Person Centered Individual Support Plan (ISP) Training For Day and Residential Providers Trainers: Prior to the training you should have reviewed and completed.

Person Centered Individual Support Plan (ISP) Training For Day and Residential Providers
Trainers: Prior to the training you should have reviewed and completed all prep work that has to be completed, including working with your co facilitator and getting them prepared for the training. Start the training on a positive note with an opening round. Go over the agenda, participants packets, and let them know that they will spend time on day 1 completing their own PC ISP’s (practicing gathering information and completing sections of the ISP on themselves). Laura Vegas, Assistant Commissioner Policy and Innovation 2015

Learning Objectives Participants will learn about concepts of person centered planning and person centered supports. Participants will learn about their roles and responsibilities regarding Individual Support Plan (ISP): Development Implementation Documentation Monitoring Trainers: This is simply an overview of the class and the focus here is on the purpose.

Learning Objectives Participants will learn about anticipated revisions to the DIDD requirements for the ISP regarding: Vision for Preferred Life Skill Acquisition And measurable outcomes.

Exit Plan Requirements
Section III – Individual Support Plans D. DIDD to provide training to residential and day service providers on person-centered planning and person-centered supports, to include ISP development, implementation, documentation and monitoring; expectations of participants in the person-centered planning process.

Person Centered Planning and Person-Centered Supports
Trainers: Prior to the training you should have reviewed and completed all prep work that has to be completed, including working with your co facilitator and getting them prepared for the training. Start the training on a positive note with an opening round. Go over the agenda, participants packets, and let them know that they will spend time on day 1 completing their own PC ISP’s (practicing gathering information and completing sections of the ISP on themselves).

Information Gathering: Three Important Things
Think of the three things in your life that are most important to you. Write one thing on each of the three pieces of paper given to you at registration. Be willing to participate.

Person Centered Planning
Centers for Medicare and Medicaid Services (CMS) Home and Community Based Services (HCBS) person-centered planning definition. Established January 10, 2014 Service planning must be person centered The person and the people closest to them are the experts about their service needs and how services should be delivered The process is driven by the person and includes only people chosen by the person

The person drives the person centered planning process with supports as needed. Planning happens at the time and place chosen and convenient to the person. Plan uses plain language. Planning process must include strategies for solving disagreements. Process results in individually identified goals and preferences.

Must offer choices to the person regarding services and supports they receive and from whom. The Plan must be reviewed every 12 months or as a person’s circumstances or needs change significantly and anytime individual requests review. Plan must be signed by all providers responsible for its implementation. The person and their representative must receive a copy of the plan. All good person centered ISPs are done in partnership among the person, families, unpaid supports, all service providers and the ISC/CM.

What is the Purpose of an ISP?
To help people obtain better lives! A guide to personal outcomes Justification for services Service authorization

Better lives? Help supporters understand the person’s interests and desires, and their vision of a preferred life. Pathway to develop and maintain personal relationships. Employment First! Increase positive control over one’s own life. Develop skills and abilities needed to achieve their goals and support their vision of a preferred life.

Vision of a Preferred Life
The Vision should be added to the ISP template, Section A. What is the person trying to accomplish with this ISP? What would the person like to learn, enhance or maintain in their life – how can the ISP help accomplish these things. The entire ISP supports the Vision of a Preferred Life.

Tools to help develop vision: Person Centered Thinking Tools What’s working/what’s not working Good Day/Bad Day Rituals Matching Learning Log Relationship Map

Vision of a Preferred Life Person Centered Thinking Skills
Personal Outcome Measures ®

Vision of a Preferred Life Person Centered Thinking Skills

Important To What is important to a person includes those things in life which helps us to be satisfied, content, comforted, fulfilled, and happy. It includes: People to be with /relationships Things to do & places to go Rituals or routines Rhythm or pace of life Status & control Things to have

Important To Includes what matters the most to the person – their own definition of quality of life. What is important to a person includes only what people “say”: with their words with their behavior

