Creating the ISP: Outcomes



| |9 | |Creating the ISP: Outcomes |

Course Map

Creating the ISP: Outcomes Objectives

At the completion of this lesson, you will be able to:

• Complete outcome information in the ISP

• Review existing outcome information in HCSIS

• Enter outcome actions in the ISP

Supports Coordination Process Flow

[pic]

Key Terms and Concepts

Outcome

Outcomes represent what is currently important to the individual, what needs to be maintained for the individual or what needs to be changed. The outcome should describe how it will make a difference in the individual’s life. The outcome must build on information gathered during the ISP process and reflect a shared commitment to action. Remember that outcomes supported by MR funding must be within the context of the health and safety of the individual and/or assuring their continued life within the community. Outcomes that address other priorities of the individual should be represented and supported with other community, family or non-traditional supports.

Use the principles of Everyday Lives to develop outcomes with the individual: choice, control, quality, community inclusion, stability, accountability, safety, individuality, relationships, freedom, success, contributing to the community, collaboration, communication and mentoring.

Outcome Actions

Outcome Actions is the action planning screen of the Outcome. This section captures the current needs of the outcome, what actions are needed to complete the outcome, who is responsible for completing the outcome, the frequency and duration of needed actions and how the action will be measured to see if progress has been made. Several outcome actions may exist for a single outcome.

It is critical for the team to address any concerns related to health and safety issues or any other barriers. Individuals need team support to attain outcomes because collective problem solving and resources will make the difference. Problem-solve to identify any needed actions. Each Outcome Summary should have an Outcome Action.

Key Terms and Concepts (continued)

Outcome Summary

Outcome Summary collects detailed information about each outcome for the individual. Outcomes include natural supports, non-paid services and MR funded supports.

Outcomes represent what is currently important for the individual to work on or to maintain. They also represent the changes an individual would like to see for him/herself. They are based on individual/family identified priorities, are responsive to formal and informal information gathering and are linked to the appropriate informal and formal supports and services.

Remember that outcomes supported by ODP funds must be in the context of supporting the health and safety of the individual and assuring their continued life in the community. Outcomes that address other priorities of the individual should be represented and supported with other community, family or non-traditional supported services.

• Outcome Phrase: This is a description to easily identify the outcome; this phase is intended to assist with easily navigating through the ISP to find all related information.

• Outcome Start Date: The date activity will begin to work toward achieving the outcome.

• Outcome End Date: The estimated date when the outcome should be achieved.

• Outcome Actual End Date: The date the outcome was completed.

• Has the outcome been successfully accomplished: An indicator (Yes or No) that shows whether the outcome was successfully accomplished.

Key Terms and Concepts (continued)

Outcome Summary (continued)

• Outcome Statement: Represents what is currently important to the individual, what needs to be maintained for the individual, or what needs to be changed. The outcome should describe how it will make a difference in the individual's life. The outcome must build on information gathered during the ISP process and reflect a shared commitment to action. Remember that outcomes supported by ODP funding must be within the context of the health and safety of the individual and/or assuring their continued life within the community. Outcomes that address other priorities of the individual should be represented and supported with other community, family or non-traditional supports.

• Use the principles of Everyday Lives to develop outcomes with the individual: choice, control, quality, community inclusion, stability, accountability, safety, individuality, relationships, freedom, success, contributing to the community, collaboration, communication and mentoring.

• Reason for the Outcome: This provides contextual information beyond the Outcome Statement for the team to understand how/why the outcome is important to the individual.

• Concerns related to Outcome: Describe any barriers (including health and safety issues) the team will need to address to successfully work towards the outcome. This may include information on what has been tried in the past but has not worked, what the individual's team has tried to figure out or other concerns any team member may have. For therapy and nursing services, document here the denial from the State Plan and/or private insurance.

• Relevant Assessments Linked to the Outcome: List any relevant formal or informal assessments that directly affect the outcome. Informal assessments may include: direct observations, interviews with family or direct care staff and/or review of previous records. Formal assessments may include: statewide standardized assessments in addition to person-centered assessments utilized by provider agencies that have previously been approved by licensing agents. (If a formal assessment has been completed, it should be noted in the "Other Non-Medical Evaluations" section of the ISP.) Assessments may be utilized to assess whether an outcome has made an impact.

