Community Integration Project Team
Community Integration Teams: Building “A Life of Possibilities for All Virginians”
The Virginia Department of Behavioral Health and Developmental Services has embraced moving from institutional practices of care for individuals living with intellectual disabilities (IDD) and has implemented strategies, supports, funding streams and policies that will support a community based system which is person centered and person directed. The Community Integration Project Team is tasked with developing and implementing a systematic process for assisting individuals and Authorized Representative’s (AR’s) with:
- Information related to options and resources for supporting individuals, families, authorized representatives and guardians.
- Choosing a home that ensures the health and safety of individuals,
- Guidance and support for individuals, AR’s and community providers during and following the move process.
To assist and guide this process, Community Integration Project Teams (CIPT) are available at each Training Center to work with leadership, Training Center staff, individuals, authorized representatives, Legal Guardians and families. The primary goals of the CIPT are to ensure:
- Individuals with IDD and their families are provided information and understand community options and services that are available to them in the Commonwealth of Virginia.
- Individuals with IDD and their representatives are provided with the support to make informed choices based on their interests, needs and resources.
- Individuals with IDD and their representatives are provided with information about employment opportunities, options for meaningful day activities- center based, non-center based and residential based- and their right to choose retirement.
- Training Center staff receives education and information related to the discharge process.
Introducing the CIP Team
- Community Integration Manager (CIM) – Manages Community Integration Project Team (CIPT) in conjunction with Central Office Leadership to coordinate the implementation of policies, procedures, regulations, and other initiatives related to ensuring individuals residing in Training Centers (TC) are served in the most integrated setting appropriate to their needs and desires.
- Discharge Quality Compliance Manager (DQCM)- Manages Community Integration Project Team in conjunction with the CIM and Central Office Leadership to provide guidance and education for the Personal Support Teams, ensures the completion of tasks required in the 12-week process and oversee the establishment of essential supports and addresses concerns.
- Community Services Director - Manages Community Services Department. In Conjunction with Community Integration Team, coordinates the implementation of policies, procedures, regulations, and other initiatives related to ensuring individuals residing in Training Centers (TC) are served in the most integrated setting appropriate to their needs and desires.
- Program Support Technician – Gathers, maintains and distributes individual discharge file information (electronic and hard copy) for timely distribution to providers, CSBs, ARs, and personal support teams. Supports CIM and DCM with special projects related to discharge process, i.e. Independent Reviews for compliance, Discharge Records Management, Birth Certificates and Social Security Card.
- CIPT Quality Manager – Implements quality review process for pertinent community integration documents to ensure consistency in common information and timely communication to chosen providers regarding essential supports. Supports TC with coordination of CIPT goals.
- Community Services Worker – Maintains regular contact with Authorized Representatives (AR) regarding individual well-being and community integration efforts. Supports the ARs and Community Service Board (CSB) Support Coordinators with choosing viable community options and scheduling tours. Educates ARs concerning CI process and related discharge topics.
- Discharge Coordinator –Manages all discharge planning and placement activities for individuals preparing to move to the community. Coordinates community integration efforts with CSB SCs to ensure transition to community living.
- Project Management/Training –Coordinates provider training with ancillary services and community providers. Ensures all individual discharge related trips are implemented as scheduled. Manages equipment loan agreements between TC and community providers.
- Service Coordinators – Facilitates individual annual and non-discharge special personal support team meetings. Develops individual discussion records and support plans in conjunction with PST members.
- Transition Service Coordinator– Facilitates individual pre-move personal support team meetings. Develops individual discharge plan and discussion record in conjunction with PST members. Ensures all components of the discharge plan are accurate and complete including the identification of essential supports and transition planning.
- Community Integration Clinician (Visit Coordination) – Coordinates individual discharge related trips and visits, ensuring medication, meals, equipment, transportation, and all aspects of individual health/safety/comfort is maintained. Provides demonstration of individual supports and ensures provider/individual interaction during provider visits. Assesses physical environment of potential homes and day supports.
- Provider Training – Ancillary staff (Rehab Services, Speech Pathology, Physical Therapy, Dietary, Psychology, and Nursing) offers general training and individual specific training to selected residential and day support providers. Offers demonstration, handouts, and question/answer sessions. Reviews provider environmental surveys and provides feedback ongoing.
- Post Move Monitoring Coordinator- Coordinates Post Move Monitoring activity to ensure assessments are conducted within 3, 10, and 17 days of individual’s move from the training center.
- Post Move Monitor – Conducts an assessment of the community provider’s implementation of individual essential supports through observation, provider interviews and documentation review. Communicates findings to CIM and CO partners for review and/or follow-up as needed.
- Direct Support Professionals-Participate as a member of the ID Team and assist the individual with tours, visits and assist in the completion of the assessment of the home and work environment. Provide demonstration and training to the potential providers.
The Twelve Week Process:
The 12-week process was developed to provide a safe and systematic strategy for moving individuals from a Training Center to community homes. While all of the steps must be completed, the length of the process can be adjusted as needed to meet the needs of the individual.
