DATES OUTCOME SUMMAY 1 What dates should be used as the start date and end date for an outcome? One county uses fiscal dates ex. 7/1 6/30 and another county uses the AUD ex. 10/13/15 10/12/16 The start date should be realistic to the specific outcome statement and desired result what will work for the person in their situation. The end date is an estimate from the team on when the outcome statement will be achieved this could be beyond the current plan year. In HCSIS/LMS (Job Aid for Creating Outcomes) key terms are identified. Outcome statements start and end dates do not necessarily match service details authorization and annual review dates. Outcome start and end dates should be tied to team meeting discussion; not the fiscal year renewal. 2 Outcome end date? If outcome achieved, do you put that as the end date? How long does that stay in an ISP? If the person has achieved their outcome statement and no longer wants support to maintain this outcome in their life, the actual end date (not a required field) can be entered into the Outcome Section. At the time of the annual plan meeting or critical revision, when services are no longer attached to the outcome phrase, the outcome statement can be removed from the ISP. EXAMPLES/TAINING SUGGESTIONS 3 ODP needs to make up detailed examples of ISP outcomes for every situation/service possible prevocational, employment, residential, supports coordination. Examples for service definitions need to be provided. How do you write an outcome statement for a day program? It is important to remember that services are not outcomes. In developing an outcome statement, the team starts with the person, not the service. The question is how does the day program support the person to achieve what is important to him/her? Providing examples limits people's creativity and does not place the focus on one person and what is important to him or her. In addition, examples tend to be used as templates for many people and therefore undermine individualized, person centered development of outcome statements. ODP plans to provide technical assistance through the regional offices so that teams can be assisted to develop person centered outcome statements with outcome actions and services that meet ODP requirements. 4 Are you able to create a tip sheet that contains what is needed in each ISP section? Differentiates the concerns related, current needs, and actions. The Annotated ISP (ISP Bulletin #00 15 01) provides tips and detailed descriptions of each part of the Outcome Section of the ISP. 5 Will you provide the notes and examples that presenter is using as part of PowerPoint? It was a lot of info to write down on the limited space available. In Fall 2015, a two part webcast will be provided on all Information Centers that will contain a printable version of the trainer notes. 9/14/15 Note: all questions were transcribed as written. 1
FEQUENCY AND DUATION OUTCOME ACTIONS 6 How should SC s determine how many service units to indicate in outcome action; frequency/duration for each outcome? Should SC s put in total # of units or breakdown units per each outcome action? It is important to remember that frequency and duration of all services is based on the individual needs of the person. The minimum monitoring requirement is identified in the Waiver; but all frequency is based on individual needs; especially in times of change and transition. The health and safety needs of the individual, identified throughout the ISP, should be reflected in the total amount of authorized service units along with services and supports that promote the achievement of the outcome statement. Frequency and duration identifies the service provided to assist the person to achieve the outcome statement. The frequency and duration is identified for the fiscal year, not for each individual SC activity/visit. The frequency and duration of a service is determined based on the outcome actions identified by the team. The question asked by the ISP eviewer is how did the team come up with the amount of service? The answer should be found throughout the needs identified throughout the ISP and is supported by the outcome actions. For example, in the Outcome Action section for a person who lives at home with their family and is supported in the P/FDS waiver, the F&D would state SC will conduct face to face monitoring once every six months and monitor by phone every three months. Service units are not identified in the Outcome Section of the ISP. In the service details section of HCSIS, there is one service authorization line which includes the total number of units for the service for the fiscal year. Multiple outcome phrases can be attached to one service. (SEE SEPAATELY POVIDED EXAMPLE). 7 Will SC units be required to be estimated for individuals receiving non funded services such as SC service only be required to be estimated in service details? No, if the person is receiving SC services only, service units are not identified in service details. 9/14/15 Note: all questions were transcribed as written. 2
8 How are SC s going to be able to put in frequency in terms of services, especially hchab, when each individual and families have different schedules? How are individuals/families supposed to be expected to identify hchab or companion services a certain # of times/week if their schedules vary? What exceptions can be made for this? Families/individuals need to have the freedom to use their services at the times they need them. Frequency and duration identifies the service provided to assist the person to achieve the outcome statement and is determined based on the outcome actions identified by the team. The question asked by the ISP eviewer is how did the team determine the amount of service? The answer should be found throughout the needs identified throughout the ISP and is supported by the outcome actions. Specificity/flexibility is based on the person's individual needs and is realistic based on the activity/circumstance/skill to be developed. Determining frequency and duration is supported by the action steps identified by the team after having thoughtful discussion during the planning process. Using a flexible approach to frequency and duration requires the team to investigate, explore and discuss the person's strengths and needs, need for service, and actions needed. If the