Supports Coordination

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9Creating the ISP: Outcomes

Course Map

Creating the ISP: Outcomes Objectives

At the completion of this lesson, you will be able to:

  • Complete outcome information in the ISP
  • Review existing outcome information in HCSIS
  • Enter outcome actions in the ISP

Supports Coordination Process Flow

Key Terms and Concepts

Outcome

Outcomes represent what is currently important to the individual, what needs to be maintained for the individual or what needs to be changed. The outcome should describe how it will make a difference in the individual’s life. The outcome must build on information gathered during the ISP process and reflect a shared commitment to action. Remember that outcomes supported by MR funding must be within the context of the health and safety of the individual and/or assuring their continued life within the community. Outcomes that address other priorities of the individual should be represented and supported with other community, family or non-traditional supports.

Use the principles of Everyday Lives to develop outcomes with the individual: choice, control, quality, community inclusion, stability, accountability, safety, individuality, relationships, freedom, success, contributing to the community, collaboration, communication and mentoring.

Outcome Actions

Outcome Actions is the action planning screen of the Outcome. This section captures the current needs of the outcome, what actions are needed to complete the outcome, who is responsible for completing the outcome, the frequency and duration of needed actions and how the action will be measured to see if progress has been made. Several outcome actions may exist for a single outcome.

It is critical for the team to address any concerns related to health and safety issues or any other barriers. Individuals need team support to attain outcomes because collective problem solving and resources will make the difference. Problem-solve to identify any needed actions. Each Outcome Summary should have an Outcome Action.

Key Terms and Concepts (continued)

Outcome Summary

Outcome Summary collects detailed information about each outcome for the individual. Outcomes include natural supports, non-paid services and MR funded supports.

Outcomes represent what is currently important for the individual to work on or to maintain. They also represent the changes an individual would like to see for him/herself. They are based on individual/family identified priorities, are responsive to formal and informal information gathering and are linked to the appropriate informal and formal supports and services.

Remember that outcomes supported by ODP funds must be in the context of supporting the health and safety of the individual and assuring their continued life in the community. Outcomes that address other priorities of the individual should be represented and supported with other community, family or non-traditional supported services.

  • Outcome Phrase: This is a description to easily identify the outcome; this phase is intended to assist with easily navigating through the ISP to find all related information.
  • Outcome Start Date: The date activity will begin to work toward achieving the outcome.
  • Outcome End Date: The estimated date when the outcome should be achieved.
  • Outcome Actual End Date: The date the outcome was completed.
  • Has the outcome been successfully accomplished:An indicator(Yes or No)that shows whether the outcome was successfully accomplished.

Key Terms and Concepts (continued)

Outcome Summary (continued)

  • Outcome Statement: Represents what is currently important to the individual, what needs to be maintained for the individual, or what needs to be changed. The outcome should describe how it will make a difference in the individual's life. The outcome must build on information gathered during the ISP process and reflect a shared commitment to action. Remember that outcomes supported by ODP funding must be within the context of the health and safety of the individual and/or assuring their continued life within the community. Outcomes that address other priorities of the individual should be represented and supported with other community, family or non-traditional supports.
  • Use the principles of Everyday Lives to develop outcomes with the individual: choice, control, quality, community inclusion, stability, accountability, safety, individuality, relationships, freedom, success, contributing to the community, collaboration, communication and mentoring.
  • Reason for the Outcome: This provides contextual information beyond the Outcome Statement for the team to understand how/why the outcome is important to the individual.
  • Concerns related to Outcome: Describe any barriers (including health and safety issues) the team will need to address to successfully work towards the outcome. This may include information on what has been tried in the past but has not worked, what the individual's team has tried to figure out or other concerns any team member may have.For therapy and nursing services, document here the denial from the State Plan and/or private insurance.
  • Relevant Assessments Linked to the Outcome: List any relevant formal or informal assessments that directly affect the outcome. Informal assessments may include: direct observations, interviews with family or direct care staff and/or review of previous records. Formal assessments may include: statewide standardized assessments in addition to person-centered assessments utilized by provider agencies that have previously been approved by licensing agents. (If a formal assessment has been completed, it should be noted in the "Other Non-Medical Evaluations" section of the ISP.) Assessments may be utilized to assess whether an outcome has made an impact.

Criteria for Best Outcomes

Outcome statements begin with the aim of the outcome, stated as a proper noun and an observable action verb. The aim is followed by the rationale (i.e. “in order to…”, “to…”, “so that…”). It explains why this action will make a difference for the individual and underscores that everybody involved in the ISP process agrees on this rationale.

When creating outcomes, use the following questions to verify whether the outcome contains the necessary details for the individual:

  • Did we refer to the information already gathered on the plan to develop outcomes?
  • Did we focus on things that we knew were important to/for the individual?
  • Will the outcome(s) be achievable within the context of the person's everyday life?
  • Is there a balance between brevity and detail? (That is, is there enough information to understand what is meant but not so much detail that the plan appears overwhelming?)
  • Did we use "I" statements or reference the person's name?
  • Is the outcome easily understood and free of professional jargon?
  • Is the outcome measurable?
  • Did we include a "so that" or an "in order to" clause?
  • Did we describe "what is happening now" with information that relates to the outcome, so that we have a baseline of information to measure progress over time?

