What does it mean/look like to “build rapport/relationship” with LifeNet Adults in Year 1 (the ‘Relationship Year’)?
Team members will build rapport and the relationship with a LifeNet adult in a number of clinically-informed ways including (but not limited to): engaging in discussion and sharing of activities that are personally interesting to the adult; getting to know/observing daily/weekly/monthly routines and structures; building trust and consistency in the meeting schedule; providing support and validation related to the central challenges in the adult’s life; building appreciation for an adult’s capabilities, strengths, and resiliency; empowering the adult as the “expert” in their own life to set priorities for support; building understanding into the priorities that the adult has identified (even if those priorities may be different from other team members’ priorities for the adult).
What is the difference between a Personal Advocate (PA) and Support Partner (SP)? Therapist and case manager? Friend and LifeNet team member?
PA and SP: A Personal Advocate (PA) is a clinician with education, training, and experience in a field like occupational therapy, mental health counseling, or social work – at LifeNet a PA leads the coordination between themselves and the SP to provide team-based support to clients. They tend to provide remote check-ins with clients, lead team meetings, and have collaborative conversations with other providers. A Support Partner (SP) is a direct care professional with experience and training working 1:1 with clients in their homes and communities – at LifeNet a SP works closely with the PA and LifeNet Adult to carry out activities in person with the client during longer visits. They participate in team meetings and contribute ideas for client support regularly.
Therapist and case manager: Therapists are clinicians that work with clients on individualized mental health goals while a case manager is a clinician that might help a client connect with a therapist and/or carry out some of the suggestions that a therapist makes. Therapists tend to focus on developing individualized treatment plans to support a client’s mental health or other specific goals. At LifeNet, a Case Manager/Personal Advocate is actively interested in working with clients on their day to day responsibilities, connecting them with additional specialized supports, and collaborating with other team members.
Friend and LifeNet team member: A friend is a fellow community member with whom one has a relationship because of willingness to mutually get to know each other, mutually support each other, and/or mutually share interests with. A LifeNet team member or employee is a paid professional with whom one has a relationship with because of mutual agreement that the client will receive services and support from the provider.
How do LifeNet team members communicate with each other for the benefit of the LifeNet Adult?
Personal Advocates (PAs) and Support Partners (SPs) meet regularly in 1:1 meetings (usually weekly) to discuss updates, observations, concerns, and recommendations regarding how LifeNet is and can be a support and advocate.
Who else is on the larger LifeNet team, beyond Personal Advocates (PAs) and Support Partners (SPs)?
Each LifeNet adult’s case is overseen by a Clinical Supervisor, who supports the primary PA and sometimes the primary SP. Additionally, all front-line staff and leadership in the LifeNet department engage in case consultations about each adult, to provide a forum for support and brainstorming to the primary team for best practices and support ideas. All front-line staff have access to relevant records in the event of the need for an on-call intervention.
What is the Clinical Supervisor’s (CS) role?
The Clinical Supervisor is an independently licensed professional who directs the clinical aspects of the program. The CS provides weekly and as needed supervision to frontline staff to develop optimal engagement and motivation, guide ongoing education, and provide support. The CS also guides the clinical eligibility screening for new clients to ensure goodness of fit, often collaborating with existing providers and other team members during that process. The CS provides ad hoc consultation and support to clients directly from time to time and provides clinical consultation to staff during crises.
What happens when members of my LifeNet team have time off?
When staff are on vacation or have other time off, PA check-ins or SP visits may be canceled, rescheduled, shortened, and/or covered by another team member – this depends on staff availability, client preference, and client need. The LifeNet team will communicate changes ahead of time when possible (i.e., for scheduled vacation days or closed AANE holidays). We appreciate your understanding and flexibility with scheduling to allow our staff time to rest and recharge in order to best support you!
What happens when LifeNet Adults do not attend their scheduled meetings or need to reschedule?
Rescheduling requests are welcomed when needed and are subject to staffing availability. We aim to be flexible and make every effort to meet at the frequency intended but cannot 100% guarantee accommodation of reschedule requests, especially when made with limited notice or when due to a no show (not attending scheduled meeting and no communication/response to staff outreach). Additional details of attendance and no-show policy are below:
LifeNet relies on adults to participate in PA check-ins and SP visits as outlined in their LifeNet Support Plan, unless modifications are made in advance. We respond to no-shows in the following ways:
PA check-ins: If a LifeNet adult is unable to be reached by a PA for a scheduled PA check-in, the PA may continue to reach out to the adult.
If the adult is not reached by the time of the next scheduled check-in, the PA will reach out to the adult’s emergency or other contacts.
