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Person-Centered Support Plan PCSP

We promote opportunities and provide support for people with disabilities to lead self-determined lives. . Purpose. Understand changes, why these change; why now.Learn how to link assessments to plans.Learn the parts of the comprehensive Action Plans.Clarify expectations of contracted provide

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Person-Centered Support Plan PCSP

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    1. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Person-Centered Support Plan (PCSP) FACILITATOR INSTRUCTIONS Opening Slide Have this up and on the screen before you begin. SAY Good morning/good afternoon. Before we begin I want to thank you for taking the time from your busy schedules to attend this training. I know you all have a more than full case load and as you sit here your in-basket is expanding exponentially. That being said, once again thank you. Please turn your cell phones off or to silent. If you know there is an emergency looming by all means take the call. If it is not an emergency please wait to return the call at the break or the conclusion of this course. Review the general schedule for the day and cover any other housekeeping issues here. This symbol is being used by USTEPS to represent the Division’s process of working with consumers from intake through dis-enrolment. The center represents the ongoing process of assessment, planning, implementing and evaluating. In reality these four areas actually overlap. Today we will be focusing on just assessment and planning. FACILITATOR INSTRUCTIONS If Support Coordinators do not know the DSPD Staff Member you are co-training with please have them introduce him/her (name and job title). FACILITATOR INSTRUCTIONS Opening Slide Have this up and on the screen before you begin. SAY Good morning/good afternoon. Before we begin I want to thank you for taking the time from your busy schedules to attend this training. I know you all have a more than full case load and as you sit here your in-basket is expanding exponentially. That being said, once again thank you. Please turn your cell phones off or to silent. If you know there is an emergency looming by all means take the call. If it is not an emergency please wait to return the call at the break or the conclusion of this course. Review the general schedule for the day and cover any other housekeeping issues here. This symbol is being used by USTEPS to represent the Division’s process of working with consumers from intake through dis-enrolment. The center represents the ongoing process of assessment, planning, implementing and evaluating. In reality these four areas actually overlap. Today we will be focusing on just assessment and planning. FACILITATOR INSTRUCTIONS If Support Coordinators do not know the DSPD Staff Member you are co-training with please have them introduce him/her (name and job title).

    2. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Purpose Understand changes, why these change; why now. Learn how to link assessments to plans. Learn the parts of the comprehensive Action Plans. Clarify expectations of contracted providers in the process SAY We are here today to familiarize ourselves with the Person-Centered Support Plan Process. Which means we will be required to: Understand the changes in the process Understand the purpose of the Redesigned Person-Centered Support Plan Learn to further link assessments to plans Complete a comprehensive Action Plan Practice applying new content requirements prior to using USTEPS. At the conclusion of this course you will have the opportunity to actually do two “pen and pencil versions” of a PCSP before the implementation of USTEPS. We will discuss the details and how we’ll do that at the conclusion of this course. SAY We are here today to familiarize ourselves with the Person-Centered Support Plan Process. Which means we will be required to: Understand the changes in the process Understand the purpose of the Redesigned Person-Centered Support Plan Learn to further link assessments to plans Complete a comprehensive Action Plan Practice applying new content requirements prior to using USTEPS. At the conclusion of this course you will have the opportunity to actually do two “pen and pencil versions” of a PCSP before the implementation of USTEPS. We will discuss the details and how we’ll do that at the conclusion of this course.

    3. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Introduction to the Person Centered Support Plan Natural progression or maturing of the process Person-centered planning is critical; not just a luxury Vehicle for change, but it is up to you to make it work! SAY We want to clarify that the new process is not another pendulum swing as we have seen in the past, but a maturing of the process you often see with change. It is the result of a more of a centering process that combines the focus on consumer’s needs and wants. As George indicated in his letter, person-centered planning is at the core of what we do. It is not an add on or afterthought. It is critical for addressing health and safety and quality of life issues. Also we need to emphasize that, this revised process can be a vehicle for significant change in the lives of people we support; however, it only enables and encourages this – it does not guarantee it. Only through your application of the principles of self-determination and person-centered planning can we make real changes in peoples lives. SAY We want to clarify that the new process is not another pendulum swing as we have seen in the past, but a maturing of the process you often see with change. It is the result of a more of a centering process that combines the focus on consumer’s needs and wants. As George indicated in his letter, person-centered planning is at the core of what we do. It is not an add on or afterthought. It is critical for addressing health and safety and quality of life issues. Also we need to emphasize that, this revised process can be a vehicle for significant change in the lives of people we support; however, it only enables and encourages this – it does not guarantee it. Only through your application of the principles of self-determination and person-centered planning can we make real changes in peoples lives.

