Oregon ISP – Planning together in partnership
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Instruction Manual for
Services Coordinators and Personal Agents
June 30, 2015
Published by: Under the direction of:
Oregon Technical Assistance Corporation (OTAC) Office of Developmental Disabilities Services (ODDS)
Salem, Oregon Oregon Department of Human Services
dhs/DD/
Table of Contents
Welcome to the Oregon ISP 3
Overview of Forms 8
Timelines 11
Person Centered Information 13
One Page Profile 15
Risk Identification Tool 17
Risk Management Strategies 21
Provider Organizations: Guidelines for developing support documents 23
The ISP Meeting 27
Desired Outcomes 29
SC/PA: Career Development Plan 32
SC/PA: Completing the ISP 38
SC/PA: Completing each section of the ISP 39
Implementing the ISP 49
ISP Implementation Strategies for Providers serving a person who lives in a Residential setting 51
Making Changes 53
Risk Assessment Matrix 56
Glossary 58
Resources 60
Welcome to the Oregon ISP
In 2013, the Office of Developmental Disability Services (ODDS) was approached by the DD Coalition (a wide-reaching stakeholder community) with a recommendation that Oregon move from 11 different Individual Support Planning tools and processes to one for all people with Intellectual or Developmental Disabilities (I/DD) receiving Medicaid-funded services.
ODDS agreed, and the first year of the process was led by a voluntary group of invested professionals, self-advocates and family members. A contract with Oregon Technical Assistance Corporation (OTAC) was established for moving the conversation to a conclusion, with continued investment and participation from stakeholders.
Statewide conversations about implementation began in January 2015 and continue as regional trainings are offered around the state. New Individual Support Plans (ISPs) developed in June 2015 and thereafter are required to use the new ISP process and materials.
The benefits of one ISP include:
• Planning using a person centered process remains constant regardless of the type of service or setting in which a person lives;
• A clear correlation between a person’s identified support needs, and the natural and other supports identified to meet those needs;
• A focus on the person’s desired outcomes and achievements and responsibilities of those providing supports;
• A “living document” that reflects ongoing changes throughout a plan year that are easily supported.
ISP Team Process
The Individual Support Plan is built on information gathered from the perspective of the person, his/her family, guardian, or designated representative, and others directed by the person such as people who provide supports. These contributors to planning are referred to as the ISP team.
The “team” could be as simple as a person sitting down with his Personal Agent and perhaps a chosen family member. For someone else, it might be a more comprehensive team made up of the person, her family, representatives of her chosen provider organizations, and her Services Coordinator.
Both of these styles of teams have a value and share a common purpose: to develop an Individual Support Plan that reflects the person’s preferences and chosen supports.
|Additional training resources including sample ISPs representing a range of ages, service settings, and support needs are available at |
|. |
Roles of ISP Team Members
Person Receiving Services
• Shares her perspective by letting team members know what is working in her life, what is important to her, what is not working, and what she would like to see different in her plan or by documenting it herself. This can happen anytime during the year.
• Identifies who he would like to participate in the development of his plan.
• Participates in the ISP meeting in the manner he chooses.
• Signs the ISP to indicate agreement. If there are areas of disagreement within the plan, she conveys those concerns to her team.
• Requests changes and approves changes or revisions to the ISP or support documents throughout the year as desired or needed.
• Shares any concerns or feedback with the Services Coordinator/Personal Agent (SC/PA), as needed, throughout the year. If disagreements are not satisfactorily resolved, she may request that they are noted on the ISP before signing it. The SC/PA will inform the person of other options that might address any disagreements or concerns.
|[pic] |Use of the word “person” |
| |Throughout the ISP forms and this instruction manual, the word “person” is used frequently to refer to the person |
| |receiving services. The group of stakeholders including advocates, families, and supporters involved in the |
| |development of this process shared concern that any word we use to abbreviate on a form or in instructions could |
| |become a label. But in the end, because we are all people first, the word “person” was chosen. |
Designated Representatives, Guardians, and Family
Family members and others the person directs may participate in this process according to their own comfort level. Guardians should participate as required by the guardianship order. This may include:
• Contribute to the Person Centered Information that is gathered.
• Offer information to identify and address known, serious risks.
• Help plan for the future and contribute to supports that will help the person have the life he/she wants.
• Review and approve the plan and other documents by signing the ISP.
• Share any concerns or disagreements during the planning process with the SC/PA.
• Review and approve changes to the ISP throughout the year when needed.
• Share any concerns or feedback with the SC/PA, as needed, throughout the year. If disagreements are not satisfactorily resolved, you may request that they are noted on the ISP before signing it. The SC/PA can inform you of other options that might address any disagreements or concerns.
Services Coordinator (SC) or Personal Agent (PA)
The SC/PA facilitates and assures the development of the ISP. In some situations, the person facilitating the development of the plan may have a different title (such as ODDS Residential Specialist in Children’s 24-hour Residential settings), but throughout these instructions we refer to the plan facilitator as the SC/PA for simplicity.
The SC/PA has the oversight and final responsibility for the accurate completion of all required ISP forms. As the delegated Medicaid authority, the SC/PA has the responsibility to ensure that the plan meets the person’s current service needs and complies with requirements for the chosen service setting(s) and associated funding. The SC/PA authorizes the ISP.
For consistency, this manual always says “SC/PA,” even relating to tasks that only happen when the person lives in a residential setting, such as 24-hour, Supported Living, or Foster care.
Provider Organizations and Foster Providers
• Support the person to participate in the ISP process as fully as possible.
• Support family members to participate in the ISP process to the degree in which they choose.
• Contribute to the development of the ISP as outlined in provided instructions and as directed by the person and the SC/PA.
• Gather person centered information and share it with the SC/PA in advance of the ISP meeting.
• Communicate with other provider organizations that serve the person, if applicable, in advance of the ISP meeting.
• Provide known medical or other historical information, as needed, to the SC/PA to assist in identifying serious risks.
• Develop, implement, and maintain instructions that tell direct support professionals or substitute caregivers how to provide supports identified by the ISP, including steps to meet the person’s desired outcomes and necessary risk management strategies.
• Provide supports as outlined in the ISP or the service agreement.
• Communicate with the SC/PA or with other ISP team members, as needed, when a person’s desired outcomes or other support needs change.
Personal Support Workers (PSWs) and Independent Contractors (ICs)
• Receive and sign a job description or service agreement that details the specific tasks the person has hired you to complete, including known serious risks, desired outcomes, and the person’s preference of how services are delivered.
• Perform the duties as outlined in the job description or service agreement.
• Communicate with the person and/or with the SC/PA if you become aware that the person’s support needs or preferences in how services are delivered have changed.
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|Providers serving people who live in Residential settings |
|Throughout this manual, reference is made to expectations of providers who serve people who live in Residential service settings. This |
|includes people who live in the following licensed settings: Non-relative Foster Care (Adults and Children), Supported Living Services, |
|Stabilization and Crisis Unit, and 24-hour Residential (Adults and Children). |
| |
|Expectations set forward in this manual are directed to all service providers supporting the person who lives in a Residential setting. This |
|includes Employment services, Employment Path services, and Day Supports and Activities providers serving a person who lives in a Residential |
|setting. |
|Considerations for CIIS |
|Children’s Intensive In-Home Services (CIIS) was developed in response to the needs of families caring for their children with intensive |
|medical or behavioral needs at home. Services Coordinators for the program collaborate with individual families statewide to identify and |
|assess needed supports. Then they work together to develop the ISP while coordinating services with local CDDPs and other government and |
|community agencies. |
|Points for Consideration |
|When CDDP or Brokerage is referenced in this manual, substitute CIIS program office. For example, when the manual states “File the complete |
|ISP at the CDDP or Brokerage,” substitute CIIS program office. |
|When SC/PA is referenced in this manual, substitute CIIS Services Coordinator. The CIIS Services Coordinator takes the lead in facilitating |
|the development of the ISP. |
|When this manual does not sufficiently address a specific detail or instructions conflict with established program policy or procedures, |
|contact CIIS program management for advice. |
|Considerations for Children’s Residential Services |
|Residential care for children consists of group homes in local communities providing 24-hour supports, supervision, and training to children |
|with developmental disabilities. Group homes for children have 24-hours, awake staffing. Services are planned, delivered, and supervised |
|within a framework of maintaining and improving child health and safety while working to increase each child’s level of independence and |
|self-confidence. Residential providers support children in their treatment, school programs, adult transition planning, and, when it is a part|
|of the child’s ISP, preserving connection with their families. |
|Points for Consideration |
|When CDDP or Brokerage is referenced in this manual, substitute ODDS Children’s Residential program office. For example, when the manual |
|states “File the complete ISP at the CDDP or Brokerage,” substitute ODDS Children’s Residential program office. |
|When SC/PA is referenced in this manual, substitute ODDS Residential Specialist. The ODDS Residential Specialist takes the lead in |
|facilitating the development of the ISP. |
|When this manual does not sufficiently address a specific detail or instructions conflict with established program policy or procedures, |
|contact ODDS Children’s Residential program management for advice. |
|List supports related to preserving a child’s connection with his/her family at a minimum on the Person Centered Information relationships |
|section. Consider adding Desired Outcomes to the ISP that support maintaining family connections. |
Overview of Forms
The Oregon ISP process includes standardized forms which are to be used whenever Medicaid-funded I/DD services are delivered. A complete ISP will include all of the following forms.
Person Centered Information
This document is the foundation of the planning process. Its purpose is to carefully and respectfully record the person’s perspective about a wide range of areas in her life. There is space for additional information to be added, when needed, and space at the end to note who contributed to this document.
The complete Person Centered Information form(s) is filed with the ISP at the CDDP or Brokerage.
Family members, as directed by the person, are encouraged to contribute information to this form. Providers supporting a person who lives in a Residential setting have a responsibility to update information on this form and share it with the SC/PA prior to the ISP meeting. See Person Centered Information, page 13.
Risk Identification Tool
This tool is used to identify known, serious risks in the person’s life. Risks which are marked with a “Yes” response are recorded on the ISP Risk Management Plan along with the strategy to address the risk. This document is best completed or reviewed near the time of the needs assessment as similar information is covered.
The complete Risk Identification Tool is filed with the ISP at the CDDP or Brokerage.
All providers who serve the person have a responsibility to communicate any known changes in serious risks with the SC/PA in a timely manner. See Risk Identification Tool, page 17.
ISP Meeting Agenda
This document serves as a record of the key topics discussed at the ISP meeting and the outcome of the discussion. It includes a number of topics to consider for discussion.
The complete ISP Meeting Agenda is filed with the ISP at the CDDP or Brokerage.
The person receiving services, her family members, and providers may contribute discussion topics to the ISP Meeting Agenda. See ISP Meeting, page 27.
Individual Support Plan
The ISP begins with at least one One Page Profile, a positive introduction to the person, which can be customized to reflect the person’s personality or preferences.
The ISP reflects the person’s desired outcomes, career development plan, risk management plan, and chosen services. It has space to record any differences of opinion as well as any legal relationships present in the person’s life.
The complete ISP is filed at the CDDP or Brokerage. A copy of the ISP is provided to the person, his guardian or designated representative, and any others directed by the person. Providers must receive a copy of the plan or a detailed service agreement or job description. See Completing the ISP, page 38, and Implementing the ISP, page 49.
Change Form
A Change Form is used to document any agreed upon changes to the ISP or related materials. It may be initiated by the person, guardian, family, provider, or SC/PA. To streamline the change process, some changes may be made immediately by notifying ISP team members. Other changes, such as adding or discontinuing services, require approval. The Change Form provides documentation of what was changed, when it was changed, and who was notified or gave approval for the change.
Completed Change Forms are filed with the ISP at the CDDP or Brokerage. Providers must be notified of changes which impact the services they are expected to deliver; the SC/PA provides a copy of the Change Form, changed document, or updated job description or service agreement. See Making Changes, page 53.
Other materials for implementing the ISP
There are other materials provided to support implementation of the ISP.
Provider Risk Management Strategies
This form is prepared by provider organizations and foster providers who maintain written instructions such as protocols, safety plans, and other support documents for their staff or substitute caregivers to follow. This form is typically not used with PSWs or Independent Contractors, unless specifically directed by the SC/PA.
The ISP Risk Management Plan or the provider’s Service Agreement details the specific risks which are to be addressed in that setting. The provider organization or foster provider completes this form listing each identified risk and the document(s) that are in place to address it. The form includes space to list the title, date, and location where each document is kept.
Providers share an updated copy of this form with the SC/PA prior to the ISP meeting and anytime it is updated. See Implementing the ISP, page 49, and Making Changes, page 53.
Required Support Documents
There is a set of required support documents which have been required for use with people who live in 24-hour residential settings, including protocols for Aspiration/Choking, Constipation, Dehydration, and Seizures as well as a Financial Plan. These support documents continue to be required in these settings. They are also available for use, as directed by the SC/PA, in other settings. See Risk Management Strategies, page 21.
