Draft –Guidelines for delivering Family and

Community Based Care and Rehabilitation

Services for Differently Abled Persons

RIGHTS: Inclusion, Accessibility and Opportunities for Persons with

Disabilities in Tamil Nadu Project

Directorate for Welfare of Differently Abled

*This guidelines will be updated from time to time as approved by the Project Director, TN RIGHTS
 Glossary

ALF Area Level Federation

ATP Advance Tour Plan
BDO Block Development Officer
B-OSC Block- One Stop Centre
BMMU Block Mission Management Unit
CB Capacity Building
CBR Community Based Rehabilitation
CDPO Child Development Program Officer
CF Community Facilitator
CRW Community Rehabilitation Worker
CST Community Self Help Group Trainer
CSP Community Service Provider
CwSN Children with Special Needs
DAP Differently Abled Person
DDAWO District Differently Abled Welfare Officer
DWDA Directorate for Welfare of Differently Abled
Person
DPIU District Project Implementation Unit
DPO Differently Abled Persons Organisation
EIC Early Intervention Centre
F&CBCRS Family and Community Based Care and
Rehabilitation Services
HCP Home Care Program
HH Household
ID Identity Card
ICP Individual Care Plan
IEC Information Education and Communication
MG Maintenance Grant
MToT Master Trainer of Trainers
MIS Management Information System
NC Neighbourhood centre
RCI Rehabilitation Council of India
TP Town Panchayat
OAP Old Age Pension
OSC One stop Centre
SS Samagrha Shiksha
SC/ST Schedule Caste/ Schedule Tribe
SHG Self Help Group
SRE Social Registry Enrolment
SSHG Special Self-Help Group
SPIU State Project Implementation Unit
 TNSRLM Tamil Nadu State Rural Livelihood Mission
TNULM Tamil Nadu Urban Livelihood Mission
VHN Village Health Nurse
VP Village Panchayat
VPRC Village Poverty Reduction Committee

Table of Contents
Chapter -1 Background......................................................................................................5
 1.1 Context.......................................................................................................................6
1.2 Introduction to TN RIGHTS..........................................................................................6
1.3 Project Development Objective (PDO).........................................................................7
1.4 Project components.....................................................................................................7
1.5. Objective/Purpose of the Guidelines.........................................................................12
1.6 Outline of the guidelines............................................................................................12
Chapter-2 Family and Community Based Care and Rehabilitation................................14
2.1 What is Family and Community Based Rehabilitation (CBR)......................................15
2.2 Why family and community-based care and rehabilitation..........................................15
2.3 Objective of Family and Community Based care and Rehabilitation...........................15
Chapter-3. Implementation arrangements.......................................................................23
3.1 Overview of Institutional arrangement........................................................................24
3.2 Community Service Provider (CSP)...........................................................................25
Overview to roles and responsibilities of CSP staff..........................................................26
Chapter-4 Training and Capacity Building......................................................................38
4.1 Training key experts of CSP......................................................................................39
4.2 Training of CRWs and CFs........................................................................................41
4.3 Training of Caregivers by CFs and CRWs capacity building.......................................42
Chapter 5. Awareness and IEC...........................................................................................43
5.1 Awareness and IEC...................................................................................................44
5.1 Community Mobilisation.............................................................................................46
5.3 Orientation/Awareness activities................................................................................47
5.3.1 At the village level...................................................................................................47
5.3.2 Orientation to Stakeholders....................................................................................47
5.3.3 Orientation at Institutions........................................................................................47
Chapter 6. Monitoring and Reporting..............................................................................49
6.1 Background...............................................................................................................50
6.2 Reporting Flowchart..................................................................................................50
6.3 Monitoring of family-based services...........................................................................51
6.4 Monitoring of Community level services.....................................................................51
6.5 Monitoring and performance appraisal of the CSP.....................................................52
6.6 Reporting formats......................................................................................................53
Annexures.........................................................................................................................54
Chapter -1 Background
1.1 Context

Disability is one of the greater concerns as its prevalence is on the rise which
could be attributed to various factors such as aging populations and the higher
risk of disability in older people, global increase in chronic health conditions, etc.
According to the 2011 Census of India, 1 in every 50 Indian citizens (2.2%) is
either physically or mentally disabled. The overall prevalence of disability in India
based on secondary data analysis of the NFHS-5 survey (2019–21) was 4.52%.
(Pattnaik S, Murmu J, Agrawal R, Rehman T, Kanungo S and Pati S (2015 ) Prevalence,
pattern and determinants of disabilities in India: Insights from NFHS (2023)

Tamil Nadu is one of the pioneers to establish a separate department for the
welfare of Differently Abled Persons. Compared to other States, Tamil Nadu has
a wide range of initiatives for Differently Abled Persons (DAPs). The Government
of Tamil Nadu through various policies and initiatives has extended full support to
(DAPs in their pursuit of full and equal involvement in every aspect of society.
Various schemes have been announced by the Government to make sure that
the (DAPs) are in equal status to the other people through implementing 82
welfare schemes. With a budget allocation of about 800 crores per annum, the
State of Tamil Nadu is funding a wide range of programs and is far ahead of
other State Governments in terms of making enabling provisions for (DAPs.

Based on the knowledge gained, the Department has identified the gaps to be
filled and the challenges such working as silos in the operation of programs by
various department, a requirement of comprehensive service, and the last mile
connectivity persons at grassroot level, To address these gaps and challenges
Tamil Nadu Government is implementing the “TN RIGHTS project” with the
support of World Bank.

1.2 Introduction to TN RIGHTS

TN RIGHTS project aims to strengthen the department to promote Inclusion,
Accessibility, and Opportunities for Differently Abled Persons. The Project plays a
supportive role in streamlining GoTN’s policy and programmatic response for
inclusion, accessibility, and opportunities through a State-wide multisectoral
convergent for action on disability.
1.3 Project Development Objective (PDO)

The Project Development Objective of TN RIGHTS is to strengthen the social

protection systems and capability of the State of Tamil Nadu to promote inclusion,
accessibility and opportunities for Differently Abled Persons.

PDO indicators

1. Beneficiaries selected using the social protection delivery system

2. Persons with disabilities receiving enhanced social care services and benefits
a. Women with disabilities receiving enhanced social care services and
benefits
b. Persons with disabilities from vulnerable groups (SC, ST) receiving
enhanced social care services and benefits
3. Models for wage and self-employment evaluated

1.4 Project components

TN Rights Project has the following four major components to promote and
facilitate Inclusion, Accessibility and Opportunity for DAPs. Each of the project
component activities will reinforce one another towards establishing a coordinated
and integrated service delivery to DAPs and their caretakers.
 Strengthen State Capability and Strengthen Last Mile Delivery of
Establish an Integrated Social Social Care Services and Benefits
Protection System

TN RIGHTS

Pilots to Enhance Resilience and

Contingent Emergency Response
Productivity of Persons with
Component (CERC)
Disabilities

Component – 1: Strengthen State Capability and Establish an Integrated Social

Protection System

This component focuses on building and strengthening the State’s capabilities

towards better delivery of benefits and services in an integrated manner. This
component will support a comprehensive state-wide program for disability inclusion
by enabling policy environment and standards, investments in capacities and
communication and an integrated Management Information System (MIS) in the
formulation of policies, standards and provision of enhanced service delivery will be
supported. Recognizing the multisectoral nature of disability and related
interventions, this component also supports strengthening the capacity of other
Departments to be disability inclusive.
The activities under this component are,

Creating enabling environment for persons with disabilities through

adequate policy and standards, mobilization and behavior change
communication

Strengthen Strengthening systems for disability assessment and determination

state capability
and establish Development and deployment of a robust social protection delivery
an integrated system for equitable, efficient, and transparent service delivery for
social persons with disabilities, including women with disabilities. IInter-
protection departmental convergent action and Implementation Support
system
Inter-departmental convergent action and Implementation Support.

Project implementation support to the DfWDAP and TNeGA.

Component 2: Strengthen Last Mile Delivery of Social Care Services and
Benefits
This component aims to improve access and quality of care and rehabilitation
services for DAPs. The project will facilitate a comprehensive ecosystem for social
care services for individual-centric needs assessment and care plan, service delivery
through family and community-based care and rehabilitation services led by a cadre
of trained frontline workers and create a strong referral network through a public-
private partnership. Special focus will be given to ensuring better inclusion and
access for women with Differently Abled Women.

Facilitating utilization
Social care and of health insurance
rehabilitation services
schemes for choice-
through one – stop
based access of public
social care centers
or private sector
(OSCs).
services.

