NC Innovations Service Definition Training
Presented by CoastalCare
March 2014
The Goals of the Waiver
 Fully integrated members of the
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community functioning at the
individuals maximum level.
Community integration through work,
lifelong learning, recreation and
socialization.
Self Sufficiency, Advocacy, SelfDetermination.
Leverage all community and natural
supports and resources.
Quality services and improved outcome
measures.
Things that are common to ALL waiver services.
 Prior authorization through the submission of the ISP
and documentation of functional needs justifying
medical necessity.
 No specific technique or model
 Specific service definitions and practice guidelines
 Designated service delivery locations in definitions
 Qualifications of staff delivering services
 Limits/exclusions for individual services and sets of
services
The role of the Medicaid Provider
in Service Delivery
 Providers are responsible for determining with the team the needs of
the person based on the assessment, and ensure the assessment
accurately reflects the individuals functional needs.
 Providers are responsible with the team to determine the appropriate
service, frequency and duration they believe needs to be requested.
 Providers are responsible for hiring qualified staff and
training/supervision to meet the unique need. of the person. Providers
are responsible for documenting and claiming billing on Medicaid
requirements.
 Providers must follow all waiver policies.
The Purpose of In-Home Skill Building
• Teaching a NEW skill for individuals
living in private homes. (not out of
home placements)
• Teaching skills to promote
independence.
• Teaching skills essential to healthcare.
• Habilitation Services are the
foundation of training and include In
Home Skill Building. Other services
that include skill building are Day
Supports, Community Networking,
Supportive Employment, and
Residential Support.
Definition In Home Skill Building:
 Provides training in skill building to enable the person
to acquire and maintain skills which support
independence.
 Augments/provides additional supports to the person’s
family and/or other natural supports.
 Consists of an array of services that are required to
maintain and assist the person to live in community
settings.
In-Home Skill Building consists of:
 *Training in interpersonal skills and the development
and maintenance of personal relationships.
 *Skill building to support the person in increasing
community living skills (i.e. shopping, recreation,
personal banking).
 *Training with therapeutic exercises; training with selfadministering on medications and other services
essential to health care, such as transferring,
ambulation and the use of special mobility devices.
 *Transportation to support implementation of InHome Skill Building.
What are Interpersonal Skills
Interpersonal skills are the life skills we use every day to
communicate and interact with other people, individually and in
groups.
 Listening Skills
 Communication Skills
 Stress management
 Verbal communication
 Assertiveness
 Decision Making
 Problem Solving
 Non Verbal Communication
How do you Train Interpersonal
Skills?
 Preplanned sessions of direct instruction that have
plans developed prior to training around new
interpersonal skills being developed including social
skills to assist with development of meaningful
relationships .
 Includes direct instructions
 Performance feedback
 Social reinforcement
 Modeling, and role-playing
 Practice
What Skill Building is!
 Structured sessions with plans developed around
objectives for each activity.
 Includes specific instructions for each step developed
through a task analysis, with individualized
interventions, tools to complete the tasks and
timelines for each step.
 Immediate feedback for each activity and social
reinforcement to assist in retention and mastery of
skills.
 Modeling, role-playing, and real life practice
What Skill Building is NOT!
 Disorganized, unstructured activities that are not planned
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and not consistent between sessions or among staff
providing the training.
Lacks specific repetitious instructions and steps for each
activity.
Missing performance feedback and redirection
No social reinforcement
Practicing skills without development of task analysis,
steps and interventions for each step, preparation
(anticipatory guidance), route practice with
documentation of outcomes/progress.
What is Therapeutic Exercise?
 Bodily movement prescribed to correct an impairment, improve
musculoskeletal function, or maintain a state of well-being. Therapeutic
exercise seeks to accomplish the following goals:
 Enable ambulation
 Release contracted muscles, tendons, and fascia
 Mobilize joints
 Improve circulation
 Improve respiratory capacity
 Improve coordination
 Reduce rigidity
 Improve balance
 Promote relaxation
 Improve muscle strength
 Improve exercise performance and functional capacity (endurance)
Therapeutic Exercises training
 Structured sessions with staff around recommended
therapeutic exercises and the steps for each exercise as
required by
 Includes specific activities and recommendations from
specialized therapies (OT, PT, ST) or medical
practitioners.
 Continuous performance documentation and
consultation with therapists or doctors for input
around outcomes.
 In-Home Skill Building is
individualized, specific, and consistent
with the person’s assessed disability
specific needs and is NOT provided in
excess of those needs.
Assessed Needs
 The assessment process determines the feasibility of NC
Innovations participation and the need for continued
participation.
 considers the services and supports needed to enable the person
to attain an optimal level of independence and self-sufficiency
 addresses the well-being of the person, including risks in the
person’s life that need to be addressed to ensure the person’s
health and welfare in the community
 determines the person's abilities; the help the person needs; the
support available from and needed by informal caregivers; the
help available from other sources; the person's living situation;
and the individual's/responsible party's preferences in regard to
care and the best strategy to meet the Life Goals of the person
What should an Assessment
include?