Action Plans
Example action plans are available for providers to create implementation strategies to reach Desired Outcomes identified in the ISP. Provider organizations and foster providers are also free to create their own action plan templates. See Implementing the ISP, page 49.
Timelines & Partnership
|For initial plans upon entry into services |
|Complete all ISP documents based on information available, noting if information is not available at this time. The Chosen Services pages are required to be |
|completed in order to begin services. Completing the Risk Identification Tool at the time of the assessment supports completion of the Risk Management section of |
|the ISP upon entry. The ISP must be signed in order for services to begin. |
|See separate ODDS guidance for required timelines of entry ISPs. (APD-PT-15-014) |
|Example: The person’s application is completed and the individual is eligible for Community First Choice or Waiver funded services on 4/18/2015. The ISP should be |
|authorized within 90 days, thus no later than 7/17/2015. The individual may begin to access services the date the ISP is authorized. |
|For renewing plans |
|For efficiency and to avoid redundant conversations, complete the Risk Identification Tool at or near the time of the needs assessment. |
|The ISP is in effect for a twelve-month period. (See APD-PT-15-014.) When renewing, begin the planning process approximately two months before the previous ISP |
|expires. Complete and implement the new ISP prior to the expiration of the previous plan. |
|Example: The initial ISP authorization date is 3/12/2015. This ISP must be authorized through 3/31/2016. The renewed ISP begins 4/1/2016 and be authorized through |
|3/31/2017. This ISP date range becomes a fixed time frame moving forward, e.g. an person’s ISP must be authorized each year by April 1. |
For Providers supporting people who live in Residential settings
For people who live in residential settings, partnership and communication between the ISP team members in preparation for the ISP meeting is especially important. We acknowledge that currently case management for people in residential settings is typically provided by a Services Coordinator through the CDDP. Nonetheless, this section is written referencing both SCs and PAs, CDDPs and Brokerages.
Providers supporting a person who lives in a residential setting are responsible to gather or prepare information in advance and share it with the SC/PA to contribute to the development of the ISP.
Unless directed otherwise by the SC/PA, providers must deliver this information to the SC/PA at least five (5) business days prior to the scheduled ISP meeting date. CDDPs (or Brokerages, if applicable) have the discretion and final responsibility for setting and communicating timelines for receiving information from the provider(s).
|Information to be prepared in advance of the ISP meeting by Providers supporting people who live in Residential settings: |
|One Page Profile reflecting, at a minimum, information gathered by the site where the person is served |
|Person Centered Information reflecting, at a minimum, information gathered by the site where the person is served |
|Known, identified serious risks |
|Unless agreed otherwise with SC/PA, this is accomplished by sending a draft of the Risk Identification Tool to the SC/PA. |
|Proposed discussion topics for the ISP Meeting Agenda |
|Unless agreed otherwise, this is accomplished by sending a draft of the ISP Meeting Agenda to the SC/PA. |
|Providers are also encouraged to develop draft action plans toward anticipated desired outcomes. |
Person Centered Information
Core Responsibility
➢ Gather person centered information in a way that is respectful to the person, his/her family, and their preferences. Meet the person “where they are at” recognizing that a person may refuse to answer some questions. This is not considered an interview process as information can be gathered over time.
➢ Seek to understand what is important TO the person from his/her perspective to live the life he/she wants. (Person’s hopes and preferences) Record this under “Person’s perspective.”
➢ Seek to understand what is important FOR the person from the perspective of others who know and care about the person for his/her health, safety, and to be a valued member of his/her community. (Necessary supports) Record this under “Additional information,” when needed.
➢ Recognize when what is important TO the person conflicts with something that is important FOR the person. Facilitate or participate in conversation about finding a balance between what’s important TO and FOR the person.
Points to Consider
• Start simple with known information. If you have limited information about the person, you might get started by asking a few questions to better understand areas that interest the person or are a current concern.
• Avoid rewriting detailed supports here that already exist somewhere else. For example, if the person already has a specific protocol or safety plan in place, you do not need to rewrite the supports from that document.
o When there are basic support needs that aren’t written in any other document, this document could be a good place to record them and share with others.
• This form does not need to be conducted as an interview. It may be completed based on information gathered from a combination of conversation with the person and others, your knowledge of the person, and file review.
• A life that only focuses on what is important TO the person while disregarding what is important FOR can be dangerous. (“Oh, but it’s her choice!”)
• A life that only focuses on what is important FOR the person without considering what is important TO leads to poor quality of life. (“He’s alive but miserable.”)
• The goal is to find a balance by finding the “hooks” of what’s important TO the person within the context of what’s important FOR him/her. (“I will quit smoking because I want to hike Mt. Hood.”)
• It is important to understand WHY something is important TO the person as well. We all have different reasons why something is important TO us. Seeking to understand why something is important TO the person can lead to a better balance between what’s important TO and important FOR the person.
• We are part of an interrelated community, with each person having skills, abilities, and knowledge they can share. While you are working through the Person Centered Information with a person, be looking for opportunities to enhance the person’s independence, integration, and productivity.
• Everyone communicates! Our job is to figure out how a person communicates and use the person’s communication style as much as possible. If you don’t know how to communicate with the person, try finding someone who does to help you gather the information.
• There are many tools available to help gather information. Here are just a few:
o Important TO/FOR – sorts what’s important TO and what’s important FOR someone, highlighting where balance is needed
o Good Day/Bad Day – highlights what’s important TO and how to best SUPPORT someone
o What’s Working & Not Working – snapshot of what’s happening right now; leads to action
o Hopes and Fears – highlights what’s important TO and FOR the person, calling out other perspectives
Completing the Person Centered Information form
|Services Coordinators and Personal Agents |Providers supporting a person who lives in a Residential setting |
|In-Home settings |Gather information from the person’s perspective and from the perspective of |
|Gather Person Centered Information in a manner that works for the person and/or |others who know and care about the person, such as the staff or caregivers who |
|family. |provide direct supports. |
|If the person or family is interested in completing the Person Centered |Provide a complete Person Centered Information form to the SC/PA prior to the |
|Information themselves, support them to contribute in a way that works for them. |ISP meeting following agreed timelines. |
|Residential Settings |Train staff or caregivers on the Person Centered Information. |
|Review Person Centered Information submitted by the provider organizations and |Make updates to the Person Centered Information anytime during the year |
|watch for issues that need to be discussed at the ISP team meeting. |following local documentation practices. |
|Ask questions, if needed, to clarify any information. | |
|Contribute additional information when needed. | |
One Page Profile
A One Page Profile provides a positive introduction to a person. It includes the following information:
• What people like and admire about the person (positive qualities)
• What is important to the person (in the environment or situation it is being written for, such as employment or home)
• How to best support the person (what is Important For the person)
One Page Profiles can be especially powerful if they are tailored to a specific setting. There must be at least one One Page Profile with the ISP; there may be more than one. The One Page Profile template included on the front of the ISP includes a place to indicate which setting the One Page Profile is for (e.g. home, work, school, etc.)
The One Page Profile may take any format. There is one available on the first page of the provided ISP form, but you may alternately use any other template as long as it includes the three statements above along with the person’s name and the date it was last updated.
Core Responsibility
➢ At a minimum, update the One Page Profile(s) annually in preparation for the ISP meeting. Changes may be made to local copies of the One Page Profile at any time following local documentation practices, without an ISP Change Form.
➢ Ask the person what he/she wants on his/her One Page Profile. Listen to the person’s words and actions.
➢ Include a picture(s) if the person wants. It could be a picture of the person or an image of something that is important to the person.
➢ Add additional information carefully and respectfully when needed for clarity.
➢ Keep the One Page Profile to one page. This is just an introduction to the person; it’s not a detailed list of everything in the person’s record or ISP.
|Services Coordinators and Personal Agents |Providers supporting a person who lives in a Residential |
| |setting |
|In-Home settings |Develop a One Page Profile for the specific environment where |
|Develop a One Page Profile in a manner that works for the person and/or family. |you support the person. |
|If the person or family is interested in creating a One Page Profile themselves, offer templates and|Provide a complete One Page Profile to the Services |
|other available resources to support them. 1PP is a good place to start. |Coordinator or Personal Agent prior to the ISP meeting |
|Residential settings |following agreed timelines. |
|Review One Page Profile(s) submitted by providers and include them with the final ISP. |Train staff on the One Page Profile for your setting. |
|Ask questions, if needed, to clarify any information. | |
|Watch for the “Common errors in One Page Profiles” listed on the next page and share feedback with | |
|the providers. | |
|Contribute additional information when needed. | |
Points to Consider
• When gathering person-centered information, think about these areas of the person’s life:
o Is there anything about the person’s routines that must happen or must not happen that reflects what is important to him?
o What helps her have a good day?
o How can you minimize the effects of a bad day?
o What is working or not working in the person’s life that others need to know?
• What One Page Profiles are not?
o Everything important to the person
o Provides detailed supports
o Outlines all supports for a person
• When identifying what is Important To the person, this is what is most important from the environment that you support the person in.
o Think about what helps the person have a good day, and the supports needed when having a bad day.
o Think about different aspects of a person’s routines that are important to him/her.
• When identifying how to best support the person, think about the key areas of support. Avoid outlining the details if they can be found elsewhere.
o Think about the supports the person needs to have the things that are important to him/her.
• When identifying what people like and admire about the person, this includes: Positive qualities, and the person’s strengths and talents.
o Some examples are: Creative, smart, great conversationalist
o Always remember that this is about the person, not about the services they receive.
o Avoid phrases such as “good hygiene.” When was the last time you complimented someone you know on their hygiene?
For more resources on building great One Page Profiles including downloadable templates, visit 1PP.
Risk Identification Tool
Core Responsibility
➢ Identify known, serious risks that are present in the person’s life.
o Serious Risk: Risks that, without support, would likely result in hospitalization, institutionalization, legal action, or place the person or others in imminent harm.
➢ SC/PA: Record each identified risk (only those with a Yes answer) on the ISP Risk Management Plan and describe what strategies are in place to address the risk.
➢ Be mindful of changing risks throughout the year. While this tool must be completed initially prior to the ISP meeting, it must also be updated throughout the year if known risks change.
Points to Consider
• Consider each risk in the absence of current supports.
• Complete this form based on information learned through conversation, file review, and your knowledge of the person. Whenever possible, identify serious risks during or near the time of the needs assessment, so that you can use information that was discussed during the needs assessment.
• Think about who has information that can help identify known risks. It may be the same people who are involved in the needs assessment. Are there others who have knowledge of the person who should be consulted? Consider: family, nurses, behavior specialists, providers, etc.
• Avoid redundant discussions. If you’ve already discussed a point and have enough information to know the risk is present, does it need to be discussed again?
Considerations when completing this tool for children:
• This tool is intended to identify risks beyond typical childhood development and parental responsibilities.
• Do not include supports provided based on a child’s developmental level that are not as a result of the disability, such as cutting a child’s meat or holding a child’s hand when crossing the street.
Completing the Risk Identification Tool
(SC/PAs, Provider organizations and Foster providers)
• Thoughtfully consider each risk category. It may be helpful to read through and review some of the typical risks encountered in each category.
• If there is no risk present in a section, mark the checkbox at the top of the category indicating that there is no risk present, then skip to the next section. There is no need to respond to each risk within any section that is marked No and skipped. See below for a detailed explanation of each response as well as the expected action.
• If a risk is present within a section, respond to each risk within the category. See below for a detailed explanation of each response as well as the expected action.
• Some risks, such as aspiration, choking, dehydration, constipation, and seizures have a series of warning signs, triggers, or observable symptoms listed to help identify whether a serious risk may be present. Follow the instructions provided on the tool. See Required Evaluations below.
• Comments section: Optional space for comments is available at the end of each category to record any useful information about why a risk was marked Yes, Possible, etc. Avoid using the comments space to record specific support strategies for any identified risk. That information belongs in the Risk Management Plan in the ISP or in support documents.
• For providers serving a person who lives in a Residential setting: Communicate proposed discussion topics for the ISP Meeting Agenda with the SC/PA at least five business days prior to the ISP meeting, or according to timelines set by SC/PA.
Expected Evaluations
Some risk factors (e.g. letters “g”-“m” under Aspiration) warrant additional evaluation or discussion with a qualified professional to determine the level of risk present. Unless the risk has already been determined “Yes” by a preceding risk factor (e.g. any of “a”-“f” were already marked under Aspiration), seek an evaluation to determine whether a risk is present.
When an evaluation is expected, consider professionals that are already in the person’s life. If the person has a nurse, ask the nurse for input. If the risk is related to behavior and the person has a behavior specialist, start there. In addition, consider if the person has already received an evaluation from a qualified professional that is still current (see below for the definition of qualified professional and current evaluation.)
For SC/PAs supporting people in an In-Home setting: Encourage the person or family to discuss the issue with his/her primary care physician. Help them in a way that works for them to support follow through. Use progress notes to indicate how follow through is working or not working. If you have concern for the person’s immediate health and safety due to this issue and an evaluation is not available or possible, seek your supervisor’s guidance and use your professional judgment in determining whether immediate intervention (such as calling 911) is necessary.
