Children's Targeted Case Management
Practice Guidelines

INDIVIDUAL SUPPORT PLAN (ISP)

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Overview of ISP Process
Crisis/Safety Plan
Discharge from Targeted Case Management Services
 

OVERVIEW OF ISP PROCESS 

The agency must have documented policies and procedures regarding the development of an Individual Support Plan for each child/family/guardian. The case manager will coordinate a Child and Family Team meeting for the development of an ISP for all children.

 The Child and Family Team shall consist of the following individuals, at a minimum:

• the eligible child unless contraindicated; and/or
• the child’s parent(s) or other legal or designated representative, such as legal guardian or advocate;
• other key persons identified and approved by the family, such as extended family members, friends, neighbors, and others who provide informal and natural support to the child and family and may assist in meeting their needs; and
• the case manager.

The following individuals may be included on the team as appropriate:

• a special education or other educational professional;
• a health/mental health professional (physician, psychiatrist; psychologist, social worker, nurse, crisis intervention worker, according to the needs of the child); and
• other key providers deemed appropriate by the Child and Family Team to identify and address the specific strengths and needs of the child.

A Child and Family Team will be created for all children and adolescents receiving Level II targeted case management services and, when appropriate, for children receiving Level I targeted case management services.

The Individual Support Plan or ISP is grounded in the principles and values of the Wraparound Process and embraces the concept of child and family planning.

The ISP is the comprehensive plan of care for the child based on results from both a comprehensive strengths and needs assessment. The comprehensive assessment of the child and family identifies their strengths and needs across the life domains in which specific goals and measurable objectives are developed.  Family teams may prioritize the life domain areas and decide which areas should be focused upon in the ISP. Safety for the child/family/community is of paramount importance in the ISP. Life domains may include (but are not limited to) the following:

·        Safety

·        Culture

·        Health

·        Legal

·        Family

·        Place to live

·        Emotional/Psychological

·        Social

·        Permanent Relationships

·        Spirituality

·        Education

·        Work

·        Behavior

·        Accountability

·        Public safety

·        Competency Development

·        Restitution

·        Finances

·        Immigration/Citizenship Status

·        Language/Communication

·        Transportation

The ISP should be strengths-based, needs driven, and focused on outcomes.  Need statements are specific, positive, and reflect a practical understanding of what it takes to get the child from point A to point B, and are written in the child’s and family’s words.  Outcome statements are clear, optimistic, realistic, and measurable.  The unmet needs, when met, become the bridges between the desired outcomes and the current reality.  (Grealish, 2000.)

The ISP also includes strategies that will be used to approach identified needs. The child’s and family’s strengths and preferences are a central aspect of developing strategies. In addition, the ISP will have goals and strategies that empower parents to be their child’s own case manager.  

ISPs will include:

·        Goal and Outcome Statements

·        Needs

·        Strengths

·        Strength-Based Strategies

·        Actions (services, supports, and specific tasks identified)

·        Responsible person to complete identified tasks

·        Crisis, Transition, and Discharge Plans

·        Identification of clear measures when targeted case management services will no longer be needed

ISPs must be developed within 30 days from open service and must be monitored monthly. The ISP must be evaluated for effectiveness every 90 days (or more frequently as the needs of the child or family dictate). 

The ISP review document must be included in the child’s record.

Planning For Transitions As Part Of The ISP Process

Planning for transitions reflects a down to earth understanding of how difficult change is for all human beings.  Children and their families have an active role throughout all phases of the planning process.  Transitions throughout the normal course of life will be anticipated and planned for by the child and family team and documented in the child’s ISP.  This process will incorporate the formal transition plans  (for example, education, employment, and adult services) (Grealish, M. 2000). 

Whenever possible, agencies should follow these principles when assisting children and families with transition planning: 

·        To whatever extent possible, establish children and their families as their own “life managers.”

·        Assist families to arrange for continuity of support during residential, educational, employment, community, and other relevant life transitions.

·        Enhance family’s self-advocacy skills so that they can manage transitions as independently as possible.

·        Consider the child’s and family’s skills, strengths, preferences, cultural values, challenges, interests, and personal goals.

·        Assist families in identifying and accessing natural support systems.

·        Incorporate the changing needs of children and their families, and provide support services that are individualized and flexible.

·        Ensure effective collaboration among relevant support resources and services.

·        Track outcomes and evaluate the effectiveness of transition plans. 

(Deschenes, N. and Clark, H.B.,1999) 

As part of the overall ISP process, the child/family must be provided with a full explanation of the risks and benefits of the recommended services and include the signature of both the child (as appropriate) and the parent/legal guardian. The child and family shall be provided with a copy of the ISP.

