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Supportive Housing & Homeless Program – Goal Setting & Record Keeping

Jonda Clemings, MSEd, LSW

Reasons for Documentation

Clinical

• Planning & monitoring progress

• Documentation of accomplishments

• Quick access• Support staff work

Clinical

• Identify patterns• Continuity of service• History of crisis

situation/pattern

Compliance

• Monitoring• Regulatory requirements

Legal

• Behavior description• Data assessment &

treatment plan• Data for evaluation• Funding source

record• Justification for staff

action

Legal Aspects of Documentation

• Direct planning & coordination

• Response to services

• Team member communication

• Regulatory compliance

Legal Aspects of Documentation

• Necessity for services• Maximize reimbursement• Provide data for staff decisions• Legal record

Legal Parameters

• Confidentiality & privileged• Accuracy• Objectivity

Legal Parameters

Goal Setting

• Consumer centric

• Help reach goals

• Celebrate success

• Problem goal vs. problem person

• Inform choices

Goal Setting Skills

Goal Setting Skills

SMART Objectives

• Specific

• Measurable/observable

• Attainable within time & conditions

• Results-oriented

• Targeted to the identified need & impact

Targeted Objectives

Goals & Objectives

Identify various issues, functions, etc. that a person may need to set a goal/objective around to improve their housing stability. List as many of these as you can for each letter in the alphabet.

Bloom’s Taxonomy

Housing Services Plan

Intention

• What is it that you want to achieve?

Specific

• Who• What• Why• Where• When

Measurable

• How much?• How often?• How many?

Attainable

• Achievable?

Relevant

• Is it important to what you want to achieve ultimately?

Time Based

• When?

Sample Goal

• Goal: Housing search

• Objective: Submit application to MHA, apartment complex

• Target date: by May 15, 2014

Amy is a new participant in your homeless shelter. When asked about her housing goals, she tells you that she doesn't have any housing goals. Amy states that she has received Medicaid in the past, but is not currently receiving it. She has no other income/benefits at this time. Amy is not interested in working nor is she interested in signing up for Medicaid, SNAPS, other housing, etc. •Goals: •Objectives:

Bill has been residing in your rapid re-housing program for six months now. He became homeless due to a layoff at the plant and has been having much difficulty finding other employment with comparable pay. Initially, Bill was sad about the loss of his housing, however he was very good at following up on possible job leads. During the past couple of months, Bill has become cool and distant. He appears disinterested and indifferent about finding a job.Goal:Objective :

What Should We Document?• Functional limitations & abilities• Barriers that led to homelessness• Program adherence• General observation

Record Maintenance

• Locked• Organized• Sequential• Participant identification• No other consumer names• Individualized• Black/blue ink

Record Maintenance

• Avoid backdating• No blank spaces• Streamline charting• Follow agency policy• Sign entry with name & title/

credentials

Record Maintenance

• Specific• Don’t label, characterize, use

cliches• Use quotes• Approved abbreviations• Legible, grammatically

correct

Documentation Methods

• SOAP – Subjective, Objective, Assessment, & Plan

• DAP – Data, Assessment & Plan

Documenting Appearance

Documenting Mobility

Documenting Communication

Documenting Cognitive Functions

Building a Case FileWhat Should Be Included

Face Sheet

Identifying Information & Picture ID

• Drivers license• State ID• Birth certificate

Ohio State ID

Social Security Cards

Homeless Status

Chronic Homeless Status• Unaccompanied individual or

adult household member

• Disabling condition• Living on streets or emergency

shelter• 1 continuous year homeless or

4 episodes of homelessness in 3 years

Housing History

• Why moved• Type of housing• Difficulties

maintaining housing• Barriers• Housing needs

Disability Status

• Long-term, indefinite duration

• Impedes ability to live independently

• Disability could be improved with suitable housing

Disability Status

• Physical, mental or emotional impairment - including impairment solely due to alcohol or drug use

• Written documentation must come from credentialed professional

Disability Documentation

• 3rd Party Written Verification – Disability verification form by state licensed

professional

• Social Security Administration

• Receipt of disability check

• Oral third-party and self-certification is not appropriate

Consent Forms• Basic elements of consent• Informed choice• Overall experience• Voluntary participation

Educational & Vocational Assessment

• Abilities

• Interests• Personality

Employment History

• Gaps in employment• Positions held• Frequency of job changes• Skills• Strengths

Criminal Background

• Criminal history as it impacts housing & employment

Psychosocial Assessment

• Mood & affect• Cognitive functioning• Memory• Communication • Appearance• Mobility

Health Assessment

• Medications• Medication log• Allergies• Illnesses

Service Plan

• Goals/objectives while in program

• Drives service planning

Income Verification

• Amount of income• Sources of income• Proof of income

Incident Reports

• What happened

• When it happened• Others involved• Follow-up

Discharge Summaries

• Reason for discharge• Income sources• Income amounts• Destination• Progress made• Referrals made

Rent Reasonableness

Charting Legally Sensitive Situations

• Objectivity• Nonjudgmental

description• Accuracy• Completeness• Legibility• Justify actions taken

Dissatisfied Consumer• Utilize “quotes”• Don’t label - describe• History or crisis

patterns• Attempts to satisfy• Choices provided

made• Never characterize

Noncompliance

• How person refused to comply

• Failure to provide information

• Attempts to remedy• Review of procedures

Confidentiality

• HIPAA• Minimal access - need to know• Privileged communications

Peer Review

• Impartial review• Share expertise• Diversity of opinion• Provide

suggestions

Quality Monitoring

• Look at process and outcomes

• Drive improvement• Accountability• Refine service

delivery• Track integrity and

effectiveness

Coalition on Homelessness and Housing in OhioJonda Clemings

175 S. Third St. - Suite 250Columbus, Ohio 43215Phone 614-280-1984

Fax 614-463-1060www.cohhio.org

jondaclemings@cohhio.org