Today s training will not focus on specific requirements, process details or timeframes associated with ISP development, review, and approval.

Transcription

1 Welcome to this webcast on Foundations for Individual Support Plan Development. This is the second in a series of trainings from Pennsylvania s Office of Developmental Programs, ODP, that focus on critical aspects of the development, review and approval of the Individual Support Plan, or ISP. If this is the first time you re viewing a webcast, take a moment to familiarize yourself with how to use Adobe Presenter. Below the window where this PowerPoint appears you ll find controls to pause and navigate through h the presentation. ti To the right of the window you will see three tabs that will also help you view or move through the presentation, including one labeled notes which will allow you to read along with the narration, if you choose. If you need to pause the presentation and finish it later, use the outline or thumbs tabs to return to where you left off. We also recommend you maximize your internet browser in order to view and access all the features of this presentation and to be able to see the presentation clearly. 1

2 Throughout this presentation, we ll be referring to Molly s Story. You ll need to have it printed and available while viewing the webcast. The link to download Molly s Story is located with the Supporting Documents in the same place you found the webcast. At certain points during the presentation, you ll be asked to provide your thoughts and ideas in a text box that will appear at the bottom of the slide. These activities are designed to give you an opportunity to pause, reflect, and apply some of the concepts in the webcast. Please know that there are no right or wrong answers. The information you ll be asked to provide is not a test. Responses will not be reported and will not be used to determine whether or not you have successfully completed the webcast. 2

3 This ISP training was developed in response to the fact that all significant partners in Pennsylvania s developmental disabilities service system have not had opportunities to receive the same ISP trainings. This training gap needs to be addressed for the benefit of all the people who are supported in the system and their families, the Supports Coordinators who write the ISPs, paid and non paid people who use ISPs as a guide in supporting individuals, and ISP reviewers. Today, we ll focus on the Individual Preferences and Understanding Communication sections of the ISP as well as other factors influencing ISP development. The purpose is to build a shared understanding of plan development. This consistent understanding of ISP development will allow all stakeholders to become true partners. 3

4 Today s training will not focus on specific requirements, process details or timeframes associated with ISP development, review, and approval. Future trainings will focus on this information and on other topics, such as outcomes, using assessment information within the ISP, services, and ISP review and approval. Also, ODP plans training on the ISP Bulletin and Manual when they are issued. 4

5 There are four objectives for this training. After viewing the webcast, you ll gain an understanding of the purpose and the importance of the Individual Preferences and Understanding Communication sections of the ISP. We ll also discuss other factors including those outside the team process itself that influence ISP development. Using an example, we ll ask you to think about the power of the ISP process to help a person make changes in his or her life. Finally, since we all need to be knowledgeable about where and how to get resources and technical assistance when we need them, we ll discuss where to locate resources that will help you learn more about ISP development. 5

6 In any training on ISP development, it s important to start at the beginning. In Pennsylvania, since 1991, that beginning is the Everyday Lives Principles. The Principles were developed by people with disabilities, family members and their allies when asked the questions such as, What is important to you? and, What do you want in your life? The answers were that people want the things that surround this circle choice, control, quality, stability, safety, individuality, relationships, freedom, success, an opportunity to contribute to the community, accountability, mentoring, community inclusion and collaboration. These answers continue to serve as the guideposts for services and supports. A review of the Everyday Lives Principles is included in many of ODP s trainings. This is one way of reinforcing the importance of the Principles. We must not assume that these Principles are part of people s lives, but must pay attention and work to ensure that they are present and respected in the lives of everyone we support. It s also important to be reminded that the Everyday Lives Principles form a foundation for policy decisions by the Office of Developmental Programs. 6

7 With Everyday Lives as a foundation, we ll now spend some time talking about the ISP and the ISP development process. In 2000, ODP worked to establish one standardized plan to be used across the Commonwealth a plan that would facilitate person centered planning, and meet federal and state regulations. This plan is the ISP. The ISP reflects the presence and promotion of Everyday Lives Principles in a person s life, and addresses the full range of the person s assessed needs as identified in ODP s statewide needs assessment and in other written assessments. Ultimately, the ISP must be meaningful in the context of a person s life. 7