team agrees that the person needs a paid service or unpaid support a certain number of days each week; frequency should be identified specifically. If the team agrees that it would be better for the person to have the flexibility of 18 hours per week without an exact number of days per week; then it is acceptable to state 18 hours per week. Another example to promote flexibility if the team agrees that 40 hours per month is the best way to provide service; the 40 hours/month is an acceptable amount of service to be identified in F&D. If service frequency and duration is identified per week or per month, that is the frequency and duration that must be provided. Service hours cannot be banked or made up. If services are being used at a different frequency than identified in the Outcome Section, the question should be asked what is the appropriate amount of service that should be provided? Up to and not to exceed totals are acceptable but words like approximate are not specific enough. 9/14/15 Note: all questions were transcribed as written. 3
9 Will S.C. frequency/duration reflect what is required as well as what is necessary to monitor satisfaction of service included for interim planning and challenges to outcomes, services, and health and safety as they arise? And can this statement itself be a satisfactory template? It is important to remember that frequency and duration of all services is based on the individual needs of the person. The minimum monitoring requirement is identified in the Waiver; but all frequency is based on individual needs; especially in times of change and transition. The health and safety needs of the individual, identified throughout the ISP, should be reflected in the total amount of authorized service units. The total amount of SC units in service details will include the amount of anticipated monitoring and considers the amount of service utilized in the prior year for locating and coordinating. The template provided does not personalize and individualize the person's support plan and does not identify frequency and duration of necessary monitoring. This template does not provide sufficient information for the person and team to know what service will be provided and how often. This is not a recommended template. 10 Frequency/Duration: A home/com hab program is authorized for a year. The use of those units should be able to be used in a year based on medical issues, family needs, weather. It was stated to us that if M, W, F is authorized and she is unavailable on M she loses those units. If specific days of the week are identified in the ISP in order to meet the person's needs and schedule; those are the exact days when service is to be delivered. If the service can be delivered any three days of the week, then there is flexibility on which days the service can be provided. Service hours cannot be banked or made up. If services are being used at a different frequency than identified in the Outcome Section, the question should be asked what is the appropriate amount of service that should be provided? 11 Flexibility cannot be used to accommodate an everyday life in frequency and duration? Why weekly instead of monthly? Specificity/flexibility is based on the person's individual needs and is realistic based on the activity/circumstance/skill to be developed. Determining frequency and duration is supported by the action steps identified by the team after having thoughtful discussion during the planning process. Using a flexible approach to frequency and duration requires the team to investigate, explore and discuss the person's strengths and needs, need for service, and actions needed. If the team agrees that the person needs the service a certain number of days each week; frequency should be identified specifically. If the team agrees that it would be better for the person to have the flexibility of 18 hours per week without an exact number of days per week; then it is acceptable to state 18 hours per week. Another example to promote flexibility if the team agrees that 40 hours per month is the best way to provide service; the 40 hours/month is an acceptable amount of service to be identified in F&D. If service frequency and duration is identified per week or per month, that is the frequency and duration that must be provided. Service hours cannot be banked or made up. If services are being used at a different frequency than identified in the Outcome Section, the question should be asked what is the appropriate amount of service that should be provided? Up to and not to exceed totals are acceptable but words like approximate are not specific enough. 9/14/15 Note: all questions were transcribed as written. 4
12 Clarify or reinforce that SC unit #s not required in frequency and duration section. We understand from this training that total annual units are not required in frequency and duration. Service units are not identified in the Outcome Section of the ISP. In the service details section of HCSIS, you can have one service authorization line which includes the total number of units for the service for the fiscal year. This one service authorization line may have multiple outcome phrases attached. 13 Does SC freq & duration need to reflect waiver requirements (i.e. 3 face to face per quarter for Cons. Waiver) in general or do they reflect how often SC monitors the specific outcome, (i.e. at least 1x per quarter for day program) dependent on the service? At a minimum, frequency and duration should reflect the waiver requirements. If the person's needs or life situation are changing (e.g. new housemate, leaving school, newly diagnosed medical condition), the frequency of the monitoring would likely increase in order to promote the person's health and safety. For example, in the Outcome Action section for a person who lives at home with their family and is supported in the P/FDS waiver, the frequency and duration would state SC will conduct face to face monitoring once every six months and monitor by phone every three months. 