Criteria for Best Outcomes

Outcome statements begin with the aim of the outcome, stated as a proper noun and an observable action verb. The aim is followed by the rationale (i.e. “in order to…”, “to…”, “so that…”). It explains why this action will make a difference for the individual and underscores that everybody involved in the ISP process agrees on this rationale.

When creating outcomes, use the following questions to verify whether the outcome contains the necessary details for the individual:

• Did we refer to the information already gathered on the plan to develop outcomes?

• Did we focus on things that we knew were important to/for the individual?

• Will the outcome(s) be achievable within the context of the person's everyday life?

• Is there a balance between brevity and detail? (That is, is there enough information to understand what is meant but not so much detail that the plan appears overwhelming?)

• Did we use "I" statements or reference the person's name?

• Is the outcome easily understood and free of professional jargon?

• Is the outcome measurable?

• Did we include a "so that" or an "in order to" clause?

• Did we describe "what is happening now" with information that relates to the outcome, so that we have a baseline of information to measure progress over time?

In supporting the Outcome:

• Did we clearly identify what will need to be done in order to assist the individual to achieve the outcome?

• Did we identify formal and informal supports and services?

• Did we represent actions that connect the individual to the community?

• Have informal, natural and community based supports been explored rather than automatically going to programmatic, more restrictive options?

• Criteria for Best Outcomes

| |Key Topic | |

| |Outcomes |is about . . . |

|The changes an individual would like to see for his or herself |

|Main Idea |Main Idea |Main Idea |

|“Priorities |“Information” |“Supported” |

|(based individual/family priorities) |(responsive to formal and informal information|(by informal and formal supports and services) |

| |gathering) | |

|Essential Details |Essential Details |Essential Details |

|Defines a planning teams’ shared vision for |Targets and builds on knowledge, skills, and |Individual and family preferences a priority |

|the individual |activities for success | |

|Followed by step by step action plan |Very much a work in progress |Discuss where individual spends time, activities they |

| | |do or wish to do |

|Maps the path team members will take together |Calls for ongoing monitoring and updating |Defines programmatic actions needed to find services, |

| | |fit them together, and create single unified plan |

| | | |

|Seek to discover what the person might like in the future and help them move in that direction (Smull 2000) |

Creating the ISP: Outcomes Task Flow

[pic]

Creating the ISP: Outcomes:

1. The Supports Coordinator meets with the individual and family to determine outcomes and outcome actions.

2. The Supports Coordinator logs into HCSIS and navigates to the Services and Supports screens in HCSIS. The Supports Coordinator can then search for the individual’s information.

OR

The Supports Coordinator may continue to enter information from the Financial Information section (Lesson 8). If the Supports Coordinator selects the [Save and Continue] button from the Financial Resources screen, HCSIS will navigate the Supports Coordinator to the first Services and Supports screen, Outcome Summary.

3. The Supports Coordinator enters the outcome summary and actions into HCSIS.

HCSIS System Task(s)

The following screens will be used in this lesson:

• Outcome Summary

• Outcome Actions

Demonstration 9-1: Creating Outcomes in HCSIS

This demonstration reviews the process for entering outcome information into HCSIS. The process of creating an outcome can be reviewed from the Supports Coordinator process training that was given in your county.

During the demonstration, you will use the following individual:

• Cindy Nissley

To become familiar with this process, use the following steps:

Menu Path:

|ISP |

|ISP ( Serv & Supp |

|ISP ( Serv & Supp ( Outcome Summary |

|ISP ( Serv & Supp ( Outcome Summary ( Outcome Summary |

Steps:

