Service Design and Planning

Intent

The development of the Persons with Developmental Disabilities (PDD) Outcome Plan captures the discussions between Individuals and regional staff regarding the Individual’s support needs, natural supports and required PDD services.  This is a dynamic process that demands nuanced and sensitive discussion between staff and Individuals (as well as their guardians, families and others as necessary).

Through the planning process, regional staff gathers, analyzes and synthesizes information provided by the Individual, their family and others to understand and make well-reasoned decisions about the provision of PDD services and engage in active case management that is timely and responsive to the needs of the Individual and their family (see Ongoing Case Management and Monitoring).

All Individuals eligible for the PDD program require a PDD Outcome Plan.

Policy and Procedures

Through the service design and planning process, regional staff, as case managers, lead the process to ensure that it is timely and responsive for the Individual, their guardian (if designated) and their family to:

  • support them in expressing their vision for the future
  • create a plan that reflects their priorities, enhances their natural support system and identifies the services and specific support strategies to be provided by the service provider, the Family Managed Services (FMS) Administrator and/or other resources
  • assist them in accessing and coordinating supports, services and resources, including providing information and assistance with coordinating other government services
  • identify strategies for monitoring service delivery and achievement of related outcomes

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

To begin the planning process, regional staff will meet with the Individual, their guardian/family to discuss the PDD Principles for Determining Individual Support Needs and identify:

  • the Individual’s vision and intended outcomes
  • the Individual’s related support needs
  • support strategies to achieve goals and outcomes
  • available supports, services and resources (both paid and unpaid)

Regional staff will work closely with the Individual and their guardian to complete the service design and planning process.

The Service Design and Planning Process includes the following steps:

  1. Determine the Individual’s vision and outcomes and discuss PDD Program Purpose (program goals and outcomes)
  2. Identify support needs in relation to vision and outcomes, including urgency of need
  3. Identify strategies and resources to address support needs, including information, referral and advocacy
  4. Complete the PDD Outcome Plan
  5. Identify costs
  6. Notification of when PDD Services will begin
  7. Develop the Individual Support Plan (Service Providers)
  8. Monitoring

1.  Determine the Individual’s Vision and Outcomes

The first step in the service design and planning process is for regional staff to support the Individual, their guardian and family to identify the Individual’s vision, along with any current or potential natural supports and/or resources that are available to the Individual to support them.

Identifying the Individual’s vision and related outcomes provides a pathway for the future.

This is an important step as both will direct the planning process.  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 need to complete activities to help with defining their vision.

Regional staff will:

  • Support the Individual and their family in developing and articulating the Individual’s vision and the outcomes they intend to achieve; and
  • Document the Individual’s vision and outcomes on the PDD Outcome Plan.

Information is available online to assist Individuals and their families in developing a vision.

Although each Individual’s vision and personal outcomes are unique, services provided by the PDD program must lead to increased independence and inclusion in the community.

2. Identify Support Needs

The second step in the service design and planning process is for the Individual and their guardian (if designated) to work with regional staff to identify the Individual’s support needs.

In situations where Individuals may be at risk of abuse or where there are immediate safety concerns, regional staff have an obligation to report and/or take action (see Safeguards and Standards – General) immediately and must follow the processes outlined in the Abuse Prevention and Response Protocol.

Regional staff will:

  • Review all available documentation to develop an understanding of the Individual’s support needs, magnitude and urgency of need, any health and/or safety risks that need to be considered;
  • Identify whether or not the Individual has complex service needs;
  • Identify opportunities to engage and/or enhance natural supports and community resources and services, and support access to these supports wherever possible; and
  • Document relevant information on the PDD Outcome Plan.

This step is critical to ensure planning is focused on promoting the Individual’s independence and supporting their inclusion and participation within their community.

2.1  Review all available documentation

Regional staff will gather and review all documentation in the Individual’s file to obtain a preliminary overview of the Individual’s support needs, magnitude and urgency of need, current situation and general support system, including but not limited to:

  • the Individual’s vision for the future and their desired outcomes;
  • Transition to Adulthood Plan (TAP) if available from Family Support for Children with Disabilities (FSCD);
  • the Application Form;
  • the PDD Intake Form;
  • the PDD Adaptive Skills Inventory; and
  • psychological and/or other assessments.

If regional staff determine that additional information for support 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. Family Support for Children with Disabilities), guardianship orders, risk assessment from sources other than PDD, and justice or probation reports.

2.2 Understand the Individual’s Needs

Developing an understanding of the Individual’s support needs is critical to facilitating the Individual’s access to the right type and amount of supports.

