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Services Coordination

What are the Responsibilities of a Services Coordination?


Determining eligibility for services

The initial eligibility for a person requesting services is to be made by the Community Developmental Disability Program (CDDP), and is often the task of a Services Coordinator. There are very specific requirements regarding eligibility for developmental disabilities, which are more fully explained in the Eligibility section of this website.


A Services Coordinator does not diagnose an individual as having a developmental disability, but does determine through review of evaluative information whether an individual meets the eligibility criteria. Once an application for services has been submitted to the CDDP, the process of determining eligibility must happen within ten days. In the case of a child, the CDDP where the parent resides or the county court having jurisdiction for the child must be responsible for making the eligibility determination (pdf).

Participating in plans and annual Summaries

A Service Coordinator must assure that an annual plan is developed for each individual receiving services through the Community Developmental Disability Program (CDDP). The Service Coordinator will attend the annual planning meeting and assist in the development of the plan for people who are receiving comprehensive services. For individuals in comprehensive services, the annual plan is most commonly known as the Individual Support Plan or ISP. For children receiving family support services, the Service Coordinator is responsible for developing the plan with the child and family. This plan is most frequently referred to as the Child and Family Support Plan (411-305-0080).

Service Coordinators are charged with supporting plans that address issues of independence, integration and productivity, and enhance the quality of life of the person with developmental disabilities. Principles which guide Service Coordinators in the development of individual plans are prescribed in the CDDP Administrative Rule (411-320-0120 Service Planning).

Some very basic principles serve as the cornerstone for Service Coordinators as they assist in plan development. Personal control and family participation must be carefully balanced when planning. Service Coordinators are charged to preserve the rights of the adult with developmental disabilities when making informed choices about the level of participation by family members. While the service system does reflect the value of family member participation in the planning process, it is the intent to support personal control and decision making for individuals receiving services. Respect for the individual and the family’s preferences and choices is critical and the individuals active participation and input must be facilitated throughout the planning process.

Identifying barriers that might influence how preferred services are provided is important, and provides opportunities for the Service Coordinator to assist in strategically overcoming those barriers. Assuring that an individual has the opportunity to exercise his or her rights can sometimes lead to tensions when interventions must also be considered to protect that individual from harm. The Service Coordinator is charged to support the ISP team in carefully nurturing the individual’s exercise of rights will maintaining an equal sensitivity to the protection of an his or her health and safety.

When a Service Coordinator is planning for a child who is living outside of the family home, in another residence (such as a foster home), a principal value is that of maintaining family connections unless contra-indicated. To that end, a goal of family unification should be established. To help reach that goal, the plan should strive to minimize moves and transfers, unless the placement is a distance away from the family. If the latter is true, than the Service Coordinator should seek another placement which would bring the child closer to the family.


Authorizing services

The signature of a Services Coordinator on an annual plan for individuals in twenty four-hour services is an assurance that the plan for the individual has been developed using a “person-centered” process. Such a process identifies what is important to and for the individual and identifies the supports necessary to address issues of health, behavior, safety and financial supports. Also see specific requirements regarding elements of the plan (411-325-0430).

Specific requirements for Family Support Services and plan content are found in the Oregon Administrative rule.

The necessary plan requirements for an individual receiving In-Home Support services are found in the Oregon Administrative rule for Comprehensive In Home Support for Adults.

The Support Specialist must receive a copy of the Individual Support Plan (ISP) developed for an individual enrolled in Support Services for adults, and the ISP must conform with the expectations identified in the Oregon Administrative Rule for support services.

Whenever a plan is submitted which commits to the expenditure of funds, the Services Coordinator or Support Specialist must review and authorize by signing within 5 working days. The expenditure of funds must address the needs of the individual, identify the type, amount, frequency, duration and provider of services, and is signed by the individual and his or her guardian, as well as any other relevant members of the team.


Monitoring

Services Coordinators are responsible for monitoring services and supports for all individuals enrolled in case management as described in section 411-320-0130 of the CDDP Administrative Rule. For children and adults who reside in a 24-hour residential program, or a foster home, regular visits by the Service Coordinator are expected. Over the course of a year, the Service Coordinator will review the services and supports provided, and ask specific questions regarding health, safety, behavioral support needs, the ISP and financial services.


See:

When a child is living in a foster home or 24 hour residential program that is contracted directly through the state (not through the county), a Children’s Residential Services Coordinator is assigned to monitor the services, and coordinate and provide findings to the CDDP Services Coordinator. For individuals who receive only case management services, the Service Coordinator must have at least an annual contact, which preferably should take place in person.