Improving access to
Family and public infrastructure,
Community-based
housing, and mobility
care and rehabilitation Strengthen for Differently Abled
services Last Mile Persons
Delivery of
Social Care
Services and
Benefits

This component will function around delivering Family and Community-Based Care
and Rehabilitation Services through a blend of both institutions based/centre- based
rehabilitation and community-based rehabilitation approach to comprehensively
deliver services and provide life cycle interventions for DAPs and their families as
hub and spoke model,
 District Level/
Sub divisional
One Stop Social

Block/Zonal
level

Neighbourhood level
centres- cluster level

Home Based
Rehabilitation
Program-
Household
level

The activities under this component are,

 The family and community will be the first level of service delivery, where the
project with the Community Rehabilitation Workers' (CRWs) support will
ensure the delivery of relevant care and rehabilitation services facilitated by a
case management approach.
 The next level of service delivery will be the Neighbourhood Centres (NC) set
up at the cluster of villages/wards that will act as community-level platforms /
safe spaces for community engagement activities, delivery of life skills
education, parents/caregiver training, essential therapy services (periodic),
access to other social protection services, among others.
 The third level of service delivery will be the Block level One Stop Social Care
Service Centres (Block-OSCs) / Early Intervention Centres (EICs) that will
provide centre-based basic care and rehabilitation services to DAPs as well
as coordinate and supervise the family and community-based service delivery
through the network of CRWs.
 The fourth and final level of the social care service delivery model will be the
Sub-divisional level Integrated One-stop Social Care Centres (OSCs) that will
act as the Hub for the respective sub-division. The Sub Divisional OSC set up
in the District Headquarters/sub divisional will act as the District/sub divisional
level Hub for the social care service delivery. These OSCs will provide DAPs
with specialised centre-based care and rehabilitation services and coordinate
and supervise all the social care services within their catchment area.
 DWDAP will establish the OSC in every sub-division, while the remaining
three tiers of service delivery will come under these terms of reference.

One of the core focuses of the project is improving access and quality of care of
rehabilitation services for Differently Abled Persons(DAPs) by setting up a
comprehensive ecosystem for social care services. This will be done by supporting
three major strategic priorities:

 Strengthening the supply side through low-cost social care services through a
public-private partnership (community rehabilitation workers [CRWs] and
community facilitators) and by training home care partnership approaches
together with identification and use of a strong referral network
 Making a shift in the social care service delivery through family and
community-based care and rehabilitation services led by a cadre of trained
frontline workers; and
 Adopting a case management approach for persons with disabilities for
individual-centric needs assessment and care plan.
Component – 3: Pilots to Enhance Resilience and Productivity of Persons with
Disabilities
This component focuses on developing strategies for creating job and
employment opportunities and piloting models for enhancing resilience and
productive inclusion of persons with disabilities, especially youth (including young
women) with disabilities and households headed by single women in Tamil Nadu,

Pilots to enhance Resilience and Productivity of DAPs

Conduct market Design and deploy

Design and deploy select pilots to evaluate
assessments and jobs
select pilots to evaluate models for completion
diagnostics for
models for completion
of secondary education of secondary education
understanding the
demand and supply for Differently Abled
for DAPs
side. Persons.
Component – 4: Contingent Emergency Response Component (CERC)

This component will enable the Project to support immediate need – based
response to a contingent crisis or emergency.

1.5. Objective/Purpose of the Guidelines

This guideline is intended to prepare for bringing coordination and ease the
implementation of Family and Community Based Care and Rehabilitation under the
RIGHTS project. To help the Community service provider, tThis guideline will provide
focus on the package of services and staffing, monitoring and evaluation areas. The
Family and Community Based Care and Rehabilitation guidelines will also assist in
delivering individual and institutions responsibilities in handling day-to-day operations
related to the Project.

This Family and Community Based Care and Rehabilitation guidelines is the
primarymain reference document to be used by Community Based Rehabilitation
Workers, Community Facilitators, Community Service Providers, State and District
Project Implementation Units. The purpose of the guidelines is to provide a clear set
of guidelines and procedures, defining the objectives, purpose, Service Standard
including participatory planning, delivery of services including roles and
responsibilities, monitoring, re-assessment, transfer of skill and knowledge, etc.,
These guidelines will provide step by step guidance on planning and implementation
of Family and Community Based Care and Rehabilitation in TN RIGHTS project.

The DWDA may revise and/or amend the guidelines from time to time based
on needs and requirements based on the approval by the Project Director.

1.6 Outline of the guidelines

The guidelines in its first section explains the context underlying the disability
in Tamil Nadu, the challenges, introduction to TN RIGHTS, Project Objective and
project components rationale and outline for improving access to comprehensive
services in TN RIGHTS Project

The next chapter of the guidelines explains the overview and approaches to
implement the Family and Community Based Care and Rehabilitation services
through TN RIGHTS Project. The subsequent chapter gives details on
implementation arrangements of the Family and Community Based Care and
Rehabilitation including the roles and responsibilities of the frontline workers and
packages of services to be delivered through Family and Community Based Care
and Rehabilitation.

The next chapter of the guidelines deals with the Training and Capacity
Building at each level for effective implementation of the project. The chapter on
Awareness and IEC give details on Community Mobilisation, orientation to various
stakeholders and other strategies to be followed for effective communication of the
project and its visibility. The last chapter is on monitoring and reporting patterns with
formats to be followed during project implementation.
Chapter-2 Family and Community Based
Care and Rehabilitation
2.1 What is Family and Community Based Rehabilitation (CBR)?
For the project, CBR is defined as family and community-based care and
rehabilitation for providing integrated care and rehabilitation services to DAPs
in and within their community or to the extent possible closer to DAPs and
their families. This will be done by delivering a package of family and community-
based care and rehabilitation services by establishing an ecosystem of frontline
cadres to deliver rehabilitation services at household level and social care
services at community level for strengthening last mile service delivery to
DAPs.

2.2 Why family and community-based care and rehabilitation?

To address the multi-dimensional needs of DAPs, various strategies, and
models such as Institution Based, and Camp Approach, have been attempted to
provide services to DAPs. Despite various initiatives, the challenges remain in
terms of coverage, outreach, and last-mile delivery thus, making rehabilitation
services inaccessible to a sizable proportion of the DAPs especially in rural
areas.

Successful rehabilitation depends on strong partnerships between DAPs,

rehabilitation professionals and community-based workers. As the needs of many
DAPs change over time and they may require periodic support in the long term,
rehabilitation plans need to be person-centred, goal-oriented and realistic. CBR will
be a viable and sustainable approach for developing individual based rehabilitation
plan for DAPs by factoring their needs based on age, gender, socioeconomic status
and home environment besides fostering community participation.
In the community-based model of family and community-based care and
rehabilitation, it will be more cost-effective, better early identification and prevention
of disabilities and make services available closer to DAPs and their caretakers, as
the frontline worker will be handheld and guided by the rehab team.,
2.3 Objective of Family and Community Based care and Rehabilitation

The objective of Family and community-based rehabilitation is to improve the

quality of care and rehabilitation services to DAPs in their family and community
settings by strengthening last mile service delivery to DAPs.

The project aims to provide family and community-based care and

rehabilitation service by improving access and quality of care and
rehabilitation services for differently abled persons through the following 3
strategies-Family based activities, Early intervention/follow up and Community
based services as follows.

