Monitoring and Updating Individual Service Plans (ISPs)
Care Coordinators will monitor Participants and work with
Participants to update ISPs as follows:
The Care Coordinator will monitor the Participant's
attendance at programs listed in the ISP, based on Provider
reporting.
The Care Coordinator will conduct a review of each Participant's
progress in achievement of the goals described in the
ISP. The Care Coordinator will update the Participant's
Case Record and share information as appropriate with
Service Providers and the SPOA.
Care Coordinators will conduct a formal review of all
Individual Services Plans every six months, and meet with
Participants, individuals designated by the Participant,
and Providers to review their progress and update the
ISP.
If a Care Coordinator learns of a critical event that
may endanger a Participant or threaten his/her recovery,
he or she will take action as appropriate to contact the
Participant, update the Individual Services Plan, and
arrange for needed services to the Participant. Treatment
services, Medication, and the Crisis Plan must be reviewed
if the Participant is no longer following the Individual
Services Plan or the treatment plan, uses the emergency
room for psychiatric reasons, is admitted to inpatient
psychiatric hospitalization, or is arrested.
