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Course Number #017-04-01

1Outcomes: A Bridge To Action

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For SCs and SC Supervisors, course requirements include successful completion of a pre‐test and post‐test.



Welcome to this webcast, Outcomes: A Bridge to Action. My name is Amy Hines and I’ll be your narrator.



Think about a young person in your life who was in the beginning stages of planning for college. Do you remember sharing feelings of hope and promise as you talked about dreams for the future? The excitement of thinking about colleges and universities? New opportunities and experiences? New friends, independence, learning, and growth?



You might also have been thinking about your own similar experiences as a young adult, remembering that there is much to look forward to when starting a college career, and many concerns to work through, as well.

You were certainly excited and happy to see the young person in your life taking this important step into adulthood, but you probably couldn’t help thinking: Will she make friends? Will they be a good influence? Will she be homesick or lonely sometimes? Will she remember to take care of her health and find a good balance between having fun and studying? What about handling money? Will she manage her budget, or spend all her money in the first few weeks?



We all start with the dream of what we want out of life: What’s most important to us and gives our lives joy, purpose, and meaning. Who to spend time with, what we want to accomplish, things to have and places to go; having a sense of status and respect, and even ordinary things like control over the pace and routines of our daily lives.

We understand the reasons why these things are important to us and what makes them so meaningful and satisfying.

But, often, after we know what we want and really understand the reasons, we may start to worry. We may find ourselves – or others – saying “yes, but…” and listing the “what ifs.” These are the barriers to our dreams and it’s natural that they occur to us – it’s a pretty common part of the human experience. The barriers or concerns – the worries that occur to us when thinking about how to get what is important to us – can stop us from thinking about how to get what’s important to us – OR, they can give us the energy to take the next steps. The concerns can help motivate us to make a plan and strive for what we want.

This process – common to all of us ‐ is exactly what teams do when beginning outcome development. The dream is an outcome statement that clearly articulates what is important to the person. When teams think about reasons, they’re delving deeper into really understanding the person’s idea of why something is important to him or her. The natural next step, then, is to think about all the things that stand in the way of accomplishing the outcome statement; people start naming the concerns.



In this webcast, we’re going to pick up where 2013’s on Outcome Statements training left off by reviewing ODP’s guidance on outcome development. Then, we’ll look at the areas of the outcome summary that come after the outcome statement: Reasons For The Outcome, Concerns Related To The Outcome, and Relevant Assessments. We’ll talk about the importance of sequence.

Much of the webcast will focus on concerns: where information comes from and how to think concerns through. Even though we won’t get into detail on Outcome Actions, by the end of the webcast you’ll see how concerns can be a bridge to helping the team begin to plan actions that are necessary to help the person make his or her outcome statement a reality.



We’ll talk about the importance of taking time to have a thorough discussion of each part before moving to the next.

As we look at the Outcome Summary section, you’ll see how each part logically leads to the next. Taking each part in order is an important theme that will come up throughout the webcast.



Let’s review past training on outcome development.

In 2011, ODP provided a series of trainings on outcomes development beginning with a webcast titled Lesson 1: Building a Foundation. The webcast reviewed basic concepts of person‐centered thinking intended to prepare participants for instructor‐led training on outcome development called, Pennsylvania’s Outcomes Training: It’s About the Person, Not Just the Process. These face‐to‐face sessions were attended by Supports Coordinators, Provider staff, Administrative Entity staff, individuals and families. After the training, the PA Outcomes Training: Follow‐Up Activity webcast provided an opportunity to practice writing outcomes.



Next, in 2013, ODP provided a webcast that focused on writing outcome statements. Central to this webcast was the concept that use of language is important in understanding outcome development. Using the word “outcomes” can be confusing –there are many different parts of the Outcome Summary in the ISP that require a significant amount of information.

If I said, “outcomes should include both paid and unpaid supports,” do you know exactly what part of the Outcomes section I’m referring to? On the other hand, if I said, “an Outcome Statement does not include services – those are included in Outcome Actions,” – is it clearer that I want to emphasize the point that services should not be included in an Outcome Statement?