1. Using the menu path above, navigate to the Outcome Summary screen.

2. The Outcome Summary screen displays with the following fields.

|Field Name |Field Description |

|Outcome Phrase |This is a description to easily identify the outcome; this |

| |phrase is intended to assist with easily navigating through the|

| |ISP to find all related information. |

|Outcome Start Date |The date activity will begin to work toward achieving the |

| |outcome. |

|Outcome End Date |The estimated date when the outcome should be achieved.  |

|Outcome Actual End Date |Date that the outcome was achieved or ended without being |

| |successfully achieved. This is an optional field. |

Continued

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

|Field Name |Field Description |

|Has the outcome been successfully |Select "Yes" or "No" from the drop-down list to indicate |

|accomplished |whether the outcome has been successfully accomplished. |

| |Note: When initially creating outcomes, this field should be |

| |"No." When this field is changed to "Yes," an Actual End Date |

| |should be entered for the outcome. |

|Outcome Statement |Represents what is currently important to the individual, what |

| |needs to be maintained for the individual or what needs to be |

| |changed. The outcome should describe how it will make a |

| |difference in the individual's life. The outcome must build on |

| |information gathered during the ISP process and reflect a |

| |shared commitment to action. Remember that outcomes supported |

| |by ODP funding must be within the context of the health and |

| |safety of the individual and/or assuring their continued life |

| |within the community. Outcomes that address other priorities of|

| |the individual should be represented and supported with other |

| |community, family or non-traditional supports. Use the |

| |principles of Everyday Lives to develop outcomes with the |

| |individual: choice, control, quality, community inclusion, |

| |stability, accountability, safety, individuality, |

| |relationships, freedom, success, contributing to the community,|

| |collaboration, communication and mentoring. |

|Reason for Outcome |This information describes how the outcome is important to the |

| |individual. It answers the question, “Why should this be an |

| |outcome?”  |

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

|Field Name |Field Description |

|Concerns related to Outcome |Describe any barriers (including health and safety issues) the |

| |team will need to address to successfully work towards the |

| |outcome. This may include information on what has been tried in|

| |the past but has not worked, what the individual's team has |

| |tried to figure out or other concerns any team member may have.|

| |For therapy and nursing services, document here the denial from|

| |the State Plan and/or private insurance. |

|Relevant Assessment |List any relevant formal or informal assessments that directly |

| |affect the outcome. Informal assessments may include: direct |

| |observations, interviews with family or direct care staff |

| |and/or review of previous records. Formal assessments may |

| |include: statewide standardized assessments in addition to |

| |person-centered assessments utilized by provider agencies that |

| |have previously been approved by licensing agents. (If a formal|

| |assessment has been completed, it should be noted in the "Other|

| |Non-Medical Evaluations" section of the ISP.) Assessments may |

| |be utilized to assess whether an outcome has made an impact. |

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

3. Enter the following information into HCSIS:

|Field Name |Data |

|Outcome Phrase |Apartment |

|Outcome Start Date |[Today’s Date] |

|Outcome End Date |[Enter a date prior to the plan end date] |

|Has the outcome been successfully |Select "No." |

|accomplished | |

|Outcome Statement |I want to keep my apartment clean so that I do not have to |

| |always depend on my sister to do it. |

|Reason for Outcome |Cindy wants to learn to keep her apartment clean and loves when|

| |friends notice how nice her apartment is. Since Cindy rents her|

| |apartment, it is critical for the apartment to be properly |

| |cleaned for the landlord to continue leasing it to Cindy. Also |

| |Cindy’s sister has a very difficult time helping Cindy keep her|

| |apartment clean. This issue becomes a source of tension between|

| |the sisters. Cindy’s sister is very willing to support her in |

| |many ways but she would really appreciate assistance in this |

| |area. |

|Concerns related to Outcome |Cindy wants to work along with whoever can help meet this need |

| |and be taught how to do things. The volunteer must have |

| |flexible hours to work within Cindy’s timeframe. |

|Relevant Assessment |Sister reports that Cindy can do simple housekeeping tasks with|

| |close supervision and assistance but hygienic cleaning of |

| |bathrooms and kitchen are difficult for her to do properly. It |

| |is hard for Cindy to keep up with multiple routines needed to |

| |maintain an apartment. |

4. Click [Save]

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

5. Click [Add].

6. Repeat Steps 3 – 5 for each outcome listed on the following pages.

7. Enter the following information into HCSIS:

|Field Name |Data |

|Outcome Phrase |Job |

|Outcome Start Date |[Today’s Date] |

|Outcome End Date |[Enter a date prior to the plan end date] |

|Has the outcome been successfully |Select "No." |

|accomplished | |

|Outcome Statement |I want to work more hours at my job so that I can have more |

| |money for my hobbies of collecting bears and going to pottery |

| |classes. |

|Reason for Outcome |Cindy would like to work more hours so that she has extra money|

