1 developing a person-centered individual support plan for a good life in virginia

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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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Collected and maintained by the Support Coordinator.


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Shared with providers initially and annually

(before or after the annual).


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Can be in the optional sample format


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or can be in CSB-specific format

Sample table of contents, may

look different per service


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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.


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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


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


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Before the meeting

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.


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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:


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Available

Tool


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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.


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Provided to the support coordinator

before or at the annual meeting.


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


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Identifies what’s WORKING and NOT WORKING across 8 life areas.


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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.


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During the

meeting

Part 3: Shared Planning

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Facilitator = Individual & SC

Recorder = Partner volunteer

Timekeeper = Partner volunteer

A person-centered team:


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.


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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


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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


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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


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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.


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A volunteer or the support coordinator records Shared Planning at the meeting.


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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.


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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.


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


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Using verbs helps clarify what we are measuring.

travels

movessings

collects

makespaints

cooks

watches

creates visits


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


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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.


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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.


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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.


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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.


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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.


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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.


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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


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

Secure email


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


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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.


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The supports are listed on the general schedule and the ISP checklist.


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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.


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


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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.


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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.

http://www.dmhmrsas.virginia.gov/OMR-PersonCenteredPractices.htm

1 developing a person-centered individual support plan for a good life in virginia

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