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Making Life WorkFreedom and Disability in a Community Group Home$

Jack Levinson

Print publication date: 2010

Print ISBN-13: 9780816650811

Published to Minnesota Scholarship Online: August 2015

DOI: 10.5749/minnesota/9780816650811.001.0001

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Paper Technologies

Paper Technologies

Doing and Documenting

Chapter:
(p.163) 8 Paper Technologies
Source:
Making Life Work
Author(s):

Jack Levinson

Publisher:
University of Minnesota Press
DOI:10.5749/minnesota/9780816650811.003.0009

Abstract and Keywords

This chapter explores the techniques for monitoring, assessment, and intervention that shape what counselors can see, know, and do at Driggs House. A significant part of the work at Driggs House involves the ongoing collection, assessment, and display of data about the work. The paperwork that counselors are always rushing to keep current is vital to their work. And though they may regard paperwork as a burdensome distraction, it is actually integral to what they consider as their “real” group home work. As embedded attributes of group home work, paper technologies shape what counselors and residents can know and do. The chapter also describes how paper technologies at Driggs House organize the work they document and translate the ideal of individualized service into practical matters of work.

Keywords:   paper technologies, monitoring, assessment, intervention, counselors, Driggs House, paperwork, group home work, individualized service

To focus on the technology of an organization is to view the organization as a place where some type of work is done, as a location where energy is applied to the transformation of materials, as a mechanism for transforming inputs into outputs.

—W. Richard Scott, Organizations: Rational, Natural, and Open Systems

A SUBSTANTIAL PART OF THE WORK AT DRIGGS HOUSE comprises the ongoing collection, assessment, and display of data about the work. The shelves in the staff office are lined with binders that document the lives of residents in multiple ways: daily, weekly, monthly, annually. These books, and the forms they contain, are more than just instrumental means of administrative and clinical operation; they are technologies that organize group home work, in its course, as a central aspect of that work. They involve many of the techniques for monitoring, assessment, and intervention that shape what counselors can see, know, and do at Driggs House. I approach records and written documents as technologies, drawing on a concept of technology developed largely in the social studies of science. I do not understand technology either in opposition to nor as the mere enhancement of cognition and perception, considered as distinctly human capacities. The technological transformation of human capacity may often involve quantitative enhancement, just as microscopes make it possible to see the unseen by making the tiny appear large. However, it is largely the qualities of seeing and knowing in new ways that begin to capture the complex role technology plays in human life and experience. At Driggs House, the paperwork that counselors are always rushing to (p.164) keep current is central to their work. And though they may regard paperwork as a burdensome, if necessary, distraction, it is actually integral to what they regard as their “real” group home work. As embedded aspects of group home work, paper technologies shape what counselors and residents can know and do. In this chapter, I pick up the discussion about technology from chapter 2, with a brief overview of the concept in various fields. Then I describe how paper technologies at Driggs House organize the work they document and, in multiple ways, translate the ideal of “individualized” service into practical matters of work.

Technology

The distinction between authority based on technical competence and authority based on bureaucratic hierarchy has widely influenced the study of work and organizations. Charles Perrow (1986), 42) argues that this distinction reflects a misunderstanding of Weber’s analysis by presuming a narrow concept of expertise that “fails to recognize the technical character of administration.” Research on organizational structure has historically defined technology as the apparatuses and processes of production in manufacture. Even conceptual attempts to encompass human knowledge and skill have excluded administrative competence (Perrow 1986;W. Scott). In Perrow’s classic paper (1967), he argues that, in order to understand a wide range of work organizations, technology should be defined by the character of the material being worked. This allows for a dynamic classification of organizations based on the relationship to their technology: distinct organizational forms develop in relation to the specific requirements of their unique raw materials. Whether the material is steel, paper, or human conduct, the specific kinds of work each requires are part of the “core technology” of plants, mills, and group homes. Fundamental to the way organizational structure is related to its core technology is the degree to which tasks are routine, and the less routine they are, the more latitude for discretion they require. Despite Perrow’s broader concept of technology, as in much organizational theory, records and written documents remain merely “basic coordination mechanisms” (W. Scott, 231). Though documentary practices may reduce the degree of task complexity and uncertainty related to a particular core technology, they are not technologies themselves.

(p.165) The field of science studies offers a concept of technology that recognizes the multiple functions even of basic coordination mechanisms. Researchers critical of structural and cognitive accounts of the development and use of technology have demonstrated the reflexive relationship between the technologies that are so integral to scientific knowledge and the everyday work of scientists. PET scans, electron microscopes, high-energy physics detectors, and observatory oscilloscopes make visible the activity of brains, cells, atomic particles, and pulsars, but they are more than just neutral instruments. This is not a concern about validity or methodological distortion. The particular kinds of visual products that scientists can make of their work are embedded in and shape the practical problems and processes that organize research.1 In Latour and Woolgar’s study of a biology laboratory, they show that technologies of writing and graphing functioned as more than just tools for the efficient manipulation of vital information. The way data could be used depended on the formats in which they could be made available visually and the standardization and durability of visual display. Photographs, scans, diagrams, graphs, tables, charts, and the like are not simply neutral representational tools but embedded practices that enable the everyday work of science.

