person centered individual support plan (isp) training for day and residential providers laura...
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Person Centered Individual Support Plan (ISP) TrainingFor Day and Residential Providers
Laura Vegas, Assistant CommissionerPolicy and [email protected] 1
Learning Objectives • Participants will learn about concepts of person centered
planning and person centered supports.• Participants will learn about their roles and responsibilities
regarding Individual Support Plan (ISP):• Development• Implementation• Documentation• Monitoring
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Learning Objectives • Participants will learn about anticipated revisions to the DIDD
requirements for the ISP regarding:• Vision for Preferred Life• Skill Acquisition• And measurable outcomes.
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Exit Plan Requirements• Section III – Individual Support Plans
• D. DIDD to provide training to residential and day service providers on person-centered planning and person-centered supports, to include ISP development, implementation, documentation and monitoring; expectations of participants in the person-centered planning process.
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Person Centered Planning and Person-Centered Supports
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Information Gathering: Three Important Things• Think of the three things in your life that are most important
to you.• Write one thing on each of the three pieces of paper given to
you at registration.• Be willing to participate.
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Person Centered Planning• Centers for Medicare and Medicaid Services (CMS) Home and
Community Based Services (HCBS) person-centered planning definition.• Established January 10, 2014• Service planning must be person centered• The person and the people closest to them are the experts about
their service needs and how services should be delivered• The process is driven by the person and includes only people
chosen by the person
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Person Centered Planning• The person drives the person centered planning process with
supports as needed.• Planning happens at the time and place chosen and
convenient to the person.• Plan uses plain language.• Planning process must include strategies for solving
disagreements.• Process results in individually identified goals and preferences.
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Person Centered Planning• Must offer choices to the person regarding services and
supports they receive and from whom.• The Plan must be reviewed every 12 months or as a person’s
circumstances or needs change significantly and anytime individual requests review.
• Plan must be signed by all providers responsible for its implementation.
• The person and their representative must receive a copy of the plan.
• All good person centered ISPs are done in partnership among the person, families, unpaid supports, all service providers and the ISC/CM. 9
What is the Purpose of an ISP?
• To help people obtain better lives!• A guide to personal outcomes• Justification for services
• Service authorization
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Better lives?
• Help supporters understand the person’s interests and desires, and their vision of a preferred life.
• Pathway to develop and maintain personal relationships.
• Employment First!• Increase positive control over one’s own life.• Develop skills and abilities needed to achieve
their goals and support their vision of a preferred life. 11
Vision of a Preferred Life
• The Vision should be added to the ISP template, Section A.
• What is the person trying to accomplish with this ISP?
• What would the person like to learn, enhance or maintain in their life – how can the ISP help accomplish these things.
• The entire ISP supports the Vision of a Preferred Life.
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Vision of a Preferred Life
Tools to help develop vision:Person Centered Thinking Tools
• What’s working/what’s not working• Good Day/Bad Day• Rituals• Matching• Learning Log• Relationship Map
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Vision of a Preferred Life Person Centered Thinking Skills
• Personal Outcome Measures ®
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Vision of a Preferred LifePerson Centered Thinking Skills
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Important To
• What is important to a person includes those things in life which helps us to be satisfied, content, comforted, fulfilled, and happy. It includes:
• People to be with /relationships
• Things to do & places to go
• Rituals or routines
• Rhythm or pace of life
• Status & control
• Things to have16
Important To
• Includes what matters the most to the person – their own definition of quality of life.
• What is important to a person includes only what people “say”:― with their words― with their behavior
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Important For• Issues of health:
―Prevention of illness ―Treatment of illness / medical conditions ―Promotion of wellness (e.g.: diet, exercise)
• Issues of safety:―Environment ―Well being ---- physical and emotional ―Free from Fear
• What others see as necessary to help the person:―Be valued ―Be a contributing member of their community 18
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Health and Safety Dictate Lifestyle
Important FORImportant
FOR
Important TO
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All Choice No Responsibility
Importa
nt
FOR
Importa
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Balance
Important FOR
Important TO
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Vision of a Preferred Life• The person’s vision may connect to one of the 3 factors (21 outcomes) of
the Personal Outcome Measures.
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My Self : Who I am as a result of my unique heredity, life experiences and decisions.
People are connected to natural support networks
People have intimate relationships
People are safe
People have the best possible health
People exercise rights
People are treated fairly
People are free from abuse and neglect
People experience continuity and security
People decide when to share personal information
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Vision of a Preferred Life
My World : Where I work, live, socialize, belong or connect.
•People choose where and with whom they live•People choose where they work•People use their environments•People live in integrated environments•People interact with other members of the community•People perform different social roles•People choose services
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Vision of a Preferred Life
My Dreams: How I want my life (self and world) to be.