Record information about any completed evaluations in the space provided at the end of the tool.
✓ Evaluation: An assessment conducted by a qualified professional to determine whether or not the identified issue is a serious risk. An evaluation may occur through observation of the person, report of observations from care providers, or other method deemed appropriate by the qualified professional. The results of an evaluation may include recommended support strategies, including preventative measures to minimize the risk from occurring as well as recommended interventions when a problem is observed.
✓ Qualified professional: A person, who is licensed, specialized, or has expertise and practices in the specialty field that is referenced. Depending on the issue, examples may include behavior specialists, speech language pathologists, or physicians.
✓ Current evaluation: An evaluation is considered current if the team knows the condition the person was in at the time of the evaluation, and the team observes that the condition of the person has not significantly changed since the time of that evaluation. If a written evaluation or applicable Oregon Administrative Rule includes an order to re-evaluate after a certain amount of time, then the evaluation would no longer be considered current after that point.
Responses on the Risk Identification Tool and expected action
|Response & Explanation |Expected Action |
|Yes: |SC/PA |Providers serving a person who lives in a |
|There is evidence of the identified|Record the risk on the Risk Management Plan in the ISP and note how the |Residential setting: |
|risk. |risk is addressed. |Mark the risk as Yes or communicate with |
| |Help the person understand that in order to receive services adequately, |the SC/PA that there is evidence of the |
| |providers need information about known risks. |identified risk. |
| |If person declines support for the identified issue: |Prepare Provider Risk Management Strategies|
| |Write it on the Risk Management plan. |which describe supports in place at this |
| |Indicate the person’s preference for supports under the “How the risk is |location. |
| |addressed” section. |See Risk Management Strategies, page 21, |
| |Indicate how the issue will be monitored, for example, information and/or |for more information. |
| |referral, monitoring, or re-assessment. | |
| |See Risk Management Strategies, page 21, for more information about | |
| |addressing identified risks within the ISP. | |
|Possible: |SC/PA: |Provider Organizations and Foster |
|There is reason to believe this |No risk recorded on the Risk Management Plan in the ISP. No support |Providers: |
|risk may be present BUT evidence of|documents are in place to address this issue. Use the comments space |If you feel a risk is possibly present, |
|the risk is not available, |provided on this tool to record what action will be taken. |discuss it with the SC/PA. |
|inconclusive, or the person |Case management actions must include: |The team may discuss what evidence is |
|declines to discuss the issue. |Provide information about available community resources, medical, or other |available regarding the possible risk. |
| |professionals for assistance assessing or addressing the issue. | |
| |Monitoring within established timelines to see if the risk is changing or | |
| |additional information becomes available. | |
| |Note the issue and planned follow-up on the ISP, Chosen Case Management | |
| |Services, as an anticipated case management service. | |
| |Document actions taken in a progress note. | |
|No: |No risk recorded on the Risk Management Plan in the ISP. No support strategies are in place to address this issue. |
|There is no available evidence of | |
|the identified risk. This response | |
|is also indicated if the person | |
|declines to discuss the issue and | |
|there is no available evidence that| |
|the risk exists. | |
|History: |The history designation is for informational purposes only. |
|There is no available evidence of |No risk recorded on the Risk Management Plan in the ISP. No support strategies are in place to address this issue. |
|the identified risk being a current|Typically, if a risk is changing from Yes to History, leave it marked History for approximately five years. |
|issue and supports are not needed |Circumstances may warrant changing the response from History to No in less than or more than five years. Consider if |
|BUT there is evidence that the |there are other documents available in the person’s file that provide information about the past issue, the person and |
|identified risk did occur or needed|family’s preference on how it is recorded, and the likelihood the risk will be present again. |
|supports within approximately the | |
|last five years. | |
Risk Management Strategies
“Overprotection can keep people from becoming all they could become. Many of our best achievements came the hard way: We took risks, fell flat, suffered, picked ourselves up, and tried again. Sometimes we made it and sometimes we did not. Even so, we were given the chance to try.” (Perske, 1972:24)[1]
We cannot eliminate risk, but we can manage it. Good risk management strategies are founded on an understanding of what is important to the person from her perspective and what is important for her to remain healthy, safe, and a valued member of her community. When we understand both of these things, then we can focus on finding a balance between the two.
“Happy and dead are incompatible, but alive and miserable is unacceptable.” (Michael Smull, 2013)[2]
Prevention
Good risk management strategies begin with prevention measures. Are there things that can be reasonably done to prevent the issue from occurring? Remember to ask what is important to the person. Think about preventative measures that the person can relate back to his own values and priorities.
What’s important to the person?
We only do things that are important for us if they can relate back to something that is important to us. In order for a risk management strategy to have the best chance of success, you must think about what is important to the person from his/her perspective. Seek a deeper understanding of what makes the person happy and fulfilled. Find ways to tailor the supports toward what you know is important to the person. This will increase the chances of the person agreeing with the strategy, which increases the chances of success.
Core Responsibilities
➢ The ISP must reflect the strategies that are in place to address each identified risk.
➢ Listen to what the person says, with her words and with her actions, to inform how strategies are developed.
➢ Include proactive strategies intended to prevent the issue from occurring or minimize harm if it does occur.
Specific strategies to address risks
Examples of risk management strategies include:
• Education
• Natural and/or paid supports
• Assistive technology or device
• Environmental modification
• Written support documents (protocols, safety plans, etc.)
• Specific written instructions in a job description or service agreement
• Case management tasks such as providing information and/or referral as well as monitoring
The SC/PA uses judgment in conversation with the person and the ISP team to determine the best support strategy or combination of strategies to use. As a guiding rule, if others are paid to provide supports to address a risk, the expected supports must be written down.
Once the support strategies have been decided, the SC/PA writes them onto the ISP. If separate written instructions (such as a job description) will be prepared, the SC/PA references this on the ISP.
If a provider organization is expected to maintain written strategies to address the issue, the SC/PA notes that on the Risk Management Plan. The provider will complete a Provider Risk Management Strategies document to identify the specific document(s) they use to address each risk, date of each document, and indicate where it is located.
Provider Risk Management Strategies
The Provider Risk Management Strategies form is used by provider organizations to itemize the specific risks they are addressing (as defined by the ISP or service agreement) and list what document they will use to address each risk. It may also be used by Foster providers when directed by the SC.
Providers complete this form, train their staff on all strategies listed on it, keep it up-to-date as changes occur, and retain it in their files.
Provider Organizations:
Guidelines for developing support documents
These guidelines apply to people who live in 24-hour residential settings. In other settings such as Foster and Supported Living, SC/PAs may apply these guidelines based on their discretion.
Required support documents
People who live in 24-hour residential settings and who experience any of the following risks must have a support document using the provided forms. Each provider organization that supports the person is responsible to prepare these support documents, list them on their Provider Risk Management Strategies, and train direct support professionals on their use.
These support documents are also available for use in other service settings, as directed by the SC/PA and reflected on the ISP Risk Management Plan.
• Aspiration or Choking -> Aspiration/Choking protocol
• Constipation -> Constipation protocol
• Dehydration -> Dehydration protocol
• Seizures -> Seizure protocol
• Risk of financial exploitation -> Financial Plan
In addition to these documents, there is a Pica protocol and a general protocol form that are also available for use. They follow the same format and can help with consistency in training direct support professionals.
Detailed instructions are available for guidance in completing these support documents. See resources.
Safety Plans
A safety plan is a support document often used to address safety issues present in the person’s life. A safety plan includes a description of each risk being addressed, what preventative measures are in place to minimize the risk(s), how to respond when the risk is present, and the author’s name and date of the document. There is no required format for a safety plan, though some provider organizations require their own format.
A safety plan typically covers safety issues identified in the ISP or provider service agreement. In addition, some provider organizations also use it to address other issues that were not identified in the ISP.
Some providers choose to use the safety plan to address other issues required by their specific Oregon Administrative Rules. Examples include missing person notification or specific variances that are needed for a location.
People will have different safety plans to meet their support needs in different environments. The risk may be the same but the supports should be outlined for each location of service. In addition, one location may have a safety risk that does not apply to the other location. For example, an equipment safety risk that is present in the workplace but not in the residential setting.
Behavior Support Plan
A Behavior Support Plan (BSP) is a support document used when the ISP team feels that interventions are needed for identified behavioral risks. The ISP team must make the decision to create a BSP. A BSP attempts to alter a person’s challenging behavior through positive supports and must be written in accordance with current Oregon Intervention System (OIS) practices and follow Oregon Administrative Rules specific to the service provided. A Functional Assessment (FA) is required prior to creating a BSP.
When considering a BSP, teams should begin by ruling out medical causes for the challenging behavior. If a medical concern such as a dental problem, ear infection, or allergies is identified and addressed, and this alleviates the behavior, no further action is necessary regarding behavior supports. Another support document such as Medical Supports or Medical Guidelines may be added, as needed.
If no medical cause for the behavior of concern is found, teams work with a behavior specialist to complete a functional behavioral analysis or FA. In addition, sometimes through the FA process, underlying medical issues could be identified or need research. The ISP team will determine how to proceed with those issues.
Once a Functional Assessment is complete, the team works with the behavior specialist to decide how to address the challenging behavior. If the person’s behavior is alleviated through a change in either the way staff interact with him/her or changing environmental factors, a BSP may not need to be developed. The ISP team may consider Interaction Guidelines as a means of alleviating the behavior of concern. These guidelines must focus solely on staff interactions and environmental factors.
If interventions are needed or other information indicates a BSP is needed, a BSP must be developed following the particular service’s Administrative Rule requirements. The Behavior Support Plan would be mentioned by the SC/PA on the ISP Risk Management Plan and the provider would list its date and location on their Provider Risk Management Strategies, page 22.
General BSP requirements include:
• Documentation that the person, the guardian or designated representative (if applicable) and the ISP team are fully aware of the development of the plan.
• A summary of the function of the challenging behavior (see OARs for detail.)
• A clear, measurable description of the behavior that includes frequency, duration, and intensity of the behavior.
• A clear description and justification of the need to alter the behavior.
Other Support Documents
For all other risks, the provider chooses the type of document(s) they will use at that location to address the risk. Some examples include Staff Guidelines, Dining Plan or Protocol, or Interaction Guidelines. Remember, support documents must provide clear instructions for direct support professionals to follow and must include preventative measures in place to minimize the risk.
Other medical protocols
A medical protocol is a set of written instructions, designed specifically for the person, that tell staff how to care for a specific medical condition.
A general protocol is provided with the ISP forms. This protocol may be useful to develop other written supports for medical issues without required forms; it looks similar to the required protocols. Providers may use their own template or start with the blank one provided. The outline below explains the basic components of a medical protocol. It may be used to develop a protocol to address any issue not covered by the required Aspiration/Choking, Dehydration, Constipation, Seizure, or Pica protocols.
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Changes to Support Documents
Support documents must be kept current at all times. This means that if any aspect of the supports provided needs to change, then the support document must be revised. Note the date of last revision on each support document.
Every time a support document changes, its date on the Provider Risk Management Strategy page must be updated as well. The Provider Risk Management Strategy page must always note the date of the most current version of each support document that is in use.
Follow the provider organization’s documentation practices to make changes to support documents. If doing so will be clear and legible, the change may be written directly on the support document, signed, and dated. If the change cannot be made legibly on the existing copy of the support document, the support document should be rewritten or retyped.
All changes to support documents listed on the Provider Risk Management Strategies page must be documented using a Change Form. See the Making Changes, page 53, for more information about when approval is required or when team members may simply be notified of a change that was made.
Annual Review of Support Documents
At a minimum, review all support documents annually prior to the ISP meeting. When two provider organizations (or a foster provider and a provider organization) support the person, they are encouraged to take this opportunity to share support documents, compare them, and look for any circumstances where something that works well in one environment could be successful within the other environment.
No new initials or dates are required on the support document on an annual basis. If a support document continues to meet the needs of the person and address the identified risk(s), there is no need to rewrite the support document or change its date. Bring the support document(s) to the ISP meeting, so the SC/PA or other team members may review them if necessary.
Approval of support documents occurs when ISP team members sign the ISP signature page, indicating approval of the ISP including the ISP Risk Management Plan. Continue to use the document(s) throughout the next ISP period or until a change is needed.
The ISP Meeting
The nature of ISP meetings can vary from situation to situation as directed by the person for whom the plan is being developed.
▪ Shawna, who lives next door to her mother and receives In-Home Support Services, has her ISP meeting with her PA and her mother. When her PA was gathering Person Centered Information, Shawna mentioned she would like to meet separately with her PA to discuss birth control options. This separate meeting happened and resulted in a case note by her PA, but didn’t get noted in Shawna’s ISP to respect her wishes.
▪ John, who lives in a 24-hour residential group home, has his ISP meeting with his SC, his parents and sister, his employment coordinator, his group home manager, and some group home staff. John excused himself at the end of his meeting and his group home manager and SC finished a conversation about his safety plan.
