A resource to promote social inclusion within group homes
From presence to participation Page 1
A resource to promote social inclusion within group homes
To receive this publication in an accessible format phone (03) 9096 8427, using the National Relay Service 13 36 77 if required, or email <>
Acknowledgements
This resource has been developed as part of a participatory community placement by occupational therapy students from Monash University. The development of this resource was made possible by the guidance of Brent Hayward, Office of Professional Practice within the Department of Human and Health Services, and the Disability Service Accommodation staff at North-East Melbourne area, North Division.By Aleisha Gillespie and Eden Leung, July, 2016
Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.
© State of Victoria, Department of Health and Human Services, July, 2016
ISBN 978-0-7311-7001-2
Available at www.dhs.vic.gov.au/officeofprofessionalpractice
(1606032)
Contents
Guide to developing support plans that promote social inclusion 7
Benefits of using the support plan template 7
Social inclusion 9
Identifying socially inclusive goals 10
Template 1: Social life domains 11
Rating goals 12
Steps to identify goals with residents 13
Example of rating importance 13
Writing goals 15
Example of a SMART goal 15
Plan for goals 16
Example of steps 16
Template 2: Goal planning template – example 18
Template 3: Progress notes 19
Reviewing goals 20
Template 4: Reviewing goals – example 22
References 23
Appendices 24
Appendix 1. Social life domains and activities 24
Appendix 2. Examples of SMART goals 29
Appendix 3. Example of goal – preparing a meal 30
Appendix 4. Example of goal – volunteering 31
Blank templates and rating scales 32
Template 1: Social life domains 32
Template 2: Goal planning template 33
Template 3: Progress notes 34
Template 4: Reviewing goals 35
Rating scales 36
From presence to participation Page 1
Guide to developing support plans that promote social inclusion
The aim of this guide is to help you develop a support plan that will promote social inclusion for residents.
The support plan is a legislative requirement of s. 54 of the Disability Act 2006.
What is a support plan?‘A required document for service users of ongoing disability support. The document includes goals of service users, and strategies and support that have been planned out by disability service providers to achieve the goals.’
(Victorian Government Department of Human services 2009)
The purpose of a support plan is to:
• record and identify the goals of the person with a disability
• describe strategies and support from the disability service provider(s) intended to achieve the person’s goals
• include actions and resources required to achieve the goals; and
• review and measure achievements and outcomes of goals
You can use goal setting to focus on the person’s needs and aspirations. This can help to promote social inclusion.
Support plans are person centred. The person with disability must guide the development of the plan.The support plan must respond to the goals and aspirations of the person with a disability, and outline assistance from family and support networks. Personalise the format, content and language of the plan to meet the needs of the person with disability.
Take noteSupport plans may also be called individualised program plans, person-centred plans, person-centred reviews, or lifestyle plans.
Benefits of using the support plan template
This guideline helps you to develop high-quality support plans. It is supported with evidence from the literature. The templates provide you with strategies to develop socially inclusive goals, and review the outcomes of goals.
For staff, the guideline:• offers a structured format to guide the development of a support plan
• provides a standardised approach to recording and reviewing goals
• enhances communication among staff, residents and their families
• helps you to meet the legislative requirements of s. 54 of the Disability Act 2006.
Take note
The guideline focuses on social inclusion. It aims to help you develop socially inclusive goals, and broaden the scope of socially inclusive activities in the person’s daily life.
For people with disabilities, the guideline:
• adopts a person-centred approach in the development and achievement of personalised goals
• will ensure plans are easy to understand
• facilitates involvement of family
• enhances social inclusion.
Social inclusion
Social inclusion for people with a disability means:
• experiencing respect for their differences, their aspirations, and their rights to have control over their own lives
• having opportunities to contribute and participate in society in a meaningful way and feel valued
• experiencing significant reciprocal relationships
• having appropriate support, where necessary.
(Family and Community Development Committee 2014)
Take noteUse this definition when you develop the support plan, and identify goals.
A goal is an aim or target that a person strives for. It involves careful planning and setting timelines. Goals are important for making changes and achieving personal outcomes.
Steps involved in the achievement of socially inclusive goals include:• identifying socially inclusive goals
• rating goals
• writing goals
• planning goals
• reviewing goals and action plan for change.
Identifying socially inclusive goals
To identify goals to promote social inclusion, see Template 1 for a list of social life domains derived from the International Classification of Functioning and Disability (ICF).
What is the ICF?The ICF is a framework that describes the interaction between the person’s health, activity, environment and personal factors.
(World Health Organization 2013)
Incorporate social inclusion in various activities within each of these domains so the person is a part of a community and has meaningful life roles. These activities should be used as a guide to lead the conversation with the person, and to identify the person’s interests.
Take noteHighlight or make note of the activities presented in Template 1 that the person is interested in. Use the ‘Importance rating scale’ on p. 9 to narrow down the number of activities.
Template 1: Social life domains
Social life domainThe domains categorise different daily life activities that are associated with social inclusion. / Activities
Social inclusion does not only include leisure within the community, but also items as listed. Detailed explanation of each item is in Appendix 1. / Importance to person / Reason why it is important /
Home life / Buying things from the shops
Cooking food
Doing housework
Helping other people
Personal life with other people / Basic communications
Complex communications
Interacting with others in the community
Formal relationships
Casual relationships
Family relationships
Close relationships
Major life areas / Learning simple skills
School education
Tertiary education
Paid job
Simple money handling
Independent money management
Community, social and public life / Community life
Leisure and play
Religion and beliefs
Human rights
Political life and citizen rights
Take note
Present this information in a way that the person will understand, for example, using pictures.
