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Office of Mental Health

Home and Community Based Services Waiver
Guidance Document
Individualized Care Coordinator Competencies

  1. Information
    The Individualized Care Coordinator (ICC) demonstrates knowledge in the following areas:
    1. Psychiatric:
      • Childhood psychiatric disorders and trauma: recognizes signs, symptoms, etiology, co-morbidity, course
      • Suicidality: recognizes signs and symptoms of suicide ideation
      • Substance Abuse: recognizes signs of active use/abuse of substances
      • Treatment modalities: discusses basic tenets of treatment models used for childhood psychiatric disorders, particularly evidence based treatments
      • Adult psychiatric disorders: recognizes signs, symptoms, course, decompensation
      • Psychiatric medications: identifies medications used in the treatment of childhood disorders, their side effects and counter indications
    2. Developmental Imperatives:
      • Developmental tasks: describes developmental tasks involved in the social and emotional development of children and teenagers associated with specific ages
      • Barriers: recognizes barriers to normal development
      • Strategies: identifies strategies for supporting growth and resiliency
    3. Systems/Resources:
      • HCBS Waiver: describes elements, philosophy, goals and guidelines
      • Systems: describes interfacing of child serving systems such as OCFS, juvenile justice, mental health, etc.
      • Treatment providers: understands importance of initial and on-going collaboration in service planning to support treatment goals and strategies
      • Entitlements: describes protocols and procedures for accessing child and family entitlements
      • Community resources: identifies local community resources
      • Medicaid and HCBS Waiver enrollment procedures
  2. Cultural Competence
    The ICC practices cultural competency as described in the following:
    • Demonstrates sensitivity to cultural and ethnic norms
    • Recognizes strengths in culturally driven parenting patterns and approaches to discipline
    • Values intergenerational relationships and extended family relationships in child rearing roles and support
    • Acknowledges and addresses culturally driven barriers to engagement
    • Links children and families to culturally relevant community resources
    • Assists children and families in addressing stigmatization and/or discrimination.
  3. Tasks And Skills
    The ICC demonstrates competency in performing the following tasks:
    1. Safety
      • Identifies predictors of violence in the home and community
      • Evaluates family stressors and coping strategies
      • Recognizes signs of escalation
      • Develops Safety Alerts Plans (SAP) with the child and family including all OMH required elements (i.e., identifying triggers, warning signs, interventions of choice, contacts)
      • Shares the SAP with Waiver service workers and treatment providers
    2. Engagement of Child and Family
      • Empowerment and Partnership with Child and Family:
        • Identifies child and family strengths, needs and priorities in all life domains in partnership with the child and family
        • Develops Safety Alerts Plan with the child and family
        • Involves child and family in the development and on-going review of individualized service plans
        • Maximizes child and family strengths to move towards wellness and independence
        • Partners with child and family in evaluating discharge readiness
        • Offers choice of available services and providers
      • Building relationships with children and families that facilitate trust and communication:
        • Employs active listening skills
        • Provides feedback to child and family
        • Maintains professional boundaries
        • Respects confidentiality
        • Encourages hope
        • Supports informed shared decision making in all phases of Waiver enrollment
        • Mediates conflicts and address satisfaction/concerns with services provided.
    3. Collaboration
      • Collaborates, throughout Waiver enrollment, with treatment provider(s) in service planning and implementation to assure a unified approach to the child’s wellness
      • Applies principles of team work
      • Ensures, with psychiatric treatment provider, reciprocal reviews and sign off’s on treatment plans and Waiver service plans
      • Plans Waiver utilization with treatment provider to coincide with treatment goals
      • Participates with the treatment provider in reciprocal sharing of information regarding the child and family on a regular basis
      • Communicates regularly with Waiver service workers both to provide and receive information
    4. Service Planning
      • Gathers and organizes information
      • Assesses strengths and needs in all life domains, mental status, progress towards achieving goals, risk factors, viability of services, developmental stages, resiliency
      • Educates the child and family about the HCBS Waiver and community resources
      • Completes the Child and Adolescent Needs Strengths (CANS) assessment instrument and integrates in the service plans
      • Interviews the child and family using CANS Interview elements
      • Develops with the child and family, service plans that address identified priorities, developmental imperatives and that support treatment strategies
      • Writes service plans, measurable goals and objectives, case budgets and progress notes in accord with Waiver and Medicaid guidelines
    5. Coordination and Service Delivery
      • Meets with the child, family members and other collateral contacts regularly
      • Assists the child and family in advocating for themselves and advocates for them when necessary
      • Assures Medicaid enrollment
      • Submits required transmittals pertaining to Waiver enrollment and disenrollment to OMH Operations Support Unit
      • Works to establish a comprehensive, individualized set of formal and informal supports, services, and strategies for each family
      • Coordinates and monitors Waiver services to ensure relatedness to goals/objectives and the projected budget
      • Maintains family/child involvement in the service plans’ goals and objectives
      • Plans for services upon disenrollment from Waiver
      • Makes referrals
      • Coordinates Service Planning meetings and other interdisciplinary team meetings, including with treatment providers, as indicated
    6. Oversight and Documentation
      • Ensures case compliance with Waiver program and fiscal guidelines
      • Ensures that individual child expenditures are within the approved cap
      • Supervises service delivery
      • Oversees the case record, including all Waiver service workers’ notes
      • Oversees the documentation and use of consumer dollars for individual families
      • Completes documentation in the case record according to Waiver guidelines
      • Enters data in CAIRS
    7. Fulfillment of Requirements
      • Adheres to NYS and agency requirements including: HIPPA, ethical guidelines, child abuse identification and reporting, incident reporting, worker safety protocols
      • Completes all required training (see 300.4 of Guidance Document)
      • Attends agency and interdisciplinary meetings as required