14 How do we handle freq/dur for a single provider providing services related to several outcomes. E.g. 3 separate outcomes for managing money, attending concerts, getting driver s license and same hab provider has actions for all 3. Team feels 6 hrs 3x/wk covers needs for all 3. Does a time period for each outcome need to be identified (eliminates flexibility) or can we have freq/dur 6 hrs 3x/wk for all 3 outcomes or either note or leave it implied that this covers all 3 outcomes each time it is written but is not (6 hrs 3x/wk) x3 for the total plan? Six hours/3 times per week would be written for each outcome statement understanding that the total amount for this service is 18 hours per week. The total amount of service is identified in the service authorization line. Specificity/flexibility is based on the person's individual needs and is realistic based on the activity/circumstance/skill to be developed. Determining frequency and duration is supported by the action steps identified by the team after having thoughtful discussion during the planning process. Using a flexible approach to frequency and duration requires the team to investigate, explore and discuss the person's strengths and needs, need for service, and actions needed. If the team agrees that the person needs the service a certain number of days each week; frequency should be identified specifically. If the team agrees that it would be better for the person to have the flexibility of 18 hours per week without an exact number of days per week; then it is acceptable to state 18 hours per week. Another example to promote flexibility if the team agrees that 40 hours per month is the best way to provide service; the 40 hours/month is an acceptable amount of service to be identified in F&D. If service frequency and duration is identified per week or per month, that is the frequency and duration that must be provided. Service hours cannot be banked or made up. If services are being used at a different frequency than identified in the Outcome Section, the question should be asked what is the appropriate amount of service that should be provided? Up to and not to exceed totals are acceptable but words like approximate are not specific enough. 9/14/15 Note: all questions were transcribed as written. 5
15 How do you document a service that is not scheduled per week ex: follow along employment support, respite, behavioral support, unlicensed residential hab? We are interpreting your question as how do you document the frequency and duration for these services. Specific to Unlicensed esidential Habilitation; this is a day unit that is authorized as 365 days per year. The frequency and duration would be identified in the Outcome Section of the ISP as 7 days per week, 52 weeks per year. In addition, as per Informational Packet 077 14, the plan should also describe the supports to be provided with projected hours per week. Day respite is authorized as a day unit and should be documented in that way. Temporary respite is authorized as number of hours per year to allow for flexibility on a weekly or monthly basis to meet the needs of the individual. Behavioral support may be documented as weekly or monthly; again depending on the needs of the individual. For employment support, the team should base the frequency and duration on what they think will happen as the individual begins or continues in employment. To allow for the greatest flexibility, it might work well to estimate weekly or monthly depending on the needs for the individual. Up to and not to exceed totals are acceptable but words like approximate are not specific enough and should not be included in frequency and duration. 16 E: Frequency & duration This information does not lineup with the provider monitoring questions 78, 79, 80. As ODP continues to refine and clarify expectations, all associated monitoring processes will be revised to measure in accordance with the direction provided in training. Specific to Provider Monitoring, there do not appear to be guidelines that are in conflict with the direction provided in this training. 17 Frequency/Duration is now being said that it can be as general as 3 days per week, but this does NOT follow AE oversight guidelines. As ODP continues to refine and clarify expectations, all associated monitoring processes will be revised to measure in accordance with the direction provided in training. Specific to AE Oversight Monitoring, there do not appear to be guidelines that are in conflict with the direction provided in this training. 18 How do you account for days missed at day program in frequency and duration? Individual attends 3 days a week. They miss a day here and there. Does a statement in frequency & duration ( missed days/time can be made up throughout fiscal year) meet requirements? Service hours cannot be banked or made up. If services are being used at a different frequency than identified in the Outcome Section, the question should be asked what is the appropriate amount of service that should be provided? Up to and not to exceed totals are acceptable but words like approximate are not specific enough. 9/14/15 Note: all questions were transcribed as written. 6
19 If frequency and duration are based on service and service is 5 days a week, 6 hrs. a day, provider outcome will be documented 2 days a week, 30 minutes each day. *Since ISP plan state 5 days a week, 6 hrs. a day, does ODP hold day program to working on outcome the entire service day. Services are selected to support the achievement of the outcome statement and meets the other needs of the person as identified in the ISP. If day support is the service that the team has identified that meets the needs identified throughout the ISP, including the Outcome Section of the ISP; that is the service selected. Services are expected to be delivered in conformance with 2380 and 2390 regulations. 