Section 11. The Interdisciplinary Team

A. The interdisciplinary team (IDT) is responsible for the development of the individual service plan (ISP) and for identifying the agencies and individuals responsible for providing the services and supports identified in the ISP. B. The IDT shall consist of the following core members: (1) individual: the individual shall be actively encouraged to participate in all IDT meetings and the ISP development process; this participation shall include, but not be limited to, expressing a personal vision statement for the future, indicating desired outcomes that help to realize that vision, identifying action plans that will achieve those outcomes, and personally chairing the IDT meeting, if desired and when able to do so; (2) case manager: the duties of the case manager in relation to the individual with developmental disabilities and the IDT shall include: 8.371.5 NMAC 5 (a) coordinating the development, modification and implementation of the ISP in consultation with the IDT and the individual; (b) monitoring the integration and coordination of the individual’s services; (c) serving as the IDT chairperson, or assisting the individual in chairing the IDT meeting if he or she is capable of doing so and wishes to do so; (d) scheduling IDT meetings annually, or more often as needed, to review or modify the ISP, and encouraging optimum participation by all IDT members; (e) monitoring supports and services being delivered as specified in the ISP as determined by the IDT; (f) reviewing progress on chosen outcomes, and action plans and through consultation with the IDT, amending the ISP, if needed; (g) through timely consultation with the IDT, modifying unsuccessful service programs and developing service programs for previously unaddressed but significant individual needs that may arise prior to the next scheduled ISP meeting; (h) advocating on behalf of the individual by making recommendations and requests on behalf of the individual; (i) ensuring objective, quantifiable data has been systematically recorded, analyzed and us the IDT, modifying unsuccessful service programs and developing service programs for previously unaddressed but significant individual needs that may arise prior to the next scheduled ISP meeting; (h) advocating on behalf of the individual by making recommendations and requests on behalf of the individual; (i) ensuring objective, quantifiable data has been systematically recorded, analyzed and used to determine effectiveness of service provided in order to justify needed changes in services; (j) coordinating and monitoring any follow-up needed as a result of reviews; (k) serving as liaison between the IDT and the public school system, the special education division, or any other community service teams relevant to the individual served; and (l) assisting the community service providers in community placement or other services as needed and as specified by the IDT; (3) the case manager ensures that the IDT identified services and supports for the individual without regard to their current availability; at the conclusion of the IDT meeting the case manager shall document unavailable services on the appropriate page of the ISP form, which is provided for this purpose, and submits this list to the DDSD, regional office; (4) guardian: the guardian shall convey to the IDT information about the individual, historical or otherwise, which shall be useful in the development of the ISP; (5) helper: the helper is someone who knows the individual’s capabilities, interests, likes, and dislikes and who can assist the individual in communicating these with the IDT; in turn, the helper may assist the individual in understanding the ISP development process and the individual service plan that is developed; (6) “key” community service provider staff: “key” community service providers are providers of residential, employment day program and behavioral services specifically designed for persons with developmental disabilities; “key” provider staff participating in the IDT shall include, at a minimum: (a) direct service staff: the pa development process and the individual service plan that is developed; (6) “key” community service provider staff: “key” community service providers are providers of residential, employment day program and behavioral services specifically designed for persons with developmental disabilities; “key” provider staff participating in the IDT shall include, at a minimum: (a) direct service staff: the participation of direct service staff in the development of the individual service plan is crucial, as they are the persons who work directly with the individual within their respective domains; at least one provider staff member from each of the “key” service areas (residential, day/work- related and behavioral), who is directly involved in the provision of services to the individual in those areas, must be in attendance at all IDT meetings; (b) service coordinator: the service coordinators of the community provider agencies shall assure that appropriate staff develop strategies specific to their responsibilities in the ISP; the service coordinators shall assure the action plans and strategies are implemented consistent with the provisions of the ISP, and shall report to the case manager on ISP implementation and the individual’s progress on action plans within their agencies; for persons funded solely by state general funds, the service coordinator shall assume all the duties of the independent case manager described within these regulations; if there are two or more “key” community service provider agencies with two or more service coordinator staff, the IDT shall designate which service coordinator shall assume the duties of the case manager; the criteria to guide the IDTs selection are set forth as follows: (i) the designated service coordinator shall have the skills necessary to carry out the duties and responsibilities of the case manager as defined in these regulations; (ii) the designated service coordinator shall have the time and interest to fulfill the functions of the case manager as defined in these regulatio he case manager; the criteria to guide the IDTs selection are set forth as follows: (i) the designated service coordinator shall have the skills necessary to carry out the duties and responsibilities of the case manager as defined in these regulations; (ii) the designated service coordinator shall have the time and interest to fulfill the functions of the case manager as defined in these regulations; (iii) the designated service coordinator shall be familiar with and understand community service delivery and supports; (iv) the designated service coordinator shall know the individual or be willing to become familiar and develop a relationship with the individual being served; 8.371.5 NMAC 6 (7) ancillary service providers: ancillary service providers shall participate in the IDT meeting and the ISP development process through written assessments, evaluations or reports to the IDT, or in person; the case manager, in consultation with the individual and the IDT, shall determine the need for personal participation at IDT meetings on the part of any ancillary service provider; (8) designated healthcare coordinator: the team member designated to coordinate medical supports and services which the individual requires to manage any chronic health conditions and to access