DBHDS Vision: A life of possibilities for all Virginians PC ISP 2015 Presented by Provider Development DBHDS Division of Developmental Services April 2015

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Slide 3 Obtaining ISP materials ISP templates and videos are available online here: Professionals And Service Providers Developmental Services Provider Development Person-Centered Planning Select links in the following order to access the ISP

Person SIS Part V Plan for Supports PC Reviews and Learning At the Annual ISP Meeting After the Annual ISP Meeting Before the Annual ISP Meeting The ISP Learning Cycle Important TO Important FOR Part III Shared Planning Part IV Agreements Part II Personal Profile Part I Essential Information START Documentation

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Slide 6 Updates emphasize… Psychotropic medication use Skill-development Employment First Comprehensive supports and most integrated settings Measurability Community participation Monitoring Risk Choice and control PC ISP

Slide 7 Steve and Mary See ISP Training Packet pages 2 and 3

Slide 8 Part I: The Essential Information PART I: The Essential Information

Slide 9 Representation Friends & Community Contacts Psychotropic Medication use Employment First Exceptional Support Needs Plan for Self-Sufficiency Review of Most Integrated Settings Key updates: Part I: The Essential Information

Slide 10 Representation CMS Final Rule guidance: People under guardianship or other legal assignment of individual rights, or who are being considered as candidates for these arrangements, should have the opportunity in the PCP process to address any concerns. Part I: The Essential Information

Slide 11 Part I: The Essential Information Representation Page 4

Slide 12 Part I: The Essential Information

Slide 13 TLC-PCP Service Life Community Life Important for addressed No organized effort to address important to To and for present Active circle of support Included in community life To and for present Closest people are paid or family Few real connections A Good Paid Life Focus on connecting, building relationships and natural supports ‘Important to’ present ‘Important to’ recognized Moving from Service Life to Community Life

Slide 14 Friends & Community Contacts Supported by… Person-Centered Practices Settlement Agreement CMS Final Rule Part I: The Essential Information

Slide 15 Part I: The Essential Information Friends & Community Contacts Page 4

Slide 16 Part I: The Essential Information

Slide 17 Psychotropic Medication use Part I: The Essential Information Per the Office of Human Rights the record should show: the medication prescribed, to include dosage; an acknowledgement, if appropriate, that the individual/decision-maker was made aware of the risk/benefits/side effects by the prescribing physician; contact information for the prescribing physician for any further questions; the signature of individual and/or decision-maker.

Slide 18 Psychotropic Medication use Part I: The Essential Information Page 4

Slide 19 Part I: The Essential Information

Slide 20 Part I: The Essential Information

Slide 21 Part I: The Essential Information Page 5

Slide 22 Part I: The Essential Information

Slide 23 Active Medical and Behavioral Support Needs Part I: The Essential Information

Slide 24 Part II: The Personal Profile What support needs must be planned for with Steve? Practice Page 2

Slide 25 Part I: The Essential Information Practice Active Medical and Behavioral Support Needs: Steve Page 6

Slide 26 Active Medical and Behavioral Support Needs: Steve Part I: The Essential Information

Slide 27 Part II: The Personal Profile What active medical or behavioral support needs must be planned for with Mary? Practice Page 3

Slide 28 Part II: The Personal Profile Active Medical and Behavioral Support Needs: Mary Page 6

Slide 29 Part II: The Personal Profile Practice Active Medical and Behavioral Support Needs: Mary

Slide 30 Part I: The Essential Information

Slide 31 Part I: The Essential Information The Plan for Self-Sufficiency Considers future plans for inclusion; Replaces “discharge plan” in the ISP; Applies to every individual.

Slide 32 Part I: The Essential Information Steve Page 7

Slide 33 Part I: The Essential Information Mary Page 7

Slide 34 Part I: The Essential Information

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Slide 36 Part II: The Personal Profile PART II: The Personal Profile

Slide 37 Part II: The Personal Profile Profile Areas: My Meeting Talents & Contributions The Life I Want My Life Today Getting the Life I Want

Slide 38 Part II: The Personal Profile Page 9

39 What makes a person happy, content, fulfilled People, pets daily routines and rituals, products and things, Interests and hobbies, places one likes to go Important TO Part II: The Personal Profile

40 What we need to stay healthy, safe and valued Physical and emotional health Safety and security Things that make you valued in community Part II: The Personal Profile Important FOR Do you know the active medical and behavioral supports needed for each person?

