The Outcome Section ISP: Better 2...Pennsylvania Department of Human Services Office of...

Pennsylvania Department of Human ServicesOffice of Developmental Programs

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Course Number: C-019 1

The Outcome Section of the ISP: Better Outcomes, Better Lives ‐ Part 2


This webcast includes spoken narration.

To adjust the volume, use the controls at the bottom of the screen. While viewing this webcast, there is a pause and reverse button that can be used throughout the presentation.

The written version of the narration appears to the right of the screen.




Certificates of Achievement will be available to Administrative Entity staff, Providers, Supports Coordinators, and SC Supervisors after completing all course requirements. Please view and then save or print your certificate in order to receive credit for this course.

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




Hello and welcome to this webcast, The Outcome Section of the ISP: Better Outcomes, Better Lives, Part 2 – Outcome Actions.

My name is Patty McCool. I am the Director of the Bureau of Supports for People with Intellectual Disabilities and will be presenting this training along with Angela Fortney on behalf of the Office of Developmental Programs. Angela is the Director of the Division of Community Services for ODP and will be joining me later in the presentation.




This is the second webcast in a two‐part series. In this training, we will focus primarily on the Outcome Actions in the Outcome Section of the ISP.

Part 1 of this series focused on the Outcome Summary part of the Outcome Section of the ISP. This is where person centered outcome statements are developed along with reasons for the outcome, concerns related to the outcome and relevant assessments are discussed and documented. If you have not viewed Part 1, please do so in order to receive credit for completing this two‐part series.




There are several supporting documents that will be referenced during this webcast. If you have not already downloaded or printed these documents, please take a moment to do that now. All supporting documents can be found on the course page where you launched this webcast.

The supporting documents are:‐ Outcome Actions Blank Template‐ Person Centered ISP FINAL 09_14_15‐ Outcome Training FAQs FINAL 09_14_15‐ Frequency and Duration Example FINAL 12_31_15 and‐ Carol’s Story




Presented today are ODP’s requirements for completing and documenting the Outcome Section of the ISP; specifically the Outcome Actions. This webcast includes additional clarification from ODP based on questions submitted at the in‐person training. In addition, follow up conference calls were held on September 30 and October 1, 2015 in which the following documents were discussed: Person Centered Plans, FAQs and Frequency and Duration Example.

The purpose of this training is to provide direction on how to develop the Outcome Action section of the ISP to support the achievement of person centered outcome statements while meeting documentation requirements for the provision of publicly funded services.

All stakeholders with a role in this process should implement these requirements as directed in order to create a consistent process for all team members. Specific questions about implementation should be directed to the SC Training Mailbox which is provided at the end of the webcast. Requests for technical assistance related to the development of the Outcome Section should be sent to the Regional Program Manager in the ODP Regional Office.




As a result of the questions submitted from the in‐person training and follow up discussion, ODP staff recognizes that in recent years more focus has been placed on policies and procedures to meet increasing federal oversight. Realizing that there is a finite amount of work time, it is important now to re‐prioritize a person centered team discussion. This team discussion about what and how services and supports are provided will help people to achieve what is important to him or her while promoting health and safety and the opportunity to learn or maintain new skills.

Throughout this webcast content and examples will be provided that support flexibility to assist all stakeholders to implement person centered practices and meet documentation requirements.




There is also an important point of emphasis to make in understanding the relationship between the person centered ISP and services. The takeaway for everyone is that ‐ while services have to be attached to an ISP through one outcome phrase, the full scope of service and service units should be based on ALL of the person’s assessed needs documented throughout the ISP. This is true for all services, not just 24/7 residential habilitation as previously instructed.

In other words, the type and amount of identified and provided services is not solely or only linked to the outcome section of the ISP. The full amount of authorized service is reflected through all of the needs and actions documented throughout the body of the ISP. The full amount of the service units identified in service details does not have to be reflected in the outcome statements.

I will continue to talk about this and provide examples later in the training.




Before we begin to learn about Outcome Actions, let’s refresh on a few of the key concepts from Part 1 of this series that focused on the Outcome Summary.

What matters most is people. It’s about helping people to have better lives.

It is more than the paper that will give us better compliance. It is about developing person centered outcome statements that reflect what is important to the person.

As the team utilizes a person centered approach, ODP’s mission, vision and values should be at the core of the discussion and inform the development of the Outcome Section of the ISP.