Diagram - Illustration of Family and Community Based Care and Rehabilitation

delivery model

Mobilisation of Differently abled Person

The first activity is to mobilise, screening and identify DAP children/persons. The
CSP will assign Community Rehabilitation Worker (CRWs) 3-5 villages/wards or as
needed based on the number of DAPs. The following steps will be followed for
mobilising the people for the screening and identification.
● The first level project information dissemination activities such as meeting and
informing CBOs and existing frontline workers in various other departments at
village level/ ward level (VPRCs, PLFs, SHGs, Village Panchayat office,
Anganwadi workers, DPOs, VHNs, schools headmaster, etc.,) will be carried
out by frontline workers (Community Rehabilitation Workers and Community
Facilitators)
● The project IEC materials will be displayed in these CBOs offices, Ration
shops, and in prominent places.
● The village social mapping exercise for mapping differently abled persons
(Disability mapping) location shall be done by the frontline workers with the
secondary data and information obtained during the interaction with CBOs.
● CFs and CRWs will participate in the monthly CBOs meeting. The
communication materials, information of the project will be shared to the
CBOs.
● CFs and CRWs will also participate in all the Grama Sabha/Area Sabha to
include disability agenda in the Village Panchayat Development Plan (VPDP)
● The Mobile Outreach Therapy Vehicle will disseminate communication,
screen films on disability, early identification, schemes and programs, etc.,
Screening and Identification

● The CRWs and CFs will map the villages/wards assigned to them and device
a plan in guidance with Block Coordinator/Community Service Providers
● The CRWs/CFs will take up visits to their assigned village/wards and
undertake a door-to-door screening of every household and schools, for
leaving no one left in the identification process.
● The frontline workers and block level specialists teams will support the school
level and hospital level screening jointly with the SSA team, RBSK, ICDS
workers and VHNs to identify children with disabilities.
● The project through its multi sectoral framework convergence action for
disability will also ensure seamless support of the screening and identification
of DAP children/people of the line department support
 ● The frontline workers will administer a simple screening checklist developed
as an app in handheld devices or as guided by the project to identify
differently abled children/persons.
● The identified and the suspected DAPs will be mobilised for assessment and
determination of their disability by competent medical officers either through
medical camps or facilitating and guiding them to DEIC/OSC.

Case Assessment of DAPs

The next activity will be the case assessment of the identified DAPs which will be
done through The Case management Tool (CMT).
The Case management Tool (CMT), a comprehensive and integrated tool developed
by the project will be used by the frontline workers and rehab professionals (at the
block level and OSC) through tablets/handheld devices for planning, delivering and
evaluating individual centric needs assessment and care plan.
CMT as to tool will facilitate to capture case history of DAPs, develop individual
therapy/education plan including referral services, monitor the rehab sessions by the
frontline workers and rehab team, evaluate the progress of the individual on the set
goals and facilitate to provide tele-rehabilitation service of experts to DAPs.
CMT will have different sections and each section will be designated with a level of
hierarchy such as for frontline works (works (CF and CRW), block and OSC rehab
team, DPIU and SPIU team to Create, Read, Update and Delete options at different
level to develop individual centric rehabilitation plan.
● The frontline worker will collect the case history which will include
demographic data, presenting complaints of DAPs/caretakers, etc., in the
CMT.
● Based on these information the DAP will be assigned to Sub Division/District
OSC for need assessment and case assessment. This will be done by
Rehabilitation Manager in the Sub Division OSC.
● Wherever there are severe DAPs/non ambulatory DAPs, the block team
during their home visit will do the case assessment at their households.
● Based on the individual assessment and need assessment, the DAPs will be
provided with one of the 3 or all 3 category of services such as Family based
activities, Early intervention/follow up and Community based services.
 ● The DAP may also be referred to other department for some other services.

Family based activities:

Under Family based activities the following activities are to be done
● Specialized Therapy and Guidance Services
Under the family-based activities, based on the individual assessment,
Individual Care and Rehabilitation Plan (ICRP) will be developed for DAPs
categorised for home based program support by the sub division OSC
team. The ICRP will include short term goals for therapy needs and
independent living skills based on the assessment. The short term goals
will be developed based on the participation and prioritisation needs of
theDAPs/caretakers.
The CMT will have provision to capture the ATP schedules of each DAPs
with geo tracking provision to monitor the frontline and block team visits,
goals planned for each 6 months, evaluate formative and summative
progress of the DAPs in each session, etc.,
● Home Based Care and Services
The frontline worker supported and shadowed by the block team will
provide regular home based follow up therapy and guidance services,
independent living skills as per the planned goals. Through the CMT
specialized therapy and guidance support will be made available by
connecting with the OSC team of experts through the tele rehabilitation
provision.
● Independent Living skills

DAPs will be provided individual centric skills for independent daily living
skill. The CRWs will be assisted to develop short term goals with the
involvement of the caretaker for Daily living activities based on the Individual
Education Plan (IEP). The CRWs shadowed by the block rehab team to
provide regular training to DAPs through regular home visit by transferring
skills and knowledge to care taker. Based on the prognosis on the short term
goals, subsequent goals/tasks for independent living skills will be developed
and captured in the case management tool.
● Appropriate Assistive devices
 In order to assist independent living, The CRWs and CFs will support
the DAPs and their caretakers for obtaining appropriate Aids and Assistive
devices. The CRWs and CFs will facilitate the DAPs to register themselves for
needy Aids and Appliances either through the online platforms (e- Seva
mayimum, OSC centre, etc.,) or through camps by DDAWO office till such
arrangement is made.
● Referral services for medical care and services
Based on the initial need assessment the CRWs and CFs as guided by
the block team will provide information and assist DAPs/caretakers for
appropriate medical care and follow up services. The CRWs and CFS will also
assist the DAPs to enroll themselves in the CMCHIS schemes and other
program.
● Guidance for skill training and support
At the household level the CRWs will provide information on the various
livelihood, skill training and schemes and programs that would be appropriate for
the DAPs for guiding them to wage and self-employment through skill training
and livelihood endeavours such as (NHFDC, bank loan subsidy. Aavin,PMEGP,
UPEGP, etc.,)
● Support Assistance for job and employment opportunities
The CRWs and CFs will provide informed about the job mela, job fairs, etc.,
that are being conducted near to them. The DAPs will also be supported to
participate in these camps for their job and employment opportunities.
● Social safeguard and Access to beneficiaries-oriented schemes
The DAPs will be facilitated and supported to social safeguard and access to
beneficiaries-oriented schemes and programs such as MG, OAP, Scholarships,
etc., The CRWs and CFs will facilitate registration of DAPs in e- Seva Mayimum
or through the case management tool
Early intervention referral and follow up
Under this service, the identified DAPs will be referred for early intervention
services for earlier rehabilitation services immediately on the onset of disabilities
identified to assist in minimising the impact of disability and improving the functional
ability, developing coping skills and inclusion, etc.,
 The frontline workers supported by the block team will assist the identified
DAP in referring to block centres, Early intervention centres, Block resource centres
for appropriate services. The frontline workers during their regular home visit
schedule will inquire about the status of the DAPs and guide them to continue the
services.
The frontline workers will provide utmost focus for the prevention of childhood
disabilities by closely working with ICDS workers, VHNs and CBOs. They will focus
on providing early intervention services for children aged 0-6 years who have been
identified as DAPs. The goal is to reduce, minimize disabilities and develop
preparatory skills to promote inclusion.

Community Based Services

The frontline workers will deliver community-based services to capacitate
DAPs/caretakers, facilitate community participation and engagement. This will be
done by establishing an ecosystem at a cluster of villages/wards namely
Neighbourhood Centres (around 7-10 village panchayats or as may be decided
based on the terrain and population of the village/wards.

Under Community Based Services the following activities are to be carried out
 Services of Neighbourhood centre
The Neighbourhood Centre (NC) will the community level hub to
provide basic therapy services, provide training for caretakers/parents, life
skill training to DAPs/caretakers, etc., through a cadre of Master Trainers
developed by the project (DPOs, CSP key experts, Block coordinator with
identified community facilitators). The NC will also mobilise DAPs/caretakers
for specialized therapy services by the rehab team during their mobile
outreach therapy vehicle visits.
 Capacity Building and Developing peer support group, interpersonal
communication support
The NC will serve as a community hub for mobilising DAPs/caretakers
to provide thematic based capacity building training, develop peer support
groups for learning and sharing together. The CFs will also provide inter
 personal counselling and communication support of experts through through
tele rehabilitation.
 Community sensitisation on program services/policies
Regular meetings with DAPs/caretakers and observation of
events/days will be carried out at NC for creating awareness, sensitising
community members and disseminate information. The block team along with
the OSC team and the CSP key experts organising IEC program through the
mobile therapy vehicle. By screening short films, experts advice through tele
rehab, etc.,

 Community engagements and citizen services

As a community hub, at the NC will work closely with the village level
institutions such as village panchayat office, ICDS, VHNs, Panchayat
Schools, association of Differently abled persons, SHGs, etc., The CFs
assisted by the CSP key experts will organise meeting with these CBOs for
facilitating and mainstreaming disability agenda for inclusion.
 Convergence with departments/ service providers
At the community level the CFs will convergence with the Village
panchayat for NREGAS job Card, housing schemes, etc., the CRWs and CFs
will also assist the inclusion of disability agenda in the Grama Sabha
meetings.
The CFs at the NC level will consolidate the needs and requirements of the
DAPs/caretakers. This will be further consolidated at the block level and
district level. The convergence requirements will be presented to the line
departments by the DDAWOs during the district convergence committee
meeting and will be followed for its compliance.

