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Pennsylvania Department of Human ServicesOffice of Developmental Programs

Music only.

Course Number: C-016-1

The Outcome Section of the ISP: Better Outcomes, Better Lives - Part 1: Outcome Summary

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This webcast includes spoken narration.

To adjust the volume, use the controls at the bottom of the screen. While viewing thiswebcast, there is a pause and reverse button that can be used throughout thepresentation.

The written version of the narration appears to the right of the screen.



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Certificates of Achievement will be available to Administrative Entity staff, Providers,Supports Coordinators, and SC Supervisors after completing all course requirements.Please view and then save or print your certificate in order to receive credit for this course.

For SCs and SC Supervisors, course requirements include successful completion of a pretest and post test.



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Hello and welcome to this webcast, The Outcome Section of the ISP: Better Outcomes,Better Lives.

My name is Jennifer Fraker. I am the Division Director for Supports Coordination andProgram Services and will be presenting this training on behalf of the Office ofDevelopmental Programs.



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This webcast is Part 1 of a two part series. In this training, we will focus primarily on theOutcome Summary part of the Outcome Section of the ISP.

Part 2 of this series will focus on the Outcome Actions part of the Outcome Section of theISP where services and supports are identified. Part 2 will include new clarification,examples and foundational information in response to questions submitted after the livetraining sessions. The release and availability of Part 2 of this webcast, will be announcedthrough ODP Communications.

The Frequently Asked Questions (FAQs), which includes responses to questions on theOutcome Summary and Outcome Actions, is posted as a supporting document to thiswebcast. In addition, the document titled – Person Centered ISP – is also posted. Readingand reviewing both supporting documents is required to receive two hours of professionaldevelopment credit for this webcast.

This slide is also posted as a supporting document (Outcome Summary) and can be foundon the course page where you launched this webcast. You may want to print this now touse later as I describe how to develop and complete this part of the Outcome Section.

Later in the training, you will also need to read Isaac’s One Page Description, so take amoment to print that too.



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The purpose of this webcast is to identify ODP’s requirements so that each member of theteam understands their role and how to apply person centered practices to thedevelopment of the Outcome Section of the ISP.

ODP recognizes there is confusion about requirements for completing the Outcome Sectionof the ISP. There are several factors that likely contribute to the confusion.Best practice, policy and state and federal guidelines can change over time; the first

training on Outcomes was in 2008.Staff changes at the state and local level andDifferent implementation practices across agencies, counties and regions

Presented today are ODP’s requirements for completing the Outcome Section of the ISP.This webcast includes additional clarification from ODP based on questions submitted atthe live training. All stakeholders with a role in this process should implement theserequirements as identified in order to create a consistent process for all team membersthroughout Pennsylvania.



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Twenty live sessions of this training were held across the Commonwealth in May and Juneof 2015. In total, 2190 participants attended these sessions. As has been the tradition ofthe Outcomes training over the past few years, the audience included ISP team membersrepresenting a variety of roles including:

A person receiving supportSupports Coordinators, SC Supervisors or other Supports Coordination Organization staffDirect Service Providers from residential, day, and employment servicesAdministrative Entity Staff andODP staff

We also asked how many people were long time professionals in the field and how manywere new. It was very interesting and satisfying to see that there is a significant number ofpeople with more than 25 years in the field. On average, in each session there were 10 to12 very new staff with less than one year of work experience.



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ODP has provided many training sessions on Outcomes, beginning in 2008, and so for someof you this will be an opportunity to refresh and reaffirm your knowledge of how todevelop an Outcome Statement and how to complete the entire Outcome Section of theISP.

For newer people in the field, this information will help you establish a foundation inunderstanding your role and responsibilities in outcome development and implementation.For all participants, this training will provide clarification on how to complete the OutcomeSummary part of the Outcome Section of the ISP.



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The theme of the 2011 Outcomes Training was – it’s about the Person, not just the Process.It is about people having better lives not just better plans. It is more than the paper, it isabout developing person centered outcome statements that reflect what is important tothe person. It is about identifying and assessing needs and preferences so that the personis supported to live a meaningful life, an Everyday Life.

When better outcome statements and actions are developed that really address what isimportant to the person and addresses assessed needs, we can support a person to have abetter life; the life they want.



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Everyday Lives was developed in 1991 by people with disabilities and their allies andremains the foundational values and philosophy of ODP.

People with disabilities were asked – what do you want in your life? And no surprise,people with disabilities want the same things that you and I want present in our lives andthe lives of people we care about – relationships, control, choice, individuality – just toname a few.

Please take a moment to read the 13 core values of Everyday Lives.



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The current Mission and Vision of ODP gives direction to the work of all ISP team membersand includes the values of Everyday Lives.

The mission of ODP is to support Pennsylvanians with developmental disabilities to achievegreater independence, choice and opportunity in their lives. The words – independence,choice and opportunity – are highlighted as this connects directly to developing personcentered outcome statements.



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ODP’s vision is to continuously improve an effective system of accessible services andsupports that are flexible, innovative and person centered.

So as you see, as a member of the ISP team, you are helping to fulfill ODP’s values, missionand vision by promoting person centered outcome statements that reflect what isimportant to the person.



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The primary matter of importance is people getting better lives. Throughout this trainingwe are going to stress two other elements of outcome development that support theplanning process to help people get that better life. The first is language and words –language and words matter.

Throughout this training, we are going to be very precise in our use of words related tooutcome development and the Outcome Section of the ISP.

One source of confusion that has been identified is that the word outcome or outcomes isused to mean many different things. Are we really talking about the Outcome Statement orWhat Action is Needed? Are we talking about the first part of the Outcome Section that islabeled Outcome Summary or are we talking about the second part that is called OutcomeActions?

Using clear and consistent language is important to be sure that we are talking about thesame thing and to better understand how to develop a person centered outcomestatement and how to complete the entire Outcome Section.



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In order to develop a person centered outcome statement and complete the OutcomeSection of the ISP, we need to follow a step by step process using person centered thinkingskills. Think of it as a building that is built with multiple floors; one on top of the other.The foundation of the building is person centered thinking and planning. Each floor as it isbuilt from the bottom supports the floors above it and ultimately produces a sound andstrong structure. The same is true for completing the Outcome Section of the ISP.

We start by listening and gathering information (using person centered skills) from theindividual and the people who know him or her best in order to develop the outcomestatement. For example What is Important To, Important For, What’s Working/NotWorking, and Understanding Communication.



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After the outcome statement is developed, the reasons for the outcome are identified,then concerns related to the outcome, relevant assessment, current needs, action needed,who is responsible, frequency and duration and measuring progress. Following this step bystep process is a logical flow and is exactly the order that the Outcome Section of the ISP isstructured.

Later in the training we are going to dig in on the Outcome Summary part of the OutcomeSection where person centered information is the focus.

In order for the team to help each other, everyone who has a role in supporting the personneeds to understand and follow the sequence in developing the Outcome Section of theISP.



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The timing of when outcome statements are developed at the ISP team meeting is also animportant part of the sequence. We know that team meetings can be long and often timesthe Outcome Section is discussed last. Team members, including the individual receivingsupport, cannot always stay for the entire meeting or pay attention for several hours. ODPis strongly recommending that SC’s facilitate the ISP meeting beginning with the OutcomeSection when the team is fresh and most engaged. By putting the development of theoutcome section first, you are saying to the team – this is what is most important, this iswhere we should spend our time.



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As we just described, in order to develop an outcome statement, we start with informationgathering. Some of the information gathering can be done in advance in preparing for theISP team meeting.

During the ISP meeting, the team briefly reviews the information gathered to establish ashared understanding and updates information by asking the individual and team: what’simportant to the person, what’s been going on, and what’s been happening in the person’slife for the past year.

Hearing from the person and people who know him or her best will begin to identify whatis working well (things to keep going) and things that are not working well (need tochange). This process for information gathering helps to ensure that the full team is on thesame page as outcome development begins.



