1. 1 Developing a Person-Centered Individual Support Plan for A Good Life in Virginia

2. 2 The 5 parts of the ISP Virginia’s PC Planning Process

3. 3 PCT Training and Tools are available

4. 4 Changes in Language Client/Consumer= Individual Case Manager = Support Coordinator Service Plan = Support Plan Training = Learning Assistance = Supports Specialized Supervision = Safety Supports Interventions/Strategies = Support Instructions

5. 5 Before the meeting Part 1: Essential Information

6. 6

7. 7 Collected and maintained by the Support Coordinator. Part 1: Essential Information

8. 8 Shared with providers initially and annually (before or after the annual). Part 1: Essential Information

9. 9 Can be in the optional sample format Part 1: Essential Information

10. 10 or can be in CSB-specific format Sample table of contents, may look different per service Part 1: Essential Information

11. 11 Regardless of format, the information is essential for accessing services and ensuring health & safety. This information should be reviewed and updated at least quarterly by the support coordinator. Part 1: Essential Information

12. 12 The Support Coordinator assures a new Supports Intensity Scale (SIS) once every three years and when support needs change significantly. for 1/3 per year Part 1: Essential Information

13. 13 The SIS includes a Risk Assessment that the support coordinator will complete annually. Part 1: Essential Information

14. 14 Before the meeting Part 2: Personal Profile

15. 15 Part 2: Personal Profile

16. 16 Prepared by the individual before planning with someone he or she trusts like a Planning Partner. Can be completed with Support Coordinator when no other partners are available. Part 2: Personal Profile

17. 17 What is a Planning Partner? - completing the profile, -arranging planning meetings, -contacting partners, -identifying off-limit topics, -communicating with SC. A friend… family member… support provider… someone who helps with: Part 2: Personal Profile

18. 18 Available Tool Part 2: Personal Profile

19. 19 The profile is a “living description” of the individual not a one-time interview. You can build it over time by talking, listening, and observing. It needs to be ready to give to the support coordinator by the annual meeting. The good life description might be completed last once the life areas are reviewed. Part 2: Personal Profile

20. 20 Provided to the support coordinator before or at the annual meeting. Part 2: Personal Profile

21. 21 Includes the vision of a good life. Looks at gifts, talents & contributions. Part 2: Personal Profile

22. 22 Identifies what’s WORKING and NOT WORKING across 8 life areas. Part 2: Personal Profile

23. 23 The final profile is shared with all partners by the support coordinator after planning - either in the optional sample format or contained in a CSB-specific format. Secure email Providers add new learning to the Profile throughout the year to share at planning. Part 2: Personal Profile

24. 24 During the meeting Part 3: Shared Planning

25. 25 Part 3: Shared Planning

26. 26 Facilitator = Individual & SC Recorder = Partner volunteer Timekeeper = Partner volunteer A person-centered team: Part 3: Shared Planning Share something that made you smile

27. 27 The meeting begins by sharing the good things that has happened in the person’s life. The individual shares his or her Profile with support as needed or desired. Part 3: Shared Planning

28. 28 It’s important to ask… What needs to change? What needs to stay the same? Are we finding a balance between what’s important TO and what’s important FOR? and Part 3: Shared Planning

29. 29 Important to What makes a person happy, content, fulfilled People, pets daily routines and rituals, products and things, Interests and hobbies, places one likes to go Part 3: Shared Planning

30. 30 Important for What we need to stay healthy, safe and valued health and safety things that others feel will contribute to being accepted or valued in the community Part 3: Shared Planning

31. 31 Part 3: Shared Planning

32. 32 Part 3: Shared Planning

33. 33 The Profile and the SIS are reviewed to identify what’s IMPORTANT TO and what’s IMPORTANT FOR planning this year. Part 3: Shared Planning

34. 34 A volunteer or the support coordinator records Shared Planning at the meeting. Part 3: Shared Planning

35. 35 Part 3 Shared Planning includes outcome numbers, what’s IMPORTANT TO, what’s IMPORTANT FOR and each Desired Outcome. Also includes how often the support is to be provided and who will be providing support in each instance. Part 3: Shared Planning

36. 36 Important TOs and FORs are global and become more specific and measurable when outcomes are defined. Important TO = baseball Desired outcome = Max watches a baseball game with his brother each month. Important FOR = personal care Desired outcome = Devon is clean and has the support he needs each day with shaving, showering, and having a neat general appearance. Part 3: Shared Planning

37. 37 Outcomes must be measurable and result in actions you can see or learning you can assess. Part 3: Shared Planning

38. 38 Using verbs helps clarify what we are measuring. travels moves sings collects makes paints cooks watches creates visits Part 3: Shared Planning

39. 39 If the supports we identify are provided, we expect that the desired outcome will be achieved. Part 3: Shared Planning