20 Can you say quarterly or every 3 months; for the fiscal year, monthly? Within the plan year, frequency and duration can be listed as quarterly, every three months or once per month. An example specific to respite families often know how many times they will need overnight respite in a quarter or even within a month; some know which months of the year they will be looking for respite. F&D is based on a thorough discussion of what the person needs and accurately reflects the service that is being provided to the individual. An ISP eviewer will look to understand why the service frequency and duration was selected. Through specificity in F&D, the provider is able to understand how to implement the plan. 21 Give an example for SC Freq/&Duration. When an individual leaves school starting a new day program SC utilization so, there won t be an accurate utilization from previous year. Based on what the team knows about the person (strengths, skills, needs and preferences) and the availability of services, the amount of service utilization should be estimated for a person in a new situation or who has changing needs. When changing needs are identified this may also be an opportunity to discuss how to address these needs through the ISP team process to possibly include updates to the ISP or perhaps even critical revision. It is important to remember that frequency and duration of all services is based on the individual needs of the person. The minimum monitoring requirement is identified in the Waiver; but all frequency is based on individual needs; especially in times of change and transition. The health and safety needs of the individual, identified throughout the ISP, should be reflected in the total amount of authorized service units along with services and supports that promote the achievement of the outcome statement. 9/14/15 Note: all questions were transcribed as written. 7
22 If one provider works across multiple outcome actions, how is time identified in freq/duration for each? Is it divided up between actions or total listed in each freq/duration w/notation hours to be split up as needed? If one service provider is providing 18 hours of service per week across multiple outcome statements, in outcome actions the total amount for this service is 18 hours per week for each outcome statement. The amount of time spent on each outcome statement each week can be flexible. It is also important to remember that sometimes people do need a certain amount of support on a particular day. If that is the situation, then the frequency and duration for one particular outcome statement may need to be specifically identified. The total amount of service is identified in the service authorization line. Specificity/flexibility is based on the person's individual needs and is realistic based on the activity/circumstance/skill to be developed. Determining frequency and duration is supported by the action steps identified by the team after having thoughtful discussion during the planning process. Using a flexible approach to frequency and duration requires the team to investigate, explore and discuss the person's strengths and needs, need for service, and actions needed. 23 Difference between actions needed (freq/dur) and service detail page for SC services. If can t say as needed how can you calculate this difference. Clarify this is only for SC service not behav support, etc. Frequency and duration identifies the service provided to assist the person to achieve the outcome statement. The frequency and duration is identified for the plan year, not for each individual SC activity/visit. The frequency and duration of a service is determined based on the outcome actions identified by the team. Service units are not identified in the Outcome Section of the ISP. In the service details section of HCSIS, you can have one service authorization line which includes the total number of units for the service for the fiscal year. This one service authorization line may have multiple outcome phrases attached. Up to and not to exceed totals are acceptable but words like approximate are not specific enough. 24 Is supports coordination the only service that does not require units to be stated in Frequency & Duration? Service units should not be provided for any service in Frequency and Duration. Frequency and duration identify how often and how long. Service units are identified in Service Details. 9/14/15 Note: all questions were transcribed as written. 8
25 How do we calculate SC hours monthly for monitoring in outcome actions when individual needs change? Based on what the team knows about the person (strengths, skills, needs and preferences) and the availability of services, the amount of service utilization should be estimated for a new situation or changing needs. The outcome actions would change to reflect greater (or lesser) frequency of monitoring. It is important to remember that frequency and duration of all services is based on the individual needs of the person. The minimum monitoring requirement is identified in the Waiver; but all frequency is based on individual needs; especially in times of change and transition. The health and safety needs of the individual, identified throughout the ISP, should be reflected in the total amount of authorized service units along with services and supports that promote the achievement of the outcome statement. When the frequency of monitoring needs to increase from the required minimum or what was outlined when the plan was written due to new circumstances, the new frequency of SC monitoring should be included in frequency and duration section of ISP Outcomes. For example, while oy is adjusting to life in the community after returning home from an TF placement, the SC will provide face face monitoring monthly rather than the minimum frequency for P/FDS Waiver recipients in his situation. This will continue for the next four months and the need for monitoring frequency will be re evaluated at that time. 26 Traditionally we included SC service frequency (how often) but never defined duration for this service. (although we would define both frequency and duration for all others services). Now you are clarifying and asking that we define SC service frequency specific to each outcome. Is there some type of guidance on how to calculate those hours? Duration for supports coordination services can be documented annually. An example for minimum monitoring specific to a person receiving support through the Consolidated Waiver Three face to face monitoring visits every three months. The amount of time per visit does not have to be identified in frequency and duration. 27 There is no clarification on frequency & duration for day programming. The AE reports one way, the SC reports another, and then in training we are again told something different. Does day program need specific days, times example 8 a. 4pm, and total hours provided? Clarified on the ISP? The total amount of time per week should be documented in frequency and duration for day habilitation services. If a person attends only on Monday, Tuesday and Thursday from 9 am to 12 pm due to other day activities or employment, those specific hours and days should be identified in the Outcome Section. If the person attends any three days per week, that should be noted. The number of hours per week should be specific to the individual and how services are used and needed. The information should be descriptive so that the provider can implement the plan as directed by the team. The time (8 am 4 pm) does not need to be included in frequency and duration unless that is specifically what is needed by the person. In general, start and end time for day habilitation is noted in Health and Safety: Supervision Care Needs: Staffing atio Day. 9/14/15 Note: all questions were transcribed as written. 9