SP visits: If a LifeNet adult does not show for a scheduled in-person SP visit, the PA may continue to reach out to the adult through the next 24 hours.
If the adult still cannot be reached after 24 hours, the PA will reach out to the adult’s emergency or other contacts. If there is no response from the contacts and/or the LifeNet adult for an additional 24 hours, LifeNet will initiate an in-person wellness check by staff and/or local police.
Depending on the specific adult and situation, LifeNet may adjust these steps with an individual. If attendance is a persistent challenge despite adaptations and interventions, staff will review a detailed participation agreement and may recommend alternative services that are more accessible and/or on-site for the adult.
Does LifeNet treat in-person and virtual (e.g. for SP visits) as the same?
In person SP visits are strongly encouraged and preferred. However, there are instances when an in-person visit is not possible due to scheduling conflicts, illness, inclement weather, or other circumstances. If a virtual visit is offered and accepted, an additional “make-up” in person SP visit will not be scheduled. In person SP visits will resume as soon as possible and part of the standing schedule of support visits.
Traditionally, LifeNet adults are offered in person SP visit time up to 2 hours at the frequency per month outlined by the service tier. The frequency of SP visits per month outlines the frequency of SP travel time allotted. Nontraditionally, some adults prefer to increase the frequency of SP contact while maintaining the total amount of time together – this schedule modification is considered on a case by case basis and subject to scheduling availability; when the frequency of SP contact is increased, some points of contact must be virtual to allow the allotted travel time to remain the same.
Does the cost of LifeNet change during the modified schedule period of Summer and Winter Block?
Payments do not change during Summer and Winter blocks. During these periods we offer the same “amount” of support to all adults, even though the support may look different. For example, there may be additional planning, administrative record keeping, and small group offerings despite fewer or different 1:1 PA check-ins or SP visits.
What is the purpose of on call for LifeNet Adults? Why is my Personal Advocate or Support Partner not always available?
PA and SPs are not available 24/7 because at AANE LifeNet we support maintaining a boundary between work and personal life – time for staff to recharge sustains engagement in the program during work hours, reducing staff turnover. LifeNet offers an on call service for urgent problems that cannot wait until the next business day and that do not necessitate other emergency services. On call is staffed by various LifeNet team members who may or may not work directly with the LifeNet Adult. Team members who work on call have access to relevant records for any adult who may call on call, and we find that most on call situations require acute problem solving support vs. in-depth knowledge of a client’s history. LifeNet adults are invited to attend small group events and other gatherings to get to know additional team members if they would like.
Additional details of On Call are below:
Because problems can happen outside of traditional business hours (e.g. 9am-6pm), LifeNet offers on-call support to LifeNet adults when an issue arises that cannot wait until the following business day. This on-call service is available evenings, weekends, and holidays to offer timely and brief problem-solving support and/or connect LifeNet adults to appropriate emergency services when needed. On-call is staffed by LifeNet team members and while we cannot guarantee the staff is awake and/or immediately available 24×7, we respond as soon as messages are seen.
Because on-call LifeNet staff support is not available in-person and AANE is unable to hold a copy of clients’ personal keys to their residence, we encourage LifeNet adults to establish a “locked-out” problem solving plan. This can be stored in our client record management software as a reference for the on-call staff to prompt/orient the adult in need to their personalized plan (i.e., telephone numbers for the landlord, or name/contact for a personal contact who has a spare key, etc.).
We ask that LifeNet adults do not use on-call in the following instances:
If there is a life-threatening emergency. Instead, call 9-1-1.
If the need is not urgent. Instead, please send an email message to be seen the next business day or bring it to the next scheduled meeting.
If a LifeNet adult misuses on-call, alternative resources or strategies will be identified and offered; if misuse continues, LifeNet may revoke the individual’s access to on-call.
How will I know if the program is working? How does LifeNet measure “progress”?
We evaluate the LifeNet program differently for each individual adult, as the priorities for each adult and the program designed to support them is different. Generally, we look for “markers” that the program is building an adult’s capacity to live the life they want for themselves as connected with the adult’s identified priorities. Some examples may include: an adult reports that they feel more confident at work after navigating a conflict successfully; an adult utilizes the program for support when they encounter a challenge in the community; an adult maintains their ability to pay their bills on time despite transitions in living situation or income; an adult forges or maintains a romantic relationship; an adult learns to cook a new meal and does so consistently; an adult learns to ride public transportation so they can navigate their city more effectively. Those are only some examples! As a team, we are continually striving to improve the effectiveness of our interventions in order to maximize adults moving forward or maintaining momentum in their priorities. We do this through an ongoing process of assessment and evaluation (using evidence based instruments, quantitative and qualitative data collected from program participants including family members, and consultation), supervision, and collaboration with internal and external team members. We also make space at regular intervals to come together as a team and discuss how things are going so that everyone’s voice is heard while respecting an adult’s self-determination.
