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Developing a Person-Centered Individual Support Plan. for A Good Life in Virginia. The 5 parts of the ISP. Virginia’s PC Planning Process. PCT Training and Tools are available. Changes in Language. Client/Consumer = Individual Case Manager = Support Coordinator

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Presentation Transcript
the 5 parts of the isp
The 5 parts of the ISP

Virginia’s PC Planning Process

changes in language
Changes in Language

Client/Consumer = Individual

Case Manager=Support Coordinator

Service Plan=Support Plan

Training = Learning

Assistance = Supports

Specialized Supervision=Safety Supports

Interventions/Strategies = Support Instructions

Before the meeting

Part 1: Essential Information

part 1 essential information
Part 1: Essential Information

Part 1: Essential Information

part 1 essential information1
Part 1: Essential Information

Collected and maintained by the Support Coordinator.

Part 1: Essential Information

Shared with providers initially and annually

(before or after the annual).

Part 1: Essential Information

Can be in the optional sample format

Part 1: Essential Information

or can be in CSB-specific format

Sample table of contents, may look different per service

Part 1: Essential Information

Regardless of format, the information is essential for accessing services and ensuring health & safety.

This information should be reviewed and updatedat least quarterly by the support coordinator.

Part 1: Essential Information

The Support Coordinator assures a new Supports Intensity Scale (SIS) once every three years and when support needs change significantly.

for 1/3 per year

Part 1: Essential Information

The SIS includes a Risk Assessment that the support coordinator will complete annually.

Part 1: Essential Information

Before the meeting

Part 2: Personal Profile

part 2 personal profile
Part 2: Personal Profile

Part 2: Personal Profile

Prepared by the individual before planning with someone he or she trusts like a Planning Partner.

Can be completed with Support Coordinator when no other partners are available.

Part 2: Personal Profile

What is a Planning Partner?

A friend…

family member…

support provider…

someone who helps with:

-completing the profile,

-arranging planning meetings,

-contacting partners,

-identifying off-limit topics,

-communicating with SC.

Part 2: Personal Profile



Part 2: Personal Profile

The profile is a “living description” of the individual not a one-time interview.

You can build it over time by talking, listening, and observing.

It needs to be ready to give to the support coordinator by the annual meeting.

The good life description might be completed last once the life areas are reviewed.

Part 2: Personal Profile

Provided to the support coordinator

before or at the annual meeting.

Part 2: Personal Profile

Includes the vision of a good life. Looks at gifts, talents & contributions.

Part 2: Personal Profile

The final profile is shared with all partners by the support coordinator after planning -

either in the optional sample format

or contained in a CSB-specific format.

Secure email

Providers add new learning to the Profile throughout the year to share at planning.

Part 2: Personal Profile

During the meeting

Part 3: Shared Planning

part 3 shared planning
Part 3: Shared Planning

Part 3: Shared Planning

part 3 shared planning1
Part 3: Shared Planning

A person-centered team:

Facilitator = Individual & SC

Recorder = Partner volunteer

Timekeeper = Partner volunteer

Share something that made you smile

The meeting begins by sharing the good things that has happened in the person’s life.

The individual shares his or her Profile with support as needed or desired.

Part 3: Shared Planning

It’s important to ask…

What needs to change?

What needs to stay the same?


Are we finding a balance between what’s important TO and what’s important FOR?

Part 3: Shared Planning

important to
Important to

What makes a person happy,

content, fulfilled

  • People, pets
  • daily routines and rituals,
  • products and things,
  • Interests and hobbies,
  • places one likes to go

Part 3: Shared Planning

important for
Important for

What we need to stay healthy, safe and valued

  • health and safety
  • things that others feel will contribute to being accepted or valued in the


Part 3: Shared Planning

The Profile and the SIS are reviewed to identify what’s IMPORTANT TO and what’s IMPORTANT FOR planning this year.

Part 3: Shared Planning

A volunteer or the support coordinatorrecords Shared Planning at the meeting.

Part 3: Shared Planning

Part 3 Shared Planning includes outcome numbers, what’s IMPORTANT TO, what’s IMPORTANT FOR and each Desired Outcome.

Also includes how often the support is to be provided and who will be providing support in each instance.

Part 3: Shared Planning

Important TOs and FORs are global and become more specific and measurable when outcomes are defined.

Important TO = baseball

Desired outcome = Max watches a baseball game with his brother each month.

Important FOR = personal care

Desired outcome = Devon is clean and has the support he needs each day with shaving, showering, and having a neat general appearance.

Part 3: Shared Planning

Outcomes must be measurable and result in actions you can see or learning you can assess.

