Community Support Services Training Supervisory Series Session 4

Transcription

1 Community Support Services Training Supervisory Series Session 4 Rutgers, The State University of New Jersey Zakia Clay, MSW, LCSW Zakia.clay@shrp.rutgers.edu Ann Reilly MA, LSW, CPRP Reillya2@shrp.rutgers.edu Anthony Zazzarino MA, LPC, CPRP Anthony.Zazzarino@shrp.rutgers.edu

2 Review from Last Session Wellness Dimensions Components of a Comprehensive Rehabilitation Needs Assessment - Wellness Assessment - Knowledge, Skills, Resource Assessment

3 Assessment follow up 1. What are the critical components of the assessments? Wellness Assessment Knowledge, Skills, Resource Assessment Rehabilitation Plan 2. What is the outcome from the assessment?

4 Learning Objectives Review and understand components of a Comprehensive Rehabilitation Needs Assessment Identify and develop S-M-A-R-T documentation (goals, objectives and interventions) Understand the link between the Comprehensive Rehabilitation Needs Assessment and the Individualized Rehabilitation Plan Develop a meaningful Individualized Rehabilitation Plan Identify the knowledge, skills and resources needed for a successful Community Support Services implementation for your agency

5 Supervisor sign off activity Which goals would you sign off on?

6 S-M-A-R-T Documentation S M A R T Specific Measureable Attainable Realistic Timely (Swarbrick, 2012)

7 The S-M-A-R-T Framework Goals should be straight forward and emphasize what you want to happen Specific Provide a clear target to work toward Timely Measurable Choose a goal with measurable progress, so you can see the changes over time This does not translate into easy, but rather do-able Realistic Attainable Select a goal that requires some effort, but seems reachable (Swarbrick, 2012)

8 Supervisor sign off activity follow up Which goals would need to be revised? What changes would need to be made?

9 I want to reduce the amount of times I visit the hospital by 6/1/14

10 I want to improve my health by losing 80lbs by 6/1/14

11 I want to build relationships in the community by making 1 friend by 9/1/14

12 I will complete a partial care program

13 I want to enroll as a full time college student by 9/1/14

14 Group Activity: Are your goals S-M-A-R-T? In groups of 4, record your goals that were derived from last sessions review of the Comprehensive Rehabilitation Needs Assessment 3 dimensions of wellness that elicited a goal(s) Every group member, share your goals with the group Provide feedback: Are the goals really S-M-A-R-T?

15 Potential Barriers Do staff utilize S-M-A-R-T documentation? How do you work with staff that do not document in S-M-A-R-T format? Why is documenting in S-M-A-R-T format essential as we move to a fee-for-service model? Implications for the electronic health record?

16 Assessment follow up 1. What are the critical components of the assessments? Wellness Assessment Knowledge, Skills, Resource Assessment Rehabilitation Plan 2. What is the outcome from the assessment?

17 Research supporting Individualized Rehabilitation Planning Links the steps to achieve the goal with the interventions Interventions aim to eliminate the deficits Identifies who is responsible for doing what, by when, for how long, and where Increases sense of accountability Operationally defines the rehabilitation team approach (Anthony, Cohen, Farkas, Gagne, 2002)

18 Individualized Rehabilitation Plan (IRP) Rehabilitation and recovery goals Objectives Strategy/intervention to be employed Anticipated outcomes Expected frequency and duration of each activity Type of practitioner to provide the service Location service to be provided (Larosiliere, 2011)

19 Individualized Rehabilitation Plan Example

20 Rehabilitation Plan Questions 1. What are the new components in the Rehabilitation Plan that are not a derivative from the assessments? 2. Why are these components so critical to the services? Wellness Assessment Knowledge, Skills, Resource Assessment Rehabilitation Plan 3. Why is it important to have staff that are developing the Rehabilitation Plan part of the Comprehensive Rehabilitation Needs Assessment? 4. How will a detailed Rehabilitation Plan assist staff in structuring intentional service delivery?

21 Intervention helpful words Staff will Partner Collaborate Link Educate Review Role Play Rehearse Problem Solve Guide Model Assist Utilize MI Encourage Evaluate Assess Monitor Coordinate Reinforce

22 Assessment follow up 1. What are the critical components of the assessments/plan? Wellness Assessment Knowledge, Skills, Resource Assessment Rehabilitation Plan 2. What is the outcome from the assessments/plan?

23 Rehabilitation Plan Process Wellness Assessment: Examines the areas of Wellness and helps the individual identify their goal. KSR Assessment: Helps identify the critical components needed to achieve the goal. Once prioritized to 3 to 5 identified areas, written in S-M-A-R-T format, becomes the objectives in the Rehabilitation Plan. Rehabilitation Plan: Incorporates the components of Wellness and KSR Assessments. Adds S-M-A-R-T interventions to match objectives and drives the intentional billable services.

24 Individualized Rehabilitation Plan Activity Part 1 (15 min) Step 1: Join members of your agency for this part of the exercise. If there are no other members from your agency, we will pair you up. Step 2: You will be looking at the goal, I will delivery CSS effectively by 6/1/15. Step 3: Brainstorm ideas that your agency needs to know, do, and/or have for a CSS implementation Just list them

25 Individualized Rehabilitation Plan Activity Part 2 (10 min) Place the items that you have brainstormed into the appropriate 3 categories on your KSR Assessment Knowledge Skill Resource

26 Individualized Rehabilitation Plan Activity Part 3 (20 min) If you are in a group with people you do not work with, break off and complete the remainder of the activity on your own. Step 1: Identify your agency s strengths and areas for improvement by checking off the appropriate boxes on the KSR assessment. Step 2: Talk within the group and prioritize 3 to 5 areas of need that your agency wants to work on first. Step 3: Break down the 3 to 5 prioritized items into S-M-A-R-T format.

27 Individualized Rehabilitation Plan Activity Part 4 (20 min) Transfer the information from the KSR Assessment to your Individualized Rehabilitation Plan Keep in mind: Strengths S-M-A-R-T objectives S-M-A-R-T interventions to match each objectives

28 Rehabilitation Plan Process Wellness Assessment: Examines the areas of Wellness and helps the individual identify their goal. KSR Assessment: Helps identify the critical components needed to achieve the goal. Once prioritized to 3 to 5 identified areas, written in S-M-A-R-T format, becomes the objectives in the Rehabilitation Plan. Rehabilitation Plan: Incorporates the components of Wellness and KSR Assessments. Adds S-M-A-R-T interventions to match objectives and drives the intentional billable services.

29 DMHAS follow up

30 References Anthony, W., Cohen, M., Farkas, M., & Gagne, C. (2002).Psychiatric rehabilitation. (2nd ed., pp ). Boston: Center for Psychiatric Rehabilitation. Larosiliere, V (2011). Community Support Services [memo]. Retrieved from ders.pdf. Pratt, C. W., Gill, K. J., Barrett, N. M., & Roberts, M. M. (2014). Psychiatric rehabilitation. (3rd ed.). San Diego, CA: Elsevier Inc. Swarbrick, M. (2012). Introduction to Wellness Coaching. Freehold, NJ: Collaborative Support Programs of New Jersey Inc., Institute of Wellness and Recovery.