The Care Coordinator works with the enrollee to develop
a person-centered Individual Service Plan (ISP). The process
for developing Individual Service Plans (ISPs) is as follows:
The Care Coordinator will obtain the initial referral
information regarding a person who might participate in
the program from the SPOA. (People who enroll in the program
are referred to as "Participants".)
The Care Coordinator will use his or her best efforts
to contact the individual within 24 hours of a referral
from the SPOA.
If a Participant needs immediate assistance to address
significant risk or safety issues, the Care Coordinator
will use his or her best efforts to meet with the Participant
within forty-eight hours.
The Care Coordinator will have face-to-face contact
with the individual within 7 days from the date of referral
from the SPOA.
The Care Coordinator will arrange for an Assessment
and/or medical examination of the Participant as needed.
The Care Coordinator will help the Participant with
a Quality of Life Self-Assessment of his or her needs
and desires in preparation of the ISP. A Self Assessment
form can be found here.
The Participant and the Care Coordinator will discuss
the self-assessment and develop an initial Individual
Service Plan. The form for the Individualized Services
Plan can be found here.
If possible, the initial Individual Services Plan should
be developed within 30 days after the initial contact
between the Care Coordinator and the Participant. If necessary,
an ISP may be completed in phases.
Once the initial ISP is prepared, the Participant and
the Care Coordinator will engage Service Providers.
Participants and Service Providers listed on the ISP
will receive a copy of the completed ISP.
A licensed outpatient service provider that serves a
Participant will develop a treatment plan describing the
services it will deliver, and how those services relate
to the goals of the ISP.
When the ISP is revised, the Participant and the Care
Coordinator will again contact Service Providers to inform
them of changes to the ISP, and to coordinate the delivery
of services to the Participant.
