Frequently Asked Questions

Personal Plan Overview

  1. What should a provider do if there is disagreement about outcomes that are outlined in the PP? Should outcomes change on a yearly basis?
    • It is vital that providers, ISC and the individual communicate effectively to support the individual. ISC should review all data and necessary documents to ensure progress is being made on outcomes. If progress is not being made, the ISC should determine why that is happening. If the individual has changed their mind regarding an outcome, the ISC and provider should respond appropriately to help the individual have a meaningful life with the experiences, opportunities and chances to achieve the desired life. If there is disagreement on outcomes among the provider, the ISC and the individual, then all parties should go through the conflict resolution process. LINK to Problem and Conflict Resolution: Addressing Issues, Solving Problems, Troubleshooting
  2. What is the difference between "Outcomes", "Goals" and "Strategies"?
    • The Personal Plan establishes Outcomes to help the person achieve the desired opportunities or life they want to have. Plans may need to include smaller, measurable strategies to assisting the person achieve their desired outcomes. Functional goals include any skills training that is in place to teach life skills. This could include training to increase adaptive skills, such as cleaning a bedroom, or completing laundry twice a week. These are goals that are not included in a desired outcome. Functional goals could also include health goals, such as maintaining or reducing blood sugar, making healthy eating choices, turning off devices an hour before bed to promote healthy sleep, etc. All goals and outcomes should be monitored on the monthly progress note.
      • Example of an Outcomes:
      • Brian will attend an MLB game so that he can enjoy his favorite sport.
      • Example of Strategies to help achieve the Outcomes:
      • Brian will watch his favorite baseball team on TV.
      • Brian will attend a local baseball game in his community.
      • Brian will watch his favorite baseball team on TV in a local sports bar.
      • Brian will save money to attend an MLB game.
      • Brian will prepare his favorite baseball game snack to enjoy during a game at home.
      • Brian will attend a college (or AAA) baseball game in a nearby town.
  3. Under what circumstances does the Personal Plan need to be updated?
    • Any time there is a significant change to the person's situation, the Personal Plan and Discovery Tool should be updated. This will trigger the update to the Implementation Strategy. For example, if an individual moves and it requires a different service provider.

Discovery Tool

  1. What is the timeframe for completing the Discovery Tool, the Implementation Strategies and the Personal Plan?
    • The Discovery Tool needs to be updated within 365 days of the previous Tool. And no more then 6 months before the Personal Plan. The Personal Plan needs to be updated every 365 from the previous PP. The date of the Discovery Tool is the date the ISC signs it; the following year's DT must be completed within 365 days.
  2. Who should be included in the Discovery meeting and how long should it last?
    • The Discovery process should include collaboration with all providers and stakeholders that support the individual. Ultimately, the individual decides who is present. The "meeting" is one key piece of the Discovery process. The only person that is required to attend the meeting is the person. If the person wants to invite other people that are important to them, they can do so. If the person doesn't want to sit for a formal meeting, they should work with the ISC to develop the plan in whatever fashion they prefer. The ISCs are responsible for having a conversation with the individual about who the individual wants at the Discovery meeting. It is important to remember that the individual receiving supports should be driving the meeting and determining who is present. If you were not invited to the meeting and the individual wanted you there, you should contact your ISC, your ISC's supervisor or the Division. Providers are also able to utilize the conflict resolution process. There is no minimum or maximum length of time for the meeting.
  3. If an area does not have an outcome, do barriers need to be listed for that section?
    • No, only risks. Barriers are factors that may prevent a desired outcome or makes it difficult for something to be achieved. Risks are factors that could be exposing someone to harm or danger; it is also the possibility that something bad or unpleasant is likely to happen
  4. If there is only 1 outcome for one of the critical life areas, do we have to complete any information in the other critical life areas that have no outcomes listed.
    • Each critical life area needs to be completed regardless of an outcome being present.
  5. Is the individual able to choose their own employment?
    • Absolutely. The individual should be determining where they want to work. The provider is there to support them in obtaining the job they want to have. The individuals should not be forced to work at a job because that is where the provider located a job. The individual must be the person making the choices for their life.
  6. Some individuals are uncomfortable discussing romantic relationships in large groups. How should this be addressed during a group meeting?
    • There may be situations that require more private conversations. The individual should not be expected to announce in a meeting their desire for more intimate relationships. Those conversations should occur in a more private setting to allow the person the autonomy to express themselves.
  7. Do all questions in the Discovery Tool need to be answered? For example, does a person who is waiting for a CILA placement need to complete the section specifically for a person living in a residential setting?
    • Not all questions will be appropriate to be asked for every person. The questions are meant to be a guide to determine satisfaction with that particular life area.
  8. How should a person who does not speak be supported during a meeting?
    • It is required that accommodations and supports are given to individuals so that they can fully participate in the process. This may mean having a person present who can interpret or assist the person with communicating.
  9. Just want to make sure I am comprehending correctly. Is she saying that the Discovery Tool will be more detailed than the personal plan?
    • Yes, the Discovery Tool has more details included. The Discovery information is summarized to be included in the Personal Plan.

Personal Plan

  1. When does the calendar start for the Provider Signature Page and development of the IS?
    • When the provider receives the approved Personal Plan, they have 10 days to complete the Provider Signature Page and return that to the ISC. Once that is returned, the provider has 20 days to complete the IS. The provider is held accountable for the date the ISC send the plan to the provider, not the date of the plan. The plans should be dated with the correct date it is signed. All verbal approvals should be followed up with written approval. ISC should not dictate what dates a family signs the document. If a plan is completed over 365 days, ISC and providers should follow their internal practices for how to respond to ensure continuity of care.
  2. When you go over the plan with the individual during the initial visit can you have them sign page 1 ready and have them sign then? Or email to QIDP and have them have individual sign?
    • No one should be asked to sign and approve a plan they haven't been able to review.
  3. If a person has an Agency Based PSW--do they have an outcome related to that in the PCP?
    • A PSW is a service; Outcomes are not required for all services. The person can have an outcome that involves the PSW. In that case the agency would provide strategies that involve the PSW.
  4. What should a team member do if the outcomes for an individual are not in line with what the individual wants? What if I am unsure how to implement the outcome? What if an outcome needs to be held for a period of time?
    • The team member should raise these concerns during the Discovery Process. Concerns can be escalated through the conflict resolution process, with the ISC's supervisor or with the Division. If a provider is unsure as to how to implement the outcome they should collaborate with the ISC and the individual. The person supported, ISC and providers should work together to determine how to best support the individual achieve their outcomes.

Implementation Strategy Questions

  1. Is a six-month plan review still necessary for individuals with a mental illness diagnosis? If so, is this something the ISC completes?
    • Yes. Semi-Annual plan review should still be completed by the service provider for any individual residing in the 24- hour CILA program that have a mental illness diagnosis. The ISC does not need to attend the meeting, but providers are encouraged to invite the ISC the meeting.
  2. Who should determine the frequency of outcomes?
    • ISCs and providers should work together, with the individual, to determine the frequency. If the individual is not happy with the frequency the provider can support, the individual can look at other providers who can meet their support needs.
  3. Are providers able to add additional information to the Implementation Strategies template at the end of the document?
    • Any additional information providers want to include must be attached as an attachment or addendum, not be included as part of the IS.
  4. Do we need to use ISCs wording from Personal Plan or our own wording.?
    • Providers should use the ISC wording for all outcomes.
  5. Are functional goals -going to have to be reported on Monthly progress note and revised every three months?
    • Functional goals should be included on the monthly progress note, but they do not need to be revised every three months. However, if the individual no longer requires support to complete the functional goals, they should be discontinued.