41 Do the individual’s desired outcomes relate to talents, preferences and needs as identified in the assessments and individual support plan? Do the individual’s desired outcomes relate to talents, preferences and needs as identified in the assessments and individual support plan? Part II: The Personal Profile

42 Do you know what is needed for health and happiness? Part II: The Personal Profile TO FOR

Slide 43 Part II: The Personal Profile

Slide 44 Part II: The Personal Profile Page 10

Slide 45 Part II: The Personal Profile What is important to YOU about work? Practice Page 11

Slide 46 Part II: The Personal Profile Page 2

Slide 47 Part II: The Personal Profile Practice What is important TO Steve about work? Page 12

Slide 48 Part II: The Personal Profile What is important TO Steve about work?

Slide 49 Part II: The Personal Profile What is important TO Steve about work?

Slide 50 Part II: The Personal Profile What is important TO Steve about work?

Slide 51 Part II: The Personal Profile Page 3

Slide 52 Part II: The Personal Profile What active support needs must be addressed in planning? Page 13

Slide 53 Part II: The Personal Profile What would be important to YOU if you had the same needs as Mary? Practice Page 13

Slide 54 Part II: The Personal Profile Practice Page 14 What is important TO Mary about Health and Safety?

Slide 55 Part II: The Personal Profile What is important TO Mary about Health and Safety?

Slide 56 Part II: The Personal Profile What is important TO Mary about Health and Safety?

Slide 57 Part II: The Personal Profile What is important TO Mary about Health and Safety?

Slide 58 Part II: The Personal Profile We need to begin thinking about how active medical and behavioral support needs relate to the important To information. To plan successfully…

Slide 59 Part II: The Personal Profile How does what’s important TO Mary relate to each of these active medical support needs?

Slide 60 Part II: The Personal Profile How does what’s important TO Mary relate to each of these active medical support needs?

Slide 61 Part II: The Personal Profile How does what’s important TO Mary relate to each of these active medical support needs?

Slide 62 Part II: The Personal Profile How does what’s important TO Mary relate to each of these active medical support needs?

Slide 63 Part II: The Personal Profile How does what’s important TO Mary relate to each of these active medical support needs?

Slide 64 Part II: The Personal Profile How does what’s important TO Mary relate to each of these active medical support needs?

Slide 65 Part II: The Personal Profile What if Mary also had asthma?

Slide 66 Part II: The Personal Profile What if Mary also had asthma?

Slide 67 Part III: Shared Planning PART III: Shared Planning

Slide 68 Part III: Shared Planning Work and Alternates Community & InterestsHome Money Health & Safety Transportation & TravelRelationships Learning & Other Pursuits Page 15

Slide 69 Part III: Shared Planning Writing outcomes… Name important TO. Writing an outcome based on the heart of each issue provides for a variety of ways to support a person having what he or she wants.

70 Outcomes are NOT meaningless to the person. “Jack ties his shoes.” Outcomes are NOT services. “Jack receives residential services.” Outcomes ARE observable and are based on what is important TO each person! W hat are Outcomes? Part III: Shared Planning

Slide 71 Part III: Shared Planning Writing outcomes… Outcome: Steve is organized. Important TO: Being organized Measure: When Steve is able to organize his DVD collection, his baseball cards and his closet himself. By when: January 1, 2016 Who will support me? ABC Residential Martha (mother)

Slide 72 Part III: Shared Planning Writing outcomes… Steve eats dinner with his friends. Previous outcome example: Steve goes to Pizza Shack in order to eat with his friends. Updated outcome examples: Steve spends time with his friends. Steve goes out to eat.

