Individualized Service Plan (ISP)
Course Introduction 4 Modules: Defining the ISP Developing the ISP Simulated ISP Planning Writing the ISP 2
OPWDD Mission We help people with developmental disabilities live richer lives. OPWDD Vision People with developmental disabilities enjoy meaningful relationships with friends, family and others in their lives, experience personal health and growth and live in the home of their choice and fully participate in their communities. 3
Defining the ISP What is an ISP? Who has an ISP? How is the ISP Used? What does Collaborative Planning and the Resulting ISP Accomplish? 4
What is an ISP? A written personal plan A plan developed through the collaborative planning process An agreement A document that substantiates Medicaid billing for HCBS Waiver Services 5
Who has an ISP? Everyone enrolled in MSC or the HCBS Waiver: regardless of living arrangements regardless of what services and supports the person receives 6
How is the ISP Used? As a document that “locks on” to outcomes As a communication tool As a master plan or blueprint 7
Flow Chart for Planning and Writing Plans Collaborative Planning ISP Res. Hab. Day Hab. Supp. Emp. Prevoc. 8
How is the ISP Used? To coordinate supports and services To set accountability To comply with Medicaid requirements To describe HCBS Waiver Services 9
What do Collaborative Planning and the Resulting ISP Accomplish? Satisfaction with supports and services Successful and desirable life in the community Health and safety Community membership and valued social roles 10
Developing the ISP Planning from a Person Centered Planning Perspective Introduction to the Five Sequential Steps Assessment Defined Assessing Health & Safety Using Discovery Tools 11
Planning from a Person Centered Perspective Builds on the person’s abilities and skills Creates a clear vision of a positive and desirable future Is collaborative Is ongoing 12
Planning from a Person Centered Perspective Inclusion Valued social roles Informed Choice Self-Determination Reflects culture and ethnic heritage Takes patience and commitment Creates a balanced and “big picture” view 13
The Big Picture 14
Five Sequential Steps to ISP Planning Step 1: Gather Information Step 2: Identify Themes Step 3: Choose Personal Valued Outcomes Step 4: Identify Safeguards Step 5: Develop next-step Strategies and a Personal Network of Assistance 15
Assessment tools Getting to know the person How learning and Discovery Occurs 16
Assessing Health & Safety Assessing a person’s needs includes determining adequate safeguards and oversight OPWDD Website – Health & Safety Alerts 17
Discovering Information Activity #1: Areas of Discovery Activity #2: Paint a Portrait of Yourself 18
Simulated ISP Planning Step 1: Gather Information Step 2: Identify Themes Step 3: Choose Personal Valued Outcome Step 4: Identify Safeguards Step 5:Develop Next-Step Strategies and a Personal Network of Assistance 19
Step 1: Gathering Information Discover information by: Asking questions Exploring pathways Learning about the person 20
Step 2: Identify Themes Themes are cues or indicators to: Person’s valued outcomes or desires What’s not working Individualized quality life How services and supports should be provided 21
Step 3: Choose Personal Valued Outcomes Anchors for the services and supports the person will receive From the person’s perspective Clearly stated Capacities and interests Responsive to change 22
Step 4: Identify Safeguards Support Needed to keep the person safe Issues discovered during the planning process Fire Safety must be discussed in the ISP 23
Step 5: Develop Next Step Strategies and a Personal Network of Assistance What Who How When 24
Writing the ISP Overview of the ISP Format and Instructions The Header Section 1: The Narrative Section 2: The Person’s ISE Signatures Attachments Reviewing and Updating the ISP Maintenance, Retention, and Distribution of the ISP 25
The ISP is written within 60 days of enrollment in the HCBS Waiver or MSC 26
The Header Four things must be in the header: 1.The date of the ISP 2.The name of the person 3.Medicaid Number 4.ISP Review Dates, MSC Initials and if review was a face-to-face meeting 27
Section 1: The Narrative Profile Valued Outcomes Safeguards 28
The Profile Contains a narrative about the person Includes person centered information discovered during planning Highlights abilities 29
Valued Outcomes Brief Clearly Stated Specific Linked to each HCBS Waiver service received 30
Safeguards Identified directly after the profile. Hab Plans provide greater detail about how safeguards are ensured within the context of the respective service. “See attached Plan for Protective Oversight” can be written in the safeguards section for people who live in an IRA. Fire safety must be discussed in the ISP (or in the attached Individual Plan for Protective Oversight for people who live in IRAs) 31
Section 2: The Individualized Service Environment Lists all the supports and services received to help the person live a successful life in the community and pursue his or her valued outcomes. Clearly sets accountability for who will assist the person to pursue his/her valued outcomes. 32
Section 2 (continued) Demonstrates the coordination between these supports and services. Keeps the person healthy and safe from harm. Must “fit” with or complement the profile. 33
The ISE Categories Natural Supports and Community Resources Medicaid State Plan Services Federal, State, or County Funded Resources HCBS Waiver Services Other Services and 100% OPWDD Funded Supports and Services 34
Natural Supports and Community Resources People, places, or organizational affiliations that are a resource to the person by providing supports or services. What the support is doing to help the person 35
Name of Provider Type of Service ISE Entries for Medicaid State Plan Services; Federal, State or County Funded Resources; Other Services or 100 % OPWDD funded supports and services: 36
ISE Entries for HCBS Waiver Services Name of Provider Type of Service Frequency Duration Effective Date 37
Signatures Service Coordinator Service Coordinator’s Supervisor The person Advocate (if the person is not self- advocating) 38
Attachments Any Waiver Hab Plans Individual Plan for Protective Oversight (if the person lives in an IRA) Medicaid Service Coordination Activity Plan (if the person has requested one; required for Willowbrook class members) Clinic treatment plan recommendations for long-term therapies provided by Article 16 Clinics 39
Changes to the ISP Attaching an addendum Dating and initialing the header to indicate that the ISP was reviewed 40
Changes to the ISP The addendum requires only the signature of the service coordinator Changes in the ISP must be communicated to service providers. 41
Reviews of the ISP The service coordinator is responsible for: Coordinating a review of the ISP Making any needed changes to the plan as a result of the review. 42
Reviews of the ISP ISP reviews must take place at least twice annually. One of these reviews must be a face- to-face review meeting with the individual and major service providers. 43
Reviews of the ISP The annual face-to-face review meeting must occur within 365 days of the prior face-to-face meeting or by the end of the calendar month in which the 365 th day occurs. 44
Documentation of the ISP Review Documentation that a review of the ISP occurred is recorded in the service coordinator’s notes. ISPs are updated as a result of the review. 45
Maintenance, Retention, and Distribution of the ISP The signed ISP (with attachments) is: Maintained by the person’s service coordinator Filed in the Service Coordination Record 46
47 Copies of the signed ISP (with attachments) are forwarded by the service coordinator to: The person His/her advocate All waiver service providers Article 16, 28, or 31 clinics Day treatment Other providers and individuals with the consent of the person and/or advocate
48 The ISP with any addendums or revisions and the services described remain in effect until a new ISP is written.
The ISP Format and detailed Instructions can be found on the OPWDD website at: 49