Shaping Support to Fit the Person

One ISP

Conference Session

How Did We Get Here

DD Coalition initiated conversations in regard to a document that would: Allow different formatting Keep relevant information as the person

aged and supports changed Maintain integrity across service settings Allow for ‘out of the box’ services

How Did We Get Here

How Did We Get Here

Conversations continued to progress amongst the DD Coalition and DD Council.

An initial brainstorming group convened that included: Provider Agencies DD Coalition DD Council DD Program Managers Brokerage Directors ODDS

How Did We Get Here

The group deliberated and came to an agreement on the following recommendation: One ISP that spanned a life time Supported an individual across all service

settings Was developed from a person centered

planning process Individual goals that made sense, were

measurable, and outcome based

How Did We Get Here

Recommendation was forwarded on to ODDS

ODDS Management Supported the concept Additional Stakeholders were needed and

gathered from the DD community The ISP-Revisioning Group was established

ISP Visual Framework

Stakeholder Group

Stakeholder Group

Goals and Responsibilities

Established the Vision and Mission

Established a framework for building one ISP

Provides ongoing feedback on materials developed by subgroups

One ISP Stakeholder Group of 46 Individual’s

• Community Developmental Disability Programs

• Brokerages• Residential Providers• Employment Providers• AFSCME and SEIU• Arc• ODDS• HSRI

 

• Licensing and Quality of Care

• Medicaid Unit• Self Advocate• Parents• OTAC• Foster Care• Oregon Council on

Developmental Disabilities

• Consultants

In The Weeds

Goals and Responsibilities: Framing the elements of ISP content Person centered processes Necessary tools and training ideas

13 individuals resenting: CDDPs; Brokerages; ODDS; Arc; Residential/Employment Providers; AFSCME; OTAC; OCCD; Parents; and Consultant

In The Dirt

Goals and Responsibilities: Developing a format for the In the Weeds

group to push up against and recommend changes

Ongoing updating of recommendations until something solid is ready for the One ISP Stakeholder group

3 to 5 individuals who enjoy and love formatting

Mission

Oregon’s ISP is a person-driven planning and training tool that identifies all

individualized supports, activities, and resources required for a person to achieve

personal life goals.

Values

Person Centered and Self Determined – as defined by the person receiving support. Empowers the person to maximize their choice and control. Planning considerations includes ‘important to’ and ‘important for’ the person. Decision making is built upon a person’s strengths, preferences, and needs.

Accessible and understandable by the person receiving supports and their family, guardian and/or people with whom they choose to share their plan.

Reasonably balances rights, risks, and personal choices. Risk is educated and explored within the context of what protects the person and their right to live how they choose.

…Values

Easy to update as support needs and goals change: living document.

Flexibility – allows for unique support needs to be identified.

Recognizes needed supports for the different stages and transitions through a person’s whole life outside the home, for example, school, employment, activities, retirement, etc.

…Values

Recognizes needed supports for the different stages and transitions through a person’s whole life inside the home ...for example, living arrangements, relationships (i.e. significant others, marriage).

Universal and qualitative standards of measurable goal setting, outcomes, and effective systems that support and demand it to occur.

Maximum use of natural supports, resources and available technology.

Fulfills all state and federal regulations.

K Plan Requirements

For Person Centered

Process and Planning

The Person Centered Planning Process

The process:

1. Includes people chosen by the individual

2. Provides necessary information and support to ensure that the individual directs the process to the maximum extent possible, and is enabled to make informed choices and decisions

3. Is timely and occurs at times and locations of convenience to the individual

The process….

4. Is timely and occurs at times and locations of convenience to the individual

5. Reflects cultural considerations of the individual

6. Includes strategies for solving conflict or disagreement within the process, including clear conflict-of-interest guidelines for all planning participants

The process….

7. Offers choices to the individual regarding the services and supports they receive and from whom

8. Includes a method for the individual to request updates to the plan

9. Records the alternative home and community –based settings that were considered by the individual

The Person Centered Service Plan

Must reflect the services and supports that are important for the individuals to meet the needs identified through an assessment of functional need, as well as what is important to the individual with regard to preferences for the delivery of such services and supports. Commensurate with the level of need of the individual, and the scope of services and supports available under Community First Choice, the plan must:

The Plan…

1. Reflect that the setting in which the individual resides is chosen by the individual

2. Reflect the individual's strength and preferences

3. Reflect clinical and support needsw as identified through an assessment of functional need

The Plan…

4. Include individually identified goals and desired outcomes

5. Reflect the services and supports (paid and unpaid) that will assist the individual to achieve identified goals, and the providers of those services and supports, including natural supports. Natural supports cannot supplant needed paid services unless the natural supports are unpaid supports that are provided voluntarily to the individual in lieu of an attendant.

The Plan…

6. Reflect risk factors and measures in place to minimize them, including individualized backup plan

7. Be understandable to the individual receiving services and supports and the individuals important in supporting him or her.

The Plan…

8. Identify the individual and/or entity responsible for monitoring the plan.

9. Be finalized and agreed to in writing by the individual and signed by all individuals and providers responsible for its implementation.

10. 10. Be distributed to the individual and other people involved in the plan.

The Plan…

11. Incorporate the service plan requirements for the self-directed model with service budget at 441.550 when applicable

12. Prevent the provision of unnecessary or inappropriate care.

13. Other requirements as determined by the Secretary

Reviewing the Person Centered Plan

The person-centered service plan must be reviewed, and revised upon reassessment of functional need, at least every 12 months, when the individual’s circumstances or needs change significantly, and at the request of the individual.

Contact Information

Marilee Bell

Services Coordinator Specialist

Office of Developmental Disability Services

503-947-5262

Fax  503-947-4245 (fax)

marilee.bell@state.or.us