📋Monitoring Tool

This document is used by support coordinators in New Jersey to capture details about the client from the required visits or contacts

DDD in New Jersey revamped the monitoring tool in 2023. You can get the latest copy of the official document from here.

The Support Coordinator Monitoring Tool (MT) is a key document in delivering services and supports for Individuals with developmental disabilities. It helps ensure adherence to best practice standards and criteria established by the Centers for Medicare and Medicaid Services (CMS) Home and Community-Based Services (HCBS), which emphasize the following:

 opportunities to engage in the life of communities

 respecting Individuals’ rights, as well as ensuring safety

 developing and strengthening important relationships

 choice about where to live, work, and the services to receive

 choice about personal goals and opportunities to realize those goals

Fieldworker uses data from its database about the customer, plan, and visit to pre-populate several fields in the document. The Fieldworker app also enforces the business logic to ensure clean and correct MT to be produced, and submitted.

The document below describes the Fieldworker implementation of this process.

Monitoring Requirements

Monthly monitoring may occur through phone/video contact or in person. Face-to-face monitoring is required by the third month from the date of initial ISP approval and at least every three months thereafter. At least one face-to-face visit each year (often referred to as the annual home visit) must take place in the Individual’s home and at least one face-to-face visit to the location in which an Individual regularly receives a particular service for more than 16 hours per week. (See the SP and CCP Policies & Procedures Manuals, section 13.1 for further information.)

Two separate monitoring tools are used to fulfill monitoring requirements:

The Support Coordinator Monitoring Tool – Monthly is used to document monthly monitoring contact. This tool may be used with any Contact Type (Phone / Video Contact, Face-to-Face Visit, or Home Visit) but may not be used for more than two consecutive months.

The Support Coordinator Monitoring Tool – Quarterly is used to document monitoring contact with greater depth and detail than the Monthly tool to ensure best practice and HCBS requirements are met. This tool may be used with any Contact Type (Phone / Video Contact, Face-to-Face Visit, or Home Visit) but must be used at least once every three months.

Nearly all Yes/No questions on the forms have an answer marked with an asterisk. Each answer marked with an asterisk requires additional information in the space for Comments / Follow-Up Items. The Fieldworker App will automatically present you with a popup to capture details about the potential follow-up or action item.

Follow-up items should state clearly and concisely who will do what and when. Case notes will contain more detail documenting the Support Coordinator’s efforts.

Quarterly Monitoring Tool

When you open a quarterly MT in Fieldworker, any outstanding, open items are opened in a separate window, on the left hand.

Section 1: Identifying Information (Section 1, Monthly MT)

The fieldworker app will pre-fill several entries in this section based on the data already available in the system. This is generally the data about the customer, plan, and contact/visit used to gather the information for this tool. Some of these fields can only be updated in their respective pages to maintain the integrity of the data.

Who is the primary contact for this Monitoring Tool? If the Individual is not the primary contact for the MT, there should be an effort to include them in the conversation. Space is provided to describe their participation or to explain why they were not involved.

Contact Type: When contact occurs by Phone / Video Contact, the Contact Location will be the location of the person with whom the SC is speaking.

The following fields are pre-filled from the existing data, or based on the other data.