▪ Fitz, who lives in an Adult Foster home, has his ISP meeting with his SC, his brother and sister-in-law, and his foster providers. Fitz likes having his meeting at his house because his foster provider makes homemade cookies. He doesn’t mind taking a vacation day to have the meeting at his house.
▪ Anna, who lives in a Children’s 24-hour residential group home, has her ISP meeting with her ODDS Residential Specialist, her mom (guardian) and sister, and a representative of her group home. Anna prefers to have her meeting in a place where she can walk around because sometimes talking about things can upset her.
Regardless of the circumstances, the ISP meeting should include people that the person invites to assist with planning. If the person requests to meet separately about a sensitive issue, the SC/PA will work with the person to meet that need.
In order to successfully develop the plan, the SC or PA must meet with or gather information from the following people:
• The person receiving services;
• The person’s legal guardian or designated representative, if any;
• The foster provider, if any;
• Provider organizations the person has chosen, if any; and
• Others the person invites.
At the ISP meeting, the SC/PA or designee serves as facilitator. An ISP Meeting Agenda is completed to record discussion topics and the outcome or action taken on each topic.
The ISP Meeting Agenda
Core Responsibilities for the SC/PA
➢ Receive draft agenda or proposed discussion topics from the person and ISP team members.
➢ Help the person maintain his/her privacy about sensitive issues. If the person doesn’t want to discuss a topic with other team members, meet with the person and/or others privately to discuss the issue.
o You may need to remind the person that in order to provide effective supports, providers need sufficient details about risks and the person’s preferences.
➢ Complete the agenda or designate a recorder at the ISP meeting to record the discussion topics and action taken or outcome of each topic.
➢ File the completed agenda with the ISP at the CDDP or Brokerage.
➢ Provide a copy of the completed agenda to the person and guardian or designated representative, if requested.
➢ Provide a copy of the completed agenda to any provider organizations when the person lives in a residential setting (e.g. 24-hour Residential, Supported Living, Foster Care, and SACU).
Core Responsibilities for Providers serving people who live in Residential settings
➢ Ask the person and/or guardian or designated representative what they want to discuss at the ISP meeting.
➢ Communicate proposed discussion topics for the ISP Meeting Agenda with the SC/PA at least five business days prior to the ISP meeting, or according to timelines set by SC/PA.
Points to Consider
• An agenda can help the ISP meeting run efficiently. When drafting an agenda in advance, provide sufficient detail so that team members can understand the topic and relevant details to help discussion proceed smoothly.
• It may be helpful to order the agenda topics in a logical flow. Ask the person in what order she’d like to discuss things.
Desired Outcomes
Desired Outcomes are what drive a person’s ISP. These are personal goals, things that the person is interested in trying, learning, doing, or achieving in the next year. Desired Outcomes must relate to what is important TO the person—desired outcomes are not simply support needs, although they may contain components of supports a person needs in specific areas or with specific tasks.
Core Responsibility for SC/PAs
➢ Facilitate the needs assessment as directed by the setting and your role.
➢ Facilitate the gathering of person centered information, as well as known, serious risks.
➢ Identify what is important TO the person and what is important FOR the person.
➢ Assess what is currently working and not working from the person’s perspective as well as from others.
➢ Recognize the natural supports that are present in a person’s life, and support opportunities for continued involvement as appropriate.
➢ Create agenda for ISP meeting, including possible Desired Outcomes to discuss.
➢ Facilitate the development of Desired Outcomes with the person and others in the person’s life if applicable (e.g. guardians, providers, family, friends, and others the person may wish to involve).
➢ Take action, determined by your role in the facilitation process, by developing implementation strategies as needed that describe what steps the provider will take to support the person to achieve desired outcomes.
Core Responsibility for Providers serving a person living in a Residential setting
➢ Participate in the needs assessment as directed by the person and their guardian (if applicable).
➢ Share person centered information gathered from the perspective of the person and including additional input, where needed. See Person Centered Information, page 13.
➢ Implement agreed Desired Outcomes. See Implementing the ISP, page 49.
➢ Communicate progress toward achieving Desired Outcomes with the SC/PA and others the person chooses as needed throughout the year.
Points to Consider
• A meaningful Desired Outcome must reflect what is important TO the person, so that it doesn’t become what we think the person should do.
• Supports for what is important FOR a person (such as for the person’s health, safety, or to be a valued member of his/her community), may also be considered in developing meaningful Desired Outcomes. Be sure that the outcome itself is based on what the person would like to do, try, learn, or achieve.
• Desired Outcomes can be tied to both paid chosen services and natural or other available supports, but there should always be action indicated that will support the person to meet his/her own definition of success.
• Desired Outcomes can encompass both long and short term goals, but timelines should be indicated so that when progress is not being made, changes to supports can be addressed in order to support progress.
• The Person Centered Information document will help those involved in planning understand the person’s perspective on all kinds of topics: where the person wants to live and with whom; what kind of job or training is desired; if lifelong learning is important; how to stay healthy and fit; if there are assistive technology devices that would increase independence, etc. Think about these in the context of what is important TO the person.
• The ISP Meeting Agenda is intended to lead conversations toward taking action, so that the outcomes the person or his/her designated representative desires to strive toward get planned out and recorded as Desired Outcomes within the person’s ISP.
SC/PA: Strategy for Developing Person Centered Desired Outcomes
1. Gather or review Person Centered Information
a. Developing person centered outcomes starts with the person. After you have gathered information from the person’s perspective, as well as other contributors who are in the person’s life, make sure you know:
i. What matters to the person, and others who know and care about the person?
ii. What are the person and others’ hopes and dreams for the person’s future?
1. Ask what’s happening now
a. Desired Outcomes are relevant to what is happening in the person’s life. In order to be able to develop such outcomes, help the team establish a clear idea of the current realities in a person’s life. The information gathered on the Person Centered Information form provides a solid foundation.
b. Find out from the person and others’ perspective:
i. What is working? (What should stay the same or be enhanced)
ii. What is not working? (What needs to change)
2. Prioritize what to focus on first
a. Once you have gathered information about what is important TO the person, hopes and aspirations for his/her future, and what is currently happening in his/her life, guide conversations to prioritize what areas are the most important to focus on right now.
i. What is the most pressing priority to the person?
ii. What do others who know and care about the person feel is the highest priority?
b. As you review or complete the ISP Meeting Agenda, keep in mind:
i. Priorities should be agreed in partnership with the person.
ii. An agenda created collaboratively is far more likely to lead to outcomes that are successfully achieved.
iii. Often, those who are involved in helping to develop a Desired Outcome are the same people who will help implement it as well.
3. Ask what success would look like
a. Reach an agreement for what successfully achieving a Desired Outcome should look like, if what is not working now was to be resolved.
i. Be clear about the broad, long term vision for Desired Outcomes in each priority area.
b. Ask the person what success looks like for him/her, to make sure:
i. The Desired Outcome is specific for the person
ii. It is not simply something that has worked for others in a similar situation and automatically assumed to work for this person as well.
4. Test it – is this really a Desired Outcome?
a. Facilitate conversation to clarify with the team that the Desired Outcome being developed is not actually just a solution disguised as an outcome. Solutions can limit the possibility of other options and take the focus away from what is most important to the person.
b. Check to make sure the Desired Outcome is taking the person a step closer to his aspirations and has not drifted off topic.
i. Ask specific questions to clarify what this Desired Outcome would give the person, do for the person, or make possible for the person.
ii. Does this Desired Outcome change something that isn’t working or support something that is working?
c. By testing the Desired Outcome, you can help make sure that it is important TO the person in some way, and that it will take the person closer to what he wants.
5. Ask what’s stopping the person now or what might get in the way
a. After drafting out a Desired Outcome, it is necessary to identify what (if any) barriers exist that could keep the outcome from being implemented successfully.
b. Facilitate problem-solving conversations to pin-point if there is anything that the person feels might stand in his/her way, as well as from the perspective of others.
6. Agree to action
a. Facilitate the identification of the steps needed to achieve the Desired Outcome and overcoming barriers.
b. Think creatively.
c. Avoid jumping to “obvious” service-oriented options, and help the person and the team explore natural and community resources first.
d. Guide the team to identify the key steps to help achieve the broader Desired Outcome.
i. Depending on the person and service setting, this may be done in different ways or even using different language/terms. This is okay, as long as there is clarity about what is the outcome.
ii. More detailed action steps should be recorded in implementation strategies appropriate for that service setting. See Implementing the ISP, page 49 for more information.
e. “SMART” Desired Outcomes are:
i. Specific: Is the outcome concrete, and does it include who or what is expected to change? Results-oriented: meaningful, valued results, what will the person “do?”
ii. Measureable: We know when we are making progress because there is a concrete way to tell how we are doing. Action can be seen or felt.
iii. Attainable: There are steps that will help achieve the person’s outcome.
iv. Relevant: The outcome is connected to something that is important TO the person.
v. Time-based: We know when things will happen; there are target dates.
7. Record Desired Outcomes in the ISP
a. Document the person’s Desired Outcomes in the ISP, in the Desired Outcomes section.
i. Specify the Desired Outcome: what is the desired result?
ii. Document key steps to work toward the outcome.
iii. If there is a paid service that supports the Desired Outcome, choose that service from the drop-down list. If there is more than one service, type them into the space provided.
iv. Note who is responsible, including, where needed or helpful, for each key step of the Desired Outcome.
v. Note timelines, including frequency or by when something is expected to happen.
vi. Document where progress will be recorded, so it is clear how the Desired Outcome will be monitored.
vii. Note if there are written implementation strategies expected or in place.
SC/PA: Career Development Plan
Core Responsibility
➢ Employment opportunities in fully integrated work settings shall be the first and priority employment option explored in the service planning for working age adults with intellectual and/or other developmental disabilities (I/DD). This means that for people who:
o Are employed in an integrated setting, annual service planning must focus on maintaining employment as well as the consideration of additional career or advancement opportunities.
o Have not yet secured employment in an integrated setting, annual service planning must include and reflect employment opportunities as a first and priority option.
➢ Apply the Career Development Plan (CDP) to every working age adult. The “Completing the Career Development Plan” section of this document provides instructions on who to include as a working age adult.
➢ Help people:
o Understand that the expectation of every employment service is individual, integrated employment. This is especially critical that people participating in the following services understand this expectation:
▪ Employment Path Services-Facility
▪ Employment Path Services-Community
▪ Small Group Employment
▪ Discovery
o Make informed decisions that are based on information such as employment data as well as interviews with prospective employment providers.
o Understand that they may receive employment services from a variety of providers.
➢ Be pro-active with financial supports such as Benefits Planning. Both Vocational Rehabilitation (VR) and Disability Rights Oregon are resources for Benefits Planning.
➢ Ensure that the employment-related supports that other service providers will be responsible for are: 1) Discussed; 2) Written into the person’s plan; and 3) Understood by the responsible parties.
Points to Consider
• Employment success depends upon everyone who is a paid or natural support – including people who support the person at home. It is critical that everyone understands their roles in supporting the person in matters such as being to work on time, adhering to the employer’s dress code, scheduling recreational activities so they do not conflict with the person’s work schedule, etc. As an Employment First state, employment is everyone’s job.
• At this time, Employment Path services are time-limited. People and families need to be aware of this and use this time well so that this change is not a surprise to the person or the people who support them.
• The ultimate outcome of Discovery is an individual, integrated job. VR is the expected funder of job development services.
• Selecting Employment Providers:
o For each service selected, a provider will need to be chosen. It is fine to select the service before a provider is chosen. A CDP often spurs people to consider things for the first time. After a provider is chosen, the Service Coordinator (SC) or Personal Agent (PA) updates the CDP. It may help to review the ODDS employment data before selecting employment providers. The data is on the ODDS website.
o The term “providers” is used to refer to organizations that deliver employment services, it also extends to PSWs who provide employment services. The “DD Employment Matrix” which is posted here (under Manuals, Guides, and Instruction) provides additional information regarding employment services.
Completing the Career Development Plan
In relation to integrated employment, the following will be required for people of working age[3]:
o The Person Centered Information document
o The “Career Development Plan (CDP)” in the ISP
o The “Decision not to Explore Employment” (DNE) for people who choose not work
o “Desired Employment Outcomes” for people who choose to explore, pursue, obtain, maintain, and/or advance in integrated employment
Ideally, the person will have experiences tailored to their skills and interests as the basis for their decision about individual, integrated employment. However, at a minimum, we would encourage you to meet with the person and any other people they would like to invite. Using the Employment Discussion Guide, facilitate a discussion about employment. Document the outcome of that discussion on the Person-Centered Information document. On the CDP page, after selecting the education level the person has completed, indicate the person’s employment choices.
The first section “Students” (Example 1) applies to students who are 16-20 and who are still in school. If a student selects any of the first three choices, regardless of whether they will use ODDS-funded employment services, create a CDP that will support them to reach their goals. If the student selects the fourth choice, although the elements of the CDP are not required to be completed, it may benefit the person to discuss how they will have opportunities to at the very least explore individual, integrated employment through other resources such as their family, the school, and VR.
