DBHDS Vision: A life of possibilities for all Virginians PC ISP 2015 Presented by Provider Development DBHDS Division of Developmental Services April 2015

DBHDS Vision: A life of possibilities for all Virginians

PC ISP 2015Presented by Provider Development

DBHDS Division of Developmental ServicesApril 2015

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Obtaining ISP materials

ISP templates and videos are available online here:

Professionals And Service Providers Developmental Services Provider Development Person-Centered Planning

http://www.dbhds.virginia.gov/

Select links in the following order to access the ISP

http://www.dbhds.virginia.gov/

Person

SIS

Part V Plan for Supports

PC Reviews and Learning

At the Annual ISP Meeting

After the Annual ISP Meeting

Before the Annual ISP Meeting

The ISP Learning Cycle

Important TO

Important FOR

Part III Shared

Planning

Part IV Agreements

Part II Personal Profile

Part I Essential

Information

STARTSTARTDocumentation

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Updates emphasize…

Psychotropic medication use

Skill-development

Employment First

Comprehensive supports and most integrated settings

Measurability

Community participation

Monitoring

Risk

Choice and control

PC ISPPC ISP

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Steve and Mary

See ISP Training Packet pages 2 and 3

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Part I: The Essential Information

PART I: The Essential Information

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• Representation• Friends & Community Contacts• Psychotropic Medication use• Employment First• Exceptional Support Needs• Plan for Self-Sufficiency• Review of Most Integrated

Settings

Key updates:


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Representation

CMS Final Rule guidance: People under guardianship or other legal assignment of individual rights, or who are being considered as candidates for these arrangements, should have the opportunity in the PCP process to address any concerns.


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RepresentationPage 4

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Slide 13TLC-PCP 2013 www.learningcommunity.us

ServiceLife

CommunityLife

• Important for addressed• No organized effort to address important to

• To and for present• Active circle of support• Included in community life

• To and for present• Closest people are paid or family• Few real connections

A Good Paid Life

Focus on connecting, building relationshipsand natural supports‘Important to’ present

‘Important to’ recognized

Moving from Service Life to Community Life

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Friends & Community Contacts

Supported by…

Person-Centered Practices Settlement Agreement

CMS Final Rule


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Friends & Community Contacts Page 4

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Psychotropic Medication use


Per the Office of Human Rights the record should show:

• the medication prescribed, to include dosage;

• an acknowledgement, if appropriate, that the individual/decision-maker was made aware of the risk/benefits/side effects by the prescribing physician;

• contact information for the prescribing physician for any further questions;

• the signature of individual and/or decision-maker.

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Psychotropic Medication use


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Active Medical and Behavioral Support Needs


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Part II: The Personal Profile

What support needs must be planned for with Steve?

Practice

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Practice

Active Medical and Behavioral Support Needs: Steve Page 6

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Active Medical and Behavioral Support Needs: Steve


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What active medical or behavioral support needs must be planned for with Mary?

Practice

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Active Medical and Behavioral Support Needs: Mary Page 6

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Practice

Active Medical and Behavioral Support Needs: Mary

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The Plan for Self-Sufficiency

Considers future plans for inclusion;

Replaces “discharge plan” in the ISP;

Applies to every individual.

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Steve

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Mary

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PART II: The Personal Profile

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Profile Areas:

• My Meeting• Talents & Contributions• The Life I Want• My Life Today• Getting the Life I Want

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What makes a person happy, content, fulfilledWhat makes a person happy, content, fulfilled

• People, pets• daily routines and rituals, • products and things, • Interests and hobbies, • places one likes to go

Important TOImportant TO


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What we need to stay healthy, safe and valuedWhat we need to stay healthy, safe and valued

• Physical and emotional health• Safety and security• Things that make you valued in community


Important FORImportant FOR

Do you know the active medical

and behavioral supports needed

for each person?Do you know the active medical

and behavioral supports needed

for each person?

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Do the individual’s desired outcomes relate to talents, preferences and needs as identified in the assessments andindividual support plan?

Do the individual’s desired outcomes relate to talents, preferences and needs as identified in the assessments andindividual support plan?


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Do you know what is needed for health and happiness?


TOTO FORFOR

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What is important to YOU about work?

Practice

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Practice

What is important TO Steve

about work?

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about work?

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about work?

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What is important TO Steve about work?

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What active support needs must be addressed in planning?

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What would be important to YOU if you had the same

needs as Mary?

Practice

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Practice

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What is important TO Mary

about Health

and Safety?

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about Health

and Safety?

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about Health

and Safety?

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about Health

and Safety?

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We need to begin thinking about how active medical and behavioral support

needs relate to the important To information.

To plan successfully…

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How does what’s important TO Mary relate to each of these

active medical support needs?

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What if Mary also had asthma?

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Part III: Shared Planning

PART III: Shared Planning

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Work and Alternates

Community & InterestsHome

Money

Health & Safety

Transportation & TravelRelationships

Learning & Other Pursuits

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Writing outcomes…

Name important TO.

Writing an outcome based on the heart of each issue provides for a variety of

ways to support a person having what he or she wants.

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Outcomes are NOT meaningless to the person.“Jack ties his shoes.”

Outcomes are NOT services.

“Jack receives residential services.”

Outcomes ARE observable and are based on what is important TO each person!

Outcomes ARE observable and are based on what is important TO each person!

What are Outcomes?What are Outcomes?


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Writing outcomes…

Outcome: Steve is

organized.

Important TO: Being organized

Measure: When Steve is able to

organize his DVD collection, his

baseball cards and his closet himself.

By when:

January 1, 2016

Who will support

me?

ABC Residential

Martha (mother)

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Writing outcomes…

Steve eats dinner with his friends.