28 If a person missed a week at a day program & wants to utilize those missed hours the next week can they? Service hours cannot be banked or made up. If services are being used at a different frequency than identified in the Outcome Section, the question should be asked what is the appropriate amount of service that should be provided? 29 Frequency & Duration: How do we word for day program /APF to allow for late pick up early drop so the provider still gets reimbursed. 5 hrs./5 days/wk. will not allow the provider to be reimbursed for the situations listed above, correct? If this is an occasional issue, no change or adjustment is needed. If this is a regular, routine issue, ask the questions what supports does the person need? What needs to change in the ISP? 30 Is there any carry over allowed for future weeks if people are ill, etc. and unable to get services within a certain week. Is there allowance of make up hrs./units after month s time missed? Example: a client was on vacation for a week and missed time over Christmas could they make it up in the spring? Service hours cannot be banked or made up. If services are being used at a different frequency than identified in the Outcome Section, the question should be asked what is the appropriate amount of service that should be provided? GENEAL 31 The recommendation for starting w/outcomes in regards to this, the recommendation should be that all team members come prepared with ideas for outcomes they have thought of as working w/ & talking to the individual throughout the year, then the discussion would not be as time consuming and the responsibility is on all team members and still person centered. While ODP recommends starting the ISP team meeting with the Outcomes Section, the training emphasized that the process begins with information gathering. Through conversation, the team is engaging about the Important TO which are the person centered sections of the ISP (Like and Admire, Desired Activities, Important To, What Makes Sense, Understanding Communication). People that know the individual and spend time with him or her on a regular basis are always getting feedback and ideas from the person about what he or she wants to do, learn, achieve, maintain. It is important for the person to feel his or her ideas are being heard and brought into the outcome discussion that happens at the ISP meeting and it is important for people that know what the person says is important feel empowered to bring the information to the attention of the team. For example, if Barbara has been talking about camping something she has not done in a long time people that spend time with her at home and work will know it and they should bring this to the attention of the team it is important to Barbara. However, Teams are not encouraged to develop outcome statements outside of the team discussion and without the person and other team members present. Teams are not encouraged to develop pre written outcome statements outside of the team discussion and without the person present. People that support the person SHOULD come with ideas about what is important to the person. The listening, discovery, and learning involved in a person centered thinking process should be encouraged at all times; it should happen all the time. However, Teams are should not encouraged to develop outcome statements outside of the team discussion and without the person and other team members present. 9/14/15 Note: all questions were transcribed as written. 10
32 What happened to Wants vs. Needs? The new outcomes sound like wants NOT needs. In turn, do we authorize (amount of) services based on desires/wants instead of needs? The 2015 Outcome training emphasized that there are two parts to the Outcome Section of the ISP. In the Outcome Summary part, person centered outcome statements are developed which help the person to get the life they want and fulfill ODP's mission, vision and promotes an Everyday Life. In the Outcome Action part, the need to learn and maintain new skills and remain healthy and safe are addressed through paid and unpaid services. Therefore, wants and needs are both part of the process of developing the complete outcome section of the ISP: wants express something that is important TO the person (in an outcome statement) while needs are often found in concerns related to the outcome and in outcome actions where the team details what is needed to support the person s health and safety while successfully achieving what is important to him or her. HCSIS 33 Character limitations make some of these changes difficult. (ex: progress made & frequency). Will the character limitation be extended from 512? There are no system enhancements to increase character limits in HCSIS at this time. It is understood that this places limitations on amount of information provided. ISP/PLANNING/MONITOING 34 When an outcome is recognized as having been achieved, would you stop providing any services specifically meant for that outcome? If the person has achieved their outcome statement and no longer wants support to maintain this outcome in their life, the actual end date (not a required field) can be entered into the Outcome Section. At the time of the annual plan or critical revision, when services are no longer attached to the outcome phrase, the outcome statement can be removed from the ISP. For example, there have been things you might have wanted to achieve in your own life say, education and training that could be thought of as your outcome statement. For most people, finishing education might take several years and the actions that support it taking certain classes, securing funding, courses of study might change. So the outcome statement of finishing education continued over years while the actions supporting it changed more frequently. 35 Should all ISP s contain outcomes, including Base consumers with no paid services? Yes, abbreviated plans include the Outcome Section of the ISP. The person still receives the benefit of a person centered plan with identified needs. 9/14/15 Note: all questions were transcribed as written. 11
