AAMR Supports Intensity Scale Implementation Training

Presented by:

Alan Tribble

Steve Wrigley

DSPD SIS Certified Trainers

October through December 2005

Overview / Agenda

Session One: Overview of Supports Intensity Scale SIS Pilot Program / Risk Assessment Administration of the SIS / Risk Assessment Screening

Tool– Review of Sections– Guidelines for Interviewing– Expanded Item Descriptions– SIS Frequently Asked Questions

Overview / Agenda

Session One Continued: Modifications for Children & Adolescents Utah’s Risk Assessment Supplement

Screening Tool How to Score SIS Booklet Practice Administering SIS / Questions Homework Assignment for Session Two

Overview / Agenda

Session Two: Review of the SIS Administration Homework

Assignment and Discussion Using the SIS in the ISP Planning Process

– Overview of SIS ISP Planning Process – SIS ISP Planning Case Examples– Implementation to Own Caseload Example

Questions Regarding Administration and Application

Roles and Responsibilities of Coordinators and Mentors

Discussion of future trainings and roles of Coordinators and Mentors

Five Trends that Created the Need for the SIS

A Paradigm Shift

Trend 1: Changes in Expectations for Persons with Disabilities.

Times have changed since ICAP All people, including people with very

significant functional limitations, can do meaningful work in the community.

Our consumers successfully challenged prevailing assumptions and questioned why things could not be different.

Trend 2: Functional Description of Disabilities

Medical descriptions have proven to be of limited usefulness in assisting people with intellectual disabilities to reach meaningful life goals.

Functional descriptions of disabilities do not focus solely on biological characteristics, but rather on indicators of a person’s performance on tasks that are required for successful functioning in contemporary society.

Trend 3: Chronologically Age Appropriate Activities

The chronologically age appropriate perspective holds that people, regardless of intellectual abilities or limitations, should have the opportunity to have life experiences and engage in activities consistent with their chronological age.

Trend 4: Consumer-Driven Services and Supports

The consumer-driven approach requires providers to tailor supports to the needs and preferences of the person and his or her family.

Providing funding directly towards people with disabilities individual needs as opposed to funding “programs” administered by the provider.

Trend 5: Support Networks that Provide Individualized Supports

Our consumers need support networks comprised of many individuals who provide many different types of supports.

The “supports paradigm” shifts the focus from caregiving to investing time in creating an nurturing supports network.

The paradigm shift redefines, but does not eliminate the role of paid support staff.

Supports should follow a person to whatever settings the person wants and need to be in.

How the SIS Differs from Instruments that Measure

Personal Competence

How Does the SIS Differ from the ICAP

Traditional IQ and Adaptive Behavioral Scales

For the past 50 years the two cornerstones have been.– IQ tests with a primary focus on the

maximal performance of an individual on tasks related to conceptual intelligence.

– Adaptive Behavioral Scales focus on the skill level a person typically displays when performing tasks in his or her environment.

Supports Needs Assessment Scales

Support Needs Assessment scales (SIS) focus on the pattern and intensity of supports needed to enable a person to participate in valued settings and activities.

The SIS is a supports needs assessment scale and is not a scale to measure personal competence.

The SIS reflects a new way of thinking about assessment, focusing on the support needs of the individual, not his/her deficits

The SIS attempts to directly measure support needs.

“Supports” are…

…resources and strategies that promote the interests and welfare of individuals and that result in: – Enhanced personal independence and productivity– Greater participation in an interdependent society– Increased community integration, and/or– Improved quality of life

- Thompson et al., 2004

SIS vs. ICAP

The SIS does not supplant the need for adaptive behavioral skills or other measures of personal competence that are essential for diagnosing the condition of intellectual disabilities.

Adaptive behavior = skills needed to successfully function in society.

Supports Intensity Scale = activates that a person does during the course of participating in everyday life.

Plan to replace ICAP with short assessment tool to directly assess Form 19 criteria for functional limitations

Multiple Uses for SIS

Individual Level – Basis for individualized Support Plan.

Agency Level – Basis for staffing, staff training, budgeting, strategic planning, and evaluation.