Example 1:
Students (age 16-20) Expected date of exit from school:
Date by which CDP will be completed:
Attending school and wants to work now.
Attending school and receiving employment supports elsewhere.
Has an IEP Post-Secondary Goal with employment or training focus.
Attending school and not receiving any employment supports.
In the second section “Status with VR,” (Example 2), select the box that represents the person’s status with Vocational Rehabilitation (VR). If selecting “Other/Not Applicable,” explain the reason.
Example 2:
Status with Vocational Rehabilitation (VR) (age 16 and up)
Currently receiving VR services Want a referral to VR
Other/Not applicable, explain:
Working age adults must choose from the applicable statements in Example 3:
Example 3:
|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. |
|Employed in integrated employment and chooses to: Check all that apply. |
|Retain current job. |
|Advance in current job (more hours, raise, new skills, promotion, etc.) |
|Get a new job. |
|Get an additional job. |
|Retire – is at least 60 or will be this ISP year. Employment Outcomes are not required. |
|No longer continue in integrated employment at this time. Complete Decision Not to Explore Employment |
|Currently not working in integrated employment and chooses to: Check all that apply. |
|Get integrated employment. |
|Explore interests in integrated employment through an Employment Path, Discovery, or other time-limited service. |
|Retire – is at least 60 or will be this ISP year. Employment Outcomes are not required. |
|Not explore integrated employment at this time. Complete Decision Not to Explore Employment section. |
Employed in integrated employment setting and chooses to: If chosen, then select the applicable sub-choice (s). The individual can make multiple selections of the sub-choices. For all choices in this section, with the exception of “Retire,” and “No longer continue in integrated employment at this time,” develop Employment Outcomes. Document Employment Outcomes on the “Desired Employment Outcomes” section of the CDP. Examples of goals include the SC or PA making a referral to VR as well as outcomes the person’s family or residential service can play a pivotal role in such as helping the person to be prepared for work by having clean clothes, waking up in time to get ready for work, etc.
If an individual is receiving employment services they must, at a minimum, have a goal to explore integrated employment. The specific goals regarding this exploration may be documented in the “Desired Employment Outcomes” section, or may be documented in an outside document such as a Job Description. At a minimum, the specific goal, as well as what support is required to reach the goal must be indicated, as well as how the goal will be monitored. If an outside document is used to document the more in-depth employment related goals, check the box in the “Desired Employment Outcomes” section which indicates that there are other written strategies and the title of the document must be written in. This document must be maintained with the CDP.
People who are not currently working in integrated employment and chooses to: If chosen, then select the applicable sub-choice (s). The individual can make multiple selections of the sub-choices. For all choices in this section, with the exception of “Retire,” and “No longer continue in integrated employment at this time,” develop Employment Outcomes.
When people select choices that require the completion of the “Decision Not to Explore Employment” (DNE): The narrative on the Person Centered Information document and the answers to five questions in the DNE section must substantiate the selected reason(s) shown in Example 4.
Example 4:
|Decision Not To Explore Employment Complete this section only if the person chooses not to work in an integrated employment setting now and does not want a |
|waiver-funded employment service at this time. Check at least one reason: Discouraged by previous employment experiences Discouraged by others |
|Transportation concerns |
|Reluctant to change routine Behavior challenges Unable to find a job that matches his/her skills, interests and abilities Concern that he/she will lose |
|his/her Social Security Disability and/or Medicaid benefit |
|Significant health problems and/or health-related needs Does not want to work Does not believe he/she is able to work Other (describe): |
As discussed previously in these instructions, before a person makes the decision to complete a DNE, ideally, they will have experiences tailored to their skills and interests as the basis for their decision about individual, integrated employment. However, at a minimum, we would encourage you to meet with the person and any other people they would like to invite. Using the Employment Discussion Guide, facilitate a discussion about employment. Document the outcome of that discussion on the Person Centered Information document. This discussion should focus on solutions and strategies that could assist them to secure, maintain and advance in individual, integrated employment. Please remind the person that by making this selection, they will not be able to receive ODDS-funded employment services in Example 5.
Example 5:
|Employment Path Services-Facility |Employment Path Services-Community |
|Discovery |Small Group Employment |
|Initial Job Coaching |Ongoing Job Coaching |
The person may change his/her mind about working at any time. If a person who has chosen not to explore integrated employment changes their mind and decides that they are interested in exploring, pursuing or securing integrated employment, amend their CDP accordingly and develop Employment Outcomes. All changes to the ISP are documented using a Change Form. The CDP is part of the ISP, so any changes to the CDP get documented on a Change Form. One single Change Form can include multiple changes, such as amending the CDP and adding Employment Outcomes. The Change Form includes space to note who gives approval for the change(s) being made.
For each person, identify and address potential barriers in Example 6. Update this section with important developments – for example, when a possible solution has been tried and has not worked – or the best scenario – when a solution has been developed.
Example 6:
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Employment Outcomes
When creating outcomes, provide as much detail as possible about what the individual wants to accomplish. This will be critical when the person decides how time in their selected service (s) will be invested to help them to reach their goal. Remember, employment services such as Small Group Employment and Employment Path Services are time-limited services, so it is crucial that the person’s time is invested wisely.
The individual does not have to receive any of these services before deciding that they want to work. If they want to work, they may proceed directly to VR for job development (help finding a job) or may decide to find a job on their own (without paid assistance through ODDS or VR to find the job.)
Discovery/Career Exploration: The optimal and expected outcomes of the Discover/Career Exploration service are:
1) A Discovery Profile; and
2) A referral to VR. Note, SCs and PAs can and should make referrals to VR if an individual indicates that they want to seek individual, integrated employment.
After the creation of the Discovery Profile, the SC or PA will collaborate with the individual’s provider of Discovery/Career Exploration to refer the individual to VR.[4]
Employment Path Services: To select an Employment Path Service, the individual must have a goal of exploring, pursuing, obtaining or advancing in community employment. The optimal and expected outcomes include individual, integrated employment.
A person may select one or both of the Path Services. Both Path Services are primarily directed at teaching non-job task specific skills that will lead to greater opportunities for competitive, integrated employment and career advancement at or above the state’s minimum wage but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.
There are two types of Employment Path Services:
Employment Path Community: To participate in this time-limited service, the individual must have employment-related goals. The service is delivered in the community.
Employment Path Facility: Same as Employment Path Community, except that the service occurs in a facility.
The following are examples of goals for Employment Path Facility and Employment Path Community:
▪ To develop my skills to communicate effectively with supervisors, co-workers and/or customers
▪ To become knowledgeable of generally accepted workplace conduct and dress
▪ To gain greater mobility skills by receiving mobility skills training
The following sample goals are options only for Employment Path Community:
▪ To volunteer at a community organization[5]
▪ To participate in services provided by my local career center
▪ To take tours of local businesses to learn about employment opportunities
Small Group Employment
The ODDS proposed waiver definition of Small Group Employment states:
Small Group Employment is services and training activities provided in regular business, industry and community settings for groups of two (2) to eight (8) individuals with disabilities. Examples include mobile crews and other business-based workgroups. Services and training activities must be provided in a manner that promotes integration into the workplace and interaction with people without disabilities in those workplaces.
The optimal and expected outcome of this service is sustained paid employment and work experience leading to further career development and individual, integrated employment for which an individual is compensated at or above the state’s minimum wage, with a goal of not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. These services and supports should be designed to support successful employment outcomes consistent with the individual’s personal and career goals.
Job Coaching: This service is support for an individual, integrated job. The mantra of a successful job coach is “the less I am needed the more I have succeeded.” Research shows that the constant presence of a job coach actually has a negative impact on a person’s ability to be as independent, productive and included as possible. [6]
This section is not designed to specify a staffing level – for example, “I will need a job coach with me all the time.” However, this is the place to explain what the individual will need and why. Often, what we think we will need changes once we get a job. If the individual’s actual job coaching needs differ from anticipated needs, the job coach and SC or PA must work together to update the CDP. A CDP is important because it records what is needed – this is especially important if there is a change in job coaches or a new SC or PA.
Job Development Individual Employment: Job development is the service of helping someone to find a job. People must be referred to VR for job development. ODDS funded job development is only available after VR has denied a person services. Job Development[7] is Support to obtain a job in an integrated employment setting in the general workforce for which an individual is compensated at or above the minimum wage, but ideally not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.
SC/PA: Completing the ISP
Core Responsibility
➢ Facilitate conversation with the person about who will be engaged in and contribute to the planning and development of the ISP.
➢ Facilitate the development of the ISP based on input provided by the person and others chosen by the person to participate.
➢ Complete the ISP accurately and according to established timelines, assuring that relevant information provided by others is included accordingly.
➢ Ensure the ISP meets Medicaid standards, follows the established ISP process and that expenditures for services follow federal and state guidelines.
➢ Obtain necessary signatures to implement the new plan.
o Person;
o Guardian or Designated Representative;
o Representative of provider organization(s) if the person lives in a residential service setting, e.g. 24-hour residential, supported living, Foster care, and SACU; and
o Your signature.
➢ Ensure that the ISP, a job description, or service agreement is signed by each provider that includes at a minimum:
o Desired Outcomes the provider is responsible to support;
o Chosen Services the provider is responsible to deliver, including:
▪ Assessed needs the service is to address;
▪ Person’s preference on how the service is delivered; and
o Known, serious risks.
Points to Consider
• Schedule ISP meetings at a time and place chosen by the person receiving services and the invited participants.
• Whenever possible, engage contributors in the development of the ISP.
• Consider cultural factors – is an interpreter necessary? Do forms need to be in another language?
• Be proactive when talking to the person about who will participate in his ISP meeting.
• How providers give input to the ISP and what parts of an ISP a provider receives may look different in various situations.
o Follow practices currently in use in your service setting or as otherwise directed by the person. For example, Personal Support Workers and Independent Contractors might not contribute to or see the entire ISP but must receive a job description or service agreement that clearly describes their responsibilities.
• The Career Development Plan can be extracted so that employment information can be given to employment service providers and others responsible for employment support, like VR and Schools.
SC/PA: Completing each section of the ISP
Person’s name and Plan Effective Dates
List the person’s full, legal name as well as the person’s preferred name in the spaces provided. Indicate the dates the ISP will start and end under Plan Effective Dates. At the time of this publication, Policy Transmittal APD-PT-15-014 provides specific guidance regarding the start and end dates of an ISP.
One Page Profile
Ensure there is at least one One Page Profile attached to the front of the ISP. There is a provided template or any other template that includes these three statements may be used:
• What others like and admire about the person
• What is important TO the person
• How to best support the person
See One Page Profiles, page 15, for more information.
Desired Outcomes
Desired outcomes reflect what is important TO the person to work toward over the next year.
See Desired Outcomes, page 29, for more information.
Career Development Plan (CDP) and Desired Employment Outcomes
Indicate Education level completed in the space provided, regardless of the person’s age. Pick the highest level of education the person has completed.
Complete the rest of the CDP, as indicated, if the person is age 16 to 60. It may be completed for someone younger than 16 or older than 60 upon request by the person or his/her guardian.
See Career Development Plan, page 32, and the “Employment Discussion Guide” for more information.
Risk Management Plan
Emergency preparedness
Facilitate a conversation about being prepared for natural disasters, power outages, community disasters, etc. Does the person have access to a basic disaster supply kit? In an emergency, it could take 3 to 5 days or longer for community services to be restored. Think about items such as durable medical equipment, assistive technology, food for special diets, prescription medicines, diabetic supplies, hearing aids and batteries, a TTY, manual wheelchair, or supplies for a service animal. There are more resources available to plan ahead for emergencies at .
Provider organizations should maintain their own emergency preparedness plans. You do not need to re-write the contents of that plan on the ISP; simply mention it here, if it exists. If necessary, remind the provider organization representatives to review and update their plan if it is out of date.
Examples taken from published sample ISPs (available at samples)
• Paul and his mom are on the disaster registry with the county he lives in. He also knows to meet his mom at the park across the street if there is a fire or if the house smells like natural gas. He knows to leave the house immediately if he smells or sees smoke or flames and then call 911. Paul has emergency numbers on his phone. He does not live in a disaster zone, but if the power goes out, his mom and he will go where there is power. When Paul moves into his own home, he will create a safety plan with his provider.
• Gloria has developed and emergency protocols and an emergency plan with her Supported Living provider: See emergency protocols and Gloria’s emergency plan.
• Javi and his family have a Ready Book (emergency disaster planning book) and he practices emergency drills at school. He is never alone and will always have someone to help him in a disaster or emergency.
• John’s home and work providers have Emergency Preparedness Plans.
Preventing abuse
Abuse, neglect, and exploitation are serious issues in the service systems that support people who experience intellectual/developmental disabilities. Consider any measures needed or available to help prevent abuse of all kinds.
If the person is known to be at significant increased risk of abuse or exploitation, mark this risk on the Risk Identification Tool and list it on the ISP Risk Management Plan along with strategies in place to address the issue.