The 12 week process provides a guideline for ensuring every individual and family member is afforded with the opportunity to learn about the array of community options that are available to them in the Commonwealth. Additionally, The 12 Week process provides a set of guidelines and common goals for the many people who are involved in making this process work for and with the individual and family members. The Community Integration team starts in the facility and over the twelve weeks becomes a team made up of Community Service Board Service Coordinators, Providers, Employers, Office of Human Rights, Office of Licensing, Community based Medical teams, Family, friends and neighbors—it truly is a path to creating a “Good Life” for everyone involved, from start to finish.
A professional guardian is appointed by the courts, as needed for individuals with impaired decision making capacity. Capacity is defined as one’s ability to consent to treatment, services, or research; or authorize disclosure of information. DBHDS offers limited funding to assist individuals who meet certain criteria with obtaining a legal guardian. Once a legal guardian is appointed, the individual’s rights are limited and the appointed guardian is paid to act as a surrogate decision maker. Although DBHDS recognizes the need for this service amongst developmental disability populations, the program is considered a program of last resort and thus Individuals referred to this program should meet the following criteria:
DHBDS Guardianship Process:
Referrals should be made by the individual’s CSB Case Manager, or Training Center Community Integration Manager. To make a referral, please submit the guardianship referral form-10-1-2016, electronically to email@example.com. The most recent capacity evaluation must be submitted along with the referral. The referring party is responsible for updating any changes in the individual’s status, including death, restoration of capacity, changes in CSB, etc. using the guardianship change form 10-1-2016.
If you have additional questions please contact Carrie Ottoson: 804-774-4472/carrie.ottoson@DBHDS.Virginia.gov or Linda Bassett at linda.bassett@DBHDS.Virginia.gov
Effective June 1, 2017, Virginia has approved limited funding as a part of the plan to support individuals transitioning from a Training Center or other state facility according to the “Community Move Process” to a community home of their choice. Transitional funding, formerly known as “Bridge Funding,” can be used in a variety of ways to support the planning and move of these individuals to their own homes or to a provider home licensed by the DBHDS.
MFP Family Resource Consultants
Family Resource Consultants (FRCs) assist families/authorized representatives of individuals residing in various state and community facilities with resources to aid in the community integration process. FRCs work with families/ARs to address concerns, issues and explore possible resolutions to ensure the success of the community integration process. FRCs also support training center/facility staff, community providers, CSBs and personal support teams throughout the community integration process. Resources available through FRCs are: educational materials, informational sessions, attending meetings, accompanying families/ARs on tours, connecting families/ARs to volunteers that have loved ones living successful lives in community and providing ongoing support. Volunteers are available throughout the state to provide supports to families/ARs through our Family Mentor Network Program and Community Living Contacts Program. Peer mentors are also available to work with individuals in our training centers and individuals living in the community desiring more information on community based services.
More information on FRCs – FRC Resource Flyer
Family Mentor Network Program - Family Mentor Network Flyer
- volunteers are paired one-on-one with families/ARs
- volunteers provide support, guidance, and education in the form of face-to-face contacts, telephone calls, and emails
- volunteers provide ongoing support throughout transition process and after successful community placement
- volunteers commit to 5-8 hours per month
- volunteers attend a 2-3 hour orientation
Peer Mentor Program - Peer Mentor Brochure
- collaboration between DBHDS, The Arc of Virginia and Hope House Foundation
- peers attend a 12 month training course
- peers provide awareness and self-confidence to other individuals with ID/DD
- peers support individuals living in training centers and individuals currently living in the community
- program encourages individuals to strive for levels of greater independence and increase awareness of community resources
Community Living Contacts
- volunteers talk via telephone with various families
- volunteers share personal experience and success stories of community transitions for their loved ones
- typically limited to one or two contacts with various families/ARs
- great opportunity for families/ARs not desiring ongoing supports
New Beginnings Video
- highlights success stories of individuals that have transitioned into community living through MFP
Regional Information Sessions for Families/ARs FRC Session Flyer
- Overview of Money Follows the Person and ID Waiver
- Community Residential Options
- Resources (Family Mentor Network, Peer Mentor Program, Community Living Contacts)
- Individuals Seeking Community Services Providers Survey & Consent Form
- Knowing how to Access DBHDS Website
- Provider Selection Guide
- Transition/Discharge Process (12 wks)
- Everyone’s Role in the Process
Related Forms and Resources:
FRCs Contact Information:
Tonya Carr, B.S.
MFP Family Resource Consultant
DBHDS-Division of Developmental Services
Post Move Monitoring
B. Contact Information by Training Center
1. Central Virginia Training Center
a) Carla Scott CI Post Move Monitoring Coordinator
2. Northern Virginia Training Center
a) Lisa Lingat CI Post Move Monitoring Coordinator
3. Southeastern Virginia Training Center
a) Sarah Stansberry Community Integration Manager
4. Southwest Virginia Training Center
a) Mike Dorsey CI Post Move Monitoring Coordinator
D. Safety Alerts
1. Purpose of these documents –guidance on training staff