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
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