Additionally, a Services Coordinator is responsible for evaluating whether the services are in accordance with the Individual’s Support Plan or the Child and Family Support Plan. In conducting that review several considerations occur. A Service Coordinator will review any serious events or unusual incident reports and will review the process by which an individual accesses and utilizes funds. When reviewing the ISP document, the Service Coordinator will also monitor whether services are being provided as described; evaluate whether the personal, civil and legal rights of the individual are being protected, fi the personal desires are being addressed and if the services provided for in the plan continue to meet what is important to and for the individual.


Assisting Individuals to Entry, Exit or Transfer between Services

The Services Coordinator is responsible for authorizing and coordinating admission to programs administered through the CDDP. Written information requirements and entry meeting expectations are detailed in the CDDP rule 411-320-0110.

Within a county, there may be other resources that are not directly administered through the CDDP. These could include children’s residential services, children’s proctor services, children’s intensive in-home supports, state operated community programs and state training centers. The SPD Services Coordinator is responsible for making referrals for admission and participating in all entry meetings when referrals to these programs occur.

For those individuals who are interested in a referral to a support services brokerage the Services Coordinator first must find the individual eligible to receive services from a Support Services Brokerage.


Eligibility requirements include: 

  • Residency in Oregon and a determination that he or she has a developmental disability;
  • An adult living in his or her own home or family home and not receiving other Department –paid in-home or community living support (other than State Medicaid Plan Services);
  • Is not enrolled in Comprehensive Services;
  • Is not receiving short term services known as crisis/diversion services; and
  • Chooses to use a Support Service Brokerage for assistance in the design and management of their personal supports.
The Individual’s Support Plan team plays a critical role when someone is considering entry into, exit from, or transfer between county funded programs. The team must meet to review the referral information and to also determine whether the move is appropriate. Specific information regarding these meetings can be found in section 411-320-0110 of the CDDP OAR. The CDDP or Department must approve any plan that is developed, as a result of the ISP teams meeting, should an entry, exit or transfer from a program be recommended.

Conducting Investigations and/or Providing Protective Service Activities?

It is important to know that all Service Coordinators and Support Specialists are mandatory abuse reporters. They are required by State Statute and Oregon Administrative Rules to report regardless of whether or not they are acting in an official capacity, 24 hours a day, 7 days a week, for any child. For adults with developmental disability, while acting in an official capacity. For more information, see http://www.oregon.gov/DHS/dd/abuse/index.shtml.

One of the County Developmental Disability Programs core responsibilities is to investigate allegations of abuse reported for any adult with a developmental disability. When allegations of abuse are reported for children, Child Welfare conducts the investigation. Get more detailed information regarding Protective Service Investigations, (411-320-0140).

Sometimes services need to be arranged to protect the individual while the investigation is being conducted. Protective services may include moving the individual to an alternative location, building additional health supports into the person’s plan, creatively finding ways to increase supports to assure that the individual remains safe, or other such strategies. A Services Coordinator assesses the need for protective services and coordinates getting the services into place. For individuals receiving brokerage services, a Personal Agent is also a part of the support team for identifying protective service resources.


A Civil Commitment is being requested

A Civil commitment is for the purpose of providing institutional supports to a “mentally retarded person” who, because of their mental retardation, is or is alleged to be either: “(1) dangerous to self or others; or (2) unable to provide for basic personal needs and not receiving care as is necessary for the health, safety or habilitation of the person, as stated in ORS 427.215 Definitions for ORS 427.061 and 427.235 to 427.290. The procedures for civil commitment processes are fully explained in the statute.

The CDDP Director or his/her designee is responsible for assuring that the individual proposed for civil commitment does have mental retardation. Once that is established, the role of the CDDP is to provide information to the individual with developmental disabilities through out the process, and if/ when appropriate, provide information to the court through out the proceedings, as called upon. A Services Coordinator may be designated as the CDDP Directors’ designee, and can often be the primary link between the individual with mental retardation, the family and the judicial system.


Providing Information and Referral

Services Coordinators are responsible for providing information and timely referral to people with developmental disabilities and their families. Often, a Services Coordinator is thought of as the “thread that ties the quilt of services” together. As such, they are quite knowledgeable about services provided within the community social service system. The Services Coordinator is also required in many cases to officially prepare and provide the referral information, participate in planning meetings, and authorize the ultimate placement of an individual into paid services.


