ISP Monitoring 2014 - Lesson 4 Printable Version PD

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Course Number: 005-15-04

1ISP Monitoring 2014 - Lesson 4

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Hello, my name is Sonya Hipple, Supports Coordination Organization (SCO) Lead for the Office of Developmental Programs. Welcome to Lesson 4 of ISP Monitoring 2014.



By the end of this lesson, you’ll have more insight into quality of services and their effectiveness in promoting health and safety and supporting the individual’s outcomes. We’ll also talk about ways to understand how to monitor service utilization to determine if the pace of service utilization matches what is written in the ISP and how to have conversations with the team if it does not.



There are a couple of different issues that we’re going to connect together. In the Monitoring Form, we’ll be referring to questions in the Individual Support Plan Status section and also pulling in some of the questions from the Consumer Satisfaction section. We’ll look at the questions on the Monitoring Tool that ask the SC to review frequency, duration, and effectiveness of services. This lesson will include discussion related to the value of utilization information in guiding decisions about planning. Also, we’ll review the methods SCOs reported they use to understand, document and use utilization information in planning with individuals, families, and providers. We’ll describe ways to determine how the individual feels about the quality and level of service he or she receives, including progress toward what the individual considers important, as written in outcome statements.

Leah Napoli from the Office of Developmental Programs Consulting System will be your narrator.



Thanks, Sonya.

Before we get started, there are three documents that are referred to in this lesson. They’re included in the Resources section of the course where you found the webcast. As Sonya mentioned, we’ll be talking about some of the questions on the Monitoring Tool as we discuss service utilization. I recommend you have a copy of the Annotated ISP Monitoring Tool in hand during the webcast.

The webcast also makes reference to ODP Bulletin #00‐10‐06, Supports Coordination Services. You can also choose to have a copy of the Bulletin if you want, but it’s not necessary to print it. Excerpts which relate to the discussion will appear on screen. The webcast also refers to the Consolidated and Person/Family Waivers. Links to those documents are also available with the Resources for this course, but I don’t recommend you print them out – they are lengthy documents.



Let’s start with looking at the big picture. We’re talking about all services and supports an individual receives, whether they are delivered according to what was outlined in the ISP, and if they’re having the positive effect that was intended.



The first thing to know is that when we talk about services, we’re talking broadly about paid services, both within the ODP system and also services that are supplied from other systems – for example, the mental health system or community supports. But it’s more than just paid services. To really get a picture of how the ISP is being implemented, the SC needs to consider whether unpaid services coordinate with paid services and if they’re having the effect that the ISP intended. In other words, the SC needs to have a birds‐eye view of the entire picture of how the individual is being supported to really understand if the ISP is being implemented in the way the team envisioned.



Going back to waiver requirements will help us think about monitoring services and supports and progress toward outcomes – monitoring is directly connected to the Waivers.

First, the waiver agreement between Pennsylvania and CMS includes detailed information about the intent of a service and exactly how and under what circumstances it is to be provided – these are referred to as the service definitions.

The waivers also stipulate that monitoring is a check that services are delivered at the frequency outlined in each individual’s ISP.



The waivers also require that, when there is more than one provider involved, theproviders’ actions are coordinated with each other – in other words, they are complementary, not in conflict, and are not duplicative.

Determining quality touches on factors such as whether services are delivered consistently without lapses, if workers are on time, and if individuals are approached as customers.



The expectation is always that services and supports are monitored from the perspective of whether they are having the intended effect, especially in regard to support for health and safety, but also if services are helping the individual move toward his or her desired outcomes. At the foundation of the waiver requirement is an opportunity for the individual to tell us: are services satisfactory to him or her? Are the services sufficient to meet the individual’s needs?



When monitoring services and supports, the SC is looking at two primary sources: the standard for service definitions outlined in the waivers and how services and supports are expected to be delivered, as outlined in the individual’s ISP.

This means that the SC needs to be familiar with the service definitions, the intent of each service, and service limits. The two sources for understanding services are the waivers and the ISP Manual. During monitoring visits, the SC is responsible for observing and reviewing documentation to determine if the conditions of the service definitions are being met.

Then, with those objective definitions in mind, the SC uses the ISP to determine if services are being implemented as outlined. Are the services supporting the individual’s outcomes – what he or she hopes to experience, learn, and achieve? What is the actual frequency of services compared to the ISP, and do services and supports promote health and safety? In thinking about outcomes, look at what the team wrote in the section, “How will you know that progress is being made?” Are those milestones actually occurring?