Historical research also demonstrates that technology does not just extend but enables new ways of seeing and knowing. John Law (1986a, 1986b, 1987) shows that, in the sixteenth century, the development of Portuguese navigational devices, shipbuilding techniques, and written protocols made possible new modes of communication and new political relationships. New kinds of persons were also both possible and necessary: the emissaries who traveled back and forth, more confident that the crucial knowledge they carried, not to mention themselves, would arrive intact. “Long distance control” (Law 1986a, 1987), or what Bruno Latour describes more broadly as “action at a distance,” depends on forms of knowledge that are durable, mobile, standardized, and reproducible. They both enable and require “centers of calculation” where information from afar can be received and evaluated, problems and courses of action assessed, and orders dispensed to be carried out elsewhere.

Conventional causal models of power are unable to account for the novel ways of knowing and acting that are harnessed through and enabled by specific technological innovation. As Latour (6) puts it, for example, “commercial interests, capitalist spirit, imperialism, thirst for (p.166) knowledge, are empty terms as long as one does not take into account Mercator’s projection, marine clocks and their markers, copper engravings of maps, rutters, [and] the keeping of the ‘log books.’” For Law (1986a, 236), technologies are “integral” to and “interwoven” with their social, economic, and cultural contexts: the “form” of technologies is “a function of the way in which they absorb within themselves aspects [of] their seemingly non-technological environments.” Michel Callon suggests “translation” as a way of understanding the reflexive relationship between technology and social action. Translation refers to the way forms of technical knowledge enable issues or problems to be realized practically and, at the same time, enable institutions and individuals to mobilize the actions of others.

Technologies of Government

In governmentality, technology is used similarly to emphasize the systematic orientation toward individual conduct that is characteristic of liberal societies. For reasons of logistics as well as legitimacy, the state’s interest and interventions in spheres of activity, such as the economy or public health, cannot occur through the direct control of citizens. Governing occurs at a distance—Miller and Rose adapt Latour’s phrase—by cultivating the capacities of individuals to govern their own conduct freely in relation to specific outcomes, according to the concerns of the state and the larger society. Similar to Perrow’s concept, governmentality focuses on the unique character of the material to be transformed: human conduct. In liberal society, human conduct is conceived, in effect, as a resource and, as such, emerges in a reflexive relationship to technologies of government. This “technological orientation to human being,” as Dean (1996, 60–61) puts it, requires that the capacities of individuals “be unlocked” and “harnessed”; governing involves the multiple “ways of conducting conduct, ways of acting upon the actions of others.”

Conduct can truly become a resource, in this sense, only when the attempts to shape it have the authority of scientific expertise and are rational, systematic, and calculative. Just as technologies of government align individual goals with broader social goals, technology is the “linchpin” that connects the government of conduct and scientific knowledge (Dean 1996, 47). What enabled psy knowledge to become fundamental to different fields was its ability to “cross a technological (p.167) threshold” (55). Community-based services provide an example, because, in the 1970s, governing individuals with intellectual disability was realized in the translation of the ideals of rights and integration into clinical problems. In the group home, this translation—of rights into the everyday technical work of becoming more independent—reflects the role of psy knowledge in contemporary society in general. This is more than a cultural or ideological matter. As a technology of government, Driggs House is an exemplary instance of the way psy knowledge and techniques have “grafted themselves onto other practices” (Rose 1998b, 87–88).

The weekly staff meeting, for example, should be considered as the gathering together both of the group home’s key personnel and of the paper technologies that are embedded aspects of the work they organize and document. In this sense, the meeting functions as the center of calculation and coordination at a distance for all the work being done. The varied technologies of monitoring, assessment, and intervention that establish the conditions of group home seeing and knowing also often organize the work of staff-meeting talk. For example, during a six-week period in which Jennifer’s doctor asked that her diabetes be monitored intensively, the staff meetings featured, far more than usual, certain technologies that document the health of residents. A good half hour of each meeting was devoted to the presentation and discussion of data that had been collected, organized, and analyzed over the previous seven days about Jennifer’s blood sugar levels, medication effects, and vital signs. Aspects of Jennifer’s routine conduct that were considered relevant were also monitored and assessed in equally systematic ways: what and how much she ate (that is, her eating behaviors or nutritional choices), how she conducted herself on doctor’s visits, her general attitude toward the problem, and so on.

