Individual Support Planning. A Resource Guide to Assist with Developing, Implementing and Monitoring an Individual Supports Plan

Transcription

1 Individual Support Planning A Resource Guide to Assist with Developing, Implementing and Monitoring an Individual Supports Plan Human Services Persons with Developmental Disabilities April

2 CONTENTS What is this Resource Guide?.. 3 Vision. 3 An cipated Long term Outcomes. 4 What is an Individual Supports Plan (ISP)?. 4 ISP Development Principles.. 5 What is a Support Team? 6 What are the Quality of Life Domains?. 7 What will you find in this guide? 7 Guideline 1: Iden fy the Individual s Goals and Strengths for the Individual Supports Plan. 8 Guideline 2: Select Support Needs that are Important to and for the Individual. 14 Guideline 3: Align Support Needs to Outcome Categories.. 19 Guideline 4: Align Support Needs to Specific Support Strategies. 26 Guideline 5: Iden fy a Specific Support Objec ve for each Support Strategy.. 30 Guideline 6: Use a Support Team to Develop the Individual Supports Plan (ISP).. 34 Guideline 7: Implement the Individual Supports Plan using Support Team Members.. 38 Guideline 8: Monitor the Status of Support Objec ves. 40 Appendix 1: Glossary of Terms 44 Appendix 2: Quality of Life Framework. 45 Appendix 3: Quality of Life Domains and SIS Support Items.. 46 Appendix 4: System of Support Elements, 7 Exemplary Strategies. 48 Appendix 5: Support Plan Templates.. 50 Appendix 6: Why Measure Outcomes?.. 53 Copies of this resource guide are available for download at the PDD Program website, 2

3 Introduction What is this Resource Guide? The purpose of this guide is to help a Support Team prepare an Individual Support Plan (ISP). It offers sugges ons on how to implement and monitor the ISP once it has been created. This resource guide was created collabora vely by community service providers and Persons with Developmental Disabili es (PDD) in consulta on with Dr. Robert Schalock and incorporates concepts from the Council on Quality and Leadership (CQL) 1. The guide can be used as a step by step framework to follow, or simply to help focus the conversa ons of a Support Team. Vision Alberta s Social Policy Framework 2 iden fies the overall direc on for social policy in Alberta. The Social Policy Framework vision is: In Alberta, everyone contributes to making our communi es inclusive and welcoming. Everyone has opportuni es to fulfill their poten al and benefit from our thriving social, economic, and cultural life. The Persons with Developmental Disabili es (PDD) vision iden fies the overall direc on of the PDD 1 CQL, an organiza on based in the United States, works with human service organiza ons and systems to con nuously define, measure and improve the quality of life of all people. 2 Alberta s Social Policy Framework website: h p://socialpolicy.alberta.ca 3

4 program and describes what PDD is striving to achieve. The PDD vision is: An Alberta that honours and respects the dignity and equal worth of persons with developmental disabili es. An cipated Long Term Outcomes Albertans are: Safe Live free from fear of abuse and violence. An Individual Support Plan is a wri en tool that describes an Individual s desired personal outcomes and how these outcomes will be achieved. Healthy Achieve the highest a ainable standards of health and well being. Secure & Resilient Support themselves and their households through safe work and career opportuni es, with access to effec ve income supports when in financial need. Lifelong Learners Develop the knowledge, skills, and commitment to learning needed to par cipate in society and reach poten al. Included Feel welcomed in the communi es where they live, learn, and work. Ac ve & Engaged Explore opportuni es to par cipate in recrea onal ac vi es and cultural experiences, and to engage in Albertan society. What is an Individual Support Plan (ISP)? An Individual Support Plan is a wri en tool that describes an Individual s desired personal outcomes and how these outcomes will be achieved through the involvement of a variety of people, services and supports. It outlines goals and the steps to follow in order to meet those goals. It ac vely involves the Individual throughout the process and builds upon his or her strengths and natural supports. The ISP can be used to help mo vate and inspire an Individual and his or her Support Team. 4