Assisting individuals to Access Comprehensive, Support and Crisis Services

Understanding the particular needs and interests of someone with developmental disabilities, and their family is often the starting point for a Services Coordinator. Once such a discussion has occurred, the Services Coordinator is better able to make appropriate referrals to other social service entities, as well as to specific services offered through the CDDP. Service Coordinators assist in the development and disbursement of referral information, coordinate with other agencies for supports as appropriate, and facilitate access for financial assistance. A standardized application form is required of all individuals who are being referred for services through the DD system.​


Also see:

At times, individuals may go through a period of crisis, during which additional resources are needed to resolve the presenting problems. Services Coordinators serve as the referral and liaison to crisis services, which are offered either through the CDDP or through Regional Partners who provide crisis/diversion services.

The Services Coordinator is responsible for determining whether the individual is eligible for crisis services and whether the risk factors rise to the level of need as specified in OAR 411-320-0160 (1) – (3) 

After determining eligibility, the Services Coordinator first seeks to use local and CDDP resources to meet the individual’s needs. Should there be no resources, the Services Coordinator then refers to the Regional Crisis Office for access to regional and statewide resources.

Monitoring the crisis services specified in the crisis plan and the individual’s Support Plan is provided through the CDDP. In some cases, a specialized staff person is assigned the responsibility for monitoring the crisis services. In other circumstances the Services Coordinator will provide the ongoing monitoring. Whether it be a Service Coordinator or other identified CDDP staff, it is critical that coordination with service providers and other support team members occurs, so that the impact of crisis services are positive and that the necessary changes are happing to support the individual.


Working with Child Welfare

For children with developmental disabilities who can no longer live in the family home, twenty four hour, out of home services, can be accessed through the CDDP program. For more information on these services, including Foster Care, Proctor Care, and Residential Care, link to the Supports for Children/Twenty-Four (24) Hour Out of home Services.

Children living outside of their family home require particular supports and coordination efforts by the Services Coordinator. Counties have worked with SPD to develop joint values and recommendations in how to best support these children. To review these values, recommendations and decision making processes, please refer to “Kids Case Management Procedural Framework for Counties”

When children are receiving services through the CDDP and Child Welfare is involved with that child, the Services Coordinator works actively with the Child Welfare case worker to ensure that the required supports are being provided. Both service systems have particular requirements that they are bound to by either rule or policy.


Also see:

DHS Co-Case Management between the DD system and Child Welfare.
This document provides guidance in this “co–case management” work

Who is Responsible for What
This matrix helps to detail the responsibilities of the family, the CDDP program, the Child Welfare system, and SPD, when placing a child in a SPD funded foster care or residential program

Enrolling Individuals into Services

The CDDP is responsible for assuring that each individual is enrolled appropriately into the services that they hope to receive. The Client Process Monitoring System, or CPMS, is the statewide system managed by SPD, which provides for the payment to CDDP and/or providers for services rendered to individuals with developmental disabilities.

Additionally the CPMS system helps to identify how those services will be paid. The State of Oregon is able to access support through the federal government by accessing Medicaid’s Home and CommunityBased Waiver program. For more information on this see Quality Assurance in Community Based Waiver Services.

Services Coordinators play a critical role in assuring that all individuals who are eligible to receive wavered services are indeed enrolled as such. Frankly, the diversity and scope of services available throughout the state would not be possible without Medicaid's home and communitybased waiver program.


Working with Individuals in Nursing Home Settings

Service Coordinators are the starting point for a nursing facility referral. However, there are important steps that must be followed before admission to a nursing facility can occur. OAR 411-320-0150, the Administrative Rule for Medicaid Nursing Facilities describes the process for entry into a nursing facility.

Before placement can be made, a Pre-Admission Screening must occur to determine the level of need of the person interested in placement, and to identify whether any mental health or developmental disability issues are apparent. This screening is known as a Level I screening. Assuming an individual indeed has a developmental disability, then a second level of screening must occur, and in the field of developmental disabilities, that is conducted by a Registered Nurse, from the Health Care Unit of SPD.

As a part of the Level II screening, the nurse determines whether the needs of the individual truly require the level of service provided through the nursing facility. Part of the equation includes evaluating whether medical or rehabilitative supports can be provided outside of the nursing facility. If so the service coordinator must pursue other means to create the supports necessary outside of the nursing facility.

