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5. The APSW

Mandate

The APSW works directly with adults who have a developmental disability who are living on their own in the community to assist them in strengthening their capacity to manage and acquire the skills necessary for daily living, and help them enhance their support network, awareness of generic community-based resources and government-funded services and supports.

The APSW program establishes a voluntary working relationship based upon mutual accountability between the adult who has a developmental disability and the APSW. Adults who have a developmental disability are active participants in all steps of the working relationship.

The APSW facilitates an individual’s involvement primarily with generic community supports wherever possible, but also with government-funded services and supports (e.g. the Ontario Disability Support Program, Passport Program, Legal Aid, Ontario Works etc.). The APSW supports the person to develop a network of supports that will foster greater personal independence and social inclusion. With the consent and direction of the capable adult who has a developmental disability, the worker will provide assistance with planning and accessing these supports based upon individual needs and goals.

Overview of Functions

The APSW conducts regular face-to-face meetings with adults who have a developmental disability to provide:

  • Advocacy on their behalf to help them access and maintain generic community supports, apply for government-funded services, and supports and to help them live safely and securely in the community.
  • Help support the individual identifying their strengths and needs and providing information and referrals at the direction of the adult who has a developmental disability.
  • Coordination and case management of community resources, service plans, mediation, and liaison with other service providers.
  • Support with problem-solving, life skills counselling (such as personal budgeting, use of transportation), general education and awareness-building on abuse prevention, help resolving landlord/tenant issues, guidance and group facilitation.

There are a number of settings where meetings between the APSW and the adult who has a developmental disability would take place. These include the individual’s home, their place of employment or appointments (e.g. doctor, lawyer). Since the program is intended to support people in the community, it is not a best practice for the majority of meetings to routinely take place in the APSW’s office. However, the APSW has the discretion to determine those individual circumstances where it may be more appropriate for many of the meetings to take place in the APSW’s office such as when there are precautionary concerns regarding the safety of the APSW or to help reinforce professional boundaries of the APSW Client relationship.

The APSW may also provide ‘outreach’ in the community; providing information to adults who have a developmental disability who are receiving little or no service in the community. In such situations, the APSW would provide the adult with a suspected developmental disability with contact information for their local DSO.

Working with Children

The APSW program is for adults aged 18 years or older who have a developmental disability.

Adults with a Developmental Disability who are Parents

The APSW may also offer services and supports to eligible adults with a developmental disability who are parents, including providing information about the type of services and supports that are available to their children. The focus of ongoing assistance from the APSW is on the needs of the parent(s) who have a developmental disability, which may include services that specialize in teaching parenting skills.

For more intensive help with CASE MANAGEMENT specifically related to the children’s needs, the APSW would support the adult to make inquiries about case management or other services for children, including child protection services or those that specialize in teaching parenting skills.

Trusteeship

In exceptional circumstances and as a solution of last resort, where an individual does not already have a legally authorized substitute (e.g. Office of the Public Guardian and Trustee, guardian of property, power of attorney for property), the APSW may, with the consent of the capable adult who has a developmental disability, apply to be appointed by the Director of the Ontario Disability Support Program (ODSP) as trustee for management of the individual’s ODSP income support.

The role of trustee by the APSW should be temporary while seeking other service alternatives to assume the role of trustee for management of the person’s ODSP income support. It is recommended that this temporary trusteeship on the part of the APSW should not exceed six months, or as agreed to by the individual, the APSW and the service agency.

It is also recommended that service agencies seek legal advice on the duties, obligations and risks of the APSW, APSW agency or other agency staff assuming trusteeship for any individuals supported by an APSW program.

ODSP Policy Directive 10.2 provides guidance on the role of an ODSP trustee in managing a recipient's income support.

Advocacy

In the role of advocate, the APSW works with community-based services and agencies to:

  • Ensure, within the scope of the APSW’s mandate and authority, that the rights of the adult who has a developmental disability are acknowledged and respected, and
  • Inform the adult who has a developmental disability of their rights.

Before acting as an advocate, the APSW determines the level at which the individual who has a developmental disability understands a potentially harmful or complex situation and can speak on their own behalf. The following are broad examples to guide the APSW in advocating on behalf of individuals:

  • The adult who has a developmental disability has limited ability to make personal decisions or respond. For example, the individual may have been seriously exploited and their rights violated. In this instance, the APSW could intervene and communicate the situation to the appropriate authorities (e.g. police).
  • The adult who has a developmental disability may be aware of exploitation (by family, friends, employers, or landlord) but is unable to speak on their own behalf. The role of the APSW is to intervene and provide the individual with guidance on how to minimize their risk and avoid similar situations in the future and/or communicate the situation to the appropriate authorities.
  • The adult who has a developmental disability does not understand their rights or what action may be necessary when their rights have been violated. In these situations, the APSW could intervene to assist the individual with taking the appropriate action.
  • The adult who has a developmental disability is aware of abuse, exploitation or disservice but needs guidance in bringing their concerns before the appropriate authority and in following the most appropriate process to do so. The APSW could provide guidance on the proper level of authority given the specific situation and the appropriate process to follow as per requirements outlined in Regulation 299/10, Quality Assurance Measures.
  • The adult who has a developmental disability is capable of self-advocacy and can use the appropriate services independently because they understand them and can communicate effectively. The APSW could offer guidance and emotional support to the individual as they advocate on their own behalf.

