This Quick Guide to the Individual Support Planning process provides a concise description of the critical parts of this important activity. We hope that it will assist you to provide guidance to individuals with disabilities and their families as they assess their needs for support, identify and choose the natural, generic and specialized supports that will meet these needs, and plan for the outcomes that would enhance their quality of life.

What principles form the basis for the Department's Individual Support Planning process?

  1. The Department's Mission and Guiding Principles;
  2. Contemporary practice in the field of intellectual disability, which builds upon the definition of intellectual disability of the American Association on Intellectual and Developmental Disabilities;
  3. The paradigm shift in service delivery in which there is increased focus on an array of environmental supports that includes family, friends, non-paid support, generic supports and specialized services and from which people with mental retardation choose; and
  4. Recognition of the six Quality of Life Areas which are the driving force of support provision within all segments of the Department and which are defined as those outcomes that bring meaning to all people's lives.

What are the six Quality of Life Areas?

  1. Rights and Dignity. Includes a review of the individual's rights and the supports necessary to insure that s/he is treated with respect and dignity.
  2. Individual Control. Centers around an individual's ability to direct his/her own life.
  3. Community Membership. Encompasses an individual's use of community resources, his/her active role in community life and a sense of belonging to that community.
  4. Relationships. Encompasses all relationships that enrich an individual's life.
  5. Personal Goals and Accomplishments. Focuses on the development and pursuit of goals and the opportunity to learn from adult life situations and to experience success.
  6. Personal Well Being (Health, Safety and Economic Security). Addresses all aspects of the individual's health; safety, security and cleanliness in the individual's home, workplace and in the community; and the sources and the use of the individual's funds.

Why did the Department change the name of its planning process from the Individual Service Plan to the Individual Support Plan?

The change in words used to describe the planning process derives from the emphasis the AAMR definition of mental retardation places on the "fit" between an individual's capabilities and the demands of the environment and on the entire range of supports family, friends, neighbors, generic and specialized services that assist an individual to meet these demands. The new name exemplifies our belief that the ISP should address the whole individual and not focus exclusively on specialized services. The term supports reflects the our policy that the ISP process should be a comprehensive one blending natural, generic and specialized supports to promote the individual's goals. The term supports encompasses specialized services.

The entire Individual Support Planning Process is designed to assist individuals and those persons closest to them to assist the individual to develop a vision and to attain outcomes in critical quality of life areas while promoting maximum control, choice and self-determination of the individual with disabilities.

What is the planning cycle for ISP development?

The regulations establish a two year planning cycle, with the option of developing a new plan each year if desired. Whether or not an ISP is being developed, an annual review is required, must take place during a meeting, and must include a comprehensive review of the ISP's implementation to date as well as any needed modifications.

How will individuals, their family members and guardians be involved with the preparation for the ISP meeting?

The Service Coordinator will contact the individual and involved family and guardian, if any, about two months prior to the date of the ISP meeting to arrange a pre-meeting. The purpose of the pre-meeting is to provide an opportunity for the individual and those closest to him/her to consider the individual's current circumstances and to discuss the individual's wishes and goals. At this meeting, the individual, with the Service Coordinator's help, will determine what issues will be covered during the upcoming ISP meeting as well as what areas will not be referenced. The individual and the Service Coordinator will decide who should be invited to the ISP meeting, its format, date and location, and any accommodations that will be required. The pre-meeting is also an opportunity for the individual, family and guardian to talk about what optional assessments should be obtained that would benefit the individual and assist the Team to identify strengths and limitations related to the individual's ability to live with greater independence and social competence in less restrictive environments.

What is the purpose of assessments?

Assessments serve to develop a body of information about an individual's desires and goals, his/her capabilities in areas in need of learning and skill development and the experiences or supports that will promote achievement of those goals.

Additionally, assessments identify the environmental and human resources that may be necessary to assist the individual to achieve positive outcomes in the areas of rights and dignity, individual control, community membership, relationships, personal growth & accomplishment and personal well-being. Assessments should consider the individual's life history, experiences and social relationships and should focus on ability and interests rather than deficits.

What are the mandated assessments within the ISP process?

The following assessments should be conducted and updated annually:

  1. The ability to make informed decisions regarding financial and personal affairs: reviewed for all individuals with an ISP.
  2. Financial status and eligibility for services or benefits from other entities: reviewed for all individuals with an ISP.
  3. Safety: developed for individuals in agency-funded or operated homes and/or workplaces, except for supported employment sites.
  4. Health and dental: assessed for individuals in agency-funded or operated homes.
  5. Funds management: assessed for individuals living in Developmental Centers.

