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Developing a Person-Centered Individual Support Plan

Developing a Person-Centered Individual Support Plan. for A Good Life in Virginia. The 5 parts of the ISP. Virginia’s PC Planning Process. PCT Training and Tools are available. Changes in Language. Client/Consumer = Individual Case Manager = Support Coordinator

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Developing a Person-Centered Individual Support Plan

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

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

  3. PCT Training and Tools are available

  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. Before the meeting Part 1: Essential Information

  6. Part 1: Essential Information Part 1: Essential Information

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

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

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

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

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

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

  14. Before the meeting Part 2: Personal Profile

  15. Part 2: Personal Profile Part 2: Personal Profile

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

  18. Available Tool Part 2: Personal Profile

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

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

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

  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. During the meeting Part 3: Shared Planning

  25. Part 3: Shared Planning Part 3: Shared Planning

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

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

  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. 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. Part 3: Shared Planning

  32. Part 3: Shared Planning

  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. A volunteer or the support coordinatorrecords Shared Planning at the meeting. Part 3: Shared Planning

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

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

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

  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. 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. We are looking for evidence that the desired outcome has occurred or if we can see movement toward the outcome. Desired outcome Jack makes five new friends who like Jazz music. 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. 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. 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. 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. Desired outcomes 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. Part 3: Shared Planning

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

  48. During the meeting Part 4: Agreements

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

  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

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