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Adult and youth support coordination/case management (SC/CM) are activities designed to provide case management services to assist individuals with developmental or intellectual disabilities in accessing needed medical, psychiatric, social, educational, vocational, residential, and other supports essential for living in the community and in developing their desired lifestyle. Support coordinators/case managers are responsible for proactively identifying risks, implementing plans to mitigate previously known and newly identified risks and resolving them in a timely manner. Support coordinators/case managers are knowledgeable of person-centered thinking and person-centered planning as part of the individual support plan. Support coordinator/case manager works with the individual, their family and/or substitute decision makers and other service providers to develop an appropriate service plan, monitor delivery of services and individual's satisfaction and provide accurate record keeping that is critical for reimbursement. Support coordinator/case manager takes the lead on ensuring that the support team follows through with the commitment(s) they made to support the person to reach their desired outcomes. Support coordinator/case manager is required to have a bachelor’s degree in a human services field.

• Liaison: SC/CM represents the MRCSB case management program, often on behalf of the individual being served with various federal, state and local entities which include but are not limited to the following: Mount Rogers Behavioral Health programs (Hospital Liaisons, Mental Health Centers, Emergency Services), state Facilities (Southwest Virginia Mental Health Institute, Training Centers), Court/Legal Systems (to include regional jails and prisons),Community Resource Consultants, Regional Support Teams, Community Resource Teams, Office of Human Rights, Office of Licensure, Community Integration Managers, Service Authorization Consultants, Regional Support Specialists, Public Guardianship Programs, Health Care Professionals (public and private), Providers of DD Waiver Services (Agency and Private), Department of Justice oversight, other Virginia Community Service Boards, Schools, Special Education Departments, Ascend/Maximus Company (SIS Interviewers), REACH, Qlarant reviewers, National Core Indicators and Department of Social Services
• Documentation and record keeping: SC/CM must maintain a record keeping and data collection system appropriate to meet the needs of individuals served in accordance with regulatory standards including, but not limited to agency, Medicaid, licensure, DBHDS, and Department of Justice regulations. Documentation for face-to-face visits must clearly state that SC/CM is in the presence of individual, date, and location. Any unmet needs must be identified and plans to address any such needs if applicable. Support coordinator/Case manager must assess individual and if applicable substitute decision maker’s satisfaction with services. SC/CM is required to complete an annual person-centered plan and update as needed. Completion of the plan can take up to four to six hours. SC/CM’s must complete person centered reviews on a quarterly basis. SC/CM is required to maintain two separate electronic health records (EHR). The agency EHR is Credible system and SC/CM are record managers for this system. Additionally, SC/CM also must submit service authorizations, plans, and enter and update demographic information in the DBHDS Waiver Management System (WaMS). SC/CM are required to have progress notes completed per agency guidelines.
• Assessment: To determine initial and ongoing eligibility for services through precise and accurate information about the individual to identify support needs, stressors, goals, values, strengths, resources, health status, activities of daily living (ADLS) and support networks. Eligibility: assess to determine if individual has a diagnosis that confirms an Intellectual Disability (ID Case Management). Assess to determine the individual has a Developmental Disability (DD Case Management). Assess functional eligibility that affects the individual’s ability to live and work independently. Assess to determine if the individual meets the financial criteria to receive Medicaid. VIDES: possess the training to administer the Virginia Individual DD Eligibility Survey (VIDES), the required assessment used by the state to establish functional eligibility. SC/CMs are trained in three levels of VIDES: Infant, Children and Adult. Supports Intensity Scale: Collaborate with the Ascend Maximus Company to schedule and participate in Support Intensity Scale (SIS) assessments, the standardized and norm referenced assessment which is required for all individuals receiving DD Waiver services in the Commonwealth of Virginia. The SC/CM is required to participate as a “respondent” during the interview process. Additionally, the SC/CM is responsible for educating the individual and family about the SIS assessment and its role in support planning and sharing the assessment results with individual, family and service providers. Risk Assessment: Complete an initial risk assessment and annually thereafter based on the numeric scale used on Sections 3A and 3 B of the Supports Intensity Scale (Exceptional Medical Supports and Exceptional Behavioral Supports) to reflect any changes in the individual’s support needs from year to year. Ongoing assessment: Gather and summarize information that guides the work between the SC/CM and the Individual receiving services to make sure health and safety needs are met, as well as, assessing the individual’s ability to independently care for themselves. SC is required to complete annual risk awareness tool annually and anytime a new medical risk has been identified. SC completes crisis risk awareness tool at every face-to-face visit to assess need for any crisis service. SC completes on site visit tool at every face-to-face visit to assess among other things change of status and ISP implemented appropriately.
