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Individual Service Plans. Mental Health and Addiction Services 2013. ISP Working Group: Randy Boyd, Brenda Francis, Siobhan O’Connor, Nicole Schumacher, Heather Smith. Today’s agenda:. Introduction ISP implementation Procedure 6700-60-003
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Individual Service Plans Mental Health and Addiction Services2013 ISP Working Group: Randy Boyd, Brenda Francis, Siobhan O’Connor, Nicole Schumacher, Heather Smith
Today’s agenda: • Introduction • ISP implementation Procedure 6700-60-003 (s:drive Mental Health Services MHAS Policies and Procedures) • Policy review & updates that impact you
Introduction : ISP Working Group • The ISP working Group came about as a result of the Accreditation process • This ISP Working Group, previously knows as Qmentum Team D, worked together when the ISP was initially “rolled-out” to the MHAS teams in the Fall of 2010 • We were tasked in the spring of 2012 to review the ISP Procedure document and recommend any changes that would assist clinicians in using this tool
ISP Purpose & Principle • Mental Health and Addiction Services is committed to ensuring a consistent, comprehensive and balanced approach to assessment and intervention. The ISP is a communication tool for clients and service providers to collaboratively set meaningful goals and share information in order to enhance service coordination and continuity.
ISP Purpose & Principle • An ISP is not to be used as the client’s progress notes. • The ISP is not intended to be a Crisis Plan, but can developed in conjunction with a Crisis Plan or Relapse Prevention Plan. • The ISP is a communication tool to document client identified goals, the actions to achieve these goals, and the outcomes.
Development of an ISP An ISP will be developed, in collaboration with the client, when they meet with one of more of the following criteria: • Currently receiving more than one service (this may include group services) • Transferring from Acute and/or Residential services to Community services • Transferring from Rural to Urban, or from Urban to Rural services • Transitioning from Child to Youth services, or from Youth to Adult services • When referred to an external resource
Development of an ISP • This does not prevent an ISP from being developed with a client who does not meet the criteria; if the service provider thinks an ISP would be useful to assist the client in treatment planning and goal development.
Development of an ISP • To prevent duplication of goals and actions, service providers shall review AMIS for current and previous ISP’s. If there are active Need for Service Categories with goals, any new action plans developed with the client should be added to the list of actions of an existing goal where possible. • A copy of the ISP will be provided to the client upon request. With client’s consent, copies will be provided to additional care provider’s external to MHAS.
Completing the AMIS Individual Service Plan (ISP) Form What does the ISP contain? • Services needs of the client as per Appendix A : Need for Service Categories • Goal /goals indicating the desired change the client wants to accomplish. • Goal: A goal is the “what” – a statement that describes a desired result Example: “to be less anxious”; “stop drinking”; “find a place to live”
Completing the AMIS Individual Service Plan (ISP) Form) • Actions the client is prepared to engage in to achieve the goal. • An action is the “how” – action (s) aimed at reaching the desired goal. • Example: “attend an anxiety group”; “Attend AA once a week”; ”Call brother to see if I can live there” • The ISP information is entered into AMIS to be available to all of the client’s MHAS service providers. (See Appendix C, Data Entry)
Updates and Adding to an existing ISP: • Updates to the ISP may be completed by any current service provider in collaboration with the client and their CSF (client service facilitator). • When an update is made to an ISP, the data entry staff will choose the email option to advise the CSF or other involved service providers of the updates • Only the original author of a goal or action has the authority to change it. No goal or action should be overwritten or deleted – if a goal or action is no longer relevant, the author should indicate in the outcome note box what the outcome was.
Updates and Adding to an existing ISP: • The ISP is intended to be a living document and should be reviewed by the CSF at a minimum of every 3 months, or more frequently in accordance with program procedures. This will ensure that progress towards meeting goals, as well as any changes in needs for service, are identified. • Whenever there is a transition point in service, the ISP will be reviewed with the client and updated if applicable.
Outcomes • Upon goal/action completion an outcome note will be added • Once all goals have been completed an outcome code will be entered • Outcomes codes are: • Resolved: Goal attained, client need was met • Partially Resolved/Ongoing: Goal active, some progress • Unresolved: No change noted , worsening of conditions, • Client withdrew: Clt left service, insufficient information re: outcome
Outcomes • When the client exits an MHAS service, an Outcome code will be entered for the goals in each active Need for Service Category based on the clinical judgement of the service provider as to whether the goals were achieved.