Part 3: Shared Planning

Using verbs helps clarify what we are measuring.











Part 3: Shared Planning

If the supports we identify are provided, we expect that the desired outcome will be achieved.

Part 3: Shared Planning

By documenting the supports we provide, we can learn if what we are doing is bringing about the desired outcome or if supports need to change.

Part 3: Shared Planning

How do we know if our supports lead to the desired outcome?

From evidence we can see or hear and report.

From evidence that the outcome happened.

From evidence based on what the person says or does.

Part 3: Shared Planning

We are looking for evidence that the desired outcome has occurred or if we can see movement toward the outcome.

Desired outcome

Jack makes five new friends who like Jazz music.

Evidence of progress

Jack joined a jazz club this quarter and went four times. He was introduced to several new people.

Part 3: Shared Planning

If no evidence of progress towards the desired outcome, changing the supports or the outcome can improve how we support people.

Desired outcome

Jack makes five new friends who like Jazz music.

Lack of evidence

Jack threw away his Jazz CDs and says he does not want to talk about it.

Part 3: Shared Planning

We also need to know if the outcome, once achieved, is still desired by the individual to know if support should continue.

Part 3: Shared Planning

Remember - we are seeking to help people build a quality life of their choosing. We are helping them assemble a desirable life.

Part 3: Shared Planning

Desired outcomes

Jack walks to the corner store each week.

Margo listens to the country band every Friday night.

Craig helps with the landscaping by pulling weeds and mowing the grass each week.

Martin cares for his dog by giving him baths each week.

Part 3: Shared Planning

Part 3 Shared Planning is shared by the support coordinator with all partners following planning.

Secure email

Part 3: Shared Planning

During the meeting

Part 4: Agreements

part 4 agreements
Part 4: Agreements

Stored in the SC record

Part 4: Agreements

All partners work together to answer the agreement questions.

Any disagreements are revisited in discussion for resolution and unresolved items are documented on the agreement page.

Part 4: Agreements

All partners sign in agreement and other contributors are listed.

All Medicaid providers must sign.

Sent by SC to all partners

Part 4: Agreements

After the meeting

Part 5: Plan for Supports

part 5 plan for supports
Part 5: Plan for Supports

Part 5: Plan for Supports

Can be in the optional sample format or in existing provider formats.

Part 5: Plan for Supports

Includes the support activities allowable under Medicaid for each service, as well as the instructions for carrying out each support in a person-centered way.

The target date is the annual ISP date unless indicated sooner. Time is added to show how long the support is expected to take each time it’s provided.

Part 5: Plan for Supports

When supports are not provided as agreed, a code is used in place of initials and a note is completed in the support log.

Part 5: Plan for Supports

Initials, codes and ongoing notes support billing and confirm the supports that are provided.

Part 5: Plan for Supports

Whenever a code is used on the checklist, there must be a corresponding note.

Routine daily or weekly notes must be written as well.

Part 5: Plan for Supports

After the meeting

Part 5: PC Review

person centered review
Person-Centered Review

Part 5: PC Review

This review is completed four times each year and whenever outcomes are changing.

Part 5: PC Review

Each provider needs to report progress toward each outcome on their plan for supports.

Part 5: PC Review

Progress is measured by evidence that the desired outcome is occurring or that movement toward the outcome is being made.

What can we see that demonstrates progress?

What was a barrier to progress?

Is the individual satisfied with the outcome?

Is the support enhancing the person’s quality of life.

Part 5: PC Review

If progress is not evident and/or the individual is dissatisfied with the outcome, there should be documentation explaining this fact and alternate plans should be pursued.

Part 5: PC Review

If progress toward the outcome is observed and documented in the review, the progress box should be checked.

Part 5: PC Review

If the outcome is continuing and is still desired by the individual, the “continued” box should be checked.

Part 5: PC Review

If the outcome is being ended and is being replaced by a different outcome, “changed” should be checked.

Part 5: PC Review

If the outcome is being ended altogether and is not replaced by a different outcome – check “ended.”

Part 5: PC Review

New outcomes are added at the bottom of the review and are described as IMPORTANT TO or IMPORTANT FOR the individual

Once approved, the supports are added to the provider’s support documents

Part 5: PC Review

Any remaining medical or significant information is added and satisfaction is described.

One question asks about a change in hours.

Part 5: PC Review

Signatures are needed upon review and when outcomes change.

The support coordinator reviews, signs and returns signature page approving changes to desired outcomes.

Part 5: PC Review


Please check

for forms, updates and contacts.