Intensive Support Coordination

New HCBS waiver service in Georgia for FY 2017


Support Coordination and Intensive Support Coordination Providers by Region
Updated March 2017

Overview of Intensive Support Coordination
Updated June 12, 2017

Support Coordination and Intensive Support Coordination Policy Manual for NOW and COMP Waiver Programs (Chapter 700)
Updated October 2017

DBHDD manages two of the state’s 1915(c) home- and community-based waivers, the New Options Waiver (NOW) and the Comprehensive Supports Waiver (COMP) programs. DBHDD has identified the need for an additional level of support coordination services for [BJ1] waiver participants with the highest risk status, resulting in the development of a new waiver service, known as intensive support coordination (ISC).

What is Intensive Support Coordination?
Intensive support coordination provides specialized coordination of waiver services and medical and behavioral support services for participants with exceptional medical and behavioral needs.

In addition to the full array of activities included in the traditional support coordination service, intensive support coordinators and their clinical supervisors will assist ISC participants by conducting the following activities:

  • Identifying and addressing barriers to care;
  • Accessing needed resources and services offered through the waiver and the larger health care system;
  • Taking active measures to address complex needs; and
  • Fostering and maintaining family and other informal relationships and supports.

Expectations for holistic care coordination and intensity of oversight are significantly increased for waiver participants receiving this service.

Who will be served?
Approximately 1,700 waiver participants living in all six of DBHDD’s geographic service regions meet eligibility criteria for intensive support coordination. All participants who meet eligibility criteria for ISC must be transferred into the service from traditional support coordination.

How is this service provided?

  • Each intensive support coordination team will consist of one ISC clinical supervisor and typically five ISC coordinators who serve up to 100 individuals.  ISC coordinators typically have caseloads of no more than 20 individuals.  However, if the ISC has a mixed caseload that includes traditional support coordination individuals, their caseload may be slightly higher.
  • ISC’s coordinators complete a minimum of one face-to-face visit with each assigned ISC individual per month and as many ancillary contacts are necessary to respond to the service and support coordination needs of the individual.
  • ISC clinical supervisors must be either a registered nurse or a licensed behavioral professional (BCBA, LPC, LCSW, psychologist, or RN) with at least three years of professional experience serving individuals with intellectual and developmental disabilities.
  • ISC extenders must have a bachelor’s degree in a human services field with at least two years of specialized experience with individuals in a health care or behavioral health setting and preferred experience with people who have intellectual and developmental disabilities.

Intensive Support Coordination Service Implementation

  • Current NOW and COMP waiver participants meeting eligibility criteria for intensive support coordination (ISC) will be transferred from traditional support coordination to intensive support coordination between October 1, 2016 and July 1, 2017.  This process has been facilitated by the DBHDD Field Offices.
  • All new NOW and COMP waiver participants meeting eligibility criteria for intensive support coordination will be enrolled in the service at the onset of the approval of their first Individual Service Plan.

  • All individuals transitioning from institutional settings into community residences will begin receiving intensive support coordination services a minimum of 60 days prior to their discharge date.

  • Any individual not identified for eligibility for ISC during the initial enrollment period who later meets criteria, as a result of an increase in medical or behavioral risk factors, will be enrolled in ISC the first of the month following identified eligibility.

  • None of the waiver services a participant currently receives will be affected or reduced as a result of the addition of ISC.