Two other elements of outcome development that support the planning process are:language and words and sequence.‐ Being precise in the choice and use of clear and consistent language and words will help to decrease confusion and make sure that we are talking about the same thing as we develop person centered outcome statements.‐ Following the sequence using a step by step process is critical to completing the Outcome Section of the ISP. Using person centered thinking skills, the team gathers information to build a strong person centered outcome statement and then develops ‐ the reasons for the outcome, the concerns related to the outcome, relevant assessments, current needs, action needed, who is responsible, frequency and duration and measuring progress.

Following this step by step process is a logical flow and is exactly the order in which the Outcome Section of the ISP is structured.




Before we move on, let’s review one more foundational concept related to both words and sequence.

In order for outcome development to be the focus of the ISP team meeting, all team members need to collect and share information about the person throughout the year. Sharing assessments, quarterly reports, new skills, strengths and interests along with changes in health and wellness before the team meeting, ensures that the team is developing outcome statements and outcome actions that are based on the most current information.

Sharing this information throughout the year, and certainly before the team meeting, allows the team to prepare ahead of the annual ISP team meeting. Preparing before the meeting allows more time for creativity and discussion on the actual outcome statement when the team is together.

The SC needs the full support of all team members to maintain the ISP as a living document to best support the needs and preferences of the individual.




To begin our discussion on Outcome Actions, let’s do a quick quiz related to some myths and facts. The next eight slides will ask you whether the statement is a myth or a fact. Choose the answer that you think is correct and click the submit button. After you click submit, you will see whether the answer you chose is the correct one.

The objective of this activity is that by the end of the webcast everyone will have the same correct answer for these myths and facts.



Pennsylvania Department of Human ServicesOffice of Developmental ProgramsCourse Number: C-019 14

















In Part 1 of this webcast, we talked about the importance of sequence in developing the entire Outcome Section of the ISP. I will continue to highlight and use a step by step approach as we develop Outcome Actions.

As an overview, the Outcome Actions support the person’s outcome statement. It is in the Outcome Actions section that services and supports are identified to address the current needs. A specific action plan is put in place to help the person achieve the desired result in the outcome statement.




The Outcome Actions section begins with the Related Outcome Phrase. This is the same as the Outcome Phrase which as you know is a tag or a keyword originally created in the Outcome Summary that helps you and other people to find this specific outcome statement. Because outcome statements are not services, services should not be used as the outcome phrase.

On the service details page in HCSIS, the SC attaches services to the Outcome Phrase. Each service that is identified in What Actions are Needed should be attached to the corresponding Outcome Phrase. For example, if a person has three outcome statements and Licensed Residential Habilitation is listed as a service for each one, then all three outcome phrases should be attached to the Licensed Residential Habilitation service.




After entering the Related Outcome Phrase, the next part of the Outcome Section answers the question –What are current needs?

Start thinking about action planning. It is important to know what the person can already do and what he or she needs to learn or be supported to do in order to achieve the outcome statement. So here in Current Needs we identify both the person’s abilities (skillsand strengths) and need for support specific to this outcome statement.




Current needs is a description of where the person is NOW in relation to the desired result in the outcome statement. As we mentioned, assessments help the team to identify needs. You, along with the individual’s team, will need to do some prep work to know and verify the Health and Safety Section of the ISP in order to be sure that current needs are up to date and fully understood.

Included in current needs is:‐What the person is able to do to achieve his or her outcome statement and‐What assistance he or she will need in working on this desired result

The needs identified should crosswalk with and be found in other sections of the ISP. In other words, when a reviewer who has read the full ISP then reads the current needs in the Outcome Section, the reviewer should have already read about this need in the previous pages of the plan.

And because the detail on needs is found in other places in the ISP, great detail is not needed in this part of the Outcome Section. You can refer to other sections of the ISP if needed.




Now that we know the person’s current needs, it is time for the team to determine what actions, services and supports are needed. Services and supports address current health and safety needs, helps the individual to learn or maintain a skill and to achieve their outcome statement.

Based on the outcome statements, reasons, concerns, assessments and needs, it is in What Actions are Needed that the team identifies steps and actions taken by unpaid (ex: family or friends) and paid people to achieve the outcome statement. It is here in Actions Needed that paid services are identified and named to meet health and safety needs and to learn and maintain new skills. An example of supports to learn a new skill might be learning how to set up a daily or weekly schedule for the week.