| |to purchase more bears. She would also like to increase the |

| |number of pottery classes she is able to take. |

|Concerns related to Outcome |Current situation at grocery store has cut hours of part time |

| |employees. Cindy has had a hard time keeping jobs over time. In|

| |the past, she has had a job coach when she started a new job, |

| |but over time, without continued intermittent support, she |

| |begins to lose skills and socialize more than work. She needs |

| |the ongoing intermittent support of a job coach to help her |

| |keep her skills and maintain her professional commitment. |

|Relevant Assessment |Supervisor has given Cindy good job ratings, the |

| |Educational/Vocational Assessment completed on 6/20/01. |

Continued

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

8. Continue to enter the following outcomes into HCSIS:

|Field Name |Data |

|Outcome Phrase |Hobby |

|Outcome Start Date |[Today’s Date] |

|Outcome End Date |[Enter a date prior to the plan end date] |

|Has the outcome been successfully |Select "No." |

|accomplished | |

|Outcome Statement |In order to have fun and meet more people, I want to join a |

| |ceramic or pottery class. |

|Reason for Outcome |Cindy likes to do things with her hands and wants to meet more |

| |friends who like to the same things. |

|Concerns related to Outcome |Cindy may need more assistance at the program than the |

| |instructor can give. Cost may be a factor in deciding where. |

| |Transportation needs to be considered depending on hours of |

| |program. |

|Relevant Assessment |Cindy has done craft activities with a friend and does well |

| |with guidance. |

|Field Name |Data |

|Outcome Phrase |Read |

|Outcome Start Date |[Today’s Date] |

|Outcome End Date |[Enter a date prior to the plan end date] |

|Has the outcome been successfully |Select "No." |

|accomplished | |

|Outcome Statement |I want to learn to read so I can read my own mail. |

|Reason for Outcome |Cindy gets frustrated that others have to read her mail for |

| |her. |

|Concerns related to Outcome |Finding a literacy program that will pace teaching so it makes |

| |sense to Cindy. |

Continued

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

9. Continue to enter the following outcomes into HCSIS:

|Relevant Assessment |Cindy has basic skills with letter recognition and attempts to |

| |sound out letters and guess at words. Has not had formal |

| |instruction in reading in over 40 years. |

|Field Name |Data |

|Outcome Phrase |Exercise |

|Outcome Start Date |[Today’s Date] |

|Outcome End Date |[Enter a date prior to the plan end date] |

|Has the outcome been successfully |Select "No." |

|accomplished | |

|Outcome Statement |In order to keep healthy, I want to find an easy dance class or|

| |dancing program so I can exercise in a fun way. |

|Reason for Outcome |Cindy likes to dance and the doctor is asking that she exercise|

| |more to control her diabetes better. |

|Concerns related to Outcome |Finding a dance class or program that has flexibility. Easy |

| |steps-aerobics was too hard in past because the movements were |

| |too fast and regimented. |

|Relevant Assessment |Cindy loves to dance. She can dance for hours at weddings or |

| |dance clubs. |

|Field Name |Data |

|Outcome Phrase |Summer |

|Outcome Start Date |6/15/2004 |

|Outcome End Date |8/31/2004 |

|Has the outcome been successfully |Select "No." |

|accomplished | |

|Outcome Statement |I want to work at the beach over summer so that I maintain the |

| |medical assistance program and see my aunt. |

Continued

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

10. Continue to enter the following outcomes into HCSIS:

|Reason for Outcome |Cindy would meet criteria for disabled workers program if she |

| |works a regular 10 hour week. Cindy’s Aunt has offered to serve|

| |as a Job Coach while spending time with her over summer. |

|Concerns related to Outcome |Current situation is Cindy will need to have the summer away |

| |from her current job. In addition, Cindy will need to have a |

| |job position at her aunt’s location. |

|Relevant Assessment |Supervisor has given Cindy good job ratings. |

|Field Name |Data |

|Outcome Phrase |Diabetes |

|Outcome Start Date |[Today’s Date] |

|Outcome End Date |[Enter a date prior to the plan end date] |

|Has the outcome been successfully |Select "No." |

|accomplished | |

|Outcome Statement |Cindy wants to be able to eat more foods that taste good to |