8 As we said earlier, one purpose of this webcast is to build a shared understanding of ISP development. The information in this presentation highlights some aspects of ISP training that Supports Coordinators and providers have received so that everyone will have a better understanding of what s expected of teams in developing ISPs. Those who are responsible for review, approval and authorization of ISPs will also find this information helpful to determine if the ISP is fully, completely and correctly developed. ISP development is a team process thatincludes the individual receiving supports, family, providers of service, the Supports Coordinator, and others who are important in the individual s life. The individual and family control the planning process. On the screen is a representation of ISP development called, Individual Support Planning Process: The Big Picture This graphic illustrates how the different steps in ISP development flow from one to the next and depend on one another. We ll talk about each of the steps down the left hand column. The first step in ISP development is to gather information. This happens all the time and in many different contexts at meetings, during monitoring, at informal visits, and in contact with doctors and other professionals. To the right of the top arrow are some of the sources from which information can be gathered. These include, of course, the person and family, and others who know the person well. In addition, information can be gathered from documents such as the Supports Intensity Scale and PA Plus, as well as other assessments and evaluations, both informal and formal. Next, information is recorded dwithin the ISP. In Individual id lpreferences, functional, health and safety, medical and Understanding Communication sections, as well as other areas. All of this information is integrated within the ISP. After information has been gathered and recorded, outcomes are identified. Outcomes represent what the person feels is important to change or maintain. They re based on everything that has come before in the ISP process. Supports Coordinators and teams are taught that outcomes are developed as a result of the first two steps and that they must connect with assessed needs and preferences. Next, the team identifies if there are needs associated with outcomes and how to address them. The team determines if needs can be addressed with natural or unpaid supports that already exist or could be fostered in a person s life, or if needs must be addressed with paid services. A subsequent training in this ISP series will focus on outcome development. The ISP development process results in a plan that incorporates Everyday Lives and person centered planning principles, identifies the person s priorities, addresses health and welfare needs, and provides the information needed to support the person successfully. 8

9 The ISP contains information that, in a sense, paints a picture of the person with words. The goal is that, after reading a well developed ISP, the reader should feel that they have a good sense of who the person is and what supports he or she may need in everyday living. On the screen is a list of the main sections of the ISP. We ll be discussing some of them during the remainder of this presentation. As we do so, we ll be referring to a document called the Annotated ISP. This document contains ODP s recommendations about what type of information should be included in each section. Look for the italicized words in the left hand column of the document. The Annotated ISP is a great resource for anyone writing or reviewing an ISP. It s available on line and can be accessed on the ODP consulting website. A link is also included in the Resources document located where you accessed this webcast. If you would like to have the Annotated ISP available for your reference during the remainder of this training, please pause the webcast and print it now. 9

10 We will start our review of the ISP with the Individual Preferences and Understanding Communication sections because we ve learned that this is typically where a person s quality of life priorities are captured. The presence and promotion of Everyday Lives Values are also often captured here as well as in outcomes. As we proceed, we will use Molly Winter s story to consider what should be included in the ISP sections. Molly is fictional, but her story is one that could easily be that of someone you know. Molly is 47 years old and lives in a Community Home with two other women with whom she s very close. Molly also has a close relationship with her mother. She has many interests. She loves to spend time with her friends and family, to go shopping, to swim, and to make things with her hands. Molly experiences seizures, for which she takes medicine and sees a physician regularly. If you have not already done so, please pause this webcast and take a few minutes to read Molly s story now. 10