• Monitoring: Regular meeting and/or contact with the individual, family, service providers and others to ensure the services continue to be appropriate and to assess satisfaction with services. SC/CMs are required to compile a person-centered review of all services received by an individual and to share the report with individual, family and substitute decision maker. SC/CM will review plan at least quarterly and make any changes needed to individual’s plan. SC/CM will review plan at least quarterly and make any changes needed to individual’s plan. SC/CMs are required to make a face-to-face visit monthly with individuals who meet enhanced case management criteria (ECM) with every other visit being in the home. ECM is required for subset of population who have met criteria set forth by Department of Justice. If individual does not meet ECM criteria a monthly contact is required and at minimum face-to-face is required, every 90 days. SC/CMs regularly assess current risks and evaluate living situation to determine if there are any new risks. SC/CM is responsible for coordination of services and will ensure that all team members are made aware of any changes or newly identified risks that may affect implementation of ISP outcomes. SC/CM sometimes have to be available after hours (nights and weekends) as needed to handle any medical or behavioral emergency that may occur with someone on their caseload.
• Linking/referral: SC/CM is aware and knowledgeable of resources in the community. SC/CM to refer to needed resources for residential, employment, community engagement, community coaching, residential in home, respite, personal assistance, and other waiver services and supports including medical, dental, and psychiatric services. Secure funding sources including, but not limited to DD waiver, CCC Plus waiver, and EPSDT (Early and Periodic Screening Diagnostic and Treatment). SC/CM will add individuals who qualify to the DD waiver wait list in the Virginia Waiver Management System (WaMS). SC/CM will determine priority status, complete, and update critical needs summary, complete choice form for choice between institutional care and community-based services and complete waiver slot allocation narratives. SC/CM will refer if applicable to public guardianship programs or assist with process for substitute decision maker.
• Planning: SC/CMs are knowledgeable of person-centered thinking and person-centered planning as part of the individual support plan (ISP). This plan will include what is working and not working for the individual and what is important to and for the individual. SC/CM, along with the individual is to form a support team made up of individual, family, service providers and others to collaboratively develop a person-centered individual service plan based on individual's desires and needs on an annual basis and update as needed. SC/CM are required to ensure that the ISP is amended when reassessment or new risk factors are noted that indicate that revisions in the plan are needed to address and meet an individual’s changed needs. The ISP should be updated as indicated and should include an implementation schedule for the changes needed to address the individual’s needs. SC/CM must ensure that the individual is given a choice of providers (including case management provider). SC/CM assists individuals and families to transition through developmental stages including transitioning from school to work, from family to a community residence, futures planning, and, if needed, from institutional to a community-based setting. This includes working with local school systems and Individualized Educational Plan (IEP) Teams, Department of Aging and Rehabilitation Services. Omnibus Budget Reconciliation Act (OBRA) and skilled nursing facilities and various worksites and training programs; and working with families to secure legal guardianship or authorized representative status.
• Education/training: SC/CM is required to have a four-year degree in a human services field. Additionally, they are required to complete DBHDS case management curriculum. SC/CM are required to complete a minimum of eight hours of relevant training annually. SC/CM must remain current with information on available state and local mental health, substance abuse and developmental and intellectual disability programs and services through reading and attending training.
• Advocacy: SC/CM assists individual in overcoming barriers to receiving services and to identify gaps in services. SC/CM advocates for needed services for individual by submitting service authorization requests and justification of need for services by adding individual to DD waiver wait list and making referrals to programs or services. Advocacy efforts also include attending Town Hall meetings and commenting on proposed changes in regulatory legislation.

• Maintain trainings.
• Perform such other duties as assigned by supervisor.

• Oral and written communication skills.
• Skills in data collection and interviewing.
• The nature and causes of developmental and intellectual disability and program philosophy for service provision.
• Treatment modalities and intervention techniques, such as behavior management, independent living skills training, supportive counseling, family education, crisis intervention, discharge planning, and service coordination.
• Different types of assessments, including functional assessment, and their uses in service planning;
• Formulating, writing, and implementing individualized service plans to promote goal attainment;
• Coordinate the provision of services by diverse public and private providers.
• Work as a team member, maintaining effective inter- and intra-agency working relationships;
• Demonstrate a positive regard for consumers and their families.

Bachelor's degree in a human services field required (not required prior to 2016). Documented experience working with individuals with developmental and intellectual disabilities preferred.

Valid Driver’s License is with a safe driving record is required.

U. S. Patents 7,080,057; 7,310,626; 7,558,767; 7,562,059; 7,472,097; 7,606,778; 8,086,558 and 8,046,251.