Experience has taught us that using clear language is important to understanding. The 2013 training clarified that the word outcomes refers to the entire Outcome section of the ISP, but Outcome Statement refers to the part that represents something that the person says (or shows through actions) is important to him or her.



The 2013 webcast reinforced ODP’s guidance that the Outcome Statement captures a person‐centered description of something the person feels is important to him or her. Outcome Statements are unique to each person’s life and circumstances. Although included in Outcome Actions, services and supports are not to be named or even made reference to in the Outcome Statement.

Even though an Outcome Statement may include what is important for the person (in other words, issues of health, safety, and well‐being) the Statement must contain what is important to the person. If both are present, important to and important for must be balanced in a way that works for the person and he or she finds acceptable.

Last, the Outcome section incorporates information from the rest of the ISP. What is written in an outcome statement is often something that is also found in the Important To section of the ISP. Concerns Related to the Outcome should reflect information from other parts of the ISP, for example, the Health and Safety Focus Areas.

In 2013, we used information from Joe’s life to illustrate how an outcome statement is developed. We’ll use Joe’s story again in this webcast to illustrate key points.



Much of the information we just reviewed is still available on the ODP Consulting System, the SC Curriculum website and the ODP Information Centers for Administrative Entities, Supports Coordination Organizations, and Providers.

That brings us up to date with the most recent ODP training.

What’s the next step after developing an outcome statement that includes what the person says or shows through actions what is important to him or her?



First, let's keep in mind that in order for outcome development to work correctly, we have to follow the sequence that is shown in the ISP. The process begins with a strong Outcome Statement that clearly expresses what is important to the person.

Next, the team makes sure they understand the person’s reasons. You and I might have similar outcome statements centered on being part of our communities, but our reasons might be completely different. I might enjoy getting to know my neighbors and form friendships because it makes me feel safer and more included. You might be motivated to get involved in your community as a volunteer because it’s important for you to have a sense that you are contributing. Our outcome statements are similar, but they start with very different motivations and lead to different actions. If we both had support people to help us achieve our outcome statements, it would be important for them to understand our reasons in order to know how to offer support.

Only after the person’s Outcome Statement is developed and reasons are fully understood is it time to start thinking about concerns. What will it take to achieve the Outcome Statement in a way that is effective, that supports health, safety, and well‐being, and addresses other concerns of the person and team?



Why is paying attention to sequence so important? Why is it vital to make sure we really fully understand what is important to the person and his or her reasons before moving on to talking about concerns?

Well, let’s think again about the young person dreaming of college and just beginning her adult life. When the concerns come first, they can cloud the dream. Imagine the young person is dreaming of a college with a great program in a field of study that’s exciting to her, but the college is a few states away from home and she and her family are worried about a medical condition that requires regular visits with a specialist. What if the young woman and her family think first about how to manage the health condition? Would that influence the choices they make? Could it prevent them from really thinking about ways to support her dream and how to balance it with making sure her health remains good?

Now, we can’t discount concerns; we must make sure people are happy AND healthy and safe.



If we start by talking about health and safety when developing outcomes, we run the risk of missing the opportunity to find out what gives the person’s life purpose and meaning. Who of us wants a life that’s all about just doing what’s good for us? Imagine a life of only doing the responsible things: never taking a break from an exercise routine, nothing but healthy foods, and never ever an occasional dessert or comfort food.

Most often, when we’re doing something that’s good for us, there’s usually something in it that it’s important to us, as well. My motivation for exercising or being cautious about diet is not just because a doctor told me that I needed to make changes. I know it’s important for me, but the way I make it happen in my life is to connect the things I need to do to take care of myself with things that are important to me. For example, it’s important to me to be as medication‐free as I can be. I just don’t like being dependent on medications and all the hassle that comes with it. Following my doctor’s advice about a healthier lifestyle could help me control my blood pressure without medication. I might also feel better and have more energy to do the things I like – such as hiking and biking with people in my life who are important to me. And I’m not always perfect, but I strive to find a pretty good balance that works for me.