11 The first Individual Preference area is Like and Admire. The Annotated ISP states that the Like and Admire section answers the question What do people like and admire about the individual? It goes on to say that this section should provide a list of attributes that other people like and find admirable about the person. The power of this section is two fold. First, since it s the first narrative section of the ISP it provides the first impression of the person. We all know how powerful first impressions can be. They can affect how people p interpret all subsequent information they learn about a person. The placement of this section first was no accident because it s designed to set a positive tone. Second, the Like and Admire section sets the stage for the person to connect with others. When we hear interesting, positive things about a person, we are more likely to want to get to know them and perhaps to realize that we have some common interests. Like and Admire should include the types of things you d say if you were introducing the person to someone. In addition to the examples on the slide, this section of the ISP could also include information i about personal interests that could help hl connect the person to others. Considering what you know about Molly from reading her story, what do you think should be included in the Like and Admire section of Molly s ISP? To help you answer this question, ask yourself What do I know about Molly that people might find likeable or admirable? and What could help connect her to others? Type your ideas in the box on the screen. Remember, there are no right or wrong answers. This is not a test. Responses will not be reported and will not be used to determine whether or not you have successfully completed this course. When you re finished jotting down your thoughts, click Next to move to the next slide and see our suggestions. 11

12 Some things that could appear in Molly s Like and Admire section are that she loves animals, is a responsible pet owner, and that she is welcoming to new neighbors. You may have thought of other things too. What all of the things in the Like and Admire section should have in common is that they are positive qualities, strengths, talents that people would find likeable or admirable and that have the potential of helping the person form connections with others. 12

13 Next is Know and Do. The Know and Do section should provide supporters with the information i they need to support a person successfully. Therefore it must be very specific. This is especially important for new support people who don t know a person at all. Know and Do includes information related to keeping a person safe and healthy, as well as other things that are critical to supporting them successfully. For example, it describes things like the best way to approach a person in specific situations, coping strategies they use to get through difficult situations, routines that they follow consistently and relationships that must be maintained. It s worth mentioning here that there are also other areas of the ISP in which health and welfare information should be recorded, such as the Health Promotion section, Health and Safety Focus Areas, and Outcomes. It is okay that certain things are mentioned multiple times in an ISP because there is a level of interchangeability and interconnectivity within the different ISP sections. What might fit in one section may also fit in another section. Now, take another look at Molly s story. What do you think people would need to know or to do to support her successfully? Remember to consider how these things can be addressed in ways that will be acceptable to Molly, and therefore be successful. Type your thoughts in the box on the screen. 13

14 Some things you may have written are shown on the screen. You also may have come up with others. As you can see, the items include how Molly s priorities and preferences have been taken into account in planning for her needs and supports. When a person s preferences are taken into account in planning for how to address concerns such as health and welfare needs, the support is more likely to be accepted by the person, which in turn helps to ensure that they stay safe, healthy and happy. 14

15 The next section in the Individual Preferences area of the ISP is Desired Activities. The Annotated ISP s description of this section says that it should include activities that the individual would like to continue, to begin, or to explore further. In other words, things the person has never done before but might be interested in trying, as well as things they already like to do. In the box on the screen, type what you think are activities that Molly likes to do or might like to try. Respectful guessing based on your true knowledge of a person is a great way to identify possible new activities. 15

16 You may have written some of these activities that Molly currently enjoys, or thought of others. Crocheting is an activity that Molly does not currently do but would like to try. 16

17 The next Individual Preferences section is Important To. This section should only include things that a person indicates are important to him or her. In other words, things that must be present in their life or absent from their life for them to feel like they have a good quality of life. This section should not include things that are important for the individual in order for him or her to remain healthy and safe. That information is included elsewhere in the ISP, such as in the Know and Do or Health Promotions section. Important To allows us to understand what things are critical to a person s satisfaction with their life. Therefore it should include things that are important to the person even if these things run counter to what is important for their health and welfare. To help you understand this, think of the things that are most important to you things you would absolutely not want to live without. What if one of these things was your pet cat or dog, but you were allergic to animal fur. If others didn t know how important having a pet cat or dog was to you, they may suggest that you avoid allergy issues by not having animals in your home. But if others know the important role that pets play in your life, they may respond differently, by helping you explore different allergy treatments for example. You would also need to decide what balance between having pets and suffering allergy symptoms works for you. And this balance might be different for someone else. But the balance may never be reached or even attempted if people don t know that having a pet is important to you. Sometimes the same thing may be both important to and important for a person, but for different reasons. If this is the case, the information can be included in Important To as well as in other places where health and welfare information is described. For example, exercise may be important to a person because it contributes to their feeling of overall selfaccomplishment and they like the people at their gym. Exercise may also be important for their health and safety in order for them to maintain a healthy weight. It s important to remember that in order for something to be included as important to the person, it needs to be expressed directly by the person. In the box on the screen, type the things that you think are important to Molly. Remember that these should be things that Molly has indicated are important to her. 17