To understand the Individual’s needs, regional staff will:

  • Meet with the Individual and guardian (if designated) and anyone else the Individual/guardian requests including 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;
  • Confirm the Individual’s goals and plans for the future and ensure these align with previously identified outcome/vision for the future and/or PDD program purpose;
  • Identify any supports available to the person through their family, friends and/or neighbors; and
  • Identify any related family or natural caregiver needs and circumstances and any immediate, urgent or critical needs or risks that must be considered as part of the planning process (e.g. need for proactive supports required by family or natural caregivers).
    • Families play a critical role in the lives of adults with developmental disabilities. They often provide support, including advocacy and providing care required for home living. Identifying the needs of caregivers will help PDD to better understand the outstanding needs of Individuals and the related needs of the their family including potential risks should the family no longer be able to provide care.
    • PDD will provide information to families on available supports and resources to assist caregivers. Regional staff will assist families in connecting to and accessing these resources as needed.
    • Regional staff will maintain an awareness and understanding of the organizations and supports in their community for caregivers enabling them to refer and support caregivers to access supports and services as required.
    • Regional staff will proactively assist families to develop and maintain their capacity to provide care through facilitating access to PDD services and supports, for example: respite support and connections to specialized training.
    • In circumstances where families and caregivers are in crisis, regional staff will work together with other Government of Alberta programs, such as Office of the Public Guardian and Trustee, to address the family’s needs.
    • In situations where there is concern for the health and safety of the Individual, regional staff must report and/or take action (see Safeguards and Standards – General).

2.3 Determine if there are Complex Service Needs

Based on information gathered during the meeting (Step 2.2), regional staff will:

  • Determine if the Individual meets the criteria for Complex Service Needs; and
  • 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 supports to meet their needs in a timely manner.

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

3. Identify Strategies and Resources to Address Support Needs, including Information, Referral and Advocacy

Once the Individual’s support needs have been confirmed, the next step in the service design and planning process involves identifying the type and amount of supports to meet the Individual’s assessed support needs and achieve their outcomes.  Supports are 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 a type of support provided by professionals/agencies.

Regional staff will assist the Individual and/or their guardian and family to explore a variety of other supports and services 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 and 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; and
  • Generic services such as grocery and housekeeping services, local gym and recreational facilities and public transportation options.

Regional staff will:

  • Maintain a working knowledge of resources available in the community and assist the Individual to access these supports by gathering information, facilitating meetings, making appropriate referrals and/or providing follow-up to facilitate referrals (e.g. confirming the Individual was able to access supports/services following referral);
  • Provide information about relevant federal or provincial programs and services, local community programs or supports and other resources including key contacts, websites and telephone numbers, including resources for the family care provider; and
  • Whenever possible, support the Individual, their guardian, and family to connect to an Alberta Supports Centre to obtain assistance with accessing other programs and services provided by the Government of Alberta.

Once all other supports available to the Individual have been accessed, the need for PDD services (home living, support to be involved in the community, employment and respite) will be reviewed.

Regional staff will:

  • Ensure the type and amount of PDD services to be provided correspond to the Individual’s assessed support needs;
  • Lead to increased independence and inclusion in the community;
  • Align with PDD Principles for Determining Individual Support Needs; and
  • Respond to any immediate, urgent or critical needs, including making arrangements for the provision of temporary and/or short-term supports that can be accessed.

4. Complete the PDD Outcome Plan

Through the service design and planning process, regional staff will gain an understanding of:

  • An individual’s vision for their future;
  • Their unique needs and circumstances;
  • The supports and services required to address their individual needs; and
  • The urgency of support needs (e.g. health, risk to self or others, and any critical supports for family or natural caregivers, such as respite).

Information gathered during the service design and planning process, including the Individual’s desired outcome(s), their support needs, natural supports and community resources and any services to be provided by the PDD program, will be documented  in the PDD Outcome Plan.

Depending on the Individual’s needs, the available community resources and their natural supports, not all Individuals will require PDD supports.  Ongoing involvement and activities with the PDD program will be determined on a case by case basis.

A copy of the PDD Outcome Plan will be provided to the Individual and/or guardian and service provider(s)/FMS Administrator.

5. Identify Costs

The PDD services to be provided must lead to the achievement of the Individual’s outcomes, align with the program goals and be most cost effective and efficient. PDD services will:

  • build on the Individual’s strengths, abilities and natural support networks;
  • lead to the achievement and promotion of positive outcomes;
  • demonstrate the responsible allocation of resources; and
  • complement supports and services provided by health providers (e.g. medical professionals, mental health therapist, etc.).

When PDD services are required, the determination of funding for services 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 services, regional staff will:

  • determine what services an agency can provide;
  • obtain cost estimates for the required type and amount of services from the service provider(s);
  • ensure cost estimates align with similar PDD services being provided to Individuals in the community/region with similar outcomes;
  • ensure all costs are directly related to the Individual’s support strategies; and
  • review the Individual’s funding for services, minimally, on an annual basis or as the Individual’s identified support needs change.

6.  Notification of when PDD services will begin

Individuals who require supports immediately to address critical or urgent needs or where access to proactive PDD services are required, such as respite or interim supports for families or natural caregivers who are under stress or in crisis, will be prioritized to ensure their needs are met as quickly as possible.

Individuals who require PDD services but who do not have an immediate critical or urgent need may not begin services right away.  Based on availability of resources, PDD may provide proactive respite or interim supports until PDD services can be provided as identified in the Individual’s PDD Outcome Plan.

