Developing plans as a collaborative process – not a discreet event: Developing collaborative efforts by building partnerships Knowing who knows what Acknowledge when it needs to be shared Recognize Roles and Responsibilities Plans are never done, but they are always due

Our Structure needs to Support Our Thinking Person centered approaches to providing supports require a person centered structure Paperwork needs to change to support the new methods. Not just the ISP: Assessments, Daily logs, quarterly reports, progress notes, case comments etc. All need to be reviewed and updated to support this new process.

Partnerships Require: Communication Cooperation Collaboration RespectTrust

Collaboration and Partnerships Effective communication is where it all begins. Collaboration creates something new. People come together because of their differences – strength and opportunity comes from building on our differences, not trying to create conformity. Collaboration requires learning.

Collaboration builds Partnerships Desire to learn, openness to learning Walk in assuming you can learn from the other team members –and you will. Walk in assuming you already know everything there is to know about the person- and you will squash collaboration Trying to make other members do things your way kills partnership.

Collaboration Exercise A walk in the woods

Partnerships and Experts All good plans are done in partnership Partnerships that work have discussed their roles and expectations ahead of time Think about the roles from the perspective of contents experts and process experts

Experts and Roles Process experts know how to do it Contents experts know what it should say Where it works there is synergy – the plan is better than either could anticipate

Experts and Roles Everyone in this room is an expert, and has a role What is yours? Process? Content? Does everyone else see you that way?

Phases in the planning process Preparation for planning- Mapping Gathering information – formerly called assessment Developing a 1st plan (draft) Team agreement on the information written down Using the information to develop outcomes Plan Approval Plan Implementation and Review

Develop Outcomes With the full team together: Review Personal Preferences Sections Review Topics to Promote Every Day Life Develop Possible Outcome Statements Review Medical/Health-Safety/Functional Information Develop Outcome Actions Determine Most Appropriate Services and Frequency/Duration of Each Determine how you will know progress is being made

Gathering Information in New Ways: Relationships, family, friends Choice and decision making Work/Education, volunteering Community participation or contribution Self image, self esteem Health Safety and individual rights Satisfaction with services Home life/housing Relaxing & having fun Communication style/preferences Conversational Areas: Suggested Topics to Promote an Everyday Life

Guidelines for Individual Support Plan Format

Outcomes within the ISP Describe for People: The expected results from activity a person engages in The current situation- before the activity begins The reason for the outcome (justification) Concerns or barriers that need to be addressed

ISP Outcomes: Reflect information gathering Requires collaboration among those who know the individual best and those who know the system requirements Use understandable language Are highly Individualized

How to Develop Outcomes Review Personal Preferences with the full team: What Makes Sense/Doesnt Make Sense What is important to the person Desired Activities Know and Do to Support the person Develop possible Outcome Statements together: Reflect what is currently Important To the person, within the context of assuring continued life within the community and health and safety. What changes would the person prefer, and why? What constants would the person prefer continue in his/her life, and why?

How to Develop Outcomes cont(2) Review Medical/Health-Safety and Functional Information – (Important FOR information) look for Current Needs related to Outcome Statement: Medical Evaluation and Medical History Health and Safety Focus Areas Supervision Needs Behavioral Support Plan Health Care and Health Promotion Functional Areas Communication

How to Develop Outcomes cont (3). Develop Outcome Actions What current needs are apparent within the previous sections of the ISP that relate to this Outcome Statement? What specific steps must be taken in order to address the persons Current Needs, the Concerns related to the Outcome, and assure the outcome is achieved? Ask, Do these actions occur within the context of what is important to the person, balanced with what we know is Important For the person?

Develop Outcomes cont(4) Determine Services, Frequency and duration. New Service? Anticipate what will meet the need Old service – if nothing has changed, what was frequency in the past? Old service – but other changes, what is anticipated to be used by the person? How long do you anticipate the need to exist? Determine how you will know progress is being made? What will be different as a result of the service, or what will continue to be observable? This is asking for recognizable differences for the person, either environmentally, skill acquisition, behaviorally, communication change, etc. Include a statement about how and when the team will provide information about progress across time.

ISP Outcome Development Addresses concerns and barriers to promote problem solving. What are we worried about? What can we do to prevent it? What can we do to lessen the impact if it is unavoidable? How can we overcome it if it occurs? Provides critical documentation about steps that will be taken to assure the individuals health and safety while working toward desired changes.

ISP Outcomes are NOT: Services…but every service needs an outcome!!!! A grouping of un-integrated goals Solely based on formal assessments Deficit focused- this is not about fixing the person Something that happens in isolation of the individuals everyday life.

