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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
DATES ‐ OUTCOME SUMMARY
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 ARUD – 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.
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/TRAINING SUGGESTIONS
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.
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. R
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The Annotated ISP (ISP Bulletin #00‐15‐01) provides tips and detailed descriptions of each part of the Outcome Section of the ISP. 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.
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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.
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
FREQUENCY AND DURATION ‐ OUTCOME ACTIONS
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 Reviewer 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 SEPARATELY PROVIDED EXAMPLE).
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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.
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
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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.
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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 Reviewer 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.
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
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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?
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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. 10
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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.
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
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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.
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
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.
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?
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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.
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
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 Residential 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.
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RE: 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. 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.
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.
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
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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.
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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. 20
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Services are expected to be delivered in conformance with 2380 and 2390 regulations.
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 Reviewer 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.
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
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
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. 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.
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Up to and not to exceed totals are acceptable but words like approximate are not specific enough.
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.
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
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.
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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 Roy is adjusting to life in the community after returning home from an RTF 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. 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.
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 Ratio Day.
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
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? 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?
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? GENERAL
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.
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
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. 33
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HCSIS
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/MONITORING
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. 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.
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Responses to Frequently Asked Questions
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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?
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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.
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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.
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 REVIEW CHECKLIST
How does the ISP Review 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 Review Checklist are suggestions; not requirements. Not every single box needs to be checked within each section of the ISP Review Checklist; information does not have to be provided for each one of the items within each section of the ISP Review Checklist. Supervision care needs identified in the ISP Review Checklist must match what is described in that section of the ISP. Monitoring verifies that the ISP Review Checklist has been completed. 9/14/15
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Responses to Frequently Asked Questions
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OUTCOME DEVELOPMENT
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? Ride 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 Reviewer 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 Reviewer 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.
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
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. 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.
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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.
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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
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
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.
Are passive but present tense verbs acceptable in outcome statements, ex. Receives, 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?
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Responses to Frequently Asked Questions
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.
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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.
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.
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
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Responses to Frequently Asked Questions
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Clarify should outcome statements be broad or specific? If specific then for someone w/many hab hours they may have many outcomes.
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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
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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.
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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.
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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
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
Do we have to do separate outcomes for things don’t pertain to the outcome? For ex. The units for the concert, but what do we do about the units needed for doc. Appts., food shopping, etc.
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. 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. 9/14/15
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Responses to Frequently Asked Questions
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The waiver states services are authorized based on need – to prevent institutionalization. The examples of turning on a fan & seeing a live country music performance do not support this requirement.
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One purpose of the waiver is to provide opportunities for people to be part of and included in their communities; not only to prevent institutionalization. Another purpose is to meet needs for health and safety while in the community. The needs are identified and supported throughout the body of the ISP; not exclusively in the Outcome Section of the ISP.
Using Carol and Isaac as examples from training ‐ teams must separate needs for health and safety from what is important to the person. It is equally important to respect the sequence of outcome development and begin with what Carol or Isaac identify as important to them (or, in Carol’s example, something that people who know her well respectfully guess is important to her.) Before identifying the person’s needs and paid and unpaid supports to meet them, the person’s outcome statement must be fully developed and understood. In Isaac’s example, going to a concert is something that is meaningful to him and therefore supports development of an outcome statement that includes what is important to him. Later in the process, Isaac and his team identify needs for health and safety that may arise when he is at the concert. Waiver services support needs for health and safety while Isaac is pursuing something important to him; this information is recorded in outcome actions. In Carol’s example, her ability to direct her own life is limited. It is very important to her to be comfortable, feeling the breeze helps her be peaceful and calm. Further, being able to operate the fan when she wants supports her in being more in control of her environment and when and how she meets her own needs. After these important values are understood by the team and clearly articulated in an outcome statement – then, the team can begin to think about Carol’s needs and actions to support them. Learning to operate the fan meets Carol’s need to be in control of her own comfort (something we all enjoy) and staff will need to help her learn to operate the fan safely. Services and supports are put in place to address needs. In particular, services for Isaac and Carol are clearly related to their needs for health and safety while they pursue what is important to them. Needs that Isaac have to be healthy and safe are identified later in the outcome development process and specific actions are identified. What is important to Carol begins with an outcome statement that meets the criteria in ODP Outcomes Curriculum.
For both Carol and Isaac, the outcome statement is person‐centered because it is represents something that is important to each person and because it will help them to achieve the values of choice and control in their Everyday Life. This outcome statement also helps to fulfill ODP’s mission to help “people with developmental disabilities achieve greater independence, choice and opportunity in their lives”.