It is worth emphasizing again that technology, in this sense, does not stand in opposition to all that is human. “Quite the reverse,” Rose (1998b, 88) explains, because technologies of government are “most frequently the promise of personhood, of being adequate to the real nature of the person to be governed.” The term “technology” points to “the characteristic ways in which practices are organized to produce certain outcomes in terms of human conduct: reform, efficiency, education, cure, or virtue … [and to] draw attention to the outcomes—ways of combining persons, truths, judgements, devices, and actions into a stable, reproducible, and durable form.” In this sense, the role (p.168) psychology has played in the community cannot be seen merely as supplanting coercive control in institutions with a normative form of technocratic control. Although Driggs House certainly does “manage” residents, it also enables a kind of psychological personhood (Rose 1998b, 27). The effective operation of the group home depends on the capacities it cultivates in residents to govern themselves freely as selves of endless improvement and potential independence.

To Rose’s outcomes of human conduct could be added independence. The promises of personhood translated in the paper technologies of Driggs House make certain persons and problems visible and knowable in everyday group home work.

Records and Written Documents as Paper Technologies

Most social science research on records and written documents has not treated them as social phenomena in themselves.2 By contrast, ethnomethodology provides an approach to records and written documents much as though they are technologies as I have described: as reflexive, “sense-making procedures” that depend on and shape what can be seen and known in the practical course of work. Ethnomethodologists have sought to understand the unavoidably practical and constitutive character of records in specific settings (Heath and Luff; Parton; Sellen and Harper; Zimmerman 1969a, 1969b). In Garfinkel’s well-known paper “Good Organizational Reasons for ‘Bad’ Clinic Records” (1984b), he argued that when researchers used ideal administrative or clinical standards, the “poor” and “incomplete” quality of psychiatric records was apparent. This wasn’t so when they were evaluated in light of the “organizationally relevant purposes and routines” of clinic work. Social science researchers make an error by treating records as “actuarial,” because reading them “correctly” relies on the practical know-how that is always a central feature of an organization’s everyday work. Tony Hak shows how psychiatric reports reflexively transform the nature of a case in an ongoing process of “reformulation” that depends on the practical methods of both psychiatric and everyday reason.

Dorothy Smith (1990) uses ethnomethodology somewhat differently, to study the ideological function of “textually mediated forms of social organization,” which she emphasizes are characteristic of institutional control in contemporary societies. Documentary technologies are the forms of accountability—and, literally, the forms—that are a (p.169) major part of community services systems. Lipsky argues that in street-level bureaucracies, the compliance function of records is substantial. The increasing emphasis on accountability and bureaucratic rationalization in social services largely reflects ongoing tensions about public resources, but in services for intellectual disability there is an additional political dimension. The extraordinary professional abuse represented by institutions—especially after Willowbrook—resulted in the extraordinary reliance on formal mechanisms of accountability to prevent such abuse and neglect from happening again. At least in New York State, since the 1970s, part of the technical solution of community-based services has been a complex regulatory climate that involves the authority of state and federal agencies over a vast network of both public and private provider agencies and local settings. As Michael Power shows, a “mistrust” is translated in the elaborate audit technologies that are now an aspect of almost all professional service. Audit technologies are the “control of control,” governing professional activity, ideally, by making it transparent without undermining its autonomy (Power; Rose 1996). Yet audit technologies also do more, shaping the activities of professionals in particular ways. Lynch, Livingston, and Garfinkel use the term “compliance documents” to describe the organization of scientists’ accountability, for example, much as Callon uses “translation” to characterize the relationship between technology and power in terms of the ability to define and mobilize the actions of others.

The ideals of accountability and service converge at Driggs House in the paper technologies that enable it to govern at a distance. “For a domain to be governable,” Rose writes, “one not only needs the language to render it into thought, one also needs the information to assess its condition. Information establishes a relay between authorities and events and persons at a distance” (1998b, 73). There is, naturally, a far greater distance between Brazil and Lisbon (especially in the sixteenth-century example cited earlier) than between Driggs House and its parent agency or between that agency, in New York City, and the State Office of Mental Retardation, in Albany. It is the same with the distance between persons: between Mike and Sonia, between Sonia and her counselors, between counselors and residents. Each involved a relationship of government that required the ability to mobilize organizational or individual others indirectly to act in certain ways. The paper technologies enable the government, at a distance, of (p.170) the relationships they organize between the agency, the group home, the counselors, and the residents, each as a particular kind of selfgoverning entity.

Translating the Ideal of Individualized Services

In the OMRDD regulations, the “overall” goals of residential habilitation services are to promote and encourage independence, integration, individualization and productivity” (14 N.Y.C.R.R. § 671.1). These goals, abbreviated as 3IP, are expressed broadly in the regulations, which provide only general instructions about habilitation services. They are formulated as ideal goals of service and, at the same time, as “opportunities” to pursue each goal. That is, as guidelines, the 3IP are the opportunities that a service and its form of delivery must both provide. Another way of putting it is that the particular “service”—working on personal hygiene, for example—is both the goal and the opportunity to pursue it, which means that the form of service delivery itself is a main concern. In this way, a recognition that goals must be translated into practical work is embedded in the regulatory language. Independence is defined by “opportunities to develop capacities that lessen his/her dependence”; integration, by “opportunities to engage in experiences and activities with those who are not disabled”; individualization ensures that in services “the person is given meaningful choices, respected, addressed and provided services in terms of his/her unique and valued individuality”; and productivity is defined by the “opportunities to make an increasingly meaningful contribution to his/her living and community environment” (14 N.Y.C.R.R. § 671.6).