Regional staff will:

  • Identify proactive or interim PDD supports to be provided while awaiting commencement of PDD services identified in the Individual’s PDD Outcome Plan;
  • Contact the Individual in person or by phone to explain the decision and ask them to contact PDD should their needs and/or circumstances change; and
  • Inform the Individual in writing of the decision and their right to access the PDD Concerns Resolution Process.

Based on the needs and circumstances of the Individual, regional staff will contact the Individual as agreed upon in their PDD Outcome Plan, minimally within one year, to determine if their needs and/or circumstances have changed.

To ensure Individuals and their guardians receive adequate notification related to when their services will begin, regional staff will:

  • Contact the Individual and their guardian in person or by phone to review the information contained in the PDD Outcome Plan, when PDD services may commence and the plan for maintaining contact;
  • Encourage the Individual and their guardian to contact PDD if their needs and/or circumstances change;
  • Provide the Individual and their guardian written notification of when PDD services may begin using the provincial letter template;
  • Maintain contact with the Individual and their guardian, minimally once a year or as identified in the PDD Outcome Plan, in order to review needs and respond to changes as needed and identify other available supports and resources, as required; and
  • Document any delays in the commencement of PDD services in the CSS Information System within the Activity tab: No services – no available funding.

6.1 Available 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.

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, regional staff will provide the Individual/family with information on FMS and link them to available resources and services.

PDD Service Provider

If the Individual and/or their guardian choose to access services from a PDD-service provider, regional staff will provide the Individual, their guardian and family with information about available resources that can meet the Individual’s identified support 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 their guardian 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; and
  • during the application process, once a service provider has indicated a willingness to engage in planning with the intent to provide a service, regional staff will provide the Health and Safety Document Summary and associated documents to the service provider to facilitate the determination if they are able to provide the requested services.

Once services become available, regional staff will mail a letter along with the completed PDD Outcome Plan to the Individual/guardian.  The service provider(s) and/or FMS Administrator will receive a copy of the letter.

The letter will include the following information:

  • the approved PDD 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) following commencement of services;
  • the role of the Individual/guardian in monitoring services;
  • the type and frequency of monitoring of services by regional staff;
  • estimated time for when services will commence; and
  • information on accessing the PDD dispute resolution process.

Once a start date has been confirmed for when the identified service provider(s) is able to commence services, the regional staff will send a Referral Confirmation Form to the service provider(s) so that the Individual can begin to receive services on the approved start date.

7.  Development and Monitoring of the Individual Support Plan

Individual Support Plan (ISP)

Once the Individual begins to receive services, their Individual Support Plan (ISP) will be finalized within three months (90 days) following commencement of services.  The 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 unpaid 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.

The service provider or FMS Administrator will typically lead the development of the ISP.  Regional staff assist with the process at the request of the Individual and their family/guardian (if designated). Regardless of who leads the ISP process, it is very important the Individual/guardian (if designated) and their support team are actively involved in the plan’s development and implementation.  Regional staff will participate as a member of the support team. 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 identified support needs;
  • the Individual’s specific support strategies;
  • measureable support objectives;
  • the person(s) responsible for implementing the support strategies; and
  • timelines for review.

A copy of the ISP will be provided to the Individual/guardian and regional staff by the service provider and/or the FMS Administrator no later than three months (90 days) following the commencement of services.

Monitoring the Individual Support Plan

Regional staff are responsible for monitoring activities that include ensuring the services described in the Individual Support Plan (ISP) occur as planned and that they continue to support the Individual’s outcomes as identified in the PDD Outcome Plan. All PDD services provided to the Individual by a service provider and/or FMS Administrator must be provided in accordance with program principles and help the Individual to reach their desired outcomes.

Regional staff will provide feedback to service providers and/or FMS Administrators who contributed to the ISP:

  • within 10 working days of receipt of the ISP;
  • indicating if the document meets the mandatory criteria (listed above) and if it is accepted or requires changes to meet mandatory criteria; and
  • indicating if the information represents the discussion and agreements made during the support team meeting.

Staff will document the receipt and acceptance of the ISP for each new PDD Outcome Plan in Mobius - PDD Outcome Plan.

After each review of the ISP by the support team, minimally to be completed once per year or more frequently if agreed by the support team, a copy of the ISP including review information will be provided to the Individual and their guardian (if designated) and all members of the support team.

Regional staff will provide feedback as described above after each updated copy is received.

8.  Monitoring

Regional staff will complete monitoring activities with all Individuals receiving supports and services from the PDD program, including those who are waiting for services to begin and those receiving information and referral services as part of the Service Design and Planning process.  Ongoing case management activities will ensure that available supports and services align with the Individuals support needs. PDD services (if required), as described in the ISP, will support the Individual to achieve their outcomes identified in the PDD Outcome Plan and will comply with program principles (see Ongoing Case Management and Monitoring Activities).

Legislative Authority

Created: 2013-08-16
Modified: 2018-04-12
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