Desired Outcomes - Oregon ISP



Person’s legal name: FORMTEXT Fitzwilliam BennetPreferred name: FORMTEXT FitzPlan effective dates: FORMTEXT 9/1/15- FORMTEXT 8/31/16One Page Profile for:Home How to best support STYLEREF PrefName2 \* MERGEFORMAT FitzBe patient. Let Fitz have time to feel comfortable with the things he is asked to do or with supports provided.Reassure Fitz that you will not make him do anything he doesn't want to do. Tell him you will stay with him until he is ready, will bring him home if today isn't a good day, or leave him alone if he is home and needs some space.Use a soft voice with Fitz.Talk to him about things like doctor appointments and taking his meds in a way that lets him know it will be o.k. and he will be safe and won't be alone.Spend time with Fitz doing the things he likes to do, like reading and playing games (especially card games).Learn Fitz's communication style. Listen to him closely and ask him a lot of questions to find out who he is and what he likes or doesn't like.Refer to Communication Chart as needed andKnow Fitz's protocols and behavior support planComplete this page based on communicating directly with the person. If additional information is needed, include information from people who have direct knowledge of the person’s perspective. For alternate templates and additional instructions, visit 1ppWhat people like and admire about STYLEREF PrefName2 \* MERGEFORMAT FitzFitz is fun loving and laughs/smiles all the time.Fitz is always helpful. He likes to help with chores or bring in the groceries when he sees you struggling.Fits makes model planes with his brother and they look so great displayed in his room. They are very detailed.Fitz has a great mustache. He is very talented with trimming scissors.Fitz is really good at cards.What is important to STYLEREF PrefName2 \* MERGEFORMAT FitzHis brother (Bill) and sister-in-islaw (Kathy)--spending time with themHaving people around him who make him feel safeHaving fun with his friends at Do Your ThingGoing to his old job and spending time with his friends there.His model planes--making them and showing them to others.His books--all of them in his collection.Being clean and having his clothes clean.Fitz likes to get up early and spend time in the quiet before anyone else is up.To edit the footer: NAME and EFFECTIVE DATES fields are located on the top of the One Page Profile.Desired OutcomesDesired OutcomeWhat is the desired result?Key steps to work toward the outcomeIs there a paid service that supports this outcome? If so, what is it?Who is responsible?TimelinesFrequency or by when?Where to record progressNote if written implementation strategies (Action Plans, Service Agreement, etc.) are expectedFitz takes a vacation to the Grand Canyon this year with Trips Inc.(Vacation Organization)Work with providers and Rep Payee to budget and plan the trip (apply with Trips Inc.).Natural Supports and Adult Foster ServicesFitz, Foster Provider, and Rep Payee, Trips. Inc.By September 2015Progress notes of SC and ProviderAction PlanFitz owns fish and cares for them.Work with Foster providers and Rep Payee to budget for, buy fish, and care for fish.Natural Supports and Adult Foster ServicesFitz, Foster Provider, and Rep PayeeBy October 2015Progress notes of SC and ProviderNo Action Plan needed. Provider understands steps to achieve.Press Tab to add additional rowsrighttopOregon is an “Employment First” state. We believe that each person:can work and there is a job for everyone.has something to contribute and needs to contribute.has the right to a competitive job in a typical community work setting, including self-employment, making comparative wages with sufficient hours to make a difference.may identify the direction of his/her employment based on skills, interests, and strengths.has a right to be informed about the employment services options that are available to him/her.To receive an employment service, you must have a goal of pursuing individual, integrated employment.00Oregon is an “Employment First” state. We believe that each person:can work and there is a job for everyone.has something to contribute and needs to contribute.has the right to a competitive job in a typical community work setting, including self-employment, making comparative wages with sufficient hours to make a difference.may identify the direction of his/her employment based on skills, interests, and strengths.has a right to be informed about the employment services options that are available to him/her.To receive an employment service, you must have a goal of pursuing individual, integrated employment.Career Development Plan (CDP)Education level completed: FORMDROPDOWN Students (age 16-20) Expected date of exit from school: FORMTEXT ????? Date by which CDP will be completed: FORMTEXT ????? FORMCHECKBOX Attending school and wants to work now. FORMCHECKBOX Attending school and receiving employment supports elsewhere. FORMCHECKBOX Has an IEP Post-Secondary Goal with employment or training focus. FORMCHECKBOX Attending school and not receiving any employment supports.Status with Vocational Rehabilitation (VR) (age 16 and up) FORMCHECKBOX Currently receiving VR services FORMCHECKBOX Want a referral to VR FORMCHECKBOX Other/Not applicable, explain: FORMTEXT ?????Working age adults (age 21-60) must choose one of the following statements: If the person is at least 18 years old and has exited school, complete this section instead of the “Students (age 16-20)” section. FORMCHECKBOX Employed in integrated employment and chooses to: Check all that apply. FORMCHECKBOX Retain current job. FORMCHECKBOX Advance in current job (more hours, raise, new