People choose personal goals
People realize personal goals
People participate in the life of the community
People have friends
People are respected
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Vision of a Preferred Life
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My World
My Self
My Dreams
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Learning about Support
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Fixing vs. Supporting
Power Over
Power With
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Individual Support Plan Development
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ISP Development
• All sections of the ISP support the person’s Vision of a Preferred Life.• Home• Day/Employment• Relationships/Natural
Support/Community Support
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ISP Development
• Decision Making/Rights• Communication• Medical Conditions• Mealtime• Personal Funds Management
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ISP DevelopmentVision of a Preferred Life• For example –
• Hollie’s vision of a preferred life is to make new friends and get a job that she can walk to from her home.
• Each section of the ISP supports the vision along with providing a description of supports and services needed.
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ISP Development Home
• How informed CHOICE was exercised in selection of home and room mate
• What new things or skills does the person want to learn that might lead
• Greater independence• Greater satisfaction with home life• Having access to environments in home (kitchen, patio, swimming
pool for example)• For Hollie’s vision, home section might discuss
• Maintaining work clothes, uniforms• Scheduling
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ISP Development Day/Employment• Employment First!
• Employment is the First Consideration for Day services• Competitive Employment
• In a typical workplace• Majority of workers do not have disabilities• Earn at least minimum wage
• What does the person want to learn that might lead to• More meaningful days• Greater independence• Relationships
• For Hollie’s vision, what supports are needed for Hollie to stay employed? 33
ISP DevelopmentRelationships/Natural Supports/Community Membership
• Who are the important people in a person’s life (unpaid)?• What supports are needed to help maintain connection to
important people?• What is person’s desire regarding their natural support
network? Expanding?• What community roles are important to the person?
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ISP DevelopmentRelationships/Natural Supports/Community Membership
• For Hollie’s vision, discuss what relationships are important in reaching her vision such as co-workers, neighbors, etc…
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ISP Development Medical Conditions• Current health issues and needed supports• Historical health information that is pertinent to current
support needs• Focus on how person makes medical decisions and what
support is needed• Important to the person in terms of managing their own
healthcare
For Hollie’s vision, discuss what health supports are needed in order to achieve or maintain best possible health, particularly as it relates to her vision.
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ISP DevelopmentMealtime/Mealtime Guidelines
• Supports needed (important to)• Include what is needed for the person to be part of cooking, meal
prep, shopping, menu planning, etc… • Preferences regarding food• Mealtime Rituals
• Supports needed (important for)• Mealtime Guidelines• Dietary considerations• Safety considerations for people with chewing/swallowing
difficulties 37
ISP DevelopmentPersonal Funds Management
• Follow personal funds management policy • The person’s abilities and desires regarding personal funds
management• The extent to which personal funds will be managed by the
provider agency or the conservator• The person’s desire, if applicable, to have a separate bank
account rather than an agency-controlled account for personal funds
• Any training or assistance needed to support the person-supported in managing personal funds or to develop skills needed to increase independence with managing personal funds
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ISP DevelopmentPersonal Funds Management
• Restitution plans addressed in ISP• Goals and objectives involving use of the person’s personal
funds• Health, safety or exploitation issues that require limitations on
the person’s access to personal funds and strategies to remove limitations at the earliest possible time
For Hollie’s vision, it would be important to address how she manages her earned income, what supports she might need or any goals she has for the earned income.
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ISP DevelopmentDecision Making/Rights
• Determine what rights and decisions are most important to the person to exercise
• Supports needed in exercising rights and making decisions• Legal representatives and area of responsibility (if applicable)• Supports needed for more independence in decision making
and rights
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ISP DevelopmentDecision Making/Rights
• Human Rights Committee • Restrictions• Restoration plan• Support needed to ensure the person attends the Human Rights
Committee meetings as applicable
• Current legal issues or concerns
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ISP DevelopmentCommunication
• Describe how the person communicates their wants and needs along with the supports needed to assist the person to communicate
• Include the support needed , if applicable, to maintain and access any communication methods, devices or assistance across all environments
• The communication chart is an excellent tool to organize and document information
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Communication• Communication chart: Learning, using, and recording
communication.
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ISP DevelopmentOutcomes
• Outcome statement is a functional statement that includes what a person would like to LEARN, IMPROVE UPON, or ACCOMPLISH.
• The person with assistance as needed from COS, develops their own outcomes. (SERVICE PROVIDERS AND ISCs DO NOT DEVELOP OUTCOMES)
• Outcomes represent the result, the ultimate place to be, the big picture, etc…
• Outcomes should reflect what is important to and important for a person (the balance).
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ISP DevelopmentOutcomes
• Outcomes • are specific and measurable• should support progress toward the
Vision of a Preferred Life• can be derived from what is working and
not working in a person’s life
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ISP DevelopmentOutcomes
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ISP DevelopmentAction Steps• Stepping stones toward outcome• Tasks that needs to be carried out in order to support a person
in achieving an outcome.• Action steps are
• SPECIFIC• MEASURABLE• ATTAINABLE• REALISTIC• TIMELY
SMART47
ISP DevelopmentStrategies for Implementation Strategies: Where there is an action step, there should be a strategy.• Especially in situations where there are different supporters
implementing the outcome, strategies can assist all supporters to know how to consistently implement each action step.