The translation of the ideals of 3IP into everyday work occurs in specific technical ways related to making services accountable for billing and reimbursement under the government-funding program. Habilitation services are funded through a state-federal Medicaid Home and Community Based Services Waiver Program (HCBS). Put simply, state requirements that define “medical” services narrowly are waived. The waiver allows Medicaid funds to be used for the variety of services that enable individuals who do not actually require a nursing facility to live in a community setting. The HCBS waiver was introduced in 1991 as an alternative to earlier Medicaid funding schemes that provided a set amount and standard package of services for each resident.3 The point of the waiver is to enable an “individualized services environment” (p.171) (ISE) by providing separate funding mechanisms for services, on the one hand, and room and board, on the other.4 In the New York State regulations, an ISE is described as

a service delivery system in which the person’s living arrangement and service delivery … are not linked, with services considered discretely rather than in a package. That is, housing and services are mutually exclusive considerations, as is the selection of specific services from the list of available approved services. The individualized services environment is in distinct contrast to an overall or comprehensive residential services model, in which housing and some services are intrinsically linked (i.e., where a person lives determines the services received). In the individualized services environment, where a person lives has no necessary connection to the services received, even those which may be received at the housing site. The administrative separation of housing from service, and the separation of services from categorical groups, is the keystone of the individualized service environment structure. It is this feature which makes it possible to achieve the goal of designing completely individualized service plans.

(14 N.Y.C.R.R. § 635–99.1)

An ISE, in principle, must be assembled for each resident service by service. And because each habilitation service must be billed separately, the funding mechanism shapes how the ideal of individualized services is translated into group home work.

The waiver program requires that each resident have a “service coordinator” in addition to and independent of group home staff. The purpose of the service coordinator is to ensure the resident’s adequate participation in planning his or her services, that those services are implemented as planned, and that “comprehensive coordination” is provided, which means the service coordinator’s work encompasses all the settings (both for services and living arrangements) in which the resident is involved (14 N.Y.C.R.R. § 671.1). To ensure independence from group home services, residents have the right to select their own qualified service coordinator. However, many agencies, including the parent agency of Driggs House, now have separate service coordination departments, which assign service coordinators unless a resident specifically requests one from elsewhere. This arrangement has obvious fiscal and administrative advantages for voluntary agencies. Castellani argues that voluntary agencies benefited in New York from the State’s extensive reliance on Medicaid funding schemes from the outset in the late 1970s, which facilitated a rapid expansion of the private-public systems that have characterized community-based services.

(p.172) Service coordinators are at the group home a few times per month, as well as for case conferences and other special occasions. There is always a potential for conflict with the counselors who provide services daily, because the service coordinator is central to the planning and implementation of group home work and is in a position to question or challenge counselors’ work there. In practice, however, service coordinators and counselors perceive each other as colleagues, and they share the basic overall goal of work: to help the residents become more independent. There are occasions when service coordinators ask counselors to explain why a resident’s goal was discontinued or how a resident’s complaints have been addressed. And it happens, though rarely, that counselors describe service coordinators as posing obstacles in their work, much of which actually overlaps in complementary ways. Although counselors recognize the general historical and legal reasons for an oversight mechanism such as the service coordination requirement, in some moments they resent the implication of mistrust and describe the requirement as a duplication of the services they themselves provide. What tension arises is mild, however, because of both the complementary overlap of responsibility and the clarity provided by the specific division of labor. Service coordinators, for example, are responsible for arranging any special or unusual activities, such as a resident’s vacation with one of the agencies that runs tours for adults with intellectual disability. As the direct-service providers, counselors are responsible for the everyday logistical work of preparation and arrangement for pick-up and drop-off. If a resident is bugging a counselor about whether a trip has been finalized, he or she may be directed to the service coordinator. If the counselor discovers from the service coordinator that such a referral has slipped her or his mind, then the counselor may ask that it be responded to “ASAP,” either because it seems unfair to make the resident wait any longer or simply because, as I heard Sally say once, “this needs to be done so Diane’ll get off my back.”

