Welcome Policy User | Behavioral Health & Developmental Disabilities
Tutorials | | What's New

Viewing: Outcome Evaluation: “Recognize, Refer, and Act” Model, 02-435

Table of Contents


Current Status: Active PolicyStat ID: 4479734

Outcome Evaluation: “Recognize, Refer, and Act” Model, 02-435

APPLICABILITY

Support Coordination and Intensive Support Coordination (SC/ISC) Providers

Community Developmental Disabilities Providers

DBHDD Office of Health and Wellness

DBHDD Field Offices

POLICY

The Recognize, Refer, and Act Model replaced the previous Rating Model used by Support Coordinators, effective July 1, 2016.

A primary goal of the Recognize, Refer and Act Model is to encourage a collaborative relationship between the Support Coordinator, provider agency staff, natural supports and the DBHDD staff. This collaboration serves as a pathway to effectively identify any unmet needs for the waiver participant, work together to reduce or eliminate any associated risks, and ultimately achieve the best outcomes for the waiver participant. If the Support Coordinator or Intensive Support Coordinator is unavailable to respond as indicated in this policy, the supervisor assumes responsibility for their duties. This policy describes the expectations for use of the Recognize, Refer and Act Model as applicable to the role of Support Coordinators.

PROCEDURES

  1. Core Principles
    1. Recognize, Refer, and Act employs the interaction of case management skills involved in the recognition of unmet needs and impending risks, and response by providing coaching, making appropriate referrals, or directly linking or advocating on behalf of the participant to obtain the most appropriate resources. 
    2. The model relies on effective observation skills, the ability to gather information from all pertinent sources, tactful interviewing skills, enhanced problem solving skills, and a sound knowledge of community resources. When there are deficits in any of these skill areas, DBHDD requires that Support Coordinators seek supervision as indicated.
    3. Recognize, Refer and Act often involves a team approach for risk recognition, but relies on Support Coordinators' ability to identify the most appropriate team discipline for each referral related to a particular risk area. 
  2. Application of the Recognize, Refer and Act Model
    1. Support Coordinators are expected to utilize the Individual Quality Outcome Measures Review User's Guide (Attachment A1) as a user's guide for completion of the Individual Quality Outcome Measures Review (Attachment A). The guide offers clarification on the intent of each question and offers additional information to be considered relating to each item, as the user applies the Recognize, Refer and Act Model.
    2. For each focus area question, the Support Coordinator completes the following steps first:
      1. Observe and interact with the participant as it relates to the elements of the item reviewed;
      2. Observe the setting for evidence pertaining to the item reviewed;
      3. Review any pertinent documentation relating to the item reviewed; and
      4. Engage in discussion with staff members and/or natural supports who may have information on the item reviewed. Observe staff and/or natural supports' interaction with the individual as it relates to the item reviewed.
    3. Based on the Support Coordinator's completion of the above steps, each focus area question is evaluated based on the following standards:
      1. Acceptable standards are reached when elements of the focus area question have been fully evaluated by the Support Coordinator and there are no concerns to report. All elements of the focus area question have been met satisfactorily and services/supports are being provided in an adequate manner;
      2. Coaching is required when a concern, issue or deficit is discovered in an element of a focus area question and, in the Support Coordinator's professional judgment, he/she determines that the concern/issue/deficit can be resolved in collaboration with the staff members and/or natural supports without intervention by DBHDD.
        1. Prior to offering Coaching, the Support Coordinator is expected to inquire about the cause of the concern/issue/deficit and if there are barriers preventing resolution. The Support Coordinator is also expected to determine if the deficit is the result of:
          • A misunderstanding about staff responsibilities;
          • A lack of awareness of the participant's support needs;
          • A misinterpretation of the participant's ISP, clinical assessments, healthcare plans, doctor's orders, or behavior support plan;
          • If there are training needs; and
          • If staff were adequately trained, but nonetheless neglected their responsibility to prevent the deficit.
        2. Coaching includes, but is not limited to:
          • Assisting the person supporting the participant with understanding the participant's support needs, as outlined in the ISP;
          • Assisting the person supporting the participant with interpreting the ISP goals, if it is evident that the support person do not understand the goal's intent or how to support the participant in achieving the goal;
          • Discussing the participant's interests/preferences and encouraging the person supporting the participant to incorporate those interests/preferences in planning for the days/weeks/months ahead;
          • Reminding the person supporting the participant of the participant's human rights, in instances where there have been observed restrictions on privacy, accessibility, community integration, freedom of choice, use of personal funds, etc.;
          • Prompting provider/natural supports to complete recommendations and/or trainings outlined in clinical assessments, transition plans, healthcare plans, behavior support plans, and/or the health/safety or personal profile section of the ISP;
          • Reminding staff to obtain needed documentation and explaining that the needed documentation remains on-site (as opposed to in an administrative office or other location);
          • Reminding the provider that an HRST, Behavioral Support Plan, Healthcare Plan or other documentation is expired and/or requires updating, if it is their responsibility;
          • Providing constructive criticism and reinforcement when a provider is not meeting standards of policy or best practice;
          • Inquiring about a provider/natural support's plan to address the concern/issue/deficit and assisting the provider/natural support with developing workable solutions when a provider/natural support indicates that there have been barriers to addressing a need; and
          • Working with the provider/natural support to problem solve when the participant expresses dissatisfaction with a component of their service delivery, living situation or quality of life.
      3. A Non-Clinical Referral (Unacceptable with Critical Deficiencies) is opened by the Support Coordinator when deficits or emerging risks remain after the established time frame for completion that was identified during coaching. Examples include:
        1. Unresolved environmental concerns (cleanliness, functionality, safety);
        2. Lack of services provided, as described in the ISP;
        3. Deficits in person-centeredness of services/support received;
        4. Deficits in documentation responsibilities;
        5. Deficits in ISP implementation;
        6. A need for non-emergency additional support, services, and/or resources; and
        7. Observed violations of participant's rights.
      4. A Non-Clinical Referral (Unacceptable with Immediate Interventions) is submitted when the Support Coordinator identifies an urgent risk of a non-clinical nature, and the provider/natural support's plan to correct the deficit is insufficient compared to the urgency or severity of the risk. Examples include:
        1. The furnace in the residence is not working and the temperature consistently falls below 65F, or the air conditioner is not working and the temperature consistently rises above 80F;
