What is a PCA?

A personal care aide is a trained caregiver who provides non-medical assistance to patients right in the comfort of their own home. They provide a wide range of services, assisting the patient with many of their day-to-day activities around the home and in the community.

What services do PCAs provide?

PCAs provide many of the necessary services to help our patients continue living a full and meaningful life. PCAs work with physically disabled, mentally challenged, and elderly patients as their personal care assistant. They will help them get in and out of bed, assist with getting dressed, bathing, grooming, meal preparation. Below is a list of much of the responsibilities our caregivers assist our patients with.

  • Personal hygiene
  • Bathing
  • Dressing
  • Feeding
  • Toileting
  • Shopping
  • Laundry
  • Escort to appointments
  • Accompany to medical appointments
  • Light housekeeping
  • Meal planning

We understand losing some of the life’s basic functionalities can be challenging. We also understand that asking or accepting help can be difficult in itself. We, therefore assure our clients, that all our PCAs are trained to provide the highest level of care while remaining sensitive to the needs and feelings of our patients. We ensure that our caregivers are providing the best possible care, by running frequent evaluations on all our staff.

What is a Home Health Aide?

Home Health Aides are trained and certified caregivers who provide in-home care and assistance to patients and able-challenged individuals. They provide assistance with day-to-day activities including bathing, dressing, cleaning, communication, and mobility, as well as other non-medical services. Unlike personal companions, HHAs are given extensive training in providing care to elderly patients.

What services do HHAs provide?

Home Health Aides are trained and certified to provide many forms of assistance to allow the individual receiving care to live a more meaningful and productive lifestyle. Being around to assist the client with many of the daily tasks and responsibilities creates a peace of mind for the client to be able to focus on recovering and returning to their fully capable self. While the HHA does not provide any medical assistance, they do provide assistance with many of the daily activities that the client may struggle with.

Below is a list of some of the different services provided by our Home Health Aides:

  • Personal hygiene
  • Bathing
  • Dressing
  • Feeding
  • Toileting
  • Laundry
  • Exercise
  • Light housekeeping
  • Accompany to medical appointments
  • Performing simple measurement and tests
  • Assisting with preparation of complex modified diets
  • Assisting with a prescribed exercise program
  • Assisting with the use of prescribed medical equipment, supplies, and devices
  • Assisting with special skin care
  • Assisting with a dressing change

What is Companion Care?

Companion Care (also referred to Personal Care Aide) provides emotional support and companionship for seniors who are generally healthy and who want to remain independent and live in their own home. It may also include a range of non-medical services that help make a senior’s life more manageable.

At its core, Companion Care offers true companionship. The senior enjoys sharing experiences and personal stories as well as day-to-day activities. This relationship can be an important one for seniors who live alone or are otherwise isolated from others.

Research shows seniors who engage in conversation and play games (checkers, Scrabble, among others) with a companion show improved mental acuity.

What services do Companion Care Aides provide?

  • Medication reminders
  • Assist with daily routines such as getting out of bed and getting in and out of the car
  • Light housekeeping duties
  • Prepare meals
  • Assist with bill paying and banking
  • Provide transportation to the store, doctor’s appointments and other general errands
  • Help with planning, scheduling and keeping appointments
  • Encourage and coordinate social activities such as movies, shopping, local sightseeing trips, visits to family and friends, the library and other activities that help the client enjoy life
  • Manage daily exercise routines such as walks in the neighborhood, swimming at the local pool, and other activities the senior enjoys.
  • Encourage the senior stays active with hobbies and games
    Interact with the senior’s family members to keep them abreast of their loved one’s condition.

Our Registered Nurses (RN)

Self-Direct’s RNs are licensed and certified in New York State, and provide the highest level of Home Care Services including:

  • Provide a complete assessment of each client’s individual needs
  • Develop and monitor the care plan
  • Medication Management
  • Provides nursing services within the client’s home
  • Perform regular assessments of functionality and home safety

Licensed Practical Nurse (LPN)

Self-Direct’s LPNs are licensed in New York State and assist the RN’s in the following services:

  • Medication management
  • Supervision of the attending Home Health and Personal Care Aides
  • And much more

Our Nursing staff is mindful of the patient’s unique personality and circumstances. And, our nurses are all respectful of their patient’s human dignity and freedom of choice.

