Developing plans as a collaborative process – not a discreet event: Developing collaborative efforts by building

partnerships Knowing who knows what Acknowledge when it needs to be

shared Recognize Roles and Responsibilities

“Plans are never done, but they are always due”

Our Structure needs to Support Our Thinking

Person centered approaches to providing supports require a person centered structure

Paperwork needs to change to support the new methods.

Not just the ISP: Assessments, Daily logs, quarterly reports, progress notes, case comments etc. All need to be reviewed and updated to support this new process.

Partnerships Require:

Communication

Cooperation

Collaboration

Respect Trust

Collaboration and Partnerships Effective communication is where it all begins.

Collaboration creates something new.

People come together because of their differences – strength and opportunity comes from building on our differences, not trying to create conformity.

Collaboration requires learning.

Collaboration builds Partnerships Desire to learn, openness to learning Walk in assuming you can learn from the

other team members –and you will. Walk in assuming you already know

everything there is to know about the person- and you will squash collaboration

Trying to make other members do things “your way” kills partnership.

Collaboration Exercise

A walk in the woods

Partnerships and Experts All good plans are done in partnership Partnerships that work have discussed their

roles and expectations ahead of time Think about the roles from the perspective of

contents experts and process experts

Experts and Roles

Process experts know how to do it Contents experts know what it should say Where it works there is synergy – the plan is

better than either could anticipate

Experts and Roles

Everyone in this room is an expert, and has a role

What is yours? Process? Content?

Does everyone else see you that way?

Phases in the planning process Preparation for planning- Mapping Gathering information – formerly called

assessment Developing a 1st plan (draft) Team agreement on the information written

down Using the information to develop outcomes Plan Approval Plan Implementation and Review

Develop Outcomes

With the full team together: Review Personal Preferences Sections Review Topics to Promote Every Day Life Develop Possible Outcome Statements Review Medical/Health-Safety/Functional

Information Develop Outcome Actions Determine Most Appropriate Services and

Frequency/Duration of Each Determine how you will know progress is being made

Gathering Information in New Ways:

Relationships, family, friends

Choice and decision making

Work/Education, volunteering

Community participation or contribution

Self image, self esteem

Health Safety and individual rights

Satisfaction with services Home life/housing Relaxing & having fun Communication

style/preferences

Conversational Areas: Suggested Topics to Promote an Everyday Life

Guidelines for Individual Support Plan Format

Outcomes within the ISP

Describe for People: The expected results from activity a person

engages in The current situation- before the activity

begins The reason for the outcome (justification) Concerns or barriers that need to be

addressed

ISP Outcomes:

Reflect information gathering Requires collaboration among those

who know the individual best and those who know the system requirements

Use understandable language Are highly Individualized

How to Develop Outcomes

Review Personal Preferences with the full team: What Makes Sense/Doesn’t Make Sense What is important to the person Desired Activities Know and Do to Support the person

Develop possible Outcome Statements together: Reflect what is currently Important To the person, within the

context of assuring continued life within the community and health and safety.

What changes would the person prefer, and why? What constants would the person prefer continue in his/her

life, and why?

How to Develop Outcomes cont(2) Review Medical/Health-Safety and Functional

Information – (Important FOR information) look for Current Needs related to Outcome Statement: Medical Evaluation and Medical History Health and Safety Focus Areas Supervision Needs Behavioral Support Plan Health Care and Health Promotion Functional Areas Communication

How to Develop Outcomes cont (3). Develop Outcome Actions

What current needs are apparent within the previous sections of the ISP that relate to this Outcome Statement?

What specific steps must be taken in order to address the persons Current Needs, the Concerns related to the Outcome, and assure the outcome is achieved?

Ask, Do these actions occur within the context of what is important to the person, balanced with what we know is Important For the person?

Develop Outcomes cont(4) Determine Services, Frequency and duration.

New Service? Anticipate what will meet the need Old service – if nothing has changed, what was frequency in

the past? Old service – but other changes, what is anticipated to be used

by the person? How long do you anticipate the need to exist?

Determine how you will know progress is being made? What will be different as a result of the service, or what will

continue to be observable? This is asking for recognizable differences for the person, either environmentally, skill acquisition, behaviorally, communication change, etc.

Include a statement about how and when the team will provide information about progress across time.

ISP Outcome Development

Addresses concerns and barriers to promote problem solving. What are we worried about? What can we do to

prevent it? What can we do to lessen the impact if it is unavoidable? How can we overcome it if it occurs?

Provides critical documentation about steps that will be taken to assure the individual’s health and safety while working toward desired changes.

ISP Outcomes are NOT: Services…but every service needs an

outcome!!!! A grouping of un-integrated goals Solely based on formal assessments Deficit focused- this is not about “fixing”

the person Something that happens in isolation of the

individual’s everyday life.

Services are not outcomes!

Examples that are NOT outcome statements:

I want a day program. I want to go to physical therapy. I want speech therapy. I want to be in the workshop.

Services are not outcomes!

Services are determined AFTER the outcome is determined.

So, how do I write outcomes? You need more information!

As a result of this service, what difference will it make in the individual’s life?

ISP Outcome Statement

Determine what needs to change, what needs to remain the same by considering: What makes sense, what is working, what is the upside of

this issue, right now, from everyone’s perspective?

What doesn’t make sense, is not working, what is the downside of this issue, right now, from everyone’s perspective?

What does everyone agree on? Where do you have common ground? Start with outcomes about those things.

ISP Outcome Statements

Maintenance of important things- Those things which all perspectives agree should continue

Desired changes- Those things which all perspectives agree should change

If the team is stuck:

Focus the WMS /DMS exercise on specific issues in the person’s life, such as: Who the person spends time with What the person’s interests are How the person spends his/her days How the person has fun What the person wants to learn. Where and with whom, the person lives

Use the Topic Questions to get you moving: Relationships, family, friends Choice and decision making Work/Education, volunteering Community participation or contribution Self image, self esteem Health Safety and

individual rights Satisfaction with services Home life/housing Relaxing & having fun Communication style/preferences

Writing Outcomes: Sources of Information in ISP Outcome Statements

Know and Do Desired Activities Important To What Makes Sense

Outcome Actions Health and Safety Understanding Communication

Writing outcomes

Begin with the aim of the outcome: Using person’s name followed by an action verb or phrase.

Only use “I” if you are absolutely sure the person would say it in the same way.

Complete the statement with how it will make a difference using “so that/in order to”

Helpful Phrases when writing Outcome Statements

So That

In Order To

Sharing the PROCESS

Share the process with Team

•Team ownership

•Stronger plan

•Simplified process

•Shared vision

•Increase effectiveness of implementation

OUTCOME Measurement: How you know progress is

being made

Used to identify the results of a person’s effort. It seeks to answer the questions:

•What difference did the services or

supports make in the person’s life?

•Is the service/support provided

having its intended impact?

HOW to Measure Outcomes…

Measuring outcomes involves gathering DATA

What are the indicators???

•Specific items of data that are tracked to measure how well a program is achieving an outcome

•Indicators translate general concepts about the program & its expected effects into specific measurable parts

•You measure whether or not progress is being made, not fully whether or not the Outcome has been achieved.

S.M.A.R.T. Outcome Statements

S Are they specific?

M Are they measurable?

A Are they achievable?

R Are they relevant?

T Are they timed?

Writing Outcomes

Begin with the aim of the outcome: Use the person’s name followed by an action verb or phrase that reflects a change the person would like to see, or what the person wants to have stay the same.

Complete the statement with how it will make a difference using “so that/in order to”

Sara wants to get a job in a retail store

so that she can pay her bills on time, live in her current apartment and have enough money to do things that she wants to do.

Outcome Statement

Only the beginning!!!!

Reason for the outcome

Provides contextual information so that the team has the full picture about how it is important.

Important to Sara that others see her as responsible

Continuing to be accepted by her friends, and has money to spend with them, is very important to her.

To live in her own neighborhood where she is familiar and comfortable

Making decisions about what she does and when she does it

Concerns Related to Outcome Informs team of

barriers that need to be addressed while working toward outcomes.

She often can’t do what she wants because she doesn’t have extra money

Figuring out change, and adding/subtracting are things She needs help with

Sometimes she walks in unsafe places by herself in her neighborhood, or late at night

Outcome Actions

What are current needs What actions are needed Who’s responsible Frequency and Duration of the actions

needed By When (mm/dd/yyyy) How will you know that progress is being

made towards this outcome?

What Are Current Needs?

Current reality related to outcome: provides a baseline of information that specifically relates to Sara’s situation

Information is recorded in health and safety Focus areas, functional abilities, employment and vocational sections, financial and communication sections of ISP

Sara does not have a job; she has just enough money to pay her rent and food bills, she does not have extra money to go out with her friends. She gets angry with her rep payee when she has to say no to her friends because of money; She asks to borrow money often. She can tell the names of currency, but has difficulty making change accurately. She will need help reading help wanted ads and completing job applications

What Actions Are Needed?

Address information identified in “concerns related to outcome” to identify steps to take.

Figure out retail jobs that do not require you to make change (S E Job development)

Discover job training classes in retail (SE Job development)

Talk with others who work in retail shops (Family members)

What Actions Are Needed?

Address information identified in “concerns related to outcome” to identify steps to take.

Help her start learning about making change (Supported Living- HCHab and basic math tutor)

Help Sara learn about budgeting money and using other resources such as food stamps, Energy assistance, etc. (Supported Living HCHab)

Help Sara learn about being safe walking at night by herself (Supported Living HCHab)

Who is Responsible?

Brainstorm who can help, how they can help and how often.

Determine who will be responsible for seeing that the specific action occurs.

Sometimes this will be non-paid people, sometimes it will be paid people.

Supported Employment Supervisor and Family for Employment Action

Supported Living Coordinator and Support Coord. for Sup. Living Actions

Frequency/duration and By When Indicate how often the

action will occur, and for how long. This should give specific information around how many times per week, or month, or year, and for how many months or years.

By when indicates when the action is expected to be accomplished

Supported Employment service, 20 hrs per week, for 6 months

Supported Living 20 hrs per week, for 12 months.

By 12/12/2004

How will you know that progress is being

made towards this outcome?

Describes what is expected as a result of the services and supports; what will you be able to see that is different, or that continues to happen, for the person?

Identify how and who will

give input about progress made over time.

Employment Actions: Sara will have found and

applied for at least one job she desires.

Sara will have information on retail jobs available to her, and will know the skills required for retail work.

At quarterly meetings, the team will provide progress notes on what has been accomplished.

How will you know that progress is being made towards this outcome?

Describes what is expected as a result of the services and supports; what will you be able to see that is different, or that continues to happen?

Identify how and who will give input about progress made over time.

Home and Comm. Actions: Sara will be confident

making purchases with dollar bills and get the correct change.

Sara will understand one method of budgeting her money that she is willing to try

Sara will have exercised at least one safe option when going home late at night.

Fundamental to Supporting People:Core Responsibilities are NOT

Outcomes Washing hair Setting the table Making a sandwich Using a fork Tying shoes Brushing teeth Combing hair Shaving

Getting dressed Staying on task Counting money Toileting Doing laundry Using zippers Dialing the phone Applying deodorant

Would You Rather…

Tie your shoes or Tie the game Comb your hair or Comb the beach Make your bed or Make a friend Plan a menu or Plan a get-together Make a purchase or Shop ‘til you drop Clean a room or Clean up on the

dance floor

Tie your shoes or tie the game & make your bed or make a friend from

Hingsburger (1998) do?be?do?

Traditional Curriculum vs. Quality of Life Outcomes (Red)

Judy will take a shower with physical guidance 6/7 days a week by 12/01. Judy wants to look nice when she goes to school for the next two semesters.

Fay will exercise three times a week with verbal prompts for 6 consecutive months by 12/01. Fay wants to earn her orange belt in karate in the next 9 months.

Anna will participate in 1 social/recreational outing a week with staff supervision until 12/01. Anna wants to join the Girl Scouts in her neighborhood and be a member this year.

From Acumen, Arizona. Courtesy of Chris teKampe 2003

One guy’s story

“Your interpersonal skills have improved.” “What do you mean by interpersonal?” That means you are getting along with people

better. Well, why didn’t you say that in the first

place?

Alternatives to jargon

Interpersonal skills Ambulates

independently Verbal cues or prompts Auditory monitoring

distance Able able able Feeds self

independently

Outcomes Thinking compared with Old Goals Going on a date- Learn Social Skills

Taking karate lessons- Increase physical activity

Looking great for school- Improve personal hygiene

Getting a job- increase vocational skills

Being a Girl Scout- Improve social skills

Putting together a photo album- Increase fine motor or Increase attention span- or increase on-task behavior

Visiting my family- improve social and emotional expressions

Outcomes Thinking compared with Old Goals – Try it yourself: Joining a health club: Taking horseback riding lessons: Being an active senior: Riding my bike: Listening to live music: Going to the beauty salon: Joining the Eagles fan club: Hosting a BBQ:

Family Member Roles in developing Outcomes Participate as Content Expert Assure the person is listened to Demonstrate the opinions and views of

people who care deeply about the person Promote the preferences of the person – not

what others think should be their preferences Contribute ideas for how to meet the needs Provide insight into resources other team

members may be unaware exist

Provider Role In Developing Outcomes Participate as one of the content experts Ensure outcome statements are in context of The

person’s individual preferences- what is important TO the person

Ensure Outcome actions meet individual needs – what is important FOR the person.

Ensure services can address individual needs within the context of individual preferences.

Ensure services are delivered. Participate in plan review.

Support Coordinator Roles in Developing Outcomes

Process Expert – what needs to be done, how it gets done, and getting it done on time

Coordinate team agreement with what is written Coordinate team meeting to develop outcomes Keep the team focused on the process Ensure the outcome summary addresses the

person’s preferences, balanced with health safety and ensuring community life.

Assure the person is listened to