Previous outcome example: Steve goes to Pizza Shack in order to eat with his friends.

Updated outcome examples:

Steve spends time with his friends. Steve goes out to eat.

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Writing outcomes…Steve eats dinner with his friends.

“I no longer want/need supports when…”

Which makes more sense with this outcome?

An achievement

introducing natural supports?or

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Writing outcomes…Steve eats dinner with his friends.

“I no longer want/need supports when…”

When Steve is able to schedule meals with his friends and has their support going to, during and returning home from meals.

Be specific!

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Steve’s important TO

list about work from his personal profile.

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Practice

Develop an outcome to address what’s important TO Steve about work Page 15

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Practice

Complete outcome to address what’s important TO Steve about work

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Example

Example outcome to address what’s important TO Steve about work

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Active need Outcome

MaryMary

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Practice

Mary’s active

support needs list

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Mary’s important TO list for Health &

Safety

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Practice

Mary’s active medical support needs list Page 17

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Practice

Mary’s active medical support needs list

??

???

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Outcome: Mary breathes easily.

Breathing easily. Using an inhaler each day.

Important TO Important FOR

Based on what we know about Mary, to resolve this outcome ask…

Can she develop a skill?Can assistive technology be used?Can natural supports be introduced?


Can the condition improve?

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I no longer want/need supports when…

Outcome: Mary breathes easily.

Mary is unable to use her inhaler and supports are expected to continue until she no longer needs it, until assistive technology can be identified or natural supports can be introduced.


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What if Steve also had asthma?

I no longer want/need supports when…

Outcome: Steve breathes easily.

Steve is able to use his inhaler as prescribed for 6 months, until assistive technology is available or until he no longer needs it.


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Using the outcomes, complete Part III.

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Outcomes needed to complete Shared Planning

1: The active medical and behavioral needs outcomes

2: The 5 required life areas3: The 3 standard outcome options


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The 5 required life areas…

Work & Alternates to WorkLearning & Other Pursuits

Community & Interests

Office of Quality

Management &

Development

HomeHealth & Safety


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The “Active Needs” outcomes…

MedicalBehavioral

Communication

Sensory needsFall risk

Psychiatric needs

DiabetesHeart conditions

Causing harm

Hurting oneself

Taking from others


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The 3 standard outcome options…Routine health and safety

Periodic Supports Support Coordination

Steve is healthy, safe and a valued member of his community.

Steve has something to do when plans are cancelled.

Steve’s outcomes are achieved.


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The 3 standard outcome options…


1: Routine tasks that are not major “active needs” or focused on skill-building and are related to health & safety such as:

Taking medicationsGoing to medical appointments

Routine personal care (bathing, dressing, cleaning, etc.)


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2: Supports that are periodic in nature and provide for semi-predicable events that result in services provided and billed under periodic support hours.


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Steve’s desired outcomes are achieved.

3: Activities related to Targeted Case Management provided exclusively by the Support Coordinator such as:

Assessing, planning, coordinating, linking and monitoring of services & supports


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Steve is not tired all the time due to diabetes.

Steve explores different ways to enjoy music.

Steve has more friends.



Steve’s outcomes are achieved.

Steve is organized.


Steve has his own business and makes more money.

Active Medical/Behavioral?5 required life areas? 3 standard outcome

options?

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Outcome Worksheet available

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Part IV: Agreements

PART IV: Agreements

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Part IV: Agreements

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Part IV: Agreements

Privacy is ensured…

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Part IV: Agreements

Self-direction is supported…

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Part IV: Agreements

The inability to meet preferences is described…

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Part IV: Agreements

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Part IV: Agreements

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Part IV: Agreements

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Part IV: Agreements

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Part V: Plan for Supports

PART V: The Plan for Supports

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Writing activities…

Name action verb activity.

Writing an activity is based on what can be seen when

supporting a person to learn or have what he or she

wants.

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Practice

Write 3 activities that support this outcome.

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Example

Write 3 activities that support this outcome.

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Example

Could any of these be skill-building?

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Develop 3 activities that support this outcome.

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Practice

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Examples

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Practice

Develop 1 outcome related to a meaningful day for Mary.Page 25

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Develop 3 activities that support this outcome.

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Practice

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Examples

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Practice

What support instructions include…

• How DSPs will support this person.

• What the individual can or likes to do.

• The type of support needed - detailed.

• What is needed for success.

• Where and what learning is recorded.

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Steve budgets his money.

Write 3 instructions related to this activity…

Practice


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Steve budgets his money.

What support instructions include…

Example


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Example


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Ongoing Learning & Documentation

Ongoing Learning and Documentation

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“Morning Routine” on the PFS=

“Morning Routine” on the schedule

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Steve’s checklist is based on his schedule

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Beware of…

Documentation Drift!

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Person-Centered Review

The Person-Centered Review

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Met = Outcome was achieved (and ended).Partially Met = Outcome was partially achieved.Not Met = Outcome was not achieved.

Outcome status definitions

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Contacts and resources:Community Resource Consultants (PC ISP): http://www.dbhds.virginia.gov/professionals-and-service-providers/developmental-disability-services-for-providers/provider-development

Person-Centered Thinking Training: http://www.personcenteredpractices.org/

Settlement Agreement information at DBHDS:http://www.dbhds.virginia.gov/individuals-and-families/developmental-disabilities/doj-settlement-agreement

CMS Final Rule information at DMAS: http://www.dmas.virginia.gov/Content_pgs/HCBS.aspx

Questions?

Documents

DBHDS Vision: A life of possibilities for all Virginians PC ISP 2015 Presented by Provider Development DBHDS Division of Developmental Services April 2015