ISP team process

The ISP is built on information gathered from the perspective of the person, their family, guardian, or designated representative, the SC or PA and others directed by the person. This might include friends, family members, teachers, providers and others who know and care about the person. These contributors are referred to as the ISP team. The ISP team is there to assist the person in making informed choices about what will be included in their ISP. They might assist the person to review available options and support the person to make decisions based on the person’s values, preferences and desires. The “team” could be as simple as a person sitting down with his Personal Agent and perhaps a chosen family member. For someone else, it might be a more comprehensive team made up of the person, her family, representatives of her chosen provider organizations, and her Services Coordinator. Both of these styles of teams share a common purpose: to develop an ISP that reflects what matters to the person and what supports are chosen to help achieve or maintain the life the person desires.
Additional training resources including sample ISPs representing a range of ages, service settings, and support needs are available here.

Roles of ISP team members

Person receiving services

  • Shares her perspective about her life and what she would like to work on. The person also shares what services she will use to meet identified support needs, what is working in her life, what is important to her, what is not working, and what she would like to see different in her plan. This can happen anytime during the year.
  • Identifies who he would like to be a part of his ISP, his ISP team and the ISP meeting.
  • Participates in the ISP meeting in the manner he chooses
  • Has the opportunity to choose the time and location of the meeting.
  • Participates in the planning process including contributing to person centered information, risk identification, and information for the needs assessment.
  • Signs the ISP to indicate agreement. If there are areas of disagreement within the plan, she conveys those concerns to her team.
  • Requests changes and approves changes or revisions to the ISP or support documents throughout the year as desired or needed.
  • Shares any concerns, disagreements or feedback with their Services Coordinator/Personal Agent (SC/PA), as needed, throughout the year. If disagreements are not satisfactorily resolved, she may request that they are noted on the ISP before signing it. The SC/PA will inform the person of other options that might address any disagreements or concerns.

Use of the word “person”

Throughout the ISP forms and this instruction manual, the word “person” is used frequently to refer to the person receiving services. The group of stakeholders including advocates, families and supporters involved in the development of this process prefer this word. We recognize that  any word we use could become a negative label. We rely on your use of professional judgment to avoid labels and promote equity in your work.

Designated representatives, guardians and family

Family members and others the person directs may participate in this process according to their own comfort level. Guardians should participate as required by the guardianship order. This may include:
  • Contribute person centered information.
  • Help the team to identify and address the person’s needs and known, serious risks to the person’s health or safety.
  • Help plan for the future and contribute to supports that will help the person have the life he/she wants.
  • Review and approve the plan and other documents by signing the ISP.
  • Review and approve changes to the ISP throughout the year when needed.
  • Share concerns, disagreements or other feedback with the SC or PA throughout the year. If disagreements are not satisfactorily resolved, you may request that they are noted on the ISP before signing it. The SC/PA can inform you of other options that might address any disagreements or concerns.

Services Coordinator (SC) or Personal Agent (PA)

The SC/PA facilitates and assures the development of the ISP. In some situations, the person facilitating the development of the plan may have a different title (such as ODDS Residential Specialist in Children’s 24-hour Residential settings). However, this manual will refer to the plan facilitator as the “SC/PA” for the sake of simplicity. The SC/PA has the oversight and final responsibility for the accurate completion of all required ISP forms. As the delegated Medicaid authority, the SC/PA has the responsibility to ensure that the plan meets the person’s current service needs and complies with requirements for the chosen service setting(s) and associated funding. The SC/PA authorizes the ISP.

Provider organizations and foster providers serving people who live in residential settings

  • Support the person to participate in and direct the ISP process as fully as possible.
  • Support family members to participate in the ISP process to the degree in which they and the person chooses.
  • Contribute to the development of the ISP as outlined in provided instructions, and as directed by the person and the SC/PA.
  • Gather person centered information and share it with the SC/PA prior to the ISP meeting.
  • Communicate with other provider organizations that serve the person, if applicable, in advance of the ISP meeting in order to gain and maintain consistency by aligning supports when appropriate.
  • Provide known medical or other historical information, as needed, to the SC/PA to assist in identifying serious risks.
  • Contribute information to assist in the assessment of support needs.Sign the ISP or Provider Service Agreement, agreeing to the supports you will be responsible to provide.
  • Develop, implement, and maintain instructions that tell direct support professionals or substitute caregivers how to provide supports identified by the ISP, including steps to meet the person’s desired outcomes and necessary risk management strategies.
  • Provide supports as outlined in the ISP or the Provider Service Agreement.
  • Communicate with the SC/PA or with other ISP team members, as needed, when a person’s desired outcomes or other support needs change.

Personal Support Workers (PSWs), provider organizations, and other independent providers serving a person in an in-home setting

  • Receive and sign a Provider Service Agreement that details the specific tasks the person has hired you to complete, including known serious risks, desired outcomes, and the person’s preference of how services are delivered.
  • Perform the duties as outlined in the service agreement.
  • Communicate with the SC/PA if you become aware that the person’s support needs or preferences in how services are delivered have changed.

Share this: