Transcript Developing plans as a collaborative process – not a

Developing plans as a collaborative
process – not a discreet event:
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Developing collaborative efforts by building
partnerships
Knowing who knows what
 Acknowledge when it needs to be
shared
 Recognize Roles and Responsibilities
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“Plans are never done, but they are always
due”
Our Structure needs to Support Our
Thinking
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Person centered approaches to providing
supports require a person centered structure
Paperwork needs to change to support the
new methods.
Not just the ISP: Assessments, Daily logs,
quarterly reports, progress notes, case
comments etc. All need to be reviewed and
updated to support this new process.
Partnerships Require:
Communication
Cooperation
Collaboration
Respect
Trust
Collaboration and Partnerships
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Effective communication is where it all begins.
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Collaboration creates something new.
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People come together because of their
differences – strength and opportunity comes
from building on our differences, not trying to
create conformity.
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Collaboration requires learning.
Collaboration builds Partnerships
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Desire to learn, openness to learning
Walk in assuming you can learn from the
other team members –and you will.
Walk in assuming you already know
everything there is to know about the personand you will squash collaboration
Trying to make other members do things
“your way” kills partnership.
Collaboration Exercise
A walk in the woods
Partnerships and Experts
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All good plans are done in partnership
Partnerships that work have discussed their
roles and expectations ahead of time
Think about the roles from the perspective of
contents experts and process experts
Experts and Roles
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Process experts know how to do it
Contents experts know what it should say
Where it works there is synergy – the plan is
better than either could anticipate
Experts and Roles
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Everyone in this room is an expert, and
has a role
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What is yours?
 Process?
 Content?
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Does everyone else see you that way?
Phases in the planning process
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Preparation for planning- Mapping
Gathering information – formerly called
assessment
Developing a 1st plan (draft)
Team agreement on the information written
down
Using the information to develop outcomes
Plan Approval
Plan Implementation and Review
Develop Outcomes
With the full team together:
 Review Personal Preferences Sections
 Review Topics to Promote Every Day Life
 Develop Possible Outcome Statements
 Review Medical/Health-Safety/Functional
Information
 Develop Outcome Actions
 Determine Most Appropriate Services and
Frequency/Duration of Each
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Determine how you will know progress is being made
Gathering Information in New Ways:
Conversational Areas: Suggested Topics
to Promote an Everyday Life
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Relationships, family,
friends
Choice and decision
making
Work/Education,
volunteering
Community participation
or contribution
Self image, self esteem
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Health Safety and
individual rights
Satisfaction with services
Home life/housing
Relaxing & having fun
Communication
style/preferences
Guidelines for Individual
Support Plan Format
Outcomes within the ISP
Describe for People:
 The expected results from activity a person
engages in
 The current situation- before the activity
begins
 The reason for the outcome (justification)
 Concerns or barriers that need to be
addressed
ISP Outcomes:
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Reflect information gathering
Requires collaboration among those
who know the individual best and those
who know the system requirements
Use understandable language
Are highly Individualized
How to Develop Outcomes
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Review Personal Preferences with the full team:
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What Makes Sense/Doesn’t Make Sense
What is important to the person
Desired Activities
Know and Do to Support the person
Develop possible Outcome Statements together:
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Reflect what is currently Important To the person, within the
context of assuring continued life within the community and
health and safety.
What changes would the person prefer, and why?
What constants would the person prefer continue in his/her
life, and why?
How to Develop Outcomes cont(2)
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Review Medical/Health-Safety and Functional
Information – (Important FOR information)
look for Current Needs related to Outcome
Statement:
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Medical Evaluation and Medical History
Health and Safety Focus Areas
Supervision Needs
Behavioral Support Plan
Health Care and Health Promotion
Functional Areas
Communication
How to Develop Outcomes cont (3).
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Develop Outcome Actions
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What current needs are apparent within the
previous sections of the ISP that relate to this
Outcome Statement?
What specific steps must be taken in order to
address the persons Current Needs, the
Concerns related to the Outcome, and assure the
outcome is achieved?
Ask, Do these actions occur within the context of
what is important to the person, balanced with
what we know is Important For the person?
Develop Outcomes cont(4)
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Determine Services, Frequency and duration.
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New Service? Anticipate what will meet the need
Old service – if nothing has changed, what was frequency in
the past?
Old service – but other changes, what is anticipated to be used
by the person?
How long do you anticipate the need to exist?
Determine how you will know progress is being
made?
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What will be different as a result of the service, or what will
continue to be observable? This is asking for recognizable
differences for the person, either environmentally, skill
acquisition, behaviorally, communication change, etc.
Include a statement about how and when the team will provide
information about progress across time.
ISP Outcome Development
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Addresses concerns and barriers to promote problem
solving.
 What are we worried about? What can we do to
prevent it? What can we do to lessen the impact if it
is unavoidable? How can we overcome it if it
occurs?
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Provides critical documentation about steps that will be
taken to assure the individual’s health and safety while
working toward desired changes.
ISP Outcomes are NOT:
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Services…but every service needs an
outcome!!!!
A grouping of un-integrated goals
Solely based on formal assessments
Deficit focused- this is not about “fixing”
the person
Something that happens in isolation of the
individual’s everyday life.
Services are not outcomes!
Examples that are NOT outcome
statements:
 I want a day program.
 I want to go to physical therapy.
 I want speech therapy.
 I want to be in the workshop.
Services are not outcomes!
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Services are determined AFTER the outcome is
determined.
So, how do I write outcomes?
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You need more information!
As a result of this service, what difference will it
make in the individual’s life?
ISP Outcome Statement
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Determine what needs to change, what needs to
remain the same by considering:
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What makes sense, what is working, what is the upside of
this issue, right now, from everyone’s perspective?
What doesn’t make sense, is not working, what is the
downside of this issue, right now, from everyone’s
perspective?
What does everyone agree on? Where do you have
common ground? Start with outcomes about those things.
ISP Outcome Statements
Maintenance of important things- Those
things which all perspectives agree
should continue
 Desired changes- Those things which all
perspectives agree should change
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If the team is stuck:
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Focus the WMS /DMS exercise on specific
issues in the person’s life, such as:
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Who the person spends time with
What the person’s interests are
How the person spends his/her days
How the person has fun
What the person wants to learn.
Where and with whom, the person lives
Use the Topic Questions to get you
moving:
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Relationships, family, friends
Choice and decision making
Work/Education, volunteering
Community participation or contribution
Self image, self esteem Health Safety and
individual rights
Satisfaction with services
Home life/housing
Relaxing & having fun
Communication style/preferences
Writing Outcomes: Sources of
Information in ISP
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Outcome Statements
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Know and Do
Desired Activities
Important To
What Makes Sense
Outcome Actions
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Health and Safety
Understanding Communication
Writing outcomes
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Begin with the aim of the outcome: Using
person’s name followed by an action verb
or phrase.
Only use “I” if you are absolutely sure the
person would say it in the same way.
Complete the statement with how it will
make a difference using “so that/in
order to”
Helpful Phrases when writing Outcome
Statements
So That
In Order To
Sharing the PROCESS
Share the process with Team
•Team ownership
•Stronger plan
•Simplified process
•Shared vision
•Increase effectiveness of implementation
OUTCOME Measurement: How
you know progress is being
made
Used to identify the results of a person’s
effort. It seeks to answer the questions:
•What difference did the services or
supports make in the person’s life?
•Is the service/support provided having
its intended impact?
HOW to Measure Outcomes…
Measuring outcomes involves gathering DATA
What are the indicators???
•Specific items of data that are tracked to measure how well a
program is achieving an outcome
•Indicators translate general concepts about the program &
its expected effects into specific measurable parts
•You measure whether or not progress is being made, not
fully whether or not the Outcome has been achieved.