Self-Direct’s Respite Services is an individually designed service that provides relief to family members, friends and other (informal) non-paid individuals who provide primary care and support to a waiver participant. Respite Services are typically provided to participants who are in need of general patient oversight and supervision as a discrete task. The primary location for the provision of this service is in the waiver participant’s home. Respite Services are provided in 24-hour blocks of time.

Home and Community-Based Services Medicaid Waiver for Individuals with Traumatic Brain Injury

The Home and Community-Based Services Medicaid Waiver for Individuals with Traumatic Brain Injury (HCBS/TBI) is one component of a comprehensive strategy developed by the NYS Department of Health. In brief, New Yorkers suffering with a traumatic brain injury are eligible to receive services within New York in the least restrictive setting available.

Philosophy

The HCBS/TBI Medicaid Waiver is based on the philosophy that:

  • An individual with a TBI has the same right to be in control of his or her life as anyone else in our society.
  • An individual with a TBI must be able to choose where he or she wants to live, with whom he or she will live, and who will provide any needed services.
  • The individual with a TBI has the right to learn as a member of society, by encountering and managing risks, and through experience learn from related failures.

Referral Process

  • Self-Direct will forward referral inquiries to the appropriate Regional Resource Development Center
  • RRDC will set appointments with individual seeking service and/or family (if desired) to assess eligibility based on medical documentation of the given disability(ies) and the anticipated level of care required
  • Self-Direct provides the individual and/or family a list of provider agencies to interview for services
  • Provider agency or agencies for the desired service(s) are selected by the individual and/or family
  • Agency’s Service Coordinator develops the Initial Service Plan (ISP)
  • Agency sends a nurse to complete necessary evaluations used to determine the individual’s level of need
  • Nurse works with family and individual to develop a plan of care
  • During the ISP development process, the Service Coordinator interviews the participant and any family to select the appropriate/desired program supports, as well as review all other available community supports
  • Agency submits the ISP for review by the RRDC for approval and authorization
  • Upon approval of ISP, the Agency will begin services with the participant

The entire process, from selection of Service Coordinator to very first day of service, typically ranges from 30 and 60 days. The timeframe depends on how quickly medical and supporting documentation is obtained, appropriate housing is located (if it is needed and if the location requested is available), and the availability of the individual and family to provide their due diligence during the ISP information gathering process.

What To Expect

  • Agency’s Schedulers work with the individual and family to adjust the service schedules as needed
  • When services begin, the nurse introduces the staff and provides training on the plan of care in the home
  • Agency care team reviews the progress of the participant on a weekly basis during team meetings and recommends solutions to any challenges or adjustments to services as necessary
  • Service Coordinator and Nurse facilitate ongoing communication with family and medical providers as requested as is necessary
  • Service Coordinator provides an updated plan of care to the RRDC for the review process every 180 days. (Agency and RRDS certification of continued need every 180 days is a NYS mandated requirement of the program)

TBI Waiver services offered:

Self-Direct believes that the overall success of an individual within this program is person-centered coordination allowing for personal choice and achievement. With this in mind, our Service Coordinators:

  • Coordinate all community based services
  • Coordinate and monitor the provision of all services
  • Organize the daily living supports and services
  • Support the participant’s independence and integration into the community
  • Maintain the health and welfare of the participant

The Self-Direct Service Coordinator works with our nurses to develop the participant’s Initial Service Plan (ISP) and will make sure that all the Waiver Services are accomplishing the participant’s goals and needs.

The ISP serves as both the authorization for services under the Waiver, as well as an individual plan for care within the community.

Over time, the Service Coordinator adjusts the services to meet new challenges or changes in needs, and regularly complete a revised service plan (RSP). The RSP authorizes continued services from the Waiver.

The participant (and the participant’s care givers) work directly with the Service Coordinator on an ongoing basis. This helps our Service Coordinators identify the services that help your loved one achieve their goals and meet their day-to-day and longterm needs.