Included are actions related to the specific outcome statement that:

‐ the person can do or learn to do

‐ are currently occurring and need to continue (for example – cooking a simple cold meal or making a sandwich) and

‐ are not occurring but will need to be in place including those actions related to supporting health and safety (for example – learning how to use the microwave and toaster oven for simple hot food preparation)

Outcome actions are measurable and observable and build to the achievement of the outcome statement. We will talk later about how outcome actions are measured to determine progress.




Let’s step back for a few moments to highlight a foundational concept that explains the relationship between a person centered outcome statement and paid services that address health and safety needs and promote learning and maintaining skills.

In order to best understand this clarification it is important to keep in mind the two parts of the Outcome Section of the ISP – the Outcome Summary and Outcome Actions.




The Outcome Statement (within the Outcome Summary) is what the person wants in his or her life and is developed by gathering information using person centered thinking skills. Person centered outcome statements helps the person to have an Everyday Life and supports ODP’s mission and vision which we described in Part 1 of this series.

Outcome Actions is the planning part and identifies what is paid for through base or waiver dollars or provided through unpaid supports. Actions address health and safety needs, and learning and maintaining skills. I will talk more in a moment about identifying these paid services in frequency and duration.




Let’s think about this some more with Carol as an example. Carol’s Story is a supporting document to this webcast. If you have not already read about Carol, please pause the webcast and do so now.

To summarize, Carol is a middle aged woman who has a long time support person named Mary. Carol communicates through facial expressions, gestures and behaviors. She needs support throughout the day to use the bathroom, dress, eat and shower. She uses a wheelchair to get around. Carol enjoys being outside and likes it when the breeze touches her face and blows her hair. Carol has responded to the breeze from a fan, and has some awareness of what a fan does.

Mary and the team make a respectful guess on something that they think would make Carol happy, provide comfort and contentment. In other words, the team thinks that something important to Carol is being able to learn how to operate a fan so that she can be more comfortable and more alert. Carol will learn a new skill and de‐stress when she wants without depending on someone else to know when she wants the fan turned on or off.




This Outcome Statement meets the criteria we outlined in Part 1 of this webcast. The statement starts with the person’s name, is written in the present tense, includes Important To and is balanced with Important For and identifies the expected result.

This outcome statement is person centered because it represents something that is important to Carol – being comfortable, not relying on others as much and being able to make a decision for her own life. What I just described as Important To Carol will help her to achieve the values of choice and control in her Everyday Life.

This outcome statement is aligned with ODP’s mission to help “people with developmental disabilities achieve greater independence, choice and opportunity in their lives”.




Before moving into actions needed, the team followed the sequence in completing the Outcome Summary for Carol based on the information gathered before and during the meeting.

The outcome statement is further understood through the following concepts:

First, the reason for the outcome provides the detail to better understand why this is important to Carol; how it will make a difference in her life

Next, the concerns related to the outcome identify the things that people on the team are worried about; it may be barriers. Concerns begin to identify what actions may be needed

Then, the relevant assessments gives us more information about Carol’s strengths, needs and abilities.

Please take a moment to read Carol’s Outcome Summary on this slide.




Continuing to think about Carol and what actions are needed, let’s first consider her current needs. Remember current needs are things that Carol can already do and also things that she will need assistance to do in order to achieve her outcome statement.

Based on Carol’s Story, what do you guess may be some of her current needs?

Here is what we came up with as Carol’s current needs. This is not complete but gives us the information we need to think about what actions are needed.




In order for Carol to achieve this outcome statement, she needs support to learn many new skills including: what the switch does and how to activate the switch by turning it on and off.

In order to make this happen, an assessment of her current skills and abilities will need to be completed. Identification of resources and equipment that might require assistive technology and/or a home modification will need to be done.

And she needs to learn these things while being supported to stay healthy and safe in her home. This skill building and support to keep Carol healthy and safe is what can be provided through ODP funding.




So from this Outcome Statement and the skills that Carol needs to learn, the What Actions are Needed section should include: ‐ Support to use the fan safely‐ Determine if an OT/PT is needed as part of this assessment‐ Follow‐up on OT/PT recommendations‐ Develop a home‐based program to teach Carol how to work the fan‐ Purchase and install a fan in Carol’s bedroom and ‐ How will the SC will monitor implementation and provide resource information if needed




It is here in ‐What actions are needed ‐ that the provider reads the description of what actions need to be taken through the provision of a paid service.