Important to and important for are connected – but we have to think of important to first.



When you and I look for balance between what’s important to us and important for us in our own lives, we are doing it for ourselves. We’re going to think harder about a balance that works for us because – well, it’s in our own best interest to do so. We also have more control over how that balance works for us – we have some authority over our own decisions and choices.

Now think about how our system is focused on health and safety for individuals receiving support. And it’s an important responsibility for all of us to make sure people have the right supports to be healthy and safe.

But our focus on health and safety means that the scale is already weighted in favor of what’s important FOR people.

So here’s why teams have to start with really understanding what’s important to a person and their reasons: it makes it more likely that what the person wants out of life is part of the conversation. If we begin there, what the person considers important has less chance of being crowded out. As we said, if we start with important FOR and then get to important TO, the vision of what’s important to a person can be obscured. Outcome development that starts with issues of health and safety tends to end up with outcome statements that are more about keeping the person healthy and safe than supporting what really matters to the person.

We have to have both important to and important for. We also have to listen and support the person in finding his or her preferred balance between them – so we start with what’s important to the person before moving on to concerns about health and safety.



So, outcome development begins with an outcome statement that clearly captures what is important to the person. Remember, the outcome statement is written in present tense language and describes the expected result: if the outcome was present in the person’s life, what would the person be doing? You do this in your own life when you imagine a time in the future when you have achieved what you hoped for; you picture the scene in your mind when everything had worked out just the way you planned.

Outcome statements are written in plain language and are unique to the person. Not only are they free of services – including reference to services ‐ they’re written so anyone can immediately grasp what they mean – they avoid vague words like “socialization” in favor of clear descriptions of what the person is doing, like going shopping with friends or having Sunday dinner with family.



During development of an outcome statement, the person’s reasons will emerge. For example, if you and I worked together, you would know that spending time with family is important to me. But what else would you need to know to understand why it’s important and the ways that I want time with family to happen? Since most of my family and I live in different cities, we try to get together for a week in Georgia every August. It’s something we count on and would really miss if something got in the way so we plan in advance and protect this time to be together.

As my coworker, knowing my reasons would help you to understand why it’s important to me to take these days off in August. It’s not just a vacation – it’s an opportunity to connect with the important people in my life that I don’t see as often as I’d like. But it tells you more than just my reasons: it gives you some idea of what kind of support I would need to make it happen. The reasons give you insight into why I would be worried about a big project that I’m responsible for checking during the time I planned to be with family. Knowing the reasons, you might offer to keep an eye on things while I’m away.

This is an example of how understanding the reasons help us to tailor our support. Reasons can be a glimpse into what needs to occur to make sure the person is getting what’s important to him or her in a way that is meaningful and satisfying.



Once we have followed the sequence and understand what’s important to the person and really know the reasons, we can move on to thinking about concerns.

In the system in which we work, it is our shared responsibility to assure health and safety, so it’s probably natural for teams to begin thinking of concerns almost immediately. When we notice that we’re doing that, it’s important to make sure we are finished really exploring and understanding what’s important to the person. Thinking about barriers too early can short‐circuit a rich discussion about what the person considers important to change or maintain in his or her life.

But it’s also important that the discussion of concerns, including health, safety and welfare, continue at the right time, in the right sequence.



Concerns related to the outcome are what people worry about when thinking about the outcome statement. For example, imagine talking with Jerry and his team about what’s important to him: being able to go to the mall by himself and spending time shopping for video games. Jerry has a lot of good skills and likes to hang with the guys at the video store talking about the latest and greatest games. Jerry’s outcome statement about spending time at the store fits right in with his interest in video games, but it also supports his desire to meet new people and be more independent.

If the team is thinking in the sequence outlined in the ISP, they’ll clarify the outcome statement and really understand Jerry’s reasons first. They might even be thinking of all the concerns while they’re still listening respectfully to what Jerry has to say about how important this is to him, but they’re waiting and listening before bringing them into the discussion. Eventually, it will be time to bring the concerns out for everyone to consider. This is when people start naming concerns – often beginning with phrases like “what if…” and “yes, but…”:

• What if Jerry overstays his welcome and annoys the salespeople or other customers?