Paper Technologies: The Organization and Documentation of Accountable Work

The “treatment book,” the comprehensive record maintained for each resident, lies at the heart of group home operations. The term “treatment” is oddly anachronistic in community services, notwithstanding (p.173) the encompassing notion of treatment that emerged in the courts in the early 1970s. At Driggs House, the name “treatment book” does not capture how it figures in counselor work, though it may well reinforce the sense of the clinical importance of the job. Gathered in each resident’s treatment book is all the information deemed relevant, for a variety of reasons, to the resident’s “placement” in the group home. It is a “master technology,” because the treatment book comprises all the documentary technologies that it organizes and monitors. These documentary technologies are the various practices of accountability and knowledge production about group home work that are primary aspects of that work. In the simplest sense, the treatment book functions as a technology because it is a physical object that enables counselors to collect, transport, and store their ongoing work. More than this, the way in which group home work is organized is reflected in the physical organization of the treatment book: it is divided into sections, which, like their contents, are ordered in a standard and specified way.

The treatment book is the material realization of the group home in a single technology. The book’s very organization can be understood as a reflexive, technical rendering of group home work. The sections into which it is divided and the standard placement of forms, evaluations, and assessments within it mark out the group home’s accountable domains. Inside the cover, preceding the titled sections, is the face sheet, which makes readily available a resident’s most basic information: name, date of birth, government-issued identification, diagnoses and special medical issues, and family and emergency contacts. Following the face sheet are the agency forms regarding placement and services (which include signed consents), the OMRDD assessment, and other eligibility instruments that establish diagnoses, personal abilities, level of care, and so forth. After this initial section are titled sections that contain the specific documentation pertaining to each: psychological, medical, vocational, and financial, among others. Each section is indicated by a divider and includes the various reports, assessments, and evaluations, whether required or otherwise, that document the specified aspect of the resident and his or her group home life in the ways identified as important to the overall goal of services and as auditable by the State of New York.

The OMRDD establishes minimum criteria for the annual and semiannual “documentation [affirming] that services are necessary to meet the person’s needs” and that they are being met, but exactly how (p.174) the treatment book is ordered and what it contains is up to the service provider (14 N.Y.C.R.R. § 671.6). In fact, an agency providing services has a great deal of discretion over the design and use of its own paperwork systems. As long as they meet the state’s minimum criteria, documentary practices may reflect the specific commitments or services of particular programs and may even be designed for internal monitoring and accountability. These documentary technologies function as specifically “auditable” practices of group home compliance. This regulatory strategy—“to set forth the specific minimum requirements and standards” (14 N.Y.C.R.R. § 633.1)—reflects how New York State authority operates over these services. OMRDD regulations are not unusual in the latitude that state agencies allow voluntary service providers. One explanation of this latitude is that it reflects trends in neoliberalism and privatization. As Castellani argues, New York’s public-private services system originated in the state’s use of Medicaid funding in deinstitutionalization, which expanded the role of established parent-based and other voluntary service providers. However, the latitude can also be understood in terms of how services on this scale must be governed at a distance, something which no doubt both reflects and shapes the changing role of the state. Such regulatory latitude permits, even encourages, agencies to translate general principles of compliance into their own technical systems to reflect a variety of circumstances and philosophies of service practice (cf. Argent).

The service coordinator’s chief task is to prepare annually each resident’s Individual Service Plan (ISP). The ISP is a comprehensive descriptive evaluation of an individual, his or her needs, and the services being provided. Service coordinators are “responsible for assisting the person … as needed, in creating and sustaining an individualized service environment by developing, implementing, reviewing and revising the [ISP]” (14 N.Y.C.R.R. § 671.1). Central to the provision of services, it is the technology that organizes a resident’s annual case conference: a new ISP is prepared based on the decisions made at the case conference, though service coordinators actually prepare it ahead in consultation with the resident and his or her primary counselor. At the conference, the new ISP is signed by everyone in attendance.

Service coordinators maintain their own master technology for each resident—the service coordinator’s book—which is kept in the staff office. It is best understood as the documentary equivalent to the group home’s treatment book in a parallel system of accountability. (p.175) The service coordinator’s book contains the ISP, notes on discussions with the resident, both scheduled and unscheduled, and notes on the special services arranged, usually with outside providers (such as holiday agencies). For the service coordinators, the book on each resident documents what it organizes: the ongoing monitoring of the ISP’s implementation. Though the ISP, which I will describe in more detail, is the responsibility of the service coordinator, it requires and depends on six paper technologies that are a main part of a counselor’s work. These six technologies involve the actual provision of habilitation services: the “activities, interventions and therapies” that promote each resident’s “independence, individualization, integration and productivity” (14 N.Y.C.R.R. § 671.1). Together, they translate the ideal of individualized service into the everyday work they document. They are assembled in the “Progress” section of the treatment book (which is second, after “Psychology”).