The institutional arrangements, implementation of family level and community

level interventions with the roles and responsibilities to deliver the above CBR
services are explained in the next chapter.
Chapter-3. Implementation arrangements
3.1 Overview of Institutional arrangement
Under the TN RIGHTS project the activities of Community Based
Rehabilitation services will be delivered at two fold levels; at the Household/Family
level and at the Community level.

Household/Family level
Community level
services through
services through
Community
Community FAcilitator
Rehbilitation Worker
(CF)
(CRW)

CBR servives by
Community
Service Provider

Household/Family level:
The Community Service Providers (CSP) will position at the frontline workers
namely the Community Based Rehabilitation Work (CRW) at household/family level.
Based on the number of DAPs, geographical terrain of the location such as
remoteness, hard to reach areas, tribal terrains, etc., one CRWs will be positioned
for every 2-3 village panchayat/wards. The CSPs during their inception report will
map each block villages/wards of each zone with the secondary data and propose
the number of CRWs required based on indicators such as (one CRWs for 75- 100
DAPs or based on the geographical terrain of the location).
The CRW will be the community level person who will provide the last mile
connectivity services to DAPs and their caretakers. The household/family level will
be the first layer in the CBR service institutional arrangement which will ensure the
availability of care and rehabilitation services to those severe and non ambulatory
DAPs at their door steps itself.
Community Level
Neighbourhood centre (NC) will be established by the CSPs for every cluster
of villages/wards. The CSP in their inception report will map each blocks/zones for
clustering villages/wards and identify suitable locations which are accessible for
DAPs/caretakers. The objective of the NC is to function as a community level hub
centre to provide the basic rehabilitation services and inclusion initiates such as
capacity building of DAPs/caretakers, community engagement activities, facilitation
of welfare and benefit oriented welfare service, etc.,
The CSPs at every NC will position one frontline worker namely the
Community Facilitator (CF) to deliver the community level services in the NC. The
NC at the community level will also be the information hub to provide information,
facilitate welfare benefits. the CFs will be the frontline workers who will closely work
and coordinate with the other department frontline workers to deliver seamless social
care and welfare services.
3.2 Community Service Provider (CSP)
Who is a CSP
A Community Service Provider (CSP) is an experienced
organisation/institution in implementing and delivering rehabilitation services to
DAPs. These are institutions who will have competency to provide implementation
support for the project CBR activities.
The CSP who will be engaged at a district level will deliver CBR services to
DAPs and their parents/caregivers by establishing the required institutional structure
and engaging a dedicated team of specialists. The project will provide administrative
support, monitoring, and supervision through its District and Block-level
administrative units led by the block coordinator.

Why CSP is required.

To facilitate and provide the CBR activities of family and community-based
care and rehabilitation services at every Blocks/Municipalities/Zonal level, it is
necessary that a competent organisation is engaged who will provide forward and
backward implementation support. The CSP will further function as an extended
support for the department to deliver the proposed services to DAPs in and within
their community level in a comprehensive and time bound manner.

Objective and Scope of CSP

The overall objective of the CSPs is to set up and manage the institutional
structure and engage qualified personnel to deliver a blend of centre based and
community-based care and rehabilitation services to DAPs through CBR in family
and community settings for the district assigned to them.

In particular, the CSP, on behalf of the project, will be responsible for the following:

 Community mobilisation and communication.

 Individual household-level case management.
 Family and community-based care and rehabilitation service delivery.
 Engagement and training of the Community Rehabilitation Workers (CRWs) and
Community Facilitators (CFs).
 CBR services delivered by trained CRWs.
 Enhancing capabilities of caregivers/parents through training and handholding
support.
 Imparting life skills education to Differently - Abled Persons using community-
based service delivery.
 Using technology to link Differently-Abled persons with professional care and
rehabilitation services.
 Establish Block OSC in every Block / Municipality / Corporation Zone of the
District and NC at a cluster of villages.
 Coordination and facilitation with other agencies/service providers for smooth
delivery of care and rehabilitation services for Differently - Abled Persons and
 Other project-related activities, including facilitating and monitoring services
provided by various service providers engaged in the project.

Overview to roles and responsibilities of CSP staff

 The Community Inclusion Specialist & Capacity Building Specialist of the CSP
will be the responsible single contact person to support the B-OSC team,
Neighbourhood Centre (NC) and CRWs to plan, strategize, delivery services
by regular visit, review and monitor.
 The Community Inclusion Specialist & Capacity Building Specialist Specialist
of the CSP will the responsible to coordinate with DDAWO team and submit
monthly report to district team as per the formats.
The following are the broad protocols for CSP staff (CIS & CB Specialist, Block
rehab team, Community Facilitator and Community Rehabilitation Workers) for the
implementation of CBR activities not limiting to,

Community Inclusion Specialist (CIS)

 The CIS in coordination with the District Project Officers (DPOs) will be in charge
of implementation for the CBR activities.
 CIS with district team will support and assist establishment of Block-One Stop
Centre (B-OSC) at every block.
 CIS in coordination with the CRWs and CFs will map and cluster the villages for
creating Neighbourhood centre (NC)
 CIS with the district team will coordinate with the Department of Rural
Development and Panchayat Raj for identification of existing buildings to
establish NC.
 The CIS will submit the Advance Tour Plan (ATP) of visit to the B-OSC and
Neighbourhood Centre to the district office.
 CIS will monitor the home visits schedules of block rehab teams and CRWs.
 The CIS will submit the monthly progress report as per the format provided by the
state and the district team.
 The CIS in coordination with district team will develop block and area specific
implementation plan for inclusion and mainstreaming Differently Abled Person
(DAP) such as plan for tribal and hilly area, SC/ST community, vulnerable
communities, gender inclusion, etc.,
 The CIS in coordination with the sub division OSC team for individual case
assessment and preparing individual care plan, etc.,
 The CIS will coordinate with the sub divisional OSC team for their outreach
mobile therapy visit schedules to villages by the outreach mobile
Capacity Building Specialist
 The CB specialist in coordination with the district team will provide training to
the block rehab team CFs and CRWs
 The CB Specialist will submit the Advance Tour Plan (ATP) of visit to the B-
OSC and Neighbourhood Centre to the district office.
 The sub division OSC team will be assisted by the CB specialist through CFs
and CRWs for awareness creation, parent/caretakers training, etc.,
 The CB specialist will coordinate with the sub division OSC team to provide
skill transfer to block rehab team, CFs and CRWs
 The CRWs and CFs will be guided and supported by the CB specialist to
provide experts advices through linking them with tele-rehabilitation
 The CB specialist will be the master trainer to train the Counsellor cum case
worker and CFs for providing life skill training to DAPs and caretakers
 The CB specialist in coordination with the district team will guide the block
team and the CFs to plan training schedules and impart life skill training to
DAPs and caretakers
Block Rehab team (Counsellor cum caseworker, physiotherapist and special
educators)
 The CSP will position the block rehab team as guided by the district and state
team
 The block rehab team will work in coordination with the block coordinator
positioned at each block OSC.
 The composition of block rehab team will be further finalised with the district
team based on the need and category of DAPs requiring services (eg. Need
of Occupational therapist more instead of physiotherapist, need of more
special educator, etc.,)
 The number of days expected by the block team to be at the block centre and
numbers of days for field visit to provide home-based therapy services will be
arrived at and finalised based on the need, number of DAPs, category of
DAPs.
 The counsellor cum caseworker in the block rehab team will collect the case
profile with need assessment of the DAPs.
 The therapist and special educators through the case management tool will
do the case assessment and develop individual care plan along with setting
short term goals.
 The block rehab team will refer DAPs to OSC for detailed assessment
wherever required with fixing appointment schedules through the case
management tool.
 The block team will also provide appropriate referral services such as medical
follow up, beneficiary-oriented scheme benefits, etc.,
 The Block rehab team will undertake regular home visit to DAPs requiring
home care program and will train the CRWs to provide shadow follow up
home care services.
 The block rehab team wherever required will provide tele- rehabilitation
guidance, advices, review and support to CRWs during the follow up home
care service to DAPs.
 The block rehab team will visit and support the community Facilitator at the
Neighbourhood centre.
 The block rehab team will be responsible for evaluation of the DAPs attending
the centre services. Each DAPs progress on the short-term goals will be
captured in the case management tool (formative and summative evaluation
of each session).
  The block rehab team will review, monitor the progress of DAPs receiving
home care services through them, CFs and CRWs.
 The block rehab team will be responsible for early identification of Children
with Special Needs through NewBorn Screening, following with Anganwadi
workers of developmental delay, coordination with RBSK team, etc.,
 The block rehab team will provide training to parents/caretakers, create
awareness on early identification of disability, mentor and support the CFs
and CRWs in their blocks
 The block rehab team will work in coordination and in tandem with the line
department officials for facilitating schemes and program benefits to DAPs.
 The block rehab team will submit the monthly reports to the coordinator, CIS
& CB, subdivision OSC team and district team.
Community Facilitators
 The number of neighbourhood centre will be arrived and finalised along with
the district team as per the need and requirement.
 The CSP shall position CFs as per the project guidelines. The CSP along with
the district team will provide orientation training and thematic training to CFs.
 The CFs will support and guide the CRWs at the village/ward level for
providing home care services.
 The CFs will provide basic rehabilitation follow up services to DAPs and
mobilise DAPs during the sub division OSC team visits, block rehab team
visit, etc.,
 The CFs will mobilise DAPs to screening and assessment camps,
convergence camps, etc.,
 CFs will do initial door to door screening of DAPs in their assigned villages.
 The CF will provide life skill training to DAPs, caretakers assisted by the block
and district team.
 The CFs will work closely with the block team and line department officials to
facilitate welfare scheme benefits to DAPs.
 Attend Review Meetings
 Maintenance of Registers
 Any other work assigned by the higher authorities
Community Rehabilitation Worker
 CSP will select the CRWs as per the project guidelines
 The number of CSP required each block will be arrived and finalised with the
district team based on the number of DAPs, terrain distribution, etc.,
 The CSP along with the district team will provide orientation training and
thematic training to CRWs.
 The CRW will undertake community level screening and identification of
DAPs through door to door visit in the village assigned to them
 CRWs will collect the case profile of DAPs already identified through Social
Registry Enrolment (A & B category) and the new DAPs identified/suspected
during the door to door visit or the category identified through Social Registry
Enrolment
 CRWs will encourage and motivate the DAPs to visit block OSC or Sub
division OSC for individual case assessment through fixing appointment
schedule with the block/sub division OSC team
 CRW will capture the progress of DAP during every therapy/training session
against the short-term goals in the case management app
 CRW will work closely with the village level community institutions such as
Panchayat office, Village Poverty Reduction Committee (VPRC), Self Help
Groups (SHGs), Panchayat Level Federation (PLF)/Area Level Federation
(ALF), etc to assist DAPs in social inclusion, beneficiaries-oriented schemes
benefits, etc.,
 CRW will also work closely with Anganwadi workers, Village Health Nurse,
School teachers to assist early identification and awareness creation on
disability
 CRWs will facilitate the DAP/Caretakers to apply for beneficiary oriented
scheme benefits of DDAWO office and from other relevant line department
schemes and programs
 CRW will mobilise the DAPs during the sub division OSC mobile therapy team
visit schedules, life skill training, parent training program, medical or ID camps
or assessment camps etc.,
 Attend Review meetings
 MAntenece oi registerd
 Any other work assigned by higher authorities
 CRWs will report to the CSP and also to the Block Coordinator
 Provisions for CBR services by CSPs
This Family and Community Based Care and Rehabilitation services will be delivered
by keeping the DAPs/families as the central focus for their social care services
through adopting a case management tool with individual-centric needs assessment
and care plans, community-based care, and rehabilitation services led by a cadre of
frontline workers. The following services will be provided.

