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Welcome
The Supportive Housing & Homeless
Program – Goal Setting & Record
Keeping webinar will begin shortly.
This is a mu...
Supportive Housing &
Homeless Program – Goal
Setting & Record Keeping
Jonda Clemings, MSEd, LSW
Reasons for
Documentation
Clinical
• Planning &
monitoring progress
• Documentation of
accomplishments
• Quick access
• Support staff work
Clinical
• Identify patterns
• Continuity of service
• History of crisis
situation/pattern
Compliance
• Monitoring
• Regulatory requirements
Legal
• Behavior description
• Data assessment &
treatment plan
• Data for evaluation
• Funding source
record
• Justificat...
Legal Aspects of
Documentation
• Direct planning &
coordination
• Response to
services
• Team member
communication
• Regul...
Legal Aspects of
Documentation
• Necessity for services
• Maximize reimbursement
• Provide data for staff decisions
• Lega...
Legal Parameters
• Confidentiality & privileged
• Accuracy
• Objectivity
Legal Parameters
Goal Setting
• Consumer centric
• Help reach goals
• Celebrate success
• Problem goal vs. problem person
• Inform choices
Goal Setting Skills
Goal Setting Skills
SMART Objectives
• Specific
• Measurable/observable
• Attainable within time & conditions
• Results-oriented
• Targeted to...
Targeted Objectives
Goals & Objectives
Identify various issues,
functions, etc. that a
person may need to
set a goal/objective
around to impro...
Bloom’s Taxonomy
Housing Services Plan
Intention
• What is it that you want to achieve?
Specific
• Who
• What
• Why
• Where
• When
Measurable
• How much?
• How often?
• How many?
Attainable
• Achievable?
Relevant
• Is it important to what you want to
achieve ultimately?
Time Based
• When?
Sample Goal
• Goal: Housing
search
• Objective: Submit
application to MHA,
apartment complex
• Target date: by May
15, 2014
Amy is a new participant in your homeless
shelter. When asked about her housing
goals, she tells you that she doesn't have...
Bill has been residing in your rapid re-housing
program for six months now. He became
homeless due to a layoff at the plan...
What Should We Document?
• Functional limitations & abilities
• Barriers that led to homelessness
• Program adherence
• Ge...
Record Maintenance
• Locked
• Organized
• Sequential
• Participant identification
• No other consumer names
• Individualiz...
Record Maintenance
• Avoid backdating
• No blank spaces
• Streamline charting
• Follow agency policy
• Sign entry with nam...
Record Maintenance
• Specific
• Don’t label, characterize, use
cliches
• Use quotes
• Approved abbreviations
• Legible, gr...
Documentation Methods
• SOAP – Subjective, Objective,
Assessment, & Plan
• DAP – Data, Assessment & Plan
Documenting Appearance
Documenting Mobility
Documenting Communication
Documenting Cognitive
Functions
Building a Case File
What Should Be Included
Face Sheet
Identifying Information &
Picture ID
• Drivers license
• State ID
• Birth certificate
Ohio State ID
Social Security Cards
Homeless Status
Chronic Homeless Status
• Unaccompanied individual or
adult household member
• Disabling condition
• Living on streets or ...
Housing History
• Why moved
• Type of housing
• Difficulties
maintaining housing
• Barriers
• Housing needs
Disability Status
• Long-term, indefinite
duration
• Impedes ability to live
independently
• Disability could be
improved ...
Disability Status
• Physical, mental or emotional
impairment - including
impairment solely due to
alcohol or drug use
• Wr...
Disability Documentation
• 3rd
Party Written Verification
– Disability verification form by state licensed
professional
• ...
Consent Forms
• Basic elements of consent
• Informed choice
• Overall experience
• Voluntary participation
Educational & Vocational
Assessment
• Abilities
• Interests
• Personality
Employment History
• Gaps in employment
• Positions held
• Frequency of job changes
• Skills
• Strengths
Criminal Background
• Criminal history as
it impacts housing
& employment
Psychosocial Assessment
• Mood & affect
• Cognitive functioning
• Memory
• Communication
• Appearance
• Mobility
Health Assessment
• Medications
• Medication log
• Allergies
• Illnesses
Service Plan
• Goals/objectives while in
program
• Drives service planning
Income Verification
• Amount of income
• Sources of income
• Proof of income
Incident Reports
• What happened
• When it happened
• Others involved
• Follow-up
Discharge Summaries
• Reason for discharge
• Income sources
• Income amounts
• Destination
• Progress made
• Referrals made
Rent Reasonableness
Charting Legally
Sensitive Situations
• Objectivity
• Nonjudgmental
description
• Accuracy
• Completeness
• Legibility
• J...