In the provider organization, detailed provider action steps which are sometimes referred to as goals are developed and should fit with the outcome actions. Detailedprovider action steps or goals should not be cut and pasted into the Outcome Actions section. Actions provided through natural supports/unpaid services should also be identified in What actions are needed.




In the Outcome Actions: What Actions are Needed section of the ISP, the “what” is provided; not the “how”. The team identifies the “what”, the actions that are needed to help the person achieve his or her outcome statement. It is the provider’s role to determine the “how” based on each person’s unique strengths and needs.

In other words, the “how” is the implementation of the outcome actions. In order for Providers to be able to give clear direction to Direct Support Professionals regarding all of the expected necessary activity required to assist an individual to achieve his or her outcome statement, Providers may need to generate additional documents to outline this direction and detail. However, this level of detail is not included in Outcome Actions: What Actions are Needed.




In April 2015, ODP met with the Director and Regional Licensing Administrators of the Bureau of Human Service Licensing to be sure there is a shared understanding of documentation of provider action steps.

The Licensing Director and Administrators reported to ODP that licensing staff typically look at provider goal plans and then progress notes that connect to the outcome actions established in the Outcome Section of the ISP. Licensing agrees with ODP that the Outcome Section of the ISP is not the appropriate location for goal‐specific provider activities.

If you find inconsistencies with how licensing staff applies this agreement, the Licensing Director suggests contacting your Regional Licensing Administrator. Of course, check first with your agency supervisor or administrator about how to proceed.




For example, going back to Carol. The team has identified many actions needed to help Carol use a fan in order to be more comfortable and more alert. The question is where does the provider start, how do they implement/operationalize/individualize these actions identified for Carol? The answer is found in assessments, throughout the ISP and what the provider staff know about Carol’s current skill level.

If we look just at helping Carol learn what the switch does – the provider might think about what they know about Carol’s communication and learning style.‐ How to teach Carol to operate the fan safely?‐ Does she learn best using pictures, hand over hand practice and repetition or a combination of both? ‐ How long can she pay attention to learning about what the switch does?‐Where is the most comfortable location for her to learn?‐What is the best time of the day for her to try this out and ‐ How will Carol tell you that what you are trying is working well for her?

These are some of the questions that will identify the details of the provider action steps and how the Direct Support Professional will work with Carol. The provider action steps details are not found in the Outcome Actions section of the ISP but are documented through provider progress notes.

Now I am going to turn the presentation over to Angela to continue.




Thank you Patty.

Now we are going to change topics and discuss Employment and Educational Services.

Prevocational, Transitional Work and Education Support Services are three services that require an employment outcome as written in the service definitions.

Previously, you asked ‐ how can ODP require an employment outcome while also saying that the outcome statement should be something that is Important To the individual and should not include a service? The answer lies in understanding what the individual is trying to make happen, using precise language and following the sequence in developing the Outcome Section of the ISP.

So we already know that it is always about the person first. Within the Outcome Summary and Outcome Statement there may be something that the person wants in his or her life related to having money, friends, or being part of the community. If this is identified as important to the person and after the team considers Reasons, Concerns, Relevant Assessments and Current Needs, the team may identify employment as an action needed to help the person achieve their outcome statement.

When a person identifies employment as something that is Important to him or her, the team should work together to strategize the concerns and assure that there are outcome actions that will assist the person to get a job.




If an action to achieve the Outcome Statement is best provided through a paid service and that the service requires an Employment Outcome, the action and service are identified in the What Actions are Needed part of the Outcome Actions section.

In other words, for the service definitions that require an employment outcome ‐ including employment actions and services in the Outcome Actions: What Actions are Needed will satisfy this requirement.




During the discussion or after the actions are developed, the person is named who is responsible for seeing that the actions occur and will assist with implementing the action. In this section, Who’s Responsible, the individual receiving services as well any paid or unpaid team members are named with their relationship noted and attached to the specific action step.

And yes, more than one provider can be responsible for the same action. And if there is more than one provider responsible for the same action, providers should work together to ensure that individual efforts are coordinated without duplication to support the work of the other team members.

SCs will gather progress information from each provider if the same action is being implemented. Each provider needs to document or report progress from their own type of service perspective to ensure that what is working and what is not working and needs to change.