    4. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Accomplishments of the Redesigned PCSP Process 1. One integrated plan 2. One process for all situations 3. Person-Centered Planning Process while meeting waiver requirements and DSPD rules 4. Balance what is most important TO with what is most Important FOR a person SAY This is a list of accomplishments we have realized with the redesigned planning process. We combined the old Individual Service Plan (ISP), the Person-Centered Plan (PCP), the Action Plan and the Budget into one integrated plan. The PCSP will be used for all situation including initial plans with just Support Coordination, those with just a little respite using Self-Administered Services (SAS) and those with 24-hour day and residential services. It was critical for us to build in all Medicaid Waiver requirements and the Department of health has approved this process. And as you have learned from the training on the Supports Intensity Scale (SIS), we are looking for a balance of needs and wants or “what is important TO and FOR the person.” FACILITATOR INSTRUCTIONS Go through these point pretty quickly, but touch on each point. This is just background, do not allow questions here or you could spend all day discussing these points. Let the group know they will have time for questions when we get into the planning process itself. SAY This is a list of accomplishments we have realized with the redesigned planning process. We combined the old Individual Service Plan (ISP), the Person-Centered Plan (PCP), the Action Plan and the Budget into one integrated plan. The PCSP will be used for all situation including initial plans with just Support Coordination, those with just a little respite using Self-Administered Services (SAS) and those with 24-hour day and residential services. It was critical for us to build in all Medicaid Waiver requirements and the Department of health has approved this process. And as you have learned from the training on the Supports Intensity Scale (SIS), we are looking for a balance of needs and wants or “what is important TO and FOR the person.” FACILITATOR INSTRUCTIONS Go through these point pretty quickly, but touch on each point. This is just background, do not allow questions here or you could spend all day discussing these points. Let the group know they will have time for questions when we get into the planning process itself.

    5. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Accomplishments continued… Link assessments directly to the plan Assessments strengthened: multi-method multi-source multi-occasion Emphasize personal goals and address quality of life issues 8 Health and safety addressed in the context of the person’s life 5. 6. We have focused a lot over the past two years on the SIS; however, we want to strengthen our use of all assessment information in the planning process. To do this we need to have high quality assessments. One way to accomplish this is to use multi-methods of assessment; not just the interview method used in the SIS and ICAP, but also professional testing and even just time spent interacting and observing is an important method of assessment. Multi-source assessments include getting information from different people, including the person, their family, provider staff, Support Coordinator, other professional, etc. Multi-occasion assessment means not just relying on a SIS done on one day, but ongoing assessments such as Monthly Progress Notes and visits are just as important. 7 & 8. We address personal goals/quality of life and health/safety. We have to do both! 5. 6. We have focused a lot over the past two years on the SIS; however, we want to strengthen our use of all assessment information in the planning process. To do this we need to have high quality assessments. One way to accomplish this is to use multi-methods of assessment; not just the interview method used in the SIS and ICAP, but also professional testing and even just time spent interacting and observing is an important method of assessment. Multi-source assessments include getting information from different people, including the person, their family, provider staff, Support Coordinator, other professional, etc. Multi-occasion assessment means not just relying on a SIS done on one day, but ongoing assessments such as Monthly Progress Notes and visits are just as important. 7 & 8. We address personal goals/quality of life and health/safety. We have to do both!

    6. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Accomplishments continued… 9. Plan includes state plan services, generic and natural supports in addition to DSPD funded supports (Waiver Services) 10. Direct link from the plan to the individual budget 11. Justify paid services with links to identified needs 12. Clarify Support Coordinator/Provider roles and responsibilities SAY 9. We need to expand the array of supports listed in the plan. The plan is not just a list of Waiver services. 10 & 11. All paid services will be listed in the Action Plan. 12. I know one of the biggest challenges in the past has been just trying to figure out what you are expected do to and who does what in the assessment and planning process. One of the benefits of USTEPS is it has forced us to clarify this in a standardized process. As you can see there are a lot of positive accomplishments as a result of the redesigned PCSP Process. Before we go any further let’s look at an actual Person-Centered Support Plan. FACILITATOR INSTRUCTIONS Have co-facilitator hand out Jackie B. Goode’s PlanSAY 9. We need to expand the array of supports listed in the plan. The plan is not just a list of Waiver services. 10 & 11. All paid services will be listed in the Action Plan. 12. I know one of the biggest challenges in the past has been just trying to figure out what you are expected do to and who does what in the assessment and planning process. One of the benefits of USTEPS is it has forced us to clarify this in a standardized process. As you can see there are a lot of positive accomplishments as a result of the redesigned PCSP Process. Before we go any further let’s look at an actual Person-Centered Support Plan. FACILITATOR INSTRUCTIONS Have co-facilitator hand out Jackie B. Goode’s Plan

    7. We promote opportunities and provide support for people with disabilities to lead self-determined lives. PCSP Outline Part I. Part I. Identifying Information and Background A. Background B. Person-Centered Profile C. Review of Previous Year Goals, Paid Services, and Support Strategies D. Assessments TO/FOR Lists SAY Now that we have read through the plan and before we address this slide, let me ask a couple of questions: What struck you as different about this plan either in detail or in “feel”? FACILITATOR INSTRUCTIONS When ever you ask a question wait for an answer. Do not rush past it, allow for silence if necessary. You can encourage participation by asking leading questions if the silence is too uncomfortable. Questions: What did you notice is different from what we are currently doing? If you had to identify one or two things that are different what would they be? What characteristics of this plan strike you as new or redesigned? Once you have sufficiently flushed out some answers address this current slide (slide #9) and slide #10 following the text…. SAY Now that we have read through the plan and before we address this slide, let me ask a couple of questions: What struck you as different about this plan either in detail or in “feel”? FACILITATOR INSTRUCTIONS When ever you ask a question wait for an answer. Do not rush past it, allow for silence if necessary. You can encourage participation by asking leading questions if the silence is too uncomfortable. Questions: What did you notice is different from what we are currently doing? If you had to identify one or two things that are different what would they be? What characteristics of this plan strike you as new or redesigned? Once you have sufficiently flushed out some answers address this current slide (slide #9) and slide #10 following the text….