Slide 73 Part III: Shared Planning Writing outcomes… Steve eats dinner with his friends. “I no longer want/need supports when…” Which makes more sense with this outcome? An achievement introducing natural supports? or

Slide 74 Part III: Shared Planning Writing outcomes… Steve eats dinner with his friends. “I no longer want/need supports when…” When Steve is able to schedule meals with his friends and has their support going to, during and returning home from meals. Be specific!

Slide 75 Part III: Shared Planning Steve’s important TO list about work from his personal profile.

Slide 76 Part III: Shared Planning Practice Develop an outcome to address what’s important TO Steve about work Page 15

Slide 77 Part III: Shared Planning Practice Complete outcome to address what’s important TO Steve about work Page 16

Slide 78 Part III: Shared Planning Example Example outcome to address what’s important TO Steve about work

Slide 79 Part III: Shared Planning Active needOutcome Mary

Slide 80 Part III: Shared Planning Practice Mary’s active support needs list

Slide 81 Part III: Shared Planning Mary’s important TO list for Health & Safety Page 16

Slide 82 Part III: Shared Planning Practice Mary’s active medical support needs list Page 17

Slide 83 Part III: Shared Planning Practice Mary’s active medical support needs list ? ? ? ? ?

Slide 84 What if Mary also had asthma? Part III: Shared Planning

Slide 85 What if Mary also had asthma? Outcome: Mary breathes easily. Breathing easily. Using an inhaler each day. Important TOImportant FOR Based on what we know about Mary, to resolve this outcome ask… Can she develop a skill? Can assistive technology be used? Can natural supports be introduced? Part III: Shared Planning Can the condition improve?

Slide 86 What if Mary also had asthma? I no longer want/need supports when… Outcome: Mary breathes easily. Mary is unable to use her inhaler and supports are expected to continue until she no longer needs it, until assistive technology can be identified or natural supports can be introduced. Part III: Shared Planning

Slide 87 What if Steve also had asthma? I no longer want/need supports when… Outcome: Steve breathes easily. Steve is able to use his inhaler as prescribed for 6 months, until assistive technology is available or until he no longer needs it. Part III: Shared Planning

Slide 88 Part III: Shared Planning Using the outcomes, complete Part III.

Slide 89 Outcomes needed to complete Shared Planning 1: The active medical and behavioral needs outcomes 2: The 5 required life areas 3: The 3 standard outcome options Part III: Shared Planning

Slide 90 The 5 required life areas… Work & Alternates to Work Learning & Other Pursuits Community & Interests Office of Quality Management & Development Home Health & Safety Part III: Shared Planning

Slide 91 The “Active Needs” outcomes… Medical Behavioral Communication Sensory needs Fall risk Psychiatric needs Diabetes Heart conditions Causing harm Hurting oneself Taking from others Part III: Shared Planning

Slide 92 The 3 standard outcome options… Routine health and safety Periodic Supports Support Coordination Steve is healthy, safe and a valued member of his community. Steve has something to do when plans are cancelled. Steve’s outcomes are achieved. Part III: Shared Planning

Slide 93 The 3 standard outcome options… Steve is healthy, safe and a valued member of his community. 1: Routine tasks that are not major “active needs” or focused on skill-building and are related to health & safety such as: Taking medications Going to medical appointments Routine personal care (bathing, dressing, cleaning, etc.) Part III: Shared Planning

Slide 94 The 3 standard outcome options… Steve has something to do when plans are cancelled. 2: Supports that are periodic in nature and provide for semi-predicable events that result in services provided and billed under periodic support hours. Part III: Shared Planning

Slide 95 The 3 standard outcome options… Steve’s desired outcomes are achieved. 3: Activities related to Targeted Case Management provided exclusively by the Support Coordinator such as: Assessing, planning, coordinating, linking and monitoring of services & supports Part III: Shared Planning

Slide 96 Steve is not tired all the time due to diabetes. Steve explores different ways to enjoy music. Steve has more friends. Steve is healthy, safe and a valued member of his community. Steve has something to do when plans are cancelled. Steve’s outcomes are achieved. Steve is organized. Part III: Shared Planning Steve has his own business and makes more money. Active Medical/Behavioral? 5 required life areas? 3 standard outcome options? Page 17

