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Developing a Person-Centered Individual Support Plan
for A Good Life in Virginia
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The 5 parts of the ISP
Virginia’s PC Planning Process
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PCT Training and Tools are available
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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
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Before the meeting
Part 1: Essential Information
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Part 1: Essential Information
Part 1: Essential Information
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Part 1: Essential Information
Collected and maintained by the Support Coordinator.
Part 1: Essential Information
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Shared with providers initially and annually
(before or after the annual).
Part 1: Essential Information
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Can be in the optional sample format
Part 1: Essential Information
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or can be in CSB-specific format
Sample table of contents, may
look different per service
Part 1: Essential Information
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Regardless of format, the information is essential for accessing services and ensuring health & safety.
This information should be reviewed and updated at least quarterly by the support coordinator.
Part 1: Essential Information
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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
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The SIS includes a Risk Assessment that the support coordinator will complete annually.
Part 1: Essential Information
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Before the meeting
Part 2: Personal Profile
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Part 2: Personal Profile
Part 2: Personal Profile
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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
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What is a Planning Partner?
-completing the profile, -arranging planning
meetings,-contacting partners,-identifying off-limit topics,-communicating with SC.
A friend…family member…
support provider…someone who helps with:
Part 2: Personal Profile
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Available
Tool
Part 2: Personal Profile
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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
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Provided to the support coordinator
before or at the annual meeting.
Part 2: Personal Profile
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Includes the vision of a good life. Looks at gifts, talents & contributions.
Part 2: Personal Profile
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Identifies what’s WORKING and NOT WORKING across 8 life areas.
Part 2: Personal Profile
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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
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During the
meeting
Part 3: Shared Planning
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Part 3: Shared Planning
Part 3: Shared Planning
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Facilitator = Individual & SC
Recorder = Partner volunteer
Timekeeper = Partner volunteer
A person-centered team:
Part 3: Shared Planning
Share something that made you smile
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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
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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?
and
Part 3: Shared Planning
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Important toImportant to
What makes a person happy, What makes a person happy,
content, fulfilledcontent, fulfilled• People, pets• daily routines and rituals, • products and things, • Interests and hobbies, • places one likes to go
Part 3: Shared Planning
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Important forImportant for
What we need to stay healthy, safe What we need to stay healthy, safe and valuedand valued
• health and safety• things that others feel will contribute to
being accepted or valued in the
community
Part 3: Shared Planning
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Part 3: Shared Planning
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Part 3: Shared Planning
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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
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A volunteer or the support coordinator records Shared Planning at the meeting.
Part 3: Shared Planning
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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
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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
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Outcomes must be measurable and result in actions you can see or learning you can assess.
Part 3: Shared Planning
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Using verbs helps clarify what we are measuring.
travels
movessings
collects
makespaints
cooks
watches
creates visits
Part 3: Shared Planning
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If the supports we identify are provided, we expect that the desired outcome will be achieved.
Part 3: Shared Planning
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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
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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
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We are looking for evidence that the desired outcome has occurred or if we can see movement toward the outcome.
Jack makes five new friends who like Jazz music.
Desired outcome
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
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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
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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
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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
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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.
Desired outcomes
Part 3: Shared Planning
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Part 3 Shared Planning is shared by the support coordinator with all partners following planning.
Secure email
Part 3: Shared Planning
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During the
meeting
Part 4: Agreements
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Part 4: Agreements
Part 4: Agreements
Stored in the SC
record
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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
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All partners sign in agreement and other contributors are listed.
All Medicaid providers must sign.
Part 4: Agreements
Sent by SC to all
partners
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After the meeting
Part 5: Plan for Supports
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Part 5: Plan for Supports
Part 5: Plan for Supports
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Can be in the optional sample format or in existing provider formats.
Part 5: Plan for Supports
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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
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The supports are listed on the general schedule and the ISP checklist.
Part 5: Plan for Supports
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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
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Initials, codes and ongoing notes support billing and confirm the supports that are provided.
Part 5: Plan for Supports
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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
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After the meetingPart 5: PC Review
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Person-Centered Review
Part 5: PC Review
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This review is completed four times each year and whenever outcomes are changing.
Part 5: PC Review
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Each provider needs to report progress toward each outcome on their plan for supports.
Part 5: PC Review
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Progress is measured by evidence that the desired outcome is occurring or that movement toward the outcome is being made.
Is the support enhancing the person’s quality of life.
What can we see that demonstrates progress?
Is the individual satisfied with the outcome?
What was a barrier to progress?
Part 5: PC Review
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Did Jack get a job that he likes?
Part 5: PC Review
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Did Angie go camping each month as planned?
Part 5: PC Review
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What steps did Charles take to enroll in class?
Part 5: PC Review
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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
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If progress toward the outcome is observed and documented in the review, the progress box should be checked.
Part 5: PC Review
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If the outcome is continuing and is still desired by the individual, the “continued” box should be checked.
Part 5: PC Review
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If the outcome is being ended and is being replaced by a different outcome, “changed” should be checked.
Part 5: PC Review
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If the outcome is being ended altogether and is not replaced by a different outcome – check “ended.”
Part 5: PC Review
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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
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Any remaining medical or significant information is added and satisfaction is described.
One question asks about a change in hours.
Part 5: PC Review
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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
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Remember plans change with people and lead to better lives.
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Questions?
Please check http://www.dmhmrsas.virginia.gov/OMR-PersonCenteredPractices.htm
for forms, updates and contacts.for forms, updates and contacts.
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