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For many of the individuals supported, the ISP is not being started as a brand new plan.Either the plan is something that the individual, current SC and team have been working onfor many years or was inherited from a previous SC. In either case, it is important toreaffirm the current information as things change over time.

But please be mindful that this review of information can lead you away from the OutcomeSection and into the many other sections and requirements of the ISP. We encourage youto complete the entire Outcome Section before moving into other needed ISPrequirements.

From this updated information gathering a natural discussion of outcome statements canbegin and then follow the sequence through the next parts of the Outcome Section. If youare not already doing this, ODP is eager for people to try this and let us know how yourexperience improves.



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A few moments ago I talked about Everyday Lives and ODP’s Mission and Vision. The teamstarts with the individual and includes many different people, with different roles andresponsibilities; but the common interest is the same for all – to protect the health andsafety of the individual and provide supports to enhance the quality of life of people wesupport.

In order to accomplish this shared interest, everybody who is part of the ISP team andprocess needs to be on the same page in how the team approaches and develops theOutcome Section of the ISP. This means following the sequence as ODP has described overthe years and putting into local practice only those requirements that ODP has identified.

Working together and understanding roles and responsibilities also helps to achieve one ofthe core values of Everyday Lives Accountability.

Let’s talk briefly about all of the members of the team and their roles.



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ISP development in Pennsylvania is a person centered planning process so we always startwith the person first. It is our job to make sure that the person is encouraged to attend theISP meeting and that all the arrangements are made to suit the person and their schedule;and that the specific needs of the individual are supported to attend and participate in theirISP meeting.

In order to develop a meaningful outcome statement, the individual needs to let us knowwhat is Important To him or her; what are his or her needs, desires and preferences. If theindividual does not attend the meeting, he or she will identify who else should be invited inorder to provide new information and/or verify what is being discussed.

While it is the individual’s choice as to whether he or she will attend, there is a long timesaying in the self advocacy community that is worth repeating here – Nothing About Me,Without Me. If you are planning for a person, the person needs to be present so thateveryone is reminded about who this individual person is and what is important in theirlife.



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Getting back to the role of the individual, he or she has responsibilities to agree to andparticipate in the outcome actions identified in order to achieve their outcome statement.Outcome actions are not done to the person; actions are done with the person.

Yes, there are many people you support who do not communicate using words. So maybethe person is not telling us through words what is Important To him or her but they aretelling us through their behavior. And if they are not telling us what they want; folks aretelling us what they don’t want. There are people on the team who will know the personvery well and know this information about Important To because of how much time theyspend with the person every day or every week or every year. We will talk more about thisas we discuss the other team member roles.



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The family brings unique historical and everyday information about the person to thedevelopment of the Outcome Section of the ISP. Information on what is working and whatis not working will help to identify what might be maintained or changed in the outcomestatement.

Like the individual receiving supports, the family may have responsibility within outcomeactions and may also be able to identify other unpaid supports that can help the personachieve what is Important To them. Family members may also be able to support theparticipation of their family member during the ISP team meeting.



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ODP encourages individuals to invite their friends, neighbors or members of thecommunity on their team; as the insights offered by these team members is valuable.These folks may have information that is only known by them because of their uniquerelationship with the individual.

For example, someone from a religious organization may know Important To informationabout the person’s spiritual needs and wants AND may also be a resource to activities orother people who can help the individual obtain what is important.

The friend, neighbor or community member may not attend the ISP meeting or evenconsider themselves part of the team but if asked might provide important informationthat another team member could bring to the meeting.



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Locate, coordinate and monitor are the three core functions of the Supports Coordinator.And within these core functions also exists – planning.

Over the years ODP training has talked a great deal about SCs as the process experts in thedevelopment of the ISP. It is the SC’s responsibility to see that the ISP gets written withinthe established time frames, meets ODP’s expectations and includes information from all ofthe team members. As the meeting facilitator, the SC is expected to assist the team togather the needed information and in following the sequence in completing the OutcomeSection of the ISP.