skills, promotion, etc.) FORMCHECKBOX Get a new job. FORMCHECKBOX Get an additional job. FORMCHECKBOX Retire – is at least 60 or will be this ISP year. Employment Outcomes are not required. FORMCHECKBOX No longer continue in integrated employment at this time. Complete Decision Not to Explore Employment section. FORMCHECKBOX Currently not working in integrated employment and chooses to: Check all that apply. FORMCHECKBOX Get integrated employment. FORMCHECKBOX Explore interests in integrated employment through an Employment Path, Discovery, or other time-limited service. FORMCHECKBOX Retire – is at least 60 or will be this ISP year. Employment Outcomes are not required. FORMCHECKBOX Not explore integrated employment at this time. Complete Decision Not to Explore Employment section.Potential barriers to working in an individualized, integrated jobHow will this obstacle be addressed?N/AN/ADecision Not To Explore Employment *** Not applicable; Decision not to work section removed. *** This section may be removed if not applicable; indicate by using the provided dropdown.Desired Employment OutcomesIs there a paid service that supports this outcome? If so, what is it?Who is responsible?TimelinesFrequency or by when?Where to record progressNote if written implementation strategies (Action Plans, Service Agreement, etc.) are expectedDesired OutcomeWhat is the desired result?Key steps to work toward the outcomeN/A---Press Tab to add additional rowsRisk Management PlanEmergency preparedness (natural disasters, power outages, community disasters, etc.)Preventing abuse (physical, emotional, financial, sexual, neglect)What happens if the person can’t be reached? (timelines for notifying others, who to contact, etc.)Fitz has an emergency plan for home.Fitz has a rep payee who is also his guardian. Fitz is never alone at home or in the community.If Fitz cannot be reached/is missing for any length of time, look for him for up to 5 minutes then call 911.RiskX if High riskHow is the risk addressed?ChokingAspiration/Choking ProtocolComplications of DiabetesHyper and Hypoglycemic Protocol Unreported pain or illnessSafety PlanWater temperature safetySafety covers on all faucets. Water temp is controlled by providers.Fire evacuation safetySafety Plan Vehicle safetySafety lock in vehicle and reminders to not take off seat beltStreet safetyAll providers stay at arm’s length and give reminders to stay close around streets and parking lotsRefusing medical careExtreme food seeking behaviorBehavior Support PlanUnsafe social behaviorAll providers give reminders to Fitz if he gets too close to someone or pokes them. He is reminded to step back and not to poke.Potential for financial abuseFinancial Plan. Rep Payee (Bill Bennet).Press Tab to add additional rowsDoes this person have a Nursing Care Plan? FORMCHECKBOX No FORMCHECKBOX Needed FORMCHECKBOX Yes, where found:Home: FORMTEXT In medical section of bookWork: FORMTEXT ?????Back-up Plans, in the event that primary support is not available Focus on known, significant support needs and immediate health and safety support needs of the person that must be addressed if primary support is not available. Example: Cell phone of back-up contact.HomeWork/School/Day SupportsOther: Other: Chosen Case Management Services Type: FORMDROPDOWN Chosen provider: FORMTEXT Wonder County CDDPPrime number: FORMTEXT XOXOXOXOAuthorized dates: FORMCHECKBOX Plan yearStart and end, if not same as plan year: FORMTEXT ?????Required frequency of case management monitoring: FORMDROPDOWN FORMTEXT ?????Case management comments/descriptors of anticipated case management services during the year; unless already described elsewhere in this plan. (Include any risks marked “Possible” on the Risk Identification Tool.): FORMTEXT SC will coordinate planning each year. Fitz has many risks and SC will check in on Fitz monthly to monitor how the effectiveness of supports in place to manage these risks. SC will monitor to see how the BSP is working when Fitz is at his brother and sister-in-law's home. If the BSP continues to not work as well when Fitz is at their home, more conversation will happen among team members and Fitz's Behavior Support Specialist. SC will communicate monthly with Fitz's nurse to monitor how his nursing plan is working. SC will revise the plan as needed to meet Fitz needs and changes in desired outcomes.Person’s preference on how case management is provided: FORMTEXT Fitz likes to have his meeting at home where it is quiet and familiar. He prefers to have information given to him in person. He wants to have his brother with him at most meetings.Natural Supports, Community Resources, and Other Voluntary Services and SupportsDescribe chosen services/supportsProvided byFitz needs support to take part in activities he does during holidays and on the weekends (every other weekend) he is with his family. Fitz needs assistance with bathing (getting in and out of tub safely and using the right amount of soap and cleaning well, as well as adjusting the water temp to a comfortable level), toileting (wiping well and cleaning up after, as well as cleaning up after accidents), oral hygiene (reminders to brush teeth and cues to brush well), dressing and haircare (wearing appropriate clothes for weather, support with buttoning, and support to comb his hair and mustache the way he prefers), full physical assistance with shaving his face and trimming his mustache, support with receptive and expressive communication (complicated info must be explained in a way that makes sense to him and he needs support expressing himself to those who do not understand his communication style-i.e. his speech is difficult to understand for those who do not know him well), safety (e.g. using chemicals, sharp items, and appliances safely), fire evac.