or
sufficient
„ May reduce services based on new supports
„ May close services based on new supports
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What are Natural Supports?
OAR 411-015-0005(20) & 411-030-0020(30)
„ Informal, unpaid resources
„ Relatives/Family
„ Friends
„ Neighbors
„ Roommates
„ Significant others
„ Community resources or agencies
„ Senior Centers
„ Advocacy and Support Groups
„ Churches
„ Home Delivered or congregate meals
„ Emergency Response Systems
„ Veterans Services
„ Veterans Services

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Case Manager Role in Natural Supports
1. Assess existing supports

2. Explore potential new informal supports

3. Identify community resources that could decrease

the need for paid services

4. Not to replace or supplant natural supports

86
The Case Management Role
1. Assessing existing supports
„ Establish natural supports at the initial service
assessment (also for on-going assessments)
„ Difficult to reduce paid services once they have been
previously authorized.
„ Establish natural supports for on-going assmts
„ Determine who is involved in the individual’s
support system?
„ What kind of help do these supports provide?
„ What are the community resources, if any, and do
they currently meet some or all of the needs?

87
Case Management Role (continued)
2. Exploring potential new informal
supports
„ Are there support persons who might be
willing to do extra tasks?
„ Are there supports living with or near the
client who might provide help?
„ Is the client involved in any community
organizations who might be able to provide
some help?

88
Case Management Role (Continued)
3. Identifying community resources that
could decrease need for paid services
„ Senior Centers
„ Advocacy and Support Groups
„ Churches, synagogues
„ Home-delivered or congregate meals
„ Emergency Response Systems
„ Veterans Services
„ ADRC-Aging & Disability Resource Connection
website (discussed in an earlier slide)

89
Case Management Role (continued)
4. Do Not replace or supplant natural
supports
„ Build a plan to supplement existing
resources – for initial & on-going services
„ Do NOT pay persons already providing
unpaid care
„ Do NOT remove unpaid support persons
and replace them with paid providers

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 Pitfalls and Assumptions
„ Do Not assume Natural Supports are:
„ Available

„ Sufficient

„ Reliable or

„ Able to meet the needs of the client

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 Pitfalls and Assumptions
Pitfalls Assumption
„ Family lives with client & „ They will meet all the
help some needs
„ Family lives with client & „ They are available to meet
is unemployed all the needs
„ Family is providing services „ They will continue to be
now available
„ Roommates or others in the „ They will help out & can
Household automatically be
considered a natural
support

92
** Look around and observe **
Natural supports may exist when:
„ Medication placed in weekly pill box
„ The apartment is clean and neat
„ Laundry and clothes are folded and put away
„ Mail is on the counter
„ Family photos walls
„ Neighbor asks why you are there
„ Refrigerator has plenty of food and leftovers
„ Cupboards are well stocked with food

93
 Considerations when
Assessing Natural Supports
„ Who is in the individual’s life?
„ What are they doing for the individual now?
„ What could they be doing, if asked?
„ Is the support providing all the services unpaid?
„ Is the support willing to provide some unpaid
hours, if we pay for other hours?
„ Are their concerns about the support person’s
skills to provide paid care?
„ Evaluate what needs will likely be met anyway
even if we don’t pay for them.
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Discussion Questions for Assessing
Informal Supports
„ What are you doing for your (relative, neighbor,
friend) now?
„ How long have you been providing that
assistance?
„ What kinds of things are you able to help your
(relative, friend, neighbor) with?
„ Is there any reason you would not be able to
continue providing that assistance?
„ Were you providing these services up until now?
If so, what has changed?
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What to ask when exploring potential
new Informal Supports
„ When you do your own shopping, can you pick
up items for the client?
„ What services can you continue to provide?
„ Are you meeting your own housekeeping needs,
and preparing your own meals? If so, can you
also provide these services for the client since
you live in the same home?
„ Do you cook, eat, shop together?
„ Can you pick up the client’s prescriptions when
you go to the pharmacy to pick up your own
medications?
96
 Payment Considerations
„ Situations when some level of payment may be
appropriate:
„ “My health is failing and I can’t provide the care
anymore.”
„ “I can’t afford to provide care for my relative
anymore. I need to get a job to make ends meet.”
„ “I am too burned out to keep providing the kind of
help I am doing now.”
„ “I prefer the natural support to provide for my
personal care, instead of a complete stranger.”
„ May pay for hours for remaining unmet needs