Let’s connect the service definitions and the ISP directly to the questions in the Monitoring Tool. For this section, we’re going to talk about three approaches to finding information to complete monitoring.

Talking with people: the individual, family and caregivers, providers, and others; observation during the monitoring visit – what the individual and others are doing; and documentation.



If services are not being delivered at the frequency outlined in the ISP, what are the barriers that the individual and caregivers identify, and what does documentation reveal? As an example, are there problems with finding and retaining staff, or perhaps with providing transportation?

Ways you might learn the answers to these questions are by talking with the individual and others. Documentation might also show if services are delivered consistently or if there are gaps during which services have not been delivered as outlined in the ISP.



When observing interaction between the individual and staff, do you see that the staff person treats the individual with respect? Is there balance between what the staff must do and opportunity for the individual to have choice and control over the way that the service is delivered?

Is the number of staff adequate to provide the services in the approved ISP and keep the person safe? Does documentation indicate that staff complement is consistent?



Does documentation including progress notes and reports show that the progress toward outcomes that the team expected is actually occurring? Is the ISP on site, and do staff have access to it? If there are multiple providers supporting the individual, are their efforts coordinated, or is there need for improvement in how they communicate and collaborate?

Think of an individual who is served by one provider during the day and another at home. Do documentation and the individual’s report indicate that they are aware of what the other is doing and working in harmony?



Let’s use a fictitious example to illustrate how monitoring can use the information in the ISP to determine if progress is being made toward outcomes and if services are being delivered as intended in the service definitions and at the frequency outlined in the ISP.

Jerry loves spending time with his brother – they are close and it is very important that they spend time together doing things they enjoy. They like to travel together to historical sites and spend a long weekend a couple of times per year. This year, they plan to go to Gettysburg to watch Civil War reenactments. This is one of Jerry’s outcome statements. He needs to have money saved for the trip.

Jerry works with a Home and Community Habilitation worker to practice skills to maintain his independence in his own apartment; one of the things they work on is budgeting. At his most recent Annual Update ISP, Jerry’s ISP was revised to include an action step that supports his outcome statement – specifically, saving $25 per month for the next six months so he has some money to set aside for his next trip. Jerry and his habilitation aide will work on this on Mondays for 2 hours over the next six months. The team agrees that checking bank statements to see savings increase is one way to determine that Jerry is making progress toward his outcome statement.



While monitoring, the SC reviews progress notes and discovers that home and community habilitation services have only been occurring once per week. The provider’s goal implementation documents indicate that budgeting skills have only been worked on once in the four weeks since the last monitoring visit. Instead, Jerry and the aide have been spending the majority of the time in recreational activities. Jerry is only saving an extra $10 per month instead of the $25 he needs to be ready for vacation with his brother.

At this point, the SC has identified several issues with service delivery. Although the service definitions state that Home and Community Habilitation service is to be focused on skills development, most of the time has been spent on recreation , which is not a waiver‐eligible service, instead of budgeting skills. Service is not occurring at the frequency in the plan. The result is that the action that supports Jerry’s outcome statement is not occurring and prevents Jerry from achieving the outcome statement that’s important to him.

The next step for the SC would be to talk with Jerry and the Provider to determine reasons why the ISP is not being implemented as planned and either make a plan to get back on track or make changes to the plan.



Imagine that, as the SC talked with Jerry and the provider of Home and Community Habilitation services, one reason rose to the top to explain why the service was not being delivered at the frequency outlined and is not addressing the outcome action of budgeting: Jerry and the aide have not really developed a rapport. The aide is a new employee who doesn’t share Jerry’s interests in the same way as the former aide.

So, as the SC worked with Jerry and the provider to address the issue she discovered in monitoring, another important aspect came to light: Jerry was not satisfied with the service and expressed interest in learning about other choices.

The monitoring process devotes an entire section to consumer satisfaction. Support for health and safety without taking into account the individual’s feelings about service is not person‐centered.

Satisfaction with services also touches on two important points. First, what is the individual’s feeling about the level of service he or she receives – is it enough to meet needs? Notice the word choices in the question: “do individuals feel that services and supports are all that they need?” So, this question is not about objective assessment of someone’s needs by others; it’s from the individual’s perspective.