See Appendix 1 for advice on helping people understand the activities presented on the table.
Rating goals
These rating scales help residents and family rate the importance of goals, and identify the current level of support the person needs to achieve the goal.
Allow the person to self-rate the importance of the goal. If they are unable to do this by themselves, involve a someone who knows the person well.Importance
1Least important / 2
Not really important / 3
Important to me / 4
Really important to me / 5
Most important to me
Take note
You don’t have to use a picture of a star on rating scales. You can change the symbol to something that is meaningful to the person, for example something they find interesting.
When you have identified what is important to the person, you will need to understand the reason why, so you can write specific and relevant goals. Also, by understanding why the person wants to participate in the activity, you can arrange the activity in a way that is meaningful for the person.
Take noteWhen determining how many goals to set, consider the person’s ability, and staff capacity to monitor the progress and achievement of goals. The number of goals should be based on what is manageable and realistic, in order to maximise the person’s chances of success.
Once goals have been identified, it is important to know the level of support the person needs to achieve the goal. The person can use the rating scale below to determine this. If the person cannot use the rating scale, staff and family can help to identify the level of support.
Take noteKnowing the level of support the person needs will help to identify the resources needed to achieve the goal, and what is required from staff, family and others to assist in the achievement of the goal. This will be addressed in the resources and responsibility section of planning.
Level of support
1Maximum assistance / 2
With some assistance / 3
Minimum assistance / 4
Prompts only/ Supervision / 5
Independent /
The descriptions below define the different levels of support.
Level of support / DescriptionMaximum assistance / Person needs direct assistance from support staff for
80 per cent or more of the time when completing the task.
With some assistance / Person needs direct assistance from support staff for about half the time when completing the task.
Minimum assistance / Person needs direct assistance from support staff for less than 20 per cent of the time when completing the task.
Prompt only/supervision / Person only needs verbal or visual prompts to complete the task, or supervision from support staff is only required for safety reasons.
Independent / Person does not need any assistance or support from staff to complete the task.
Steps to identify goals with residents
• List the social life domain activities, and work with the person and others to identify the activities they are interested in.• Rate the identified activities according to the importance to the person, using the rating scale provided.
• Through discussion, identify why these goals are important, as this will help in writing goals that are meaningful for the person.
• Highlight or make note of the activities the person rated as most important to them. Activities that scored the highest on the importance rating scale will be used to form the goals.
• Once goals have been identified, use the rating scale to identify the level of support the person needs to achieve the goal.
In the following table, cooking meals, informal relationships and community life scored the highest ranking in importance. These will form the goals.
Activities / Importance to client / Reason why it is important /
Buying goods and services / 3 / I want to help in choosing groceries. I would like to help more.
Cooking meals / 5 / I want to learn how to make breakfast.
Informal relationships / 5 / I want to see my friends more often.
Community life / 5 / I want to make new friends and go out with them.
Leisure and play / 4 / I like basketball and want to play in a team.
Example of rating importance
Take noteKeep in mind that goals need to be person centred. The person and their family should direct the development of goals. Staff can guide and facilitate if needed, but goals should match the person’s interest and aspirations.
The person can rank themselves (with or without assistance) using the ratings scales.
Writing goals
The best way to write goals is to use SMART goals. This will help you develop goals that are detailed, and can be measured. SMART stands for goals that are:
Specific: provide a detailed description of the goal. The more detailed the goal, the more likely it will be achieved. Think about who, what, where and when.Measurable: describe how progress will be made. This will help you determine whether the goal has been achieved. Measurement can be based on numbers, for example how many sessions attended, or descriptive, for example how much the person enjoyed the activity.
Achievable/attainable: the person must be able to accomplish the goal, considering their abilities and the resources and support available. Consider the barriers and challenges the person faces, and how these can be overcome.
Relevant/realistic: goals need to be realistic, based on the person’s capabilities, availability of resources, and schedule. Goals must have meaning for the person and be relevant to their desires.
Time: include a deadline for achieving the goal.
*Note: This description of SMART goals is from two sources referenced in the reference list.
Example of a SMART goal
Take noteWhen writing a goal, it is important to note if the person wants to increase their skills or participation in an activity, or if they want to maintain their current level. This will be important when it comes to reviewing the outcome of the goals.
Dan will attend a movie session at the local cinemas (specific) accompanied by a friend of his choice (relevant/realistic), with minimal assistance as specified in responsibilities and resources (achievable/attainable) within four months (time/measurable).
This is an example of a socially inclusive goal. For more examples refer to Appendix 2.
Plan for goals
In order to develop a solid plan for goals, staff need to consider the following: steps and strategies, responsibilities and resources, timeline, date action occurred, progress notes, and review date. These components will be described below in greater detail.
Steps and strategies
To help measure and monitor the progress, break goals down into smaller steps with accompanying strategies. Steps assist planning and monitoring the progression of the goal. Strategies look at how the goal will be achieved, by breaking down the steps into specific tasks. See Template 2 for an example.
Take noteTo determine what the steps are, ask, ‘What activities does the goal include?’
To determine what the strategies are, ask, ‘How will these steps be achieved?’
Example of steps
See Template 2 for accompanying strategies for the steps provided.Dan will choose a movie he would like to watch
Dan will choose a friend or family member he would like to go to the cinema with.
Dan will record his plans in his diary
Transport will be organised for Dan to attend the movies.
Dan will buy tickets at the counter with his own money.
Breaking the SMART goal into individual steps and strategies will: