First, grounding questions:
- Have individuals with their family and community done everything possible to meet their current, changing needs using their own social, financial and community resources?
- Within the limits of a person’s current individualized rate, personal resources and social connections, does the plan reflect the person’s expressed values and preferences regarding retirement planning, living environment and end-of-life decision-making?
- Does the plan assure a level of health and safety that all are comfortable with?
It’s never too early! Encourage young people with developmental disabilities and their families to begin planning far ahead. People should take into account the likelihood of diminishing public sector resources and the possibility of additional acquired disability.
Use the annual review and planning process to note physical and behavioral changes related to medical needs and aging, as well as, make plans that reflect a person’s health care needs, living environment preferences and end-of-life decision making choices.
Identify potential compromises and conflicts that may arise if confronted with insufficient financial or social resources to implement the ideal plan. What are the person’s highest priorities?
The need for baseline assessments, chronic health conditions or dementia varies based on factors such as a person’s disability, genetic condition and lifestyle choices, but typically begin at age 50. Familiarize yourself with the aging issues associated with a person’s specific genetic disorder or developmental disability and adjust assessments and screening appropriately.
Determine if a person wishes to remain in their current home and can do so safely by utilizing their natural supports, individualized rate and other available community resources.
- Does the person have any community connections that they can more fully utilize?
- Does the person have financial resources that, if used differently, would better support them in their home?
- Does the person recognize his home and familiar people?
- Is the person terminally ill?
- Is the person still safe in his residence?
- If safety risks exist, are they at a level the individual and team is willing to accept?
- Are there frequent emergency and crisis situations, including repeated hospitalizations?
- Is the person in the hospital without a viable, sustainable plan to go home?
- Have repeated and continuing EERs failed to stabilize a person’s health or support needs?
- Has the situation become so costly that the county can no longer fund it?
- Has a supported living agency expressed an inability to support the person in their current home or elsewhere within their current individualized rate?
If the answers to the critical questions indicate that the person’s needs cannot be fully addressed in their current home using existing resources, contact the County Manager to schedule an Intake meeting. Prior to attending an Intake meeting, Broker must complete a 1-page written summary of what the team has tried and planning efforts currently underway.
When a person and their team cannot create a plan that helps a person meet their outcomes while simultaneously ensuring health and safety within their current individualized rate, County Managers may request that DD Intake staff complete a face-to-face assessment.
Intake will use a screen and an evaluation tool focused on the person’s functioning. Intake will also complete a re-assessment of the person’s individualized rate.
County Managers will set a new SDS rate based on the DD Intake staff’s assessment. The County will work with the individual’s Broker to establish a timeline to develop an individualized plan within the new individualized rate. The new plan should seek to balance a person’s desired outcomes with their health and safety needs. If an alternate plan cannot be developed within specified financial and safety parameters, County Management will make recommendations.
County recommendations will seek to provide continuity of support and relationships. When this is not possible, the County may recommend:
- A change in providers.
- A referral to a setting specializing in supports to frail elders such as a licensed adult family home, CBRF or assisted living provider. Funding could be through the Developmental Disabilities system or another funder.
- A nursing home placement may be recommended if the person meets the federal definition as someone who no longer needs Active Treatment and is unlikely to improve (NAT on the PASARR screen).