● Family and community-based care and rehabilitation using a case

management approach to facilitate early identification and intervention,

care and rehabilitation services championed by a community level frontline
worker

● Training of parents and caregivers for enabling them in better care and

management of Differently Abled Persons within the home environment

● Specialized Neighbourhood services operated by trained frontline workers

and service providers having provisions for basic therapy services,

guidance, etc

● Life skills education on selfcare, daily living skills, counselling, self-image

and aspirations of DAP youth at the neighbourhood service centres located

in the community.

Protocols/roles and responsibilities- CSP preparatory work

Step -1 The selected NGO will be engaged as CSP through a performance-based
contract executed through District Differently Abled Welfare Office (DDAWO)
Step -2 The CSP will implement the Community Based Rehabilitation (CBR) activities at
the Block, Neighbourhood and village/ward levels on behalf of the project
Step -3 The CSP shall onboard the Community Intervention Specialist (CIS) and
Capacity Building Specialist (CB)
Step - 4 Project orientation to the CSP’s Community Intervention Specialist (CIS) and
Capacity Building Specialist (CB) will be provided by the State office
Step -5 The CSP shall submit their inception report along with their proposed work plan
Step-6 Based on the approval of the inception report and work plan by the state and
district team, the CSP will select the Block Rehab team, Community Facilitator
(CFs) for Neighbourhood centre and Community Rehabilitation Worker (CRWs)
for village/ward level frontline worker as per the project guidelines.
Step - 7 The list of the selected Block team, CFs and CRWs in accordance to the project
guidelines should be submitted to the District Differently Abled Welfare Office
(DDAWO) along with the reserve list.
Step -8 Based on the approval by the State and district office, the CSP shall engage the
selected Block Rehab team, Community Facilitator (CFs) and Community
Rehabilitation Worker (CRWs) by executing contract agreement as guided by
the project
Step -9 The project orientation and thematic training including the case management
tool will be provided to the CSP team by the state and district team.
Step- 10 Community Based Rehabilitation services will be delivered by the CSPs at the
family level and community through the CRWs and CFsThe CSP will be
responsible to replace in case of staff attrition with the due approval of the
district team

Implementation of family level services

 Household with DAPs Case assessment conducted
CRW visits assigned
CRW engaged identified through handheld device
Households

Individual Need assessment

Individual care and rehabilitation services provided by CFs through
conducted and categorised
Family/household level services and community level services through
Neighbourhood centre by CFs

Home Based Program

● CRWs will undertake door to door first level screening for identification of

Differently Abled Person (DAP) through the mobile Case Management Tool
for identified of left out or new DAPs

● CRW will support the suspected or newly identified DAP for assessment

and determination either through sub division OSC or camps organised by

District Differently Abled Welfare Office (DDAWOs)

● CRW will visit the identified DAPs (data list of DAP captured through Social

Registry Enrolment (SRE) and the newly identified) to collect their case
profile and basic need assessment – therapy, referral needs, scheme
benefits needs, etc., in the case management tool

● CRW will provide information of sub division OSC and B-OSC to the DAPs

identified with therapy needs and will encourage them to visit sub divisional
OSC for detailed assessment and Individual Care Plan (ICP)

● Based on the ICP the sub division OSC and B-OSC will assign the DAPs

either to Home Care Programs (HCP) or Centre Based follow up services

along with the therapy goals in the case management tool.

● The block rehab team along with the district team will fix up visit schedules

of CRWs and Block team for those DAPs requiring HCP

 ● The Block team will deliver centre based and undertake House Hold (HH)

visits (No. of centre based and village visit will be arrived based on the
DAPs required)

● The CRW will inform the DAPs on the home visit of block rehab team.

During the visit the CRW will accompany the block team

● The block team during their HH visit will provide mentoring and skill transfer

by hands on therapy training to the CRWs during their HH visit

● CRW will undertake regular visit to HH of DAPs to provide HCP by

capturing each day session of formative and summative progress

evaluation on the short-term goal

● CRW along with the Community Self Help Group Trainer (CST) will

facilitate inclusion of DAP in Self Help Groups (SHG)/Special Self Help

Group (SSHGs), support in bank linkages, etc.,

● CRWs along with the block team will facilitate beneficiary oriented

schemes, social safety net services to DAP

● CRW along with the Anganwadi worker, Village health Nurse will create

awareness and disseminate information to DAP/caretakers

● CRW will participate regularly in Village Poverty Reduction Committee

(VPRC), Panchayat Level Federation (PLF)/Area Level Federation (ALF)

and Grama Saba /Area Saba to meeting represent the needs/requirement
of DAPs and their HHs.