(cues to evacuate and move to a safe area), medication management (taking meds on time and in the proper amount), health management (expressing pain, daily checks for any signs of illness or injury, making and keeping appointments and following through with doctors’ orders), intermittent nighttime supports (support for any daytime support needs that come up at night), supervision within visual and hearing distance, support to access the community (transportation to all the places he needs to go, as well as reminders to not take off the seat belt or open the car door while in motion), support to take part in community activities and events (finding activities of interest and providing all support needs during activity including communicating effectively and making monetary exchanges), and support to socialize appropriately and safely (e.g. not poking at others or getting too close to others when it is not appropriate to do so).Family (brother, Bill, and sister-in-law, Kathy)Fitz needs his support needs (see above) while on vacation to the Grand Canyon with Trips Inc.Trips Inc. (private pay)Fitz needs new eyeglasses, but his insurance will not pay for them. Clear Vision Works (local non-profit that helps people get their eyeglasses at a much discounted price) Fitz brother will pay for the difference.Fitz needs to have an eye exam this year. His insurance would not pay for it, so he received his eye exam from a local nonprofit. Lions ClubPress Tab to add additional rowsChosen State Plan Personal Care (SPPC) services *** Not applicable; SPPC section removed. *** This section may be removed if not applicable; indicate by using the provided dropdown.Chosen K Plan Services *** Not applicable; Chosen K Plan services section removed. *** This section may be removed if not applicable; indicate by using the provided dropdown.Chosen Waiver Services *** Not applicable; Chosen Waiver services section removed. *** This section may be removed if not applicable; indicate by using the provided dropdown.Chosen K Plan Residential Service ------ This section may be removed if not applicable; indicate by using the provided plete the following only if the person chooses RESIDENTIAL services:Service setting: Non-relative Foster Care - Adults DD 58Chosen provider: Beth and Charlotte Luca Foster HomeAuthorized dates: ?Plan yearStart and end, if not same as plan year: ---The K Plan services already included in residential services:? Attendant care – ADL / IADL ? Skill training ? Community TransportationAdditional K Plan services included in residential services:? Behavior supports ? Nursing supportsList identified needs that this service will address (including results of needs assessment):Fitz needs assistance with bathing (getting in and out of tub safely and using the right amount of soap and cleaning well, as well as adjusting the water temp to a comfortable level). Toileting (wiping well and cleaning up after, as well as cleaning up after accidents)Oral hygiene (reminders to brush teeth and cues to brush well) Dressing and haircare (wearing appropriate clothes for weather, support with buttoning, and support to comb his hair and mustache the way he prefers)Full physical assistance with shaving his face and trimming his mustache Support with receptive and expressive communication (complicated info must be explained in a way that makes sense to him and he needs support expressing himself to those who do not understand his communication style-i.e. his speech is difficult to understand for those who do not know him well) Safety (e.g. using chemicals, sharp items, and appliances safely), fire evacuation (cues to evacuate and move to a safe area)Medication management (taking meds on time and in the proper amount)Health management (expressing pain, daily checks for any signs of illness or injury, making and keeping appointments and following through with doctors’ orders)Intermittent nighttime supports (support for any daytime support needs that come up at night) Supervision within visual and hearing distanceSupport to access the community (transportation to all the places he needs to go, finding the destination he needs to get to, reading all the street signs, as well as reminders to not take off the seat belt or open the car door while in motion)Support to take part in community activities and events (finding activities of interest and providing all support needs during activity including communicating effectively and making monetary exchanges).Support to socialize appropriately and safely (e.g. not poking at others or getting too close to others when it is not appropriate to do so).Person’s preference on how this service is delivered:Give privacy and modesty around all supports. (i.e. provide supports like helping with going to the bathroom, bathing in his bathroom, and dressing and changing in his room)Tell Fitz what you are going to do to help him before you do it. Ask him for permission.Fitz likes to have his face shaved twice a day. (keep the mustache)Fitz wants juice with his medication.Chosen K Plan Community Transportation Service Specific to travel to and from vocational program. Complete DD 53 budget.Transportation typeAuthorized datesChosen provider type or description of servicePlan yearStart and end, if not same as plan year----?----------?----------?