40. 40 By documenting the supports we provide, we can learn if what we are doing is bringing about the desired outcome or if supports need to change. Part 3: Shared Planning

41. 41 How do we know if our supports lead to the desired outcome? From evidence we can see or hear and report. From evidence that the outcome happened. From evidence based on what the person says or does. Part 3: Shared Planning

42. 42 We are looking for evidence that the desired outcome has occurred or if we can see movement toward the outcome. Jack makes five new friends who like Jazz music. Desired outcome Evidence of progress Jack joined a jazz club this quarter and went four times. He was introduced to several new people. Part 3: Shared Planning

43. 43 If no evidence of progress towards the desired outcome, changing the supports or the outcome can improve how we support people. Desired outcome Jack makes five new friends who like Jazz music. Lack of evidence Jack threw away his Jazz CDs and says he does not want to talk about it. Part 3: Shared Planning

44. 44 We also need to know if the outcome, once achieved, is still desired by the individual to know if support should continue. Part 3: Shared Planning

45. 45 Remember - we are seeking to help people build a quality life of their choosing. We are helping them assemble a desirable life. Part 3: Shared Planning

46. 46 Jack walks to the corner store each week. Margo listens to the country band every Friday night. Craig helps with the landscaping by pulling weeds and mowing the grass each week. Martin cares for his dog by giving him baths each week. Desired outcomes Part 3: Shared Planning

47. 47 Part 3 Shared Planning is shared by the support coordinator with all partners following planning. Secure email Part 3: Shared Planning

48. 48 During the meeting Part 4: Agreements

49. 49 Part 4: Agreements Stored in the SC record

50. 50 All partners work together to answer the agreement questions. Any disagreements are revisited in discussion for resolution and unresolved items are documented on the agreement page. Part 4: Agreements

51. 51 All partners sign in agreement and other contributors are listed. All Medicaid providers must sign. Part 4: Agreements Sent by SC to all partners

52. 52 After the meeting Part 5: Plan for Supports

53. 53 Part 5: Plan for Supports

54. 54 Can be in the optional sample format or in existing provider formats. Part 5: Plan for Supports

55. 55 Includes the support activities allowable under Medicaid for each service, as well as the instructions for carrying out each support in a person-centered way. The target date is the annual ISP date unless indicated sooner. Time is added to show how long the support is expected to take each time it’s provided. Part 5: Plan for Supports

56. 56 The supports are listed on the general schedule and the ISP checklist. Part 5: Plan for Supports

57. 57 When supports are not provided as agreed, a code is used in place of initials and a note is completed in the support log. Part 5: Plan for Supports

58. 58 Initials, codes and ongoing notes support billing and confirm the supports that are provided. Part 5: Plan for Supports

59. 59 Whenever a code is used on the checklist, there must be a corresponding note. Routine daily or weekly notes must be written as well. Part 5: Plan for Supports

60. 60 After the meeting Part 5: PC Review

61. 61 Person-Centered Review Part 5: PC Review

62. 62 This review is completed four times each year and whenever outcomes are changing. Part 5: PC Review

63. 63 Each provider needs to report progress toward each outcome on their plan for supports. Part 5: PC Review

64. 64 Progress is measured by evidence that the desired outcome is occurring or that movement toward the outcome is being made. Is the support enhancing the person’s quality of life. What can we see that demonstrates progress? Is the individual satisfied with the outcome? What was a barrier to progress? Part 5: PC Review

65. 65 Did Jack get a job that he likes? Part 5: PC Review

66. 66 Did Angie go camping each month as planned? Part 5: PC Review

67. 67 What steps did Charles take to enroll in class? Part 5: PC Review

68. 68 If progress is not evident and/or the individual is dissatisfied with the outcome, there should be documentation explaining this fact and alternate plans should be pursued. Part 5: PC Review

69. 69 If progress toward the outcome is observed and documented in the review, the progress box should be checked. Part 5: PC Review

70. 70 If the outcome is continuing and is still desired by the individual, the “continued” box should be checked. Part 5: PC Review

71. 71 If the outcome is being ended and is being replaced by a different outcome, “changed” should be checked. Part 5: PC Review

72. 72 If the outcome is being ended altogether and is not replaced by a different outcome – check “ended.” Part 5: PC Review

73. 73 New outcomes are added at the bottom of the review and are described as IMPORTANT TO or IMPORTANT FOR the individual Once approved, the supports are added to the provider’s support documents Part 5: PC Review

74. 74 Any remaining medical or significant information is added and satisfaction is described. One question asks about a change in hours. Part 5: PC Review

75. 75 Signatures are needed upon review and when outcomes change. The support coordinator reviews, signs and returns signature page approving changes to desired outcomes. Part 5: PC Review

76. 76 Remember plans change with people and lead to better lives.

77. 77 Questions? Please check http://www.dmhmrsas.virginia.gov/OMR-PersonCenteredPractices.htm for forms, updates and contacts.