Slide 97 Page 18 Outcome Worksheet available

Slide 98 Part IV: Agreements PART IV: Agreements Page 19

Slide 99 Part IV: Agreements

Slide 100 Part IV: Agreements Privacy is ensured…

Slide 101 Part IV: Agreements Self-direction is supported…

Slide 102 Part IV: Agreements The inability to meet preferences is described…

Slide 103 Part IV: Agreements

Slide 104 Part IV: Agreements

Slide 105 Part IV: Agreements

Slide 106 Part IV: Agreements

Slide 107 Part V: Plan for Supports PART V: The Plan for Supports

Slide 108 Part V: Plan for Supports Page 20

Slide 109 Part V: Plan for Supports Page 21

Slide 110 Part V: Plan for Supports

Slide 111 Part V: Plan for Supports

Slide 112 Part V: Plan for Supports Writing activities… Name action verb activity. Writing an activity is based on what can be seen when supporting a person to learn or have what he or she wants.

Slide 113 Part V: Plan for Supports Steve eats dinner with his friends. Practice Write 3 activities that support this outcome. Page 22

Slide 114 Part V: Plan for Supports Steve eats dinner with his friends. Example Write 3 activities that support this outcome.

Slide 115 Part V: Plan for Supports Steve eats dinner with his friends. Example Could any of these be skill-building?

Slide 116 Part V: Plan for Supports

Slide 117 Part V: Plan for Supports Develop 3 activities that support this outcome.

Slide 118 Part V: Plan for Supports Practice Page 23

Slide 119 Part V: Plan for Supports Examples

Slide 120 Part V: Plan for Supports Page 24

Slide 121 Part V: Plan for Supports Practice Develop 1 outcome related to a meaningful day for Mary. Page 25

Slide 122 Part V: Plan for Supports Develop 3 activities that support this outcome.

Slide 123 Part V: Plan for Supports Practice Page 26

Slide 124 Part V: Plan for Supports Examples

Slide 125 Part V: Plan for Supports Practice What support instructions include… How DSPs will support this person. What the individual can or likes to do. The type of support needed - detailed. What is needed for success. Where and what learning is recorded.

Slide 126 Steve budgets his money. Write 3 instructions related to this activity… Practice Part V: Plan for Supports Page 27

Slide 127 Steve budgets his money. What support instructions include… Example Part V: Plan for Supports

Slide 128 Example Part V: Plan for Supports

Slide 129 Part V: Plan for Supports Page 28

Slide 130 Part V: Plan for Supports Page 29

Slide 131 Ongoing Learning & Documentation Ongoing Learning and Documentation

Slide 132 Ongoing Learning & Documentation “Morning Routine” on the PFS = “Morning Routine” on the schedule

Slide 133 Ongoing Learning & Documentation Steve’s checklist is based on his schedule Page 30

Slide 134 Ongoing Learning & Documentation Page 31

Slide 135 Ongoing Learning & Documentation Page 32

Slide 136 Ongoing Learning & Documentation

Slide 137 Ongoing Learning & Documentation

Slide 138 Ongoing Learning & Documentation

Slide 139 Ongoing Learning & Documentation

Slide 140 Ongoing Learning & Documentation Page 33

Slide 141 Ongoing Learning & Documentation Page 34

Slide 142 B eware of … Documentation Drift!

Slide 143 Person-Centered Review The Person- Centered Review Page 35

Slide 144 Person-Centered Review Met = Outcome was achieved (and ended). Partially Met = Outcome was partially achieved. Not Met = Outcome was not achieved. Outcome status definitions

Slide 145 Person-Centered Review

Slide 146 Person-Centered Review

Slide 147 Person-Centered Review

Slide 148 Person-Centered Review

Slide 149 Person-Centered Review

Slide 150 Contacts and resources: Community Resource Consultants (PC ISP): providers/developmental-disability-services-for-providers/provider-development Person-Centered Thinking Training: Settlement Agreement information at DBHDS: disabilities/doj-settlement-agreement CMS Final Rule information at DMAS: Questions?