36 If a service is important to that person or something that they WANT; what is the best way to word this so that it can be in their plan and be paid for? The 2015 Outcome training emphasized that there are two parts to the Outcome Section of the ISP. In the Outcome Summary part, person centered outcome statements are developed which help the person to get the life they want and fulfill ODP's mission, vision and promotes an Everyday Life. Through conversation, the team is engaging about the Important To which are the person centered sections of the ISP (Like and Admire, Desired Activities, Important To, What Makes Sense, Understanding Communication). In the Outcome Action part, the need to learn and/or maintain new skills and remain healthy and safe are addressed through paid and unpaid services. During past outcome training, audience members were asked to relay their experience of receiving a service, such as physical therapy. As the trainer and volunteer talked through the experience, it became clear that receiving physical therapy service was not what was important to the person; most people wouldn t say going to a therapist is their goal. Instead, participants said their reasons for getting the service were things like being able to do things they enjoyed without pain or limitation. So, the service was not the person s outcome statement; it was the means to the end of what was important TO the person, being able to run, walk, take care of their own home, or spend time with loved ones doing fun physical activities. For more information on developing a person centered outcome statement, view the 2014 Outcome Statements webcast available on all Information Centers. 37 Is it required to have the individual s perspective in what makes sense? Certain AE s require this. Some SCs have been told that they aren't supposed to include different perspectives, like single team members. What Makes Sense/What Doesn't Make Sense is a person centered thinking skill that identifies areas of agreement and disagreement from multiple perspectives. All person centered skills and the ISP in PA, start with the person. The person him or herself is always first and their perspective and preferences are identified, understood and documented in this section of the ISP. 38 When will the monitoring tools be updated to reflect all changes wanted in outcomes? As ODP continues to refine and clarify expectations, all associated monitoring processes will be revised to measure in accordance with the direction provided in training. ISP EVIEW CHECKLIST 39 How does the ISP eview Checklist (specifically SH/AIS) line up with the information provided on the Outcome Section of the ISP? The total service authorization, including SH/AIS, is understood through all of the individual's needs that are documented throughout the ISP. The recommended ISP sections identified in the ISP eview Checklist are suggestions; not requirements. Not every single box needs to be checked within each section of the ISP eview Checklist; information does not have to be provided for each one of the items within each section of the ISP eview Checklist. Supervision care needs identified in the ISP eview Checklist must match what is described in that section of the ISP. Monitoring verifies that the ISP eview Checklist has been completed. 9/14/15 Note: all questions were transcribed as written. 12
OUTCOME DEVELOPMENT 40 For Outcome development moving forward, does it now need to be very specific to a task or situation and not global example: should it be John going to concert versus John will increase community activity? If you have a participant that wants to do many things in community? ide bike, ride bus etc., do these need to be separate outcomes? Short lived outcomes leads to constant critical revisions? Can multiple things an individual wants to accomplish be linked to one outcome? Ask yourself do you want to increase community activities? Or would you say I want to go to the movies or go to the diner on Sunday with my sister? If I was paid to assist you, which example would help me to know what is important to you and what you really want? Each year the ISP team convenes in order to plan for the coming year. Outcome statements are developed to bring a focused attention to the one or many things that are important to the person and for which they want to work on in that year. For that reason, outcome statements should be specific to what is important to the person and provide detail to the team in order to develop the appropriate services. For example, if you ask James what do you want to do in your free time? James might say I want to spend time out of the house with my friends. Other people on the team who know James well start to brainstorm on things that James might like to do with his friends out of the house. The team also looks at the Individual Preferences section of the ISP to be reminded about what James likes to do (Desired Activities). Throughout the ISP, things James needs to stay healthy and safe to spend time out of the house with friends are identified; and begin to identify services and supports. If a person has one outcome statement about spending time out of the house with friends, there are likely many other things that 24/7 residential habilitation staff are doing to help James continue to be part of the community. If he likes to go grocery shopping with staff or go to a place of worship and he needs staff support to be healthy and safe while in the community; the provider understands that is all part of the 24/7 residential service that is being provided. The same is true for all services. When the AE is reviewing the service details and service authorization line for any services, the AE eviewer will look to understand the need for service as identified in the Outcome Section of the ISP AND also through the entirety of the ISP (for example: Health and Safety Focus Areas, Supervision Care Needs, Know and Do). There are care needs that need to be addressed throughout the person's day and across various service providers. Through the development of the plan, it becomes clear what the individual needs and what is important to the person to be happy and comfortable. In reading the body of the plan, the AE eviewer and ODP should be able to clearly identify what assistance (paid and unpaid) is needed to help keep the person healthy and safe and learn and/or maintain new skills. Therefore, separate outcome statements do not need to be developed for everything a person needs help to stay healthy and safe. Global outcome statements are not needed as it is understood that the 24/7 provider will be helping the person to be safe and learn new things throughout the year. h h ld k h l d h b ll h l l? h k ll d b bl d f l 9/14/15 Note: all questions were transcribed as written. 13
