PC ISP 2015 Presented by Provider Development DBHDS

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

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Obtaining ISP materials ISP templates and videos are available online here: http: //www. dbhds. virginia. gov/ Select links in the following order to access the ISP Professionals And Service Providers Developmental Services Provider Development Person-Centered Planning Slide 3

The ISP Learning Cycle Before the Annual ISP Meeting Important TO Important FOR Part II Personal Profile At the Annual ISP Meeting Part III Shared Planning Person Part I Essential Information After the Annual ISP Meeting Part IV Agreements Part V Plan for Supports SIS START PC Reviews and Learning Documentation

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Updates emphasize… Comprehensive supports and most integrated settings Measurability Employment First PC ISP Community participation Skill-development Psychotropic medication use Monitoring Choice and control Risk Slide 6

Steve and Mary See ISP Training Packet pages 2 and 3 Slide 7

Part I: The Essential Information PART I: The Essential Information Slide 8

Part I: The Essential Information Key updates: • • Representation Friends & Community Contacts Psychotropic Medication use Employment First Exceptional Support Needs Plan for Self-Sufficiency Review of Most Integrated Settings Slide 9

Part I: The Essential Information 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. Slide 10

Part I: The Essential Information Page 4 Representation Slide 11

Part I: The Essential Information Slide 12

Moving from Service Life to Community Life A Good Paid Life Service Life ‘Important to’ recognized ‘Important to’ present • Important for addressed • No organized effort to address important to Focus on connecting, building relationships and natural supports • To and for present • Closest people are paid or family • Few real connections • To and for present • Active circle of support • Included in community life TLC-PCP 2013 www. learningcommunity. us Slide 13

Part I: The Essential Information Friends & Community Contacts Supported by… Person-Centered Practices Settlement Agreement CMS Final Rule Slide 14

Part I: The Essential Information Friends & Community Contacts Page 4 Slide 15

Part I: The Essential Information Slide 16

Part I: The Essential Information 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. Slide 17

Part I: The Essential Information Psychotropic Medication use Page 4 Slide 18

Part I: The Essential Information Slide 19

Part I: The Essential Information Slide 20

Part I: The Essential Information Page 5 Slide 21

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Part I: The Essential Information Active Medical and Behavioral Support Needs Slide 23

Part II: The Personal Profile Page 2 What support needs must be planned for with Steve? e c i t c a r P Slide 24

Part I: The Essential Information Active Medical and Behavioral Support Needs: Steve Page 6 e c i t c a r P Slide 25

Part I: The Essential Information Active Medical and Behavioral Support Needs: Steve Slide 26

Part II: The Personal Profile Page 3 What active medical or behavioral support needs must be planned for with Mary? e c i t c a r P Slide 27

Part II: The Personal Profile Active Medical and Behavioral Support Needs: Mary Page 6 Slide 28

Part II: The Personal Profile Active Medical and Behavioral Support Needs: Mary e c i t c a r P Slide 29

Part I: The Essential Information Slide 30

Part I: The Essential Information The Plan for Self-Sufficiency Considers future plans for inclusion; Replaces “discharge plan” in the ISP; Applies to every individual. Slide 31

Part I: The Essential Information Page 7 Steve Slide 32

Part I: The Essential Information Page 7 Mary Slide 33

Part I: The Essential Information Slide 34

Part I: The Essential Information Page 8

Part II: The Personal Profile PART II: The Personal Profile Slide 36

Part II: The Personal Profile Areas: • • • My Meeting Talents & Contributions The Life I Want My Life Today Getting the Life I Want Slide 37

Part II: The Personal Profile Page 9 Slide 38

Part II: The Personal Profile 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 39 39

Part II: The Personal Profile Important FOR What we need to stay healthy, safe and valued • • • Physical and emotional health Safety and security Things that make you valued in community l a c i d e m e v i t c a e h t ed d w e o e n n k s Do you ioral support v a h n? e o b s r d e p an h c a e r o f 40 40

Part II: The Personal Profile Do the individual’s desired outcomes relate to talents, preferences and needs as identified in the assessments and individual support plan? 41

Part II: The Personal Profile Do you know what is needed for health and happiness? TO FOR 42

Part II: The Personal Profile Slide 43

Part II: The Personal Profile Page 10 Slide 44

Part II: The Personal Profile Page 11 What is important to YOU about work? e c i t Prac Slide 45

Part II: The Personal Profile Page 2 Slide 46

Part II: The Personal Profile Page 12 What is important TO Steve about work? e c i t c a r P Slide 47