Field on the MT from	Source
Individual's Name	from the customer detail
Current Program	from the plan detail
DDD ID	from the customer detail
Current Living Arrangement	from the previous month's answer
NJCAT Score	from the customer detail
Tier	from the customer table
Is an Approved ISP in Place?	based on If the checkout date is within 12 months of the project start date
Name of Support Coordination Agency	from the company detail of the user creating the form
Name of Assigned Support Coordinator	from the employee detail about the user filling in the form
Contact Date	from the visit detail (empLocate) or user filled if the company of the current user is not time managed
Contact Period	Type of form selected ie. Monthly/Quarterly
If Phone, enter the phone #	from the customer table. Enabled if Contact Type is selected as Phone/Video Contact The phone number can be updated by the user, as needed.
Relationship to the Individual	Selectable from a drop down menu
If Other, please describe	enabled if Contact Location is selected as Other
If the Individual is not the primary contact, were they involved in the conversation?	enabled if the Relationship to the Individual is selected as Self
Please describe or explain	enabled if the Relationship to the Individual is selected as Self
Does the Individual currently attend a DDD-funded provider-managed day program?	Carried over from the previous month's answer
If Yes, please enter name of agency and address of program	Carried from the previous month's answer. Enabled if "Does the Individual currently attend a DDD funded provider managed day program?" is answered yes
Does the Individual currently reside in a DDD funded provider managed residential setting?	Carried over from the previous month's answer
If Yes, please enter name of agency and address of program	Previous month's answer, if Current Living Arrangement is Provider Managed Residence. Enabled if "Does the Individual currently reside in a DDD funded provider managed residential setting?" is answered yes.
Does the Individual currently use Self-Directed Employees (SDEs)?	Carried over from the previous month's answer
If Yes, please enter name of agency and address of program	Carried over from the previous month's answer. Enabled if "Does the Individual currently use Self-Directed Employees (SDEs)?" is answered yes

Section 2: Follow-Up Items (Section 2, Monthly MT)

This section includes follow-up items identified during the previous monitoring contact and also longer-term items identified in prior Monitoring Tools, which were not resolved at the time of last month’s contact.

Section 3: Community Connections

This section is about what the Individual has been doing in the community recently, who they’ve been doing things with, if they enjoy the activities or not, and if they decide, or help decide, activities they do and who with.

Section 4: Relationships

Discuss how the Individual is staying in touch with people who are important to them.

Quarterly monitoring should help ensure the Individual is maintaining relationships and staying in touch with people important to them.

Section 5: Personal Rights and Autonomy

Questions in this section are a small sampling of potential questions pertaining to rights, respect, autonomy, and opportunity for choice and decision-making.

Section 6: Continuity and Stability with Living Arrangement (Section 4, Monthly MT)

This section monitors the Individual’s stability and satisfaction with the current living arrangement and conditions.

The following fields are pre-filled from the existing data, or based on the other data.

Field	Source of data or rule
Question e	enabled if question d is answered yes

Section 7: Employment and Day Services (Section 3, Monthly MT)

This section monitors the Individual’s satisfaction with how they spend their weekdays. Listen to ensure the Individual enjoys what they are doing during the day, and whether adjustments or changes are needed.

The following fields are pre-filled from the existing data, or based on the other data.

Field	Source of data or rule
Question d	only one of questions d or e can be answered
Question e	only one of questions d or e can be answered
Question f	only if d is answered is Yes
If applicable, explain the referral status	enabled if question f is answered Yes/No

Section 8: Outcomes and Services

This section helps ensure that outcomes remain relevant and that services support the outcomes. This section helps assess satisfaction with services and prompts discussion about potential changes and new opportunities

Pay particular attention to question e. regarding the rate of budget expenditure. If the answer to this question is “No,” further discussion is needed with the Individual/Planning Team.

Section 9: Health and Safety (Section 5, Monthly MT)

This section captures the details about the health of the client.

When completing quarterly monitoring with someone in a DDD-funded, provider-managed residential or day program setting, speak with provider staff to complete questions a. through j. in this section. Be sure to note the staff member’s title along with their name in the space provided.

When completing quarterly monitoring with someone in a setting other than a DDD-funded, provider-managed setting, complete only questions f. through l. with the Individual/caregiver.

The implmentation for sectopn 9 is expected to be updated in next build. It will be driven by contact person filling the form (or helping fill the form) and their relationship to the client.

The following fields are pre-filled from the existing data, or based on the other data.