Implementation of Community level services

● CSP will be responsible for setting up of NC for cluster of villages to

deliver CBR activities

 ● The CF will be responsible for running and delivering services at the NC

such as community level information and counselling centre, creating

platform for need articulation and facilitating DAP submit their applications
for beneficiary-oriented scheme and program benefits,

● CF will work closely with Anganwadi workers, Village Health Nurse (VHNs),

School teachers, Samaghra Siksha (SSA) block team, Ilam Thedi

Maruthuvoom, Block team, Block Mission Management Unit (NMMU) of
Tamil Nadu State Rural Livelihood Mission (TNSRLM)/ Tamil Nadu Urban
Livelihood Mission (TNULM) etc., for screening, identification, referral
support, social inclusion and livelihood support, etc.,

● CF assisted by the CRWs will mobilise DAPs, caretakers to NC and provide

life skill training as guided by the district team

● The CFs along with the CRW will mobilise DAPs, caretakers at the centre

for the sub division OSC team to provide outreach and mobile therapy
service

● CF along with CRW will mobilise DAPs for delivering basic rehabilitation

services such as therapy, functional academics as group therapy assisted

by the block rehab team.

● The CF along with block rehab team will guide and monitor the CRWs to

provide home based therapy services

● The CF will be responsible to consolidate the reports of the CRWs and

submit the MIS reports

Planning and protocols for delivering CBR service by CSPs
● An experienced NGO will be engaged as Community Service Provider (CSP)
at district level to deliver CBR activities at each block/zone.
● The CSP will position 2 specialists at every district- Community Inclusion
specialist and Capacity building specialist coordinate the district level
implementation in collaboration with sub division OSC team and district team.
● The block team (physiotherapist and 2 special educators (intellectual
disabilities & for children with sensory impairments) and frontline workers
 (CFs and CRWs) will be responsible to implement CBR activities at every
block/zonal level
● Upon onboarding and orientation to the CSP, the CSPs will develop work plan
for positioning block team and frontline cadre, establish rationale-based
centres (block and Neighbourhood).
● The CSP will be responsible for selection and recruiting of block/zone core
rehab team, and frontline workers (CFs and CRWs). This team will report to
the block coordinator who will be positioned by the HR agency engaged by
the project. The block coordinator will be responsible to coordinate and
manage the entire block/zonal level CBR activities.
● Upon the positioning of the block/zonal team and the frontline worker, project
orientation and thematic training including CMT will be provided for delivering
services to DAPs.
● The frontline workers will be provided RCI accredited training as arrived by
the project in collaboration with training institutes
● The frontline workers (CRW and CFs) will be responsible at the village
level/ward level for initial level screening and identification of DAPs by door-
to-door visits, convergence with frontline worker such as ICDS, VHN, VAO,
CBOs. DPOs, etc.,
● The identified DAPs will be referred to Sub divisional OSC or block/zonal level
OSC for individual assessment. The frontline workers will support in
mobilizing DAPs for individual assessment
● Wherever the DAPs are non-ambulatory/severely affected, the CRWs/CFs will
identify such persons and intimate the block rehab team.
● The core rehab team (physiotherapist and 2 special educators (intellectual
disabilities & for children with sensory impairments) will carry out the
individual assessment of DAPs referred to block/zone centre.
● On completion of the assessment by the core team will provide their
recommendation along with short-term goals/activity and appointment/date for
next visit.
● The block rehab team will undertake regular home visits to provide door step
rehab services to the identified severe and non-ambulator DAPs. This will be
done by dedicating 3 days for centre-based services and 3 days for home
 based visits based on the geographical and needs of DAPS in the particular
block/zone.
● The block/zone team will prepare Advance Tour Plan (ATP) visit schedule
(based on factors such as number of DAPs requiring therapy support, number
of DAPs requiring special education/independent living training, remote and
inaccessible places, etc.,) which will also be captured in CMT for review and
monitoring.
● The ATP/visit schedule of the block/zone therapist/special educator will be
intimated to the CFS and CRWs in advance for informing DAPs, caretakers.
● The block/zone rehab team will provide individual therapy and rehabilitation
services by developing short term goals in thematic areas. Every session
progress will be captured in CMT as formative and summative progress.
● The block/zone team will also transfer skills and knowledge to CRWs and
caretakers during the home visits.
● The CRWs will be responsible to provide follow up home training shadowed
by the therapist and educators.
● The CFs will be responsible for mobilization of DAPs/caretakers for capacity
building trainings, life skill training facilitating welfare program and scheme
benefits, etc.,
● The CFs with the support of the block coordinator and the district team will
facilitate welfare schemes and benefits to DAPs.
Chapter-4 Training and Capacity Building
Background

Training and capacity building is the process that enables a team to develop
and strengthen skills and abilities. In order to equip the project staff to deliver
effective services in a mission mode and time bound manner, an integral training and
capacity building plan is a strategic plan will be very crucial to optimize resources for
improved service delivery, focusing on identifying and addressing gaps in skills,
processes, and technology. A systematic training plan will assist the project team in
better understanding of their responsibilities and the knowledge and skills they need
to do that job. This training and capacity building may involve different strategies
such as hands-on practical experience, theoretical learning, or a combination of
both.
In TN RIGHTS project training and capacity building will be an integral part for
staff at all levels to ensure meaningful transfer of skills and knowledge. A cascade
model of training approach will be followed to capacitate and strengthen the project
staff and the field staffs. This will be carried out through dedicated supporting
mechanisms of agencies such as Training Need Assessment, Disability Inclusive
Communication agency, etc., engaged by the project to support in developing
training modules, manuals, IECs to project staff and various categories of
stakeholders. This chapter deals with the training and capacity modality for CSP
team, field level workers and training of parents/caretakers by frontline workers

4.1 Training key experts of CSP

It will be imperative that the CSP team positioned at the block level as key
experts in the districts are adequately trained on the project activities. The CSPs
serve as conduits of institutional wisdom and practical know-how for implementation
support for TN RIGHTS CBR activities and therefore the training of the CBR staff
positioned by the CSP especially the key experts at the district will be very crucial as
they will be the focal person to guide, handhold and support the field staff and the
frontline worker
 Facilitating trainer-of-trainer sessions to efficiently disseminate knowledge is
crucial. The state team DPOs and the CSP team must undergo ToT training to
guarantee the thorough and ongoing training of teams. By becoming trainers
themselves, they can conduct initial, refresher, and induction training for new
recruits, ensuring continuity even when staff turnover occurs. The CSP district level
key experts namely the Community intervention Specialist and the Capacity Building
specialist being the focal person of the CSP will be provided the following training

S. Name of
Details of the
N the By whom and when Participants
training
o training
3 days Induction CSP Management
training on TN and Key Experts of
RIGHTS and the the CSP
By the SPMU team
Induction CBR activities to be
1 during the onboarding of
training supported for
CSP
implementation at
the Block and the
community level
2 Master
● 3 days training ● By the SPMU team ● Key Experts of the
Trainer of
as master during the inception CSP and Program
Trainers
trainers to report finalisation of Officers of the
training block CSP concern team
team
● By the SPMU team ● Key experts, block
● 3 days training during the onboarding team and
as master of frontline workers Program officers
trainers for CRWs and CFs. of the concern
training field district
staff- frontline
● By the agency
workers  Selected CFs,
engaged for Key experts,
● 5 days training
developing curriculum Program Officers
on master
for Life skill training to of the district
trainers for Life
 S. Name of
Details of the
N the By whom and when Participants
training
o training
skill trainers to train DAP/caretakers
frontline workers

● Refresher and ● By CSPs as directed ● Key Experts of the

thematic training by the project CSP and Program

for effective Officers of the
Refresher
implementation concern team
and
3 of CBR
Thematic
activities,
trainings
transfer of
institutional
knowledge

4.2 Training of CRWs and CFs

The frontline worker namely the Community Facilitator (CFs) and the Community
Rehabilitation Workers (CRWs) will be the foundation for the project to deliver the
CBR activities of Family based services and Community based services. The project
with its integral plan of capacity building and training will ensure through intensive
training that the CRWs and the CFs are adequately trained and imparted the skills
and knowledge to deliver seamless services through family based services and
community based services to DAPs and their caretakers. This will involve a multi
pronged approach of training such as class room training, on the job training, hand
on training, etc., as follows,

S. Name of
N the Details of the training By whom and when
o training
24 days of foundation training By the Master ToTs and CSPs
Foundation
1 for transfer skills, knowledge on during the onboarding of CRWs
training
CBR activities in 3 spells and CFs
Training to CFs and CRWs on
Life Skill
2 Life skill trainers to DAPs and By the Master ToTs
training
caretakers
 S. Name of
N the Details of the training By whom and when
o training
Refresher Refresher and thematic training By Master ToTs and CSPs as
and for effective implementation of directed by the project
3
Thematic CBR activities, transfer of
trainings institutional knowledge

4.3 Training of Caregivers by CFs and CRWs capacity building

Differently Abled Persons are largely dependent on family members for long-
term care and support including activities of daily living (ADL) and activities
pertaining to the essential services (IADL). Mostly these family caregivers include
partners and relatives who are mostly unpaid and under-resourced. A good home
caregiver requires a wide range of knowledge and skills to meet the challenges of
caregiving including safety hazards, first aid, health issues, patient management,
personal care, among others. In order to enhance capabilities of homecare providers
in performing caregiving tasks, handling difficult situations, and reducing their burden
and risk of physical strain, anxiety or depression, the project will introduce a
homecare providers training program.

