Peer Support (Adult/Family/Youth) Fidelity Checklist Agency: - - PDF document

Peer Support (Adult/Family/Youth) Fidelity Checklist

1 Rating is based on percentage of fidelity occurrence: 1 = 0-20%, 2 = 21-40%, 3 = 41-60%. 4 = 61-80%. 5 = 81-100%

2 Peer Wellness Specialist (PWS), Peer Support Specialists (PSS), Family Support Specialist (FSS) or Youth Support

Specialist (YSS). See AOR 410-180 for definition and certification requirements. Peer Delivered Services Fidelity Checklist July 2018 frances.s.purdy@state.or.us 1 of 4 Agency: Service: _______ Date: Reviewer: ________________________________ Enter a 1-5 for the rating for the percentage of chart/interview based on observation or found documented during the visit about Peer Delivered Services (PDS).

• 1. PEER DELIVERED SERVICES AVAILABILITY

Rating 1 -5 1 Comments Observations or chart review 1 2 3 4 5 Is there a note that the PWS, PSS, FSS or YSS2 explained PDS 1 2 3 4 5 Did the client have access to PWS, PSS, FSS or YSS at the time of each appointment? 1 2 3 4 5 Is PDS considered/included during intake and/or referral? 1 2 3 4 5 Did the client have access to PDS to prepare for appointments? 1 2 3 4 5 Is there documentation the client had access to PDS after appointments? 1 2 3 4 5 Is PDS considered/included as part of the treatment plan? 1 2 3 4 5 Is PDS available outside of the building (at the client’s home, in the community, by telephone?

• 2. PEER DELIVERED SERVICES STAFFING

Rating 1-5 1 Comment Observations or chart review 1 2 3 4 5 Is the PWS/PSS/FSS/YSS integrated in team/staffing meetings? 1 2 3 4 5 Is the PWS/PSS/FSS/YSS on the OEI/THW registry and registered as a Medicaid/CCO provider? 1 2 3 4 5 Is the PWS/PSS/FSS/YSS operating within their scope of practice? 1 2 3 4 5 Does the PWS/PSS/FSS/YSS receive weekly consultation from a

Peer Support (Adult/Family/Youth) Fidelity Checklist

1 Rating is based on percentage of fidelity occurrence: 1 = 0-20%, 2 = 21-40%, 3 = 41-60%. 4 = 61-80%. 5 = 81-100%

2 Peer Wellness Specialist (PWS), Peer Support Specialists (PSS), Family Support Specialist (FSS) or Youth Support

Specialist (YSS). See AOR 410-180 for definition and certification requirements. Peer Delivered Services Fidelity Checklist July 2018 frances.s.purdy@state.or.us 2 of 4 clinician and a PWS/PSS/FSS/YSS in the same field of practice? 1 2 3 4 5 Are PWS/PSS/FSS/YSS supervised by a peer supervisor who has lived and professional experience in the same field of practice 1 2 3 4 5 Are PWS/PSS/FSS/YSS regularly considered/included in the development of the services and treatment plans? 1 2 3 4 5 Do PWS/PSS/FSS/YSS receive regular continued education

• pportunities?

1 2 3 4 5 Are PWS/PSS/FSS/YSS encouraged to join and participate in regional, state or national meetings of their discipline?

• 3. PEER DELIVERED SERVICES DELIVERY

Rating 1-5 1 Comment Observations or chart review 1 2 3 4 5 Is the PDS documentation developed, reviewed and approved by the client? 1 2 3 4 5 Is the client able to choose a PWS/PSS/FSS/YSS who reflects their goals and culture? 1 2 3 4 5 Does the PWS/PSS/FSS/YSS advocate according to the client’s wishes and goals on the treatment team, in services systems, and in the community? 1 2 3 4 5 Does the PWS/PSS/FSS/YSS support a network of “warm-hand

• ff” in referrals to agency partners,

community members or other PWS/PSS/FSS/YSS? 1 2 3 4 5 Is there documentation that that the PWS/PSS/FSS/YSS has provided the client sufficient information in

• rder to make decisions related to

treatment choices, resources, and do

Peer Support (Adult/Family/Youth) Fidelity Checklist

1 Rating is based on percentage of fidelity occurrence: 1 = 0-20%, 2 = 21-40%, 3 = 41-60%. 4 = 61-80%. 5 = 81-100%

2 Peer Wellness Specialist (PWS), Peer Support Specialists (PSS), Family Support Specialist (FSS) or Youth Support

Specialist (YSS). See AOR 410-180 for definition and certification requirements. Peer Delivered Services Fidelity Checklist July 2018 frances.s.purdy@state.or.us 3 of 4 they exercise personal rights and responsibilities? 1 2 3 4 5 Is there documentation that that the PWS/PSS/FSS/YSS has provided the client sufficient information and support to exercise their personal rights and responsibilities? 1 2 3 4 5 Is there documentation that the client is more informed and feels confident to advocate for self or family members as a result of having PDS? 1 2 3 4 5 Is there documentation that the client is more hopeful and supported as a result of receiving PDS?

• 4. ORGANIZATIONAL SUPPORT FOR PEER DELIVERED SERVICES

Rating 1-5 1 Comment Observations or chart review 1 2 3 4 5

Has the organization developed a communication and support plan to bring PDS to patients/clients?

1 2 3 4 5

Has the organization developed information to be shared as part

• f intake process that the

PWS/PSS/FSS/YSS can use with patient/client to describe the peer support role, its purpose and potential benefits?

1 2 3 4 5

Do all supervisors encourage their staff to include the description of PDS and the use

• f PWS/PSS/FSS/YSS as part of

the intake process?

1 2 3 4 5

Do all supervisors encourage their staff to include the description of PDS and the use

• f PWS/PSS/FSS/YSS as part of

the treatment or services process?

Peer Support (Adult/Family/Youth) Fidelity Checklist

1 Rating is based on percentage of fidelity occurrence: 1 = 0-20%, 2 = 21-40%, 3 = 41-60%. 4 = 61-80%. 5 = 81-100%

2 Peer Wellness Specialist (PWS), Peer Support Specialists (PSS), Family Support Specialist (FSS) or Youth Support

Specialist (YSS). See AOR 410-180 for definition and certification requirements. Peer Delivered Services Fidelity Checklist July 2018 frances.s.purdy@state.or.us 4 of 4 1 2 3 4 5

Does the organization have

• rientation and training for

PWS/PSS/FSS/YSS that is specific to their role within the

• rganization, to educate agency

staff, contractors and volunteers?

1 2 3 4 5

Does the organization have

• rientation and training for all

staff within the organization, to educate agency staff, contractors and volunteers about the role of each type of PDS?

1 2 3 4 5

Does the organization include the PWS/PSS/FSS/YSS supervisor/manager in the leadership/management team?

• 6. Additional Recommendations:

___________________________________ __________________________________ Name and Signature (Reviewer) Name and Signature (Agency)