Systems Level – Basis for resource allocation, research / evaluation, and systems planning.

SIS Pilot Group and Risk Assessment Committee

How Did We Get Here?

Why the SIS vs. Other Assessment Tools

New USTEPS system require decision to continue use of ICAP or Alternative Tool

Statewide Committee formed to review National Assessment Instruments.

SIS was picked for pilot test and piloted by committee across the state.

DSPD chose to implement the SIS to address concerns of last CMS Review. Due date January 2006

SIS has the ability to eventually be used to help develop individualized budgets (DOORS Model)

Administration of the SIS

What you are dying to know about the SIS Administration.

The SIS Sections

Administration: 30 – 45 minutes– Section One: Supports Needs Scale (49 items)– Section Two: Supplemental Protection and

Advocacy Scale (8 items)– Section Three: Exceptional Medical (16 items) and

Behavioral (13 items) Support Needs– Section Four: Utah Additional Support Needs/ Risk

Assessment Questions

SIS Administration

SIS is administered via a semi-structured interview with preferably two or more respondents who know the individual well.

Respondents should be individuals who have known the person being evaluated for at least 3 months and have observed the person in one or more environments for substantial periods of time (parent, staff, job-coach, teacher, self).

Setting the Stage

Introducing SIS to the respondents

Key Points:– Look and speak directly to the respondents.– Briefly explain everyone’s role and reason for being present.– Briefly explain the purpose of SIS.– Practice this introduction before you do an interview.

Influences on the Intensity of a Person’s Support Needs

What are the Factors?

Factors that influence Intensity of a Person’s Support Needs

Personal competence of the individual Exceptional medical support needs. Exceptional behavioral support needs. Number and complexity of the settings in which

a person participates. Number and complexity of life activities in

which the person participates.

Walkthrough of the Items

Open the SIS Users Manual to page 16–the Interview and Profile Form. Follow along as we go through the items on the Scale.

For further description of items use the Expanded Item Descriptions and Tables 2.1 – 2.9 in the SIS Users Manual (pp 27-37).

Section One: Support Needs Scale

Six Life Activity Areas (49 life activities)

1. Home Living Activities

2. Community Living Activities

3. Lifelong Learning Activities

4. Employment Activities

5. Health and Safety Activities

6. Social ActivitiesNote: You may start the SIS administration with any item/section, as long

as ALL items are completed.

Section One: Supports Needs Scale Ratings

Frequency (how often is the support needed)– 0 to 4 (<monthly …. Hourly)

Daily Support Time (when needed, how much time is required for the support)

– 0 to 4 (none to > 4 hours)

Type of Support (what is the type of support needed)– 0 to 4 (none to full physical assistance)

(See page two Interview and Profile form for Rating Key)

Important “To” and “For” the Person

As you complete each interview question consider if the questions is most important “To the person” (what they tell us either verbally or behaviorally) or what others think is most important “For the person” to be successful.

Mark these questions with a “T” and/or “F” to the left of the question.

It is not necessary to mark a T or F for every question, only the ones you feel are most appropriate.

Use these questions when you are developing your Individuals Support Plan to help you address those objectives that are most important to the individual and/ or for their Health and Welfare.

Supports Needs Scale Ratings Continued

Ratings should reflect the supports that would be necessary for this person to be “successful” in each activity. – To be successful is defined as engaging in all

aspects of an activity as judged against contemporary community standards and resulting in maximal involvement of the person in the activity.

Supports Needs Scale Ratings: Type of Support

Rating Type of Support – Focus on the following:– If a person were to engage in the activity on a

regular basis over the next several months, what would be the nature of the extraordinary support needed to enable the individual to be successful in the activity?

– This scale is concerned with identifying the kind of support provided by others.

Supports Needs Scale Ratings: Frequency

Rating Frequency – Focus on the following: – If the person were to engage in the activity on a regular basis

over the next several months, how often would extraordinary support be needed to enable the individual to be successful in the activity?

– The intent is not to measure how frequently the person currently engages in the activity, but rather how frequently the person would need support if they were to engage in the activity.

