Chosen Services: “List Needs Identified by the Needs Assessment”

Tips for Services Coordinators and Personal Agents

This month, we will take a close look at the Chosen Services section of the ISP, focusing specifically on one box within this section: “List needs identified by the needs assessment that this service will address”. This box can be found for each authorized service in the plan, regardless of funding stream (example: Chosen K plan services, Chosen waiver services, etc.). .

We’ve heard many questions over the years from Services Coordinators and Personal Agents about what information to include in this section, and we hope this article answers a few questions you may still have.

Minimum Expectation

It is an expectation that a person’s Oregon ISP will address all needs identified by their needs assessment. In other words, a person’s plan should include all of their support needs, whether those needs are being met by formal services, through other supports, or if a person is declining support at this time. There are many places in the ISP that different support needs are addressed. The section “List needs identified by the needs assessment that this service will address” for authorized services is one important place where support needs are addressed in the plan.

At a minimum, the “List needs identified by the needs assessment that this service will address” box should include a list of areas of support that the service will be assisting the person with, unless the need is addressed in another section of the ISP (such as the risk management plan).

For example, Alek’s in-home support provider assists him with cooking, laundry, transportation, and money management. Alek is at risk of financial exploitation, so his support need of money management is addressed the risk management section of his ISP. The chosen services section of Alek’s ISP that authorizes his in-home support provider might look something like this:

Writing “ADL/IADL” or “see ONA” is not enough information for this section. Areas of support should be clearly listed. The example above meets the minimum expectation; however, you may consider how much information and detail is helpful, as well as what language works best for the person and their family.

Consider how much detail is helpful

The example above does not provide any information about what best support looks like for Alek. Consider ‘laundry’. Does Alek just need some reminders or instructions on how to do the laundry? Does he need help carrying his clothes to the laundry machine? Does Alek need someone to do laundry for him, while he gives instructions on what clothes need to be washed?

If Alek has been with the same in-home support provider for a while, it may be that they already have a good idea of what support works best for Alek. They may already have worked with Alek to capture this information in his Person Centered Information form or have created instructions for new supporters about this best support. In this case, the example above may be enough information.

However, if the provider is new to Alek, additional information in this section would be extremely helpful. After all, ‘laundry’ only gives an idea of what area Alek wants support, but no clues on what that support should look like. Here’s another, more detailed example of this section:

Why not ‘Copy and Paste’?

Copying information from a person’s needs assessment and pasting it into the “list needs identified by the needs assessment that this service will address” is not considered a best practice. There are a few different reasons for this.

First, the plan belongs to the person. Language used in needs assessments is often technical and not person-centered. If this language is copied into the ISP, it may alienate someone reading their own plan. Instead, we want to consider what words or ways of writing information work best for the person and their family. What language would you want to see if this was your plan? The plan of someone close to you?

Second, the needs assessment is full of systems language and jargon which is not easily understood. A person has a right to understand and direct the contents of their plan. Plain language should be used whenever possible.

Consider the following examples:

Copied and Pasted	Plain language
Elimination, Toilet hygiene- supervision or touching assistance	After using the bathroom, Margret is supported to adjust and fasten her pants.
Transferring and Positioning- Partial/moderate assistance	Amir needs to grab onto a steady arm that he can pull on when he stands up from a chair, couch, or his bed.
Transportation- substantial/maximal assistance, persons providing support accompany person on bus/van	Lidia gets around town with the support of staff in the accessible agency van. She also uses accessible busses if a supporter rides along.

While copying and pasting is typically not a best practice, you may consider whether ONA assessor notes provide helpful context and details about a person’s support needs. This information may be useful to include in the plan, while still using plain, person-centered language