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The SCO’s role is to review the Outcome Section of the ISP in order to assure that theexpectations for sequence and content meets ODP’s expectations. The SCO should identifywho (SC Supervisor, Quality Manager) is reviewing the ISP (including the Outcome Section)prior to submission to the AE. Plans that do not meet ODP’s expectations should bereturned to the SC for revision. This is the first level of review before the ISP is sent to theAE for approval and authorization and can prevent delays in plan approval and servicedelivery.



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Let me give you two examples.If an ISP includes an outcome statement with named services, the plan should be

returned to the SC for revision; not sent to the AE for authorization.If in reading the outcome statement, the SC Supervisor cannot identify what is Important

To the person or is confused about where this outcome statement came from because it isnot tied back to the rest of the ISP; then the SC Supervisor should return the plan to the SCfor revision.

In addition, the SCO should have in place, local practices to ensure that SCs are well trainedand developing plans as per ODP requirements. Follow up targeted training and technicalassistance provided by the SCO should ensure that the SCs and Supervisors are able toembed the practices identified through statewide training.



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Like the family, the Provider has unique current and historical information about theindividual. If a person attends a day program 30 hours a week or lives in a residentialsetting, the Direct Support Professional (the DSP) is one person who really knows thisindividual well.

Here again, that provider can bring information that identifies what is working/what is notworking and then what needs to be maintained or changed. Someone who the individual iscomfortable with and knows him or her well can help the individual participate during theteam meeting, and possibly assist with communication and identifying signs of agreementor discomfort.



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So the questions ODP asked in developing this training regarding the Provider is – whoreally knows the individual, who really has a good relationship with the person, does thisstaff member work in the afternoon or weekend? Is it possible for this person to attend theISP meeting for 30 minutes?

It is also in the best interest of the provider agency to have the DSP attend the meeting tobe sure that outcome actions that are identified for the provider are achievable in thecontext of the day to day life of this person, their preferences and routines.



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If it is not possible for the DSP to attend, then whoever represents this DSP must comeprepared to the meeting with the information that is known to the person who knows thisindividual best. This is especially crucial for individuals who do not communicate usingwords to be sure that the outcome statement is based in Important To and outcomeactions are real considering the person’s abilities, strengths and needs.

The DSP is not often asked questions like – what makes Bill happy, what does he like to do,what doesn’t he like to do, how do you connect with Bill, how is it that you are able to keyin to his likes and dislikes? This is the information about the person that is unique to theDSP who knows the person best and should be shared at the ISP meeting.



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One role of an AE is to review, approve and authorize the ISP according to ODP’srequirements. Specific to the Outcome Section of the ISP, the AE is the last reader, the finalperson who reads this section to determine if ODP’s expectations have been met.

In order to determine if the outcome section reflects what is Important To the individualand meets ODP’s expectations, the AE ISP Reviewer should read the entire ISP.



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And here’s why at the point of reading the Outcome Section, the AE ISP Reviewer shouldfeel confident in authorizing services. This confidence is built as you can see how the teampulled together the information provided from various other sections of the ISP. We like tothink about a thread that is pulled through the personal preference section of the ISP allthe way to the end. In reading the Outcome Section, the ISP Reviewer should be able tosay – yes, I get this; it makes sense based on everything else that I read.

A review conducted by ODP finds that as a result of findings of AE Oversight Monitoring,the AE is returning more plans for revision. For example, plans are being returned forrevision if the outcome statement does not connect to information from the rest of the ISP;or if the outcome statement includes a service or if the service does not seem to addressthe need or provide the support needed to achieve the outcome.



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Returning plans for revision may cause service delays and is time consuming for everyone.That is why it is critical that the AE return plans only for reasons that are in line with ODPexpectations. Adding additional requirements is making it very confusing for SCOs andProviders who work in multiple counties to know what is expected and works against theefforts to have one consistent statewide system. For everyone involved in thedevelopment of the ISP, including the Outcomes Section, following the sequence andmeeting ODP’s expectations, supports the work of everyone.

One last thing about the AE role – AE leaders should evaluate why the Outcome Section ofthe ISP is being returned for revision; identify training and technical assistance needs; andmay incorporate trend information into quality management plans.