– Every person must have the potential opportunity to score the highest score on every item.

Supports Needs Scale Ratings: Daily Support Time

Rating Daily Support Time – Focus on the following:– If a person were to engage in the activity on a

regular basis over the next several months – during the course of a TYPICAL day (24hours) how much time would be needed to provide extraordinary supports to enable the individual to be successful in the activity?

– This scale is concerned with identifying the kind of support provided by others.

Section Two: Supplemental Protection & Advocacy Scale

This is supplemental to Section One Items

– Encouragement and acceptance– Opportunity and access– Exercising legal responsibilities– Assisting with the acquisition and expression of

skills.– Every activity is scored on frequency, time, and

support

Section Three: Exceptional Medical and Behavioral Support Needs

This section consists of 15 medical conditions and 13 problem behaviors that typically require increased levels of support.

The interviewer assesses the individual’s intensity of supports need for each medical and behavioral item using a 3-point Likert rating scale.

Complete all items – the lower the rating, the lower the extent or intensity of supports needed

Using the Inventory

Complete all items even if a life activity is not applicable to the individual.

Complete items based on supports that would be necessary for the individual with disabilities to be successful in each activity.

If a person uses Assistive Technology (AT), then rate them with the AT in place.

Include 2 respondents who know the individual to determine appropriate ratings.

Using the Inventory Continued

The scale should be completed without regard to services or supports currently provided or available.

All medical and behavioral issues should be taken into considerations when completing the SIS.

In cases where there is an “even split” in someone’s intensity of supports needs, the higher or MORE INTENSE rating should be selected.

Scoring of SIS

Scoring the SIS Made Easy?

Review of Sections

Look Over Section One: Life Activities and the Corresponding item descriptions

Look over Section Two: Support Considerations Based on Protection and Advocacy Scores

Look over Section Three: Exceptional Behavioral Support Needs

Question???

Data Provided by SIS

Profile of needed supports Standard scores computed for each of the 6 Activity

Subscales provide a pattern of an individual’s support needs

A composite standard score calculated from scores from the 6 Activity Subscales provides an indication of the intensity of supports needs.

Protection and advocacy scores Exceptional medical and behavioral support needs

Scoring and Interpreting the SIS

SIS Users Manual (pages39-42) Cover Page – Demographics Section One: Support Needs Scale

– Raw Scores – Subscale Standard Scores and Percentiles

(Appendix 6.2)– SIS Supports Needs Index (Appendix 6.3)– Supports Needs Profile

Scoring Section 1

1. ADD the scores horizontally for Frequency (F), Daily Support Time (DST), and Type of Support (TS) for each life activity in all of the 6 Activity Domains to get the RAW SCORES (pp 2-5, SIS Interview and Profile Form).

2. ADD the RAW SCORES vertically for all items within each of the 6 Activity Domains to get the TOTAL RAW SCORES.

3. Enter the TOTAL RAW SCORES for each of the 6 Activity Domains Subscales in the corresponding space in the table labeled Section 1A: Support Needs Ratings on page 8 of the SIS Interview and Profile Form.

Scoring Section 1, cont.

4. Using the table on page 119 of the SIS Users Manual, use the TOTAL RAW SCORE to find the STANDARD SCORE and PERCENTILE RANKING for each of the 6 Activity Domain Subscales (A–F).

5. Enter the STANDARD SCORE and PERCENTILE RANKING for each of the 6 Activity Domain Subscales in the appropriate space on the Section 1A table on page 8.(SIS Interview and Profile Form).

6. Using the Section 1A table, ADD the STANDARD SCORES for each of the 6 Activity Domain Subscales to get the STANDARD SCORES TOTAL. Enter this total in the corresponding box.

7. Using the Table on page 123 of the SIS Users Manual, use the STANDARD SCORES TOTAL to find the SUPPORT NEEDS INDEX (Composite Standard Score) and the SUPPORT NEEDS INDEX PERCENTILE RANK.

8. Enter the SUPPORT NEEDS INDEX and the SUPPORT NEEDS INDEX PERCENTILE RANK in the corresponding box in the Section 1A table.