 Various evaluations that are applicable to the person’s
situation, that are required to determine the person’s needs
related to their mental retardation (intellectual disability)
or related developmental disability, to live inclusively in
their community with maximum independence.
Occupational Therapy Evaluation
 Physical Therapy Evaluation
 Speech Therapy Evaluation
 Psychological Evaluation
Assessments, continued
 Assessments should focus on the person’s strengths,
abilities and positive steps used to enhance the
person’s ability to meet his or her Life Goals, or to help
the person determine what Life Goals to pursue.
 Assessments should also show the barriers to a
person’s attainment of his/her Life Goals and be a
foundation for determining how to address the
barriers.
 In-Home Skill Building is different from Personal Care
by the presence of training.
 It is anticipated that the presence of In-Home Skill
building will result in a gradual reduction in hours
as the person is trained to take on additional tasks and
masters skills to their optimal functional level.
 On-going authorization of this service requires the
demonstration and documentation of progress.
Service Exclusions
 In-Home Skill Building is furnished in a manner not
primarily intended for convenience of the person,
primary care-giver(s), or providers.
 This service IS NOT to be provided in the home of the
direct care staff.
 The service MUST start and/or end at the person’s
private home.
 The person may NOT be also receiving Residential
Supports.
Service Exclusion – Continued
 In-Home Skill Building may NOT be provided at the same
time of day as Day Supports, Community Networking, InHome Intensive Supports, Personal Care, Respite, Supported
Employment, and/or one of the State Plan Medicaid services
the works directly with the person.
 For school-age children, In-Home Skill Building does NOT
include transportation to/from school settings, including
to/from the child’s home or any other location where the
person may be receiving support before or after school.
 Note: The amount of this service is subject to the Limits on
sets of Services.
The Purpose of Personal Care
• Support, Supervision, and
engaging in ADL’s
• Maintenance of skills already
mastered.
• Supervision of independent
activities.
Definition of Personal Care
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Personal Care Services under the waiver include
support,
supervision
engaging participation with eating, bathing, dressing,
personal hygiene and other activities of daily living.
 Support and engaging the participant describes the
flexibility of activities that may encourage the participant
to maintain skills gained during habilitation while also
providing supervision for independent activities.
 This service may include preparation of meals, but does
not include the cost of the meals themselves.
Definition of Personal Care
 When specified in the ISP, this service may also include housekeeping
chores such as bed making, dusting and vacuuming, which are
incidental to the care furnished or which are essential to the health and
welfare of the participant, rather than the participant’s family.
 Personal care also includes assistance with monitoring health status
and physical condition, assistance with transferring, ambulation, and
use of special mobility devices.
 Personal Care Services may be provided outside of the private home as
long as the outcomes are consistent with the support described in the
ISP.
 Services may be allowed in the private home of the provider, staff or an
Employer of Record, or staff of an Agency With Choice if there is
documentation in the ISP that the participant’s needs cannot be met in
the participant’s private home or another community location
Personal Care Exclusions
 Does not include medical transportation and may not be provided
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during medical transportation and medical appointments.
Participants, who live in licensed residential facilities, licensed AFL
homes, licensed foster homes, or unlicensed alternative family living
homes serving one adult, may not receive any aspect of this service or
any other State Plan Personal Care Service.
Personal Care cannot be provided in a licensed program.
This service may not be provided on the same day that the participant
receives State Plan Medicaid Personal Care Services, a home health
aide visit, Residential Supports or another substantially equivalent
service.
Transportation between the participant’s home and the provider’s
home is not billable service time
Personal Care Exclusions,
continued
 This service may not be provided at the same time of day that a participant
receives Day Supports, Community Networking, In-Home Intensive Support,
In-Home Skill Building, and Respite, Supported Employment or one of the
State Plan Medicaid services that works directly with the person.
 The service does not cover the staff member completing home maintenance,
housekeeping for areas that are used by other members of the household
and/or meal preparation when the same meal is being prepared for other
family members.
 For participants who are eligible for educational services under the Individuals
With Disability Educational Act, personal care does not include transportation
to/from school settings. This includes transportation to/from the participant’s
home, provider home where the participant may be receiving services before or
after school or any other community location where the participant may be
receiving services before or after school.
Comparison of In Home Skill
Building and Personal Care
In-Home Skill Building
Personal Care
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 Requires assessed needs
 Does not have to be instruction of new
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Requires assessed needs
Structured
Requires specific Instruction
Continuous Performance
feedback
Social reinforcement
Modeling, and role-playing
Practice
Must start in and end the home
Gradually reduces in hours as
progress is made
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skills
Assist person as they need assistance
Occurs naturally throughout the service
Encouragement to participate
Can be delivered in setting including the
community, but not licensed facilities,
school or hospitals.