In supporting the Outcome:

  • Did we clearly identify what will need to be done in order to assist the individual to achieve the outcome?
  • Did we identify formal and informal supports and services?
  • Did we represent actions that connect the individual to the community?
  • Have informal, natural and community based supports been explored rather than automatically going to programmatic, more restrictive options?

Creating the ISP: OutcomesVersion 7.01

Supports Coordination

Criteria for Best Outcomes

Key Topic
Outcomes / is about . . .
The changes an individual would like to see for his or herself
Main Idea
“Priorities
(based individual/family priorities) / Main Idea
“Information”
(responsive to formal and informal information gathering) / Main Idea
“Supported”
(by informal and formal supports and services)
Essential Details
Defines a planning teams’ shared vision for the individual / Essential Details
Targets and builds on knowledge, skills, and activities for success / Essential Details
Individual and family preferences a priority
Followed by step by step action plan / Very much a work in progress / Discuss where individual spends time, activities they do or wish to do
Maps the path team members will take together / Calls for ongoing monitoring and updating / Defines programmatic actions needed to find services, fit them together, and create single unified plan
Seek to discover what the person might like in the future and help them move in that direction (Smull 2000)

Creating the ISP: OutcomesVersion 7.01

Supports Coordination

Creating the ISP: Outcomes Task Flow

Creating the ISP: Outcomes:

  1. The Supports Coordinator meets with the individual and family to determine outcomes and outcome actions.
  2. The Supports Coordinator logs into HCSIS and navigates to the Services and Supports screens in HCSIS. The Supports Coordinator can then search for the individual’s information.

OR

The Supports Coordinator may continue to enter information from the Financial Information section (Lesson 8). If the Supports Coordinator selects the [Save and Continue] button from the Financial Resources screen, HCSIS will navigate the Supports Coordinator to the first Services and Supports screen, Outcome Summary.

  1. The Supports Coordinator enters the outcome summary and actions into HCSIS.

HCSIS System Task(s)

The following screens will be used in this lesson:

  • Outcome Summary
  • Outcome Actions

Demonstration 9-1: Creating Outcomes in HCSIS

This demonstration reviews the process for entering outcome information into HCSIS. The process of creating an outcome can be reviewed from the Supports Coordinator process training that was given in your county.

During the demonstration, you will use the following individual:

  • Cindy Nissley

To become familiar with this process, use the following steps:

Menu Path:
ISP
ISP  Serv & Supp
ISP  Serv & Supp  Outcome Summary
ISP  Serv & Supp  Outcome Summary  Outcome Summary
Steps:
  1. Using the menu path above, navigate to the Outcome Summary screen.
  2. The Outcome Summary screen displays with the following fields.

Field Name / Field Description
Outcome Phrase / This is a description to easily identify the outcome; this phrase is intended to assist with easily navigating through the ISP to find all related information.
Outcome Start Date / The date activity will begin to work toward achieving the outcome.
Outcome End Date / The estimated date when the outcome should be achieved.
Outcome Actual End Date / Date that the outcome was achieved or ended without being successfully achieved. This is an optional field.

Continued

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:
Field Name / Field Description
Has the outcome been successfully accomplished / Select "Yes" or "No" from the drop-down list to indicate whether the outcome has been successfully accomplished.
Note: When initially creating outcomes, this field should be "No." When this field is changed to "Yes," an Actual End Date should be entered for the outcome.
Outcome Statement / Represents what is currently important to the individual, what needs to be maintained for the individual or what needs to be changed. The outcome should describe how it will make a difference in the individual's life. The outcome must build on information gathered during the ISP process and reflect a shared commitment to action. Remember that outcomes supported by ODP funding must be within the context of the health and safety of the individual and/or assuring their continued life within the community. Outcomes that address other priorities of the individual should be represented and supported with other community, family or non-traditional supports. Use the principles of Everyday Lives to develop outcomes with the individual: choice, control, quality, community inclusion, stability, accountability, safety, individuality, relationships, freedom, success, contributing to the community, collaboration, communication and mentoring.
Reason for Outcome / This information describes how the outcome is important to the individual. It answers the question, “Why should this be an outcome?”

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:
Field Name / Field Description
Concerns related to Outcome / Describe any barriers (including health and safety issues) the team will need to address to successfully work towards the outcome. This may include information on what has been tried in the past but has not worked, what the individual's team has tried to figure out or other concerns any team member may have.For therapy and nursing services, document here the denial from the State Plan and/or private insurance.
Relevant Assessment / List any relevant formal or informal assessments that directly affect the outcome. Informal assessments may include: direct observations, interviews with family or direct care staff and/or review of previous records. Formal assessments may include: statewide standardized assessments in addition to person-centered assessments utilized by provider agencies that have previously been approved by licensing agents. (If a formal assessment has been completed, it should be noted in the "Other Non-Medical Evaluations" section of the ISP.) Assessments may be utilized to assess whether an outcome has made an impact.