41 How long do you leave completed (achieved) outcome in the plan? If the person has achieved their outcome statement and no longer wants support to maintain this outcome in their life, the actual end date (not a required field) can be entered into the Outcome Section. At the time of the annual plan or critical revision, when no services are no longer attached to the outcome phrase, the outcome statement can be removed from the ISP. 42 Is it acceptable to keep the outcomes the same year after year? When is it acceptable? Medically fragile? Is it necessary to indicate progress?? Yes, an outcome statement may be maintained over many years if it continues to be important to the person and needs to be kept in the spotlight. Over years, outcome actions may be changed to reflect the person's changing needs or interests. Outcome actions is also where needs related to what is Important For the person is identified. For a person who is medically fragile, does not communicate using words, has significant disabilities the work of the team is to explore and take a respectful guess based on what the person is saying through behavior and what the team knows about the person. The team identifies something that might be important to might bring happiness, joy, comfort, choice, relationships into the person's life. That one outcome statement then reflects what is Important to the person. All of the other person's health and safety needs and what is important for the person is identified through the full body of the ISP. The team will look at each outcome statement to determine if this is still something that is Important To the person considering their current skills and abilities. In terms of measuring progress for people with degenerative conditions yes, progress needs to be documented. Progress may not be about improving or learning new skills or moving forward. In these situations, the outcome actions may be preventing loss of skill or maintaining the person's current abilities. In long term care services, helping people to stay where they are (to prevent regression) is an acceptable measure of progress. 43 If an individual is non verbal, is the team able to select an outcome based on a skill the team thinks will benefit the individual in learning? How does this work for individuals who are non verbal? These individuals have no way to express what they would like to/want to do. For people who do not communicate using words, person centered thinking training teaches us to look at behavior. Through behavior, people will tell us what they want and what they don't want, what makes them happy or unhappy. In addition to the person's behavior, the people on the team, especially family or staff who spend the most time with the person, will know about what is important to the person and with respectful guessing can suggest an idea to the team about something to try. Sometimes, learning a new skill is satisfying in itself; some people might say learning the skill is important TO them. However, learning a skill almost always points to something else that is important to him or her. For example, Vera might want to learn to cook pasta, but her reason for doing so is that she can contribute something of value to the monthly dinners with her large Italian family. Learning the skill is an action that will lead to a deepening of relationships, which is really what is important to her. 9/14/15 Note: all questions were transcribed as written. 14
44 Why the redundancy in Outcome Action, F&D or repeating what SC or service is going to do? This is not redundancy but continuity and providing different details as you continue through the Outcome Actions part of the Outcome Section of the ISP. 45 Are passive but present tense verbs acceptable in outcome statements, ex. eceives, has, likes, enjoys? Push back on these words from teams. Also a lot of push back on present tense vs. future tense words such as wants. Please explain why this is future tense and why it is not an action verb (for families who refuse to accept we cannot say Joe wants ). The outcome statement should include an action verb in the present tense. This is the explanation provided during the 2015 training. Write outcome statements in the present tense in order to identify the expected result; not what will happen or what should happen. This has been a challenge for some team members for whom it does not make sense how this is present tense if it is not happening now? Here is something that might help you and other team members to better understand why outcome statements are written in the present tense. Think about that organizational mission statements are written in present tense as this is what is to be achieved; look at ODP s mission as an example. The following is from Power of Ted, Empowerment Dynamic by David Emerald. It was written to describe outcomes outside of the disabilities field. Desired Outcomes are Stated in Present Tense Outcomes are statements of vision. When we envision something, we see it as complete, whole, finished to the best of our ability. Some visions are clear and concrete, while others may be more vague with only a sense of direction to guide us. Yet, we need to step into that vision and state as if it were already here. Writing an outcome statement in the present tense answers the question How will I know when I have created it? 9/14/15 Note: all questions were transcribed as written. 15