Self-Direct is dedicated to assuring that your loved one is at the center of their individual care plan. This proven approach helps preserve your loved one’s independence and helps them achieve their individual goals.

Additionally, the Self-Direct Service Coordinator is responsible for:

  • The development and management of the TBI Service Plan and updating it every 180 days as required by NYS. (The service plan is the request by the “participant” for approval from NYS to be provided the Waiver services in the plan each 180 day period.)
  • Overseeing all the waiver services, ensuring the goals of each service (ILST, CIC, PBIS, HCSS) are being met and
  • Working closely with the RN when there is HCSS (personal care services) in place. (These coordinated services work to provide all the collaborative supports necessary for helping a participant remain safe and independent in their community.)
  • Linking the Waiver participant with any additional services such as:
    • HEAP, mental health counseling, legal housing subsidies
    • Alcohol or Substance abuse services
    • Help locating an apartment
    • Working with attorneys for setting up/managing Special Needs Trusts
  • Ensuring all entitlements are kept current and (re)applied for on a yearly basis, such as HEAP, Housing, Medicaid, Food Stamps or Prescription Plans (Medicare Part D if necessary).
  • Ensuring any Excess Income (anything over and above the Medicaid monthly income limits) is paid to the Special Needs Trust or the county as a spend-down to ensure continuation of Medicaid. (This is a very important responsibility. If this is not managed correctly, the Waiver participant may lose his or her Medicaid eligibility. This will put all Wavier services at risk, or even the ability to obtain prescriptions. This is  VERY important for Waiver participants who have income beyond Social Security such as a pension, or in combination with Social Security Disability.

The Waiver is designed to provide as much independence at home and in the community as possible. Home and Community Support Services (HCSS) are the support services that enable the participants to remain healthy, safe and manage their daily tasks and activities. These services provide supervision, prompting and cueing at home and in the community.

  • Activities of Daily Living (ADL’s)
  • Independent Activities of Daily Living (IADL’s)
    • Supporting Integration into the Community
    • Medication Reminders
    • Bathing and daily personal hygiene tasks
    • Laundry and dressing
    • Meal planning and preparation
    • Light and Heavy Household Tasks

HCSS is in place to promote as much independence in these activities as possible. For Waiver participants that are able to complete tasks on their own, HCSS is there to monitor and provide a prompt to complete the tasks as necessary (and to provide only as much assistance as needed for any given task’s completion).

HCSS will complete any tasks that the participant is unable to complete in their entirety (with the exception of administering medication).

Self-Direct’s HCSS staff follow a plan of care developed by our Nurse (RN) in conjunction with the Waiver participant’s doctor. The doctor is required to be notified and sign off on any changes to the plan of care resulting from changes in needs, the prescriptions, or even the reduction of family supports.

HCSS staff maintain a daily log that is reviewed our nursing staff for any indications of changes in health status. The RN and the participant’s doctor will follow up on all concerns noted by the HCSS.

Home and Community Support Services are scheduled around the participant’s needs, and scheduling can be provided in blocks of hours through out the day and night or throughout the entire (24-hour) day.

This program provides Independent Living Skills Training and Development (ILST).

The Self-Direct Structured Day Program provides assistance, training, and supervision to individuals with varying abilities related to:

  • Self-Care
  • Medication Management
  • Communication Skills
  • Task Completion
  • Problem-Solving Skills
  • Interpersonal Skills
  • Sensory/Motor Skills
  • Socialization
  • Community Transportation Skills
  • Mobility
  • Challenging Behaviors
  • Financial Management

Individually designed services are coordinated to help participants maintain the skills and abilities to live as independently as possible in their community.

The philosophy of the Waiver ensures that participants:

  • Live as independent as possible
  • That they do all they can for themselves, and apply themselves to re-learn any skills that may have been lost as result of an injury.

Independent Living Skills Training is intended to be a teaching service. It also intended to create a routine of physical and mental activity for the participant with the goal of increasing or preserving overall mental and physical health.