Why is ODP asking for the name of the actual person who is providing the service?

The answer starts with the fact that the plan belongs to the person. In order to help the person and their family know who is responsible and to promote accountability, it is preferred to list the actual name of the person responsible for the service or support.

For example, if this was your plan, would you want it to say – the family is responsible? Or would you prefer it to say Jen’s sister Kate will help with this action? Would it be more likely that people reading your plan would pay attention to the fact that it is your sister Kate, not your sister Toby, or your Mom or Dad, that you rely on for this support? By naming the person, there can be no mistake about who is responsible for taking action and who is the point of contact.




The responsible person named should be long‐term. To reflect the reality of staff turnover and desire to keep the plan current without repeated general updates, if the actual person responsible is not long‐term, or if this is a service with multiple responsible staff or changing staff, another person who is ultimately responsible within the organization should be named.

Plans do not need to be revised every time there is a staff change. During another ISP update, the plan can be changed to include the current name of who is responsible.




The next part of the development of the Outcome Actions is to identify the Frequency and Duration of each service. To say this a little bit differently – frequency and duration are measurements of the service; not the action. Frequency and duration must be identified by the team for the delivery of each identified service.

It’s in this section of the Outcome Actions that the actual service is selected using the Service Definitions that are described in the ISP Manual and the Consolidated and P/FDS waivers. The service is specifically named along with how often (frequency) and how long a time period (duration).

Frequency and duration identifies the service provided to assist the person to achieve this outcome statement and is determined based on the outcome actions identified by the team.

The frequency and duration should include the service provided to achieve the outcome statement plus other needs that are identified throughout the ISP. The question asked by the ISP Reviewer is ‐ how did the team determine the amount of service? The answer should be found throughout the needs identified in the ISP and is supported by the outcome actions.




Specificity and reasonable flexibility is based on the person centered planning that identifies the person's individual needs and is based on the activity or circumstance or skill to be developed. The availability of provider staffing is not a determinant that is considered in identifying frequency and duration of service.

Determining frequency and duration is supported by the action steps identified by the team after having a thoughtful conversation during the planning process. Using a flexible approach to frequency and duration requires the team to investigate, explore and discuss the person's strengths and needs, need for service, and actions needed.

Over the next few slides, we are going to look at several examples of specificity and reasonable flexibility. Be reminded ‐ the team determines the frequency and duration of each service that best meets the needs of each individual person and their situation. The frequency and duration of service that is identified in the ISP must be provided during that time period.




Let’s start with a situation where the team agrees that the person needs a paid service or unpaid support a certain number of days each week and so frequency should be identified specifically.

For example – 3 days a week, 2 hours per day would be identified in a situation where a family caregiver is not home three days a week and that is when the service is needed. But which days of the week can change; and flexibility is needed. Not specifically identifying which days each week is better for the individual and their family. So some weeks, it may be Monday, Tuesday and Saturday. Other weeks it may be Monday, Wednesday and Friday. The exact day of the week does not matter but the service must be provided 3 days each week for 2 hours.




Further specificity might be needed if the person needs the service on an exact day, perhaps a job coach when a person works on Tuesday and Thursday. In that case the frequency and duration would be – Tuesday and Thursday, 6 hours each day.




If the team agrees that it would be better for the person to have the flexibility of 18 hours per week without an exact number of days per week; then it is acceptable to state ‐ 18 hours per week.

So in other words, when a person wants the flexibility of supports that are not matched to certain days of the week (like Monday, Tuesday, Friday for 6 hours each day); then 18 hours per week can be identified if this meets the needs of that individual as understood and documented throughout the rest of the information provided in the ISP.




Another example to promote flexibility based on the individual’s needs ‐ if the team agrees that 40 hours per month is the best way to provide service; then 40 hours per month is an acceptable amount of service to be identified in frequency and duration.




Frequency and duration for out of home respite can also be written to promote flexibility that best meets the needs of the person. Families know how many times overnight respite will be needed in a quarter or even within a month; some know which months of the year they will be looking for respite.

As shown on this slide, out of home respite can be written as twice per quarter or eight times per year depending on what works best for the person, their family and the specific situation.