preventative healthcare services; (9) others: unless the individual objects, other participants may include family members not already mentioned, if invited by the individual or the ISP development process on the individual’s behalf; representatives of general services, who may participate in the IDT with the individual’s or guardians’ consent; representatives of the public school system, if the individual is of school age and attends public school; and, any others that the individual wishes to have attend the IDT meeting. [8.371.5.11 NMAC - N, 7/1/2024] 8.371.5.12 DEVELOPMENT OF THE INDIVIDUAL SERVICE PLAN (ISP) - PARTICIPATION IN AND SCHEDULING OF INTERDISCIPLINARY TEAM MEETINGS: A n the IDT with the individual’s or guardians’ consent; representatives of the public school system, if the individual is of school age and attends public school; and, any others that the individual wishes to have attend the IDT meeting. [8.371.5.11 NMAC - N, 7/1/2024] 8.371.5.12 DEVELOPMENT OF THE INDIVIDUAL SERVICE PLAN (ISP) - PARTICIPATION IN AND SCHEDULING OF INTERDISCIPLINARY TEAM MEETINGS: A. Prior to the initial IDT meeting the case manager shall provide the individual and guardian, if any, with an orientation to the person-centered planning process, purpose of the ISP and roles and responsibilities of IDT members. After completion of the ISP, the individual and guardian shall be offered the opportunity to meet with the case manager and ask questions regarding the completed ISP within 30 days of the meeting, if desired. B. The IDT shall be convened at least annually and may be convened as frequently as conditions or circumstances warrant to review and modify the ISP. If an ISP includes programs or services which restrict an individual or a behavioral program subject to the DDSD behavior support policy, the IDT shall review the relevant program or service at least quarterly. In situations where an individual is at risk of significant harm, the team shall convene within one working day, in person or by teleconference. If necessary, the ISP shall be modified accordingly within 72 hours. C. The IDT meeting shall be scheduled and conducted by the case manager who will solicit and facilitate the full participation of all team members. The individual shall be present unless he/she chooses not to attend. If any member is unable to attend IDT meetings, arrangements for their involvement shall be made through teleconference, designated representatives, or in the case of ancillary services, written reports provided to the case manager prior to the meeting. D. The case manager shall provide written notice of the annual IDT meeting at least 21 days prior to the meeting ess he/she chooses not to attend. If any member is unable to attend IDT meetings, arrangements for their involvement shall be made through teleconference, designated representatives, or in the case of ancillary services, written reports provided to the case manager prior to the meeting. D. The case manager shall provide written notice of the annual IDT meeting at least 21 days prior to the meeting. Notice shall be provided to the individual, their representative, guardian, providers and other invited participants. The case manager shall consult IDT members prior to scheduling the meeting in order to determine the best dates and times. The case manager shall attempt to accommodate team member’s scheduling needs shall be accomodated as long as the timing does not jeopardize continued eligibility for the DD Waiver. A request for a change of meeting date made by the individual and guardian. Written documentation of notice and scheduling activities will be maintained by the case manager in the individual’s records. E. For state general funded services, the initial IDT meeting shall be held within 60 days of the start of services, and then annually thereafter. For all other developmental disabilities medicaid waiver recipients, the IDT meeting shall be held annually based upon the previous or initial ISP approval date. F. In the event the individual or guardian requests that others be invited to attend the IDT meeting, the case manager shall also provide them with notification of the meeting. G. The case manager will convene the IDT on an “as needed” basis to modify (revise or amend) the ISP once it has been developed. Participants may attend through teleconference. H. The IDT shall be convened to discuss and modify the ISP, as needed, to address: (1) a significant life change, including a change in medical condition or medication that affects the individual’s behavior or emotional state; (2) situations where an individual is at risk of significant harm odify (revise or amend) the ISP once it has been developed. Participants may attend through teleconference. H. The IDT shall be convened to discuss and modify the ISP, as needed, to address: (1) a significant life change, including a change in medical condition or medication that affects the individual’s behavior or emotional state; (2) situations where an individual is at risk of significant harm. In this case the team shall convene within one working day, in person or by teleconference; if necessary, the ISP shall be modified accordingly within 72 hours; (3) changes in any desired outcomes, (e.g. desired outcome is not met, a change in vocational goals or the loss of a job); (4) the loss or death of a significant person to the individual; (5) a serious accident, illness, injury or hospitalization that disrupts implementation of the ISP; 8.371.5 NMAC 7 (6) individual, guardian or provider requests for a program change or relocation, or when a termination of a service is proposed; the DDSD’s policy no. 150 requires the IDT to meet and develop a transition plan whenever an individual is at risk of discharge by the provider agency or anticipates a change of provider agency to identify strategies and resources needed; if the individual or guardian is requesting a discharge or a change of provider agency, or there is an impending change in housemates the team must meet to develop a transition plan; (7) situations where it has been determined the individual is a victim of abuse, neglect or exploitation; (8) criminal justice involvement on the part of the individual (e.g., arrest, incarceration, release, probation, parole); (9) any member of the IDT may also request that the team be convened by contacting the case manager; the case manager shall convene the team within 10 days of receipt of any reasonable request to convene the team, either in person or through teleconference; (10) for any other reason that is in the best interest of the individual, or any other reason deemed appropriate, including development, integra ) any member of the IDT may also request that the team be convened by contacting the case manager; the case manager shall convene the team within 10 days of receipt of any reasonable request to convene the team, either in person or through teleconference; (10) for any other reason that is in the best interest of the individual, or any other reason deemed appropriate, including development, integration or provision of services that are inconsistent or in conflict with the desired outcomes of the ISP and the long term vision of the individual; (11) whenever the DDSD decides not to approve implementation of an ISP because of cost or because the DDSD believes the ISP fails to satisfy constitutional, regulatory or statutory requirements.