Self-Direct provides skills assessments, as well as a staff of professionals to provide the teaching and training of important life skill areas including:

  • Independent self-care
  • Establishing systems that ensure any medications are taken correctly and on time
  • Developing appropriate communication skills
  • Scheduling and keeping appointments
  • Planning for and utilizing of community transportation
  • Implementing any plans developed by the PBIS service that address any impulsive behaviors, or communication issues
  • Money management including budgeting, bill paying and records keeping
  • General household maintenance
  • Responsibilities associated with going back to school or finding paid/volunteer work

The philosophy of the Waiver ensures that participants remain as independent as possible. Its goal is to ensure that they that they do all that they can for themselves on a day-to-day basis. Furthermore, it provides a framework for participants to apply themselves to new situations and re-learn any skills that may have been lost as result of the injury.

Independent Living Skills Training is a teaching service. It also helps to develop routines for the participant that increases or preserves overall mental and physical health.

Self-Direct provides the staff to perform the skills assessments, as well as provide the instruction, strategies and training of important life skill areas including:

  • Independence in self-care
  • Developing systems for taking medications properly and on time
  • Appropriate communication skills
  • Scheduling and keeping appointments
  • Scheduling and utilizing community transportation
  • General household maintenance
  • Money management including budgeting, setting up budgets and systems for managing and paying bills, record keeping
  • Returning to school, vocational training or finding paid or volunteer work
  • Implementing any plans developed by the PBIS service that address impulsive behaviors and or verbal outbursts

Positive Behavioral Intervention and Supports (PBIS) are incorporated into a Waiver participant’s service plan when he or she would like to work on impulsive behaviors that developed since his or her injury. These behaviors may include verbal outbursts or other behaviors that work against the participant in meeting the goals of his or her service plan and/or even hinder the participant’s ability to remain living independently in the community.

The PBIS staff works with the participant to identify any such behaviors, and develop a behavior support plan of  “interventions”. These interventions are designed to help a participant identify when these behaviors are prone to display.

PBIS staff will also work with the participant to put together a plan of action to deal with them as they occur. The goal of any such plan is to eliminate/decrease the frequency of the behaviors, and/or their severity. The end result is the participant’s ability to work on achieving their goals by managing counter productive behaviors, and improving the communication with people in the community, the participant’s staff, and family caregivers.

Self-Direct provides the assessment of these counter-productive behaviors, develops a plan of action to deal with them, and works with the participant, family, and staff to ensure the plan is followed.

The PBIS plan consists of a comprehensive assessment of the behavior(s) and the “Behavioral Intervention and Support Plan (BISP)” is outlined. The BISP is designed to exchange negative behaviors for other, more benign socially-appropriate behaviors.

The BISP also provides methods that the Waiver participant can use to elimination impulsive behaviors, ensure consistent implementation of the plan, and the on-going training and supervision of the people who are instrumental to the participant’s total plan of care and goals for independence.

PBIS helps to improve the following:

  • Improve communication and avoid conflict by reducing verbal outbursts
  • Identify what prompts these counter productive behaviors
  • Developing skills to avoid and manage any such outbursts
  • Identifying impulsive behaviors and developing skills to manage them

Community Integration Counseling (CIC) is an individualized service designed to assist the Waiver participant in working through the emotional difficulties and stresses of living in the community after adjusting to life with brain injury.

It is available to both Waiver participant, their family other non-paid caregivers as they, too, are adjusting to a new role and set of responsibilities. Its purpose is to provide a forum for discussing and providing an outlet for dealing with change. It is intended to providing new perspectives, and developing appropriate goals and outcomes.

This service also helps the participant and their family members understand what each side of the caregiving equation means.

The ultimate goals of this service include helping foster increased positive communications between the family members and the participant, as well as improving participant’s self-esteem or countering a negative self-image.