The capabilities of the caretaker the CRWs and CFs will adequately train to
facilitate these trainings with the support of master trainers. The frontline workers will
also facilitate setting up of community level caregivers support groups to bring
together all the homecare providers from the area for sharing their experiences and
learn from each other for improving their skills and alleviate their stress and fatigue.

To support DAPs, particularly children with life skills training of parents,

teachers and caregivers will be very crucial. The project through the agency
engaged will develop and customised life skills curriculum for DAPs as well as their
parents, caregivers and teachers to facilitate supplementary education on selfcare,
daily living, life skills and counselling, self-image and aspirations of youth with
disabilities. The agency will develop a cadre of master trainers (DPOs, CSP key
experts, Block coordinator) who in turn will develop Trainers of Trainers (CFs and
CRWs) to conduct the life skills education through Neighbourhood centres created
by the project. The life skill training will be provided as a series of training to
DAPs/parents as per the curriculum developed.
Chapter 5. Awareness and IEC
5.1 Awareness and IEC
In CBR program Information, Education, and Communication (IEC) is a
integral part which encompass a wide range of activities aimed at empowering
communities with knowledge and skills to improve their inclusion, accessibility and
opportunities. The IEC as a strategy will assist to spread awareness through
conventional and non-conventional communication channels to increase awareness,
change attitudes and bring about behavioural change and health seeking behaviours
.

Information, Education, and Communication (IEC) are indispensable

components of community development. They serve as the foundation for creating
awareness, fostering participation, and catalysing sustainable change within
communities. Awareness and IEC also empowers individuals, builds social capital,
and promotes the holistic development of communities, ultimately leading to
improved quality of life and greater self-reliance. The broad road map for awareness
and IEC will be as follows,

Awareness
creation

Assisting and
empowering Fostering
DAPs, caretakers, participation
community

Nurturing
frontline
workers social
capital

Awareness creation will serve as a platform to disseminate information on

prevention, early identification, importance of early intervention, health, scheme and
programs benefits, social Safety net and various other aspects that directly benefit
the community by disseminating information, access to services. Further through the
IEC campaigning the DAPs, caretakers and community members will be facilitated to
make informed decisions and foster participation for Behavioural Communication
Change (BCC) and Interpersonal Communication (IPC) for their rehabilitation.

Creating Awareness: One of the primary functions of IEC in to disseminate

information and assist people to take informed decision by assisting access to
services.
Fostering Participation IEC and awareness activities acts as a catalyst for
facilitating participation and to take an active role in reaching out for their services
required. shaping This involvement can lead to the identification of local issues, the
formulation of solutions, participation and mobilization of resources and community
members to take ownership of the program. Further, IEC plays a pivotal role in
facilitating behavioural communication changes as part of facilitating participation
Nurturing frontline workers: Awareness and IEC program enables the frontline
worker be informed on the services, provisions and better guide the beneficiaries to
optimally benefit from these services who in turn, can enhance the community's
ability to work together effectively for common goals and foster a sense of unity and
belonging.
Assisting and empowering DAPs and caretakers: Awareness and IEC is a
powerful tool tailored to address specific issues faced DAPs and caretakers. By
providing targeted information and resources, IEC initiatives can help these groups
overcome barriers to development and participate fully in community life.
In TN RIGHTS awareness raising will be carried out in various modes not
limiting to the following activities

Modes of
S.
awareness Details of awareness
N Who will do When and how
creation/IEC creation/IEC programs
o
programs
1. Awareness and
During the initial
IEC activities Cultural program - CRWs and
roll out of project
Street theatre, folk CFs assisted
assisted by the
arts, flash mob, by CSP
block district team
pledge/commitment,
Public campaigns – District team, Periodical basis
Rallies, Auto CSP team
campaigns, Signature
 campaigns, wall
paintings
Meetings-
Stakeholders meeting,
DAPs meetings,
CSP through
DPOs, caretakers
CRWs and Periodical basis
meeting. Schools,
CFs
NGOs, CBOs
meetings, thematic
competitions
Print media Poster, Pamphlets,
2 awareness handbills, stickers, State office Periodical basis
activities articles
Website, Facebook, State office
Digital and social
3 Twitter, Instagram, FM and District Periodical basis
media activities
radio, T.V. level

5.1 Community Mobilisation

The awareness and sensitisation programs

will be carried out by mobilising community
members such as during SHG/PLF meetings,
Anganwadi mother day/adolescence girl day or
immunisation day, youth club meetings, Parent
teacher Association meetings, etc., as a part of
stakeholder engagement plan.

The awareness programs will focus on early

identification of children / persons with disabilities,
reducing the stigmas about the disability in the
community and minimising the stress and strain of the caregivers, peer group
support, gender equality, inclusive education, integration of people with disability into
peer groups, provision of intervention, accessibility, and promotional activities

The awareness programs will be aligned to different stakeholders, frontline workers

of Anganwadi workers, VHNs, School teachers, representatives of Community based
Organisations, Panchayat Raj Institutions (PRIs) and Urban Local bodies.
The awareness programs will be conducted in different places like educational
institutions, Government departments; private working places and in the community
mainly focuses on school going children, women, village leaders and elderly
community people.

Community mobilisation play important role to implement the community based

services. Local stakeholders need to be mobilised to sensitise them about the
importance of the project and services. The CRW and CF shall ensure all the
services details are shared to the during the mobilisation. Awareness to be
documented and submitted.

5.3 Orientation/Awareness activities

5.3.1 At the village level

The awareness and sensitisation at the community level will include agenda not
limiting to focus on early identification of children / persons with disabilities, reducing
the stigmas about the disability in the community and minimising the stress and
strain of the caregivers, peer group support, gender equality, inclusive education,
integration of people with disability into peer groups, provision of intervention,
accessibility, and promotional activities.

5.3.2 Orientation to Stakeholders

The IEC and awareness programs will be conducted about TN RIGHTS

project and its services in the different levels for the DAPs. It will also be aligned to
different stakeholders, frontline workers of Anganwadi workers, VHNs, School
teachers, representatives of Community based Organisations, Panchayat Raj
Institutions (PRIs) and Urban Local bodies. The CRWs and the CFS will also be
assisted to establish close links with the frontline workers for assisting with post
follow up support services.

The block team and the CSP along with the OSC Mobile Outreach Therapy
unit team will assist the CRWs and CFs by providing expert inputs and information
by disseminating information through tele-rehabilitation and IEC activities.

5.3.3 Orientation at Institutions

The IEC and awareness programs will be conducted in different places like
educational institutions, Government departments, private working places and in the
community mainly focused on school going children, youths, women, village leaders
and elderly community people. The community facilitators will be responsible for the
mobilisation of the people for the awareness program, specialists will do the content
delivery and documentation part will be carried by the community Rehabilitation
workers. Similarly, all the OSCs, Block/zonal centres and the Neighbourhood centre
will have repository of IEC materials Printed, Audio- Visual, and Digital media. Every
awareness programme will be evaluated by designed pre and post questions in
order to measure the knowledge transition.
Chapter 6. Monitoring and Reporting
6.1 Background

Monitoring and Evaluation is an essential element in TN RIGHTS project to

ensure that services are responsible, accountable, effective, timely delivered, and
meets the needs and requirements of DAPs. As systematic monitoring will facilitate
evaluation and course correction, the project activities will be closely monitored as
follows,

● Progress monitoring

● Process monitoring

Progress monitoring
Progress monitoring will include capturing and monitoring the physical and
financial progress of the project activities. The CSPs will be responsible for
submission of the activity progress reports. The reports will be consolidated digitally
through an online MIS format (till the MIS format is available online, the reports will
be consolidated through excel or other mode as directed by DWDA).

