4.J.1.
The persons served are linked to services and resources as identified in their individual plans.
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4.J.2.a-c.
Services coordination personnel maintain a working knowledge of:
- Services/resources that are appropriate for the needs of the persons served
- Support systems that are relevant to the lives of the persons served
- Funding issues pertinent to the referral process
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4.J.3.a-h.
Based on the needs of the persons served, services coordination includes:
- Activities carried out in collaboration with the persons served and/or their families, as appropriate
- Outreach/facilitation to encourage participation of the persons served
- Coordination of, or assistance with, crisis intervention and stabilization services, as appropriate
- Assisting the persons served to achieve goals for independence as defined by the persons served
- Optimizing resources and opportunities through:
- Community linkages
- Enhances social support networks
- Assistance with:
- Accessing transportation
- Securing safe housing that is reflective of the:
- Abilities of the persons served
- Preferences of the persons served
- Needs of the persons served
- Exploring employment or other meaningful activities
- Accessing employment training
- Job seeking
- Career development and advancement
- Provision of, or linkages to, skill development services needed to enable the person served to perform daily living activities including, but not limited to:
- Budgeting
- Meal planning
- Personal care
- Housekeeping and home maintenance
- Other identified needs
- Evidence of linkages with necessary and appropriate:
- Financial services
- Medical or other healthcare
- Other community services
- Assistive technology assessment
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4.J.4.
The organization provides services coordination activities at times and in locations that meet the needs of the persons served.
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4.J.5.
The intensity of services coordination is based on the needs of the person as identified in his or her individual person-centered plan.
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4.J.6.a-b.
When multiple services coordinators exist:
- A primary service coordinator is identified
- There is coordination to:
- Facilitate continuity of care
- Reduce duplication of services
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4.J.7.
With the permission of the persons served, personnel provide advocacy by sharing feedback regarding the services received with the agencies and organization providing the services.
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