    8. We promote opportunities and provide support for people with disabilities to lead self-determined lives. PCSP Outline Parts II - IV. Part II. Action Plan A. Personal Goals B. Additional Supports and Services C. Purchased Services Part III. Budget Part IV. Signatures SAY – Slide #7 As the slides point out Jackie’s plan has 4 parts. FACILITATOR INSTRUCTIONS FLIPCHART 4 Parts of PCSP Have these 4 parts of the PCSP written on flip chart before course 4 Parts of PCSP 1.Identifying Information and Background 2.Action Plan 3.Budget 4.Signatures Please take the yellow highlighter in front of you and highlight each part. This is just a brief overview of a Person-Centered Support Plan to point out the basic structure. Is the structure clear? Great! Then let’s move on…. SAY – Slide #7 As the slides point out Jackie’s plan has 4 parts. FACILITATOR INSTRUCTIONS FLIPCHART 4 Parts of PCSP Have these 4 parts of the PCSP written on flip chart before course 4 Parts of PCSP 1.Identifying Information and Background 2.Action Plan 3.Budget 4.Signatures Please take the yellow highlighter in front of you and highlight each part. This is just a brief overview of a Person-Centered Support Plan to point out the basic structure. Is the structure clear? Great! Then let’s move on….

    9. We promote opportunities and provide support for people with disabilities to lead self-determined lives. DSPD Assessments Functional Behavior Assessments Rights Assessments Supports Intensity Scale Risk Assessment Social History Summary Psychological Evaluation Developmental Assessment Psychiatric Mental Health Medical evaluations OT, PT, Speech ABI specific assessments CBIA ICAP Monthly Summaries Essential Lifestyle Plan Informal questioning / interviewing Education Voc Rehab Person-Centered Profile (new) FACILITATOR INSTRUCTIONS SAY Here is a list of assessments that are common in DSPD. A definition of assessment: The process of documenting knowledge, skills, attitudes, and beliefs. Information is traditionally gathered in measurable terms but this can be flexible. I am sure this is not everything; do you notice something missing? What about your log notes? – they often include assessment information too! Notice the last one is the new Person-centered Profile, let’s look at that in some detail next. FACILITATOR INSTRUCTIONS SAY Here is a list of assessments that are common in DSPD. A definition of assessment: The process of documenting knowledge, skills, attitudes, and beliefs. Information is traditionally gathered in measurable terms but this can be flexible. I am sure this is not everything; do you notice something missing? What about your log notes? – they often include assessment information too! Notice the last one is the new Person-centered Profile, let’s look at that in some detail next.

    10. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Person-Centered Profile First section of the Person-Centered Support Plan Important information about the individual Information that helps to know new people Is a living document that grows with the person The profile can include information from all those who know and support the individual SAY You will note right after the section titled Background we have the Person-Centered Profile. In some ways, the new Person-Centered Profile replaces what some called an Essential Lifestyle Plan from Michael Smull (it rarely really was) or similar types of Assessment Information sometimes referred to as person-centered planning or person-centered assessments. The Profile can be found in (read through text on Power Point)SAY You will note right after the section titled Background we have the Person-Centered Profile. In some ways, the new Person-Centered Profile replaces what some called an Essential Lifestyle Plan from Michael Smull (it rarely really was) or similar types of Assessment Information sometimes referred to as person-centered planning or person-centered assessments. The Profile can be found in (read through text on Power Point)

    11. We promote opportunities and provide support for people with disabilities to lead self-determined lives. The Person-Centered Profile is initially completed by the Support Coordinator when a person transitions into services (may not have a lot of detail) Most people in services have this type of information in their file as a good starting point The Team provides the Support Coordinator with updated information on the Person-Centered Profile annually The Person-Centered Profile is updated by the Support Coordinator when significant changes are noted or at least annually Person-Centered Profile SAY To bring a sense of sequence the Person-Centered Profile is follow text.. As part of the contract, providers are required to participate in assessments. We interpret that to include the SIS and this Profile. We expect residential providers to be major contributors to this.SAY To bring a sense of sequence the Person-Centered Profile is follow text.. As part of the contract, providers are required to participate in assessments. We interpret that to include the SIS and this Profile. We expect residential providers to be major contributors to this.