Examples taken from published sample ISPs (available at samples)
• Paul is really good with money and is not at any heightened risk for being financially exploited. He is also a good advocate for himself and is able to tell people what he does and does not like or want to do. He tells his mom when he is troubled about something and would tell her if someone hurt him or threatened to hurt him. He said he would be interested in taking a Relationship class so he can learn more about healthy intimate relationships.
• Gloria receives one-on-one support 24 hours a day by trusted support staff. Gloria is encouraged to contact or ask for a visit by her Services Coordinator, as well as to let Blue Skies management know if she has any concerns or if anything has happened.
• Javi has a supportive family that he is always with if not at school. They keep him safe from harm. His parents watch him closely for changes in his behavior that might be an alarm that he has been hurt or is ill or injured.
• John is around someone at all times who can help him protect himself. He advocates for himself and has trusted people around him at home, work, and with friends who he feels comfortable expressing concerns to, when necessary. John has reported in the past when someone has tried to take money from him.
What happens if the person can’t be reached?
Indicate what steps would be taken if the person cannot be found or contacted as usual. Consider any timelines the team expects for notifying others and who is expected to be notified.
Examples taken from published sample ISPs (available at samples)
• If PA cannot reach Paul, she will call his mom and see if she has heard from him. If Paul is missing and cannot be reached by his mom, they will call 911 depending on the circumstances. Paul is very independent and will be when he moves out of his mom’s house. There will be times when he cannot be reached for personal reasons. If his mom is concerned that she cannot reach him and feels he is in danger, she will contact the authorities. Paul knows that his PA will need to do quarterly monitoring and he will call her back if she tried to contact him.
• Someone is with Gloria 24 hours a day. If Gloria cannot be reached, call her brother and see if he has spoken to her. If Gloria cannot be found and her staff and brother are concerned about her, call 911 immediately.
• If Javi is missing, look for him for up to 5 minutes and then call 911.
• John has a missing person’s plan located both at home and at work.
Risks
List every risk marked “Yes” on the Risk Identification Tool. In the space provided, describe the specific supports in place to address the issue. Consider supports necessary in various settings, such as at the workplace or when visiting friends.
If the provider organization or foster provider maintains written instructions to address the issue, you may simply note the name of the provider organization or note “foster provider.” They will complete and maintain a Provider Risk Management Strategies sheet (see page 22) to identify the specific documents or strategies they have in place for each risk.
If support strategies are not yet in place, but have been discussed and a plan has been agreed to, describe the anticipated support strategies, timelines expected, and who is responsible. As long as the support strategy is implemented within the timelines noted, a Change Form is not required unless specifically requested by the SC/PA. For example, if a BSP is anticipated to be completed by a certain date, indicate that. If the BSP is implemented within that timeline, a Change Form is not needed. Consider if any increased monitoring or other services are needed while supports are developed and implemented.
Assessing high risks
The SC/PA assesses identified risks and support strategies in place to determine if there is a “high” level of risk. Assess if the supports in place will manage the identified risk to prevent serious harm to self or others. Consider the likelihood the issue will occur in the next year and the potential consequence if the issue does occur. To assist with this assessment, a Risk Assessment Matrix is available on page 56 of this manual. If a risk is determined to be a “high” risk, mark an “X” next to the risk in the column provided on the ISP Risk Management Plan.
If there are three (3) or more high risks, case management contact must happen at least monthly. Note this contact frequency and the reason in the “Chosen Case Management Services” section of the ISP.
Considerations upon entry to services or significant change in support needs: The SC/PA should consider what information is available about supports that have been in place for identified risks. Increased monitoring may be warranted until existing supports have been demonstrated to effectively address the risks.
Examples based on published sample ISPs (this detail does not appear in the ISP itself; this is a summary of why the risk was marked as “high” within the published samples.)
• John experiences Congestive Heart Failure. He sees his health care providers regularly and follows their instructions. There are support strategies in place at his home and work providers. Despite these supports in place, his team believes it is still likely that John may experience a critical consequence due to this risk. His Services Coordinator has marked the risk of Congestive Heart Failure as a High risk on John’s ISP.
• Gloria is at risk of Aspiration. She is not able to swallow effectively and is also at times appearing to be congested or to experience thicker mucus. Her Employment Path Services provider and Residential provider both maintain aspiration protocols with specific supports (such as thickening all liquids, suctioning) to help prevent aspiration from occurring. Over the last 6 months, Gloria has been experiencing increased episodes of appearing to gag when she is given thickened liquid, as well as other seemingly random times. Gloria is not able to communicate that she is having trouble breathing or may be choking, other than physically gagging and appearing as though trying to cough, which can be observed by others when watching her. Due to this and despite the supports in place, her team believes it is still likely that Gloria may experience a critical consequence due to this risk. Her Services Coordinator has marked the risk of Aspiration as a High risk on Gloria’s ISP.
Nursing Care Plan
If there is a current Nursing Care Plan (NCP) in place for the person, note where it is kept at home and/or at employment services. If the person’s assessed needs qualify them for a Medicaid-funded nursing service, authorize that service in the appropriate Chosen Services section in the ISP.
If the team feels a NCP is needed but not currently in place, mark “needed.” Note within the plan what follow-up will be done on this issue.
Examples taken from published sample ISPs (available at samples)
• If case management will provide information and referral for nursing services, note that under the Chosen Case Management Services.
• If a foster provider will be researching and securing a nurse, list it under “needs this service will address” in the Chosen K Plan Residential Services section.
Back-up Plans
Facilitate a conversation about available back-up plans in the event the 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.
Examples taken from published sample ISPs (available at samples)
• Paul (In Home Support Services):
Home: Paul choses to wear a life alert necklace that will call emergency help if he needs it. Paul has all his emergency numbers in his phone. He can also go next door to the neighbors (Rita and Brad 555-555-5555).
Work: Paul has chosen to list his mom (Susie Kiel 577-555-5555) as his emergency back up for work and will give them her number. He wants her to be called if he needs someone to pick him up early for work and, for some reason, can't call her himself or if 911 is called.
• Gloria (Supported Living Services):
Home: Follow Blue Skies emergency protocol and Gloria’s emergency plan.
Work: Follow emergency protocol. If support is unavailable, contact Stacy Blonde (Blue Skies) (555-566-9980).
Other (In emergency): Contact Gloria's brother Reggie Amsterdam (555-555-5555).
• Javi (In-Home Comprehensive Services, 6 years old):
Home: Javi would live with his Aunt Gerte if anything were to happen to his parents (555-555-5555). She can also be called anytime to pick up Javi.
School: Mom and dad (Irita and Roberto) are emergency backup. If they are unreachable, his grandmother -Marta (555-665-7676) or his Aunt-Savia Torino (555-997-5555) should be called as backup.
• John (24-Hour Residential, Adult):
Home: Call mom (Nancy), 541-555-1592
Work: Call group home, 541-555-9907
Chosen Services
Chosen Case Management Services
Type: Select Waiver Case Management or Non-Waiver Case Management by selecting from the drop down list.
Selection of case management type indicates the person’s and/or their representative’s choice between Waiver and Non-Waiver Case Management. The discussion of types of case management available is part of the choice advising process.
If more than one case management type is provided, such as when CIIS Services Coordination and local CDDP case management is offered, note this in the additional text box provided in this section. List both case management providers in the “Chosen Provider” field. Use the “Anticipated case management activities field” to describe the types of services each case management entity will provide.
Authorized Dates: If authorization dates match the ISP effective dates, check the box provided. Otherwise, indicate start date and end date of the service by entering the dates in the space provided.
Chosen Provider: Enter the chosen provider of Case Management service (CDDP, Brokerage).
Required frequency of case management monitoring: Monthly case management, Quarterly case management, Other case management (specify).
Case Management Comments: Include a description of the case management activities anticipated to be provided throughout the plan year.
Anticipated case management activities may include (but are not limited to) the following:
• Provision of choice counseling and choice advising
• Following up on any risks identified as “possible”
• Assessment of support needs and level of care
• Development of Individual Support Plan
• Assisting in accessing of services
• Provision and evaluation of information and referral resources
• Coordination of community services
• Monitoring of services and supports
• Assessment, identification, planning, and monitoring of crisis services
• Provision of protective services and completion of SERT reports
Person’s preference on how case management is provided: includes the person’s preference of support. This may include information such as preferred meeting places, preferred time of day, preferred method of contact, etc.
Natural Supports and Other Voluntary Services and Supports
Use this section to reflect on the natural supports discussed during the needs assessment, and engage in a conversation that encourages consideration of continued involvement. This may include care or support provided by family members, friends, community programs, grants, trusts, private insurance, etc.
Describe the chosen services/supports and by whom they are provided. The description may include typical frequency.
Please note the identified supports are intended to capture resources available to the person in relation to the assessed need as determined by a needs assessment.
Chosen State Plan Personal Care (SPPC) Service
Only complete this section if the person has chosen SPPC services. SPPC services are limited to 20 hours per month unless an exception is authorized.
If this section is not needed, the SC/PA may remove it from the plan, leaving a note indicating that the section was not needed and has been removed.
Chosen K Plan Services
Complete this section for identified K Plan services or items the person and/or his/her representative chooses to meet assessed needs.
Refer to the Expenditure Guidelines for specific definition, scope of services, and requirements for selected services. Expenditure Guideline requirements and restrictions apply.
If this section is not needed, the SC/PA may remove it from the plan, leaving a note indicating that the section was not needed and has been removed.
Chosen Waiver Services
Complete this section for all identified Waiver Services chosen by the person and/or his/her representative to meet assessed needs.
Refer to the Expenditure Guidelines for specific definition, scope of services, and requirements for selected services. Expenditure Guideline requirements and restrictions apply.
If this section is not needed, the SC/PA may remove it from the plan, leaving a note indicating that the section was not needed and has been removed.
Chosen K Plan Residential Service
Only complete this section if the person has chosen residential services.
K Plan Residential service settings include:
• Supported Living (DD51)
• 24-Hour Residential Services- Adults (DD50)
• 24-Hour Residential Services- APD Licensed Setting (DD50)
• 24-Hour Residential Services- Children (DD142)
• Non-Relative Adult Foster Care (DD58)
• Non-Relative Foster Care- Children (DD58)
• Stabilization and Crisis Unit- SACU (DD141)
K Plan services already included in residential services: K Plan services included as part of the monthly service budget for the above listed service settings are: Attendant Care - ADL/IADL support and health-related tasks, Skill Training, and Community Transportation (non-medical and not specific to travel to and from a vocational program).
People receiving services in these residential service settings may also receive Behavior Supports and/or Nursing Supports. Select the appropriate box for Behavior Supports and/or Nursing Supports if the person has been determined to have a need for these specific services and they are provided as part of their monthly services in the residential setting.
If this section is not needed, the SC/PA may remove it from the plan, leaving a note indicating that the section was not needed and has been removed.
Chosen K Plan Community Transportation Service
Transportation Type: Select the type of transportation services from the drop down list. Options include: Bus Pass, LIFT, Van Transportation, Mileage, and Match-Funded Transportation.
This category is intended to capture only transportation traditionally funded through DD53 Transportation funding or in some circumstances, match-funded transportation which supports people traveling between their home and vocational program site.
For people enrolled in match-funded transportation, please notate this service and demonstrate there is no cost to the K Plan services by completing the table with a $0 value for monthly budget amount.
Additional Chosen Services
Use this section to record General Fund services. You may also use this section as overflow for additional K Plan or Waiver services if you run out of space in the provided rows.
All General Fund expenditures require prior authorization from ODDS. A copy of the exception approval must be attached to the ISP.
Differences
Note any differences between the contents of the plan and what the person wants. Note any differences between the contents of this plan and what any other ISP team member wants. Consider if a change to the plan is needed to address the difference(s) and describe the decision.
Look carefully at the supports that are in place. Do any of the supports conflict with what the person is saying is important TO him/her? If so, discuss and see if the supports can be adjusted in a way that honors what is important TO the person. If the person is still not satisfied with the outcome and the ISP team agrees there is reason to continue the supports as outlined in the ISP, describe the decision in this section.
Differences in Opinion
Other than a legal guardian, no one participant of the person’s chosen ISP team has the authority to make decisions for the person. If any ISP team member objects to a decision made by the ISP team, it must be documented in this section.
Disagreements can be documented in several ways:
• If there are difference between what the person wants and the contents of the plan, document this in the Differences section.
• If there are differences between what other participants want and the contents of the plan, document this in Differences section.
• Differences in opinion and perspective can be documented, where appropriate, throughout the Person Centered Information.
• There is room on the ISP signature page for comments next to any participant’s signature. A team member may sign in agreement to the plan while noting any specific objection or other comments.
• Differences can be noted on the ISP Meeting Agenda and discussed or negotiated towards resolution in the meeting.
Legal Relationships
Identify any legal relationships the person has in his/her life. If an adult has any legal relationship, such as a guardian or health care representative, documentation should be located in the person’s file at the CDDP or Brokerage. This is also a good time to ensure that those who have a legal relationship role, such as a guardian, understand the scope and limitations of his/her role.