CIC helps to improve the following:

  • Provide emotional support to the participant’s family members (or any non-paid person providing care) as it relates to the stresses associated with providing care to the participant
  • Improve the Waiver participant’s family (and other supporters) understanding of the nature of the participant’s disability(ies)
  • Provide counseling to the Waiver participant’s family (and other supporters) manage or relate to their possible feelings of helplessness, sense of loss of previous abilities, changes in social-life, adapting to role changes, the managing of the challenges of cognitive difficulties

Assistive Technology Services supplements the State Plan Medicaid Service for Durable Medical Equipment and Personal Emergency Response System/Medical Alert System. The Medicaid State Plan and all other resources must be utilized before considering Assistive Technology Services. This service will only be approved when the requested equipment and supplies directly contribute to the participant’s level of independence, ability to access needed supports and services in the community or maintain or improve the participant’s safety.

Home and Community-Based Services Medicaid Waiver for Nursing Home Transition and Diversion

The Home and Community-Based Services (HCBS) Medicaid Waiver for Nursing Home Transition and Diversion (NHTD) is one of the options available to New Yorkers with disabilities and seniors so they may receive services in the most appropriate, least restrictive setting. This summary provides a general overview of the NHTD waiver. This waiver may help people leave a nursing home (Transition) or remain in the community (Diversion).

Philosophy

The NHTD Medicaid waiver was developed based on the philosophy that individuals with disabilities and/or seniors have the same rights as others to:

  • Be in control of their lives.
  • Encounter and manage risks and learn from their experiences.

To be eligible for the NHTD Waiver a person must:

  • Capable of living in the community with needed assistance from available informal supports
  • Medicaid State Plan services and be in need of one or more waiver service
  • Eligible for nursing home level of care
  • Authorized to receive Medicaid Community Based Long Term Care
  • 18 years of age or older
  • Choose to live in the community as a participant in this waiver rather than in a nursing home

Referral Process

  • Self-Direct will forward referral inquiries to the appropriate region’s Regional Resource Development Center
  • RRDC will set appointment with individual and/or family (if desired) to assess eligibility based on medical documentation of disability and anticipated level of care
  • Individual and/or family is provided a list of provider agencies to interview for services
  • Individual selects a provider agency or agencies for the desired service(s)
  • Agency’s Service Coordinator develops an Initial Service Plan (ISP)
  • Agency sends a nurse to complete an evaluation to determine the level of needs
  • Nurse works with family and individual to develop a plan of care and assess the number of hours
  • During the ISP development process, the Service Coordinator interviews the participant and any family to select the appropriate/desired program supports, as well as review all other available community supports
  • Agency submits the ISP for review by the RRDC and for approval/authorization
  • Upon approval of ISP, the Agency will begin services with the participant

The process from selection of Service Coordinator to first day of service generally takes between 30 and 60 days, depending on how quickly medical and supporting documentation can be obtained, housing is located (if needed and if available in the location requested), and the availability of the individual and family to provide their time during the ISP information gathering process.

What To Expect

  • Agency’s Schedulers work with the individual and family to adjust the service schedule as needed
  • When services begin, the nurse introduces the staff and provides training on the plan of care in the home
  • Agency care team reviews the progress of the participant on a weekly basis during team meetings and recommends solutions to any challenges or adjustments to services as necessary
  • Service Coordinator and Nurse facilitate ongoing communication with family and medical providers as requested/necessary
  • Service Coordinator provides an updated plan of care to the RRDC for the review process every 180 days. Agency and RRDS certification of continued need every 180 days is a requirement of the program

Self-Direct believes that the overall success of an individual within this program is person-centered coordination allowing for personal choice and achievement. With this in mind, our Service Coordinators:

  • Coordinate all community based services
  • Coordinate and monitor the provision of all services
  • Organize the daily living supports and services
  • Support the participant’s independence and integration into the community
  • Maintain the health and welfare of the participant

The Self-Direct Service Coordinator works with our nurses to develop the participant’s Initial Service Plan (ISP) and will make sure that all the Waiver Services are accomplishing the participant’s goals and needs.

The ISP serves as both the authorization for services under the Waiver, as well as an individual plan for care within the community.

Over time, the Service Coordinator adjusts the services to meet new challenges or changes in needs, and regularly complete a revised service plan (RSP). The RSP authorizes continued services from the Waiver.

The participant (and the participant’s care givers) work directly with the Service Coordinator on an ongoing basis. This helps our Service Coordinators identify the services that help your loved one achieve their goals and meet their day-to-day and longterm needs.