    12. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Person-Centered Profile Handout (outline) Introduction Likes/dislikes Communication style/preferences Contributions/ Relationships Hopes/Dreams/Fears and Personal Goals Health and Safety Issues Legal/Rights Issues Guardianship Court orders Rights restrictions Other Considerations Emotional/self-esteem/spiritual/cultural Other “Need to Know” information Historical information Reference other assessments HANDOUT #4 Person-Centered Profile SAY ________is passing out a sheet that further elaborates on the Person-Centered Profile. So let me ask a couple of questions….. When is the profile required? When entering services initially, everyone in services will have a profile. Who completes the profile? Support Coordinator responsible for it, but most information from providers. When is the profile updated? When significant changes are noted, at least annually. We will be talking about this next, but when USTEPS in in place, items on the TO and FOR list marked as “important information” will automatically be added to the profile under “Other Considerations.” This will make more sense latter. Now let’s move on to Assessments as a whole. HANDOUT #4 Person-Centered Profile SAY ________is passing out a sheet that further elaborates on the Person-Centered Profile. So let me ask a couple of questions….. When is the profile required? When entering services initially, everyone in services will have a profile. Who completes the profile? Support Coordinator responsible for it, but most information from providers. When is the profile updated? When significant changes are noted, at least annually. We will be talking about this next, but when USTEPS in in place, items on the TO and FOR list marked as “important information” will automatically be added to the profile under “Other Considerations.” This will make more sense latter. Now let’s move on to Assessments as a whole.

    13. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Important TO What the person tells us, either verbally or behaviorally, is “most” important TO the person. What is important TO a person includes only what people are saying: With their words With their behavior When what the person says is different from what they do, the bias is to rely on behavior. SAY We are funneling all assessment information we think is useful in planning into two lists: important TO and important FOR Let’s take a look at exactly what is meant by Important TO or FOR the person This is review from the SIS training, so hopefully it looks familiar. We are looking for a shorter list here, maybe 5-12 items (could be more). Focus on things important to keep as is and change. These should directly relate to quality of life issues. FACILITATOR INSTRUCTIONS Follow the text on the slides #19, #20 and #21SAY We are funneling all assessment information we think is useful in planning into two lists: important TO and important FOR Let’s take a look at exactly what is meant by Important TO or FOR the person This is review from the SIS training, so hopefully it looks familiar. We are looking for a shorter list here, maybe 5-12 items (could be more). Focus on things important to keep as is and change. These should directly relate to quality of life issues. FACILITATOR INSTRUCTIONS Follow the text on the slides #19, #20 and #21

    14. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Important FOR What others tell us is important FOR the person to be successful What is important FOR the person Issues of health or safety What others see as important to help the person (the person may or may not agree)

    15. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Michael Smull Balance between important TO and FOR Balance between Choice and Responsibility “Happy and dead are incompatible, alive and miserable is unacceptable” Michael Smull is one of the leaders in the person-centered planning movement. He is the author of “Essential Lifestyle Plans” and is the one we got the idea of “TO” and “FOR” Question: -Why is the distinction between important TO and important FOR important? -How does the distinction between important TO and FOR fit in with the mission and values of DSPD? DSPD Mission may be useful here (located in the Introduction Section).Michael Smull is one of the leaders in the person-centered planning movement. He is the author of “Essential Lifestyle Plans” and is the one we got the idea of “TO” and “FOR” Question: -Why is the distinction between important TO and important FOR important? -How does the distinction between important TO and FOR fit in with the mission and values of DSPD? DSPD Mission may be useful here (located in the Introduction Section).

    16. We promote opportunities and provide support for people with disabilities to lead self-determined lives. SAY HANDOUT #5 Flow chart This is an overview of how the identification of TO and FOR items fits into the larger planning process. Take just a minute to walk yourself through it. We have a handout of this if this is too small to read. Walk through the four components left to right: #1 Assessments (primarily the SIS) #2 Develop “TO” and “FOR” List #3 Categorize the items on the lists #4 Use in Action Plan Development (bottom of the page) SAY HANDOUT #5 Flow chart This is an overview of how the identification of TO and FOR items fits into the larger planning process. Take just a minute to walk yourself through it. We have a handout of this if this is too small to read. Walk through the four components left to right: #1 Assessments (primarily the SIS) #2 Develop “TO” and “FOR” List #3 Categorize the items on the lists #4 Use in Action Plan Development (bottom of the page)

    17. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Planning Steps A. Pre-meeting 1. Update TO/FOR List  2.  Copy And Distribute B. PCSP Meeting 1. Review all assessments 2.  Celebrate 6. Write Current Status of Goals 3.  Add to TO/FOR List  7. Identify Supports and Services 4.  Categorize TO/FOR List 8. Additional Supports and Services 5. Identify and Write Clear Personal Goal(s) SAY Alright, to date we’ve spent some time looking at the Person-Centered Profile and the role of assessments. Now let’s consider the Planning Process itself. As you can see by the slide the process involves; The Pre-Meeting Then the Annual Meeting (understanding this may be more than annually) In the Pre-Meeting we were asking that you Update TO/FOR List (this would be taking the TO and FOR lists from the SIS and add from the review of other assessments like we just did Make copies of the updated materials and distribute to all team members before the PCS Planning Annual Meeting B. During the Annual Meeting you along with the Team will follow these 8 steps.SAY Alright, to date we’ve spent some time looking at the Person-Centered Profile and the role of assessments. Now let’s consider the Planning Process itself. As you can see by the slide the process involves; The Pre-Meeting Then the Annual Meeting (understanding this may be more than annually) In the Pre-Meeting we were asking that you Update TO/FOR List (this would be taking the TO and FOR lists from the SIS and add from the review of other assessments like we just did Make copies of the updated materials and distribute to all team members before the PCS Planning Annual Meeting B. During the Annual Meeting you along with the Team will follow these 8 steps.