“Progress” contains the following: a copy of a resident’s Individual Service Plan (ISP) and the counselors’ six technologies that form a network that translates the ideals of independence, integration, individualization, and productivity into actual everyday work. What makes them a network is that each is designed in relation to the technical requirements of one or more of the others. Each technology makes habilitation services accountable in different ways, furnishing specific documentary procedures of defining, collecting, formulating, analyzing, and displaying knowledge about the residents’ services. The knowledge produced by each technology is usable for its own specific purposes, one of which is always the ongoing transfer of knowledge to or from other technologies in the documentary network. This involves the standardization characteristic of all technical forms of knowledge, especially procedures of simplification that permit ease of circulation and administration in ways that preserve a recognizable object (Knorr-Cetina; Latour; Star). As work tasks that are also durable forms of knowledge, these technologies can be physically gathered and brought to meetings, and are available to staff not copresent, across shifts, and up and down the chain of command. This network forms the technical basis for the ongoing government of group home work at a distance by organizing several relationships of accountability at once: between the group home and the OMRDD; between counselors and their supervisors; between residents and their counselors; and between group home workers and themselves. (p.176)

Paper TechnologiesDoing and Documenting

The network of counselors’ paper technologies

  • Residential Plan of Services: lists a resident’s “identified needs” and services—all the “activities, interventions and therapies”—by allowable category in the group home and elsewhere

  • Annual Summary of Services: indicates all services a resident has received during the year and a description of his or her progress

  • Monthly Progress Notes: list a resident’s current services and indicate whether they are effective

  • Goal Plans: the clinical plans written for individual residents to address specific aspects of conduct

  • Data Collection Technologies: the variety of technologies used, usually daily but sometimes weekly, to monitor the progress of each goal

  • Habilitation Services Billing Form: documents monthly the resident’s services for which provider agencies will claim government reimbursement

(p.177) These six technologies, which are the responsibility of counselors, all determine and are determined by the ISP. The ISP is often more than ten pages long and contains an abundance of factual information about financial entitlements, names and addresses of service providers, day treatment programs, a resident’s capacity to evacuate in emergencies, and more. But a documentary emphasis does not encompass the function of the ISP; it also contains narrative descriptions meant to capture the individuality of a resident. Service coordinators are urged to understand an individual’s preferences and personal goals in terms of the 3IP. According to an OMRDD training manual for service coordinators (2000), the ISP is meant to reflect every aspect of a resident’s life and “to help the consumer achieve his or her Individualized Services Environment.”

The ISP is the waiver program’s central technology and translates the regulatory ideals embodied in the concept of the ISE.5 In the regulations, “ISP” sometimes refers to a single documentary technology:

[The ISP is] … the written document that is developed … [that] describes the services, activities and supports, regardless of the funding source which constitutes the person’s individualized service environment. The goal of the individualized service plan is to ensure the provision of those things necessary to sustain a person in his/her chosen environment and preclude movement to [a more restrictive setting]. These services, activities and supports, identified in the individualized service plan, are to reflect the preferences, capabilities and capacities of the person and emphasize the development of self-determination (i.e., making personal choices), independence, productivity, and integration into the community.

(14 N.Y.C.R.R. § 686.99)

But “ISP” also refers to the system (or what I call the network) of technologies that it coordinates and on which it depends:

[The ISP is] a written person-oriented record system … which documents the process of developing, implementing, coordinating, reviewing and modifying … [the system itself]. It is maintained as the functional record indicating current assessments, all planning activities as well as services (i.e., activities, therapies and interventions), and interventions provided to the person…. It constitutes the main portion of the clinical record.

(14 N.Y.C.R.R. § 671.99)

The ISP translates the ideal of individualized services into everyday work for counselors and residents: the documentary tasks and goals of conduct, each of which is a service. The waiver funding mechanism (p.178) requires that each service be billed separately, which enables the ISE to be more than rhetoric. The ISE for each resident realizes technically the combination of customized services and outcomes. Professional expertise, the state-federal waiver funding mechanism, and provider accountability all come together in the selection of “allowable” services, which are formulated in the state regulations as categories of “skills training” to “promote” or “maximize” a resident’s 3IP.6 Specifying categories of allowable services in the regulations is about not delimiting but enabling the nature of clinical problems, providing a mechanism by which the everyday clinical work of service selection automatically produces standardized accountability in other systems. Thus, “individualizing” services makes certain aspects of providers’ clinical work specifically auditable across the network of six technologies outlined earlier.

The ISP is the central coordinating technology in habilitation services, but it is the residential plan of services that is at the center of the counselors’ documentary network. The residential plan of services specifies a resident’s chosen habilitation service outcomes, developed at his or her annual case conference and described in the ISP, and incorporates any ongoing modification or substitution of goals. At the case conference, the annual summary of services is used to review a resident’s progress in the past year, furnishing, at a glance, eleven months of counselors’ documentary work. The summary presents the durable and mobile data that have been collected, organized, and displayed by the monthly progress notes and the often daily documentation of progress with specific goals. Finally, counselors submit monthly the billing form to the supervisor, the information from which is used ultimately by the agency to claim reimbursement under the waiver program.

What Do You Need to Be Working On?