18 Did any of the items on the screen appear on your list? You may have thought of other things as well. What all of them have in common is that they are things that Molly considers to be necessary for her to be happy for her to be satisfied with her life. Notice that staying out of the hospital is one of the items. This item is on Molly s Important To list not because i it s health hrelated, but because it is something that Molly desires in her life. Therefore it s appropriate to include this item in Molly s Important To section. 18

19 The next section is What Makes Sense. This section is designed to be a picture of a person s current life. It describes what is currently making sense or in other words, what is currently working well or going well in the person s life, and what is not making sense (or not going well) in the person s life right now. What Makes Sense should present a snapshot of the person s current reality. It is not intended to be a wish list of things that would make the person s life better if they were present or things that used to be present but no longer are. What Makes Sense is also designed to capture the perspectives of different team members separately. This helps to identify areas of common ground and agreement among team members, as well as areas of disagreement that need to be better understood and resolved. So let s begin by looking at Molly s perspective. Please take another look at her story and, in the box on your screen, type things that you think Molly would say are going well in her life right now. 19

20 Some of the things that Molly s story tells us are going well in her life from her perspective are listed on the screen. This information is important to know because Molly may need support to maintain these things in her life. Similarly it s important for people to understand what Molly thinks is not going well in her life right now so they can help her change these things. With this in mind, look at Molly s story and, in the box on the screen, type the things that you believe Molly feels are currently not going well in her life the things she s not happy with right now. 20

21 On the screen are some things that Molly s story indicates that she is not happy with in her current life. With this information, Molly and the people supporting her can work on changing these situations and remove them from her life or at least help make them more tolerable to her. For example, as you can imagine, there may always be occasional situations that come up that would cause unanticipated changes in Molly s routine. So since these situations cannot by completely avoided, the questions for Molly and her supporters are how can these situations be minimized, and what kind of support will help Molly get through them when they can t be avoided. 21

22 As was mentioned earlier, the What Makes Sense section of the ISP is designed to capture different team members perspectives separately. Including the perspectives of other people who know the person well provides valuable information that is then used during the planning process. Sometimes there may be disagreement among team members about what is making sense or not making sense for the person. For example, from Molly s perspective it makes sense that she buys gifts for family and friends. But from her mother s perspective it does not make sense that Molly spends so much of her discretionary money on other people. Mom would like to see Molly spend more money on herself. Recording team members disagreeing viewpoints accurately is important because it can lead to discussion that can help the team move toward greater understanding of both the person s perspective and of each others perspectives. Then this understanding may contribute to the development of outcomes that help the person move toward something that he or she wants, while at the same time taking into account team members concerns. Addressing team members concerns when developing an outcome helps to ensure that all the team members will be committed to and feel comfortable implementing the outcome. In addition, capturing multiple perspectives in What Makes Sense/What Doesn t Make Sense can show the team that in fact there are some things that are seen the same way by all team members. Realizing this common ground can help the team to move forward with shared purpose. 22

23 Now we are going to jump to the Understanding Communication of the ISP section now, even though this section is not the one that comes next in the ISP. We are doing this because the Understanding Communication section, like the Individual Preferences sections that we just reviewed, captures ways in which a person s preferences can be honored. In this case, we re talking about the person s communication preferences. This includes his/her preferences for how others should respond to the communication, whether that communication is verbal or nonverbal. The Understanding Communication section of the ISP provides a means for ensuring that a person s methods and style of communication are understood by those who support him/her. It can include communication in words or actions anything that might not be easily understood by others. One very important function of this section of the ISP is that it helps the people providing support recognize a person s expressions of pain or illness. 23