46 Please comment on statements for people living in CLAs Is it referencing a paid service to say, Joe lives in the community so that he has independence and grows confident in his abilities? The lives in community is commonly used in CLA outcomes. Is this a reference to a paid ID service (i.e. CLA)? Whatever the person wants to achieve in their life is dependent on the person being healthy and safe and learning new skills. Through an understanding of what is important to the person and supervision care needs, know and do, medical and health and safety focus areas the necessary supports provided through CLAs are identified and understood. Although CLA's don't have outcomes; a residential habilitation service is provided to support the person to achieve their desired outcome statement. In addition, the residential habilitation service provides supports and care to the person that is identified throughout the ISP. Then the questions to develop outcome statements that are asked by the team are what is important to the person, who is this person and what is something that he or she wants in their life that is not present right now. Digging in deeper, then the conversation might go to what can the person learn to be more a member of the community, to make friends and have a fuller life? These are the questions that might lead to the development of an outcome statement for the person for that plan year. But all of this is individual to the person and it is based on the discussion, the information gathering and the knowledge of the people who know that person best. Outcome phrases like gym, worship services, and time with Mom are preferable to socialization because they point to outcome statements that are individualized and describe something that is important to the person. 47 Outcome actions What actions are needed does hab need to ID specific skill(s) to be worked on in this section (maintain, acquire increase)? The skills that are being worked on through the hab services should be identified throughout the full body of the ISP and provider actions should be found in provider documentation of service delivery. Frequency and duration are validated through all of the needs identified throughout the ISP; including but not only the Outcome Section of the ISP. 48 Can you use socialization or community integration as an outcome phrase. The outcome phrase is a key word or tag line to find the outcome statement. When developing a person centered outcome statement it is critical to identify what is important to the person and use language that is clear, understandable and common place. Community integration or socialization are not words that most people would use to describe what is important to them. Questions should be asked to find out who the person wants to spend time with and what he or she wants to be doing in the community. Finding out what is important to the person will help the team to develop a plan to obtain the desired result. Does the person want to join the gym, attend a faith based program, spend time with Mom or other family? In other words, who does the person want to be with and how do they want to spend their time? The outcome phrase could be Gym, Worship Service, or Time with Mom 9/14/15 Note: all questions were transcribed as written. 16
49 Clarify should outcome statements be broad or specific? If specific then for someone w/many hab hours they may have many outcomes. Ask yourself do you want to increase community activities? Or would you say I want to go to the movies or go the diner on Sunday with my sister? If I was paid to assist you, which example would help me to know what is important to you and what you really want? Each year the ISP team convenes in order to plan for the coming year. Outcome statements are developed to bring a focused attention to the one or many things that are important to the person and for which they want to work on in that year. For that reason, outcome statements should be specific to what is important to the person and provide detail to the team in order to develop the appropriate services. For example, if you ask Jimmy what do you want to do in your free time? Jimmy might say I want to spend time out of the house with my friends. Other people on the team who know Jimmy well start to brainstorm on things that Jimmy might like to do with his friends out of the house. The team also looks at the Individual Preferences section of the ISP to be reminded about what Jimmy likes to do (Desired Activities). Throughout the ISP, things Jimmy needs to learn to spend out of the house with friends and to stay healthy and safe are identified; and begin to identify services and supports. If a person has one outcome statement about spending time out of the house with friends, there are likely many other things that 24/7 residential habilitation staff are doing to help Jimmy continue to be part of the community. If he likes to go grocery shopping with staff or go to a place of worship and he needs staff support to be healthy and safe while in the community; the provider understands that is all part of the 24/7 residential service that is being provided. Separate outcome statements do not need to be developed for everything a person needs helps to stay healthy and safe. Global outcome statements are not needed as it is understood that the 24/7 provider will be helping the person to be safe and learn new things throughout the year. 50 What is ODPs expectation to answer questions: has the outcome been successfully accomplished. when the outcome/action is to maintain a skill? Maintaining an outcome typically means you re outcome actions are to maintain the accomplished outcome. Outcome statements that focus on "maintenance" mean it is important to the person that the team continue to perform actions to ensure what is important TO a person continues to be present in his/her life. It's an important to that might not occur without support to keep it going. 51 How do you relate residential goals to the ISP outcomes? We have always been told that all goals must be related to specific outcome statements. The provider action steps operationalize and individualize the actions identified in What actions are Needed? The actions are what is needed, the how is then developed by the provider specific to the person. 9/14/15 Note: all questions were transcribed as written. 17