Important For Issues of health: Issues of safety:
Prevention of illness Treatment of illness / medical conditions Promotion of wellness (e.g.: diet, exercise) Issues of safety: Environment Well being ---- physical and emotional Free from Fear What others see as necessary to help the person: Be valued Be a contributing member of their community

© TLC-PCP 2012 www.learningcommunity.us
Health and Safety Dictate Lifestyle PURPOSE: A visual to help people think thru the concept of important to and for and the balance between before moving to stories and exercises to practice. SCRIPT This is where we were. We organized services around diagnosis and type of support needed (medical, behavioral etc…). You can often tell where someone is going to live or where they will spend their days if you know their labels. Examples: The “Behavior home” or the “non-ambulatory home”. We grouped people based on labels – not based on how people want to live. When we only concentrate on what is important for the person, we often end up limiting their ability to exert control in their life. This often leads to the restriction of rights that are important to the person. i.e. I have high cholesterol therefore staff now limits my intake of potato chips, cheese, etc. TIPS: You can use these 3 slides to have a very fruitful discussion about where services have been, are now, and where they should go – but not now. It makes for a good follow-up session. TIME: 1 Minutes NOTES: Important TO Important FOR Important FOR © TLC-PCP TLC-PCP

All Choice No Responsibility
Important FOR PURPOSE: Visual –Important for - conversation continued. SCRIPT This is what every parent is afraid of. This is what we need to avoid. One of the mistaken assumptions about person centered practices is that is about “choice”. We only listen to what is important to and ignore what is important for. We all have examples of where choice was used as an excuse - we don’t want to set people up to be hurt We want to recognize that what we are trying to do is just what we do for ourselves – find a balance. In the potato chip example, the decision to eat what I want to eat and as much as I want to eat would be left up to me, without providing me with the information and supports necessary to make an informed decision regarding the risks associated with my behavior TIPS: Try asking if any of the participants have seen choice used as an excuse – use the question as the segue to the next slide TIME: 1 minute NOTES: Important TO TLC-PCP

Balance Important TO Important FOR PURPOSE:
To introduce the key concept of balance between- important to and for before moving to stories and exercises to practice. SCRIPT This is what we seek in our own lives and often find it difficult. When our lives feel out of balance we look to see what we can change to get a better balance. So our work can be seen as trying to do for others what we do for ourselves. We recognize in our own lives that it is never perfect and it is ever shifting. It is even more difficult when we are describing what a balance looks like for another person and recognize that it shifts for them as well. How important are your key confidants to you – the people that you share your secrets with? How does it affect your balance when one of them moves away? If you were someone who only had paid staff as your confidants and had no control over who came into your life next, how would it affect your balance? How do we help figure out the balance for someone else? Listen to them? Where is the conflict? Where is the balance? In the potato chip example, how can we assist the person in lowering their cholesterol levels without having to give up their chips? Maybe the person would rather cut back on other foods, exercise more, etc and continue to have potato chips on a regular basis. Our efforts need to be guided by what is important to the person. TIPS: TIME: 2 Minutes NOTES: Important TO Important FOR TLC-PCP

The person’s vision may connect to one of the 3 factors (21 outcomes) of the Personal Outcome Measures. My Self : Who I am as a result of my unique heredity, life experiences and decisions. People are connected to natural support networks People have intimate relationships People are safe People have the best possible health People exercise rights People are treated fairly People are free from abuse and neglect People experience continuity and security People decide when to share personal information Trainers: The Personal Outcome Measures focus on the choices people have in their lives. Choice and personal control in one’s own life remains at the heart of personal quality of life. The focus is one of making connections to people and places and building trusting relationships to promote personal and community quality of life.

My World : Where I work, live, socialize, belong or connect. People choose where and with whom they live People choose where they work People use their environments People live in integrated environments People interact with other members of the community People perform different social roles People choose services Trainers: It is key to point out that people define outcomes for themselves. The outcomes are non-prescriptive; they have no norms. Each person is a sample of one. We all define friendship, health, or respect uniquely. Thus, the meaning and definition of personal outcome items will vary from person to person.