24 There are four parts to the Understanding Communication section of the ISP. They re listed on the screen. The first is When this is happening. This includes external factors or triggers to any behavior or attempt to communicate things in a person s environment that could cause them to try to communicate something. It is not intended to include things that are happening within a person, such as any emotions we think they re feeling. Next is The individual does. This describes what others see or hear the person s behavior or words or sounds. Next is We think it means. This describes the message that we think the person is trying to communicate, and this is where any emotions that we think the person is trying to express would be described. Lastly, We should. This describes the response that supporters should give (or should avoid) in response to the person s communication. 24

25 On the screen is an example of one item you would expect to see in Molly s Understanding Communication section. It describes non verbal ways in which Molly communicates that she may be experiencing medication side effects or even toxicity. It also gives supporters guidance on how to respond. Molly s Understanding Communication section would also contain several more items, for example how she expresses frustration about a change in her schedule or routine. The Understanding Communication section of the ISP is intended to expand over time as people get to know an individual better and better, and gain an ever greater understanding of how the person communicates. 25

26 In addition to documenting a person s priorities and desired quality of life, which can be done through the Individual Preferences and Understanding Communication portions of the ISP, it s important to document his or her health, safety, and support needs. This type of information is touched on in some places in the Individual Preferences section such as Know and Do, but other sections of the ISP are specifically designed to capture it more fully. As we know, this information is needed because Waiver funding for services is authorized based on Assessed Health and Welfare Needs of a person. But it is also important for other reasons too. For example, when developing action steps for Outcomes, knowing the type and level of support a person needs will help ensure that the outcome actions are developed in a way that will have the best chance of being successful for the person. As the term implies, Assessed Needs are needs that are identified through an assessment process. This process could be the statewide Standardized Needs Assessment or other assessments that have been conducted dbased on the person s unique circumstances, for example speech/language assessments, vocational assessments, or specific observations of the person. So, needs are identified through formal and informal assessments. But the question is: where then are they documented in the ISP? To answer this question, look at the list of ISP sections and sub sections on the screen. This list is also available as a printable document called Documenting Assessed Needs in the ISP. The link to this document is located in the Resources section under Supporting Documents where you launched this webcast. If you haven t already printed this document, please pause the webcast and print it now. Now take a moment and look at your printed list and think about where in the ISP you might look for documentation of an assessed need. Then put a check mark in the box to the left of each section you think might contain information about an assessed need. What do you notice about where you have placed these check marks? 26

27 What you probably noticed is that you placed check marks by just about all of the ISP sections. This is because an assessed need could be represented anywhere in the ISP depending on the type of need; and everyone s needs are different. For example, an assessed need concerning taking medications could be documented in the Health and Safety area; an assessed need having to do with counting money could be represented in the Functional Information area. The important point is an individual s assessed needs need to be documented in their ISP, and that how and where these assessed needs are addressed in the ISP depends on each individual s circumstances. 27

28 As we discussed earlier in the presentation, promoting an Everyday Life is important to keep in mind when planning with people with disabilities. Knowing a little bit about Molly and what is important to her from reading her story, what Everyday Lives Principles would you think might be important to her? And why? Take a few minutes to reflect on this. Then, in the text box, type the Principles you are thinking of and why you think they re each important to Molly. 28

29 From learning a bit about Molly, you may have said relationships are an Everyday Lives value that is very important to her she looks forward to the time she spends with her mother, and she cares a lot about the women she lives with. Due to Molly s concern about seizures and her need for support during activities like swimming, you might also have said that the Everyday Lives Principle of Safety is important to her. You might also have said that it is important for Molly to be involved in making decisions about changes to her routines, as this helps her have a sense of control. Molly also enjoys getting to know her neighbors and helping to welcome new people to the neighborhood. ihb h This hl helps her contribute tib t to her community. Cross walking these Everyday Lives values back to Molly s Important To section would be a great way to make sure that everything that s Important To her has been recorded. 29

30 Natural supports are unpaid supports that are provided or just happen through ordinary relationships with people like with family members, friends and neighbors. Natural supports can play a very important role in many aspects of a person s life and can reinforce the presence of Everyday Lives Principles. They can help people experience all that their neighborhoods and communities have to offer, such as worshiping, playing, and having friendships. Teams can help strengthen a person s natural supports by fostering and supporting their natural relationships. For example, when a person s team supports them in spending time with family, friends and others in the community, the person may be more likely to be involved in and feel more a part of their community. When natural supports are not present, teams should always be looking for ways to help people find and build them. These efforts should be part of the ISP development process. Teams must always make sure that health and safety concerns are addressed no matter how supports are provided but natural supports can often help people live lives with a greater degree of choice and control. 30

31 If you were a member of Molly s team, what ideas for fostering and enhancing her natural supports could you discuss? Type a few or your ideas into the text box on the screen. Be sure to be thinking about specific things that natural supports might offer to Molly that could help to enhance the quality of her life. 31

32 On the screen are two examples or ways that Molly s team could foster rich, rewarding relationships and natural supports in her life. 32

33 When we discuss the ISP team, we often think of a group of people that bring different perspectives and play different roles. Some are considered content experts those who know the person best. These include the person him or herself, or course, but also include family, friends, neighbors, and many times, direct care staff. Others are considered experts on the process, such as Supports Coordinators who are knowledgeable about timelines, or provider staff who contribute valuable assessment data, or information that meets regulation. Together, content and process experts composing the ISP development team share a commitment to take action on what is important to a person, while maintaining health and welfare needs. 33

34 As we discussed earlier, ISP development is completed through a team process. The team meets to develop the ISP, but the information they use is gathered over time in a variety of ways: from assessments, monitoring visits, reviews, progress notes, and through formal and informal conversations with the individual, family, friends and other people providing support. All of this information is reviewed and considered in the development of a comprehensive ISP. Teams must keep in mind, however, that their work happens within a larger context and not in isolation. While the ISP team holds the greatest responsibility for assuring the development of the ISP, others outside the team also influence the development of the ISP. SCO administration is responsible to review ISPs before they are submitted to the Administrative Entity for review, approval, and authorization. Direct service providers have responsibility to ensure the ISP reflects their understanding of the individual s priorities and needs. For example, if it s found that the current ISP no longer reflects the correct level of support due to an individual s change in need, the team would need to reconvene to review and discuss the changes and identify more appropriate supports/services, if necessary. Because of its responsibility to review and approve ISPs and authorize services within them, the Administrative Entity may influence an ISP team s actions by asking for more information to be documented in the ISP. For example, more detail, or stronger links between assessed needs and services. ODP promotes the integration of Everyday Lives Principles and person centered approaches in ISP development through existing business practices, policy and training. In addition, ODP assures compliance with state and federal requirements and statewide consistency in ISP development. The Centers for Medicare and Medicaid Services (CMS) affects ISP processes through the assurances that ODP must meet associatedwith funding for waiver services. So, influences outside the team process could result in the team needing to update the ISP content, or make changes to information in order to meet requirements. However, even if an ISP meets requirements and contains sufficient information for approval and authorization, review may point out opportunities for quality improvement. For example, an AE may ask the team to more fully explore the Understanding Communication section for a person whose actions are not well understood by others. The team would then work to revise the ISP. While SCO and provider administration, AE s, ODP and CMS do not actually sit on the ISP teams, they often influence the work of teams that develop the ISP. This is not to imply that any of these groups insert themselves directly into the ISP development process. But, any of these entities can have an impact on ISP development. Teams must bear in mind that their work is part of a larger context of development, review and revision that continues over time. 34