97
Common statements focused on Payment
rather than Service needs
„ “If I don’t get paid for providing care, then I am
going to stop doing it.”
„ “I won’t be able to make my house payment if I
can’t be paid as the clients provider.”
„ “My neighbor’s niece is getting paid and all she
does is my neighbor’s laundry.”
„ “If you are going to pay someone else why can’t
you pay me?”
„ “The client and I just got married. Can I continue
to get paid?”
98
Common Statements which will lead you
to ask more clarifying questions
„ “I’d like to get paid for taking care of my
relative.”
„ “I do everything for my relative.”
„ “Yes, my father lives with me but he doesn’t help
me at all. “
„ “My roommate only takes care of his half of the
house.”
„ “My daughter has her own family to take care
of.”

99
Factors in payment decisions:
„ Consider the whole context of the situation

„ No factor is an automatic reason to pay

„ No factor is an automatic reason not to pay

100
Payment Factors to consider
„ Extent of care needs
„ Support availability
„ Support distance: is support right next door or
coming across town just to provide help?
„ Client preferences
„ Personal care and intimacy concerns
„ Language and communication
„ Cost effectiveness
„ Adaptive equipment/community resources

101
RAFH and Natural Supports
„ RAFH is an all or nothing payment
„ Consider natural supports prior to setting up RAFH:
„ Is it cost effectiveness?
„ Does the current situation support the plan?
„ Do NOT set up a RAFH when:
„ Relative provides for all services as a natural support
„ Relative doesn’t want to be paid for any needs, and
meets all the needs of the client
„ In-home plan with outside provider can be set up
for unmet needs within the relative’s home as long
as the relative is not paid for any services in the
plans
102
 Community Resources that may
Decrease need for service hours:
„ Emergency Response Systems
„ Home-Delivered Meals
„ Assistive devices/service animals
„ Lifespan Respite
„ Family Caregiver Support
„ Older Americans Act/OPI programs
„ Commission for the Blind
„ Other resources that may replace or reduce
a need for a paid service
103
Why Evaluate Natural Supports?
OAR 411-015-0000 Purpose
„ To serve the most functionally impaired

„ To serve those with no or inadequate

alternative service systems; and

„ To manage limited resources through a

priority system based on the individual’s
assessed need
104
 In-Home Services Program
OAR 411-030-0040 Eligibility Criteria
„ Payments are not intended to:
„ Replace the resources available from natural
supports
„ Payments can be considered or authorized when
resources are:
„ Not available or
„ Not sufficient or
„ Cannot be developed to adequately meet the
needs
„ Payment can not be authorized if service needs are
fully met by a natural support
„ Least costly means of providing care
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 In-Home Services Program
OAR 411-030-0070 Maximum Hours of Service
„ Authorized hours are subject to availability of
funds
„ To reduce paid in-home service hours, CM must
assess & utilize appropriate:
„ Natural supports
„ Cost-effective assistive devices
„ Durable medical equipment
„ Housing accommodations
„ Alternative service resources
„ In-home services are paid:
„ To supplement potential or existing resources 106
 In-Home Services Program
OAR 411-030-0050 Case Management

„ To meet the identified assessed needs, the

Service Plan must consider:

„ In-home service options

„ Assistive devices
„ Architectural modifications, and
„ Other community-based care resources

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 Websites
„ SPD Case Management Tools
http://www.dhs.state.or.us/spd/tools/cm/index.htm

„ Assessment, Narration & CAPS Tools

http://www.dhs.state.or.us/spd/tools/cm/capstools/index.htm

„ New – Risk Assessment section with:

„ Generic Risk Assessment Tool
„ Generic Risk Assessment Tool Guidelines
„ NWSDS Risk Assessment Tool
„ NWSDS Service Review, Client Monitoring & Risk Assessment Policy
„ New - Assessing Natural Supports
http://www.dhs.state.or.us/spd/tools/cm/capstools/natural_supports.pdf

„ ADRC-Aging & Disability Resource Connection

www.ADRCofOregon.org
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Contact Information
„ Suzy Quinlan, In-home Services Policy
Analyst
„ (503) 947-5189
„ [email protected]
„ Suzanne Huffman, Homecare Commission
Policy Analyst
„ (503) 373-1078
„ [email protected]
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