In addition, monitoring seeks to gauge satisfaction with services – again, from the individual’s own perspective. People express level of satisfaction in many different ways: by what they tell us both in words and, even more often in their actions. During monitoring, an SC should ask the individual about satisfaction, when appropriate. However, more may be learned by observing the individual and reviewing documentation of service delivery and progress. Does documentation show that the individual is actively engaged in service delivery? Does he or she seem interested or disinterested when receiving services? And the question goes beyond whether or not the individual is satisfied. If words or actions tell us that the individual is dissatisfied, is that being paid attention to and addressed? Does the individual know what other options may be available and how to begin exploring choices?



No audio. Transition slide – Service Utilization.



Several times throughout this webcast, we’ve discussed that one of the most important responsibilities of ISP Monitoring is to determine if services are being delivered as the team planned in the ISP. Again, looking at the waivers give us the foundation: service utilization is required, as is resolution when issues are identified. When the waivers define the locating, coordinating, and monitoring role of Supports Coordinators, the reference to resolving barriers to service delivery is also stated. The Consolidated and Person/Family Directed Supports Waivers are both clear about the expectation to identify and act on concerns regarding service delivery.



To think through service utilization, we have to keep in mind that the ISP includes two requirements for each service. The first is frequency – the number of times a service is provided; and duration – the span of time over which the service is to be provided. An example of frequency of service is “5 hours a day from 4pm‐9pm.” The duration could be expressed as a span of time “7 days a week for 52 weeks a year.”

Frequency and duration should be outlined specifically so the individual/family is clear about when to expect the service and the provider is clear on when the service should be delivered. Monitoring, then, is the check on whether services are being implemented at the frequency and duration outlined in the ISP.



Let’s think about reasons to monitor service utilization. We’ll borrow a quality management technique that many organizations use called a “Logic Model.” Simply stated, when a sound plan is developed and then implemented correctly, it is logical to assume that the desired results are more likely to occur. In our system, we expect that if services are provided at the frequency and duration the team outlined in the ISP, then it is more likely that health and safety will be adequately supported and progress will be made toward outcomes. On the other hand, when services are not delivered with the frequency and duration in the ISP, it may increase risks to health and safety. In addition, the individual may not have an adequate support to achieve what he or she considers important outcomes and there is a greater likelihood of dissatisfaction.



Although some services may be used at exactly the frequency and duration that is outlined in the ISP, the SC needs to be prepared to monitor what is actually happening in the individual’s life.

Are services being over‐utilized – in other words, at a faster rate than anticipated?

Or are services being under‐utilized – at a slower pace than the team planned?

Whether services are being under‐ or over‐utilized as compared to the ISP, finding the variation is just the beginning. More important is finding out why services are not being utilized at the expected frequency.



Has it been challenging to find staff to provide a needed service? Is it a less‐than‐ideal match between the individual and those providing service making it challenging for the service to be provided consistently and in a way the individual wants? If services are being over‐utilized (more frequently than planned) it may point to changes in need that may be already known or not yet known by the SC and team.

Significant variation in utilization always points to an underlying reason. Think of an example in which a family uses respite much more quickly than anticipated. How would you, as an SC, respectfully try to learn the reasons? How would you help the individual and family understand the concern about using services more quickly than planned?



So if planned frequency and duration for each service are included in the ISP – and the ISP looks forward to what everyone expects to occur ‐ then monitoring service utilization is a backward‐looking analysis that determines whether the service has actually been occurring the way the team expected.

How do SCs approach monitoring of service utilization?



Preparation will make the difference in effective ISP Monitoring in all areas. This is equally true for monitoring of service utilization; the SC has to review utilization information before the monitoring visit occurs. The first place to look is in the ISP – what is the frequency and duration of services outlined in outcome actions and service details? HCSIS also provides service utilization data, but during the conference calls in February 2014, SCOs said they advise SCs to keep in mind that very recent HCSIS service utilization information may not contain information on services for which a provider has not yet billed.

Many SCOs use HCSIS utilization reports to spot trends over time. The Individual’s Expense Summary Report provides a summary of an individual’s services and expense information across multiple fiscal years (two fiscal years in the past and current fiscal year.)

In addition to using HCSIS, the SC may need to review service notes or previous monitoring visits to recall past issues with service utilization and what was done to address them.



During the visit, the SC uses the same methods to learn about service utilization as used to learn about any issue: talk with the individual and family and review provider documentation.

Above all ‐ keep in mind that learning about over‐ or under‐utilization of services needs to be followed up with discovering the reasons why it’s occurring and finding solutions to address it.