Dissatisfied Consumer
• Utilize “quotes”
• Don’t label - describe
• History or crisis
patterns
• Attempts to satisfy
• Cho...
Noncompliance
• How person refused to
comply
• Failure to provide
information
• Attempts to remedy
• Review of procedures
Confidentiality
• HIPAA
• Minimal access - need to know
• Privileged communications
Peer Review
• Impartial review
• Share expertise
• Diversity of opinion
• Provide
suggestions
Quality Monitoring
• Look at process and
outcomes
• Drive improvement
• Accountability
• Refine service
delivery
• Track i...
Coalition on Homelessness and
Housing in Ohio
Jonda Clemings
175 S. Third St. - Suite 250
Columbus, Ohio 43215
Phone 614-2...
Supportive housing & homeless program   goal setting & record keeping
Supportive housing & homeless program   goal setting & record keeping
Supportive housing & homeless program   goal setting & record keeping
Supportive housing & homeless program   goal setting & record keeping
Supportive housing & homeless program   goal setting & record keeping
Supportive housing & homeless program   goal setting & record keeping
Supportive housing & homeless program   goal setting & record keeping
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Supportive housing & homeless program goal setting & record keeping

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Documentation training for supportive housing and homeless programs.

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Supportive housing & homeless program goal setting & record keeping

  1. 1. Welcome The Supportive Housing & Homeless Program – Goal Setting & Record Keeping webinar will begin shortly. This is a muted call, please submit your questions via the GoToMeeting question feature. Handouts will be made available after the webinar concludes.
  2. 2. Supportive Housing & Homeless Program – Goal Setting & Record Keeping Jonda Clemings, MSEd, LSW
  3. 3. Reasons for Documentation
  4. 4. Clinical • Planning & monitoring progress • Documentation of accomplishments • Quick access • Support staff work
  5. 5. Clinical • Identify patterns • Continuity of service • History of crisis situation/pattern
  6. 6. Compliance • Monitoring • Regulatory requirements
  7. 7. Legal • Behavior description • Data assessment & treatment plan • Data for evaluation • Funding source record • Justification for staff action
  8. 8. Legal Aspects of Documentation • Direct planning & coordination • Response to services • Team member communication • Regulatory compliance
  9. 9. Legal Aspects of Documentation • Necessity for services • Maximize reimbursement • Provide data for staff decisions • Legal record
  10. 10. Legal Parameters • Confidentiality & privileged • Accuracy • Objectivity
  11. 11. Legal Parameters
  12. 12. Goal Setting • Consumer centric • Help reach goals • Celebrate success • Problem goal vs. problem person • Inform choices
  13. 13. Goal Setting Skills
  14. 14. Goal Setting Skills
  15. 15. SMART Objectives • Specific • Measurable/observable • Attainable within time & conditions • Results-oriented • Targeted to the identified need & impact
  16. 16. Targeted Objectives
  17. 17. Goals & Objectives Identify various issues, functions, etc. that a person may need to set a goal/objective around to improve their housing stability. List as many of these as you can for each letter in the alphabet.
  18. 18. Bloom’s Taxonomy
  19. 19. Housing Services Plan
  20. 20. Intention • What is it that you want to achieve?
  21. 21. Specific • Who • What • Why • Where • When
  22. 22. Measurable • How much? • How often? • How many?
  23. 23. Attainable • Achievable?
  24. 24. Relevant • Is it important to what you want to achieve ultimately?
  25. 25. Time Based • When?
