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Procedure No. Issue Date:  April 2006 
Subject:  Family Respite Center Referrals  Effective Date:  Upon Release 
Section:  Individual and Family Support 
A.  Purpose
To delineate a  standardized process for referrals to DMR Family Respite Centers.
B. Applicability
This procedure shall apply to all individuals requesting services at a DMR Family Respite Center.  This procedure shall apply to all individual and family support and public services staff responsible for referrals to or operations of Family Respite Centers.
C. Definitions
Family Respite Center - homes or residential units operated by DMR which provide planned,
temporary supports to individuals who reside with their families, community training home providers or DCF foster families and who are eligible to receive services from DMR.
Respite Guest - the individual who receives supports at a Family Respite Center.
D. Implementation
All individuals who are eligible for services from DMR and currently reside with family members are eligible to request respite at a Family Respite Center. Individuals who live with their families will have first priority. Individuals residing in community training homes or DCF foster homes may utilize the Family Respite Centers dependent upon available resources.
  1. Request for Respite Services
    All requests for respite stays at a Family Respite center shall be directed to the individual's case manager. The case manager will forward the completed Request for Respite Services form to the respite coordinator.

    Family members will be sent an introductory packet by the case manager. The introductory packet includes a letter of introduction, brochure, directions and phone number of the Family Respite Center. The family member and individual who will be the respite guest must visit the center for a pre-visit meeting.  If the family is interested in using the Family Respite Center, they will be assisted by DMR staff to complete the following:
    a) Guest Profile
    b) Emergency and Authorization Form
    c) Physician's Orders
    d) Respite Center Guests Permission Form
    e) Leisure Interests Survey
    f) PICA Information for Respite Center Visits Form.

    The case manager will ensure that a screening of health and safety issues on the Level of Need form is completed as described in DMR procedures and that a copy is forwarded to the Family Respite Center.
  2. Selection
    Each region shall have a regional review committee to review, approve, modify, and schedule all respite visits. Committee members shall include, at a minimum, representatives from the Individual and Family Support resource team and the Family Respite Center.

    Every attempt will be made to accommodate each request for respite services. The criteria used to review requests include: space available based on the number of  requests for a particular time period, ability to group individuals into compatible peer clusters,  safety concerns based on particular individual challenges, and frequency with which the individual has stayed at the respite center relative to other individuals.  Individuals with the most challenging needs should be given first priority provided health and safety issues can be accommodated.   An individual’s need level should be included on the Request for Respite Services form.

    After each meeting, the Respite Services Coordinator will notify the individual's case manager, in writing, of the status of the request and available dates, if applicable.  The case manager shall contact the family with the decision. If the family member is unable to use the respite center on the available dates, the case manager shall notify the respite coordinator or respite center staff, who will offer the opening to alternate families.
E. References
1. Request for Respite Services
2. Introductory Packet
3. Guest Profile
4. Emergency and Authorization Form
5. Physician's Orders
6. Respite Center Permissions Form
7. Leisure Interest Survey Form
8. PICA Information for Respite Center Visits Form
9. Level of Need Form