5 The ISP iden fies: Specific goals that are ed to the Quality of Life domains; The ac ons or objec ves needed to meet those goals; The support strategies or resources required for the goals; The outcomes and indicators that the goals have been met. An ISP should be based on a set of principles that reflects what is important to and for the Individual. The terms goals, objec ves, support strategies and outcomes are used throughout this guide. Defini ons are available in the Glossary (Appendix 1) so that there is some consistent understanding of their usage in the guide. An ISP should be based on a set of principles that reflects what is important to and for the Individual. The ISP should contain easy to understand support objec ves that facilitate the plan s successful implementa on and monitoring. Individual Support Plan Development Principles 1. The Individual and the Individual s natural supports (including but not limited to family members) are ac vely involved in the plan s development and implementa on. 2. The support team that develops the ISP includes people who know the Individual well and will be involved in the plan s implementa on. 3. Priority is given to those outcome areas that reflect the person s goals, relevant major life ac vity areas, and excep onal medical and behavioral support needs. 4. A quality of life framework is used to show how supports and outcomes can affect many aspects of a person s life. 5

6 5. Support objec ves are about specific support strategies and how they are carried out. 6. The ISP is implemented by the Individual and his or her support team. The ISP format should be user friendly and easy to communicate so as to facilitate effec ve implementa on. What is a Support Team? Once the ISP is created, the Support Team is responsible for both implemen ng and monitoring it. A Support Team is a group of people who work together to create, implement and monitor the ISP. The Support Team is composed of the Individual receiving supports and services, his/her parents or family members, the guardian when applicable, direct service staff who work with the Individual, PDD supports coordinator, other professionals and people who may be involved in planning with the Individual. When crea ng an ISP, the responsibili es of the Support Team typically involve: Iden fying what is important to and for an Individual Iden fying what fits with the Individual s strengths Ensuring that the ISP is meaningful to the Individual and his/her natural supports, such as family members or friends Ensuring that the ISP provides clear goals, objec ves, support strategies and outcomes all based on the Quality of Life domains and fits with the Individual s strengths Iden fying which team member is responsible for implemen ng each support strategy Once the ISP is created, the Support Team is responsible for both implemen ng and monitoring it. The ISP is based on the Quality of Life framework, which means that the goals and outcomes reflect specific Quality of Life domains. 6

7 What are the Quality of Life Domains? Quality of Life domains are a way of measuring the degree to which a person enjoys the possibili es of his/ her life given the person s unique opportuni es and limita ons. The domains describe personal and environmental factors that influence quality of life. This guide describes eight Quality of Life domains. The full descrip ons and examples of each domain can be found in Appendix 2 of this guide. What will you find in this guide? Quality of Life domains are a way of measuring the degree to which a person enjoys the possibili es of his/her life given the person s unique opportuni es and limita ons. Eight best prac ce guidelines form the basis of this resource guide. These are: 1. Iden fy the Individual s goals and strengths 2. Select support needs that are important to and for the Individual 3. Align support needs to outcome categories 4. Align support needs to specific support strategies 5. Iden fy a specific support objec ve for each support strategy 6. Use a Support Team to develop the Individual Support Plan (ISP) 7. Implement the Individual Support Plan using Support Team members 8. Monitor the status of support objec ves The guide can help the Support Team iden fy goals, objec ves and strategies and link the goals to Quality of Life domain(s). This allows for the ISP to be con nuously monitored and outcomes evaluated. Through this process, the Support Team will iden fy what an Individual can do and what the person is passionate about. From there, the Individual and the team will iden fy flexible, responsive supports the Individual needs to lead a good life in the community. 7

8 1 Guideline #1 Iden fy the Individual s Goals and Strengths for the Individual Supports Plan It is essen al for the Support Team to fully understand the Individual s personal goals. Iden fying and understanding these goals is the most important step in the process since the value of the ISP will depend on the quality of the informa on gathered here. In order to accurately iden fy the Individual s goals, he or she must be central in the planning and included throughout the ISP process. Some strategies the Support Team can use to ensure the Individual is fully engaged in the discussion are: Capability should always be assumed. Start with the knowledge that this person makes decisions every single day. Assess how he or she makes those decisions, and how he or she communicates those preferences. Let this knowledge guide you in providing the appropriate resources and experiences to aid in decision making. 3 Be ac vely involved in the interac on and discussion and pay close a en on to the Individual s responses. Listen to what the Individual is saying and look for body language that may indicate whether her or she is engaged. 8