To illustrate the network of documentary technologies, it makes sense to begin with a relatively simple goal plan. Goal plans are the most specific and individualized technology in the group home, because they translate specific individual “needs” and “preferences” into systematic and accountable clinical work. The basic formula of a goal plan includes a concise statement of the plan’s outcome(s) of conduct, the plan’s rationale, specific techniques for the resident and staff to follow, and procedures for documenting the resident’s progress (and sometimes the staff’s conduct).

(p.179)

Paper TechnologiesDoing and Documenting

James Franklin’s personal appearance goal

Driggs House staff developed a “personal appearance goal” for James, because he occasionally neglected his personal appearance and they regarded this as a sign of his depression. It was agreed that the use of a daily checklist would, as the plan reads, “help James selfmonitor his appearance and provide assistance in times when he is having a depressive episode.” The outcome for James is stated thus: “James will monitor his personal appearance daily.”

The goal plan specifies the following procedure: “James will be presented daily with his personal appearance checklist and will be required to work through it independently.” When James achieves the outcome, the plan specifies for counselors a technique of reinforcement: “James will be verbally praised for looking well groomed.” In the conduct specified for James and the counselors, the goal plan establishes an association between James’s depression and managing his appearance. (p.180)

Paper TechnologiesDoing and Documenting

James Franklin’s appearance checklist

Even though the goal plan names an association between a resident’s inner state and conduct that is regarded as its visible manifestation, such a plan cannot be considered simply to have constructed or to be the origin of the association. What the plan does, as it emerges reflexively in the course of counselor work, is to translate a problem into techniques of assessment, intervention, and documentation as part of that work. The goal plan itself—the photocopyable technology—could be said to formalize the practical conditions for certain persons by explicating the possible ways of knowing and acting on them. In this case, those practical conditions are shaped by how the plan organizes contact between James and the counselors and in the relationship it organizes between James and aspects of his own conduct.

Counselors are required to “document whether James was able to monitor his personal appearance on the data sheet + (yes) or − (no).” This daily work of collecting goal data forms the basis of the monthly progress notes. The regulations require that “progress notes shall be recorded, at least monthly, by the staff member(s) having a substantive responsibility for delivering or monitoring delivery of the [residential] plan of services” (14 N.Y.C.R.R. § 671.6). Counselors must complete monthly progress notes for each resident on their caseloads and file them in the residents’ treatment books. Only James’s personal appearance goal is used here to illustrate the monthly progress notes, which are usually several pages long. (The residential plan and annual summary of services are also illustrated this way here.)

These paper technologies not only organize the services they document but also create certain conditions of accountability within the group home. Certain technologies make aspects of counselor work specifically visible to the supervisor. Just as progress notes can be used to (p.181) monitor the progress of residents on a monthly basis, for example, they can be used to monitor counselors, because they make visible to the supervisor certain aspects of their work, much of which takes place out of view in individual contact with residents. In this way, the schedule of review and revision of habilitation services required by the state provides technologies for supervision within the group home. The ability to follow instructions and meet simple deadlines, in addition to assessment and writing skills, was available to Sonia as an indicator of the counselors’ organizational capacities, knowledge, and commitment to their work. At the end of each month, counselors were required to submit to Sonia the completed monthly progress notes and billing summaries for each resident on their caseloads.

The network of documentary technologies organizes a chain of accountability that stretches from the daily details of a resident’s goal work to the performance of individual counselors to the performance of the supervisor (reflected in the data she submits to the agency) and thus to the performance of the group home overall. These relationships of accountability extend indirectly all the way up to the state. It is through the technologies submitted by Sonia that the agency governs her and the group home site at a distance; in turn, the agency must continuously demonstrate to the OMRDD that the standards of certification are being met in each of its facilities in order to operate and therefore to receive reimbursement (14 N.Y.C.R.R. § 635–4.2).

The monthly progress notes show how techniques of collecting data on goals make those data durable and transferable as they move across the network of documentary technologies. The monthly progress notes must identify a resident’s specific services, indicate when and how they are delivered, significant events that have occurred in relation to their delivery, and any recommendations for change. The daily monitoring of each goal, the monthly notes that monitor each resident’s progress, and the semiannual case conference are aspects of an ongoing, ever-adjustable review process.

The residential plan of services is the technology that reflexively organizes, modifies, and documents this ongoing process by identifying each chosen category of service, the “need” it addresses, and the form of its delivery. The residential plan is used to record any modifications in a resident’s service outcomes or services as they occur. Between annual case conferences, each resident has a six-month conference to review his or her goal work and ongoing medical, personal, (p.182)

Paper TechnologiesDoing and Documenting

James Franklin’s data sheet

(p.183)
Paper TechnologiesDoing and Documenting

James Franklin’s monthly progress notes

(p.184) or vocational issues. The residential plan of services is central to the six-month case conference, because it reflects, or is amended to include, any changes that have been made since the annual conference. At the annual conference, the annual summary of services is used to make an overall assessment of the resident’s habilitation services over the past year. It organizes twelve months of data about services, transferred in
Paper TechnologiesDoing and Documenting

James Franklin’s habilitation services billing form

(p.185) various ways from the monthly notes and goal data where they have been collected, into a form that is easily readable and usable at a glance by the service coordinator and others involved in the annual serviceplanning process.