• Jerry has diabetes. What if his insulin levels become too low because he loses track of time and forgets to eat something?

• Video games are really important to Jerry, but should he spend all his time and money on them?

• We’d like to support Jerry’s interests as much as possible, but there isn’t staff to be with him every time he goes to the game store in case something happens.

When concerns start to emerge in team meetings you’re part of, do people start to offer solutions? This is our natural tendency: after all, we are expected to support people to get what they need and live meaningful and satisfying lives. But remember it is all about the sequence so before offering solutions we need to hear all of the concerns from everyone on the team.



When the team is thinking of concerns and then beginning to brainstorm solutions, what they are really doing is starting to think about action planning. Understanding concerns and then begining to think them through is a first step on the bridge from the outcome statement to outcome actions.



Let's go back to an earlier point: When concerns start to emerge and team members are offering solutions, they are in planning mode. Think about what’s happening at that point. When people are talking about solving problems, even when they have the best of intentions, their focus may have turned away from listening and learning about what’s important to the person.

So, while it’s a natural tendency to think about concerns and then leap right into solutions – or action planning ‐ timing is everything. As you facilitate and participate in team discussions, be aware of when people may be moving too quickly past really understanding what someone is trying to say about what’s important to them. And slow the discussion down until the time is right to think about concerns and possible actions to address them. Even when it’s time to talk about concerns, what’s important to the individual is always kept in mind.



Let’s go a little deeper into thinking about concerns related to the outcome.

When I talked about concerns a few minutes ago, I used the word “worry” and phrases like “what if” and “yes but.” Those are commonplace words but asking questions like those is really what the team is doing when thinking about concerns related to the outcome. These are the barriers that prevent us from moving in the direction of the outcome statement. Here are some examples:

Most often, concerns about health and safety are the ones that come up first. Remember that, as we said earlier, if health and safety trump what the person considers important to him or her, then the discussion can result in lack of balance between important to and important for. Discussions about health and safety must be taken seriously and thought completely through by the team; but they have to come at the right time.

Teams sometimes worry that they will not be allowed to try something new or take a big step toward an outcome statement that comes with potential risks. If so, they are anticipating an obstacle that may not exist. That may keep the team from really understanding what the person is telling us and figuring out what is possible. One thing’s for sure: If we stop talking about big steps and never get to the point of asking for support, then we will never know what’s possible. So it’s important to think through outcome statements that seem to be, at first, too big and full of concerns to consider.

Our perspective working within the system also tends to drive us quickly toward paid services as solutions. They may sometimes be the best answer. But if services are not readily available, then the lack of services by itself can stop discussion of an outcome in its tracks. Sometimes, a solution lies in thinking about unpaid supports to help people get what’s important to them, which provides opportunity to build and foster relationships and connections with the community. Other times, when services are not readily available, it’s an opportunity for the team to think more deeply about what the person is really telling us and how that need can be met in other ways.

Teams can also get stuck in thinking of the past as a barrier. At some point we have all thought, “We tried this before and it didn’t work.” If that is indeed true, another way to look at history is to learn what didn’t work and try a different approach next time.

Teams can also wonder whether fulfilling the person’s outcome statement is possible or if plans will really work. Concerns like these can be a barrier to taking action. But, they can also propel the team into thinking constructively about actions: What will it take to make the dream a reality? What will it take to make things work?



If I asked you where to find information that would help me understand what concerns there might be for a person you support, you might point me to what’s written about the person. That’s a good place to start. Remember that information throughout the Individual Support Plan should be integrated into discussion about outcomes and referenced in the appropriate areas of the outcome summary. Some places where concerns related to the outcome might be found are the Know and Do and Health and Safety Focus Areas of the ISP. There are others, too. Such information could be found throughout the ISP.

What an SC learns through the ISP Monitoring process might also provide information about concerns related to the outcome statement. If the person receives paid services, provider documentation could be another good place to find detailed information about concerns: for example, what do progress reports reveal about the concerns of people who support the individual on a daily basis?