Scoring and Interpreting the SIS

Section Two:– Booklet page 8- List four highest ranked Activities– Highly ranked P&A activities will be helpful in developing

individualized support plans. Section Three:

– Transfer information on pages 6 &7 to Section 3 page 8.– Is this total larger than 5?– Is at least one “2” circled?– If yes was circled on any of these questions, it is highly likely

that the individual has greater support needs than others with similar SIS Support Needs Index.

Scoring Section 2

Add the 3 ratings (F, DST, TS) across for each item to get a RAW SCORE.

Rank order the items from highest to lowest RAW SCORE. List the FOUR highest ranked Protection & Advocacy Activities in

order and enter their raw scores on page 8.

Activity Raw Score

1. _________________________ __________

2. _________________________ __________

3. _________________________ __________

4. _________________________ __________

Scoring Section 3

In both the Medical and Behavioral supportsneeds sections:

ADD the ratings of “1” for each item = SUBTOTAL of “1” column.

ADD the ratings of “2” for each item = SUBTOTAL of “2” column.

ADD the subtotals from both “1” and “2” columns = TOTAL.

Enter the corresponding totals in the two boxes on page 8, Section 3.

Scoring Section 3, cont.

A. MEDICAL1. Enter the TOTAL2. Is this TOTAL larger than 5?3. Is at least one “2” circled?

B. BEHAVIORAL1. Enter the TOTAL2. Is this TOTAL larger than 5?3. Is at least one “2” circled?If “YES” has been circled on any of the questions above, it is highly

likely that this individual has greater support needs than others with a similar SIS Support Needs Index.

Scoring and Interpreting the SIS

The subscale standard scores provide a pattern or profile of an individual’s support needs.

The SIS Support Needs Index provides an overall indication of the intensity of an individual’s support needs.

Interpreting the SIS Score

The 6 Activity Domain (subscale) Standard Scores provide a pattern or profile of an individual's support needs.

The SIS Support Needs Index provides an overall indication of the intensity of an individual's support needs.

Cautions in Using SIS Information

SIS data should not be viewed in isolation.

Overreliance on scores and labels contradicts the primary philosophy of person-centered planning.

Cautions Continued

Although team members may perceive support needs in a given domain as being very important, the individual / family may not be interested in any significant change.

The prioritization of needs remains a subjective determination based on the unique interests and goals of the person.

SIS Frequently Asked Questions

What Those have Dared Not Ask…

Essential Points for Proper Administration

Ratings should reflect the supports that would be necessary for the person to be successful in each activity.

Each item assumes that the person has the opportunity to participate at levels potentially requiring maximum frequency, time, and type of support. Therefore, respondents should remember that ratings can reflect this maximum level of potential activity.

SIS Frequently Asked Questions

Interviewing Respondents– It is acceptable for interviewer to interview respondents

separately or interview two or more respondents at the same time.

Sequence of Administration of Items Domains– All items on the SIS must be rated for the individual’s support

needs. However, the order presented will not affect the score. Rating Support Needs for Activates that the Person

does not do, has never done, and has no intention of doing.

– All items should be completed, even if the person is not currently performing a listed activity.

SIS Frequently Asked Questions Continued

Rating a frequent and intense support that is needed temporarily or for a short time period.

– Rate the individual’s support needs as the person is currently functioning. It does not matter whether the person’s functioning might improve. The SIS should be filed out based on the person’s current status and condition.

Rating varying support needs – sometimes it’s full physical, but most of the time only monitoring?

– Rate the individual in regards to the typical intensity of support that is needed.

SIS Frequently Asked Questions Continued

Rating the supports needs for activities that the person does not do,has never done, and has no intention of doing.

– All items should be completed, even if the person is currently performing a listed activity.

Rating transportation needs.– Supports needed for transportation are embeded within three

items (Part B, Item1- Part B, Item 4 and Part C, Item 5) Once an individual’s transportation needs are captured on these three items, transportation needs should not influence the remaining items.