Acknowledgments
Describe the supports the person needs to understand this plan, if any. Review the plan with the person and his/her parent or representative, if applicable. If the person understands the contents of the plan you can indicate that by marking “Yes” in the box provided. If the person indicates that he/she does need support understanding the plan, or if the team agrees that the person needs additional support to understand it, describe the supports that will be used. Indicate who will be responsible for supporting the person and timelines for completing this.
Does this ISP reflect the services the person chooses and the outcomes the person wants to work toward? Through a thoughtful planning process, the person’s choices should be reflected in the services they have chosen to meet assessed needs and desired outcomes. Making sure a person’s choices are being honored should be happening throughout the ISP process and reflected in the Person Centered Information or in progress notes.
Has the person been provided information about the planning process and how to request changes and updates to the ISP? Discussions should be happening so that the person and their parent or representative, if applicable, understand that the ISP and all support documents can be revised as assessed needs change significantly or when there is a change in a desired outcome for which a revision is warranted. Talk with the person and other team members so that it is clear when and how they can communicate the need for changes. This might be as simple as communicating your office hours, or finding out what the most efficient form of communication is, such as phone or email.
Did the person choose the location of their ISP meeting? The person should direct where and when the meeting is held. Information can be gathered in any way that works best for the team as directed by the person, but it is important to have meetings at a place and time that the person has chosen. This could be a place where they feel most comfortable and at a time when they won’t be at work or school.
Did the person choose who participated in their ISP development? The person should be choosing those people who they wish to contribute to the ISP development process. It is important to have proactive discussions with the person so that the people who know and care about the person are included. This will create the opportunity for richer person centered information to be gathered and a more meaningful ISP. When there are differences in opinion about who should be included in the process, discussions to discover what’s working and isn’t working and how relationships can be built or changed should happen.
As the person providing case management, you can help the person make informed choices about who is at the meeting or to take steps to resolve conflicts. For instance, if there is conflict between the person and the provider who supports the person, there might be a need for further discussion about how to resolve this conflict or options might need to be offered for finding providers that the person would prefer to work with.
Did the SC/PA review the services that are available to the person? The person should be informed of all the services identified to meet their assessed needs, and for which they are eligible. Known resources are offered or developed where possible to support the person’s desired outcomes. A conversation about available natural supports and needed paid services will assist the person and the guardian in making more informed decisions.
Did the person receive notification of his/her DHS rights? Ensure the person has been notified of his/her DHS rights and that the required form has been signed and placed on file. If the person needs any supports to understand his/her rights, indicate this in the space provided at the top of the page, including who will support the person and when.
Does this ISP reflect what is needed for the family to effectively provide supports? The ISP should reflect what is needed for an involved family member and/or guardian to effectively provide supports. Ask the family if they know what steps they need to take to support desired outcomes. If the family requires additional support, provide resources or further instruction to help them be successful. This might be a list of steps they can take, like an Action Plan, or referring the family to needed resources to support desired outcomes, such as family training opportunities.
Does the ISP reflect Independence, Integration, and Productivity? The team should discuss and conclude that the plan supports and encourages Independence, Integration, and Productivity. This is a core value to be included in every plan. Throughout the ISP development process, there should be ongoing discussion about how the person has control and choice over his/her life. Consider and offer ways that the person could increase his/her independence. Does the person live near and use the same community resources and participate in the same activities as, and together with, people without disabilities? If not, how can opportunities for participation be increased? How does the person contribute to his/her household or community? Is the person engaging in income-producing work? Does the person see increased income, employment status, or job advancement?
Describe the reason for any question above remaining “no” and the plan to address it. If a person has restrictions on his/her independence or freedom to make choices, indicate why. Explain the plan to address regaining independence and freedom and how progress will be measured and monitored.
Agreement to this Plan
The ISP team agrees to the 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. If there are disagreements with the contents of the plan, team members may still sign and have the opportunity to note their objections on the plan.
The SC/PA ensures that a person centered planning process results in an ISP that meets the person’s current assessed service needs and complies with requirements for the chosen service setting(s) and associated funding.
Providers agree that they can implement the portions of the plan for which they are responsible. A signed contract, job description, or service agreement may be used in lieu of their signing this signature page. If the identified risks are outside the scope of the provider’s ability, then a new provider may need to be identified.
See next section on Implementing the ISP for more information about service agreements, job descriptions, and copies of the ISP.
Implementing the ISP
Core Responsibility for SC/PAs
• Give copies of the completed ISP to the person, guardian, if any, and others, as directed by the person.
• Take any steps needed to authorize chosen ODDS-funded services prior to the intended start date. Depending on the practices at the CDDP or Brokerage, this may include entering information into eXPRS, Plan of Care, MMIS, or sharing relevant documentation with data entry personnel.
• Assist the person or employer of record to develop detailed job descriptions or service agreements for the chosen providers. It is important to include information related to any known risks. The person must consent to this information being provided. If the person does not consent to the sharing of information relevant to the provider’s ability to do the job, then further discussions must occur. Discussions might include the possibility that a new provider will need to be sought, with whom the person feels comfortable sharing the information.
o Personal Support Worker (PSW): job description.
o Independent Contractor (IC): service agreement.
o Provider organization (e.g. respite or employment-related services): service agreement.
• If the person lives in a Residential service setting (e.g. 24-hour residential, supported living, Foster care, SACU) ensure that providers have a complete copy of the Person Centered Information, Risk Identification Tool, Meeting Agenda, ISP, and any subsequent Change Forms.
o If the person requests not to share the ISP or portions of the ISP with a provider organization, then the SC/PA facilitates a conversation to talk about options, understanding that the provider may not be able to serve the person if they do not have adequate information about important support needs.
• File the complete ISP, including the Person Centered Information, Risk Identification Tool, ISP Meeting Agenda, and any subsequent Change Forms at the CDDP or Brokerage.
• Monitor implementation of the plan according to timelines noted in the Chosen Case Management Services section of the ISP, SC/PA judgment, and ODDS expectations.
Core Responsibility for Providers serving a person who lives in a Residential setting
• These chosen providers begin (or continue) services once they have received and signed a complete copy of the ISP or a detailed service agreement.
• Develop action plans to address desired outcomes as well as support documents to manage risks, as needed and directed by the ISP.
• Train direct support professionals or substitute caregivers on ISP implementation strategies.
• Share copies of ISP implementation strategies with the SC/PA, as requested by the SC/PA.
• If supports within the ISP or in the provider’s implementation strategies need to be changed, take appropriate action or communicate with the SC/PA. See Making Changes chapter, page 53, for more information.
Service agreements and job descriptions
A service agreement or job description contains the necessary information for a selected provider (e.g. PSW, Independent Contractor, or Provider Organization providing respite, employment, or other specific services) to provide the services they are hired to perform. It is prepared by the SC/PA to address specific needs of the person as agreed at the ISP meeting. Within In-Home Comprehensive settings, the employer of record develops the job descriptions.
Service agreements and job descriptions must include the person’s preferences on how specific services are to be delivered as well as identified risks, risk management strategies, and other necessary contractual information. There must be an opportunity during the development of the service agreement for providers to indicate any other information that is minimally necessary for them to provide services effectively.
ISP Implementation Strategies for Providers serving a person who lives in a Residential setting
In this section, “provider staff” or “staff” is used to refer to employees of a provider organization who directly support the person. It also refers to employees of the foster provider, such as substitute caregivers.
Providers who support a person who lives in a Residential setting (see page 6) are responsible to implement the parts of the ISP for which they have been designated to provide services. This includes the following areas:
• Person Centered Information
• One Page Profile
• Desired Outcomes and Desired Employment Outcomes
• Risk Management Plan
• Specific services authorized in the Chosen Services section
Person Centered Information
At a minimum the provider keeps a copy of the Person Centered Information that they have gathered and submitted to the SC prior to the ISP meeting. Train staff on the contents of this document.
Revisions may be made to the Person Centered Information anytime during the year following local documentation practices.
One Page Profile
Train staff on the One Page Profile. If there is more than one One Page Profile (e.g. other profiles prepared by the person, family, or other providers), train staff on the profile(s) most relevant to the setting in which they support the person.
Revisions may be made to the One Page Profile anytime during the year following local documentation practices.
Action Plans
For the purpose of these instructions, we refer to Desired Outcomes and Desired Employment Outcomes collectively as “Desired Outcomes.”
For all Desired Outcomes on the ISP or service agreement which the provider is designated to support, the provider must train their staff on specific steps, timelines, and responsibilities to carry this out.
After discussion during development of the ISP, and as directed by the ISP or service agreement, the provider develops implementation strategies (e.g. Action Plans) that detail the steps, timelines, and responsibilities their staff have to implement the specific Desired Outcomes.
Providers may develop their own action plan format or use available electronic recordkeeping systems. Example action plans are available at forms that may be used. Action plans must include, at a minimum:
• The person’s name and the date of implementation;
• Desired Outcome;
• Measurable steps to be taken, including details of the person’s preference on how each step is to be taken;
• Timelines or frequency of completion of each step;
• Who is responsible to complete each step; and
• Where to record completion or progress toward the desired outcome.
Risk Management Plan
Unless specifically otherwise directed by the SC/PA in a service agreement (e.g. if the provider is only contracted to provide a specific service), provider staff must be trained on the contents of the ISP Risk Management Plan, including emergency preparedness procedures, preventing abuse, specific risk management strategies, Nursing Care Plan (if any), and back-up plans.
Providers must also develop and implement specific risk management strategies as outlined in the ISP or service agreement. These are documented by the provider organization on a Provider Risk Management Strategies form.
See Risk Management Strategies chapter, page 21, for additional information, including provider responsibilities for creating support documents and instructions for completing the Provider Risk Management Strategies form.
Making Changes
Core Responsibility for SC/PA
➢ Ensure necessary changes are made to the ISP in a timely manner.
➢ Review and file Change Forms received from provider organizations or foster providers.
➢ Change the ISP when a new service is added or an existing service is discontinued.
➢ Change the ISP when assessed needs change significantly.
➢ File completed Change Forms with the ISP at the CDDP or Brokerage.
➢ Ensure providers impacted by the change are appropriately notified of the change. For example, this may require revising a PSW’s job description or completing a new service agreement.
Core Responsibility for Providers serving a person who lives in a Residential setting
➢ Ensure necessary changes to the ISP and related documents are communicated to the SC/PA in a timely manner.
➢ Take action on needed changes according to the chart provided.
➢ When initiating a Change Form, keep a copy and send the original to the SC/PA.
|Type of change |Change form initiated by |Approval or |Notes |
| | |Notification? | |
|Revised, added, discontinued desired outcomes |SC/PA or Provider |Approval | |
| |org./Foster prov. | | |
|Revised, added, or discontinued Chosen Services |SC/PA |Approval |* The addition or subtraction of a service (such as attendant |
| | | |care) requires the signature of the person receiving services,|
| | | |guardian or designated representative (if applicable), and the|
| | | |SC/PA. Changes within an authorized service may be made with |
| | | |the documented, verbal approval of the individual, their |
| | | |guardian or designated representative. |
|New or discontinued |SC/PA or Provider |Approval | |
|Risk |org./Foster prov. | | |
|Change in risk management strategy that is |SC/PA or Provider |Approval | |
|written on the ISP Risk Management page |org./Foster prov. | | |
|Extending the ISP beyond 12 months |SC/PA |Approval |*Requires approval of all ISP team members. Requires |
|(Only to be done in extenuating circumstances) | | |additional approval from ODDS for expenditure of General Funds|
| | | |to cover services until the new plan is developed. |
|Revision to provider support documents that |SC/PA or Provider |Approval | |
|changes the scope of the supports provided (see |org./Foster prov. | | |
|“Support Document Changes,” page 55) | | | |
|Minor changes to the Risk Identification Tool |SC/PA or Provider |Notification only |*Send copy of changed document including Change Form to SC/PA |
|(no risk added or removed) |org./Foster prov. | | |
|Revision to provider support document that does |Provider org./Foster prov. |Notification only |*Send copy of changed document including Change Form to SC/PA |
|not change the scope of the supports provided | | | |
|(see “Support Document Changes, page 55) | | | |
|Revision to provider’s implementation |SC/PA or Provider |Notification only |*Send copy of changed document including Change Form to SC/PA |
|strategies, such as Action Plans |org./Foster prov. | | |
|Revision to One Page Profile or Person Centered |Local changes may be made by any ISP team member following local documentation practices. No formal approval or |
|Information |notification is required. |
Approval of changes
Approval of changes may be given verbally or in writing. When approval of a change is required (see matrix above), it must be sought and obtained from (or attempted to be obtained from):
• the person,
• guardian, if applicable, and
• Services Coordinator/Personal Agent.
Acknowledgement of changes
Signature, email, or verbal acknowledgement is expected from any service provider impacted by the change. A change is implemented as soon as possible after approval has been obtained and the provider has acknowledged it.
Exception: Interim supports to address the person’s immediate health or safety needs are to be implemented by provider organizations upon identification of a new serious risk. Initiate communication with other ISP team members as soon as possible and document agreed changes on a Change Form.