Services are not outcomes! Examples that are NOT outcome statements: I want a day program. I want to go to physical therapy. I want speech therapy. I want to be in the workshop.

Services are not outcomes! Services are determined AFTER the outcome is determined. So, how do I write outcomes? You need more information! As a result of this service, what difference will it make in the individuals life?

ISP Outcome Statement Determine what needs to change, what needs to remain the same by considering: What makes sense, what is working, what is the upside of this issue, right now, from everyones perspective? What doesnt make sense, is not working, what is the downside of this issue, right now, from everyones perspective? What does everyone agree on? Where do you have common ground? Start with outcomes about those things.

ISP Outcome Statements Maintenance of important things- Those things which all perspectives agree should continue Desired changes- Those things which all perspectives agree should change

If the team is stuck: Focus the WMS /DMS exercise on specific issues in the persons life, such as: Who the person spends time with What the persons interests are How the person spends his/her days How the person has fun What the person wants to learn. Where and with whom, the person lives

Use the Topic Questions to get you moving: Relationships, family, friends Choice and decision making Work/Education, volunteering Community participation or contribution Self image, self esteem Health Safety and individual rights Satisfaction with services Home life/housing Relaxing & having fun Communication style/preferences

Writing Outcomes: Sources of Information in ISP Outcome Statements Know and Do Desired Activities Important To What Makes Sense Outcome Actions Health and Safety Understanding Communication

Writing outcomes Begin with the aim of the outcome: Using persons name followed by an action verb or phrase. Only use I if you are absolutely sure the person would say it in the same way. Complete the statement with how it will make a difference using so that/in order to

Helpful Phrases when writing Outcome Statements So That In Order To

Sharing the PROCESS Share the process with Team Team ownership Stronger plan Simplified process Shared vision Increase effectiveness of implementation

OUTCOME Measurement: How you know progress is being made Used to identify the results of a persons effort. It seeks to answer the questions: What difference did the services or supports make in the persons life? Is the service/support provided having its intended impact ?

HOW to Measure Outcomes… Measuring outcomes involves gathering DATA What are the indicators??? Specific items of data that are tracked to measure how well a program is achieving an outcome Indicators translate general concepts about the program & its expected effects into specific measurable parts You measure whether or not progress is being made, not fully whether or not the Outcome has been achieved.

S.M.A.R.T. Outcome Statements SAre they specific? MAre they measurable? AAre they achievable? RAre they relevant? TAre they timed?

Writing Outcomes Begin with the aim of the outcome: Use the persons name followed by an action verb or phrase that reflects a change the person would like to see, or what the person wants to have stay the same. Complete the statement with how it will make a difference using so that/in order to Sara wants to get a job in a retail store so that she can pay her bills on time, live in her current apartment and have enough money to do things that she wants to do.

Outcome Statement Only the beginning!!!!

Reason for the outcome Provides contextual information so that the team has the full picture about how it is important. Important to Sara that others see her as responsible Continuing to be accepted by her friends, and has money to spend with them, is very important to her. To live in her own neighborhood where she is familiar and comfortable Making decisions about what she does and when she does it

Concerns Related to Outcome Informs team of barriers that need to be addressed while working toward outcomes. She often cant do what she wants because she doesnt have extra money Figuring out change, and adding/subtracting are things She needs help with Sometimes she walks in unsafe places by herself in her neighborhood, or late at night

Outcome Actions What are current needs What actions are needed Whos responsible Frequency and Duration of the actions needed By When (mm/dd/yyyy) How will you know that progress is being made towards this outcome?

What Are Current Needs? Current reality related to outcome: provides a baseline of information that specifically relates to Saras situation Information is recorded in health and safety Focus areas, functional abilities, employment and vocational sections, financial and communication sections of ISP Sara does not have a job; she has just enough money to pay her rent and food bills, she does not have extra money to go out with her friends. She gets angry with her rep payee when she has to say no to her friends because of money; She asks to borrow money often. She can tell the names of currency, but has difficulty making change accurately. She will need help reading help wanted ads and completing job applications

What Actions Are Needed? Address information identified in concerns related to outcome to identify steps to take. Figure out retail jobs that do not require you to make change (S E Job development) Discover job training classes in retail (SE Job development) Talk with others who work in retail shops (Family members)