Self-Direct is dedicated to assuring that your loved one is at the center of their individual care plan. This proven approach helps preserve your loved one’s independence and helps them achieve their individual goals.

Additionally, the Self-Direct Service Coordinator is responsible for:

  • The development and management of the TBI Service Plan and updating it every 180 days as required by NYS. (The service plan is the request by the “participant” for approval from NYS to be provided the Waiver services in the plan each 180 day period.)
  • Overseeing all the waiver services, ensuring the goals of each service (ILST, CIC, PBIS, HCSS) are being met and
  • Working closely with the RN when there is HCSS (personal care services) in place. (These coordinated services work to provide all the collaborative supports necessary for helping a participant remain safe and independent in their community.)
  • Linking the Waiver participant with any additional services such as:
    • HEAP, mental health counseling, legal housing subsidies
    • Alcohol or Substance abuse services
    • Help locating an apartment
    • Working with attorneys for setting up/managing Special Needs Trusts
  • Ensuring all entitlements are kept current and (re)applied for on a yearly basis, such as HEAP, Housing, Medicaid, Food Stamps or Prescription Plans (Medicare Part D if necessary).
  • Ensuring any Excess Income (anything over and above the Medicaid monthly income limits) is paid to the Special Needs Trust or the county as a spend-down to ensure continuation of Medicaid. (This is a very important responsibility. If this is not managed correctly, the Waiver participant may lose his or her Medicaid eligibility. This will put all Wavier services at risk, or even the ability to obtain prescriptions. This is  VERY important for Waiver participants who have income beyond Social Security such as a pension, or in combination with Social Security Disability.

The Waiver is designed to provide as much independence at home and in the community as possible. Home and Community Support Services (HCSS) are the support services that enable the participants to remain healthy, safe and manage their daily tasks and activities. These services provide supervision, prompting and cueing at home and in the community.

  • Activities of Daily Living (ADL’s)
  • Independent Activities of Daily Living (IADL’s)
    • Supporting Integration into the Community
    • Medication Reminders
    • Bathing and daily personal hygiene tasks
    • Laundry and dressing
    • Meal planning and preparation
    • Light and Heavy Household Tasks

HCSS is in place to promote as much independence in these activities as possible. For Waiver participants that are able to complete tasks on their own, HCSS is there to monitor and provide a prompt to complete the tasks as necessary (and to provide only as much assistance as needed for any given task’s completion).

HCSS will complete any tasks that the participant is unable to complete in their entirety (with the exception of administering medication).

Self-Direct’s HCSS staff follow a plan of care developed by our Nurse (RN) in conjunction with the Waiver participant’s doctor. The doctor is required to be notified and sign off on any changes to the plan of care resulting from changes in needs, the prescriptions, or even the reduction of family supports.

HCSS staff maintain a daily log that is reviewed our nursing staff for any indications of changes in health status. The RN and the participant’s doctor will follow up on all concerns noted by the HCSS.

Home and Community Support Services are scheduled around the participant’s needs, and scheduling can be provided in blocks of hours through out the day and night or throughout the entire (24-hour) day.

This program provides Independent Living Skills Training and Development (ILST).

The Self-Direct Structured Day Program provides assistance, training, and supervision to individuals with varying abilities related to:

  • Self-Care
  • Medication Management
  • Communication Skills
  • Task Completion
  • Problem-Solving Skills
  • Interpersonal Skills
  • Sensory/Motor Skills
  • Socialization
  • Community Transportation Skills
  • Mobility
  • Challenging Behaviors
  • Financial Management

Individually designed services are coordinated to help participants maintain the skills and abilities to live as independently as possible in their community.

The philosophy of the Waiver ensures that participants:

  • Live as independent as possible
  • That they do all they can for themselves, and apply themselves to re-learn any skills that may have been lost as result of an injury.

Independent Living Skills Training is intended to be a teaching service. It also intended to create a routine of physical and mental activity for the participant with the goal of increasing or preserving overall mental and physical health.