As the primary deliverers of service, counselors are responsible for maintaining this network of technologies. They are also responsible

Paper TechnologiesDoing and Documenting

James Franklin’s residential plan of services

(p.186)
Paper TechnologiesDoing and Documenting

James Franklin’s annual summary

(p.187) for coordinating and documenting services provided by others (outside psychotherapists, speech therapists, physicians, and the like). The “description” required of specific services is a distillation of a year’s daily and monthly work that is organized by the other technologies.

Conclusion

The paper technologies of habilitation service delivery shape the group home’s particular temporality of progress. There must always be measurable progress, even when a resident has made no obvious progress in the simple sense. From the agency’s perspective, this is expressed in the emphasis on “continuity” in the clinical work, especially in the continuity of information that counselors can produce in their routine documentary work. As with many voluntary agencies, this one has its own compliance unit devoted to making sure that its various service sites are meeting the OMRDD’s basic standards for certification. To ensure that each site is at any time always auditable, the agency periodically audits its own facilities, because the state is entitled to do so randomly. In addition to the agency’s self-auditing, staff from the compliance unit periodically attend group home staff meetings to provide training in how to use the paper technologies and to emphasize why they are so important beyond the clinical aims of the group home. The focus of one training at Driggs House was the annual review process. The trainer concluded by summarizing her presentation this way:

All plans and goals are written with a one year target dated from the Annual Case Conference. At the [six-month] conference, progress is noted in specified sections on the [residential plan of services]. Addenda can be added if there are significant changes. The ISP must contain every plan, activity, or goal that is indicated on the [residential] plan of services or it cannot be billed. This continuity is one of the things that [the compliance unit] looks for. A new ISP must be written every year and there has to be some progress, some growth.

There must always be progress, and there can be. Progress is possible because of the ways in which the group home’s paper technologies organize the work they document. By examining these paper technologies, one can understand how what Latour (3) describes as “the precise practice and craftsmanship of knowing” is accomplished in the group home.

(p.188) Driggs House does not involve the attention-grabbing, even epochmaking technologies described at the beginning of this chapter. The knowledge produced in and about the group home does not include discoveries of neuronal receptors or celestial objects, and treatment books and goal plans may not be equivalent to PET scanners and observatory scopes. But even the group home can function only by acting at a distance in several ways, all enabled by the paper technologies that translate clinical and administrative ideals into accountable everyday work. As in a scientific laboratory, the production of knowledge about group home work forms an awfully large part of that work. What makes the group home very much like a laboratory is the role its own technologies play in making the objects of its work, and the work itself, knowable, seeable, and doable.

Notes:

(1.) See Beaulieu 2001, 2002; Dumit; Garfinkel, Lynch, and Livingston; Knorr-Cettina and Mulkay; Lynch 1985, 1993; and Traweek.

(2) The focus of most social science research has been on the unintended consequences or inappropriate use of records and written documents: as instruments of client control or worker discretion in people-processing work (Goffman 1961; Lipsky; McCleary; Meehan; Prottas), as professional organizational accounts that contrast with the perceptions and experience of crime victims (Fleury, Sullivan, and Bybee) and patients (Weiss), as inaccurate accounts of actual social work practice (Floersch; Monnickendam, Yaniv, and Geva), as evidence of racial and ethnic bias in juvenile justice (Mesch and Fishman) and in hospital (Weiss), or, more broadly, as central to control in organizations historically (Wheeler; Yates).

(3.) Social Security Act § 1915[c]; U.S. Department of Health and Human Services Health Care Financing Administration, 42 CFR 430.25.

(4.) I provide here only an overview of the waiver program, and my discussion is limited to those aspects which are relevant to group home work. For example, I do not address the complex calculation of room and board fees, which are paid by a combination of an individual’s federal entitlement and OMRDD funds, because this work is done not at Driggs House but at the main office of its parent agency. Since I completed my fieldwork, there have been some changes in the federal funding scheme and OMRDD practice, which I address briefly in the conclusion of the book.

(5.) The OMRDD is apparently concerned about its own contribution to a bureaucratic climate that discourages participation. One Medicaid Service Coordinator training manual instructs, “Avoid Acronyms. The use of unexplained or (p.253) confusing acronyms puts people off, and makes them feel uninformed. It’s okay to use acronyms—after you have explained what they mean” (OMRDD 2000).

(6.) The allowable categories of service are training in health skills, selfadministration of medication, socialization skills, communication skills, assertiveness/self-advocacy skills, behavior skills, community integration and resources utilization skills, motor skills, and employment skills (14 N.Y.C.R.R. § 671.5; 14 N.Y.C.R.R. § 635.10–4). (p.254)