Field	Source of data or rule
Name of Service Provider	Entry is available but mandated only if the Contact Location is Home AND Current Living arrangement is Provider Managed Residence OR Contact Location is Day Hab Site
Name and Title of Staff Member	Entry is available but mandated only if the Contact Location is Home AND Current Living arrangement is Provider Managed Residence OR Contact Location is Day Hab Site. The title is changed when "Who is the primary contact for this Quarterly/Annual Face-to-Face Visit?" is changed
Program Name and Type	Entry is available but mandated only if the Current Living arrangement is Provider Managed Residence OR Contact Location is Day Hab Site
Question a	Entry enabled if the Contact Location is Home AND the Current Living arrangement is Provider Managed Residence OR Contact Location is Day Hab Site
Question b	Entry enabled if the Contact Location is Home AND the Current Living arrangement is Provider Managed Residence OR Contact Location is Day Hab Site
Question c	Entry enabled if the Contact Location is Home AND the Current Living arrangement is Provider Managed Residence OR Contact Location is Day Hab Site
Question d	Entry enabled if the Contact Location is Home AND the Current Living arrangement is Provider Managed Residence OR Contact Location is Day Hab Site
Question e	Entry enabled if the Contact Location is Home AND the Current Living arrangement is Provider Managed Residence OR Contact Location is Day Hab Site
Question j	Entry enabled if the Contact Location is Home AND the Current Living arrangement is Provider Managed Residence OR Contact Location is Day Hab Site and if Question i is answered Yes
Question k	Entry enabled if the Current Living arrangement is NOT Provider Managed Residence
Question l	Entry enabled if the Current Living arrangement is NOT Provider Managed Residence

Section 10: Medicaid Status (Section 6, Monthly MT)

As Medicaid eligibility is required for DDD services, if there is a problem or a question about Medicaid eligibility, reach out for assistance promptly, either to the DDD SCHelpdesk or the DDD Medicaid Eligibility Helpdesk.

The following fields are pre-filled from the existing data, or based on the other data.

Fireld	Source of data or rule
Question a	From the Customer detail
Question b	From the Customer detail If the date exists, create a comment with the date

Section 11: Closing Question for the Individual/Caregiver (Section 8, Monthly MT)

Be careful not to rush through this question.

 Occasionally, critical information may be disclosed here.

 This space may also be used to document any other topics of discussion, not included elsewhere on the form, such as ABLE accounts, burial planning, etc.

Section 12: To be answered by the Support Coordinator

The Support Coordinator completes this section based on the monitoring conversation that has taken place, information from other sources, and their knowledge of the Individual and their situation.

The following fields are pre-filled from the existing data, or based on the other data.

Field	Source of data or rule
Question f	Yes, if DDD Tier is either Aa, Ba, Ca, Da, or Ea
Question h	enabled if Question g is answered Both or g is answered Medical
Question i	enabled if Question g is answered Both or g is answered Medical
Question j	enabled if Question g is answered Both or g is answered Behavioral
Question k	enabled if Question g is answered Both or g is answered Behavioral and Question k is answered yes
Question l	enabled if Question g is answered Both or g is answered Behavioral and Question k is answered yes
Question m	enabled if Question g is answered Both or g is answered Medical

Section 13: Areas Requiring Division Assistance (Section 7, Monthly MT)

Section 14: Contact Summary (Section 9, Monthly MT)

The entry in this section should give a “flavor” of the Individual’s past month and reflect the tone of the conversation. This section should record things like impressions about the Individual’s mood, appearance, and interactions, as well as observations about the environment.

It is good practice to begin the contact summary by stating whom you spoke with and how the meeting took place, even though this information is noted in Section 1.

Section 15: Completed By (Section 10, Monthly MT)

This form should be consistently completed by the SC assigned in iRecord. Occasionally, due to illness, scheduling conflicts, etc. someone other than the SC might complete the MT. However, this should be the exception. If someone other than the assigned SC completes the MT, a brief explanation is needed in the space provided.

This detail is prefilled by the Fieldworker app based on the associated task. The Title field is hard-coded as 'Support Coordinator'.

Section 16: Reviewed By (Section 11, Monthly MT)

According to the CCP and SP Policies and Procedures Manuals, SCS review is required for the first 60 days of any new Support Coordinator, when performance issues have been identified, and for complicated or difficult situations.