| |her. She would like to eat throughout the day so that she can |

| |keep her blood sugar at a safe level and make controlling her |

| |diabetes easier. |

|Reason for Outcome |Cindy struggles with her diet. She wants to stay healthy yet |

| |likes to eat snack foods throughout the day. She is tired of |

| |the veggies and fruits that have helped her in the past. She |

| |has begun to eat more carbohydrates as snacks and it can throw |

| |her blood sugar off. |

|Concerns related to Outcome |Helping Cindy with portion control with any food that is |

| |selected will need to be addressed. |

|Relevant Assessment |Physician assessment occurs every 3 months. Ongoing monitoring |

| |of blood levels by family and physician. |

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

11. Click [Save]. The screen will appear as follows:

[pic][pic][pic]

12. Click [Save and Continue]. The Outcome Actions screen appears.

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

13. The Outcome Actions screen appears with the following fields.

|Field Name |Field Description |

|Related Outcome Phrase |This is created in the Outcome Summary and selected here to link the|

| |Outcome Summary and Outcome Actions. It is a description to easily |

| |identify the outcome; this phrase is intended to assist with easily |

| |navigating through the ISP to find all related information. |

|What are current needs |Describe the current reality related to the outcome. This should be |

| |related specifically to the individual – what they are able to do |

| |toward the outcome, including assistance that is necessary. This |

| |should crosswalk with previous sections of the ISP where needs are |

| |described. |

|What actions are needed |Identify steps and actions to achieve the outcome. Include those |

| |provided by paid and non-paid people such as family members or |

| |friends. |

| |Include actions that currently occur and need to continue; this |

| |should describe any actions, including those provided by natural |

| |supports, non-paid and paid support. What happens currently to meet |

| |the need; is it adequate? Are there parts of the individual's |

| |specific outcome being met and others not being met? If a specific |

| |service is required, it can be named here. |

| |Document steps to assure the individual's health and safety while |

| |working toward desired changes. |

|Who’s responsible |Include the individual and/or other team members (name and |

| |relationship to the individual) involved who will assist with the |

| |implementation of the outcome and that will be responsible for |

| |seeing that the actions occur. |

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

|Field Name |Field Description |

|Frequency and Duration of the actions|Include the frequency (number of times) and the duration |

|needed |(length of time) for each of the needed actions. Include those |

| |provided by paid and non-paid people such as family members or |

| |friends. |

| |Specific information on total number of units is listed on |

| |Service Details. |

|By when |List the anticipated date (or end of plan date) the actions |

| |will be accomplished; whichever is appropriate. |

|How will you know that progress is |Progress links directly to outcome. Describes what is expected |

|being made towards this outcome? |as a result of the services and supports. Identify how and who |

| |will give input about progress made over time. |

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

14. Enter the following information on the Outcome Actions screen:

|Field Name |Data |

|Related Outcome Phrase |Apartment |

|What are current needs |Cindy has depended on her sister and her family to help her |

| |each week with cleaning, shopping, paying bills, transportation|

| |and having evening meals together. The one area that causes |

| |stress for all is cleaning the apartment. |

|What actions are needed |Homemaker will assist four hours per week. Jobs to be done will|

| |be determined by Cindy, sister and homemaker. |

|Who’s responsible |Supports Coordinator |

|Frequency and Duration of the actions|Referral to homemaker agency that Cindy/sister chooses. |

|needed | |

|By when |[Enter a date prior to the plan end date] |

|How will you know that progress is |Cindy and her sister will report that the homemaker is teaching|

|being made towards this outcome? |Cindy to clean the apartment and Cindy depends less on her |

| |sister to accomplish this task. |

15. Click [Save]

16. Click [Add]

17. Repeat steps 16–17 for each outcome action listed on the following pages.

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

18. Enter the following information into HCSIS:

|Field Name |Data |

|Related Outcome Phrase |Job |

|What are current needs |Cindy is currently working 8 hours per week. She would like to |

| |work up to 16 hours per week. Cindy also works an erratic |

| |schedule each week. She needs ongoing intermittent job coach |

| |support to maintain her skills. |

|What actions are needed |Job coach who has helped in past will be contacted to see if |