My Dreams: How I want my life (self and world) to be. People choose personal goals People realize personal goals People participate in the life of the community People have friends People are respected Trainers: The Personal Outcome Measures enable us to learn about people in new and different ways. They provide a guide to person centered planning.

My Self My World My Dreams Trainers: My Focus: What is most important to me now? My quality of life is about me. It is about My Self, My World, and My Dreams. I define each area based on what is Important 2 me. My Focus is what I am paying attention to now. It is what is most important to me now. It might be about me and where I live because that is what is most important to me today. It might be about several things, from my relationship with my best friend to my dream to own my own home. The circles interconnect and may not always look the same. At some points in my life, the circle dealing with my world will be bigger and will only overlap a little bit with my dreams. My Focus is the basis from which all planning and personal goals flow.

Learning about Support
PURPOSE: To provide a visual while you help people have a conversation about the differences between fixing and supporting. SCRIPT: Yesterday we discussed how to identify what is important to people and for people and the desired balance between. Now we will take some time to think thru what is meant by support. Most of us don’t recognized the support we get and the support we need - usually because we have the illusion we are competent adults..and your partner is more likely to suggest something to fix you rather than support you. For Example: Some of us probably had not getting up on time as a characteristic of a bad day If your partner suggests say setting 3 alarm clocks to go off at 15 minute intervals to ensure you get up...your partner is trying to fix you--- Conversation with the group: How many of you have felt a pressure to address difficult situations as demands to “fix it”? Where is the power if we are “fixing” ? Fixing has a coercive quality, it is more about power over than power with. For example: Remember yesterday we talked about environments -Toxic; Tolerated: Supportive; Healing. What type of environment would you be most likely to find “fixing” as the predominant form of help? What is most likely to happen to our suggestions that fix it? Right, they are most likely to be ignored. People just don’t work this way; good solutions are not found this way. However supporting you when late means recognizing that support means different things for different people… How many of you want people to go aha! Late again!..OR Act as if you are not late and let you slide into work-OR Give you an opportunity to vent… Which one feels better? Which one might help you get thru the frustration? Tips: Slide is animated. Time: 5 Minutes Power Over Power With Fixing vs. Supporting TLC-PCP

Individual Support Plan Development

ISP Development All sections of the ISP support the person’s Vision of a Preferred Life. Home Day/Employment Relationships/Natural Support/Community Support

ISP Development Decision Making/Rights Communication
Medical Conditions Mealtime Personal Funds Management

ISP Development Vision of a Preferred Life
For example – Hollie’s vision of a preferred life is to make new friends and get a job that she can walk to from her home. Each section of the ISP supports the vision along with providing a description of supports and services needed.

ISP Development Home How informed CHOICE was exercised in selection of home and room mate What new things or skills does the person want to learn that might lead Greater independence Greater satisfaction with home life Having access to environments in home (kitchen, patio, swimming pool for example) For Hollie’s vision, home section might discuss Maintaining work clothes, uniforms Scheduling

ISP Development Day/Employment
Employment First! Employment is the First Consideration for Day services Competitive Employment In a typical workplace Majority of workers do not have disabilities Earn at least minimum wage What does the person want to learn that might lead to More meaningful days Greater independence Relationships For Hollie’s vision, what supports are needed for Hollie to stay employed?

ISP Development Relationships/Natural Supports/Community Membership
Who are the important people in a person’s life (unpaid)? What supports are needed to help maintain connection to important people? What is person’s desire regarding their natural support network? Expanding? What community roles are important to the person?

ISP Development Relationships/Natural Supports/Community Membership
For Hollie’s vision, discuss what relationships are important in reaching her vision such as co-workers, neighbors, etc…

ISP Development Medical Conditions
Current health issues and needed supports Historical health information that is pertinent to current support needs Focus on how person makes medical decisions and what support is needed Important to the person in terms of managing their own healthcare For Hollie’s vision, discuss what health supports are needed in order to achieve or maintain best possible health, particularly as it relates to her vision.