Since adults who have a developmental disability are obliged, like all citizens, to abide by society’s laws, the advocacy role may involve the APSW in court proceedings. If the adult who has a developmental disability is involved in legal proceedings, the APSW can help the individual to access Intensive Case Management services that may be available in the person’s community.

The Intensive Case Manager provides referral resources to assist the court support workers and discharge planners in the appropriate case management of individuals. The Intensive Case Manager establishes collaborative contacts with community-based services to divert individuals with dual diagnosis in conflict with the law to community-based developmental (MCSS-funded) and mental health (Ministry of Health and Long-Term Care-funded) resources and services. The APSW and Intensive Case Manager should work together to support the individual because the APSW might have a long term relationship with the individual while the Intensive Case Manager might not be as familiar with the individual.

In some communities, the APSW has also been designated as the Intensive Case Manager and can assist the individual. In other communities, the services of a separate Intensive Case Manager may not be available. The APSW should not provide legal advice but rather direct the individual to a lawyer for legal advice and assistance.

Where there is no Intensive Case Manager support available, the APSW can:

  • Help provide information to the individual about their rights and responsibilities.
  • Help the individual to receive the services of a lawyer including help with the process for making an application for legal aid.
  • With the individual’s permission, discuss the situation with the Crown Attorney and defense counsel (Note: the APSW does not talk with the judge on the client’s behalf or provide paralegal representation).
  • Explain court proceedings to the individual during the trial process.
  • Help to clarify for the individual, the legal advice given to them by their lawyer.
  • Assist the probation officer in compiling a pre-sentence report or develop recommendations in the report.

When determining whether the APSW is the primary support in assisting individuals in legal proceedings, it is important to note the APSW is not to duplicate or replace the services offered by the Intensive Case Manager supports where they are available to support individuals.

Case Management

Case management is a collaborative process to assess, plan, implement, coordinate, monitor and evaluate the options and services required to meet the individual’s service needs.

In the case management role, the APSW facilitates the achievement of individual wellness and autonomy through advocacy, skills assessment, planning, communication, education, resource management and service facilitation. Planning and service facilitation are based on the needs and values of the individual who has a developmental disability. The results of the needs assessment (Supports Intensity Scale) from the individual’s application for adult developmental services and supports can provide guidance for the APSW.

The underlying premise of sound case management is that everyone benefits when people who have a developmental disability reach their optimum level of self-management and functional capability.

The role of the APSW as case manager is to meet regularly with adults who have a developmental disability to identify and access the necessary supports and services appropriate to their needs. The APSW’s objective is to help people access generic community services wherever possible, and to support people in applying for government-funded and operated services to address individuals’ needs.

The process should begin with a person-centred planning approach to develop, implement and maintain an INDIVIDUAL SUPPORT PLAN (ISP) with and for the individual. The ISP is to be developed jointly between the adult who has a developmental disability and the APSW. The ISP must promote the concepts of choice, individualized services and supports, consumer satisfaction and build on the strengths and abilities of individuals.

The functions of the APSW may include (but are not limited to):

  • Monitoring and assisting with revisions to the ISP.
  • Facilitating community access and inclusion (i.e. locating or developing opportunities, providing information about resources etc.).
  • Assisting with completing the appropriate applications for services in the community.
  • Monitoring the provision of services to individuals including activities such as interviews and monitoring visits with the individual and service provider.
  • Engaging in activities aimed at building capacity in the broader community.
  • Maintaining current, accurate, complete and timely documentation of progress in the individual’s agency records.
  • Supporting the individual to contact their local DSO organization as necessary, for example, if the individual plans to move away from the APSW agency’s service area, or their needs change and they request other Ministry-funded adult developmental services and supports.

Limitations on the Role of the APSW

Participation in the APSW program is strictly voluntary. The APSW cannot compel an unwilling or disinterested individual to accept the services of the program or advice from the APSW.

APSWs do not have a mandate to provide care or to compel compliance to treatment or to other recommended support services. While the APSW can assist people in making healthy and safe decisions, ultimately the final decision belongs to the adult who has a developmental disability and who is capable of making those decisions.

Situations that require direct observation of an individual after medical treatment or care, assistance with medical treatment, enforcement of treatment guidelines or orders, or other more intrusive or intensive measures fall beyond the scope of what the APSW is mandated to provide. The APSW does not serve in a guardianship or power of attorney capacity for the individuals they support and does not make personal care or financial/property decisions on their behalf. In addition, the APSW cannot assume legal responsibility for the adult or supervise their children.