This is only a partial list of sources of information that could tell us about potential concerns. There are many others and it is important to identify all concerns before taking the next step in the sequence of outcome development.



Now that we’ve established some of the sources that can help us pinpoint concerns related to the outcome, let’s think a little more broadly. Look at the list of examples in the upper right corner: would you expect to find all of these concerns written down?

You are probably thinking that information about health and safety can be found in many documents. But you also know some of the concerns that people have might not be written down. Perhaps there’s a new concern that no one has thought of before. Or maybe a concern is difficult to voice. This is especially true when concerns bring up feelings and emotions of fear or anxiety about safety, about whether the outcome statement is possible, or doubts about how things will work out.

What the person is concerned about – his or her worries – need to be understood and listened to. After all – it’s his or her life we’re talking about. It’s also important to make sure that the perspective of those who truly love and care about the person are heard. Someone who loves the person brings a strong investment in the person’s dreams and in making sure concerns are addressed. And then, the concerns of everyone on the team – especially those who will play a part in supporting the person’s outcome statement – need to be heard and understood.



Making sure that everyone’s concerns are heard and that people with differing perspectives have the opportunity to understand one another and find common ground is an important part of outcome development.

People need to have time to discuss concerns. Figuring out concerns is not limited to researching what’s written in documentation. It’s the Supports Coordinator’s responsibility as facilitator of the outcome development process to make sure that everyone’s concerns are respectfully listened to. As a facilitator, the SC should anticipate and plan for how to supportively help people voice concerns, especially those that come with strong emotions. Sometimes, this means talking concerns through outside a big meeting and finding ways for people to have a voice.



Okay, so after the concerns are on the table, what happens next?

The team needs to take the stack of concerns and think through each to determine whether each concern is likely to happen or if it’s unlikely. The second factor to consider in addition to likelihood is: If the concern could happen, how serious is the level of risk?

Here’s an example of how those two factors – likelihood and seriousness – work together:

If you lived in Kansas, many miles away from the nearest ocean, you might wonder what would happen if a tsunami hit. The consequences would be severe – all that water rolling over flat land – but it’s not very likely to happen, and in fact has never happened. It’s not a concern that you would think about making preparations for.

On the other hand, if you lived in San Francisco, you would know that it’s not only possible for an earthquake to happen, it’s likely because it has happened many times before because the city is on an earthquake fault line. The consequences could be relatively minor if the quake were small, or they could be more severe. If you lived in an earthquake‐prone area, you would take precautions to prepare for the likelihood that one will happen.



Getting a handle on likelihood and seriousness of the concerns means using available information and analyzing it logically. History can be one method. Has what people are concerned about happened before? How often? What was the impact? How did the person and people around him or her manage it when it occurred?

When a concern is raised but there is no history to predict what might happen in the future, assessment information may be useful. For example, think about someone who is moving from the country to an apartment on a busy city street. She has never had to deal with lots of traffic in the country so people are not sure how she will handle crossing streets and negotiating a crowded sidewalk. Is there information from formal or informal assessments that will give the team a clue about whether or not to be concerned? Does the information shed any light on how the new city‐dweller will react to crowds, traffic, or unexpected situations?



If a concern is likely to occur and carries high risk, the team needs to talk about solid supports for health and safety. It may also lead the team to worry a lot about potential risk and think about the deeper meaning of what the person is asking for and find less risky ways to satisfy what the person wants.

If a concern is not as likely to occur, then the team thinks through the circumstances that might cause it and plan steps to reduce or eliminate the concern. This includes how to manage the situation if what people are concerned about actually does occur, perhaps including supports that are needed when risk is greatest, but not all the time.

What about concerns that are likely, but don’t pose a great risk? That might be an opportunity for the team to support the person in managing the risk in ways that he or she chooses. This could be a time to try different strategies to address a concern to see what works. For example, if I go with my nephew to get coffee and see he doesn’t respect the line (because he struggles with reading social cues), I might talk with him before going into the coffee shop about how he can make sure he doesn’t cut line. We might talk about things we should do to make it a good experience, and we might even talk about things that we should avoid doing. Even though there probably isn’t a great risk if he did cut line, working out a plan with him in advance helps him feel in control.