S.M.A.R.T.
Outcome Statements
S
Are they specific?
M
Are they measurable?
A
Are they achievable?
R
Are they relevant?
T
Are they timed?
Writing Outcomes
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Begin with the aim of the
outcome: Use the
person’s name followed
by an action verb or
phrase that reflects a
change the person would
like to see, or what the
person wants to have
stay the same.
Complete the statement
with how it will make a
difference using “so
that/in order to”
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Sara wants to get a job
in a retail store
so that she can pay
her bills on time, live in
her current apartment
and have enough
money to do things that
she wants to do.
Outcome Statement
Only the beginning!!!!
Reason for the outcome
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Provides contextual
information so that
the team has the full
picture about how it
is important.
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Important to Sara that others
see her as responsible
Continuing to be accepted by
her friends, and has money to
spend with them, is very
important to her.
To live in her own
neighborhood where she is
familiar and comfortable
Making decisions about what
she does and when she does
it
Concerns Related to Outcome
 Informs team of
barriers that need
to be addressed
while working
toward outcomes.
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She often can’t do what she
wants because she doesn’t
have extra money
Figuring out change, and
adding/subtracting are
things She needs help with
Sometimes she walks in
unsafe places by herself in
her neighborhood, or late at
night
Outcome Actions
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What are current needs
What actions are needed
Who’s responsible
Frequency and Duration of the actions
needed
By When (mm/dd/yyyy)
How will you know that progress is being
made towards this outcome?
What Are Current Needs?
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Current reality related to
outcome: provides a
baseline of information that
specifically relates to
Sara’s situation
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Information is recorded in
health and safety Focus
areas, functional abilities,
employment and vocational
sections, financial and
communication sections of
ISP
Sara does not have a job; she
has just enough money to pay
her rent and food bills, she
does not have extra money to
go out with her friends. She
gets angry with her rep payee
when she has to say no to her
friends because of money; She
asks to borrow money often.
She can tell the names of
currency, but has difficulty
making change accurately.
She will need help reading help
wanted ads and completing job
applications
What Actions Are Needed?
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Address information
identified in
“concerns related to
outcome” to identify
steps to take.
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Figure out retail jobs that do not
require you to make change (S
E Job development)
Discover job training classes in
retail (SE Job development)
Talk with others who work in
retail shops (Family members)
What Actions Are Needed?
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Address information
identified in “concerns
related to outcome” to
identify steps to take.
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Help her start learning about
making change (Supported
Living- HCHab and basic math
tutor)
Help Sara learn about
budgeting money and using
other resources such as food
stamps, Energy assistance, etc.
(Supported Living HCHab)
Help Sara learn about being
safe walking at night by herself
(Supported Living HCHab)
Who is Responsible?
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Brainstorm who can help,
how they can help and how
often.
Determine who will be
responsible for seeing that
the specific action occurs.
Sometimes this will be nonpaid people, sometimes it
will be paid people.
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Supported Employment
Supervisor and Family
for Employment Action
Supported Living
Coordinator and
Support Coord. for Sup.
Living Actions
Frequency/duration and By When
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Indicate how often the
action will occur, and for
how long. This should give
specific information around
how many times per week,
or month, or year, and for
how many months or years.
By when indicates when the
action is expected to be
accomplished
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Supported Employment
service, 20 hrs per
week, for 6 months
Supported Living 20 hrs
per week, for 12
months.
By 12/12/2004
How will you know that progress is being made towards
this outcome?
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Describes what is expected
as a result of the services
and supports; what will you
be able to see that is
different, or that continues
to happen, for the person?
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Identify how and who will
give input about progress
made over time.
Employment Actions:
 Sara will have found and
applied for at least one job
she desires.
 Sara will have information
on retail jobs available to
her, and will know the skills
required for retail work.
 At quarterly meetings, the
team will provide progress
notes on what has been
accomplished.
How will you know that progress is being made
towards this outcome?
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Describes what is expected
as a result of the services
and supports; what will you
be able to see that is
different, or that continues
to happen?
Identify how and who will
give input about progress
made over time.
Home and Comm. Actions:
 Sara will be confident
making purchases with
dollar bills and get the
correct change.
 Sara will understand one
method of budgeting her
money that she is willing to
try
 Sara will have exercised at
least one safe option when
going home late at night.
Fundamental to Supporting People:
Core Responsibilities are NOT Outcomes
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Washing hair
Setting the table
Making a sandwich
Using a fork
Tying shoes
Brushing teeth
Combing hair
Shaving
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Getting dressed
Staying on task
Counting money
Toileting
Doing laundry
Using zippers
Dialing the phone
Applying deodorant
Would You Rather…
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Tie your shoes
Comb your hair
Make your bed
Plan a menu
Make a purchase
Clean a room
or
or
or
or
or
or
Tie the game
Comb the beach
Make a friend
Plan a get-together
Shop ‘til you drop
Clean up on the
dance floor
Tie your shoes or tie the game & make your bed or make a friend from
Hingsburger (1998) do?be?do?
Traditional Curriculum vs. Quality of Life
Outcomes (Red)
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Judy will take a shower with physical guidance 6/7 days a week
by 12/01. Judy wants to look nice when she goes to school for
the next two semesters.
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Fay will exercise three times a week with verbal prompts for 6
consecutive months by 12/01. Fay wants to earn her orange belt
in karate in the next 9 months.
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Anna will participate in 1 social/recreational outing a week with
staff supervision until 12/01. Anna wants to join the Girl Scouts
in her neighborhood and be a member this year.
From Acumen, Arizona. Courtesy of Chris teKampe 2003
One guy’s story
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“Your interpersonal skills have improved.”
“What do you mean by interpersonal?”
That means you are getting along with people
better.
Well, why didn’t you say that in the first
place?
Alternatives to jargon
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Interpersonal skills
Ambulates
independently
Verbal cues or prompts
Auditory monitoring
distance
Able able able
Feeds self
independently
Outcomes Thinking compared with Old Goals
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Going on a date- Learn Social Skills
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Taking karate lessons- Increase physical activity
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Looking great for school- Improve personal hygiene
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Getting a job- increase vocational skills
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Being a Girl Scout- Improve social skills
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Putting together a photo album- Increase fine motor or
Increase attention span- or increase on-task behavior
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Visiting my family- improve social and emotional
expressions
Outcomes Thinking compared with Old
Goals – Try it yourself:
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Joining a health club:
Taking horseback riding lessons:
Being an active senior:
Riding my bike:
Listening to live music:
Going to the beauty salon:
Joining the Eagles fan club:
Hosting a BBQ:
Family Member Roles in developing
Outcomes
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Participate as Content Expert
Assure the person is listened to
Demonstrate the opinions and views of
people who care deeply about the person
Promote the preferences of the person – not
what others think should be their preferences
Contribute ideas for how to meet the needs
Provide insight into resources other team
members may be unaware exist
Provider Role In Developing
Outcomes
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Participate as one of the content experts
Ensure outcome statements are in context of The
person’s individual preferences- what is
important TO the person
Ensure Outcome actions meet individual needs –
what is important FOR the person.
Ensure services can address individual needs
within the context of individual preferences.
Ensure services are delivered.
Participate in plan review.
Support Coordinator Roles in Developing
Outcomes
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Process Expert – what needs to be done, how it
gets done, and getting it done on time
Coordinate team agreement with what is written
Coordinate team meeting to develop outcomes
Keep the team focused on the process
Ensure the outcome summary addresses the
person’s preferences, balanced with health
safety and ensuring community life.
Assure the person is listened to