What Actions Are Needed? Address information identified in concerns related to outcome to identify steps to take. Help her start learning about making change (Supported Living- HCHab and basic math tutor) Help Sara learn about budgeting money and using other resources such as food stamps, Energy assistance, etc. (Supported Living HCHab) Help Sara learn about being safe walking at night by herself (Supported Living HCHab)

Who is Responsible? Brainstorm who can help, how they can help and how often. Determine who will be responsible for seeing that the specific action occurs. Sometimes this will be non- paid people, sometimes it will be paid people. Supported Employment Supervisor and Family for Employment Action Supported Living Coordinator and Support Coord. for Sup. Living Actions

Frequency/duration and By When Indicate how often the action will occur, and for how long. This should give specific information around how many times per week, or month, or year, and for how many months or years. By when indicates when the action is expected to be accomplished Supported Employment service, 20 hrs per week, for 6 months Supported Living 20 hrs per week, for 12 months. By 12/12/2004

How will you know that progress is being made towards this outcome? Describes what is expected as a result of the services and supports; what will you be able to see that is different, or that continues to happen, for the person? Identify how and who will give input about progress made over time. Employment Actions: Sara will have found and applied for at least one job she desires. Sara will have information on retail jobs available to her, and will know the skills required for retail work. At quarterly meetings, the team will provide progress notes on what has been accomplished.

How will you know that progress is being made towards this outcome? Describes what is expected as a result of the services and supports; what will you be able to see that is different, or that continues to happen? Identify how and who will give input about progress made over time. Home and Comm. Actions: Sara will be confident making purchases with dollar bills and get the correct change. Sara will understand one method of budgeting her money that she is willing to try Sara will have exercised at least one safe option when going home late at night.

Fundamental to Supporting People: Core Responsibilities are NOT Outcomes Washing hair Setting the table Making a sandwich Using a fork Tying shoes Brushing teeth Combing hair Shaving Getting dressed Staying on task Counting money Toileting Doing laundry Using zippers Dialing the phone Applying deodorant

Would You Rather… Tie your shoesorTie the game Comb your hairorComb the beach Make your bedorMake a friend Plan a menuorPlan a get-together Make a purchaseorShop til you drop Clean a roomorClean up on the dance floor Tie your shoes or tie the game & make your bed or make a friend from Hingsburger (1998) do?be?do?

Traditional Curriculum vs. Quality of Life Outcomes (Red) Judy will take a shower with physical guidance 6/7 days a week by 12/01. Judy wants to look nice when she goes to school for the next two semesters. Fay will exercise three times a week with verbal prompts for 6 consecutive months by 12/01. Fay wants to earn her orange belt in karate in the next 9 months. Anna will participate in 1 social/recreational outing a week with staff supervision until 12/01. Anna wants to join the Girl Scouts in her neighborhood and be a member this year. From Acumen, Arizona. Courtesy of Chris teKampe 2003

One guys story Your interpersonal skills have improved. What do you mean by interpersonal? That means you are getting along with people better. Well, why didnt you say that in the first place?

Alternatives to jargon Interpersonal skills Ambulates independently Verbal cues or prompts Auditory monitoring distance Able able able Feeds self independently

Outcomes Thinking compared with Old Goals Going on a date- Learn Social Skills Taking karate lessons- Increase physical activity Looking great for school- Improve personal hygiene Getting a job- increase vocational skills Being a Girl Scout- Improve social skills Putting together a photo album- Increase fine motor or Increase attention span- or increase on-task behavior Visiting my family- improve social and emotional expressions

Outcomes Thinking compared with Old Goals – Try it yourself: Joining a health club: Taking horseback riding lessons: Being an active senior: Riding my bike: Listening to live music: Going to the beauty salon: Joining the Eagles fan club: Hosting a BBQ:

Family Member Roles in developing Outcomes Participate as Content Expert Assure the person is listened to Demonstrate the opinions and views of people who care deeply about the person Promote the preferences of the person – not what others think should be their preferences Contribute ideas for how to meet the needs Provide insight into resources other team members may be unaware exist

Provider Role In Developing Outcomes Participate as one of the content experts Ensure outcome statements are in context of The persons individual preferences- what is important TO the person Ensure Outcome actions meet individual needs – what is important FOR the person. Ensure services can address individual needs within the context of individual preferences. Ensure services are delivered. Participate in plan review.

Support Coordinator Roles in Developing Outcomes Process Expert – what needs to be done, how it gets done, and getting it done on time Coordinate team agreement with what is written Coordinate team meeting to develop outcomes Keep the team focused on the process Ensure the outcome summary addresses the persons preferences, balanced with health safety and ensuring community life. Assure the person is listened to