What are optional assessments and consultations?

The Service Coordinator, through discussion with the individual and other Team members, may determine that additional assessments and professional consultations would benefit the individual or assist the Team in identifying strengths and limitations related to the individual's ability to live with greater independence and social competence in less restrictive environments and to achieve his or her specific outcomes. Such assessments may include, but are not be limited to, an assessment of the individual's daily

living skills, social and communication skills, psychological status, social network, ability to do a particular job, knowledge of health and human sexuality and whether the individual would benefit from assistive technology.

Can the individual and/or his family or guardian meet with the person who prepares the assessment?

Yes. The Service Coordinator will tell the person conducting the assessment that the assessment process includes a follow-up consultation with the individual or his/her family or guardian if s/he should request further information about the results of in the assessment.

Who will get an ISP?

  1. All individuals with special eligibility will be offered an ISP.
  2. All individuals receiving individual or residential supports provided or purchased by the Department and who do not reside with their family, excluding individuals who have an Individual Transition Plan for the period of 12 months following his or her 22nd birthday.
  3. All individuals who receive day or employment supports provided or purchased by us.
  4. All individuals receiving day habilitation services and referred for such services by us.
  5. At the request of the individual or his or her family, guardian or designated representative, individuals receiving other supports provided, purchased or arranged by the Department including but not limited to service coordination, referral, DMA-funded adult foster care, and transportation or vocational services funded by MRC.
  6. With the agreement of the individual or his or her guardian, any individual other than those for whom an ISP must be developed as listed above and who the Area Director determines would benefit from an ISP.

What are the different components of the ISP meeting?

The ISP meeting is divided into five parts:

Section A - Individual Goals. The purpose of this part of the meeting is to develop a shared vision for the future in terms of desired goals that focus on increasing the opportunities for the individual to participate fully in community life. Discussion with the individual/family/ guardian at the pre-meeting should inform this part of ISP development. Goals are delineated in each of the Quality of Life Areas. Later in the meeting, the Team will determine those Areas which will be the focus of the ISP.

Section B - Critical Events. Section B consists of a discussion of all experiences in recent years that may affect the individual unless the individual does not want this issue/event addressed, as determined at the pre-meeting.

Section C - Current Services and Supports. In the third section the Team reviews information about the individual's current circumstances gathered at the pre-meeting. The individual should be given the opportunity to comment on the information and add any information that has not already been shared. The formal/informal, paid/unpaid supports which are part of the fabric of the individual's life should be listed. Current services and supports are reviewed within the six Quality of Life Areas. The information gathered during this discussion will naturally lead the Team into the identification of goals for the current ISP.

Section D - Desired Quality of Life Areas. In the fourth section, the individual and Team select those Quality of Life Areas upon which they intend to focus during the ISP cycle. These should be those Areas that require the most intensive attention to assist the individual to attain his or her desires and needs as identified in the person's vision. The selected Areas should be specific to the individual and based on the individual's unique preferences, strengths, interests and needs. Once only those areas of focus are identified, they will be further documented in the final section of the ISP.

Section E - The Support Agreement. The Support Agreement is a forecast that sets the expectations of what will be accomplished for the time period under discussion.

  1. Goals. The first step in developing the Support Agreement is the determination of desired goals for the individual. Participants discuss and identify a variety of goals toward the expected or desired outcome within the focus areas identified in any of the selected six Quality of Life Areas.
  2. Strategies and Resources. The Service Coordinator will then facilitate the Team in listing the possible strategies and resources (formal and informal, generic and specialized, natural) that are least restrictive and that can assist the individual to meet the desired goal.
  3. Settings. Next the settings or locations that provide opportunities that support the accomplishment of the goal and provide choices and options to assist the individual in attaining his/her goals are listed. Settings must be functionally appropriate community environments typical of the individual's age, peers and culture.
  4. Duration and Frequency. Support intensity varies across people, situations and life stages. Consideration needs to be given to the individual's learning style and pace as well as the magnitude of the goal when determining the duration and frequency of strategies and supports.
  5. Unmet Support Needs. An unmet support need is what the individual needs to overcome a limitation in an adaptive skill area in the normal course of life which is not currently being provided. These obstacles may be limitations in adaptive skills; lack of accommodations; and assistive technology needed within the context of home, work and community environments. The Team should identify how they intend to address those needs.
  6. Implementation Responsibility. The job title of the person(s) responsible for providing the support or assistance is identified in this section.
  7. Oversight Responsibility. The oversight agency or organization or the job title of the person responsible for monitoring the implementation of the strategies, supports and resources and the frequency of monitoring and reporting are identified in this section.
  8. Review Date for Each Outcome. The date of the next review of each goal and progress toward each goal is identified in this section. The time period for review and documentation of each goal is flexible and will be determined by the consensus of the Team. Minimally, review of progress towards the goals will occur semi-annually; however, review may occur monthly or quarterly depending on the particular goal, the needs of the individual and the perspective of Team members.
  9. Review Date for the ISP. The next ISP review date will typically be within one year of the date of the ISP meeting. However, any special considerations should be determined and factored into the decision on a date. The preference of the individual or his/her family or guardian for a more frequent review of goals, objectives or interventions should be acknowledged and, to the greatest extent possible, honored.

