Service Design and Planning

Intent

To describe the Persons with Developmental Disabilities (PDD) program’s service design and planning process.

Policy

Through the service design and planning process, the services and specific support strategies to be provided by the service provider and/or other resources will be identified, as well as strategies for monitoring service delivery and achievement of related outcomes.

Service design and planning process is influenced and informed by the PDD Principles for Determining Individual Support Needs.

To begin the planning process PDD regional staff will meet with the Individual and/or guardian and their family to discuss:

PDD regional staff will work closely with the Individual and/or guardian to complete all components of the service design and planning process.

The service design and planning process includes the following steps:

  1. Discuss PDD Program Purpose (program goals and outcomes) and confirm the Individual’s vision and outcomes
  2. Identify service and support needs in relation to vision and outcomes
  3. Identify strategies and resources to address support needs
  4. Complete the PDD Outcome Plan
  5. Identify costs
  6. Link Individual/Guardian to Service Options
  7. Commence service provision/develop the Individual Support Plan (Service Providers)
  8. Monitor the Individual Support Plan

1. Discuss Program Purpose and Determine the Individual’s Vision and Outcomes

The first step in the service design and planning process is for the Individual and/or their guardian to meet with PDD regional staff to discuss the Individual’s vision and the PDD Program Purpose (outcomes). This is an important step as both will direct the planning process. Identifying the Individual’s vision and related outcomes provides a pathway for the future.

A clear vision for the future will assist in the planning process and lead to improved outcomes. Some Individuals will already have defined a vision for their future while other Individuals will not. Information is available to assist the Individual/guardian and/or family in developing a vision. Although the Individual’s vision and personal outcomes are unique, PDD funded supports are intended to lead to increased independence and inclusion in the community.

2. Identify Service and Support Needs

The second step in the service design and planning process is for the Individual and/or their guardian to meet with PDD regional staff to identify the Individual’s service and support requirements based on their assessed support needs. This includes gathering and reviewing available documentation, confirming the individual’s service and support needs, including determining whether or not the individual has complex service needs.

2.1 Review all available documentation
PDD regional staff will review all documentation in the Individual’s file to obtain a preliminary overview of the Individual’s support needs, current situation and general support system, including but not limited to:

  • Vision for the future and their desired outcomes
  • Registration Form
  • PDD Intake Form
  • PDD Adaptive Skills Inventory
  • Psychological and/or other assessments

If PDD regional staff determine that additional information needed for service planning is required, they may need to request documents from others. These documents may include: discharge summaries or records from hospitals or long-term care facilities, school/educational reports, service agreements from other organizations (e.g. FSCD), guardianship orders, risk assessment from sources other than PDD, and justice or probation reports.

2.2 Understand Service and Support Needs
PDD regional staff will arrange a meeting with the Individual and/or guardian and anyone else the Individual/guardian requests to begin the planning process. This may include family members, service providers who were previously involved or are still involved with the Individual, current support workers, other government agency staff and/or community supports.

The meeting is an opportunity for PDD regional staff to better understand the Individual’s service and support needs, to explain the types of supports available from the PDD program, and the types of outcomes PDD funded supports are intended to achieve as identified in the PDD Program Purpose.

Points of discussion at the meeting will include:

  • Reviewing the PDD Principles for Determining Individual Support Needs
  • Describing how program and individual goals and outcomes drive the design and delivery of paid and unpaid supports and services
  • Identifying if there is someone who will support the Individual with planning
  • Determining the Individual’s likes, dislikes, interests related to service planning
  • Discussing the Individual’s goals and plans for the future related to service planning
  • Exploring the current and/or potential available home and community supports, both paid and unpaid
  • Reviewing information related to hospitalizations, residential treatment or incarceration (if applicable)
  • Explaining the PDD program service options (i.e. Service Provider Agreement or Family Managed Services Agreement)
  • Explaining the type and amount of support the Individual may require based on their identified support needs
  • Reviewing tasks around guardianship and trusteeship applications, AISH, etc., as appropriate
  • Identifying timelines for paid and un-paid services to begin

2.3 Determine if there are Complex Service Needs
Based on information gathered during the meeting (Step 2.2), the PDD regional staff will determine if the Individual meets the criteria for Complex Service Needs.

The PDD regional staff will work with the Individual and family during the planning process to ensure that an Individual with complex service needs has access to the most appropriate services and supports to meet their needs in a timely manner.

A summary of the Individual’s service and support needs will be documented on the PDD Outcome Plan.

3. Identify Strategies and Resources to Address Support Needs

The next step in the service design and planning process involves identifying the type and amount of supports to meet the individuals assessed support needs and achieve their outcomes. Supports have been defined as both the resources and strategies that aim to promote the development, education, interests, and personal well-being of a person and enhance his or her functioning. Services are one type of support provided by professionals and agencies.

PDD staff will assist the Individual and/or their guardian and family to explore a variety of other supports (paid and unpaid) and resources required by the Individual, including but not limited to:

  • Resources in the community that can help in addressing the support needs. These types of supports are available to all Albertans, such as: Alberta Health Services, Family and Community Support Services, AISH, Alberta Works, etc. that can be connected through Alberta Supports.
  • Natural supports available from family members, friends, co-workers, neighbours and acquaintances who provide important friendship, community connections natural to everyday life
  • Technology and innovation, including, but not limited to, software applications that can remind Individuals when to carry out certain activities, assistive products and equipment
  • Generic services such as grocery and housekeeping services, local gym and recreational facilities and, public transportation options.

PDD will not duplicate supports and resources provided by community and natural supports; however, PDD regional staff will support the Individual and/or family to connect with these resources.

