Support Coordination

Updated January 2018

New Directives for Support Coordination on Describing Services in ISP’s
Updated May 2017

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

Support Coordination and Intensive Support Coordination Policy Manual for NOW and COMP Waiver Programs (Chapter 600) 
Updated October 2017

New DBHDD Support Coordination Policy Manual
Operating Principles for Support Coordination & Intensive Support Coordination Providers, 02-430
Updated July 2016

Questions and Answers

What is Support Coordination?

Support Coordination services identify, coordinate, and oversee the delivery of services and supports to enhance the health, safety, and general well-being of NOW and COMP waiver participants within the context of the person's goals toward maximum independence. The DBHDD Division of Developmental Disabilities contracts with provider agencies across the state to deliver Support Coordination services to NOW and COMP waiver participants.  Additionally, individuals who receive state funds for HCBS services receive a similar service, referred to as State Service Coordination, managed by DBHDD.

The State of Georgia serves more than 12,000 participants through the NOW and COMP Waivers. Each of these participants begins receiving Support Coordination services upon initiation of services and continues to receive Support Coordination services as long as they remain a waiver recipient.  In the State of Georgia, Support Coordinators have caseloads of 40 or fewer waiver participants.  Each waiver participant receive visits from their Support Coordinator either quarterly or monthly, at minimum, based on considerations set forth in Support Coordination Contact Frequency Requirements, 02-433. Support Coordinators provide additional contacts, as needed, based on the identified needs of the participant.

The primary responsibilities of Support Coordinators are:

  1. Facilitating the Service Planning Process and Individual Service Plan Development
  2. Coordinating Waiver Services
  3. Coordinating Non-Waiver Services, Community Engagement and Resource Development
  4. Evaluating the Quality and Outcome of Services and Identifying Unmet Needs
  5. Assessment and Evaluation Related Tasks

New Support Coordination Method of Quality Outcome Evaluation

  • As of July 1, 2016, support coordinators began using a new documentation form to evaluate outcomes and service delivery for waiver participants.  This review is called the Individual Quality Outcome Measures Review
  • The Outcome Review uses a new model for evaluating holistic outcomes for waiver participants.  Focus Areas include: environment, appearance and health, supports and services, behavioral and emotional state, home and community opportunities, financial condition, and overall satisfaction.  Support coordinators will continue to evaluate service delivery based on individualized service plans, but the new review method will focus on quality outcomes.
  • The Recognize, Refer, and Act model is taking the place of the previously used Monitoring Tool Rating system.  Rather than rating providers on a 1-to-4 scale, support coordinators will be evaluating service delivery and individual outcomes bases on the principles outlined below. See Outcome Evaluation: “Recognize, Refer, and Act” Model, 02-435 for the full DBHDD policy.
  • Recognize Refer and Act involves recognizing concerns, unmet needs, and impending risks, and responding by either directly linking—or advocating on behalf of—the individual to the most appropriate resources, providing coaching to service providers or natural supports, or making referrals to an appropriate party.
  • Each focus area on the Individual Quality Outcome Measures Review is evaluated based on the following criteria:
    • 1. Acceptable: All elements of the focus area have been met satisfactorily, and services/supports are being provided in an adequate manner; no concerns to report.
    • 2. Coaching: An opportunity for the support coordinator and the provider/natural support system to collaborate on a resolution to a concern prior to informing or requesting assistance from DBHDD.  Based on the risk to the individual, the support coordinator will work with the provider/natural support to determine an appropriate timeframe for a resolution before a referral is needed.
    • 3. Non-Clinical Referral—Critical: Coaching efforts have not been successful in resolving the issue, and assistance from DBHDD is needed.
    • 4. Clinical Referral—Critical: Coaching efforts have not been successful in resolving the issue, and assistance from DBHDD is needed.
    • 5. Clinical or Non-Clinical Referral—Immediate Interventions Needed: The person is at imminent health and/or safety risk, and the DBHDD field office must be informed immediately to assist with resolution.
  • Unlike the previous rating model, the results of any one Outcome Review do not necessarily result in any corrective action. 
  • New technology has been developed to document efforts made to “close the loop” on identified issues and new report-generating capabilities will promote improved accountability of all parties.
  • A primary goal is to encourage a collaborative relationship between the support coordinator, provider agency staff, natural supports, and DBHDD staff.  This collaboration serves as a pathway to identify an individual’s unmet needs, work together to reduce or eliminate any associated risks, and ultimately achieve the best outcomes for the individual.

For information on Intensive Support Coordination, visit the ISC webpage.