Let’s look at one more example. Behavioral Support is a service that, for many people, requires a great deal of reasonable flexibility. To begin to figure out frequency and duration for an individual, a question to ask is – what do I know about this person and their need for this behavior support service in the past years? Can you identify patterns of high and low behavioral support needs throughout the year? Does the person need more support at certain times of the year (like holidays) or at events (like an anniversary of a death or trauma)?

The information documented in the ISP should identify the reason for the flexibility needed in delivering this service based on an assessment. If there is an “event”; that may identify a change in need prompting a critical revision. During an individual monitoring, the effectiveness of the behavior support plan is reviewed and service needs may be changed based on the individual’s needs.

Considering this pattern of need and all of the information that is documented in the ISP, the team can determine a plan for the need for this specific service. So then, how is frequency and duration written in the plan to allow for this greatest amount of flexibility?




Here are two ways of writing frequency and duration that promote the needed amount of reasonable flexibility for behavioral support services. For one person, it might work best to identify frequency and duration by hours for each quarter. For example, 20 hours per quarter.

For a different person, the team may decide that the best way to provide flexible supports is identifying the total amount of service for the year. For example, 80 hours per year.




This annual total gives the team the flexibility to mobilize more supports when needed. But by specifying the total amount in the plan, there is also accountability and some assurance that is required by the waiver. This will also help prevent over‐authorization. It is important to remember that whatever frequency and duration is identified in the plan, that is how much and how often the service is to be delivered.

It is recognized that behavioral support is a somewhat unpredictable service. The best way to manage this service delivery is to keep a watch on the pace of utilization. Are services being more heavily used than what was anticipated in the plan? Or perhaps, is the service not being used as much as the team thought it would be needed. If the pace is different than the plan, the team needs to examine the reasons and discuss possible changes to the plan.




Here are four last points about frequency and duration for you to keep in mind.

If service frequency and duration is identified per week or per month, that is the frequency and duration that must be provided. Service hours cannot be banked or made up. If services are being used at a different frequency than identified in the Outcome Section, the question should be asked ‐ what is the appropriate amount of service that should be provided?

For all frequency and duration documentation, it is fine to state – up to and not to exceed totals. However, it is not specific enough and therefore NOT acceptable to use approximate amounts.

And although frequency and duration can be identified for the year, be mindful that this is always based on the individual’s needs. Remember, the process of team discussion, SC Supervisor review and AE approval and authorization is critical when identifying frequency of service. This is especially important for frequency of service that is stated as an annual amount. The ISP is a living, breathing document and process. SC Monitoring will review the need for service and frequency and duration on an ongoing basis. We would not expect to see this broadest use of frequency and duration used regularly or routinely.




A frequently asked question is – how do I identify frequency and duration for one provider delivering the same service to support several outcome statements?

Let’s answer this through an example. Robert has three outcome statements in his ISP and the team has identified actions needed that will be provided through home and community habilitation. The team has discussed Robert’s strengths and needs and decided that the total number of hours per week that would be needed to support the achievement of all three outcome statements is 10 hours. The frequency and duration would be identified as 10 hours per week.




One of the supporting documents to this webcast is the Frequency and Duration Example. We will be using this example to highlight several important points related to Outcome Actions.

First, we see here that the Outcome Phrase is a non‐service, keyword that describes what Robert wants to make happen in his life – save money.

The outcome actions identify the activities that will be provided and is the first time a service is identified. Notice that the actions needed identify what will be provided, not how it will be provided. How it will be provided is found in the provider’s documentation.

In frequency and duration, the service is named and in this case a specific number of days per week is stated with a total number of hours per week. Robert has three outcome statements and this one provider will deliver services that teach skills needed across all three outcome statements. The same total number of hours (10 hours) is written for each outcome statement.




Another frequently asked question is ‐ how does the SC determine how many service units to indicate in Outcome Actions?

First, service units are not identified in the Outcome Section of the ISP. In the service details section of HCSIS, there is one service authorization line which includes the total number of units for the service for the fiscal year. Multiple outcome phrases can be attached to one service as shown above in the example for Robert.

You also see through this example that the total number of service units is more than the total amount of service that is needed to help Robert achieve his three outcome statements. This takes us back to the beginning of this webcast when we talked about person centered plans.




We said, and it is worth repeating ‐ the type and amount of identified and provided services is not solely or only linked to the Outcome Section of the ISP. The full amount of authorized service is reflected through all of the needs and actions documented throughout the body of the ISP. The full amount of the service units identified in the service details does not have to be reflected in the Outcome Actions.