9 Observe how the Individual is communica ng and include their responses in the discussion. Be aware of your own personal judgments and opinions and do not let them influence the outcome of the discussion; what ma ers are the goals of the Individual. It is important to focus on the Individual s personal strengths or assets, which include his or her a tudes, interests, skills, and natural supports Whenever possible, keep ques ons open ended [ques ons that need more than one or two words as an answer and cannot be answered with yes or no alone]. Open ended ques ons elicit more informa on, which can lead to a greater understanding of what the Individual is explaining. Do not rush the conversa on; make sure that the Individual has enough me to respond and to finish his/her thoughts. Spend me learning about how the Individual prefers to communicate. In order to iden fy goals that reflect a person s interests, some ques ons that can be asked are: How do you want to spend your day? What do you want to learn? Where do you want to live and work? Who do you want to spend me with? What would make you feel more safe and secure? It is important to focus on the Individual s personal strengths or assets, which includes his or her a tudes, interests, skills, and natural supports. An Individual s strengths can fall in the areas of: Conceptual skills such as language, reading and wri ng, selfdirec on, me awareness, and problem solving Social skills such as interpersonal rela ons, responsibility, self esteem, ci zenship, manners, wariness, and social problem solving Prac cal skills such as ac vi es of daily living (personal care), occupa onal skills, use of money, safety, health care, travel/ transporta on, schedules/rou nes, and use of telephone 9

10 The Individual s natural supports are those opportuni es and support strategies provided by family members, friends, colleagues, peers, other members of a social network, generic agencies, and self help groups. It is important to remember that since the ISP is based on the Individual s personal goals and strengths, each ISP will look different. Ques ons that help draw out these strengths and assets can include: What are your goals? What do you want life to be like in the future? How do you want to live? How do you want to spend your me (work, school, recrea on)? What supports do you already have (family, friends, other service organiza ons)? Some mes an Individual may not know how to describe his or her skills/strengths, so it can be useful to ask more focused ques ons such as: Do you enjoy reading and wri ng? Do you like to meet new people? What are your hobbies and ac vi es you do for fun? What do other people like about you /tell you that you are good at? It may also be important to talk to people outside of the Support Team who know the Individual well. The Support Team may not be made up of all of the people the Individual feels are important in his/her life, so having these additional conversations may increase the team s knowledge and understanding of the Individual. It is important to remember that since the ISP is based on the Individual s personal goals and strengths, each ISP will look different. Like anyone s goals, the Individual s goals, objectives and outcomes will also change over time, so it is important to have ongoing conversations with the Individual to ensure that he or she has the opportunity to iden fy and explore new goals or move on from old goals. 10

11 Throughout this guide, two example s will be used at the end of each Guideline sec on to help clarify how these guidelines can be put into ac on. This example will follow one goal, recognizing that this is only one part of a bigger conversa on and a bigger plan. David GUIDELINE #1 Example: Iden fy David s Goals David and his Support Team, which consists of David, agency staff, and his parents, have been talking about what is important to David. David tells everyone he would like to purchase a computer. As he talks more about this, it is apparent that David wants to buy this computer with his own money. The Support Team members ask David ques ons to help them understand why David wants a computer Team: David what do you like best about using a computer? David responds with comments about mee ng other people online through gaming, Facebook and other applica ons. How does this help you with your future goals? David says that it is easier for him to meet people on line than it is mee ng them in person. Some of these strategies are adapted from the CQL website: h p:// 11

12 David s Individual Support Plan Outcomes Goals Assessed support needs Support Strategies Support Objec ves Who is responsible Progress Review Timelines Comments To buy a computer To buy the computer with his own money 12

13 GUIDELINE # 1Example 2: Identify Jane s Goals Jane and her Support Team have been talking about what is important to Jane. Jane requires high levels of support in all areas of her life as result Jane s parents are speaking on Jane s behalf. Her parents tell everyone they want Jane to be happy. Team: What does happy mean to you? Jane Jane s parents respond with comments about her spending time doing things she enjoys and with people she likes. Jane s Individual Support Plan Outcomes Goals Assessed support needs Support Strategies Support Objec ves Who is responsible Progress Review Timelines Comments To do things and be with people that make me happy 13

14 2 Guideline #2 Select Support Needs that are Important to and for the Individual It is crucial that an ISP includes details about what the Individual considers important to him or her. For instance, what does the Individual want to work on and achieve? These wishes need to be central to the plan so that the Individual clearly sees the ISP as his or her plan and is thus more mo vated and commi ed to making the plan successful. Some mes the needs iden fied by an Individual are different from the needs seen by caregivers, families, friends or other professionals. The Supports Intensity Scale (SIS) focuses on life ac vity areas and excep onal medical and behavioural supports that the Individual may not always take into considera on. In the process of iden fying goals and needs with the Individual, it is possible to connect some of the SISrelated needs with the Individual s goals. For example, if a goal is to find employment, a discussion could take place about how important it is to improve personal hygiene in order to find work. If the Individual agrees that this is important and that he or she needs support in this regard, the next step is iden fying what that support will look like. 14

15 Example: With reminders, the Individual will begin a daily hygiene rou ne. If one looks only at SIS related numbers, then the holis c aspect of an Individual is not being considered. This is a way of incorpora ng what is important for the Individual and to the Individual. The person wants a job, and the SIS informa on clearly iden fies that the Individual requires support in the area of personal hygiene. If one looks only at SIS related numbers, then the holis c aspect of an Individual is not being considered. A strong ISP emerges from collec ve wisdom of the Support Team. Important to the Individual (based on personal goals and preferences): How do I want to spend the day? What do I want to learn? Where do I want to live? Where do I want to work? Who do I want to spend me with? Important for the Individual (based on SIS iden fied areas of support): Home Living: Bathing and taking care of personal hygiene and grooming needs Employment: Accessing work related supports Health Safety: Taking medica ons Protec on and Advocacy: Protec ng self from exploita on Medical: Example: Seizure management and control 15

16 Guideline 2 Example: Needed Supports Based on What Is Important To and For the Individual David gradually iden fies other elements to the primary goal of purchasing a computer. The team asks for more details about his wish to pay for a computer with his own money. The team members and David discuss where he would like to work. All of this is important to David. The team recognizes that it is important for David to know how he will manage money he receives and money he earns in order to make his goal come true. (This does not appear to be important to David, but it is clear that managing money will be important for David, so that he can reach the goals that he values.) As well, the Support Team, with the help of SIS informa on, notes that David will need to protect himself from exploita on. The team recognizes that it must be aware of situa ons where David could be at risk, without le ng this interfere with his eagerness to find work and to achieve his goal. Some examples of what is important to David: Open a bank account Finding a good place to work Increasing computer skills Some examples of what is important for David (as iden fied by David s Support Team): Be er money management skills Safety in the community and online 16

17 David s Individual Support Plan Outcomes Goals Assessed support needs (What does David s SIS assessment Support Strategies Support Objec ves Who is responsible Progress Review Timelines Comments tell the support team about his support needs in the area of learning and using new skills?) To buy a computer Shopping and purchasing goods To buy the computer with his own money To have be er money management skills To be safe in the community and online Ge ng employment Learning and using money management skills Protec on from being manipulated or harmed Goals that are important to David Goals that are important for David 17

