Case Management Monitoring:

Using Risk Assessment and Mitigation Strategies

Monitoring Services and Supports

What’s required? What’s important? What’s good practice? How to develop a comprehensive

plan? How to individualize monitoring?

Challenges

Increased scrutiny from regulators and the general public.

Greater diversity of services and service settings.

Increasingly litigious society.

Challenges

Funding stream changes over the past few years;

Complexity of CM/RC role; CCB size and geographic variables; Unchanging responsibility of

CMs/RCs to monitor individuals on their caseload.

Challenges

Changing face of Case Management/Resource Coordination More documentation Less time in the field Changing Roles in Support Services Less familiarity with consumers

Basic Questions

Who is responsible for monitoring? How to determine what should be

monitored? How do you determine how monitoring

occurs? How do you determine how often

monitoring occurs? What do you do with the results?

Who is Responsible for Monitoring?

DDS Overall Service Provider Organization monitoring

CCB Overall Service Provider Organization monitoring

SPO Individual and overall organizational monitoring

CM/RC Individual specific monitoring

DDS Monitoring Requirements

Monitoring by Case Management ensures that: The IP is implemented; Health and safety needs are addressed; People’s rights are respected People are satisfied with services and supports Monitoring activities are documented Follow-up is completed in a timely manner.

What Should Be Monitored?

Health, Safety and Welfare Medical/medication needs are being

addressed. Therapy needs are being addressed. Dietary needs are being addressed. Home safety is being addressed. ADA/Accessibility is being addressed. Community safety is being addressed. Critical incidents receive proper follow-

up.

What Should Be Monitored?

Rights are Respected Statutory Requirements are Met Involvement of Other Authorities Possible Dangerous Behavior

Endangering Self Endangering Others Endangering Property

Determining Monitoring Frequency

Everybody, Everything, Everywhere at a Fixed Frequency; or,

Everybody, Everything, Everywhere at a Variable Frequency; or,

Everybody, and/or Everything, and/or Everywhere at a Fixed and or Variable Frequency; or

Everybody, Everything, Everywhere at a Frequency Based Upon Identified Risks.

Risk Management

“A planned and proactive process for reducing and minimizing an individual’s potential loss or injury.”

Risks are activities, situations and circumstances that may lead to any unintended consequence which is or may potentially be harmful to the individual.

Risk Management

Identify the risks; Evaluate the risks; Prepare and implement a plan to

mitigate the risks; and Evaluate the effectiveness of the

plan.

Identify Risks

Who- Case managers/RC with input from the IDT.

When- Identify risk factors at the time of annual assessment, IP development and during monitoring;

How- Utilize a risk assessment tool or checklist;

Health and Safety Monitoring

Risk Management is Commensurate to Programs Role Comprehensive-Assess, Plan and

Mitigate SLS-Assess, Plan and Counsel/Advise CES*-Observe and Counsel/Advise FSSP*-Observe and Counsel/Advise

*Including legal responsibilities for children at risk

Identify RisksFactors for persons in comp. services include:

ADLs

Eating

Ambulation

Transfers

Toileting

Communication

Community access

Bathing

Behavior/ Psychiatric

Self –abuse

Aggression

Property destruction

Use of restraint

Psychotropic meds

Criminal behavior

Sexual risks

Identify RisksFactors for persons in comp. services include:

Medical/Physiological

Gastrointestinal

Seizures

Anticonvulsant meds

Skin breakdown

Bowel obstruction

Nutritional

Aspiration

Safety

Injuries

Falls

Victimization

Community access

Emergency response

Home maintenance

Identify RisksFactors for persons in support services include:

Living Environment

Hazardous, sanitation

neighborhood

Home stability/situation

Housemate compatibility

Accessibility

Community access

Health/Medical/Nutrition

Chronic health conditions

Access to medical services

Treatment compliance

ER visits & hospitalization

Nutrition & special diets

Mental health

Identify RisksFactors for persons in support services include:

Medications Multiple prescription

medications

Medication compliance

Psychotropic meds

Use of OTC/herbals, etc

Lifestyle Issues

Substance abuse

Sexual behavior/practices

Victimization - exploitation

Criminal behavior

Justice system involvment

Isolation

Identify RisksFactors for persons in support services include: :

Family Home/Caretaker

Caretaker capability

Service Refusal

Social Opportunities

Victimization – exploitation

Isolation

Other Limited support system

Evaluate Risks

Severity of Outcome Inconvenience; Possibly effect on

placement/status; Likely harmful to

health and welfare; Immediate risk to

health and welfare Debilitating or Death

Frequency of Risk Rare/Annually Seasonal Monthly Weekly Daily More than Daily

Evaluate Risks

Low Frequency High Frequency

Low

Severity

High Severity

Low Risk

High Risk?