This example for Robert shows the service details with three outcome phrases attached to one service and the total number of units is greater than the amount of service provided to achieve the outcome statement. The need for the additional service hours are identified throughout the ISP in sections such as Know and Do, Health and Safety Focus Areas and Desired Activities.




In this next part of Outcome Actions, you will list the anticipated date the actions will be accomplished or end of plan date; whichever is appropriate.

These actions are identified for the current plan year and cannot go past the end of the plan year.




I am going to take a moment to talk about how long outcome statements can be maintained in the ISP and short term versus long term outcome statements.

The end date for outcome actions is different than how long an outcome statement can be maintained in the ISP. While outcome actions cannot go past the end of the plan year, an outcome statement may be maintained over many years if it continues to be important to the person and needs to be kept in the spotlight. Over years, outcome actions may need to be changed to reflect the person's changing needs or interests.




Related to this, team members ask – why would we write outcome statements that can be achieved in less than one fiscal year?

Outcome statements may be short or long term depending on the individual's needs. Some outcomes statements, such as going to a concert, are an event that happens at a specific time and place and the outcome statement will be completed in less than a year.

Other examples, such as going to an exercise class with friends in order to strengthen relationships and enjoy being healthier may occur over an entire year – or even several years. On the other hand, outcome actions (such as what class the friends attend or whether they decide to walk to the mall instead of class sometimes) may change more frequently than a year.

When thinking about the length of time it takes to accomplish the person’s outcome statement, it is entirely dependent on understanding exactly what the person wants to achieve, not the length of time of the plan. If the outcome is achieved in less than one year, but the person wants to maintain focus and services in this area, the outcome statement can be continued.




Think about yourself – we all have things we want in our lives (outcome statement) and how we go about getting there (outcome actions) changes all the time. We try different things (actions) to get there and figure out if it is working or not. If it is working, we continue to do the same thing because we still want what is important to us. If it is not working, we try something differently (new actions). This is the same approach that we can use with the people we support.

Over time, actions related to the outcome statement may change as a person learns new skills, grows more independent and/or expands the scope of what is important to him or her.




And the last part of the sequence in developing the Outcome Section of the ISP is answering the question – how will you know that progress is being made toward this outcome?

This is the last part of the Outcome Action section and here we are measuring progress on What Actions are Needed. Measuring progress tells us what to look for to let us know if supports and services are making a positive difference in the individual’s life.

Included in this section are the what, how and who. We already identified when in the Outcome End Date.• What – the difference in the person’s life; what has changed or what needs to be

maintained; what has been achieved related to the identified outcome actions?• How – what methods are being used to determine progress; how does the system

record and check the progress?• Service notes, quarterly progress notes, SC Monitoring, talking with the

individual and team and• Who – identifies the people who will monitor and document progress




One question that is asked about measuring progress is – how do we measure progress when the person is maintaining a skill? This question is very relevant for people as they get older or for people who have deteriorating medical conditions or health issues.

In these situations, progress is measured on outcome actions that work to prevent the loss of skill or promote maintaining the person’s current abilities. Ultimately, the person him or herself will be telling us through their words or behavior if the actions are helping them to achieve what is important to them.




In thinking about measuring progress, let’s go back to where we began – it’s about the person, their outcome statement and what they want changed or maintained in their life.

The team should be measuring the progress on both the outcome actions and the ultimate achievement of the outcome statement. If the outcome actions are being achieved but the desired result identified in the outcome statement is still not present, the team should reconsider the action steps to make sure that the outcome statement is achieved; not just the outcome actions.

If individuals are showing progress on outcome actions but never achieving their desired result, the team needs to look at what’s not working and figure out why the outcome statement is still not present. Ask – are the action steps working?

During individual SC Monitoring, the SC will be reviewing progress on outcome statements throughout the year to maintain a focus on what is important to the person and their quality of life. The Provider also has the responsibility to be monitoring progress on a regular basis to determine if provider action steps are working or need to be changed to help the person achieve their outcome statement.




By looking at provider progress notes, the ISP team will be able to evaluate progress on outcome actions and the achievement of the outcome statement.