        2. The residence does not have working plumbing or electricity;
        3. There is evidence of financial exploitation or theft of monies in the participant's name; and
        4. A significant fire, flood, or natural disaster has occurred and the participant has not already been relocated to another safe and appropriate setting.
          Note: In all instances of Non-Clinical Referral (Unacceptable with Immediate Interventions), the Support Coordinator refers to the policy on Reporting and Investigating Deaths and Critical Incidents in Community Services, 04-106 to determine if the circumstances meet criteria to be a reportable incident.
      5. A Clinical Referral (Unacceptable with Critical Deficiencies) is opened when the Support Coordinator identifies a health and/or safety risk for which action is necessary to promote improved health outcomes for the participant. These risks must be addressed immediately by a provider and/or natural support. The Support Coordinator is responsible for documenting actions taken to mitigate and resolve the health and safety risks from the time of identification to the time of completion of needed actions. A clinical referral is warranted for the following circumstances including, but not limited to:
        1. An immediate health and/or safety risk has not yet been addressed by the provider/natural support, but as a result of the Support Coordinator's identification of the problem, the provider/natural support addresses the risk immediately with the proper action. The Support Coordinator is expected to submit a Clinical Referral (No Action Needed) indicating the identified risks and actions taken in order to trigger follow-up on this concern thereafter;
        2. Emerging health and/or safety risks that were identified during the previous visit were not resolved, despite the Support Coordinator's coaching efforts and the risk(s) are now more imminent;
        3. The Support Coordinator identifies a health and/or safety risk and the provider/natural support has not taken action to address the risk;
        4. If a Clinical Referral was made during the last visit and the referral has exceeded the target closure date, without being resolved by the provider/natural support, the Support Coordinator captures the reason the needed actions were not or could not be taken within Referral Follow-Up Notes in CIS. The Support Coordinator is not to open another Clinical Referral on the same unresolved issue;
        5. Note: Opening a clinical referral, in and of itself, is not to be seen as a negative action against the provider/natural support. Opening a clinical referral can present an opportunity to capture appropriate collaborative actions taken to resolve any health and safety risks identified.
      6. A Clinical Referral (Unacceptable with Immediate Interventions) is submitted when a participant is determined to be in immediate health and/or safety risk.
        1. As a result of identifying an immediate health and/or safety risk in any area listed in the examples below, the following steps are taken:
          • SC assesses whether or not the risk is imminent enough to call 911 or GCAL for emergency response;
          • SC contacts the DBHDD Field Office RSA to inform them of the immediate health and/or safety risk;
          • SC remains on site until the issue is corrected, a new placement is identified or until the DBHDD Field Office indicates that the SC can leave the premises; and
          • SC follows up on their next visit to document the resolution of the immediate risk circumstance.
        2. Examples of an immediate health or safety risk include but are not limited to:
          • A medical appointment is an immediate need and the provider/natural support has been non-responsive;
          • Nursing hours are not being delivered, as ordered;
          • The staffing present is observed to be inadequate to minimally meet the health and safety needs of the person, especially if one or more has exceptional medical or behavioral support needs;
          • The participant has visible signs of emerging medical needs or vocally complains of a health issue or pain and the provider/natural support is not responding immediately to attend to the participant's health needs; and
          • The participant is demonstrating erratic or dangerous behavior and the provider/natural support's response is not adequately able to maintain the safety of the participant and others.
        3. In all instances of Clinical Referral (Unacceptable with Immediate Interventions), the Support Coordinator refers to Reporting and Investigating Deaths and Critical Incidents in Community Services, 04-106 to determine if the circumstances meet criteria to be a reportable incident.
  3. Referral Response Pathways
    1. Non-Clinical Referrals
      1. If a Non-Clinical Referral remains unresolved by the provider/natural support despite numerous attempts at coaching and ongoing efforts to coordinate resolution by the Support Coordinator and the referral has exceeded the target closure date, the Support Coordinator refers to Reporting and Investigating Deaths and Critical Incidents in Community Services, 04-106 to determine if the provider/natural support's failure to respond to referral within the proposed time frame meets criteria for neglect to the participant;
      2. On an ongoing basis, the Division of DD works with DBHDD's Office of Performance Analysis to review data on Non-Clinical Referrals that remain unresolved and identifies providers who have recurrent deficiencies. Based on this data analysis, the Division of DD refers specific providers to DBHDD's Office of Provider Certification and Services Integrity (OPCSI) for Specific and Targeted Reviews.
      3. A provider's ongoing failure to correct identified deficiencies can result in a Corrective Action Plan (CAP) and further disciplinary action by DBHDD as described in Internal and External Reviews and Corrective Action Plans, 13-101.
    2. Clinical Referrals
      1. If a Clinical Referral has exceeded the target closure date without being resolved by the provider/natural support, the Support Coordinator refers to Reporting and Investigating Deaths and Critical Incidents in Community Services, 04-106 to determine if the provider/natural support's failure to respond to the health and safety risk within the proposed time frame reflects healthcare neglect to the participant;
      2. DBHDD's Office of Health and Wellness reviews Clinical Referrals to make the following determinations:
        1. Appropriateness of the referral (if it is indeed a clinical concern/deficit);
        2. Risk level of the referral;
        3. Additional actions not already taken by the Support Coordinator, provider staff or natural supports that contribute to mitigation or elimination of the health and safety risk;
        4. Direct providers to work with clinical professionals (PCP, OT, PT, etc.) to identify and implement risk mitigating activities;
        5. Dispatch clinical staff who may assess a need for additional training for provider staff or natural supports' responsible for meeting the participant's health and safety needs;
        6. If the deficit reflects a trend with broader implications for provider training; and
        7. If the deficit indicates a provider compliance issue that needs to be addressed by DAC.
      3. On an ongoing basis, the Division of DD works with DBHDD's Office of Performance Analysis to review data on Clinical Referrals that remain unresolved and identifies providers who have recurrent deficiencies. Based on this data analysis, the Division of DD refers specific providers to DBHDD's Office of Provider Certification and Services Integrity (OPCSI) for Specific and Targeted Reviews.
      4. A provider's ongoing failure to correct identified deficiencies can result in a Corrective Action Plan (CAP) and further disciplinary action by DBHDD as described in Internal and External Reviews and Corrective Action Plans, 13-101.