What are Provider Support Strategies?

Provider Support Strategies are the ways that services and supports are going to be delivered by the provider agency(ies). These strategies are negotiated in a meeting between the provider agency(ies) and the individual being served/family/guardian shortly after the ISP meeting. Once agreement is reached, the provider(s) will send the information to the Service Coordinator for review and approval of the final ISP by the Area Director. The Provider Support Strategies will be mailed out to the parties with the ISP document and should be considered a part of the official ISP document.

What is the role of the family in the ISP process?

The family plays an important and ongoing role in the life of a person with mental retardation. The Department honors this relationship and wants to promote strong familial ties. Family and guardian involvement is presumed at each stage of the ISP process. Nevertheless, if individuals do not want their families involved, the Department will respect that request.

How will the Service Coordinator keep the Team apprised of the status of ISP implementation?

The Service Coordinator is responsible for completing a semi-annual report that discusses: the individual's satisfaction with the ISP; the effectiveness of the supports and the quality of the interventions being provided; and any need for modification. The report may also be used to discuss issues that have arisen during the six month period on which the report is based. The Service Coordinator will disseminate this report to all of the ISP participants and file a copy in the individual's record. A meeting is not required unless requested by the individual, family or guardian.

How does one modify an ISP?

Requirements. An ISP Modification is required whenever any of the following changes are being proposed to be made prior to the individual's next periodic review:

Any change in the goals for an individual in the areas of: Rights and Dignity; Individual Control; Community Membership; Relationships; Personal Growth and accomplishments; and Personal Well-Being (Health, Safety, and Economic Security); Any change in the types of supports or services that will be utilized to assist the individual to attain his or her outcomes, in the duration and frequency of such supports (keep in mind that the strategies, supports, services and resources utilized must be the least restrictive available); A change in the strategies that will be utilized to address unmet support needs;

A change in the priority for services or supports assigned to the individual 's needs where such change will affect the provision of services or supports that are available to the individual; Initiation of a behavior modification plan or modification of any part of a behavior modification plan involving the use of an aversive or intrusive technique; and

A change in the location of an individual's home, from a home or Developmental Center operated by the Department or a provider certified by the Department to another such home.

Any proposed changes that are not listed above do not require that the Team follow the ISP modification procedure established in the Department's regulations. However, in order to implement changes which are not subject to modification requirements, a meeting of the Team may be appropriate, even if not required.

Procedure. When any of the following individuals believes that a change in one of the above listed areas has or will occur, s/he should contact the Service Coordinator and explain the nature of the change and the reason for the request for modification: the individual; the individual's guardian, if any; family members of the individual who are not guardians, if the individual does not object to their request; or a current provider of services or supports to the individual.

Within 30 days of a request for a modification, the Service Coordinator must convene a meeting to determine whether a requested modification should be made and provide at least 10 days notice to the following persons, who must be invited to attend the modification meeting: the individual; the individual's guardian, if any; family members of the individual who are not guardians, if the individual does not object to their presence; and representatives of providers of services or supports to the individual. (N.B. all providers of supports to the individual should be notified but the Service Coordinator may waive participation by providers who do not have a vested interest in the issue which is the subject of the requested modification).

Modifications of the ISP for an individual who resides in a Developmental Center must be made as soon as possible under the Title XIX regulations.

Requirements To Waive the Meeting. Under certain circumstances, it may not be necessary to hold the modification meeting. At the discretion of the Service Coordinator, the modification meeting and any timeline related to such meeting may be waived with the documented approval of: the individual, if not under guardianship and capable in fact of understanding the consequences of the waiver; the individual's family, if the individual is not capable in fact, is not under guardianship, and does not object; or the individual's guardian, if any, if the individual does not object.

Within ten days after either the modification meeting or waiver of such meeting, the Service Coordinator must notify those required to be invited to the modification meeting of both the decision on the requested modification and of their right to appeal the modification to the extent provided by the applicable regulations.

This information is provided by the Department of Developmental Services.