ISP Development Mealtime/Mealtime Guidelines
Supports needed (important to) Include what is needed for the person to be part of cooking, meal prep, shopping, menu planning, etc… Preferences regarding food Mealtime Rituals Supports needed (important for) Mealtime Guidelines Dietary considerations Safety considerations for people with chewing/swallowing difficulties

ISP Development Personal Funds Management
Follow personal funds management policy The person’s abilities and desires regarding personal funds management The extent to which personal funds will be managed by the provider agency or the conservator The person’s desire, if applicable, to have a separate bank account rather than an agency-controlled account for personal funds Any training or assistance needed to support the person-supported in managing personal funds or to develop skills needed to increase independence with managing personal funds

ISP Development Personal Funds Management
Restitution plans addressed in ISP Goals and objectives involving use of the person’s personal funds Health, safety or exploitation issues that require limitations on the person’s access to personal funds and strategies to remove limitations at the earliest possible time For Hollie’s vision, it would be important to address how she manages her earned income, what supports she might need or any goals she has for the earned income.

ISP Development Decision Making/Rights
Determine what rights and decisions are most important to the person to exercise Supports needed in exercising rights and making decisions Legal representatives and area of responsibility (if applicable) Supports needed for more independence in decision making and rights

ISP Development Decision Making/Rights
Human Rights Committee Restrictions Restoration plan Support needed to ensure the person attends the Human Rights Committee meetings as applicable Current legal issues or concerns

ISP Development Communication
Describe how the person communicates their wants and needs along with the supports needed to assist the person to communicate Include the support needed , if applicable, to maintain and access any communication methods, devices or assistance across all environments The communication chart is an excellent tool to organize and document information Trainers: The communication chart is a great tool for everyone, but it can be very helpful for people who are identified as having risks with communication.

Communication Communication chart: Learning, using, and recording communication. Trainers: Ask someone in the audience to help you walk through this chart. The example given can be on anyone that they know. The purpose of the exercise is to show the group how you complete the chart. Again, remind people that they should have practiced this tool in the 2 day PCT class.

ISP Development Outcomes
Outcome statement is a functional statement that includes what a person would like to LEARN, IMPROVE UPON, or ACCOMPLISH. The person with assistance as needed from COS, develops their own outcomes. (SERVICE PROVIDERS AND ISCs DO NOT DEVELOP OUTCOMES) Outcomes represent the result, the ultimate place to be, the big picture, etc… Outcomes should reflect what is important to and important for a person (the balance).

are specific and measurable should support progress toward the Vision of a Preferred Life can be derived from what is working and not working in a person’s life

ISP Development Action Steps
Stepping stones toward outcome Tasks that needs to be carried out in order to support a person in achieving an outcome. Action steps are SPECIFIC MEASURABLE ATTAINABLE REALISTIC TIMELY SMART

ISP Development Strategies for Implementation
Strategies: Where there is an action step, there should be a strategy. Especially in situations where there are different supporters implementing the outcome, strategies can assist all supporters to know how to consistently implement each action step. Strategies shall focus on: How the individual learns best (if teaching is involved) Instructions to teach Defines what it takes to reach the action How to best document progress This is the information needed to understand the individual’s expectations, family / team expectations, staff / agency expectations, etc., to implement each action.

Strategies for Implementation
Outcome Strategies for Implementation Action Steps Measure Progress Who/When? Hollie will learn the walking route to and from work so that she can travel alone. Hollie needs a (prepaid) cell phone to use in case of emergency. Will need help making sure the phone has minutes. Hollie needs written reminders of which turns to take on the route to work until she memorizes them. Hollie carries a notepad with her important information in her bag. 1. Hollie will walk to work with staff and write the directions in her notepad. 2. Hollie will follow directions in her notepad to walk to work with assistance from staff. 3. Hollie will walk to work with staff without using her directions in the notepad and no staff assistance. 1. Written instructions in Hollie’s notepad. 2. Successful trips to work as indicated in daily notes. 3. Successful trips to work without assistance from staff or notepad as indicated in daily notes. 1. Hollie and job coach by June 1, 2015 2. Hollie and job coach for three months beginning June 2015. 3. Hollie and job coach for three months beginning September 2015. “I Want” “I Need” “I Will” “I Did” Trainers: Engage the group in discussion. Spend time covering strategies for implementation. Have the group take the information that they gathered from the conversation earlier and use that information to practice writing strategies for implementation. The strategies helps to break the outcome down more, and it shows how the person/COS arrived to the decisions that are made for action steps. It helps the person/COS brainstorm and create action steps that will help the person be successful in achieving their outcomes.