    18. We promote opportunities and provide support for people with disabilities to lead self-determined lives. B. PCSP Meeting 1. Review the summary of assessments Quick – brief review of key issues including: Person-Centered Profile Last year’s 1) goals, 2) purchased services, 3) support strategies, and 4) other supports Others critical changes and events We would like for contracted providers to provide a “year end summary” however, at this time there is not a specific requirement in their contract so the details/formats will have to be negotiated with the provider. You could ask a provider to do a more comprehensive review of the year along with the 11th months progress note (but we can’t require it!).We would like for contracted providers to provide a “year end summary” however, at this time there is not a specific requirement in their contract so the details/formats will have to be negotiated with the provider. You could ask a provider to do a more comprehensive review of the year along with the 11th months progress note (but we can’t require it!).

    19. We promote opportunities and provide support for people with disabilities to lead self-determined lives. B. PCSP Meeting 2.      Celebrate !!!   Big challenge – even when the consumer accomplishes things, they still have a severe disability and a long list of needs to address. The whole team needs to recognize accomplishments and take time to celebrate! This is not just added in for fun or to add a light moment to the meeting. This is a critical component that requires a Support Coordinator with specific knowledge, skills and abilities. Practice! SAY This is not just for fun. This is really important for planning to be successful!!!SAY This is not just for fun. This is really important for planning to be successful!!!

    20. We promote opportunities and provide support for people with disabilities to lead self-determined lives. B. PCSP Meeting 3.   Add to To & For List  This is the same process as in A. 1. above. This time it is with the whole team Add, combine, clarify, do not delete anything This will usually be very brief, we just want to make sure the whole team has a chance for input before we go to the next step. One of the practical features in USTEPS is that you can always go back and add or change something. So even if we leave something off the list at this step we can add it later if we need to.This will usually be very brief, we just want to make sure the whole team has a chance for input before we go to the next step. One of the practical features in USTEPS is that you can always go back and add or change something. So even if we leave something off the list at this step we can add it later if we need to.

    21. We promote opportunities and provide support for people with disabilities to lead self-determined lives. B. PCSP Meeting 4. Categorize TO & FOR List TO: Current Goal Future Goal Important Information NA FOR: Address in the Plan Important to know NA SAY As an interim step the team will sort through the TO and FOR lists and categorize each item according to how they want to use that information in the development of the plan. TO List: Current Goal: items related to a goal you want to focus on this year Future Goal: items that relate to a goal, but not one to focus on this year, a lower priority Important Information: other things of importance, but not related to goals. This might include something they might want in their life (“non-negotiables” or “highly desirables”). These will be listed in the Person-centered Profile. NA: “not applicable” - even if it is on the list, the team can determine the item is no longer relevant and will not be used in planning. FOR List: Address in the Plan: this is an item that the team needs to address somehow in the plan Important to know: these are items that supporters will need to know in supporting the person in general or in writing specific support strategies NA: “not applicable” - even if it is on the list, the team can determine the item is no longer relevant and will not be used in planning. SAY As an interim step the team will sort through the TO and FOR lists and categorize each item according to how they want to use that information in the development of the plan. TO List: Current Goal: items related to a goal you want to focus on this year Future Goal: items that relate to a goal, but not one to focus on this year, a lower priority Important Information: other things of importance, but not related to goals. This might include something they might want in their life (“non-negotiables” or “highly desirables”). These will be listed in the Person-centered Profile. NA: “not applicable” - even if it is on the list, the team can determine the item is no longer relevant and will not be used in planning. FOR List: Address in the Plan: this is an item that the team needs to address somehow in the plan Important to know: these are items that supporters will need to know in supporting the person in general or in writing specific support strategies NA: “not applicable” - even if it is on the list, the team can determine the item is no longer relevant and will not be used in planning.

    22. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Personal Goal What makes it personal? “Personal” is: What the person wants What is important to the person What is the person’s passions and values What brings the person pleasure and enjoyment “Personal” is not: What the person needs (habilitation, health & safety) What is good for a person What others think the person should want SAY In the past the appropriate focus for goals has been unclear, but now we want everyone on the same page. All goals have to be personal goals. This is not a general guideline – it is an absolute! If you find you are stuck as to what defines a Personal Goal think of it in this manner. Follow text….SAY In the past the appropriate focus for goals has been unclear, but now we want everyone on the same page. All goals have to be personal goals. This is not a general guideline – it is an absolute! If you find you are stuck as to what defines a Personal Goal think of it in this manner. Follow text….

    23. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Personal Goal What makes it a goal? The “Goal” is: The desired end result What we hope to accomplish this year Use “short-tem goal” if needed What we will see in the person’s life The “Goal” is not: the process (supports and services) the result of the Support Strategy SAY Additionally we are defining “ goal” by what it is and by what it is not. The word “Goal” will only be used for “personal goals” Use the word “Objective” for the desired result of Support Strategy.SAY Additionally we are defining “ goal” by what it is and by what it is not. The word “Goal” will only be used for “personal goals” Use the word “Objective” for the desired result of Support Strategy.

