Developing A Comprehensive Plan of Service

1、Developing A Comprehensive Plan of ServiceAnnual Home and Community Based Waiver Conference 2009 Charlyss BrandonAudrey CraftLinda FletcherLori IrishWhat we will do todayIntroduce the why and what of developing a comprehensive plan.Define what goals and objectives are.Break into small groups to prac

2、tice writing goals and objectives.Groups report out on plans.Review what we learned today. Eat earned rewardsyum!Individual Plan of Services (IPOS)As cited in the Mental Health Code, Chapter 7, 330.1712 sec.712 (1)The responsible mental health agency for each recipient shall ensure that a person-cen

3、tered planning process is used to develop a written Individual Plan of Services in partnership with the recipient.A preliminary plan shall be developed within 7 days of commencement of services or, if an individual is hospitalized for less than 7 days, before discharge or release.The individual plan

4、 of services shall consist of a treatment plan, a support plan or both and establish meaningful and measurable goals with the recipient.The individual plan of services shall address, as either desired or required by the recipient, the recipients need for food, shelter, clothing, health care, employm

5、ent opportunities, educational opportunities, legal services, transportation, and recreation.Individual Plan of Services (IPOS)The plan shall be kept current and be modified when indicated. The individual in charge of implementing the individual plan of services shall be designated in the plan.If a

6、recipient is not satisfied with his or her individual plan of services, the recipient, the person authorized by the recipient to make decisions regarding the individual plan of services, the guardian of the recipient, or the parent of a minor recipient may make a request for review to the designated

7、 individual in charge of implementing the plan. The review shall be completed within 30 days and shall be carried out in a manner approved by the appropriate governing body.An individual chosen or required by the recipient may be excluded from participation in the planning process only if inclusion

8、of that person would constitute a substantial risk of physical or emotional harm to the recipient or substantial disruption of the planning process. Justification for an individuals exclusion shall be documented in the case record. Development of the IPOSAssessments by identified team members prior

9、to the development of IPOS.Must consider health & safety, but not make it a barrier to achieving desired outcomes in the IPOS.IPOS must be kept current.IPOS must be signed by physician and parent at least annually.IPOS must designate who is responsible for implementing the plan.SupportNatural Su

10、pportsFriends, family, neighbors, co-workers, volunteers, peers, church membersCommunity SupportsCan be used by all, not just those with disabilitiesOther “system players”Schools, judicial system, Department of Human ServicesServices Specialty Mental Health, Substance Abuse and Developmental Disabil

11、ity servicesState Plan, Waiver, B3 (alternative)Receiving A Service Doesnt Always Equate to Meeting NeedsA Allow families to express their needs.A Avoid telling families what they need.A All service & support plans must be based on the identified needs.A Amount of service must be based on need.A

12、 Achieve the measurable outcome identified by the family.GoalsBroad statement of what the individual will do-what we expect. Goals DoAddress the persons whole life. Are about the person, not the system.Map the outcomes to individual wants to achieve/accomplish.Are focused on strengths.Change as the

13、individual changes.Goals-ExamplesTo maintain a healthy lifestyle. To participate in community events. To feel safe most of the time. To obtain a job. Goals and Objectives are NOT ServicesTo attend workshop 5 days per week. To receive supports coordination services. To have Community Living Supports.

14、 To continue current guardianship services. To receive Occupational Therapy. ObjectivesSteps to achieve the goal.Attainable for the individual.Results focused.Performance of specific behavior.Conditions or circumstances under which the behavior is performed includes level of prompting.Criteria for a

15、ttainment, progress of level of performance.The Difference Between Goals and ObjectivesGoals are broad: objectives are narrow.Goals are general intentions; objectives are precise. Goals are abstract; objectives are concrete. ObjectivesMake sure that the measure is:Observable CountableRelevantAttaina

16、bleNeil Brown, National Consultant-WraparoundDead Mans TestIf a dead man can do it, it is not an objective!Could a dead man do the following? To speak calmly to housemates without swearing 90% of the time over 3 consecutive months. With staff verbal prompts, will calmly engage in unfamiliar social e

17、vents at least 4 times per month for 3 months. Objectives-ExamplesWith the assistance of staff as needed, Carol will choose an activity in her community in which to participate 2 times per month for 3 consecutive months. When asked by staff, I will verbally state one positive aspect of each communit

18、y activity in which I engage 9 out of 10 consecutive times. Tips for Goal WritingUse the individuals own words when possible.If a service is requested dig deeper (what would the service accomplish?)Goals must need action to reach or maintain.Use a strength-based approach.Establishing Methodology for

19、 Implementing the IPOS For each service provided, including respite, there must be a goal related to the service. The service can be identified as a part of the methodology. The methodology must identify the amount, scope and duration. What is the service? Who will do it?What & when will it be d

20、one?How often will it be done?How long will it take? How will we know when we accomplish it? (measurable)Who will monitor for progress or need to change it?Establishing Methodology for Implementation of IPOSRevising the IPOS A change in the individuals present needs.Completion of goal.A new need is

21、identified.A change or disruption in the family or support system.IPOS Evaluation ProceduresMeasures of progress.A standard of performance.Related to method of keeping data of information.When Do I Need to Send Copies to MDCH for the CWP?If the child:Meets criteria for Category 1 of the CWP Decision Guide.Meets Intensity of Care-H