  26. 26. Sample Goal • Goal: Housing search • Objective: Submit application to MHA, apartment complex • Target date: by May 15, 2014
  27. 27. Amy is a new participant in your homeless shelter. When asked about her housing goals, she tells you that she doesn't have any housing goals. Amy states that she has received Medicaid in the past, but is not currently receiving it. She has no other income/benefits at this time. Amy is not interested in working nor is she interested in signing up for Medicaid, SNAPS, other housing, etc. •Goals: •Objectives:
  28. 28. Bill has been residing in your rapid re-housing program for six months now. He became homeless due to a layoff at the plant and has been having much difficulty finding other employment with comparable pay. Initially, Bill was sad about the loss of his housing, however he was very good at following up on possible job leads. During the past couple of months, Bill has become cool and distant. He appears disinterested and indifferent about finding a job. Goal: Objective :
  29. 29. What Should We Document? • Functional limitations & abilities • Barriers that led to homelessness • Program adherence • General observation
  30. 30. Record Maintenance • Locked • Organized • Sequential • Participant identification • No other consumer names • Individualized • Black/blue ink
  31. 31. Record Maintenance • Avoid backdating • No blank spaces • Streamline charting • Follow agency policy • Sign entry with name & title/ credentials
  32. 32. Record Maintenance • Specific • Don’t label, characterize, use cliches • Use quotes • Approved abbreviations • Legible, grammatically correct
  33. 33. Documentation Methods • SOAP – Subjective, Objective, Assessment, & Plan • DAP – Data, Assessment & Plan
  34. 34. Documenting Appearance
  35. 35. Documenting Mobility
  36. 36. Documenting Communication
  37. 37. Documenting Cognitive Functions
  38. 38. Building a Case File What Should Be Included
  39. 39. Face Sheet
  40. 40. Identifying Information & Picture ID • Drivers license • State ID • Birth certificate Ohio State ID
  41. 41. Social Security Cards
  42. 42. Homeless Status
  43. 43. Chronic Homeless Status • Unaccompanied individual or adult household member • Disabling condition • Living on streets or emergency shelter • 1 continuous year homeless or 4 episodes of homelessness in 3 years
  44. 44. Housing History • Why moved • Type of housing • Difficulties maintaining housing • Barriers • Housing needs
  45. 45. Disability Status • Long-term, indefinite duration • Impedes ability to live independently • Disability could be improved with suitable housing
  46. 46. Disability Status • Physical, mental or emotional impairment - including impairment solely due to alcohol or drug use • Written documentation must come from credentialed professional
  47. 47. Disability Documentation • 3rd Party Written Verification – Disability verification form by state licensed professional • Social Security Administration • Receipt of disability check • Oral third-party and self-certification is not appropriate
  48. 48. Consent Forms • Basic elements of consent • Informed choice • Overall experience • Voluntary participation
  49. 49. Educational & Vocational Assessment • Abilities • Interests • Personality
  50. 50. Employment History • Gaps in employment • Positions held • Frequency of job changes • Skills • Strengths
  51. 51. Criminal Background • Criminal history as it impacts housing & employment
  52. 52. Psychosocial Assessment • Mood & affect • Cognitive functioning • Memory • Communication • Appearance • Mobility
  53. 53. Health Assessment • Medications • Medication log • Allergies • Illnesses
  54. 54. Service Plan • Goals/objectives while in program • Drives service planning
  55. 55. Income Verification • Amount of income • Sources of income • Proof of income
  56. 56. Incident Reports • What happened • When it happened • Others involved • Follow-up
  57. 57. Discharge Summaries • Reason for discharge • Income sources • Income amounts • Destination • Progress made • Referrals made
  58. 58. Rent Reasonableness
  59. 59. Charting Legally Sensitive Situations • Objectivity • Nonjudgmental description • Accuracy • Completeness • Legibility • Justify actions taken
  60. 60. Dissatisfied Consumer • Utilize “quotes” • Don’t label - describe • History or crisis patterns • Attempts to satisfy • Choices provided made • Never characterize
  61. 61. Noncompliance • How person refused to comply • Failure to provide information • Attempts to remedy • Review of procedures
  62. 62. Confidentiality • HIPAA • Minimal access - need to know • Privileged communications
  63. 63. Peer Review • Impartial review • Share expertise • Diversity of opinion • Provide suggestions
  64. 64. Quality Monitoring • Look at process and outcomes • Drive improvement • Accountability • Refine service delivery • Track integrity and effectiveness
  65. 65. Coalition on Homelessness and Housing in Ohio Jonda Clemings 175 S. Third St. - Suite 250 Columbus, Ohio 43215 Phone 614-280-1984 Fax 614-463-1060 www.cohhio.org jondaclemings@cohhio.org

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