------Additional Chosen ServicesUse to record General Fund services as well as overflow for any of the above Chosen Services.Describe service setting, service code, # units, frequency, authorized dates, and chosen provider type as applicableList identified needs that this service will addressPerson’s preference on how this service is deliveredCommunity Nursing Services/MMIS1 event per week for plan yearCarol Dorn, RNFitz has diabetes and the nurse comes in once a week to work with him on managing his diabetes, checking blood sugars, talking about his diet, and checking his feet for any problems.Fitz likes the nurse who comes to the house. He wants to be poked for testing on the first two fingers on his left hand and not touched with cold hands.Press Tab to add additional rowsDifferences Note any differences between the contents of this plan and what the person wants. Consider if a change to this plan is needed to address the difference(s) and describe the decision.NoneNote any differences between the contents of this plan and what any other ISP contributor wants. Consider if a change to this plan is needed to address the difference(s) and describe the decision.Bill and Kathy have been noticing that Fritz is having more instances of poking and talking very loudly to strangers when they are in the community, as well as leaving the area they are in and trying to walk off on his own. When they attempt to follow the BSP and redirect Fritz accordingly it doesn't work as well as they feel it did in the past. Fitz became angry with Bill when he tried to redirect Fitz on two occasions. Foster providers have not noticed a change. For now, Bill and Kathy are willing to see how things go over the next few months, but would like to look into making sure the BSP is still working or if Fritz needs to meet with the Behavior Support specialist to see if there is something new going on with Fritz. The team decided to start by having Fritz see the doctor to make sure there isn't anything medical causing a change in Fritz's behavior. SC will follow up after the medical appointment.Legal RelationshipsParent(s) of minor child who retain parental rights: FORMTEXT N/ALegal Representative/Guardian(s), if any: FORMTEXT William BennetScope of authority: FORMTEXT FullDesignated Representative(s) for service planning, if any: FORMTEXT N/ADesignated Representative(s) for employer representative/employer of record issues, if any: FORMTEXT ?????Health Care Representative, if any: FORMTEXT N/AAppointment Date: FORMTEXT N/A FORMCHECKBOX Self-Appointed FORMCHECKBOX ISP Team AppointedRepresentative Payee(s), if any: FORMTEXT William BennetConservator(s), if any: FORMTEXT N/AAny other Legal Documents on file limiting personal decision making: FORMTEXT N/AAcknowledgments Describe the supports the person needs to understand his/her rights or to understand this plan, if any: Indicate who will be responsible for supporting the person and timelines for completing this.Check here if no support is needed FORMCHECKBOX Brother Bill, sister-in-law, Kathy, and Foster providers will help to advocate for Fitz and make informed decisions in Fitz's best interest. They will continue to look for what works and doesn't work for Fitz, along with asking him about preferences to determine what services will work best for himPerson Receiving Services YesNoDeclinedDoes this ISP reflect the services the person chooses and the outcomes the person wants to work toward? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Has the person been provided information about the planning process and how to request changes and updates to the ISP? FORMCHECKBOX FORMCHECKBOX Did the person choose the location of their ISP meeting? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Did the person choose who participated in their ISP development? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Did the SC/PA review the services that are available to the person? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Did the person receive notification of his/her DHS rights? FORMCHECKBOX FORMCHECKBOX Families and/or Guardian who provide support YesNoN/ADoes this ISP reflect what is needed for the family to effectively provide supports? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ISP Team – Does this ISP reflect…YesNoIndependence: Having control and choice over one’s own life. FORMCHECKBOX FORMCHECKBOX Integration: Living near and using the same community resources and participating in the same activities as, and together with, people without disabilities. FORMCHECKBOX FORMCHECKBOX Productivity: Engaging in contributions to a household or community; or engaging in income-producing work that is measured through improvements in income level, employment status, or job advancement. FORMCHECKBOX FORMCHECKBOX Describe the reason for any question above remaining “no” and the plan to address it:N/AAgreement to this PlanThese people agree to this plan and associated documents as reflecting the person’s strengths and preferences, support needs as identified by an assessment, and the services and supports that will assist the person to achieve identified desired outcomes.Services Coordinator/Personal Agent/ODDS Residential Specialist: Ensure the plan meets the person’s current service needs and complies with requirements for the chosen service setting(s) and associated funding.Providers: Agree to implement and provide the supports that have been designated as their responsibility in this ISP. A signed contract, job description, or service agreement may be used in lieu of this signature page.NameRelationship to this personPresent at meeting?SignatureDateComments STYLEREF FirstName \* MERGEFORMAT Fitzwilliam BennetSelf / Person Receiving ServicesYesJane BingleyServices CoordinatorYesBill BennetLegal GuardianYesBeth LucasFoster ProviderYesCharlotte LucasFoster ProviderYes ................
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