Caseload

APSW caseloads fall into two categories:

  • Active, and
  • Closed

All adults with a developmental disability whose eligibility has been confirmed by their local DSO organization and have subsequently been referred from the DSO, request help from an APSW and have been accepted for involvement in the APSW program are considered Active until closed.

There are two broad categories of Active situations:

  • Service situations in which the person who has a developmental disability and the APSW have begun working toward agreed-upon goals identified in the person’s ISP. These situations are considered to be high priority for Adult Protective Services and require extensive, ongoing meetings and assistance from the APSW, and
  • Service situations that require monitoring but less frequent contact with the individual and minimal ongoing support. These situations are also those that involve minimal temporary intervention. Although still considered Active, these situations may be classified as ‘support’ situations because:
    • The adult who has a developmental disability has achieved the goals they originally identified but still needs the support of an APSW to help address temporary issues when they arise, or
    • It is considered advisable to maintain regular contact with the individual in order to maintain their stability in their current situation and to identify and minimize risk or prevent further issues from arising, or
    • The adult who has a developmental disability requests regular contact and monitoring by the APSW as a form of ‘social safety net’ for emotional support and advice.

Each person who has a developmental disability has unique needs and circumstances. Therefore, there is no prescribed time limit that an individual may be considered Active for the services provided by the APSW program. The practice of setting time limits for involvement in the Adult Protective Service program is inconsistent with the fundamental principles of fairness and equity that require services to be tailored to meet individuals’ needs and goals.

Files are Closed when:

  • The adult who has a developmental disability has decided they no longer need or want the services of the APSW.
  • The adult who has a developmental disability has moved out of the area that is served by the APSW. With the permission of the individual who has a developmental disability, the APSW is responsible for contacting their local DSO organization, linking the individual with the DSO in the new community and, as directed by the DSO, their APSW counterpart in the area to which the individual has moved or will be moving in order to facilitate the transition. This may include transferring appropriate documentation (with the consent of the individual who has a developmental disability).
  • Follow up and service for the person who has a developmental disability has been undertaken by another developmental services agency (following successful referral from a DSO organization).
  • The behaviour of the person who has a developmental disability poses a risk to the APSW’s safety and security.
  • The person’s whereabouts is unknown for four to eight months, depending on the individual and in consultation with the APSW supervisor, or the person is deceased.

The individual with a developmental disability or the APSW on behalf of the individual must contact their local DSO organization when the individual moves or wishes to move from one location to another. The DSO can assist with service navigation in the new community.

APSW agencies are required to report service availability to the DSO.

The caseload size for each APSW will vary based on agency capacity and resources, but ultimately depends on:

  • the individual needs of the people being supported by the APSW, including the type and level of involvement individuals need;
  • the administrative responsibilities directly related to the support of the individuals on the APSW’s caseload; and
  • the availability of community resources and the amount of time the APSW is dedicating to help the individuals acquire the supports they need.

Caseloads should be managed so that APSWs can effectively fulfil their roles and responsibilities supporting those on their caseloads. Supports are tailored to individuals’ needs while encouraging as much independence in the community as possible.

Developing Community Capacity and Inter-agency Relationships

An important role for the APSW is to help individuals use natural supports as one of the primary and most meaningful ways of enhancing the lives of people with a developmental disability. Natural support refers to the support and assistance that flows from the associations and relationships typically developed in environments such as the family and community.

To accomplish this goal, the APSW should play an active part in enhancing their community’s capacity to connect with, include and involve adults who have a developmental disability. The APSW should also seek to increase community awareness and develop partnerships for supporting people who have a developmental disability.

The characteristics and opportunities for enhancing community capacity will vary from one community to the next. The APSW may use a number of strategies to improve community capacity starting with developing a good understanding of the range of opportunities and services and supports that exist in their communities and the organizations that function within them. The APSW should look for opportunities to work with community groups to identify barriers to accessing some aspects of the community and could begin by developing strategies to overcome them.

The APSW is encouraged to establish positive working relationships with all sectors of the community as an essential component to developing community capacity. These relationships give the APSW an opportunity to provide information to the range of community networks and organizations to raise awareness about the valued social roles and positive contributions that people who have a developmental disability can make.

At the broader community level, the APSW could participate in networks and organizations that have decision-making responsibility for the delivery of generic community services, programs, or the allocation of resources. This could influence the degree to which decisions made at the community level reflect the diversity of the community by responding to the needs of adults who have a developmental disability.

Best Practices

A useful approach may be to develop partnerships with organizations that represent people who have other forms of disability to aid in informing and educating local business, recreation and social networks about the rich diversity of people that are part of their community. Depending on the community, some examples of strategies for developing community capacity could include engaging local business improvement associations or social planning councils.

At an individual level, opportunities could be sought for linking individuals with other people, groups and activities in the community that meet the individual’s personal goals and needs.

Greater participation in natural, generic community supports and programs promotes the concept of social inclusion, enhances individuals’ valued social roles and places people with a developmental disability in the life of the community, to the benefit of all.