18 Guideline 2 Example2: Needed Supports Based on What Is Important To and For the Individual Jane s parents gradually iden fies other elements to the primary goals of being happy. The team asks for more details about what ac vi es or events does Jane enjoy. How does Jane communicate and show she is enjoying something or not enjoying something. They also ask for names of people Jane enjoys being with or who would have valuable informa on about Jane s likes/dislikes, etc. Discussion about Jane s support needs reveals she will need help to ensure she is safe during the ac vi es. Some examples of what is important to Jane and her parents: Find ac vi es she enjoys Spend me with people she likes Some examples of what is important for Jane and her parents: Outcomes Goals Assessed support needs Support Strategies Support Objec ves Who is responsible Progress Review Timelines Com To do things and be with people that make me happy To be safe while par cipa ng in ac vi es Maintaining emo onal well being and making choices and decisions. Protec on from being manipulated or harmed 18

19 3 Guideline #3 Align Support Needs to Outcome Categories The Support Team needs to integrate all the informa on into an ISP that is relevant to the Individual, outcome oriented and prac cal. This informa on will include: The personal goals of the Individual, SIS informa on and other professional recommenda ons Objec ves and support strategies Expected outcomes as they relate to the eight Quality of Life domains Defini ons of the terms objec ves, goals, support strategies and outcomes can be found in the Glossary in Appendix 1 at the end of this document. The development of an ISP can involve professional terminology and concepts. It is very important that the professional informa on does not remove the Individual from the centre of the planning process. Support teams need to use a framework that aligns these three components as they develop an individualized plan. Although there are op onal 19

20 formats that can be used to align these three components, the framework used in this Guideline is based on the eight Quality of Life domains found in Appendix 2. Support teams need to understand how each Individual defines the result or benefit of supports for her/himself. Understanding the Individual s point of view will help support teams align the support objec ves and support strategies with the Quality of Life domains and measure if the personal outcome has been achieved. An Individual may say he/she wants to move from where they currently live. Asking why ques ons reveals that the Individual wants to move closer to a specific church or community ac vity they want to a end regularly. During further conversa on the Support Team finds out the Individual wants to a end church without staff. Reviewing the Quality of Life framework with this new knowledge will help the team iden fy the Quality of Life domain(s) that represent the Individual s personal outcomes. Guideline 3 Example: Aligning support needs to outcome categories The Support Team meets with David and other people he wants to have at the mee ng. They discuss his goals, which include buying a new computer and finding work. Everyone supports this and when the issue of money management is raised, David states that he can handle money well. The family members and his friends have had some experiences with David that contradict this statement. Everyone has agreed beforehand that it is important not to impose opinions on David, but it is also important to point out areas where David could use more support to achieve the desired outcomes. 20

21 With encouragement from the other team members, his family and friends point out some areas where he could use help. For example, his friends remind him that he some mes doesn t have enough money to buy something when they are out together. A er some discussion, he agrees with them that some support here would help. A er the mee ng is over, the team organizes the informa on from this discussion into a format that aligns his goals to Quality of Life domains and outcomes. They do this this by referring to the Quality of Life Framework document and reading the descrip on and indicators for each domain. This is done so that there is a consistent and accepted way to measure his progress and to ensure that supports and support needs iden fied will actually lead to improved Quality of Life. Below is an outline of the Quality of Life domains. Quality of Life Domains Exemplary Indicators Outcomes Personal Development Educa onal status, personal competence, ac vi es of daily living and instrumental ac vi es of daily living David has learned new skills with money management, using computers and is developing new social ac vi es Self Determina on Choices, decision making, autonomy, personal control, personal goals David has more independence and expresses pride in the decisions that he is making, both in terms of finances, socializa on and self care Interpersonal Rela ons Social networks, family, friends, peers, social ac vi es, rela onships David is sa sfied with his social life and he is able to expand his social network Con nued on next page 21

22 Quality of Life Domains Exemplary Indicators Outcomes Social Inclusion Community integra on/ par cipa on, community roles, volunteering, ability to par cipate in desired social and community ac vi es David is happy with new social ac vi es at work and in other areas Rights Emo onal Well Being Human rights: respect, dignity, equality, Legal rights: access and due process Posi ve experiences in an Individual s life and life sa sfac on David feels safe in his interac ons and believes that his rights as an employee are respected David s self esteem and his pride in work and in his social life Physical Well Being Health status, nutri onal status, recrea on/physical, mobility, wellness David is balancing work and me on the computer with other ac vi es Material Well Being Financial status, employment status, housing status, possessions, ownership David s able to purchase a computer and to maintain expenses, to keep a job and to manage his money The quality of Life Framework is included as Appendix 2 in this document. The team also uses the SIS informa on and links it to the Quality of Life domains. On the next page is an example of how David s team could take SIS support items and match them to the relevant Quality of Life domains. (The complete set of SIS Support items and the Quality of Life domain that relates to each of them can be found in Appendix 3.) 22

