Case Study - Mr. Sam Wilson
Ruby contacted Sam and his mother to set up a time to begin the service planning process. She asked them who helps Sam and who is important in his life to make sure she invited everybody involved to participate. Sam gave her the phone number of his best friend Ed who takes him to church each Sunday. Sam’s Dad was now home from the hospital and very much wanted to be part of any planning process as well. Ruby scheduled a time to go to the home when everyone identified was available to meet.
Later that week Ruby sat down with Sam, his mom, his dad and his friend Ed. Ruby talked with Sam, his parents and his friend and identified the support he needed, how often and from whom. This covered the help he needed at home and in the community; his longer term goals for living on his own and working; and his need for help monitoring his health and medical conditions. She was very attentive to Sam as she moved the conversation through the agency’s needs assessment protocol. She paused often to confirm that the discussion was in line with Sam’s needs and wishes. Sam repeated that his goal was to someday live on his own and to get a job where he could be part of a team. After a lengthy conversation everyone agreed that Sam’s needs included:
- Help with bathing and dressing in the morning
- Skills training for meal/snack preparation and other independent living skills
- Monitoring of seizure medications and blood levels
- Job training
In response to the needs identified, Ruby included the following HCBS supports in Sam’s plan:
- A direct support staff for 2 hours a day Monday thru Saturday to assist with dressing and bathing and one hour in the afternoon to provide skills training in IADLs as Sam prepares to live more independently
- Monthly RN visit to check Sam’s seizure activity log, his medications, and check his insulin log
- Supported employment position
- Community integration training once a week
She provided the family with a list of available agencies in the area. The family chose one based on a neighbor’s recommendation. Ruby also discussed a back-up plan with the family and they identified a second support person to fill in when needed. Ruby knew from prior conversations that Sam wanted to live at home so she made a note of that in the file and did not waste his time discussing other options, such as living in an ICF-MR.
The group also discussed a number of services and supports to be provided by the family and other community partners outside of the HCBS program, (e.g. Community Education walking program) but since those were not HCBS services Ruby did not include them in the plan.
She sent the draft plan to Jane for her review.