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After every outcome is achieved (ex. Isaac attended concert) do we have to write a new outcome every time?
Outcomes may be short or long term depending on the individual's needs. If the outcome is achieved in less than one year, but the person wants to maintain focus and services in this area, the outcome statement can be continued.
Over time, actions may change as a person learns new skills, grows more independent and/or expands the scope of what is important to him or her. 9/14/15
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The Outcome Section of the ISP: Better Outcomes, Better Lives
Responses to Frequently Asked Questions
Action steps in outcome actions ‐ are they the same as individual goals written by the provider to help accomplish the outcome?
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. It is repeatedly noted that the “outcome phrase” is a key word indicator – not a meaningful content area. Why is there a need to exclude service name in the phrase as these terms are most easily identifiable keywords. How would the exclusion improve quality?
You are correct. The outcome phrase is used as a function to search for the particular outcome statement. If you are searching for the outcome statement, a named service would not help as services are not named in outcome statements. This is consistent with ODP's direction that the ISP is a person centered process and outcome statements are about what is important to the person. The desired result, what the person wants present in their life is the keyword search. Why would we write an outcome so limited that it would be accomplished in a few months and not last through the entire fiscal year?
Outcome statements may be short or long term depending on the individual's needs. Some outcomes statements, such as Isaac’s concert, are an event that happens at a specific time and place and the outcome statement will be completed in less than a year. Other examples, such as going to an exercise class with friends in order to strengthen relationships and enjoy being healthier may occur over an entire year – or even several years. On the other hand, outcome actions (such as what class the friends attend or whether they decide to walk the mall instead of class sometimes) may change more frequently than a year.
When thinking about the length of time it takes to accomplish the person’s outcome statement, it is entirely dependent on understanding exactly what the person wants to achieve, not the length of time of the plan. If the outcome is achieved in less than one year, but the person wants to maintain focus and services in this area, the outcome statement can be continued.
Over time, actions related to the outcome statement may change as a person learns new skills, grows more independent and/or expands the scope of what is important to him or her. 9/14/15
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Responses to Frequently Asked Questions
OVERALL
Why do you have speakers not from ODP delivering ODP trainings? Why doesn’t the ODP personnel who create these changes do the trainings? Why doesn’t someone from ODP come to trainings to answer questions?
The content that was provided during this training was developed and approved by ODP. ODP staff are program and policy specialists. The trainers are experienced in delivering presentations to audiences and facilitating large groups. ODP was present at each training to hear the discussion and questions. Questions were not answered during the live trainings in order to maintain statewide consistency and in some cases identified issues that required further analysis and decision making by ODP.
Providers should be MANDATED to attend these trainings – SCs should not be required to train providers. The biggest struggle SCs have in creating good outcomes is getting providers to buy into the process. What plans are there to train providers?
Currently, there is no statutory requirement for mandated Provider training. Required provider training is being discussed for the future. If an SC is experiencing difficulty with a provider in the process for development of the Outcome Section of the ISP, the SC should inform their supervisor/administration. The SCO should then inform the Administrative Entity to request additional support. Trends identified within a provider organization should be made known to ODP for additional technical assistance.
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PROGRESS MADE ‐ OUTCOME ACTIONS
How do you know progress is being made: this measure against actions needed not against if the outcome statement is being achieved, for example, has Isaac purchased tickets attended to concert or that he has worked on his behaviors, save $?
The answer is both. The team should be measuring the progress on both the outcome actions and the ultimate achievement of the outcome statement. If outcome actions are being achieved but the outcome statement is still not present, the team should reconsider the action steps to make sure that ultimately the outcome statement is achieved; not just the outcome actions. By looking at provider progress notes, the ISP team will be able to evaluate progress on outcome actions and the achievement of the outcome statement.
How will we know progress is made? Contradicts maintaining skills which is OK. Ex: When we have aging individuals who may have dementia or such and they are only maintaining skills how do we monitor progress?
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, it may not about improving or learning new skills. In these situations, the outcome actions may be preventing loss of skill or maintaining the person's current abilities. How are home‐based providers being held accountable to provide documentation? Some do not provide the paperwork, so progress is based on observations by SC, & discussion with family or individual. An SC is an integral part of monitoring to ensure that documentation is present to account for the authorized service. When the SC finds that no documentation is present, the SCO administration should notify the Administrative Entity of the issue that needs to be resolved and request assistance. In addition, review of provider documentation is included in the Provider Monitoring process.
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Responses to Frequently Asked Questions
PROVIDERS
Providers were told @ recent licensing that “maintaining” is no longer appropriate. Person must show progress or outcome must be ended.