REFERENCES

Department of Community Health (DCH) NOW and COMP Manual for Support Coordination and Intensive Support Coordination, located at https://dbhdd.georgia.gov/intensive-support-coordination

RELATED POLICIES

Operating Principles for Support Coordination & Intensive Support Coordination Providers, 02-430

Reporting and Investigating Deaths and Critical Incidents in Community Services, 04-106

Internal and External Reviews and Corrective Action Plans, 13-101

Attachments:

Approval Signatures

Approver Date
Anne Akili, Psy.D.: Director, Policy Management 1/19/2018
Ron Wakefield: Director, Division of Developmental Disabilities 1/19/2018
Robert Bell: Director of Community Supports 1/16/2018
Anne Akili, Psy.D.: Director, Policy Management 1/16/2018
Angela Jones, MHA: Policy Coordinator 1/16/2018
Older Version Approval Signatures
Approver Date
Anne Akili, Psy.D.: Director, Policy Management 1/19/2018
Ron Wakefield: Director, Division of Developmental Disabilities 1/19/2018
Robert Bell: Director of Community Supports 1/16/2018
Anne Akili, Psy.D.: Director, Policy Management 1/16/2018
Angela Jones, MHA: Policy Coordinator 1/16/2018
Older Version Approval Signatures
Anne Akili, Psy.D.: Policy Director 10/4/2016
Dan Howell: Director Division of Developmental Disabilities 10/4/2016
Frank Kirkland: Assistant Division Director for DD 10/3/2016
Ron Wakefield: Director, Office of Field Operations for DD 10/3/2016
Robert Bell: Director of Community Supports 10/3/2016
Anne Akili, Psy.D.: Policy Director 10/3/2016
Anne Akili, Psy.D.: Policy Director 7/5/2016
Dan Howell: Director Division of Developmental Disabilities 7/5/2016
Frank Kirkland: Assistant Division Director for DD 7/3/2016
Ron Wakefield: Director, Office of Field Operations for DD 7/1/2016
Robert Bell: Director of Community Supports 7/1/2016
Anne Akili, Psy.D.: Policy Director 7/1/2016