Here are some examples that illustrate potential reasons:

In the first scenario, service utilization information shows Jake is not attending day program five days per week as outlined in his ISP, but everyone knows that this is because he has been staying home under doctor’s orders while he recovers from pneumonia. Jake wants to return to day program as soon as he can and everyone expects service utilization to return to normal.



The second scenario illustrates that the SC has reviewed historical service utilization information and used it to have a conversation with Jana and her family. Although they have requested 20 days of respite in years past, they have only ever used at most 15 days. The family’s situation is stable and they were comfortable with the SC revising the number of days from 20 to 15. The SC would reflect the decision in monitoring documentation and a service note and make the changes to the ISP.



Susan and her family have been using Home and Community Habilitation at a pace that indicates they will use up all the units before the end of the plan year. The SC points out that it may not be possible to secure additional units of service before the ISP is renewed, which may cause a potential interruption in service toward the end of the plan year. They agree that they need to continue to monitor usage, look at the reasons why it’s faster than anticipated, and then discuss alternatives. The SC plans to continue talking with Susan and her family over the coming weeks to figure out why the pace is faster and what options might be available. Then, at the next monitoring visit, they can discuss changes that are necessary to ensure utilization is on track.



As always, if utilization indicates changes may be necessary to the ISP to address changing needs, the SC is responsible to facilitate a discussion with the team to ensure the ISP is updated and to advocate for new or different services and supports to meet changing needs.

Services cannot be “banked” or stored for later if they are underutilized. Adjustments should be made to service authorization if services were not utilized for whatever reason. If the pace of service utilization indicates that services outlined in the ISP will not be sufficient, the team should discuss the reasons why this is occurring and if there is a need to request increased units.



Resolution of issues with service utilization issues begins in the same way as resolution of any issue: planning that includes the individual and team. The waivers include several actions that could be taken when service utilization is different than planned: there might be a need to look at provider options or schedule. The SC’s role is to facilitate team discussion about the reasons for over and underutilization, potential strategies to correct the issue, implementation and then continue monitoring to determine if the strategies are effective. Note that both the waivers and the SC Services Bulletin outline these same steps but go farther to include the AE in the process, if the team cannot resolve the issue. The waivers in particular require the AE to keep ODP informed and include specific timeframes for remediation.



When ODP talked with SCOs in February, they contributed many ideas to understanding and tracking service utilization that they use with their SCs.

SCOs remind their SCs that service utilization can vary depending on the type of service. Monitoring residential service utilization for someone living in a group home is straightforward; the service is authorized to be provided every day, 365 days per year.

On the other hand, think about an ISP that includes a certain number of respite days for the year, but the caregiver is not exactly sure when they will be used. For example, the caregiver uses respite when taking a weekend trip with a friend, but none are scheduled yet. In that case, the SC would need to stay in communication with the individual and family and keep a close eye on utilization data to ensure the service is being used and to anticipate if there may be issues of under or over utilization.



SCOs also described that reports in HCSIS can be useful for determining trends of service utilization over time, but SCs need to be cautious that the information is only as current as provider billing and processing. Another valuable use for service utilization data is in the planning process.

All of us use our own experience to think about planning for the future. If I want to know how often I will use a service in the year ahead, one way to begin thinking about it is to look back and see how often I’ve actually used it in the past. My decision process might be to think about, do I expect the future to be like what’s happened in the past? Or, are there differences now that mean I might need more or less service than I have before?

SCOs told us that reviewing historical service utilization can be a powerful way to have conversations about service needs. For individuals and families who have some experience of using services in the past, thinking about how much service to include in an upcoming plan might be less challenging if the team helps them think about it in terms of previous service amounts. Did we underestimate the amount of service needed or did we project too high and not use the full amount of service? Perhaps it was exactly right to meet the needs. Perhaps the amount of service used in the past needs to be re‐evaluated in terms of changing life circumstances.



So, when the team has gathered information on what is actually happening compared to what was expected in the ISP and has discussed and understands the reasons for variation in service utilization, if there are any – the next step is to determine if the ISP needs to be changed. Subsequent monitoring continues to look at the resulting changes. Did the discussion address the variation between planning and actual service utilization? Monitoring may reveal that the team needs to gather more information, understand reasons, and review the plan again.



This webcast has been developed and produced by the Office of Developmental Programs Consulting System on behalf of the Pennsylvania Department of Public Welfare, Office of Developmental Programs.

Thank you for participating in this lesson.



Documents

ISP Monitoring 2014 - Lesson 4 Printable Version PD