SIS Frequently Asked Questions Continued

Rating fluctuating support needs, such as cases where a person needs full physical some of the time, but most of the time only requires monitoring.– The Interviewer / Respondent should rate the

individual’s support needs as the person is currently functioning. The Interviewer must fully consider the life activity as it is described, and rate the person in regard to the type of support the person typically requires.

SIS Frequently Asked Questions Continued

To what extent should the individual’s exceptional medical and behavioral needs be weighed in responding to the amount of supervision and support needed in the times Part A-F.

– The individual’s support needs across all SIS items/ activities in Parts A through F should be completed based upon the individual as he or she is currently functioning. All medical and behavioral issues should be taken into consideration when completing the SIS.

Real Life Cautions

SIS data should not be viewed in isolation. When incorporating information from SectionThree, Exceptional Medical and BehavioralNeeds, into an individual’s plan:

– Allow clinical judgment to trump any classification level identified through scores from the Support Needs Scale.

– Increase the support intensity classification level based on specific criteria.

Guidelines for Interviewing

What every good interviewer should know….

Guidelines for Interviewing

See “Guidelines for Interviewing People with Disabilities” booklet.– Conducting SIS Interviews– Guidelines for SIS Interviews with Self-Advocates– Ten Essential Do’s and Don’ts for SIS Interviewers

SIS Child – Adolescent Modifications

Modifications to Original SIS for Use with Children

SIS Child – Adolescent Modifications

Original SIS standardized for Adults Child – Adolescent Modifications (age 5 to 16 years) Modifications to Existing Questions: Section I:Part A: Home Living Activities (same)

– Part B: Community Living Activities (same)– Part C: Learning Activities (same)– Part D: Employment – (removed)– Part E: Health and Safety Activities (remove E:4)– Part F:Social Activities (remove F:7&8)

Section II: Supplemental Protection (removed) Section III: Medical and Behavioral (Same)

Utah’s Risk Assessment Supplement Screening Tool

Risk Assessment Screening Tool

Committee formed to look at National Risk Assessment Screening Tools to supplement SIS Supports information.

Utah Risk Assessment Screening Tool developed

Risk Assessment Tool cross walked with SIS Evaluation / 16 Items added to SIS

Interim Risk Assessment Screening Tool

Interim Risk Assessment Screening Tool

Category One– Risk to Personal Safety: Caretaker and

Environmental Risk (8 questions) Category Two:

– Individual Behavioral Risks (14 questions) Category Three:

– Health Risks (9 questions)(15 questions included in original SIS Form and 16

Supplemental Items for Utah)

Scoring and Administering the Interim Risk Assessment Screening Tool

The Interim Risk Assessment Screening Tool will be used until the Computerized version is available in January.

Answer each question as either 0= No support needed, 1= Some support needed, or 2 = Extensive support needed.

List any other issues that may be risk factors for this individual.

Practice Conducting the Interview

Your Chance to Learn Hands On….

SIS Practice with Partner

30 Minute Practice in Pairs (interviewer and respondent – trade roles after 15 minutes)

Complete some of each of the Three sections in the SIS.

As a respondent – think of someone with a disability that you know well as you respond.

Use the Expanded Item Descriptions for more in-depth item descriptions.

Note any questions

Let’s Discuss the Exercise

In small groups, discuss your experience with SIS.

Choose a note-taker and consider the following:

1. Best practices noticed?2. Items that were confusing?3. Obstacles found in administering SIS?4. Suggestions for improving your interviewing skills?

Report back to class

Final Question and Answers

What are the burning Questions on your mind? Assignment for Session Two….

Session Two:

SIS Applications to Treatment Planning

Overview / Agenda

Session Two: Review of the SIS Administration Homework

Assignment and Discussion Using the SIS in the Planning Process

– Overview of SIS Planning Process– SIS Planning Case Example Melvin Thurber– Implementation to Own Caseload Example

Questions Regarding Administration and Application

Review of the SIS Administration Homework Assignment and

Discussion

What were your experiences? What did your learn?