    24. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Personal Goal focus Maintain something good Avoiding something bad Accomplishing something good SAY Personal Goals often have a focus follow text…. Give examples: Maintain something good: “Continue to live with parents” Avoiding something bad: “Stay out of nursing facility” Accomplishing something good: “Get a higher paying job” Can mix and match, but avoid all maintain and avoid – that’s a depressing life. Working for something good/desirable is best!!! FACILITATOR INSTRUCTIONS FLIP CHART: Criteria for Goal After you have reviewed this slide. Turn to the flip chart page titled Criteria For A Good Goal and go through the following verbiage: Criteria for a Good Goal 1. Clarity: Does everyone understand the terms and criteria used? 2. Practicality: Is it easy for both consumers and staff to use? Is it written in positive language?  Could consumers use it to self-assess? SAY Personal Goals often have a focus follow text…. Give examples: Maintain something good: “Continue to live with parents” Avoiding something bad: “Stay out of nursing facility” Accomplishing something good: “Get a higher paying job” Can mix and match, but avoid all maintain and avoid – that’s a depressing life. Working for something good/desirable is best!!! FACILITATOR INSTRUCTIONS FLIP CHART: Criteria for Goal After you have reviewed this slide. Turn to the flip chart page titled Criteria For A Good Goal and go through the following verbiage: Criteria for a Good Goal 1. Clarity: Does everyone understand the terms and criteria used? 2. Practicality: Is it easy for both consumers and staff to use? Is it written in positive language?  Could consumers use it to self-assess?

    25. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Prioritizing Goals What does the person want to focus on? What is most Important TO the person? What will make the biggest difference ? What is doable in the next year? What will require coordinated multiple supports on the Action Plan? versus a single assignment What is better to re-categorize as a Future Goal SAY Not only is the team going to identify goals they/you must also prioritize Goals to ultimately identify the 2 - 4 Goals that will appear in the Person-Centered Support Plan. Follow text.SAY Not only is the team going to identify goals they/you must also prioritize Goals to ultimately identify the 2 - 4 Goals that will appear in the Person-Centered Support Plan. Follow text.

    26. We promote opportunities and provide support for people with disabilities to lead self-determined lives. SAY On Jackie’s plan you see a list of 2 Items that are most “Important TO” her. These items have been prioritized and will be written as goals. Jackie’s #1 goal (not to be interpreted as holding more significance than #2 this is just a numbering) is Jackie wants to move into her apartment within 2 years. Underneath that you’ll see the Current Situation, Strengths and Barriers are addressed.SAY On Jackie’s plan you see a list of 2 Items that are most “Important TO” her. These items have been prioritized and will be written as goals. Jackie’s #1 goal (not to be interpreted as holding more significance than #2 this is just a numbering) is Jackie wants to move into her apartment within 2 years. Underneath that you’ll see the Current Situation, Strengths and Barriers are addressed.

    27. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Personal Goals - Examples Jackie Goal #1 Jackie wants to move into her own apartment within 2 years. Goal #2 Jackie would like to keep her job and keep making money. Others Bob will continue living with his parents. Jane will go on at least one date a month. SAY Here are an example of a couple other goals in addition to Jackie’s. We have started a list of possible personal goals and will add to this over time. This list is available on the USTEPS Help menu with other PCSP information.SAY Here are an example of a couple other goals in addition to Jackie’s. We have started a list of possible personal goals and will add to this over time. This list is available on the USTEPS Help menu with other PCSP information.

    28. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Write the current status of goal Current status of the Goal How close to the Goal? History? Keep it focused on the goal itself Strengths: prerequisite skills, steps accomplished, relationships Barriers: If this is important, why hasn’t already happened might include items from the “FOR” list SAY Learning Exercise #4a. Happy’s Action Plan – Goal Related Supports Now that you have practiced writing the goal, lets all start with the same goal we have written for you and your task is to add the following information: - Current Status (don’t include strengths and barriers here) - Strengths – this can also include things outside the person (resources, money, opportunities, etc.) - Barriers – this can also include things outside the person (resources, money, opportunities, etc.) So let’s actually practice this.SAY Learning Exercise #4a. Happy’s Action Plan – Goal Related Supports Now that you have practiced writing the goal, lets all start with the same goal we have written for you and your task is to add the following information: - Current Status (don’t include strengths and barriers here) - Strengths – this can also include things outside the person (resources, money, opportunities, etc.) - Barriers – this can also include things outside the person (resources, money, opportunities, etc.) So let’s actually practice this.

    29. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Identify supports and services Formal/Written Support Strategies Medicaid State Plan Services Natural Supports One-Time and On-Going Behavior Supports & Psychotropic Med Plans Specific Medical Skill Training, Opportunities, Relationships, etc… SAY Supports can include any specific assignment to some one on the team include the following……. follow the text on slide To be listed here the support has to be directly or indirectly related to the personal goal in that by providing the support successfully the person will be more likely to accomplish their goal. Do not stretch the connection too far (if they don’t brush their teeth, they could get an infection and die, and if they were dead they wouldn’t be able to…), it needs to be logically linked to the goal. Are you familiar with the gospel song: “You don’t need to move that mountain, just show me a way around it” – all personal goals do not require traditional supports and services to be realized – be creative! SAY Supports can include any specific assignment to some one on the team include the following……. follow the text on slide To be listed here the support has to be directly or indirectly related to the personal goal in that by providing the support successfully the person will be more likely to accomplish their goal. Do not stretch the connection too far (if they don’t brush their teeth, they could get an infection and die, and if they were dead they wouldn’t be able to…), it needs to be logically linked to the goal. Are you familiar with the gospel song: “You don’t need to move that mountain, just show me a way around it” – all personal goals do not require traditional supports and services to be realized – be creative!