For example: going back to Carol’s outcome statement ‐ Carol turns on and off the fan switch in her room in order to make herself more comfortable and more alert. The SC will be monitoring progress on actions needed related to teaching Carol what a fan does and how to use the switch. However, the foundational question to be answered by the team in measuring progress is – does Carol have a fan, know how it works and operates it when she wants? If the answer is no, the follow up question is – are the actions needed working or not working and need to change.




In this last part of the webcast, I am going to focus specifically on Supports Coordination and provide some details and examples on how this service is identified in actions needed, frequency and duration and measuring progress.

First, let’s review what we know: • The Supports Coordination service is not a result in itself, and therefore cannot be

named in the Outcome Statement or Outcome Phrase in the ISP• Outcome Actions in the ISP is where the activities that lead to the achievement of the

outcome statement should be identified • All services are attached in HCSIS to an Outcome Phrase and• Monitoring of supports and services by supports coordinators is a required service. The

intensity and frequency of monitoring is determined by the needs of the individual.

The three core functions of Supports Coordination are locate, coordinate and monitor. ODP expects that these three activities should be listed in the Outcome Actions, specifically: What Actions Are Needed, Frequency and Duration and Measuring Progress specific to the individual and their needs.




The frequency of the SC monitoring should be at a minimum what is required by the specific waiver. But all frequency is based on individual needs; especially in times of change and transition. The team asks ‐ is something new happening in the person’s life, is there a transition to a new home or activity, is there a new health issue?

The complexity and intensity of the individual’s needs and risk factors drive the frequency and duration of SC monitoring and reflect the person’s needs identified throughout the ISP.

in the Outcome Action section a person who lives at home with their family is supported in the P/FDS waiver, the minimum frequency and duration would state – the SC will conduct face to face monitoring once every six months and monitor by phone every three months.

The frequency and duration is identified for the fiscal year, not for each individual SC activity or visit. In addition, the amount of time for each visit or activity does not need to be noted in frequency and duration.




But what if the person is starting to make plans for transition from school to work? How would the SC know what would be the frequency of monitoring? When there is no prior information to consider, the team would estimate the amount of service utilization based on what the team knows about the person (strengths, skills, needs and preferences).

When changing needs are identified this may also be an opportunity to discuss how to address these needs through the ISP team process ‐ to possibly include updates to the ISP or perhaps even a critical revision.




As I mentioned previously, service units are not identified in the Outcome Section of the ISP. And the full total amount of service units for any service, including supports coordination, is not identified completely and solely through the Outcome Section of the ISP.

So, keeping this in mind, the SC frequency that is identified in the Outcome Section of the ISP should only include frequency of monitoring. The need for locating and coordinating activities are identified throughout the entire ISP and in the SC service notes. These additional hours (beyond monitoring) are based on prior utilization and anticipated changing needs. The total amount of SC service units includes monitoring, locating and coordinating activities.

Frequency and duration identifies the service provided to assist the person to achieve the outcome statement. In the service details section of HCSIS, there is one service authorization line which includes the total number of units for the service for the fiscal year. Multiple outcome phrases can be attached to one service.




The health and safety needs of the individual, identified throughout the ISP, should be reflected in the total amount of authorized service units. As the SC monitoring is required practice, it is likely that the Supports Coordination service will be listed within the outcome actions for each outcome statement developed by the team.

One last point about the SC role in measuring progress. An integral part of the SC role in monitoring is to ensure that progress notes describe the support that is being provided and that progress in being made in achieving the outcome statement. When the SC finds that no documentation is present, the SCO administration should notify the Administrative Entity of the issue that needs to be resolved and request assistance.




In closing, let’s remember that this is about people. It is about helping the individuals that you support to have what is important to them; to have a better quality of life as they see it for themselves; to learn new skills and to be healthy and safe.

The Outcome Section of the ISP is where the individual and team work together to make sure that what is important to the person is known and there is a plan in place to achieve and/or maintain the desired result. But it is not only about providing services and supports for the one or more outcome statements that are important to the person.

It is about planning for the person’s whole life recognizing all of the strengths and needs of the person identified throughout the ISP. Services and supports identify actions to help the person achieve their outcome statement AND also provide services to meet other needs and preferences while keeping the person healthy and safe.




If you have additional questions, please send an email to the SC Training Mailbox or contact your ODP Regional Program Manager.




This webcast has been developed by the Pennsylvania Department of Human Services, Office of Developmental Programs and produced by The Columbus Organization.

Thank you for participating in this lesson.



Date post:	12-Apr-2020
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