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:
  1. Enter the following information into HCSIS:

Field Name / Data
Outcome Phrase / Apartment
Outcome Start Date / [Today’s Date]
Outcome End Date / [Enter a date prior to the plan end date]
Has the outcome been successfully accomplished / Select "No."
Outcome Statement / I want to keep my apartment clean so that I do not have to always depend on my sister to do it.
Reason for Outcome / Cindy wants to learn to keep her apartment clean and loves when friends notice how nice her apartment is. Since Cindy rents her apartment, it is critical for the apartment to be properly cleaned for the landlord to continue leasing it to Cindy. Also Cindy’s sister has a very difficult time helping Cindy keep her apartment clean. This issue becomes a source of tension between the sisters. Cindy’s sister is very willing to support her in many ways but she would really appreciate assistance in this area.
Concerns related to Outcome / Cindy wants to work along with whoever can help meet this need and be taught how to do things. The volunteer must have flexible hours to work within Cindy’s timeframe.
Relevant Assessment / Sister reports that Cindy can do simple housekeeping tasks with close supervision and assistance but hygienic cleaning of bathrooms and kitchen are difficult for her to do properly. It is hard for Cindy to keep up with multiple routines needed to maintain an apartment.
  1. Click [Save]

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:
  1. Click [Add].
  2. Repeat Steps 3 – 5 for each outcome listed on the following pages.
  3. Enter the following information into HCSIS:

Field Name / Data
Outcome Phrase / Job
Outcome Start Date / [Today’s Date]
Outcome End Date / [Enter a date prior to the plan end date]
Has the outcome been successfully accomplished / Select "No."
Outcome Statement / I want to work more hours at my job so that I can have more money for my hobbies of collecting bears and going to pottery classes.
Reason for Outcome / Cindy would like to work more hours so that she has extra money to purchase more bears. She would also like to increase the number of pottery classes she is able to take.
Concerns related to Outcome / Current situation at grocery store has cut hours of part time employees. Cindy has had a hard time keeping jobs over time. In the past, she has had a job coach when she started a new job, but over time, without continued intermittent support, she begins to lose skills and socialize more than work. She needs the ongoing intermittent support of a job coach to help her keep her skills and maintain her professional commitment.
Relevant Assessment / Supervisor has given Cindy good job ratings, the Educational/Vocational Assessment completed on 6/20/01.

Continued

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:
  1. Continue to enter the following outcomes into HCSIS:

Field Name / Data
Outcome Phrase / Hobby
Outcome Start Date / [Today’s Date]
Outcome End Date / [Enter a date prior to the plan end date]
Has the outcome been successfully accomplished / Select "No."
Outcome Statement / In order to have fun and meet more people, I want to join a ceramic or pottery class.
Reason for Outcome / Cindy likes to do things with her hands and wants to meet more friends who like to the same things.
Concerns related to Outcome / Cindy may need more assistance at the program than the instructor can give. Cost may be a factor in deciding where. Transportation needs to be considered depending on hours of program.
Relevant Assessment / Cindy has done craft activities with a friend and does well with guidance.
Field Name / Data
Outcome Phrase / Read
Outcome Start Date / [Today’s Date]
Outcome End Date / [Enter a date prior to the plan end date]
Has the outcome been successfully accomplished / Select "No."
Outcome Statement / I want to learn to read so I can read my own mail.
Reason for Outcome / Cindy gets frustrated that others have to read her mail for her.
Concerns related to Outcome / Finding a literacy program that will pace teaching so it makes sense to Cindy.

Continued

Demonstration 9-1: Creating Outcomes in HCSIS (continued)

Steps Continued:
  1. Continue to enter the following outcomes into HCSIS:

Relevant Assessment / Cindy has basic skills with letter recognition and attempts to sound out letters and guess at words. Has not had formal instruction in reading in over 40 years.
Field Name / Data
Outcome Phrase / Exercise
Outcome Start Date / [Today’s Date]
Outcome End Date / [Enter a date prior to the plan end date]
Has the outcome been successfully accomplished / Select "No."
Outcome Statement / In order to keep healthy, I want to find an easy dance class or dancing program so I can exercise in a fun way.
Reason for Outcome / Cindy likes to dance and the doctor is asking that she exercise more to control her diabetes better.
Concerns related to Outcome / Finding a dance class or program that has flexibility. Easy steps-aerobics was too hard in past because the movements were too fast and regimented.
Relevant Assessment / Cindy loves to dance. She can dance for hours at weddings or dance clubs.
Field Name / Data
Outcome Phrase / Summer
Outcome Start Date / 6/15/2004
Outcome End Date / 8/31/2004
Has the outcome been successfully accomplished / Select "No."
Outcome Statement / I want to work at the beach over summer so that I maintain the medical assistance program and see my aunt.

Continued