Notification of changes
If approval is not required for a specific change, notification of the change must still occur. Examples include telephone call, email, or fax notification.
Providing copies of changes
Copies of all changes to the ISP, including a copy of the Change Form (if required) and any additional changed documents, are provided to:
• the person, if desired;
• guardian or designated representative, if desired;
• Services Coordinator/Personal Agent;
• any service provider impacted by the change.
Change Form
The provided Change Form tracks:
• Reason for change
• Description of what is changing - “List specific change(s)”
• Effective date
• Date Change Form initiated
• Name of person initiating change
• Name and title of persons approving change, date approval given, and signature or note of how approval was obtained
Support Document Changes
Further discussion about scope of changes
Notification is expected to occur with any change to a support document.
Approval must be obtained any time a revision to a support document would
• restrict a person’s rights or restore rights that had been previously restricted (e.g. restrictions on community access),
• make the environment more restrictive or less restrictive (e.g. locking common areas of the home),
• compel the person to make restitution for damages,
• add or change a Protective Physical Intervention (PPI) in a Behavior Support Plan,
• contradict a doctor’s order (e.g. Sometimes teams make specific exceptions to doctor’s written orders to honor the person’s expressed preferences, such as having hamburgers once a week despite a written low-cholesterol diet order).
Risk Assessment Matrix
The SC/PA uses this matrix to answer the question “will the supports in place manage the identified risk to prevent serious harm to self or others?” This is a tool for assessing whether a risk is “high” and is not a required document within the ISP.
The SC/PA reviews supports in place for each risk identified by the Risk Identification Tool to assess the likelihood and potential consequence of each risk occurring in the next year with the current supports in place.
Considerations upon entry to services or significant change in support needs: SC/PA should consider what information is available about supports that have been in place for identified risks. Increased monitoring may be warranted until existing supports have been demonstrated to effectively address the risks.
| |Consequence |
| |1. Minimal |2. Moderate |3. High |
|Unlikely |It is possible but not anticipated to|History has shown that it rarely occurs. |90% chance |
| |next year. |No supports currently in place; seeking supports or treatment. | |
| | |Unstable and unpredictable. | |
|Consequence |1. Minimal |2. Moderate |3. High |4. Critical |
|Health/ Wellness |Minor, explainable cuts, scrapes, |Illness or injury requiring medical |Results in an ER visit or |Death of self or others. |
| |bruises, typically resolved with |intervention (excluding ER), doctor |hospitalization of self or others. | |
| |basic first aid. |visit, consultation with a medical | |Abduction. |
| | |professional, etc. of self or others.|Victimization. | |
| | |Unexplainable cuts, bruises, scrapes.| | |
| | | |Results in a segregated setting. | |
|Financial/ Property |Results in financial/ property |Results in costs to the |Results in a financial hardship |Results in loss of |
| |loss that is affordable to the |person/family/provider that are |that makes it difficult to pay |sustainable/safe housing or the |
| |person/family/provider to manage. |affordable for the time being but if |bills/rent. |current provider/family may |
| | |it continues a financial hardship is | |become unable to continue |
| | |possible. | |supporting the person as a |
| | | | |result. |
|Impact on ability to |Minimal impact on ADLs. |Partial temporary or permanent loss |Partial temporary or permanent loss|Complete temporary or permanent |
|perform activities of | |of previously present ADL that would |of previously present ADL: |loss of previously present ADL: |
|daily living | |not require additional support. |ambulation, expressive and/or |ambulation, expressive and/or |
| | | |receptive communication, ability to|receptive communication, ability |
| | | |eat/drink that would requires |to eat/drink. |
| | | |additional support. | |
|Legal |Possible police involvement. |Police involvement but arrest is |Judicial action: |Incarceration. |
| | |unlikely (example: staff call the |By definition of the law, the | |
| | |police for a challenging behavior |person could be arrested and |By definition of the law, the |
| | |that is not necessarily illegal but |sentenced with a fine and/or |person could be arrested and |
| | |they are unable to manage the |probation. |sentenced with incarceration. |
| | |situation with their current |The person is currently on | |
| | |training). |Parole/Probation for the identified| |
| | | |risk. | |
Glossary
|Agenda |This document serves as a record of the key topics discussed at the ISP meeting and the outcome of the |
| |discussion. |
|Behavior Support Plan (BSP) |Support document used when the ISP team feels that interventions are needed for identified behavioral risks. |
|Career Development Plan (CDP): |A section within the ISP that indicates the person’s choices regarding employment, any barriers to integrated |
| |employment, and desired employment outcomes. |
|Change Form |A Change Form is used to document any agreed changes to the ISP or related materials. |
|Chosen Services |Services a person chooses to meet assessed needs. |
|Current Evaluation |An evaluation is considered current if the team knows the condition the person was in at the time of the |
| |evaluation, and the team observes that the condition of the person has not significantly changed since the time |
| |of that evaluation. If a written evaluation or applicable Oregon Administrative Rule includes an order to |
| |re-evaluate after a certain amount of time, then the evaluation would no longer be considered current after that|
| |point. |
|Desired Outcomes |Desired Outcomes are what drive a person’s ISP. These are personal goals, things that the person is interested |
| |in trying, learning, doing, or achieving in the next year. |
|Direct Support Professional |This term is typically used in comprehensive service settings. It refers to employees of a provider organization|
| |who directly support the person. It also refer to employees of the foster provider, such as substitute |
| |caregivers. See also Staff. |
|eXPRS |Express Payment and Reporting System. |
|Financial Plan |Set of written instructions, designed specifically for the person, that tell staff how to care for a person’s |
| |finances. |
|In-Home Service Setting |A setting in which the person is receiving "In-Home Services," which are those activities of daily living and |
| |self-management tasks that assist an individual to stay in his or her own home. |
|Individual Support Plan (ISP) |The ISP reflects the person’s desired outcomes, career development plan, risk management plan, and chosen |
| |services to meet the person’s identified needs. |
|Local documentation practices |Local documentation practices vary depending on the situation, ranging from electronic documentation systems |
| |(e.g. Therap) to traditional pen and paper. In all cases, local documentation must be accurate, legible, and |
| |completed in a timely manner. |
| | |
| |When changes or corrections must be made to a record, it must be clearly indicated as such. The resulting |
| |document must be plainly readable, including the date of the change and an indication of who made the change. |
|Medical Protocols |Set of written instructions, designed specifically for the person, that tell staff how to care for a specific |
| |medical condition. |
|MMIS |Medicaid Management Information System, a computer application operated by the Oregon’s Department of Human |
| |Services. |
|One Page Profile |The One Page Profile provides a positive introduction to the person. It includes the following information: |
| |What people like and admire about the person (positive qualities) |
| |What is important to the person (in the environment or situation it is being written for, such as employment or |
| |home) |
| |How to best support the person (what is Important For the person) |
|Person Centered Information |This document is the foundation of the planning process. Its purpose is used to carefully and respectfully |
| |record the person’s perspective about a wide range of areas in the person’s life. |
|Preferences |Those thing that are important to a person about how, when and by whom their services are delivered. |
|Protocols |Set of written instructions, designed specifically for the person, that tell staff how to care for specific |
| |risks and other medical issues. |
|Provider Risk Management Strategies |This form is prepared by provider organizations and foster providers who maintain written instructions such as |
| |protocols, safety plans, and other support documents for their staff or substitute caregivers to follow. |
|Qualified professional |A person, who is licensed, specialized, or has expertise and practices in the specialty field that is |
| |referenced. Depending on the issue, examples may include behavior specialists, speech language pathologists, or |
| |physicians. |
|Residential Service Setting |The person lives in one of the following licensed service settings: Non-relative Foster Care (Adults and |
| |Children), Supported Living Services, Stabilization and Crisis Unit, and 24-hour Residential (Adults and |
| |Children). |
|Risk Management Plan |A page within the ISP that lists all risks identified by the Risk Tool and how each risk is being addressed. |
|Risk Matrix |Used to identify known, serious risks that are present in the person’s life. |
|Risk Tool |This tool is used to identify known, serious risks in the person’s life. |
|SACU |Stabilization and Crisis Unit. |
|Safety Plan |Support document used to address safety issues present in the person’s life. |
|Serious Risk |Risks that, without support, would likely result in hospitalization, institutionalization, legal action, or |
| |place the person or others in imminent harm. |
|Staff |This term is typically used in comprehensive service settings. It refers to employees of a provider organization|
| |who directly support the person. It also refers to employees of the foster provider, such as substitute |
| |caregivers. See also Direct Support Professional. |
Resources
There are more resources available at resources.
To stay informed about the latest Oregon ISP news and Questions & Answers (Q & A), subscribe to the ISP Pipeline email newsletter published by OTAC. Look for the sidebar on the Oregon ISP website and enter your email address to subscribe.
If you have questions or need support with the ISP forms or process, submit a support request at support or call (503) 428-5435.
-----------------------
[1] Perske, Robert. 1972. “The Dignity of Risk and the Mentally Retarded.” Volume 10:24-27.
[2] Smull, Michael. 2013. “Thinking About Risk.”
[3] To understand who is included in “working age” please see the directions of the “Career Development Plan” page of the ISP. Please remember that people who are 60 or over may choose to have a CDP or a DNE.
[4] An application to VR is not needed if the individual is going to find a job without using funding from ODDS or VR.
[5] Volunteering is not to be at organizations that provide the individual with ODDS-funded services.
[6] Demystifying Job Development: Field-Based Approaches to Job Development for People with Disabilities (Hoff, Gandolfo, Gold, & Jordan, ICI, 2001)
[7] From June 2014 ODDS Waiver submission to CMS
-----------------------
Common errors in One Page Profiles
← Assuming that if it is important to others in the person's life (for example, staff or family), it must be important to the person. Among the worst examples was a one page profile that said that implementing a restrictive behavior support plan (that the person clearly hated) was important to the person.
← Describing what is important to the person in short, cryptic phrases that give an idea of what's important, but are easily subject to misinterpretation by the reader. A common example is to have the single word 'privacy' listed, without saying more about what privacy means to the person. Since, in the absence of other information, people apply their own experiences instead, privacy will be interpreted as what it means to the reader, which is likely different than what it means to the person.
← The basics should be assumed, unless there is a history of their being absent. Listing off food, shelter, clothing, safety, etc. should be avoided unless they have been absent in the person's life. Someone who has lived in an unsafe situation may want their profile to say that he must not live with people who hurt others. Someone who has never lived in such a situation will take that as a given.
Other One Page Profile tips can be found at
reading-room/how/person-centred-thinking/one-page-profiles.aspx
General Protocol Outline
▪ Title: the protocol should have the name of the risk listed or an identifier on the document
▪ Name: the person for whom the protocol is written
▪ Description: describe the problem, issue or risk
▪ Prevention: specific steps to prevent the problem from happening or from getting worse; all protocols must have preventative measures
▪ Signs and Symptoms: what staff would see/observe if problem occurs
▪ Intervention or direction: information for staff to follow if the problem occurs or gets worse
▪ 911 section: circumstances when staff must call 911
▪ Author & Date: The name of person writing the protocol needs to on the protocol as well as the date it was most recently revised. If this protocol addresses an issue covered on a current Nursing Care Plan, the nurse must sign it.
Avoid the Solution trap!
A solution is the service or support you need to achieve a desired outcome. It may be an item or an activity and it may have a cost associated with it or it may be free.
Example solution trap: “Gloria participates in community events at least two times a month.”
Instead, try: “Gloria has a group of friends that she spends time with in her community.”
This makes the intent of the action, what is important TO her, clearer.
Common fields in this section
Service Element & Service Code: Select the service or expenditure chosen by the person during the plan year from the drop down list. Use the expenditure guidelines for detailed descriptions and instructions for each service. If an approved service code is not included in the drop-down, the SC/PA may type the appropriate service code into the field.
# Units: Enter the number of units in the text box. This is typically the number of hours, but may also be a dollar amount.
Unit Type: Select the Unit Type from the drop down list in accordance with the information entered in the "# units" field. These options include: Hours, Miles, Days, Each, Event, Dollars (use only for one time authorizations).
Per: Select the frequency from the drop down list. These options include: Day, Week, Month, and Plan year.
Authorized Dates: If authorized service dates match the ISP effective dates, check the box provided. Otherwise, indicate start date and end date of the service by entering the dates in the space provided.
Chosen Provider Type(s) and Rate(s): Enter the chosen provider type(s) (PSW, IC, Provider Organization, General Business) and the associated rate for each type of provider. [pic][8] KPRYNote that the ISP is not required to be updated if the provider’s rate adjusts due to across the board wage increases or as a result of collective bargaining agreements.
List needs identified by the needs assessment: Briefly describe what assessed needs the service is supporting.
Person’s preference on how this service is delivered: Briefly describe the person’s preference on how this service is delivered, for example, prefers mom’s assistance; prefers relief care the third weekend of the month; a female or male to provide the service; no one before 10 am, etc.
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