Can start and end anywhere; but cannot be
provided in a licensed facility, school or
hospital.
Hours of support generally do not decrease
over time, but can decrease with needs
changing, implementation of a behavior
plan, addition of assistive technology.
Cannot start or end at school
What can you expect from CoastalCare?
 In-Home Skill Building will be assessment driven and outcome oriented.
 will need to show progress during an authorization period or will need new assessment
and revised goals, interventions and strategies. (provider quarterly progress
summaries and daily grids will be crucial for documentation of
progress/outcomes and determining recommendations for continuation,
reduction or termination of an outcome)
 is viewed as a service to be delivered over a individual period of time to address new skills
for individuals that have the capacity to develop for specific outcomes and fade as
mastery is obtained.
 Individuals who receive this service will need to demonstrate the functional capacity and
level of readiness to obtain the skills outlined in the ISP as evidenced by ongoing
assessments.
 PCS will be viewed as a support service that includes supervision that does not have a
fading expectation.
Time for Questions???
Teaching skills first means you must understand
how to make the training “ergonomically sound”.
 At its simplest definition ergonomics literally
means the science of work. So ergonomics is the
study of work/tasks, how work is done and how to
work better.
 To do this you must understand 3 things:
1. Body Mechanics
2. The tool being used
3. The task being performed
When Providers write short term goals for InHome Skill building for Teaching a NEW skill to
individuals
 Its important to match the task to the adaptive functional need.
 It is important to create a “task analysis”.
 A task analysis is a document where the instructor breaks down a
task into it’s component parts.
 The component parts or steps often start as repetitious and time
consuming tasks, but the steps can be adjusted and
interventions designed to match the participant’s skill level.
 Individuals with strong receptive language skills may be able to
respond to verbal prompts as an intervention, while individuals
with poor fine motor skills may need more discrete steps or
modifications including adaptive equipment or a unique way to
complete the task independently.
Task Analysis is used to break down a variety of tasks in
the steps to complete the work or activity.
 Example “A Task Analysis for Tooth Brushing”
1. Remove cap from tooth paste and set on the counter to left of sink
2. Turn on cold water
3. Take brush in right hand, holding bristles up, with right thumb up
4. Wet the brush under the running cold water
5. Squeeze toothpaste onto tooth brush
6. Place toothbrush with bristles against the right rear molars on the
top, and move bristles up and down from back to front.
7. Repeat on left top.
8. Move to the right bottom and left bottom. Repeat the up and down
brushing.
9. Spit saliva and toothpaste into sink after each quadrant.
10. Rinse out the brush with water and replace in holder/case.
11. Fill glass with water
12. Fill mouth with water, swish around and spit into sink.
Task Analysis also identifies the tools to complete the task and
the amount of time each step will take to complete the work or
activity.
 Example for “Brushing your Teeth”
Tools: toothbrush, toothpaste, water source(faucet),
sink, glass, towel.
Time:
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Unscrew toothpaste cap (15 seconds)
Squeeze toothpaste onto toothbrush bristles (15 seconds)
Turn on faucet (5 seconds)
Wet toothbrush (2 seconds)
Brush teeth (120 seconds)
Fill glass with water (3 seconds)
Rinse mouth and spit into sink (6 seconds)
Turn off faucet and dry mouth and hands with towel (8 seconds)
If needed steps can be broken down further to elemental actions
to perform a task called “Critical Task Analysis”.
 Critical is defined as necessary for success. In brushing
your teeth the steps involving toothpaste and brushing
are “critical”.
 If you cannot unscrew the cap you cannot get to the
toothpaste, which means you cannot brush your teeth,
which means you cannot complete the task. Rinsing
your mouth and drying your hands are not critical to
completing the task.
Once the Task Analysis is completed the instructor will
decide how to support the instruction.
 The support could be:
 Hand-over-hand assistance
 Modeling
 Verbal prompting
 Back-ward chaining
 Forward chaining with instruction
 Instruction with the use of adaptive equipment
These will be individualized based on the persons needs
so the instruction personalized for success and the
individual can independently complete the task.
Instruction and progression with mastery of a
new skill should be documented for each step
 The daily grid should document each step, type of
support or intervention, time required, and progress in
a very systematic way-not flowing naturally but in a
organized, methodical manner.
 Instruction should also be time limited before mastery
of the skill, or change in the task, or change in the
support/intervention occurs.
 If complete mastery of the task is not attainable due to
functional limitations even with appropriate supports
training of the new skill may appropriate.
Helpful links for tasks analysis
Helpful links for Task Analysis
National Secondary Transition Technical Assistance
Center
 http://nsttac.org/content/evidence-based-practicessecondary-transition
Exceptional Children Assistance Center
http://www.ecac-parentcenter.org/
More Time for Questions??