?

Risk Reduction Utilize the IP process to specify

programs and protocols for mitigating risks prioritized through risk assessment. Specify as services and supports; Require ISSPs where required and

appropriate; Ensure documentation of

implementation and effectiveness of risk reduction plans.

Risk Reduction Examples of services and support to be

provided to mitigate risks include: Fire evacuation drills, safety skill training; Bathing, feeding, bowel protocols; Behavioral programming, health monitoring,

nutrition plans, PT/OT, psychotherapy; Sex offender containment and treatment,

safety control procedures, rights suspensions.

Develop a Monitoring Plan

•Monitor settings in which high risks occur.

•Frequency of monitoring should be commensurate with the level of risk.

•Use multifaceted methods.

•Specify documentation/feedback mechanism.

Monitor Risk Plan Effectiveness

Target Efforts to High Risk Issues What are the High Risks? Where do the High Risks Occur? When do the High Risks Occur? What plans have been implemented

to reduce the High Risks? How Effective are the risk reduction

plans?

Monitor Risk Plan Effectiveness

Utilize a multi-faceted approach in monitoring: Review program data in summary reports and on-

site in program files and other data documenting risk reduction (e.g., fire drills, med. admin. records, use of restrictive procedures etc.);

Review SPO contact notes, incident reports and Interview staff/providers.

Interview the individual, their family and friends; Visit the person at home and review the status of

identified risk issues (e.x., adequate food, safe medications, etc.)

Methods of Monitoring

Must include direct observation Includes a variety of activities:

Face to face Site visits Consultations Phone calls Documentation review

Individualizing Monitoring

Other Factors affecting Monitoring: The IP History of the individual History of the provider History of the SPO Funding Setting: Family, Host Home, Independent

Home, PCA, Group Home Services for people with higher needs

should be monitored more frequently

Planning On-site Monitoring

Determine the Mode: Unannounced Visit- Often useful if the

agency/provider has a mixed history or if there have been indications or reports that the provider has prepared for monitoring visits.

Announced Visits- Always the preferred mode for logistical reasons and to maintain rapport.

Good Practice- Vary your pattern.

Conducting On-site Monitoring

Maintain Rapport: Agency Staff

Ask inquisitive and supportive questions. Be polite and be prepared to provide

support and information Be candid, clear and concise. Avoid expressing displeasure, bias or

confusion. Validate good work and express concern

re: questionable/bad practice.

Conducting On-site Monitoring

Maintain Rapport: Host Home Providers

Same list as agency staff. Monitoring=Intrusion vs Visit=Concern Understand role of the person to the

family unit Review only those environments &

documents related to the person. Consider only communicating negative

outcomes to provider agency.

Conducting On-site Monitoring

Maintain Rapport: Day Program Providers

Same list as agency staff. Often very busy and can be short on time

to discuss person. For integrated work- Need to consider

setting as typical employment and adjust monitoring accordingly.

Attempt to be discrete.

Conducting On-site Monitoring

Monitor Broadly Follow-up on items not on the

checklist. Look, listen, and smell. Consider emerging issues . Identify obvious problems for other

persons. If in doubt, reference others

Documentation and Follow-up

Documentation Monitoring activities are documented Follow-up, where needed, on findings

is documented. Follow-up

Follow-up is completed in a timely manner

Others notified as needed or required

Documentation

When did monitoring occur? What was monitored? How did monitoring occur? Outcome of the monitoring Actions needed/taken as

appropriate

Follow-up

Documented What actions were needed as a result

of the monitoring activity? Timeliness is commensurate with risk. Loop closed What is done with information

gathered? Obligations regarding rules and

regulations, Social Services, agency Policy and Procedures

Case Management Administration

Formal Supports Policies, Procedures and Protocols

Requirements for risk assessment and monitoring Conflicts with SPO (Including CCB SPO) Collection and analysis of data

Personnel Practices Job Design Validates Importance of Monitoring Training Addresses Needed Knowledge and Skills Evaluation Includes Performance re: Monitoring