| |there are creative ways to increase hours even if it means |

| |learning a new task so that Cindy can work extra hours a week. |

|Who’s responsible |Supports Coordinator will coordinate job coach assistance. |

|Frequency and Duration of the actions|Refer to original job coach agency. |

|needed | |

|By when |[Enter a date prior to the plan end date] |

|How will you know that progress is |Cindy reports that she is working at least 12 hours per week |

|being made towards this outcome? |and has a more predictable schedule. |

|Field Name |Data |

|Related Outcome Phrase |Hobby |

|What are current needs |Cindy would like more friends who like to do things with her. |

| |She likes working with her hands and ceramics and pottery |

| |interest her. |

|What actions are needed |Community art programs will be explored and one selected. |

|Who’s responsible |Sister |

Continued

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

19. Continue entering the following outcome actions into HCSIS:

|Frequency and Duration of the actions|Sister will locate program and accompany Cindy for awhile to be|

|needed |sure it is a good match. |

|By when |[Enter a date prior to the plan end date] |

|How will you know that progress is |Cindy will report that she is enrolled in a program that she |

|being made towards this outcome? |enjoys and has found others she likes who have same interest. |

|Field Name |Data |

|Related Outcome Phrase |Read |

|What are current needs |Cindy reluctantly gives mail to family members who support her |

| |to read contents to her. She sometimes opens and hides mail |

| |when it arrives out of frustration of having to depend on |

| |others to read it to her. |

|What actions are needed |Cindy’s nephew will contact the literacy council to locate |

| |volunteer. He will provide transportation if needed. |

|Who’s responsible |Nephew |

|Frequency and Duration of the actions|Nephew will make arrangements for volunteer to be assigned. |

|needed |Literacy council volunteer will set up schedule for evening |

| |sessions. Nephew will take Cindy to sessions. |

|By when |[Enter a date prior to the plan end date] |

|How will you know that progress is |Cindy will report reading skills are improving. |

|being made towards this outcome? | |

Continued

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

20. Continue entering the following outcome actions into HCSIS:

|Field Name |Data |

|Related Outcome Phrase |Exercise |

|What are current needs |Cindy walks one way to or from work 2 or 3x a week. She also |

| |walks her sister’s dog every other day. Her doctor is |

| |suggesting more activity to help control her weight because of |

| |her diabetes. |

|What actions are needed |An easy dance program such as square dancing at community Y or |

| |township recreation program will be explored. A copy of Richard|

| |Simmons Dancing to Oldies videotape will be borrowed from the |

| |local library. If Cindy enjoys it, it will be purchased as a |

| |gift from her sister. |

|Who’s responsible |Sister |

|Frequency and Duration of the actions|Sister will call community Y and township recreation office to |

|needed |make arrangements and will accompany Cindy to first few |

| |classes. Sister will take Cindy to library and borrow the |

| |Richard Simmons oldies video. If Cindy uses it, sister will |

| |purchase a copy as a gift to her sister. |

|By when |[Enter a date prior to the plan end date] |

|How will you know that progress is |Cindy will report that she has found a way to dance on a |

|being made towards this outcome? |regular basis and that it is helping her to lose weight. |

Continued

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

21. Continue entering the following outcome actions into HCSIS:

|Field Name |Data |

|Related Outcome Phrase |Summer |

|What are current needs |Cindy enjoys visiting her aunt when possible. The summer is a |

| |slow time for her current employer, and her hours are often cut|

| |back. Recognizing that Cindy needs intermittent job support, |

| |Cindy’s aunt has offered to provide job support to Cindy for 10|

| |hours each week over the summer. |

|What actions are needed |Aunt will provide job coach support over the summer for 10 |

| |hours per week. SC will work with Cindy’s Aunt to provide |

| |funding through an ISO Agency. |

|Who’s responsible |Aunt |

|Frequency and Duration of the actions|Aunt will set-up interviews in her location and locate a place |

|needed |of employment for Cindy. |

|By when |[Enter a date prior to the plan end date] |

|How will you know that progress is |Aunt will provide weekly progress reports to the Supports |

|being made towards this outcome? |Coordinator. In addition, the employer will provide a |

| |performance review at the end of the summer. |

|Field Name |Data |

|Related Outcome Phrase |Diabetes |

|What are current needs |Cindy has been in control of her diabetes for the past year |