The reporting will be consolidated block wise by the concerned block co-ordinator
and district level by the CSP Specialists. The DDAWOs shall conduct a monthly
review of the consolidated progress reports of district activities with the block team
and the CSP. The State team will conduct a regional wise quarterly review meeting
of the district progress. The reports should be given periodically, and the formats
attached in the annexure. The format may be revised from time to time as per the
requirements of the project.
Process monitoring
Process monitoring is the method through which the compliance to the
process is complied. This will be done by regular monitoring of the indicators
regarding the process of delivery of the CBR services such as stakeholders’
engagement, community Score card, Social audit by CBOs, etc., DWDA will develop
IEC materials, indicators for Process monitoring which will be carried out on a half-
yearly basis.
6.2 Reporting Flowchart
There will be regular monitoring of the CSP activities. The Block Coordinator
will monitor the block daily activities. The Block Coordinator will closely monitor the
field staff and the frontline workers in the field and in the centre based on the
Advance Tour Plan (ATP) and will track the activities on a daily basis through an IT
platform (GIS in the case management tool). The concerned Sub Divisional OSC
Manager will also monitor the activities of the blocks under the subdivision. The
mobile outreach therapy unit besides providing field support will also monitor the
block and the frontline workers. Block Coordinator will visit the block for a surprise
inspection or on issue basis.
The Program Officer- Community Services in the district will visit all the
centres and the community activities on a periodical
basis. The District Differently Welfare Officer will
jointly take up field visits with PO-CS for inspecting
the work of the CSP and block activities.
Program Officer – Training and Program
Officer- Partnership Development will also visit the
activities of the block and communities in need
basis and as per the direction of the DDAWO.
6.3 Monitoring of family-based services
 The family-based service delivered by the CRWs will be monitored through
the Case Management Tool. Till the time case management tool is put in place,
monitored and reported will be captured through the standard formats given by the
state office. The monitoring and the reporting will capture the adherence to the visit
schedules of the CRWs, progress against the set goals in the individual rehabilitation
plan of each DAPs availing home based
OSC team and
programs, referral and support services, etc., The Mobile outreach
therapy unit
team
CRW will monitor at the field by the block
Block
CSP key experts
coordinator and
coordinator. The CSP experts, OSC team and and DPOs at the
district level
block rehab
team
the block rehab team, Mobile rehab team will
provide professional support, guidance to CRWs CRW/CFs
to effectively deliver the services to DAPs at their
household level.
6.4 Monitoring of Community level services
The community level service delivered by the CFs will be monitored by the
block coordinator. The activities of the Neighbourhood centre, Life skill training,
Peer/Caregiver group meeting referral and convergence support will be captured in
an online MIS and till it is put in place the progress and the reporting will be captured
as per the standard formats developed by the project. The CSP key experts will
make at least one visit to each block in a month to guide, transfer institutional skills
and knowledge assisted by the CSP, review the CFs, CRWs and the block rehab
team. A visit note shall be maintained at the neighbourhood centre in which the CSP
experts, block coordinator, rehab team, OSC mobile outreach team and DPOs to
record their observation, recommendations of the ongoing activities by the CFs and
the same will be recorded in the monthly tour dairy of the above and submitted to
DDAWO.
A period review meeting once in every month will be conducted by the
DDAWO either at the district office or at sub division or at block/zone level centre to
review the status and monitor the implementation process of the CRWs and the CFs
along with the Block rehab team and CSP key experts.
6.5 Monitoring and performance appraisal of the CSP
The key specialist of the CSP team will report to the DDAWO office and
submit their ATPs to DDAWO. The DPOs will be responsible for monitoring the
adherence of the key specialist to the proposed visit schedule. Similarly, the block
rehab team will report to their block/zone level centre and submit their ATP to block
coordinator and the CSP key experts. The CSP key specialist will submit a
consolidated monthly report to DDAWO on the implementation status of CBR
activities to DDAWO as per the format developed by DWDA. The DDAWOs shall
submit a quarterly progress report of the CSP performance to DWDA which will
include progress status of family based, community based and block/zone centres,
achievements to the deliverables, adherence to the process in implementation,
CSPs technical assistance and special initiatives, etc., as per the format developed
by the DWDA.
The CSP will be reviewed on a half-yearly basis by the State office on a
regional basis based on the deliverables for performance appraisal of the CSPs.
Based on the agreed deliverables the CSPs will be rated as highly satisfactory,
moderately satisfactory, satisfactory moderately unsatisfactory, unsatisfactory and
highly unsatisfactory. The objective of the performance appraisal is to facilitate the
CSP in their better performance, improve implementation support by identifying
bottlenecks and assist DWDA in contract management of the CSP

6.6 Reporting formats

In the TN RIGHTS project, an online MIS and Case management tool will be
put in place for reporting, monitoring and reviewing the implementation status of the
CSP and their teams. Till such arrangements are made, the consolidation of the
reports will be captured manual both quantitatively and qualitatively as per the format
developed by the project for monthly review meetings. The reporting formats will be
as follows and not limited to,

S.
Cadre of
N Monthly reporting formats
staff
o
ATPs
Screening and identification
1 CRWs Individual assessment and care plan of DAPs
Home based program
Special initiatives
 ATPs
Screening and identification
DAPs mobilised and assisted for OSC mobile outreach therapy
2 CFs programs
DAPs assisted with referral services, welfare program benefits
DAPs/caretakers assisted with life skill training
Special initiatives

Annexures
Reporting format

1. Need Assessment form

Staff information:

Name of the Panchayat:

staff

Mobile Date of visit:

number:

No of Visit: Duration of
Visit:
 Demographic Details of DAP

Name Age Gen

der:

Caregiver Age Gen

Name der

Education Occupati Inco

on me

Full
Address
Details

Contact
details

Type of New/ Existing If existing

registration reg .no

Disability Details:

Disability
Type Disability
%

1. Temporary
Duration: Status 2. Permanent

Physical Health:

Any Co- Diabetes/Cholesterol,

morbid Yes or No If yes, Blood pressure/
 Anaemia/ Cardiac
condition disease etc..

Any Family
history

Current
medication

Basic Assessment

Observatio Mil Moder Severe Prof Remarks

n d ate ound

Speech

Visual

Hearing

Mobility

Cognition

Socialisation

Existing Support Systems

S.n Status
o List of support
systems

1
Family support

2
Caregiver
Assistance

3
Social support
Networks

4
Accessible
 environment

Social Care and support services

Re Plan
S.n Interven S marks Outco Remar
of
o tions ub type me ks
action
√

Home
1
based
care

Centre
Care and based
Rehabilitation care
Services

Long
term care

IP care
Day care

Vocational
Skills
training

Employm
Training and
2 ent
capacity building
facilitation

Life skills
Education

3
Social Security DWDA
Schemes schemes
 Other
Dept
Schemes

Counsellin
g-
Individual
or Family

Social Emotional
4 Group
Support
Therapy-
Peer
group,
Caregiver
support
group

5 Assistive Devices

Allowances/
6
Assistance

Legal aid
7 Others
services

Referral services
Conta
Concern
Referred ct Remar
Purpose departme Status
To perso ks
nt
n

Physical health
1
problem

2 Surgery
 Welfare schemes
3 of other
department-

4 Disability card

Other Cards-
Aadhar, UDID,
5
Voter id, CMCHIS,
Pan card, RC

Skills training and

6
employment

Any other information related to individual:

Signature of the Staff: …………………………………….. Review Officer:
……………………………………

2. Home Based Service reporting format

S. Name o the No. of No of Numb No of No of Children No of

Village DAPs DAPs er of DAPs with Special DAPs
N Panchayat/ identifi assign DAPs provided Needs (CwSN) exercised
o Ward ed ed case Individua provided mobile
profile l Therapy Individual therapy
s Plan Education Plan services
create (ITP) (IEP)
d

3. Home visit report format

Name of the CRW/CFs: Date:

S. Name Activities Duration of Outcome Observation Next follow

of the carried Visit( Hour) up
No DAP out /challenges

Rehab/
Welfare
4. Advance Tour Plan format

Name of the CRW/CFs:

S. Date Location- Purpose of visit (Clearly Proposed activities-

Village/ state the purpose of the
No Office/ tour, such as assessing (Assess DAPs'
Centre community needs, progression,
conducting rehabilitation Develop
sessions, training local individualized
staff, etc.) rehabilitation plans/
Conduct therapy
sessions/ Referral/
Facilitate Welfare
Schemes/ Awareness
programe/Training

5. Referral form

S. Type of services Home based Neighbourhood

centre
No
Male Female Male Female

1 Assessment
2 ID card

3 Rehabilitation
services

4 Assistive device

5 Skill training

6 Life Skill Education

7 Scheme benefits

8 Any other (plz

specify)