ISP Development Measure Progress
Helps the Circle of Support determine if progress is occurring, what needs to continue to occur, if more time is needed to achieve the action taken, if the means of measuring progress is working or not working and if the timeline makes sense.

Individual Support Plan Implementation

ISP Implementation Without implementation, the best person-centered planning leads nowhere. Implementation of person centered planning is a promise A Promise to listen To listen to what is being said and to what is meant by what is being said To keep listening

Independent Support Plan Implementation
Implementation of person centered planning is a promise…. A Promise to act on what we hear To always find something that we can do today or tomorrow To keep acting on what we hear

ISP Implementation A Promise to be honest
To let people know when what they are telling us will take time When we do not know how to help them get what they are asking for When what the person is telling us is in conflict with staying healthy or safe and we can’t find a good balance between important to and important for

ISP Implementation Authorized services must also be implemented as written per the current approved ISP, including the type, amount, frequency, and duration listed Section C of the ISP. Those responsible for service implementation are accountable for services as indicated in the ISP and are responsible for documentation to support the provision of services.

ISP Implementation Outcomes and Action Steps
Implementation plans are helpful to provide a step-by-step method to teach skills in a consistent way Teaching methods can be inconsistent among staff without a plan to implement

ISP Implementation Outcomes and Action Steps
As indicated in Section B Action Plan Action Steps Strategies for Implementation How Will Progress be Measured Who will do it? By When?

ISP Implementation Training
Specific to the person’s individual needs, interventions and programs Any responsibilities they have to carry out related to activities identified in the plan

ISP Documentation Staff Communication Notes
Narrative description of Information relative to implementation of staff instructions Information about the implementation of action steps such as progress, lack of progress, barriers to implementation or accomplishment of action step

Learning Log Using the learning log to replace typical progress notes
Date What did the person do? (What, where, when, how long, etc.) Who was there? (Names of staff, friends, others, etc.) What did you learn about what worked well? What did the person like about the activity? What needs to stay the same? What did you learn about what didn’t work well? What did the person not like about the activity? What needs to be different? PURPOSE: Overview – a visual introduction to the Learning Log SCRIPT This is a way to record learning as it is happening, a way to journal learning. For example to take the place of typical progress notes-or when to capture learning outside of typical notes- TIPS: Guiding question for participants: How many of you write progress notes that you know will never be used for anything? Time: no more than 15 minutes for the entire overview (slides ) – 30 seconds per slide NOTES: TLC-PCP

ISP Documentation Learning Log
Great for documenting what worked and didn’t work for action steps and waiver services. Includes information for next steps.

ISP Documentation Periodic Review/Monthly Review
Revised ISC Monthly review template to require substantive narrative review of ISP Outcomes and Actions including progress, lack of progress and next steps as applicable. Providers periodic reviews will need to include meaningful review of ISP Outcomes and Action Steps falling under their responsibility.

ISP Documentation Barriers to achieving outcomes should be identified
ISPs should be revised as needed to address barriers and general lack of progress toward outcomes

Expectations of Participants ISP Process
Person - THE Content Expert Other content experts Service providers Family Friends ISC/CM Process Expert – ISC/CM Is the author of the plan. Makes final determination of content based on the person’s decisions.

Wrap Up ISP must be person-centered
Person is EXPERT on the content of their plan Person’s Vision of a Preferred Life should be guiding principle of ISP Implementation of a person-centered ISP is key, otherwise…it is just more paper We support people and have a huge impact on their LIVES….we must keep trying to get it right!

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Person Centered Individual Support Plan (ISP) Training For Day and Residential Providers Trainers: Prior to the training you should have reviewed and completed.

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