Self-Direct provides skills assessments, as well as a staff of professionals to provide the teaching and training of important life skill areas including:

  • Independent self-care
  • Establishing systems that ensure any medications are taken correctly and on time
  • Developing appropriate communication skills
  • Scheduling and keeping appointments
  • Planning for and utilizing of community transportation
  • Implementing any plans developed by the PBIS service that address any impulsive behaviors, or communication issues
  • Money management including budgeting, bill paying and records keeping
  • General household maintenance
  • Responsibilities associated with going back to school or finding paid/volunteer work

The philosophy of the Waiver ensures that participants remain as independent as possible. Its goal is to ensure that they that they do all that they can for themselves on a day-to-day basis. Furthermore, it provides a framework for participants to apply themselves to new situations and re-learn any skills that may have been lost as result of the injury.

Independent Living Skills Training is a teaching service. It also helps to develop routines for the participant that increases or preserves overall mental and physical health.

Self-Direct provides the staff to perform the skills assessments, as well as provide the instruction, strategies and training of important life skill areas including:

  • Independence in self-care
  • Developing systems for taking medications properly and on time
  • Appropriate communication skills
  • Scheduling and keeping appointments
  • Scheduling and utilizing community transportation
  • General household maintenance
  • Money management including budgeting, setting up budgets and systems for managing and paying bills, record keeping
  • Returning to school, vocational training or finding paid or volunteer work
  • Implementing any plans developed by the PBIS service that address impulsive behaviors and or verbal outbursts

Positive Behavioral Intervention and Supports (PBIS) are incorporated into a Waiver participant’s service plan when he or she would like to work on impulsive behaviors that developed since his or her injury. These behaviors may include verbal outbursts or other behaviors that work against the participant in meeting the goals of his or her service plan and/or even hinder the participant’s ability to remain living independently in the community.

The PBIS staff works with the participant to identify any such behaviors, and develop a behavior support plan of  “interventions”. These interventions are designed to help a participant identify when these behaviors are prone to display.

PBIS staff will also work with the participant to put together a plan of action to deal with them as they occur. The goal of any such plan is to eliminate/decrease the frequency of the behaviors, and/or their severity. The end result is the participant’s ability to work on achieving their goals by managing counter productive behaviors, and improving the communication with people in the community, the participant’s staff, and family caregivers.

Self-Direct provides the assessment of these counter-productive behaviors, develops a plan of action to deal with them, and works with the participant, family, and staff to ensure the plan is followed.

The PBIS plan consists of a comprehensive assessment of the behavior(s) and the “Behavioral Intervention and Support Plan (BISP)” is outlined. The BISP is designed to exchange negative behaviors for other, more benign socially-appropriate behaviors.

The BISP also provides methods that the Waiver participant can use to elimination impulsive behaviors, ensure consistent implementation of the plan, and the on-going training and supervision of the people who are instrumental to the participant’s total plan of care and goals for independence.

PBIS helps to improve the following:

  • Improve communication and avoid conflict by reducing verbal outbursts
  • Identify what prompts these counter productive behaviors
  • Developing skills to avoid and manage any such outbursts
  • Identifying impulsive behaviors and developing skills to manage them

Community Integration Counseling (CIC) is an individualized service designed to assist the Waiver participant in working through the emotional difficulties and stresses of living in the community after adjusting to life with brain injury.

It is available to both Waiver participant, their family other non-paid caregivers as they, too, are adjusting to a new role and set of responsibilities. Its purpose is to provide a forum for discussing and providing an outlet for dealing with change. It is intended to providing new perspectives, and developing appropriate goals and outcomes.

This service also helps the participant and their family members understand what each side of the caregiving equation means.

The ultimate goals of this service include helping foster increased positive communications between the family members and the participant, as well as improving participant’s self-esteem or countering a negative self-image.