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CRISIS/SAFETY

The agency must have documented policies and procedures regarding the development of crisis stabilization plans for each child.   Case Managers are responsible for coordinating development of Individual Support Plans which "shall detail . . . a written crisis plan that identifies early warning signs of a possible crisis situation, behavioral indicators which necessitate crisis intervention, an indication of what actions have been helpful and/or hurtful in past crisis situations, and who to involve as well as who not to involve in resolving the crisis"  (MaineCare Benefits Manual 13.12-3B(4)). 

A crisis plan is a detailed, practical response that prevents or minimizes potential crises and safety issues.  

·        The plan must realistically and thoroughly assess whether or not the individual or family faces uncomfortable or difficult transitions and it plans how to help them manage change.

·        Crisis planning should recognize the cyclical nature of crisis from equilibrium to escalation triggered by an event, a peak, then recoil and eventually a return to equilibrium.

·        At a minimum, a plan must address potential safety issues that can help to keep children, families, and team members safe. 

·        Plans must be realistic, capturing the feelings, values and actual responses of individuals in crisis.

·        Plans include as many informal supports as possible, capitalizing on positive relationships or helping to build them.

·        A proactive crisis plan should be developed to prevent crises and identify known and potential “triggers” that could result in a crisis situation.

·        The plan builds on individual, family and team strengths to achieve enduring change.

·        There is a focus on positive actions rather than exclusive reference to what to avoid.

·        The plan reflects a practical attitude about situations in which ongoing crises are likely to continue, despite intervention.  

Transitional crisis plans should be developed when significant changes are expected in children’s lives in order to reduce or eliminate the amount of time children spend in formal therapeutic environments. These plans should acknowledge the universal difficulty of change, and account for differences in companionship, support, external motivation and structure.

(For further reading on how crisis/safety plans can be effective, please find more specifics in:  Grealish, M. (2000). The Wraparound Process Curriculum, Orientation Part 2: How it Works, pages 38-39, Community Partners Inc.)

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DISCHARGE FROM TARGETED CASE MANAGEMENT SERVICES 

Discharge is the process of ending or terminating services with children and families.  Discharge from targeted case management services should result from child and/or family functional improvement and/or family choice.  The discharge planning process should be discussed regularly from the very inception of service delivery. The agency must have documented policies and procedures regarding the discharge planning process.  

CBHS reason codes for closing/discharge in targeted case management are as follows:

        1.          Family has not responded to contacts (phone calls, letters or visits);
        2.          Family no longer wants services;
        3.          Child is currently receiving services through another agency;
        4.          Family has moved to a different area;
        5.          Child’s goals have been met;
        6.          Child is currently in a long-term out of home placement (includes removal by DHHS or DOC);
        7.          Child was found to be ineligible for services; or
        8.          Other (any other reason given by the agency which does not meet one of the above categories). 

It is also important to note the following procedures for discharge:

·        A discharge summary must be entered into the child/family record within 15 days of discharge or on the 90th day of inactive status. 

·        The discharge summary must include documentation of the child’s course of treatment as well as any ongoing needs at discharge.

·        A letter must be sent to the family notifying them of the closure. 

Each discharge summary must also minimally address, but need not be limited to, the following (Licensing regulations, CS 15. A. 1. - CS. 15. A. 4.):

·        The reasons for termination of service;

·        The final assessment, including the general observations and significant findings of the child’s condition initially, while services are being provided and at the time of discharge;  (To ensure that required assessments are completed at the time of discharge, please see CBHS’ Children’s Assessment Instruments, revised 10/16/03, on page 26 of these Practice Guidelines.)

·        The course and progress of the child with regard to each identified problem; and

·        The recommendations and arrangements for further continued services if needed. 

Some principles that define best practices for discharge planning as well as incorporate the Wraparound Process are as follows:

·        Assist children and their families in not only accomplishing goals that were established in the ISP, but also help them develop plans to pursue and maintain gains they can achieve after discharge. 

·        Help children and their families anticipate stressors and negative forces that may lead to a crisis, as well as identify interventions.

·        Help children and their families plan for potential crisis that may occur immediately after discharge.  Assist children and their families to safely manage the crisis, as well as to be closely connected with both formal and informal supports so that they are not navigating the system alone. 

·        Provide opportunities for a family member to facilitate team meetings so that eventually the case manager plays less of a role on teams and over time, no longer needs to attend team meetings.

·        Recognize that in order for services to end, families don’t need to be free of all problems.  Be realistic about what can be accomplished in this process.

·        Be sensitive to the loss, sadness, joy, and sense of accomplishment that families may be experiencing at the time that services are terminated. 

(Some of the above language that defines best practice is referenced from Lee LeGrice, n.d.  Begin with the End in Mind: Strategies for Successful Graduations.)

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