Using the SIS for Treatment Planning

The SIS in development of a PCP / Action Plan

Four Components of the Planning Process

Best Practices in Development of a Treatment Plan

(see handout)

Component 1: Identify Desired Life Experiences and Goals

Possible support areas:– Home Living, Community Living, Education/

Training, Employment, Health & Safety, Behavioral, Social, Protection & Advocacy.

– All the above areas of supports are addressed in the SIS.

Component 2: Determine the Intensity of Support Needs

Possible support areas:– Home Living, Community Living, Education/

Training, Employment, Health & Safety, Behavioral, Social, Protection & Advocacy.

Needed Levels of Support– Support Frequency, Support Duration, Support

Type.

Component 3: Develop the Individualized Support Plan

Use a team planning process to prioritize preferences in regards to life experiences and goals.

Use the SIS to identify the support sources that are needed and that are currently used.

Arrange access to supports in order of priority. Write and Individual Support Plan

Component 4: Monitor Progress

Extent to which desired life experiences and goals are being realized.

Extent to which desired life experiences and goals remain relevant.

Extent to which ISP is implemented Return to Component 1 as needed.

SIS

“To” (Possible

Goals)

Risk Assessment

Initial Risk Screen (Health & Safety)

“For”Needs

Goal 1 Barrier(s) & strength(s) Need(s)

Important Info

Future Goals

Team Discussion

Team Discussion

Personal Goals

Review Support Options

& Budget

Goal 1: Support Strategies, Service, Provider, Duration, FrequencyGoal 2: Support Strategies, Service, Provider, Duration, Frequency

Additional Risk Plan: Support Strategies, Service, Provider, Duration, Frequency

Risk Needs (Health & Safety)

Action Plan

Required info 3:

Required info 2:

Required info 1:

The Plan

Other Waiver Required Info

Other Important Info 3:

Important Info 1:

Important Info

Important Info 2:

Goal 2 Barrier(s) & strength(s) Need(s)

Other Assess-ments

Person Centered Assessment &

Planning Process8-31-2005

SIS Individual Support Planning Case Example Melvin Thurber

Team Exercise in ISP Development

ISP Planning for Melvin Thurber

Form groups of two to three people Review the Case Study, SIS Interview and Profile,Risk

Assessment Forms and Action Plan provided. Answer the following questions in the Action Plan Format :

– What are some personal goals important “To” Melvin?– What are are some Health and Safety Risk / Issues that are

important “For” the Melvin?– How are Health and Safety Risk going to be addressed in the

Plan? (e.g. supports strategies, provider contract requirements) Review His Individualized Support Plan and compare.

Use of Mental Retardation Treatment Planner

Choose a question from the SIS Interview and Profile Form that is important “to” or “for” the individual.

Choose a Behavioral Definition for the ISP/ Action Plan. Select your Long-Term Goal/s.

Choose Short-Term Objectives and Therapeutic Intervention for the Support Plan.

Results of Team Exercise

What worked well? Where did you have difficulty? Does your team’s plan seem reasonable?

Application to Your Personal Case Examples

Time to make it all real.. Applying what you have learned to the individuals you support.

ISP / Action Planning for Personal Examples

Risk Planning Considerations Risk Assessment questions to be addressed in the

individual’s Person Center Plan or in a separate Risk Plan for each identified area of risk.

– What is the team’s evaluation of the risk? Have the risk/ benefits been weighed?

– What can be done differently to prevent these safety risks? What strengths/ assets does the individual have towards prevention?

– Who can help with prevention measures?– What supports would minimize the risks?– Who can provide these supports?

Action Plan Planning Using Personal Examples Continued

Form groups of two Review the your SIS Interview, Profile and Risk

Assessment Forms Answer the following questions in the Action Plan

Format:– What are some personal goals important “To” the Individual?– What are are some Health and Safety Risk / Issues that are

important “For” the Individual?– How are Health and Safety Risk going to be addressed in the

Plan? (e.g. supports strategies, provider contract requirements)

Results of Team Exercise

What worked well? Where did you have difficulty? Does your team’s plan seem reasonable?

Final Question and Answer Time

What are your final burning issues?

Process Improvement Time

What worked well with this training? What would you suggest we modify?