N.M. Admin. Code § 8.371.5.7 - DEFINITIONS
A.
The
Interdisciplinary Team (IDT):
(1) The
"interdisciplinary team (IDT)" is responsible for the development
of the individual service plan (ISP) and for identifying the agencies and
individuals responsible for providing the services and supports identified in
the ISP.
(2) The IDT shall consist
of the following core members:
(a)
"individual": the person with a developmental disability for whom
the ISP is written;
(b)
"case
manager": the independently-funded professional responsible for service
coordination to indviduals with developmental disabilities on the developmental
disabilities medicaid waiver; the case manager must be external to, and
independent from, the community service provider agency;
(c)
"guardian": the court
appointed guardian of an adult individual or the custodial parent(s) if the
individual is a minor;
(d)
"helper": the individual may choose a helper to assist with
communication; in instances where the individual is unable to make this choice,
the guardian may choose a helper, if desired; the helper may be a friend,
housemate, family member, teacher, co-worker, current or former employee of an
agency or facility with which the individual has had contact, foster
grandparent, or any other person from the individual's circle of relatives,
friends and acquaintances;
(e)
"key community service provider staff": "key" community service
providers are providers of residential employment, day program and behavioral
services specifically designed for persons with developmental disabilities;
"key" provider staff participating in the IDT shall include, at a minimum:
(i)
"direct service staff": the
provider staff member(s) directly responsible for the provision of specified
services to the individual with developmental disabilities;
(ii)
"service coordinator": the
community provider staff member, sometimes called the program manager or the
internal case manager, who supervises, implements and monitors the service plan
within the community service provider agency;
(f)
"ancillary service
providers": the service provider agencies and staff providing
non-residential and non-day services, either specifically designed for
individuals with developmental disabilities or generic in nature, regardless of
funding source; examples of ancillary services include nutritional services,
physical therapy, occupational therapy, speech therapy, respite, nursing, etc.;
as well as services provided by the individual's physician and other medical
personnel;
(g)
"designated
healthcare coordinator" the team member designated to coordinate medical
supports and services which the individual requires to manage any chronic
health conditions and to access preventative healthcare services;
(h)
"others": unless the
individual objects, other participants may include family members not already
mentioned, if invited by the individual or guardian; advocates or other chosen
representatives who participate in the ISP development process on the
individual's behalf; representatives of generic services, who may participate
in the IDT with the individual's or guardian's consent; representatives of the
public school system, if the individual is of school age and attends public
school; and, any others that the individual wishes to have attend the IDT
meeting.
B.
Content of individual service plans:
(1)
"Demographic information":
The individual's name, age, date of birth, important identification numbers
(i.e., medicaid, medicare, social security numbers, level of care), address,
phone number, guardian information (if applicable), physician name and address,
primary care giver or service provider(s), date of the ISP meeting (either
annual, or revision), scheduled month of next annual ISP meeting, and team
members in attendance.
(2)
"Longterm vision": A written statement of the individual's
personal vision for the future.
(3)
"Outcomes": Desired outcomes generated by the individual, guardian
and the team. An outcome is a realistic change that can occur in the
individual's life, that the individual can achieve and that leads towards the
attainment of the individual's long-term vision. For example, an outcome may
state that the individual obtain preferred employment or that the individual
learn to drive.
(4)
"Individual preference": The individual's preferences,
capabilities, strengths and needs in each life area determined to be relevant
to the identified ISP outcomes shall be reflected in the ISP. The long term
vision, age, circumstances and interests of the individual, shall determine the
life area relevance, if any, to the individual's ISP.
(5)
"Action plans":
(a) specific action plans designed to assist
the individual in achieving each identified desired outcome listed in the ISP,
by the team, which include criteria for measuring progress, timelines and
responsible parties on each action step.
(b) service providers shall develop specific
tasks and strategies (methods and procedures) for implementing each specified
action step within timelines established by the IDT.
(6)
"Assistive technology":
Necessary support mechanisms, devices, and environmental modifications
including the rationale for the use of assistive technology or adaptive
equipment when a need has been identified, shall be documented in the ISP. The
rationale shall include the environments and situations in which assistive
technology is used. Selection of assistive technology shall support the
individual's independence and functional capabilities in as nonintrusive a
fashion as possible.
(7)
"Availability of supports and services": Identification of
potential supports and services for individuals by the IDT should be undertaken
without regard to the cost of the supports and services or whether they are
actually available at that time in the community.
(8)
"Signature form": A
signature form, containing the name, phone number and role on the IDT of all
team members shall be included in the ISP. All individuals attending the annual
IDT meeting shall sign the signature form to indicate their participation in
the planning process. For all team members not in attendence the alternative
method of their participation shall be stated on the signature line. (e.g.
telephone, written report, premeeting consultation or designated
representative).
(9)
"Budgetpage": For individuals receiving services through the
developmental disabilities medicaid waiver a proposed budget page developed by
the case manager in consultation with the various service providers shall be
included in the ISP.
Notes
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