The standards outlined below were established for the development
of ISPs. With the introduction of Person-Centered Planning,
a new set of indicators was developed to measure the degree
to which ISPs adhered to these values. The WNYCCP
2005 Indicators of Person-Centered Planning form
includes the initial indicators against which ISPs are reviewed
annually.
The original standards for the development of ISPs were:
Individuals are full participants in all aspects of
the development of the ISP and provider specific treatment
plans.
Participants are entitled to have a family member, peer,
or other person of their choice present during the process
of development of their ISP. The Participant, or with
the agreement of the Participant, the Care Coordinator
may invite such persons to participate in the process
of the development of the ISP.
Participants can request changes to the ISP.
The ISP is unique to the needs and desires of the individual.
The ISP is goal oriented as articulated by the individual.
It must reflect the Participant's self-identified recovery
goals as well as indicators of goal completion or achievement
of milestones, strengths, and supports.
The ISP should describe the resources available to the
individual, including income and other financial supports,
housing, natural supports or significant others, transportation,
etc.
The treatment, rehabilitation, support, self-help, and
empowerment services necessary to help the Participant
achieve recovery goals should be identified in the ISP.
The description of required services must include, for
each service, the provider name, relationship of the service
to the recovery goals, anticipated frequency and duration
of service, and the anticipated outcomes of the service.
The ISP should identify all necessary linkages with
health care (including managed care plans) and human service
providers.
The ISP should identify supports or services to be purchased
with ICM/SCM/ACT wrap around dollars or Care Coordination
Funds.
The ISP should include a Crisis Plan that describes
recommended services and options to be pursued and individuals
to be notified in the event of a crisis situation such
as hospitalization, medical emergency or loss of housing.
The ISP should record the existence of any Advanced
Directive and a copy should be attached to all copies
of the ISP distributed to providers.
The Participant, Care Coordinator, and Service Providers
will negotiate a "best service available" plan
if services identified in the ISP are not immediately
available (e.g. other services to be provided in the interim).
A "best service available" plan can also be
used in the case of an emergency or as unplanned needs
arise.
The ISP is a dynamic document and must reflect any significant
clinical development or change that affect the delivery
of care.
The Individual Services Plan form approved by the WNYCCP
and OMH for use in the Care Coordination Program will
be used to document the ISP.