    30. We promote opportunities and provide support for people with disabilities to lead self-determined lives. SAY Here is an example of Jackie’s Goals, Current Situation, Strengths, Barriers. Read them. These are followed by supports. Read Support Item #1 and #2. Notice under each Support Item, there is a list of additional information. Support Item: just say what the support is. This can just be a general reference (i.e. behavior support plan, transportation, respite, go to the gym, etc.) there is a place for more details if needed. Who: this can be a name if it is not expected to change, with a provider it might be a job title (if it is a person with a provider, you will put the provider below) Dates: these are typically for the whole year starting the day of the plan; however, they can be narrower if needed. Details: put anything the team wants to say to the person being assigned this item. This could include specific targets, objectives, methods, procedures, data reporting, etc. If nothing is included here the person/agency providing the support will make the decisions about all the details. Paid: indicate if this is a DSPD funded support, meaning that it will be provided under a contracted service. It could be a support that can be provided by staff while the person is being supervised even if the support is not normally a core function of that service. Do not mark “paid” here if paid for by some other source. If an items is marked “no” indicating it is not paid by DSPD, then the following five questions do not need to be answered. Provider: List the name of the contracted provider Service Code: list the code Support Strategy: indicate if you are requesting the provider to send you a written document describing the specific support. Remember under “details” you can include and specific that you want included. Monthly Summary: indicate if you are requesting the provider to send you a written document monthly reporting on the support provided and the results. Remember under “details” you can include and specific that you want included. The last item, “FOR Item(s): is optional if not a paid support; however, if it addresses a FOR item categorized as ”in the plan” we want to indicate the FOR item number here so we make sure we have addressed them all when we are finished with the plan. We are now going to walk through this same process with Happy. FACILITATOR INSTRUCTIONS Read Exercise Instructions on following page.SAY Here is an example of Jackie’s Goals, Current Situation, Strengths, Barriers. Read them. These are followed by supports. Read Support Item #1 and #2. Notice under each Support Item, there is a list of additional information. Support Item: just say what the support is. This can just be a general reference (i.e. behavior support plan, transportation, respite, go to the gym, etc.) there is a place for more details if needed. Who: this can be a name if it is not expected to change, with a provider it might be a job title (if it is a person with a provider, you will put the provider below) Dates: these are typically for the whole year starting the day of the plan; however, they can be narrower if needed. Details: put anything the team wants to say to the person being assigned this item. This could include specific targets, objectives, methods, procedures, data reporting, etc. If nothing is included here the person/agency providing the support will make the decisions about all the details. Paid: indicate if this is a DSPD funded support, meaning that it will be provided under a contracted service. It could be a support that can be provided by staff while the person is being supervised even if the support is not normally a core function of that service. Do not mark “paid” here if paid for by some other source. If an items is marked “no” indicating it is not paid by DSPD, then the following five questions do not need to be answered. Provider: List the name of the contracted provider Service Code: list the code Support Strategy: indicate if you are requesting the provider to send you a written document describing the specific support. Remember under “details” you can include and specific that you want included. Monthly Summary: indicate if you are requesting the provider to send you a written document monthly reporting on the support provided and the results. Remember under “details” you can include and specific that you want included. The last item, “FOR Item(s): is optional if not a paid support; however, if it addresses a FOR item categorized as ”in the plan” we want to indicate the FOR item number here so we make sure we have addressed them all when we are finished with the plan. We are now going to walk through this same process with Happy. FACILITATOR INSTRUCTIONS Read Exercise Instructions on following page.

    31. We promote opportunities and provide support for people with disabilities to lead self-determined lives. List Additional Supports and Services Not related to Personal Goals not already addressed Address health and safety issue from the “FOR” list that were categorized as “address in the plan” Address preferences and wants from the “TO” list that were categorized as other “important information” SAY This brings us to the portion of the plan where you address Additional Support & Services. As you can see by the slide Additional Supports and Services include….follow text on slide.SAY This brings us to the portion of the plan where you address Additional Support & Services. As you can see by the slide Additional Supports and Services include….follow text on slide.

    32. We promote opportunities and provide support for people with disabilities to lead self-determined lives. SAY If you noticed at the end of the Action Plan, under the heading of Additional Supports, there is a subheading called: “Standard Supports.” This is included in everyone's PCSP as every consumer should have an identified medical provider and Support Coordinator. You can always add other medical specialists, but this space is automatically included in all plans. We indicate Support Coordination as not “paid” just because it is not included in the person’s budget.SAY If you noticed at the end of the Action Plan, under the heading of Additional Supports, there is a subheading called: “Standard Supports.” This is included in everyone's PCSP as every consumer should have an identified medical provider and Support Coordinator. You can always add other medical specialists, but this space is automatically included in all plans. We indicate Support Coordination as not “paid” just because it is not included in the person’s budget.