If the concern is unlikely to occur and won’t have a serious impact if it does occur – it’s time to note the concern, pay attention to make sure the concern doesn’t become more serious, and focus on the concerns that require more thought and action.



Although it’s not a focus of this training, I want to talk briefly about relevant assessments in relation to concerns.

In Relevant Assessments, we’re not including all assessments, but information which directly connects to the specific outcome statement. Think about Jerry, the man we talked about a few minutes ago who loves video games. His team would find it useful to consider assessment information about his diabetes and how often he should eat because it has direct bearing on spending time in the video store without staff. Relevant Assessments could also include informal information, such as how he reacts to unexpected situations, like not being picked up on time.

Also, information in Relevant Assessments can be used to measure whether the outcome has a positive impact. For example, assessments say that Jerry tends to lose track of time when he’s really focused on something he likes (such as video games). People who support Jerry know that talking about games in the video store can cause him to be late sometimes in getting back to the meeting point to go home. But being responsible is connected to Jerry’s desire to spend time doing things he likes with as much independence as possible. Therefore, if we saw that, over time, Jerry meets staff at the time they agreed to meet, we know that the outcome is having a positive impact on the assessed issue of being late.



What we’ve talked about so far is how to take things one step at a time, starting with the person’s outcome statement, and then how concerns can begin the process of thinking about actions. Next, we’re going to use an example to illustrate how this works. We are going to talk about Joe from the 2013 Outcomes Statement training.



Joe lives in central Pennsylvania. His information is being used with his permission. Names and minor details have been changed.

You might recall that some of the things that are important to Joe are “being his own man” and making decisions for himself. Like all of us, he wants to feel that others respect him and that he is safe. Joe likes making new friends and spending time with them doing things they enjoy together. A point of connection between Joe and others is love of music – especially live music at local establishments. It’s important to Joe to have a predictable routine; he doesn’t like plans to be changed without knowing in advance. Mike is an important person in Joe’s life. Mike lives a few doors down from Joe’s apartment and although he is paid to support Joe, the guys think of each other as friends. It works out well for Joe, too. Mike happens to be in a band and being friends with him, Joe has learned how to use some of the equipment in the recording studio. He loves being a part of making the music happen.

Joe’s team pulled many of the things that are important to Joe together into an outcome statement:

Joe is a member of the band’s sound crew, spends time with his friends and family doing things he enjoys in order to remain healthy and strong.

The last part, “healthy and strong” refers to managing mental health concerns, which is important for Joe. Staying connected with Mike, other friends, and family makes it more likely that he will manage symptoms and remain out of the hospital.



Joe’s reasons for staying connected to family and friends are not only about managinghis mental health successfully. The reasons are pretty common: He likes spending time with people and having interesting things to do. And he especially enjoys when it involves music. These are some of the reasons that helped Joe’s team find a direction and figure out exactly how to make Joe’s outcome statement happen in a way that was meaningful and satisfying to him.



Joe and his team are aware of the concerns that are connected to the outcome statement of being with family and friends enjoying time together in a public place. Many of them center on Joe’s mental health. He can sometimes react strongly if something he is looking forward to is cancelled or someone he was counting on doesn’t follow through. Joe has a tendency to misread others’ words and actions and can become angry. He has difficulty expressing feelings and may assume that people don’t like him. Both of these concerns can be barriers to meeting new people and forming friendships.

Sometimes, he might need to be reminded to shower or shave – that’s important to being accepted as a member of the group.



I mentioned that Joe can react strongly to changes in plans or when he can’t get in touch with someone. At times, his reaction can be quite strong – Joe may yell or swear. People know that in Joe’s past, he has been threatening and destructive of property when angry. It’s important for Joe to take his medications – if he doesn’t, there’s risk of mental health problems or even hospitalization. Joe relies on Mike and others – they have routines to check in daily to make sure things are okay. But people are concerned that when Joe is going through a tough time, he can tend to isolate himself from others, even going so far as to accuse them of things. When Joe does this, his isolation causes people to be very concerned about his stability and well‐being.