• Strategies shall focus on:• How the individual learns best (if teaching is involved)• Instructions to teach Defines what it takes to reach the action• How to best document progress
• This is the information needed to understand the individual’s expectations, family / team expectations, staff / agency expectations, etc., to implement each action. 48
Strategies for Implementation
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Outcome
Strategies for Implementation
Action Steps
Measure Progress
Who/When?
Hollie will learn the walking route to and from work so that she can travel alone.
Hollie needs a (prepaid) cell phone to use in case of emergency. Will need help making sure the phone has minutes.
Hollie needs written reminders of which turns to take on the route to work until she memorizes them.
Hollie carries a notepad with her important information in her bag.
1. Hollie will walk to work with staff and write the directions in her notepad.
2. Hollie will follow directions in her notepad to walk to work with assistance from staff.
3. Hollie will walk to work with staff without using her directions in the notepad and no staff assistance.
1. Written instructions in Hollie’s notepad.
2. Successful trips to work as indicated in daily notes.
3. Successful trips to work without assistance from staff or notepad as indicated in daily notes.
1. Hollie and job coach by June 1, 2015
2. Hollie and job coach for three months beginning June 2015.
3. Hollie and job coach for three months beginning September 2015.
“I Want”
“I Need”
“I Will”
“I Did”
ISP DevelopmentMeasure Progress
• Helps the Circle of Support determine if progress is occurring, what needs to continue to occur, if more time is needed to achieve the action taken, if the means of measuring progress is working or not working and if the timeline makes sense.
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Individual Support Plan Implementation
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ISP Implementation
Without implementation, the best person-centered planning leads nowhere.
Implementation of person centered planning is a promiseA Promise to listen
• To listen to what is being said and to what is meant by what is being said
• To keep listening
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Independent Support Plan Implementation Implementation of person centered planning is a promise….
A Promise to act on what we hear• To always find something that we can do today or
tomorrow • To keep acting on what we hear
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ISP ImplementationA Promise to be honest
• To let people know when what they are telling us will take time
• When we do not know how to help them get what they are asking for
• When what the person is telling us is in conflict with staying healthy or safe and we can’t find a good balance between important to and important for
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ISP Implementation
• Authorized services must also be implemented as written per the current approved ISP, including the type, amount, frequency, and duration listed Section C of the ISP.
• Those responsible for service implementation are accountable for services as indicated in the ISP and are responsible for documentation to support the provision of services. 55
ISP ImplementationOutcomes and Action Steps
• Implementation plans are helpful to provide a step-by-step method to teach skills in a consistent way
• Teaching methods can be inconsistent among staff without a plan to implement
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ISP ImplementationOutcomes and Action Steps
• As indicated in Section B Action Plan
• Action Steps• Strategies for Implementation• How Will Progress be Measured• Who will do it? By When?
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ISP ImplementationTraining
• Specific to the person’s individual needs, interventions and programs
• Any responsibilities they have to carry out related to activities identified in the plan
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ISP DocumentationStaff Communication Notes
• Narrative description of
• Information relative to implementation of staff instructions
• Information about the implementation of action steps such as progress, lack of progress, barriers to implementation or accomplishment of action step
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Date
What did the person do?
(What, where, when, how long, etc.)
Who was there?
(Names of staff, friends, others, etc.)
What did you learn about what worked well? What did the person like about the activity? What needs to stay the
same?
What did you learn about what didn’t work well? What did the person not like
about the activity? What needs to be different?
Learning LogUsing the learning log to replace typical progress notes
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ISP DocumentationLearning Log
• Great for documenting what worked and didn’t work for action steps and waiver services.
• Includes information for next steps.
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ISP DocumentationPeriodic Review/Monthly Review
• Revised ISC Monthly review template to require substantive narrative review of ISP Outcomes and Actions including progress, lack of progress and next steps as applicable.
• Providers periodic reviews will need to include meaningful review of ISP Outcomes and Action Steps falling under their responsibility.
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ISP Documentation
• Barriers to achieving outcomes should be identified
• ISPs should be revised as needed to address barriers and general lack of progress toward outcomes
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Expectations of Participants ISP Process
• Person - THE Content Expert• Other content experts
• Service providers• Family• Friends• ISC/CM
• Process Expert – ISC/CM• Is the author of the plan. Makes final determination of
content based on the person’s decisions.64
Wrap Up
• ISP must be person-centered • Person is EXPERT on the content of their plan• Person’s Vision of a Preferred Life should be
guiding principle of ISP• Implementation of a person-centered ISP is key,
otherwise…it is just more paper• We support people and have a huge impact on
their LIVES….we must keep trying to get it right!
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Questions?
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