I have had the opportunity to review the "Draft ISP Guidance" being submitted for what I'm assuming is implementation in the next few months. I want to start by saying that I appreciate the hard work folks have put into this document and I understand that in order to comply with the Settlement Agreement, change is inevitable. I'm sure this is as frustrating for folks in the department as it is for the people on the front lines trying to balance the provision of quality care with the ever growing mountain of required documentation.

For those of us who have been in the field and system for some time, this new guidance is looks a whole lot like a return to the original Outcome development format that we were all taught nearly a decade ago. It's maddening to think that the past few years in terms of time, expenses, and hard work have essentially been for nothing. It's also maddening to see that we are seemingly returning to the old plus and minus data driven documentation that pervaded this field in the sheltered workshops and day centers of the 1980's and 90's. Unfortunately, if this new process is implemented as is, providers will be asked to yet again increase the amount of daily documentation that is required. They will be tasked with figuring out how to incorporate data collection forms into the EHR's and front line staff will have a new documentation requirement to add to the already ridiculous amount of work they already do each day where they balance caring for the least among us with somehow being responsble for clinical documentation requirements that RN's don't even utilize.

It's important to note that over the past decade, documentation in terms of sheer volume has increased radically. Part I-IV are now routinely over 30 pages. Part V's now are routinely 15-20 pages. Then you have an enourmous volume of support note documentation each month. Adding new forms to track data that should already be identified in the support note is redundant and completely unecessary. In my opinion, adding additional documentation is simply not conducive to allowing front line staff to devote the time they need to skill building, routine care, and health and safety, etc. 

Going back to the old way by adding prepositional phrases to outcomes is fine. The logic makes sense. In fact, I like the logic behind requiring more specificity with outcomes and adding measurement phrases to both outcomes and support activities. I think it actually helps staff identify what they should do and then write better notes. But creating new forms and more documentation in a system that is inarguably over saturated with documentation makes zero sense.  There is simply no other Medicaid service that requires the amount of documentation as ID/DD Waiver services. Quite frankly, it's ludicrous considering that all across the heatlh care industry and Medicaid service spectrum, service plans can be accomplished in 1-5 pages. Somehow, we've established a system where an individual who has 3-4 Waiver services can legitimately have a 100+ page support plan (counting Part 1-4 and all Part V's). How is 100+ page support plan efficient and effective with helping people live the lives they want? Let's stop losing quality staff at unprecedented rates because of the documentation requirements and let's figure out a more common sense way to document progress.

Thank you for the time and work that went into the creation of this document. In reviewing it over the last few days, I have appreciated that the guidance is clear and concise, with practical examples. In many ways, it synthesizes the information we have received over the past few years and is not inconsitent with the expectations we've been operating under. We're grateful to have this tool for training and orienting new members of our staff to the Person-Centered ISP process, and for improving our work as we develop future plans with the core members living in our two Arlington houses.

To whom it may concern:

I have reviewed the "Draft ISP Guidance" that has been open to public comment. I do understand that change is inevitable. Change has always been the only constant that I have encountered during my tenure I have had the privilege to work in this field providing Virginia based DSP and Supervisory services for 12 years and have been exclusive to Virginia as a DSP and Residential Service Coordinator for the past almost 5 years. By explaining this, I understand the struggle of the amount of documentation that is required from different perspectives.

The basis of what I have reviewed seems very similar to “the old way” of how we collected data. I will admit, the “If/then” format of the Outcome statements makes complete sense to me. I feel like that sentence structure is straight forward and gives DSPs a clear path to what is expected of them in terms of measurability and the type of data that needs to be observed in order to have a clear and concise picture of progress in the people whom we/they support.

Unfortunately, if this new process is implemented as explained, DSPs will be asked to yet again increase the amount of daily documentation that is required. It is to my experience that when paperwork or the amount of documentation is increased, less time is able to be spent with the people whom we support to ensure that they are able to pursue a meaningful path to a life like ours. In essence, the person-centered approach regresses due to the demands of paperwork.

In my opinion, the last thing any new documentation process should do is take time away from the people whom desperately need our quality time OR to place a more unmanageable work load on those whom are trying to implement an exceptional standard of quality of care to those same people.

To Whom it May Concern:

My family and I have been providing Sponsor Home Services for the past 16+ years.  We have seen countless documentation changes and have gladly gone with it without comment or complaint.  However there comes a time when we feel we must interject our feelings on a proposed change. We provide the best services that we can possibly povide with the amount of paperwork that is already asked of us.  But there comes a time when YOU, the powers that be, need to decide if you want "quality of care" or "quanity of paperwork".  There have been countless changes and with each change we have to spend more and more time learning what exactly you want and how to make these changes work to the advantage of our Supported Individuals.  We urge you to take a step back and look at it from the frontlines.  Please use a commonsense approach before implementing more work for us to do.  Find a way to take paperwork off us and make the paperwork we do say what you need to be said. 

Respectfully,

Sharon Looney, Sponsor Home Provider, Stevie Looney, R.N., Amy Looney, M.A. (Guardian of Supported Individuals)

Thank you to the DBHDS staff members who drafted and sought public comments on this document.  The expectations contained in it will be familiar to those who have worked in the field and completed required documentation for some years.  The clarity and examples are appreciated.  Here are our requests:  To complete the process of clarifying ISP expectations, we ask that DBHDS create an ISP template.  The quarterly review template which DBHDS provided and made optional in April 2018 helped providers to understand the minimum amount of information required in the quarterly review.  The certainty of knowing that both DMAS as well as all Offices within DBHDS approved the quarterly review template allowed providers to implement it without fear of negative reviews by external regulatory bodies.  We request a similar template for the ISP - one which contains the minimum amount of information required, approved by all of DBHDS and DMAS.  On page 9 of the draft ISP guidance document, the last paragraph describes support instructions, noting, and data collection.  We also request a template for daily notes to accompany the ISP template.  We would like to have specific information about whether daily notes should be limited to data and other information about support activities related to ISP outcomes, or whether the daily notes must also contain information about general supports throughout the service period, to justify the hours/units billed under the ISP.  One Qlarant reviewer recommended that daily notes could be limited to documenting support activities, but without DBHDS approval of that approach we cannot use it.  In summary, we appreciate the quarterly review template provided and request that ISP and daily note templates be provided as well, and that they similarly include the minimum information required for documentation.  

Thank-you for the opportunity to provide comments. It would be helpful to include more examples of case management outcomes in your guidance documents and when training occurs on the new ISP's for  providers and case managers.