What is the timeline for supporting LifeNet Adults around multiple priorities?
LifeNet team members are trained to go at an adult’s pace and at their direction. Building capacity to manage multiple priorities at once is always within scope, but may take time to develop. We have found that capitalizing on an adult’s own intrinsic motivation for making progress on their priorities rather than being more directive is the best way to make consistent progress over the long term. LifeNet is not a short term, goal oriented program; it is designed to set adults up for success in building the life they want over the entire life course.
How can LifeNet Adults meet other adults in LifeNet and/or make new friends?
LifeNet Adults are invited to meet other adults at small group activities which are offered weekly and at annual (or semi-annual) adult and family member community gatherings. A third way that adults in LifeNet can meet peers in the program is by telling their PA and SP that this a priority for them, and asking for help in identifying opportunities to develop new relationships. Some adults choose to connect 1:1 with peers in the program to talk or do an activity that is a shared interest. LifeNet does not mandate participation in social activities or peer matching.
What if a LifeNet Adult wants more support in skill development in a certain area?
LifeNet team members will consistently be assessing skills in the adult’s prioritized areas. When a skill development area is identified and aligns with the LifeNet Adult’s priorities, LifeNet staff may offer direct teaching for skills within the scope of LifeNet or make referrals to other professionals and services who can provide specific skill development support in the identified area.
Can you help LifeNet Adults get a job? Go back to school? Get an apartment?
LifeNet can support adults who identify these priorities in a number of ways. However, LifeNet staff are not job coaches, tutors, or realtors, and will often collaborate with professionals to support areas that are outside of the program’s scope.
Why can’t the Support Partner clean the LifeNet Adult’s apartment consistently?
LifeNet is a case management program with some focus on skill building. To that end, team members sometimes teach skills such as home maintenance and organization as a part of regular engagement with an adult. However, if the need or the desire of the adult is to have consistent cleaning and there are barriers to building that skill or following through, LifeNet would assist the adult and family in problem solving availability of resources that may be added to an adult’s team. LifeNet is not meant to provide services over the long term (such as cleaning, tutoring, therapy, etc.) although team members may have training or expertise in those areas; as the program focuses on managing the needs of the entire person rather than filling holes in an adult’s team of supports indefinitely.
What if LifeNet sees the LifeNet Adult needs more (or less) support than they’re currently getting?
We are continually evaluating goodness of fit both overall and within the service tier in formal and informal ways including tracking time use/allocation through our electronic case management system. If there is a discrepancy between tier and utilization, it will be a topic of discussion both with the adult and the payor to determine barriers, increase engagement and effectiveness, or potentially to up or down tier, depending on the needs and desires of the adult.
What if LifeNet sees a concern with the LifeNet Adult?
LifeNet’s staff are skilled at identifying and managing risks and concerns that may arise with the adults we work with. When a concern arises, LifeNet will work directly with the adult to review the concern and move towards a solution. Some concerns may be addressed quickly while others may take more time and depend on the readiness of the adult to participate in the problem solving process. Depending on the circumstance, this may include bringing in various other members of their support team. For example, if a mental health emergency arises LifeNet will support the adult in accessing their current mental health providers or emergency services. Similarly, if an issue arises at work and the adult has a job coach on their team we might support the adult in communicating with the job coach to gain further support. If they do not have an existing job coach, we might use this as an opportunity to pursue adding one to the adult’s team.
How do you approach privacy/confidentiality?
We believe privacy and confidentiality are both key ingredients to building trusted, long-term relationships between the LifeNet Adult and their LifeNet team. LifeNet Adults are asked to sign Release of Information consent forms for family and other team members who they wish LifeNet to be in touch with. In addition, we work to support our LifeNet adults in participating in communication with their various team members in the ways that work best for them.
What if there are concerns about whether LifeNet is the “right” program for the LifeNet Adult?
LifeNet begins by completing an initial assessment to determine whether an adult is interested and their needs are a good fit for what the program can provide. After enrollment, LifeNet is continually assessing the appropriateness and fit of services offered to an adult. These conversations are part of weekly case consultation with peers and supervisors, with special attention paid during the first 90 days of enrollment and when life circumstances shift. These conversations will first occur within the LifeNet team and may eventually be brought directly to the individual adult and/or the wider team. Initially, collaborative problem solving and information gathering will be the focus, and depending on the input from team members, a shift in tier or an alternative service/program may be recommended.