Reach out to the Administrative Entity or ODP Regional Office when licensing requirements do not match with ODP direction. Outcome statements can be maintained over time while outcome actions change in order to continue to meet the changing needs and abilities of the person.
ROLES AND RESPONSIBILITIES
Is ODP going to make sure that SC, SCO, AE’s are doing this correctly?
ODP continues to monitor the requirements related to the Outcome Section of the ISP. Questions are included in both the AE Oversight and SCO Monitoring instruments. In addition, follow up will be conducted ODP regional office meetings with each Administrative Entity and stakeholders webinars.
Would an AE ISP Reviewer approve a plan with an outcome for Support Coordination? How will the agencies (SCO’s) that practice this be made aware that there should not be an SC outcome? Will there be an information memo to address this issue?
Correct, Supports Coordination should not be it's own outcome statement. This has been part of ODP training and direction since 2008. AE ISP Reviewers were required to attend this 2015 training where this direction was provided again. Follow up will be conducted through AE Oversight Monitoring, ODP regional office meetings with each Administrative Entity and stakeholders webinars.
SERVICES
With County: We currently are required to have a separate Supports Coordination Outcome – the outcome action spells out the hours (in freq & duration) of supports coordinator. that we will use that year. County AE requires us to have a separate outcome action for each billable service. How can we consolidate the supports coor. outcome with the others, and still meet the County AE requirements?
In 2008, ODP began to train on the fact that services are not outcomes. Specifically, Supports Coordination, cannot be it's own outcome statement. Yes, the SC service should be listed separately and specifically as an outcome action supporting the achievement of the outcome statement. As the SC monitoring service is required; it is likely that the SC service will be listed for each outcome statement developed by the team. In the 2015 training, the following direction was given ‐ Presented today are ODP’s requirements for completing the Outcome Section of the ISP. All stakeholders with a role in this process should implement these requirements as identified in order to create a consistent process for all team members
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Responses to Frequently Asked Questions
Outcomes for AIS/SH and Behavioral Supports. These are not outcomes individual asks for or wants, but is a need.
Outcomes are not developed for services. Outcome statements identify something that is important to the person and something he or she wants in their life.
SH/AIS or behavioral supports are identified by the team in order to support the person to achieve their outcome statement. The question asked is ‐ what might be preventing the person from achieving their outcome statement? If these are things like ‐ behavior ‐ then the behavior support service is understood as Important For the person to achieve this outcome statement. Similarly, an identified medical or behavioral need requiring additional staff support authorized through SH/AIS would be identified through outcome actions: what action is needed. Services to achieve the outcome statement are identified in outcome actions: frequency and duration.
Outcomes – where do we place PT, speech, OT Behavioral supports? – Residential (if, say, he/she reside there) – or can it still be a separate outcome and then are they attached to community homes? Because PT, speech etc. are separate services so service details would be separate.
Following the sequence of developing the outcome section of the ISP, the team first develops the outcome summary including the outcome statements. Later, when outcome actions are identified, the team then discusses the services that best support the achievement of the outcome statement. It is in outcome actions: frequency and duration that the service is named. Services are not outcomes and so each service would not have a separate outcome statement.
On the service details screen, each specific service will be shown attached to an outcome phrase. Remember the outcome phrase is a key word search related to the outcome statement; also not the name of a service.
UTILIZATION
How will utilization be tracked if multiple providers are attached to the same outcome?
The outcome phrase will appear attached to each service; so listed more than one time. That service and attached units are tracked separately through
the service details screen. For example, if the need is 30 hours per week of nursing and provided by two different providers; the utilization will be tracked by each individual provider. Sometimes it is difficult in these circumstances to identify the exact number of hours to be provided by the different service providers. In this case, the two different providers need to coordinate and communicate to make sure that the total number of authorized hours per week are not overused. Depending on the model (AWC, Vendor/Fiscal, Traditional Providers), the SC is responsible for monitoring
and service utilization. WHO'S RESPONSIBLE ‐ OUTCOME ACTIONS
How do we name team members in the “who’s responsible” section when those team members change and there is turnover? Titles would be broader
and more consistent when talking long term.
The plan belongs to the person. In order to help the person and their family know who is responsible and to promote accountability, it is preferred to list the actual name of the person responsible for the service/support. If the person can be named (person is long‐term); the person's name should be listed. To reflect the reality of staff turnover and desire to keep the plan current without repeated general updates, if the actual person responsible is not long‐term, or if this is a service with multiple responsible staff or changing staff, another person who is ultimately responsible within the organization should be named.
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