| |with a diet that had been prescribed for her by a Nutritionist.|

| |She is unhappy with the food choices for snacks and has been |

| |sneaking carbohydrates (chips, too many sugar free cookies in a|

| |day etc.) that can increase her blood sugar level. |

Continued

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

22. Continue entering the following outcome actions into HCSIS:

|What actions are needed |Revisit nutritionist in doctor’s office that had developed |

| |current diet to help her with other food choices. Identify and |

| |make referral to local diabetic support group for nutritional |

| |assistance and creative ways to stay healthy. |

|Who’s responsible |Sister will arrange nutritional consult at physician’s office. |

| |Supports Coordinator will make referral for local support |

| |group. |

|Frequency and Duration of the actions|Sister will make appointment and accompany Cindy to visit with |

|needed |nutritionist. Supports Coordinator will make referral and send |

| |information about where and when the support group meets to |

| |Cindy and her sister. Family will give Cindy a ride to group. |

|By when |[Enter a date prior to the plan end date] |

|How will you know that progress is |Cindy’s blood levels will be at safe range. Cindy will report |

|being made towards this outcome? |she is eating more foods she likes. |

23. Click [Save]

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:

24. The screen will appear as follows:

[pic][pic]

25. Click [Save and Continue]

Lesson Exercise 9-1: Creating Outcomes in HCSIS

For this exercise, use the following individual:

• Tim Fiore

Using Tim from prior exercises, develop two to three outcome statements for entry into HCSIS. Keep in mind the following information:

• What is the outcome statement?

• What is the reason for the outcome?

• Are there any possible concerns related to the outcome?

• What type of relevant assessments can be linked to the outcome?

Take about ten minutes to work in small groups to develop outcome statements. Use the handout to record your information.

After about ten minutes, your instructor will ask you to enter the information into HCSIS.

After completing the Outcome Action screen in HCSIS, you have completed this exercise.

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Creating the ISP: Outcomes Review

| |Why are outcomes important? |

| | |

| |What is the process for entering outcomes in HCSIS? |

| | |

| |Why should outcomes be recorded in HCSIS for non-funded services? |

| | |

Answers to Creating the ISP: Outcomes Review

| |Why are outcomes important? |

| |Outcomes should define the steps required to assist an individual in reaching or continuing a certain goal in|

| |living the life that he/she wants. Outcomes are an important aspect in helping individuals on the path of |

| |self-determination. |

| |What is the process for entering outcomes in HCSIS? |

| |The Supports Coordinator works with the individual and family to identify outcomes. Once the outcomes are |

| |identified, the Supports Coordinator enters the Outcome information into HCSIS on the Outcome Summary screen.|

| |After completing the Outcome Summary screen, the Supports Coordinator completes the Outcome Actions screen |

| |representing the action planning to achieve the outcomes. |

| |Why should outcomes be recorded in HCSIS for non-funded services? |

| |The ISP is a tool for the Supports Coordinator to help monitor the individual’s progress in achieving their |

| |goals and desires. Not all outcomes will require services, but they are still critical to the individual. |

| |These outcomes should be identified and maintained in HCSIS to represent the individual’s accomplishments |

| |over time. Previous outcomes may lead to future outcome development. |

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RETIRED

Tip

When an outcome is accomplished, use a General Update to change the Has the outcome been successfully accomplished field. Since no services are being changed, the General Update plan will automatically return to approved status once it is submitted.

Tip:

Due to the size of the screen, use the vertical scroll bar to scroll to the bottom of the screen. The [Save and Continue] button is located at the bottom of the page.

Tip:

Notice that the list box continues to build for all of the outcome actions entered into HCSIS.

Tip:

Notice that the list continues to build for all of the outcomes entered into HCSIS.

Tip:

Due to the size of the screen, use the vertical scroll bar to scroll to the bottom of the screen. The [Save and Continue] button is located at the bottom of the page.

Tip:

If you are currently working with an individual’s information in HCSIS, the system will remember the individual as you navigate through the screens. This means you will not be required to search for the individual’s information again.

For example, if you were working with Cindy Nissley, when navigating to any of the ISP screens, Cindy’s information will automatically pre-populate without having to perform another search.

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Notes:

Notes:

Notes:

Notes:

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