Once all other supports available to the Individual have been identified, the need for PDD-funded supports (home living, support to be involved in the community, employment and respite) will be reviewed. The type and amount of supports to be provided by PDD must correspond to the Individual’s assessed support needs, lead to increased independence and inclusion in the community, and align with PDD Principles for Determining Individual Support Needs.

4. Complete the PDD Outcome Plan

After the Individual’s outcomes, support needs and required PDD funded supports have been identified, PDD regional staff will complete the PDD Outcome Plan. If the Individual is currently receiving PDD funded services, the service provider may be invited to participate in this process with the consent of the Individual and/or their guardian, supporter or co-decision maker. All services to be funded by the PDD program will be identified in the PDD Outcome Plan. A copy of the PDD Outcome Plan will be provided to the Individual and/or guardian.

5. Identify Costs

The supports to be provided through PDD funding must align with the program goals and outcomes and be cost-effective and efficient. Accordingly, PDD funded supports will:

  • Build on the Individuals/family's strengths, abilities and natural support networks
  • Lead to the achievement and promotion of positive outcomes at the Individual and program levels
  • Demonstrate the responsible allocation of resources.

The determination of funding for supports will take into consideration the above conditions. If a service provider has not yet been chosen by the Individual and/or their guardian this step will not be finalized until a service provider has been engaged in the planning process.

To identify funding for supports, PDD staff will:

  • Obtain cost estimates for the required type and amount of supports from the service provider(s)
  • Ensure cost estimates align with similar PDD funded supports being provided to Individuals in the community/region with similar outcomes
  • Ensure all costs are directly related to the individual’s support strategies
  • Review the Individual’s funding for supports, minimally, on an annual basis or as support needs change.

6. Link Individual/Guardian to Service Options

Two service options are available through the PDD program. The PDD program can provide funding for staffing supports through a Family Managed Services Agreement and/or a Service Provider Agreement.

Family Managed Services (FMS)
If the Individual, their family or a person close to the Individual chooses to directly hire paid supports from a private citizen or a community service provider, PDD regional staff will provide the Individual/family with information on FMS and link them to available resources and services.

PDD funded Service Provider
If the Individual and/or their guardian choose to access services from a PDD-funded service provider, PDD regional staff will provide the Individual/guardian with information about available resources that can meet the Individual’s assessed support and service needs and facilitate an exploration of available service providers. This may include:

  • Providing a list of available service providers and their contact information to the Individual/guardian
  • Scheduling meetings with multiple service providers
  • Scheduling and/or accompanying the Individual on tours of agencies
  • Assisting the Individual and/or the guardian/family to complete the service provider application when required or requested
  • Providing any additional information or documentation that may be necessary to complete the service provider application.

7. Commence Service Provision/Develop the Individual Support Plan

Once it has been confirmed that the identified service provider(s) is able to provide services, the PDD regional staff will send a Referral Confirmation Form to the service provider(s) so that the Individual can begin to receive services.

PDD regional staff will mail a letter to the Individual/guardian to confirm the Individual’s PDD-funded services and service provider(s). The service provider(s) and/or Family Managed Services (FMS) Administrator will receive a copy of the letter.

The letter will include the following information:

  • The approved PDD-funded supports/services and related outcomes
  • Contact information for the service provider(s) and/or FMS Administrator
  • The term of services
  • The requirement for an Individual Support Plan (ISP) within three months (90 days)
  • The role of the Individual/guardian in monitoring services
  • The type and frequency of monitoring of services by PDD regional staff.

Individual Support Plan (ISP)
Once the Individual begins to receive services, it is important that their Individual Support Plan (ISP) is finalized. ISP is a document that describes the Individual’s desired personal short-term outcomes and how these and program goals and outcomes will be achieved through the involvement of a variety of people, paid and/or un-paid services and supports.

Aspects of the ISP may have already been discussed during the development of the PDD Outcome Plan and the initial/preliminary identification of funding for the individual. Only one ISP is required for each Individual, regardless of the number of service providers for that Individual.

The service provider(s) and/or FMS Administrator may lead the development of the ISP; however, PDD regional staff can provide leadership with the consent of the individual and their family/guardian. Regardless of who leads the ISP process, it is very important the Individual/guardian and their support team are actively involved in the plan’s development and implementation. The support planning process is outlined in the Individual Support Planning guide.

The ISP may take any format but must contain the following components:

  • The Individual’s vision and outcomes
  • The Individual’s and program’s goals and outcomes
  • Important/relevant assessed support needs
  • The Individual’s specific support strategies
  • Measureable support objectives
  • The person(s) responsible for implementing the support strategies
  • Timelines for review.

A copy of the ISP will be provided to PDD regional staff by the service provider and/or the FMS Administrator not later than three months (90 days) following the commencement of services.

8. Monitor the Individual Support Plan (ISP)

It is expected that the service and support plans for achieving Individual’s outcomes be monitored and evaluated from time to time to see the need for modifications as needed. PDD regional staff will monitor provision of the PDD-funded services described in the ISP to ensure they support the Individual outcomes identified in the PDD Outcome Plan.

The supports provided to the Individual by the service provider and/or FMS Administrator must comply with program principles, and help the Individual to reach their desired Individual outcomes.

The frequency of monitoring completed by PDD regional staff must fit with the Individual’s level of support need and the complexity of the supports being provided. However, at a minimum, this will include one face-to-face meeting of the support team per year.

For an individual with higher support needs requiring complex supports, PDD regional staff may conduct regular and ongoing monitoring of the plan to ensure that support strategies are being carried out and that supports align with the individual’s vision and outcome (s).

Legislative Authority

Created: 2013-08-16
Modified: 2016-06-08
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