In some cases, the nursing facility will be identified as the most appropriate referral, but because of the persons mental retardation, additional supports are needed to assure the most beneficial rehabilitative period. Specialized services for people in nursing facilities can be accessed by the Services Coordinator on behalf of the individual.

Working with Adults Who Receive No Other Service besides Service Coordination

If an adult is not enrolled in services other than case management, and requires more than occasional services, or requires services that are available through a support services brokerage, a Services Coordinator must make a referral to a brokerage.

In the event the person with developmental disabilities refuses a referral, than the Services Coordinator provides information, referral and support as appropriate. An annual summary must be completed with an individual receiving case management only services, within 60 days of intake and annually thereafter.

The Services Coordinator includes in this summary:


Reporting Serious Events

Services Coordinators review incident reports that are completed by providers of service. An incident report is defined as " a written report of any injury, accident, acts of physical aggression or unusual incident involving an individual.” In some circumstances, an incident report may reflect a serious event. When such an incident is reviewed, the Services Coordinator must report the incident to SPD, using the procedures established in SPD’s Serious Event Review Team manual. Service Coordinators review the action taken following such reported incidents and assure through monitoring that the individual’s health, safety and rights are protected.


Assuring that the Requirements of our Federal Waivers are Being Met with Regard to Individuals in Services

The Federal government requires that all individuals interested in services are first offered the choice of living in an institutional or a community based setting. Services coordinators extend this offer to the eligible individual or their legal representative. If the individual chooses community based services, then the CDDP and SPD can waive the requirement of institutional services, and access a matched amount of federal dollars to help pay for the community based services in which the individual is interested. For more information on waivers, link to Vicki Stories page on Quality Assurance in Community-Based Waiver Services. Although institutional services in Oregon are extremely limited (one institution located in eastern Oregon), Services Coordinators should contact their Regional Coordinator to discuss possible options, should institutional services be requested.

A Services Coordinator is required to complete a Title XIX Waiver form on each eligible individual. This form indicates the level of care an individual needs, and documents eligibility for services. It also serves to document that the individaul has been offered the choice of institutional verses community services. (See: Title XIX Document - Frequently Asked Questions) If an individual is not given the choice of wavered services, or is denied their choice, a Fair Hearing may be requested. Services Coordinators are responsible for giving notification of an individual’s right to a Fair Hearing, and provide a document entitled “Applicable Laws and Rules.”

A Health Care Representative is Needed

SPD recognizes the rights of adults to make informed choices, which include refusal of and consent to health care. When an adult is incapable of making health care decisions, accessing a Health Care Representative is an option that Services Coordinators can help facilitate. This rule encourages the use of health care representatives as provided under ORS 127.505 to 127.660 and provides for the appointment of a health care representative in situations not covered by ORS 127.505 to 127.660 (provisions permitting capable individuals to appoint a health care representative to make health care decisions in the event they are incapable) and when there is no legally appointed guardian with authority over health care decisions.

This rule provides for the appointment of a health care representative for making health decisions for incapable individuals in situations where the ISP team agrees regarding the individual's incapacity. The ISP determines who will serve as the health care representative, and serves as the discussion group regarding any significant health care decisions. Service Coordinators and at least one person who is a residential provider from each ISP team shall receive approved training from SPD before using this rule to designate a health care representative.


Working with Individuals Receiving “In Home Services”

Each CDDP is responsible for ensuring that a Services Coordinator is available to provide or arrange for comprehensive services to be provided in the individuals home or family home as required to meet the support needs of the eligible individuals. (Link to Molly’s (Supports for adults with Developmental Disabilities: Supports in the Home; Link to Leatha’s stuff on County Services: Comprehensive In-Home Support Services for Adults).

A Services Coordinator will assist in determining the needs of the individual; help plan for the needed the supports and assist in finding and arranging resources and supports. Other responsibilities include providing education and technical assistance so that informed decisions are being made. Services Coordinators may also arrange for fiscal intermediary services and assist with employer related supports. Finally, a Service Coordinator will assist in overall monitoring focusing on improving the quality of supports being provided.


Services Need to be Prioritized

At times, the CDDP may feel that it is necessary to prioritize the availability of case management services, differently than the requirements of the Administrative Rule, 411-3320-0090-5. In those circumstances, the CDDP must request and have an approval for a variance against the rule. The variance request must document the reason the service prioritization is necessary (including the alternatives considered), detail the specific service priorities being proposed and provide assurances that the basic health and safety of individuals will continue to be addressed and monitored.

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