RC 4: Service Planning and Monitoring
Each caregiver participates in the development and ongoing review of a service plan
that is the basis for delivery of appropriate services
Caregivers are engaged in a strengths-based planning
process for identifying needed services and desired results.
During service planning the organization explains:
- available options;
- the benefits and alternatives of planned services; and
- how the organization can support the achievement of desired outcomes.
An expedited service-planning process is available when crisis or urgent need has been identified, and service plans are completed within time frames established by the organization.
The service plan is developed with the caregiver prior to the provision of care, and includes:
- a description of services to be provided;
- service goals, desired outcomes, and timeframes for achieving them;
- guidelines for requesting additional planned or emergency respite care;
- fees and payment arrangements, when applicable; and
- the caregiver’s signature on the initial plan and significant revisions to the plan.
Research Note: Research
suggests that respite care for caregivers of adults and children with serious emotional distubance is more effective when used regularly and frequently.
The service plan addresses, as appropriate:
- the family’s unmet service and support needs;
- possibilities for maintaining and strengthening family relationships; and
- the need for support of the individual’s informal social network.
The worker and a supervisor, or a clinical, service, or peer team, review the case to assess:
- service plan implementation;
- progress toward achieving goals and desired outcomes; and
- the continuing appropriateness of the agreed upon goals.
Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the worker's supervisor reviews a sample of the worker's evaluations as per the requirements of the standard.
Timeframes for the review should be adjusted depending upon issues and needs of persons receiving services, and the frequency and intensity of services provided. Planned respite care should be reviewed at least quarterly, and crisis respite care should be reviewed in a timeframe consistent with the length and frequency of service.
The worker and caregiver regularly review progress toward achievement of agreed upon service goals.