The first step in looking at these concerns is to determine how likely they are to occur and what the consequences would be if they did occur. This gives the team a first idea of actions needed.

When Joe and the team looked at the concern about taking medications, they discussed that it has happened, but doesn’t occur nearly as often now as it has in the past. However, they realize that if the concern was not addressed well (and in a way that worked for Joe) the impacts for Joe could be serious; he has a history of inpatient mental health treatment and does not want to be hospitalized.

Knowing what they do about this concern, including Joe’s history and the risk of hospitalization, Joe’s team began thinking about actions that will support him in taking his medications regularly like checking in by phone each morning.



When thinking about Joe’s interest in music, helping with the band, and especially spending time with family and friends in public places, Joe’s team thought about the concern that he sometimes doesn’t shower or shave for a few days. In order for any of us to be accepted by a group of friends, it’s important for us to pay reasonable attention to our appearance and how we present ourselves. Joe’s team realized that it’s just the same for Joe: they want friends to be interested in Joe as a person but not be distracted by appearance.

Knowing this, Joe and his team were ready to brainstorm actions that would help him be welcomed and valued in a group of friends. They did this by connecting what’s important to him – spending time with the band in the studio – to what’s important for him – making time in his schedule to clean up and pick out nice clothes. They realize that using humor works for Joe and people who support him might use a gentle reminder such as, “You know all the ladies like a fresh shave!” Joe gets the hint.



The process of thinking through concerns leads naturally to thinking about actions to address them. When we know what the barriers are to what we want to accomplish, we are on the path to making action plans to find ways to deal with them.

Joe and his team developed his outcome in sequence. They started with really understanding what’s important to him. They continued by looking at concerns that stood in the way – and this propelled them forward into action steps.

They kept the balance between what is important to Joe and what is important for him in mind – and worked to understand and achieve balance in the way that Joe found satisfying and meaningful and fit with his lifestyle.



There is one last part of the timing involved in outcome development with ISP teams. Think about your own life: When you are telling someone what’s important to you, where do you prefer to start? Most of us would say that we’ll make sure we cover the concerns but only after we’ve had a chance to describe what we want to accomplish and our reasons. That’s where our hope and positive energy are, at the beginning of the discussion, when we’re sharing our hopes and dreams with someone else.

One way to make this easier might be to remember something we talked about earlier: information about concerns comes from a number of sources, including provider documentation, ISP Monitoring forms, past years’ ISPs. So, when the team is gathered for an Annual Update ISP meeting, isn’t it very likely that much of the information has been being collected and documented for months?

A recommended practice is that teams prepare ahead of the ISP meeting, sharing updates to important information, such as medications and appointments, in advance. This opens up time at the beginning of the meeting for everyone to contribute what they have learned from the person’s words and actions about what is important to him or her, develop Outcome Statements to reflect it, and complete the Outcomes section when all participants have enthusiasm and energy.



In this webcast, we talked about the need to listen to the person’s perspective and that of those who care about him or her. This will help us to stay in sequence in developing outcomes and begin with an outcome statement that captures what the person considers important to him or her and is free of services. Outcome development includes discussion to understand the person’s reasons so that we know exactly what it is the person will find meaningful and satisfying and the outcome is unique and individualized.

We talked about the need to stay in sequence and only discuss concerns after the outcome statement is developed and reasons are clear.

Concerns are barriers to making the outcome happen in the person’s life. They are often found in documentation, but team members should be supported to express concerns even if they aren’t written down. Concerns should be discussed in terms of how likely they are to occur and what the potential impact could be – this will help the team take the first step toward actions to address the concerns.



This webcast has been developed and produced by the Office of Developmental

Programs Consulting System on behalf of the Pennsylvania Department of Public

Welfare, Office of Developmental Programs.

Thank you for participating in this lesson.



Date post:	31-May-2020
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