23 David s Individual Support Plan Outcomes/ Domains Goals Assessed support needs (What does David s SIS assessment Support Strategies Support Objec ves Who is responsible Progress Review Timelines Comments tell the support team about his support needs in the area of learning and using new skills?) Material well being (indicators are ownership, posses To buy a computer Shopping and purchasing goods sions) Material well being (indicators employment, financial sta To buy the computer with his own money. Ge ng employment tus) and personal development (indicators personal competency) Personal development (indicators, personal competency) To have be er money management skills Learning and using money management skills Emo onal and physical well being (indicators safety, posi To be safe in the community and online Protec on from being manipulated or harmed ve experi 23

24 Guideline 3 Example 2: Aligning support needs to outcome categories The support teams meets to iden fy things Jane likes to do and people she likes to be with. Jane s parents gave two examples, other support team members were unsure what Jane liked. There was further uncertainty on how Jane communicated her feelings. Team: How would people in her life know Jane was enjoying something? Jane s parents said: She smiles and is quiet, calm. They all agree Jane s safety is a top priority in everything she does. Outcomes Goals Assessed support needs Support Strategies Support Objec ves Who is responsible Progress Review Timelines Comments Emo onal well being and Self determina on (indicators posi ve experiences, life sa sfac on, choices, personal control, decision making) To do things and be with people that make me happy Maintaining emo onal well being and making choices and decisions. Emo onal well being (indicators safety, life sa sfac on) To be safe while par cipa ng in ac vi es Protec on from being manipulated or harmed 24

25 Quality of Life Domains SIS Support Items for David s ISP Personal Development Interac ng with others in learning ac vi es (C 1) Par cipa ng in training/educa on decisions (C 2) Managing money and personal finances (P & A 2) Self Determina on Belonging to/par cipa ng in self advocacy group (P & A 5) Making choices and decisions (P & A 7) Interpersonal Rela ons Interac ng with community members (B 7) Interac ng with co workers (D 3) Interac ng with supervisors/job coaches (D 4) Par cipa ng in recrea on/leisure ac vi es with other people (F 2) Making and keeping friends (F 4) Social Inclusion Transporta on (B 1) Par cipa on in recrea on/leisure ac vi es in the community (B 2) Rights Protec ng self from exploita on (P & A 3) Exercising legal responsibili es (P & A 4) Emo onal Well Being Learning self management strategies (C 9) Maintaining emo onal well being (E 8) Physical Well Being Learning health and physical educa on skills (C 7) Maintaining physical health and fitness (E 7) Material Well Being Learning and using specific job skills (D 2) Comple ng work related tasks with acceptable speed (D 5) and quality (D 6) Changing job assignments (D 7) 25

26 4 Guideline #4 Align Support Needs to Specific Support Strategies One of the most significant developments over the last decade has been the emergence of the concept of a system of supports. A system of supports is an approach to providing individualized supports. The system is based on having a method to assess individual support needs (such as those obtained from the SIS) and involves the implementa on of individualized support strategies (see Appendix 4 for examples of support strategies). Through the development of an Individual Support Plan, the supports provided to an Individual are matched to the person s assessed support needs, and this provides a structure for service providers to support individuals. When a Support Team starts to develop an ISP, it is helpful to think about supports as a system. Every member of the team is working within the system of supports to address needs that the Individual considers important. A system will be be er equipped to prevent old habits of teaching skills and decreasing undesirable behaviours because no member of the team works in isola on. Support strategies are organized so that each team member s input affects the system of supports and its outcomes. Support strategies make effec ve use of various resources (natural supports, skills and 26