CIC helps to improve the following:

  • Provide emotional support to the participant’s family members (or any non-paid person providing care) as it relates to the stresses associated with providing care to the participant
  • Improve the Waiver participant’s family (and other supporters) understanding of the nature of the participant’s disability(ies)
  • Provide counseling to the Waiver participant’s family (and other supporters) manage or relate to their possible feelings of helplessness, sense of loss of previous abilities, changes in social-life, adapting to role changes, the managing of the challenges of cognitive difficulties

Assistive Technology Services supplements the State Plan Medicaid Service for Durable Medical Equipment and Personal Emergency Response System/Medical Alert System. The Medicaid State Plan and all other resources must be utilized before considering Assistive Technology Services. This service will only be approved when the requested equipment and supplies directly contribute to the participant’s level of independence, ability to access needed supports and services in the community or maintain or improve the participant’s safety.

Respite Services is an individually designed service intended to provide relief to natural (informal), nonpaid supports who provide primary care and support to a waiver participant. This is usually provided for participants who are in need of oversight and supervision as a discrete task. The primary location for the provision of this service is in the waiver participant’s home. Respite Services are provided in a 24-hour block of time.

Self-Direct Your Own Care

The Consumer Directed Personal Assistance Program (CDPAP) allows consumers to self-direct their in-home care by providing them the control to interview, hire, train, terminate, and schedule their own caregivers. They can schedule weekly hours on a flexible day-to-day basis, rather than following a daily schedule of hours set by a third party. Under CDPAP, people with long-standing illnesses or disabilities have much greater control and freedom over their own care than under traditional home care services.

The definition of a self-directing consumer is “a consumer who is capable of making choices regarding the consumer’s activities of daily living and the type, quality and management of his or her consumer directed personal assistance; understands the impact of these choices; and assumes responsibility for the results of these choices.”  (10 NYCRR 505.28(b)(9))

Hire a Caregiver of Your Choice

Consumers have the freedom to hire almost any caregiver or personal assistant they would like, except for spouses and the designated representative. CDPAP helps to eliminate potential stress from strangers in the home or language/cultural barrier issues, by allowing them to hire friends or loved ones; such as siblings, trusted neighbors, in-laws, nieces, nephews or a friend.

What can a Personal Assistant do?

A personal assistant can provide any of the services typically provided by a nurse, home health aide, or personal care aide. Below are examples of tasks that may be completed by a personal assistant.

  • Dressing
  • Bathing
  • Dispensing and Administering Medications
  • Meal Preparation
  • Assistance with Eating
  • Toileting
  • Oxygen Administration
  • Transferring
  • Insulin Injections
  • Transportation
  • Tracheostomy Care

How do I Get Started?

To be eligible for CDPAP, an individual must:

  • Be Medicaid eligible
  • Be eligible for home care services, personal care services, or private duty nursing
  • Have a stable medical condition
  • Willing and able to recruit, hire, train, supervise and terminate their own personal assistants
  • Be self-directing or have a designated representative who is willing and competent to assume the roles and responsibilities of the program.

If an individual is Medicaid eligible, they should contact his/her Medicaid Managed Care (MMC), Managed Long Term Care (MLTC) insurance plans, or county Department of Social Services (DSS). Once evaluated by a nurse and approved for the program, the individual will select a Fiscal Intermediary (FI).

Click here to view a directory of Managed Long Term Care Plans in NYS and a list of the Local Departments of Social Services.

What is Self-Direct, Inc.’s Role?

Self-Direct, Inc. is the Fiscal Intermediary and is responsible for processing all administrative tasks such as collecting paperwork, payroll, benefits and supporting consumers. Once an individual is approved for CDPAP services, they must select a Fiscal Intermediary (FI). If an individual chooses Self-Direct as their FI, their insurance plan will send the referral to Self-Direct, who will then contact the individual directly to enroll them and their Personal Assistants in the program.

Self-Direct, Inc. is a member of the Consumer Directed Personal Assistance Association of New York State (CDPAANYS). The Consumer Directed Personal Assistance Association of New York State supports consumer directed personal assistance providers and recipients in all counties of New York State, offering supportive services, including, but not limited to: advocacy, systems change, and the promotion of consumer control and self-determination. Click here for more information about CDPAANYS.

Click here to learn more about the NYS CDPA Program or call Self-Direct at 315-635-5374 ext. 301 to speak to our CDPAP Coordinator.