Part II: The Personal Profile What is important TO Steve about work? Slide 48

Part II: The Personal Profile What is important TO Steve about work? Slide 49

Part II: The Personal Profile What is important TO Steve about work? Slide 50

Part II: The Personal Profile Page 3 Slide 51

Part II: The Personal Profile What active support needs must be addressed in planning? Page 13 Slide 52

Part II: The Personal Profile Page 13 What would be important to YOU if you had the same needs as Mary? e c i t Prac Slide 53

Part II: The Personal Profile Page 14 What is important TO Mary about Health and Safety? e c i t Prac Slide 54

Part II: The Personal Profile What is important TO Mary about Health and Safety? Slide 55

Part II: The Personal Profile What is important TO Mary about Health and Safety? Slide 56

Part II: The Personal Profile What is important TO Mary about Health and Safety? Slide 57

Part II: The Personal Profile To plan successfully… We need to begin thinking about how active medical and behavioral support needs relate to the important To information. Slide 58

Part II: The Personal Profile How does what’s important TO Mary relate to each of these active medical support needs? Slide 59

Part II: The Personal Profile How does what’s important TO Mary relate to each of these active medical support needs? Slide 60

Part II: The Personal Profile How does what’s important TO Mary relate to each of these active medical support needs? Slide 61

Part II: The Personal Profile How does what’s important TO Mary relate to each of these active medical support needs? Slide 62

Part II: The Personal Profile How does what’s important TO Mary relate to each of these active medical support needs? Slide 63

Part II: The Personal Profile How does what’s important TO Mary relate to each of these active medical support needs? Slide 64

Part II: The Personal Profile What if Mary also had asthma? Slide 65

Part II: The Personal Profile What if Mary also had asthma? Slide 66

Part III: Shared Planning PART III: Shared Planning Slide 67

Part III: Shared Planning Page 15 Work and Alternates Learning & Other Pursuits Relationships Transportation & Travel Money Home Community & Interests Health & Safety Slide 68

Part III: Shared Planning 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. Slide 69

Part III: Shared Planning What are Outcomes? Outcomes are NOT services. “Jack receives residential services. ” Outcomes are NOT meaningless to the person. “Jack ties his shoes. ” Outcomes ARE observable and are based on what is important TO each person! 70

Part III: Shared Planning Writing outcomes… Important TO: Being organized Outcome: Steve is 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) Slide 71

Part III: Shared Planning Writing outcomes… Previous outcome example: Steve goes to Pizza Shack in order to eat with his friends. Updated outcome examples: Steve eats dinner with his friends. Steve spends time with his friends. Steve goes out to eat. Slide 72

Part III: Shared Planning Writing outcomes… Steve eats dinner with his friends. “I no longer want/need supports when…” Which makes more sense with this outcome? An achievement or introducing natural supports? Slide 73

Part III: Shared Planning 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. ! c i f eci B p s e Slide 74

Part III: Shared Planning Steve’s important TO list about work from his personal profile. Slide 75

Part III: Shared Planning Develop an outcome to address what’s important TO Steve about work Page 15 e c i t c a r P Slide 76

Part III: Shared Planning Complete outcome to address what’s important TO Steve about work Page 16 e c i t c a r P Slide 77

Part III: Shared Planning Example outcome to address what’s important TO Steve about work e l p xam E Slide 78

Part III: Shared Planning Active need Outcome y r a M Slide 79

Part III: Shared Planning Mary’s active support needs list e c i t Prac Slide 80

Part III: Shared Planning Mary’s important TO list for Health & Safety Page 16 Slide 81

Part III: Shared Planning Mary’s active medical support needs list Page 17 e c i t Prac Slide 82

Part III: Shared Planning Mary’s active medical support needs list ? ? ? e c i t Prac Slide 83

Part III: Shared Planning What if Mary also had asthma? Slide 84

Part III: Shared Planning What if Mary also had asthma? Important TO Important FOR Breathing easily. Using an inhaler each day. Outcome: Mary breathes easily. 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? Slide 85

Part III: Shared Planning What if Mary also had asthma? Outcome: Mary breathes easily. I no longer want/need supports when… 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. Slide 86

Part III: Shared Planning What if Steve also had asthma? Outcome: Steve breathes easily. I no longer want/need supports when… Steve is able to use his inhaler as prescribed for 6 months, until assistive technology is available or until he no longer needs it. Slide 87

Part III: Shared Planning Using the outcomes, complete Part III. Slide 88

Part III: Shared Planning Outcomes needed to complete Shared Planning 1: The active medical and behavioral needs outcomes 2: The 5 required life areas 3: The 3 standard outcome options Slide 89

Part III: Shared Planning The 5 required life areas… Work & Alternates to Work Learning & Other Pursuits Community & Interests Home Health & Safety ality u Q f eo Offic gement & Mana lopment Deve Slide 90

Part III: Shared Planning The “Active Needs” outcomes… Medical Behavioral Taking from others Heart conditions Hurting oneself Diabetes Psychiatric needs Communication Fall risk Causing harm Sensory needs Slide 91

Part III: Shared Planning 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. Slide 92

Part III: Shared Planning 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 medications Going to medical appointments Routine personal care (bathing, dressing, cleaning, etc. ) Steve is healthy, safe and a valued member of his community. Slide 93

Part III: Shared Planning The 3 standard outcome options… 2: Supports that are periodic in nature and provide for semi-predicable events that result in services provided and billed under periodic support hours. Steve has something to do when plans are cancelled. Slide 94

Part III: Shared Planning The 3 standard outcome options… 3: Activities related to Targeted Case Management provided exclusively by the Support Coordinator such as: Assessing, planning, coordinating, linking and monitoring of services & supports Steve’s desired outcomes are achieved. Slide 95

Part III: Shared Planning 5 required life areas? Active Medical/Behavioral? 3 standard outcome options? Steve is not tired all the time due to diabetes. Steve has his own business and makes more money. Steve has more friends. Steve explores different ways to enjoy music. Steve is organized. 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. Page 17 Slide 96

Page 18 Outcome Worksheet available Slide 97

Part IV: Agreements Page 19 PART IV: Agreements Slide 98

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Part IV: Agreements Privacy is ensured… Slide 100

Part IV: Agreements Self-direction is supported… Slide 101

Part IV: Agreements The inability to meet preferences is described… Slide 102

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Part V: Plan for Supports PART V: The Plan for Supports Slide 107

Part V: Plan for Supports Page 20 Slide 108

Part V: Plan for Supports Page 21 Slide 109

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Part V: Plan for Supports 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. Slide 112

Part V: Plan for Supports Page 22 Steve eats dinner with his friends. Write 3 activities that support this outcome. e c i t c a r P Slide 113

Part V: Plan for Supports Steve eats dinner with his friends. Write 3 activities that support this outcome. E e l p xam Slide 114

Part V: Plan for Supports Steve eats dinner with his friends. Could any of these be skill-building? E e l p xam Slide 115

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Part V: Plan for Supports Develop 3 activities that support this outcome. Slide 117

Part V: Plan for Supports Page 23 e c i t Prac Slide 118

Part V: Plan for Supports E s e l p xam Slide 119

Part V: Plan for Supports Page 24 Slide 120

Part V: Plan for Supports Develop 1 outcome related to a meaningful day for Mary. Page 25 e c i t Prac Slide 121

Part V: Plan for Supports Develop 3 activities that support this outcome. Slide 122

Part V: Plan for Supports Page 26 e c i t Prac Slide 123

Part V: Plan for Supports E s e l p xam Slide 124

Part V: Plan for Supports 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. e c i t Prac Slide 125

Part V: Plan for Supports Write 3 instructions related to this activity… Page 27 Steve budgets his money. e c i t c Pra Slide 126

Part V: Plan for Supports What support instructions include… Steve budgets his money. E e l p xam Slide 127

Part V: Plan for Supports E e l p xam Slide 128

Part V: Plan for Supports Page 28 Slide 129

Part V: Plan for Supports Page 29 Slide 130

Ongoing Learning & Documentation Ongoing Learning and Documentation Slide 131

Ongoing Learning & Documentation “Morning Routine” on the PFS = “Morning Routine” on the schedule Slide 132

Ongoing Learning & Documentation Steve’s checklist is based on his schedule Page 30 Slide 133

Ongoing Learning & Documentation Page 31 Slide 134

Ongoing Learning & Documentation Page 32 Slide 135

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Ongoing Learning & Documentation Page 33 Slide 140

Ongoing Learning & Documentation Page 34 Slide 141

Beware of… Documentation Drift! Slide 142

Person-Centered Review Page 35 The Person. Centered Review Slide 143

Person-Centered Review Outcome status definitions Met = Outcome was achieved (and ended). Partially Met = Outcome was partially achieved. Not Met = Outcome was not achieved. Slide 144

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Questions? Contacts and resources: Community Resource Consultants (PC ISP): http: //www. dbhds. virginia. gov/professionals-and-serviceproviders/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/developmentaldisabilities/doj-settlement-agreement CMS Final Rule information at DMAS: http: //www. dmas. virginia. gov/Content_pgs/HCBS. aspx Slide 150