Updated on January 3, 2022
Virginia and many other
states have moved to more individualized service planning for individuals with
intellectual disabilities. Depending on where you live, service plans may be
recognized by several different names but they all serve the same purpose.
Service plans are often referred to as Individual Service Plans (ISP), Consumer
Service Plans (CSP), or Person Centered Plan (PCP). Regardless of what you name
it, the ultimate purpose is to help the client achieve their personal goals.
Case managers and service coordinators have been using person-centered planning
for years. The goal is to expand on what we already provide in order to give
the client an even more personalized service plan. The person centered plan or
PCP puts more emphasis on what the client wants and the support team adjusts to
make it happen. The support team is dedicated to providing the supports needed
to help the individual thrive. Everything down to the venue of the planning
meeting is based on the individual needs of the person. Person centered plans
are not as simple as meeting for a few minutes and coming up with a few goals
for the year. The person centered plan is a process that involves gathering as
much information as possible in order to provide the most comprehensive,
personalized level of support. This includes obtaining a social history and
completing a number of assessments. I will discuss a few of them but of course
the process varies from state to state.
Social History/Personal Profile
One of the keys to developing a good person
centered plan is to find out as much information possible about the client.
This information is most often gathered at the intake process with the social
history assessment. Case managers ask questions regarding service history,
medical/hospitalization history, and any behavioral issues that may hinder
progress on personal goals. Case managers also gather information about
specific likes and dislikes. This information can be used to develop goals that
are tailor- made for the client instead of just generalized goals that are used
on every treatment plan.
Daily Routines
Case managers gather information about a
person’s daily routine and activities. It’s important for clinicians to obtain
an in-depth look at what the person does every day and determine if there are
any desired changes or things that could be improved.
School/Work/Day Support
Clinicians ask questions regarding progress
in school and any services that may be needed. Case managers work with school
staff and assist the client with obtaining services such as occupational and
speech therapy, or behavioral consultation.
If the client is out of school then the
case manager will have to determine if day support or vocational placement is
the most appropriate for the client needs.
Evening/Weekend Recreational Activities
Gathering information about recreational activities
help case managers and the client find the appropriate activities needed for
community integration. This information is also helpful for support staff that
provide services in the home.
Working/Not working
The main purpose of the person profile and
social history assessments is to determine what is working and not working for
the client. Case managers ask specific questions to determine if the services
they have in place are adequate. Whatever is not working can be changed or
adjusted. The appropriate service can be put in place so the problem that is
not working can be resolved.
Assessments
Functional Assessments
Functional assessments evaluate several key areas of development to
determine how much support is needed to complete basic activities of daily
living. The seven areas are Health, Task Learning Skills, Communication,
Mobility, Behavior, Personal Care, and Community Living Skills. In many states, individuals must meet the level of need in at least two (sometimes three) of the categories to
qualify for additional Medicaid Waiver services.
1. Health- This
section evaluates any medical needs such as assistance needed with taking
medications and obtaining care for any medical conditions.
2. Task Learning
Skills- This area measures the ability to complete multi-step tasks for
extended periods of time. This area is helpful in determining if a client needs
vocational services or day support services.
3. Communication- This
area of the assessment determines the ability to communicate verbally or
through gestures or signs. This information can determine if specialized
equipment such as communication boards or other forms of assistive technology.
4. Mobility- This area
determines the level of need regards to moving around their environment. It
also evaluates the need for certain equipment such as walkers, wheelchairs,
lifts, etc.
5. Behavior- This
section evaluates the need for behavioral consultation or other interventions
due to physical or verbal aggression.
6. Personal Care- This
section evaluates the level of care needed to perform basic activities of daily
living such as bathing, grooming, getting dressed.
7. Community Living
Skills- Case managers also evaluate the individual’s readiness to live in the
community and to determine if additional support is needed.
Health Status Assessment
Health status assessments are completed in
order to gather information on any family history of health problems as well as
any current health concerns. Case managers also collect information on all
current medications and health care providers. It is critical that case
managers obtain information on medications, dosages, and all doctors who
provide treatment. This information is stored in the client file and is
important in case of an emergency or a referral for other services.
Fall Risk Assessment
Fall risk assessments are extremely
important, as they provide information that can be used to ensure client
safety. Information from the fall risk assessment can be used by the support
team to put the appropriate precautions in place. A fall risk assessment can
determine if specialized equipment is needed such as stair lifts, walkers, and
wheelchairs. The fall assessment can also provide staff with a guide for
providing the right support during transportation such as a van with wheelchair
lift. Support staff will also have more specific instructions on how to provide
assistance with ambulating (moving around) their environment.
Plan Development
Finally, after completing all of the
assessments and gathering background information, it’s time to actually develop
a plan and put it into action. Case managers use the information to develop
goals and objectives. Some states refer to goals and objectives as “desired
outcomes”. Desired outcomes are categorized in two categories, “Important To”
and “Important For”. Outcomes that are important to the individual tend to be
goals that are centered on what they like to do. Outcomes that are important
for the individual are more focused on health and safety. I have listed just a few
examples of “important to” and "important for" outcomes.
Outcome examples that are “Important To”
the individual:
1. Obtaining a Job
2. Participating in Social Activities
3. Making Choices and Decisions
Independently
4. Learning to Cook on the stove
5. Obtaining an apartment
Outcome examples that are “Important For”
the individual:
1. Obtaining adaptive equipment
2. Maintaining Physical Fitness
3. Health and Safety Activities
4. Obtaining Healthcare Services
5. Behavioral Support
The PCP is never set in stone and can be
changed and adjusted throughout the year. The plan changes as the needs change
and as outcomes are achieved. Case managers maintain regular contact with the
client, family and service providers to ensure that support is provided and
that the desired outcomes are addressed according to the plan.
