Support Coordination Questions and Answers

Visit frequency is no longer dependent on participation in the NOW or COMP waiver, or a designated service. New visit frequency requirements were developed based on factors that contribute to increased risk to the waiver participant.

All waiver participants will receive support coordination visits at least quarterly. For individuals who meet the following criteria, monthly support coordination visits are required.

1. The participant is identified as part of the ADA population, as a result of a transition from a state hospital into home and community-based services.
2. The participant resides in a community residential alternative—out-of-home placement.
3. The participant resides in a setting operated exclusively by paid community living support (CLS) staff. This includes individuals living alone (or with housemates) and those who reside in a setting without natural supports, where CLS assists with support needs (regardless of the number of hours per day/week). If an individual lives with a spouse or other family member who is also a NOW/COMP waiver recipient, a monthly support coordination visit is required.
4. The participant spends the night in an out-of-home placement, such as an extended overnight respite setting. Individuals who are temporarily in a crisis respite setting require monthly visits while they are in that residence. For individuals who are in respite setting longer than seven days, the visit should occur at the respite location, during their stay.

Support coordinators are responsible for completing an Individual Quality Outcome Measures Review during contractually mandated visits. If a support coordinator makes more frequent visits due to emerging needs, he or she is not responsible for completing additional reviews for those visits, but will capture the purpose and document outcomes and/or progress in support notes.

Support coordination agencies may prescribe more frequent visits than required by policy if they deem an individual to be at higher risk. DBHDD supports additional visits whenever a risk is identified if it is believed that the support coordinator can help mitigate it.

No. Service providers will no longer be required to submit corrective action plans based solely on a support coordinator reporting a concern. It is expected that support coordinators will collaborate with providers to resolve identified issues. If a concern is not addressed in a reasonable time frame, support coordinators will refer the concern to DBHDD for assistance.

1. Field offices are no longer responsible for overseeing service provider contracts. Contracts are now held by centralized account managers within DBHDD’s Office of Provider Network Management. Where ongoing compliance or quality issues cannot be resolved between support coordinators and service providers, account managers may work directly with providers to prompt resolution.
2. DBHDD’s Division of Accountability and Compliance and Office of Incident Management hold service providers accountable for meeting contractual obligations; they may intervene following critical incidents or ongoing concerns to prompt action and resolution.
3. DBHDD’s Division of Performance Management and Quality Improvement was established to identify underperforming providers and help improve performance. The Division supports a variety of initiatives that focus on overall quality improvements across the provider network.
4. DBHDD’s Office of Health & Wellness oversees the clinical needs of individuals receiving developmental disability services. The office will triage referrals from support coordinators based on identified health and safety concerns, delegating the referrals to field office clinical staff or integrated clinical support services.

The Georgia Department of Community Health’s Division of Healthcare Facility Regulations is responsible for many provider compliance matters previously handled by support coordinators. DBHDD’s Division of Accountability and Compliance will also play a role.

Where the participant-directed representative assumes responsibility for overseeing service provision, he or she is expected to take actions to resolve issues and mitigate risks identified by the support coordinator. The support coordinator is responsible for tracking his or her efforts toward resolution. If the support coordinator and participant representative are not able to reduce identified risks or resolve identified issues, clinical or non-clinical referrals should occur in the manner described in DBHDD Policy 02-435, Outcome Evaluation: “Recognize, Refer, and Act” Model, to prompt support from DBHDD.

DBHDD policies on support coordination can be found at https://gadbhdd.policystat.com. Search for “02-430” to view the policy titled, Operating Principles for Support Coordination and Intensive Support Coordination Services. This policy index was released July 1, 2016, with six policies available for view. For additional guidance on support coordination, refer to the NOW/COMP Part III policy, Support Coordination and Intensive Support Coordination Services, at www.mmis.georgia.gov.

Does the support coordinator have to “start over” with the new process, or can he or she open a referral right away?

In a case such as this, the support coordinator should open a clinical or non-clinical referral with a short time frame for completion, so that notification can go out to DBHDD for follow-up.

Under the new process, support coordinators have been trained to discuss issues, concerns, or deficits identified in the Outcome Review on site at the time they are identified. Additionally, providers can access the completed Outcome Reviews within “SC Forms” in the Client Information System (CIS). Providers may also view any concerns for which coaching or referrals were indicated.

In addition to tracking resolution of identified issues, the clinical and non-clinical referral system helps DBHDD collect data that can be used to improve outcomes. For example, DBHDD’s Office of Health and Wellness will be tracking identified issues of clinical significance for the purpose of determining trends for future health and safety trainings for service providers. In cases where the provider is taking immediate action to resolve a clinical issue, support coordinators have been trained to document resolution efforts within an open clinical referral, but indicate “no action needed,” so the Office of Health and Wellness knows that their support is not yet needed.

Not necessarily. When a support coordinator determines that coaching or a referral is indicated, it should not necessarily be perceived as negative. Many identified issues are not a reflection on the provider (e.g. new health concerns or hospitalization). The Recognize, Refer, and Act system helps document collaboration efforts between the support coordinator, the provider agency staff, natural supports, and DBHDD, and facilitates improved outcomes for the waiver participant. Opening referrals can indicate that the individual’s support team is working together to promptly resolve issues that arise. However, if providers are non-responsive in resolving identified issues captured through the referral process, they will be urged by DBHDD to do so and will ultimately be held accountable.

Yes. Prescribed medications are a medical order that must be followed. Support coordinators are expected to review records to determine if medications are being administered as ordered. If deficits in medication administration or documentation are identified, they should be captured under Question 10 on the Outcome Review (Are all medical/therapeutic appointments, follow-up appointments/ recommendations/orders, and required assessments/evaluations, being attended, followed, and/or, completed, as ordered?). That said, if the medication problem is difficult to solve, for example difficulty in working with the physician’s office to complete a continuation order with the pharmacy, the expectation is that support coordination engage and collaboratively assist.