    33. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Complete the Person-Centered Support Plan The last part of the Action Plan is the Purchased Services Copy and Paste Service Descriptions amount , duration, frequency Part III of the PCSP is the Budget Signatures SAY These last section of the plan are just like the old ISP. Service Code: just list it Service Code Description: we have provided an electronic list of all the descriptions, so you just copy and paste the ones you need. Complete the amount ,duration, and frequency as you do now. The last item is new. “FOR Items” can be listed here, indicating that the provider of this service will address the specific FOR item in addition the the general service description. When you are done with this section, all FOR items categorized as “in the plan” must be addressed somewhere: goal related, non-goal related, or here tied to a paid service. If the FOR item was previously tied to a support, it does not need to be repeated here. This is just for FOR items not already listed. Some services (i.e. day and residential) are very broad and providers are expected to provide for basic health and safety. Every detail does not need to be included in the plan, only those identified in the assessments, put on the FOR list and categorized as”in the plan” will need to be addressed. For now, until the budget is produced in USTEPS, continue to use current forms for the budget portion of the plan. Only the signature of the Support Coordinator and the consumer/guardian are required. It is recommended that you get an attendance list and include the names of those at the meeting here after the signatures under the heading of “Planning Team in Attendance:” In the past many people have been completing the ISP prior to the meeting and obtaining signatures at the time of the meeting. This was convenient but not really appropriate. It is possible to complete the plan at the meeting; however, most will find this difficult without a co-facilitator. In most cases the PCSP will need to be completed after the planning meeting and signatures obtained later when visiting or by mail.SAY These last section of the plan are just like the old ISP. Service Code: just list it Service Code Description: we have provided an electronic list of all the descriptions, so you just copy and paste the ones you need. Complete the amount ,duration, and frequency as you do now. The last item is new. “FOR Items” can be listed here, indicating that the provider of this service will address the specific FOR item in addition the the general service description. When you are done with this section, all FOR items categorized as “in the plan” must be addressed somewhere: goal related, non-goal related, or here tied to a paid service. If the FOR item was previously tied to a support, it does not need to be repeated here. This is just for FOR items not already listed. Some services (i.e. day and residential) are very broad and providers are expected to provide for basic health and safety. Every detail does not need to be included in the plan, only those identified in the assessments, put on the FOR list and categorized as”in the plan” will need to be addressed. For now, until the budget is produced in USTEPS, continue to use current forms for the budget portion of the plan. Only the signature of the Support Coordinator and the consumer/guardian are required. It is recommended that you get an attendance list and include the names of those at the meeting here after the signatures under the heading of “Planning Team in Attendance:” In the past many people have been completing the ISP prior to the meeting and obtaining signatures at the time of the meeting. This was convenient but not really appropriate. It is possible to complete the plan at the meeting; however, most will find this difficult without a co-facilitator. In most cases the PCSP will need to be completed after the planning meeting and signatures obtained later when visiting or by mail.

    34. We promote opportunities and provide support for people with disabilities to lead self-determined lives. What’s changed? Standardized process & document Help with Person Centered Profile Goal = Personal Goal (not day/residential) Action Plan expanded Do not come to the meeting with the answer (goal & supports) Come to the meeting with good information about the person and as a team member, use creative problem solving, to address quality of life and health/safety

    35. We promote opportunities and provide support for people with disabilities to lead self-determined lives. Guiding principle: The best (most effective & efficient) way to address a person’s needs is in the context of trying to provide the life they want What’s next? Practice with “mentor” over next 6 weeks Apply PCSP process in USTEPS SAY As we said earlier in this training, today is just an overview of the process. We’ve provided these handouts and additional resource materials to spark your memory when you actually do the pre-meeting, annual meeting and finalize the plan. From this point we are asking you to complete a PCSP in the paper and pencil version 2 times before the implementation of USTEPS which is slated for May! We have Word template documents to assist you in this process, so you do not need to actually write it all up by hand. Either you supervisor or a staff member from the state office will accompany you to your first PCSP Annual Meeting. They will act as a partner and coach in this process. You may also have a partner accompany you on your second PCSP Annual meeting if you like or if need be. We will complete this by the end of April as USTEPS will be rolling out shortly. We are not doing this in tandem with USTEPS because we want to make sure we all understand the process before we employ the mechanics. So, here is what will happen next _______ Thank you for your time and attention today!SAY As we said earlier in this training, today is just an overview of the process. We’ve provided these handouts and additional resource materials to spark your memory when you actually do the pre-meeting, annual meeting and finalize the plan. From this point we are asking you to complete a PCSP in the paper and pencil version 2 times before the implementation of USTEPS which is slated for May! We have Word template documents to assist you in this process, so you do not need to actually write it all up by hand. Either you supervisor or a staff member from the state office will accompany you to your first PCSP Annual Meeting. They will act as a partner and coach in this process. You may also have a partner accompany you on your second PCSP Annual meeting if you like or if need be. We will complete this by the end of April as USTEPS will be rolling out shortly. We are not doing this in tandem with USTEPS because we want to make sure we all understand the process before we employ the mechanics. So, here is what will happen next _______ Thank you for your time and attention today!

    36. We promote opportunities and provide support for people with disabilities to lead self-determined lives. the end…

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