35 Here are some primary responsibilities of the ISP team. The team is responsible for the accuracy and consistency of the information in the ISP. It s vitally important that if contradictions or omissions are found, that they re corrected. When changes are necessary, the team agrees to them and then the ISP is revised to reflect them. Completing or revising plans on time is also a responsibility of the team; it relies on respectful collaboration and cooperation among team members. And overall, the ISP Team is responsible for developing a planning document that paints that full and complete picture of the person and the supports that he or she receives. 35

36 To highlight the importance of committed person centered planning in ISP development and the positive effect that this approach can have on the life of an individual, we re now going to learn a little bit about a person named Al. Although Al isn t his real name, he is a real person who lives in a community home in western Pennsylvania with three other men. He receives services and supports through ODP. Al and his sister have given permission to share his story. WhenAl firstleft the institution tion to live in the community, people were concernedabo about his health and safety because he would eat cigarette butts and tobacco products. He had a reputation for doing anything to get something he wanted, including attempting to get out a second floor window or diving under cars. Sometimes Al would shove or push other people. He d unbuckle his seat belt and change seats in a moving vehicle. His actions were not well understood; not only did they cause concern for his safety and that of others, it also became clear that his quality of life was poor. You may be thinking of people in your community that have similar challenges to face. 36

37 However, Al s team made a strong commitment to person centered planning as a way to understand and support him. Just to illustrate that point: The Understanding Communication section of Al s ISP has evolved to contain over 15 pages of detailed observations of Al s actions and responses that work. For example, the team was initially puzzled why Al would attempt to remove his seatbelt while in the car. This of course was a concern for safety. But through observation and trying different responses, people figured out that this was a way for Al to communicate that he needed to stop and use a restroom. Once staff understood Al s communication, their alarm when he removed his seatbelt was replaced with a clear idea of what action to take to support him. Not everyone would need such an extensive Understanding Communication section in their ISP, but it has made a difference for Al who doesn t communicate using words. 21 months after leaving the institution, his life had changed dramatically. Those actions that caused concern for Al s safety and that of others had dropped sharply; some had stopped altogether. Eventually, Al was able to stop taking all medications for behavior management. He s also spending more time with his family and overall is living more of the everyday life that he wants and needs. This detailed work and the resulting change occurred because of the combined efforts of all team members. 37

38 As we close, I d like you to reflect on this presentation and how you could apply what we ve discussed in your role in ISP development. As you think about these questions, jot down some notes for your own use. What do you currently do preparing for and participating in ISP development that you want to continue or do more of, based on this information? Perhaps you heard things during this presentation that were reinforcing to good habits or practices that you already do. How can you support others in doing them, as well? During this presentation, you may have thought h of ways to improve your contribution to the ISP development process. Think of a specific situation coming up in the next few weeks; what will you do differently? 38

39 This part in the series Enhancing the Quality of ISPs lays a foundation for other topics to be more fully explored in later parts, some of which are shown here. Together, all the information will help teams to really develop an ISP that contains a complete picture of the person. Further information is being developed to assist teams in incorporating assessed health and welfare needs into the ISP, including information from the Supports Intensity Scale and PA Plus, and provider and informal assessments. Sound ISP development results in a plan that captures preferences, personal priorities, addresses assessed needs, and conveys a sense of who the person is behind the paper : personality, style, expression, likes, and dislikes. 39

40 ODP has issued bulletin # , Individual Support Plans which establishes requirements for ISPs. Attached to the Bulletin is the ISP manual, which includes standardized processes for preparing, completing, documenting, implementing, and monitoring ISPs. ODP has established these processes to ensure ISPs are meaningful in an individual s life and to ensure ISPs are consistently developed and meet state and federal requirements. Also attached to this bulletin is the ISP timeline which includes role expectations and timeframes; the ISP signature page; the revised Annotated ISP; and the waiver service request form. Copies of these documents are available on the ODP Consulting System website. The website address is on the next slide. 40

41 Make sure to download the list of ISP Resources in the supporting documents section where you launched this webcast. And, watch for further information on these topics, including ODP Communications, which are posted on the ODP Consulting System website at the address shown on the screen. Thank you for viewing this presentation! 41