Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

Policy

Each ICC Agency must have qualified workers to function as Individual Care Coordinators. The client to ICC ratio is 6 to 1.

Job Description:
The Individualized Care Coordinator (ICC) is responsible for engaging the child and family in a partnership of shared decision-making and service plan implementation throughout their enrollment in the HCBS Waiver.  The ICC ensures and coordinates a comprehensive set of supports, resources and strategies for each child and family.  The ICC works closely with outpatient clinics, day treatment programs and other providers to assure that Waiver services and clinical treatment modalities augment each other for optimal outcomes for children and families.  The ICC, the child and family, treatment providers, Waiver subcontractors and natural supports work together on an on-going basis to:

• develop and periodically review individual service plans and treatment plans to ensure coherence between the two plans,
• deliver services as indicated  in the Individual Service Plan,
• coordinate the development and implementation of a safety plan, and
• design and coordinate discharge plans.

The ICC is responsible for compliance with Waiver fiscal and program guidelines through all phases of the child’s enrollment.

Individualized Care Coordination includes the following components:

• engagement of child and family throughout Waiver enrollment;
• intake and screening - the process of reviewing the referral packet from SPOA;
• initial assessment of strengths and needs - the preliminary process of assessing a child and family’s strengths and needs as a precursor to service plan development;  this may include completing an initial CANS if not already completed by the SPOA;
• on-going assessment and documentation of the child and family’s strengths and needs, progress towards achieving goals, and efficacy of delivered services;
• completion of the Child and Adolescent Needs and Strengths (CANS) 30 days after enrollment, every 180 days thereafter, at discharge and as needed;
• on-going consultation with:
  • treatment providers to reciprocally inform both clinical treatment and Waiver strategies,
  • physical health care providers, schools and other relevant collateral sources,
  • Respite, Skill Building, Family Support, and Intensive In-Home workers and others (e.g., paid through flex dollars) who are involved in implementing the service plan.
• development and updating of services plans in partnership with the child and family that are:
  • reflective of the child and family’s priorities,
  • individualized, strength-based, and related to all life domains,
  • culturally sensitive and relevant,
  • complimentary with any psychiatric treatment  received through other providers,
  • focused on developmental tasks, resiliency and wellness,
  • inclusive of safety issues,
  • targeted to address assessment indicators (e.g., CANS), and
  • oriented towards discharge readiness;
• oversight of all documentation in the case record;
• development and updating of a Safety Alert Plan with the child and family in collaboration with the treatment provider;
• coordination and monitoring of Waiver service delivery;
• discharge and after-care planning;
• linkage and referral to services and supports as specified in the service plan; this encompasses:
  • identifying local resources and services for use during both enrollment and discharge planning,
  • sharing information with the child and family concerning relevant resources and service providers, including local family support programs, advisors and advocates,
  • engaging the child and family in making informed choices,
  • facilitating connection with selected resources and providers;
• advocacy which includes:
  • the process of helping to empower children and families to initiate and sustain interactions that support their overall wellness,
  • interceding on their behalf when necessary to gain access to needed services and supports; and
• maintenance of the approved HCBS Waiver budget designated for each child.

See ICC Competencies for a complete description competencies.

Qualifications:
Each ICC must meet the following qualifications:

• ICC’s hired after June ‘03 must have a Master’s degree in one of the following fields: audiology, child and family studies, communication disorders, community mental health, counseling, education, nursing, occupational therapy, physical therapy, psychology, recreation, recreation therapy, rehabilitation, social work, sociology, or speech and language pathology, human services, human development, criminal justice or other related degrees, or a NYS Teacher’s Certificate, and  two years experience* providing direct services for children with one or more of the following primary diagnoses: mental illness, mental retardation, alcoholism, chemical dependency or substance abuse.

  or

• a Bachelor’s degree in one of the above fields, or a NYS Teacher’s Certificate, and four years experience* providing direct services, or providing linkage to services, for children with one or more of the following primary diagnoses: mental illness, mental retardation, alcoholism, chemical dependency or substance abuse.

  *Qualifying experience may be pre- or post- degree. Candidates may qualify by meeting the qualifications for the NYS Intensive Case Manager position.

Under extenuating circumstances, the LGU in consultation with the OMH Field Coordinator may request a review of the candidate’s credentials to determine their qualification requirements.

Fingerprinting And Child Abuse Register Clearance

• Workers hired after 4/1/05 must have completed fingerprinting clearance to ascertain no criminal history.
• Workers must be cleared through the State Central Child Abuse Register.*
  Note: If an agency does not have required documentation of fingerprinting and/or State Central Abuse Register clearance, that worker must not be alone with and must be directly supervised during all contacts with Waiver clients until appropriate documentation is received.

* Child Abuse Register Guidelines for Mental Health Facilities and Programs - Applicant Inquiry Process contains relevant information; ICC Agencies can obtain this guide by contacting OMH, Division of Children and Families, Albany, NY.

Training:

ICC’s must:

• complete OMH approved training in the Individualized Care Model,
• receive orientation from their ICC Agency to the Waiver Program and the ICC Agency’s policy and procedures, including the staff safety protocols, child abuse identification and reporting, and incident reporting,
• participate in technical assistance sessions and agency inservices,
• complete the 14 C.A.R.A.T. training as soon after hire as possible and
• complete additional training as mandated.

Comments or questions about the information on this page can be directed to the Home and Community Based Waiver Program.