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We began this part of the training by talking about ODP’s role in establishing and sustainingvalues, vision and mission. ODP has also established the required practice of developing aperson centered ISP, using person centered principles in working with an individual and theteam.



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The ongoing role of ODP as the state Medicaid agency for the Consolidated and P/FDSwaivers is to: continue to provide policy and practice clarification, technical assistance,compliance monitoring and oversight (questions on outcome statements were added tothe AE Oversight Monitoring Process Cycle 6) and training to the field in order to achieve aconsistent statewide system where individuals are supported to have an everyday life.Lastly ODP has an overall quality improvement role for the system plan, do, check, act.

With the mission, vision, values, roles and responsibilities in mind, let’s explore the basicconcepts of person centered thinking.



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The balance of Important To and Important For is the core concept in Person CenteredThinking. Let’s just spend a moment to review Important To and Important For to makesure we have a shared understanding.

Here are the six categories that commonly make people happy, fulfilled, content, satisfied,and/or comforted.

We are talking about:People and relationshipsThings to do and places to goRituals or routinesRhythm or pace of lifeStatus and control andThings to have

These are the same things that are important to all of us. This is about human beings; notjust about disability.



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What is Important To a person are the things that matter most; the things that bytheir definition makes for a good quality of life. These are the things that peoplesay they cannot or choose not to live without.

What is important to a person includes only what people are “saying,” in theirown words or through behavior.

Where what the person says is different from what they do; the bias is to rely onbehavior and ask why?



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Important For are the things that people need to be healthy, safe and valuedmembers of the community. These can be complex issues.

Support teams may have an easier time identifying what is Important For aperson based on things like environmental risks, prevention and treatment ofillness, and health promotion. However, teams also want to consider what isImportant For a person beyond obvious risks to health and safety and how tooffer support.

The more subtle piece, or the piece people often miss about Important For, arethe things we pay attention to in order to help the person be a valued andcontributing member of their community.



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When we are supporting someone to achieve their outcome statement, what we try to helpthe person to achieve is the balance of Important To and Important For.

Remember the words from Michael Smull – when we pay more attention to what isImportant To the person, and little or no attention to what is Important For the person, theperson is happy, but dead. When we pay more attention to what’s Important For the person(their health and safety), with little or no respect for what is important to them, the person issafe, but miserable. Our work is to help the person find ways to balance getting what isImportant To them with those things that are Important For them.

In terms of outcome statements, if Important For is included in the outcome statement it isalways linked to what is Important To the person.



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For example, here is an outcome statement for Maria: Maria walks to the grocery storein order to buy diet soda and to exercise. What we know about Maria is that she doesnot like to exercise but she does like to drink diet soda. Does that sound familiar? Isn’tthat something that we all do – link something that is important to us in order to copewith or accomplish something important for us?



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Keeping in mind ODP’s mission, vision, Everyday Lives and person centered thinking nowwe are going to dig into the Outcome Summary part of the Outcome Section of the ISP.

When I talked earlier about sequence, I highlighted the importance of informationgathering as the first step in the sequence. Information gathering is the foundation to thedevelopment of the Outcome Section of the ISP. Each of these sections of the ISP, that areshown on the slide, can tell us about what is important to the person; not just the sectiontitled “Important To”.



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For example, outcome statements describe desired positive change and what needs to bemaintained. The What Makes Sense/What Doesn’t Make Sense skill is very helpful inidentifying what is important to the person as well as what the person wants to change andwhat needs to stay the same.

The “Know and Do” section can tell us what others need to know and do for the individualto have what is important to them and/or for them to be healthy and safe (Important For).

In fact, all of the information collectively included in the ISP identifies the person’spreferences, choices, strengths and needs and that information in total supports the teamin the selection of paid and unpaid services.



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In addition to what is written in the ISP, the team members who are part of the individual’slife have critical current information about the person. Every effort should be made to havethese people attend the annual ISP team meeting to contribute their knowledge.

This is especially true for a person who is unable to communicate using words. If the staffmember who works weekends is the person who knows this individual best, can some shiftchanging be done to have this staff member attend for one hour? If the staff personcannot attend, the representative must come prepared with this information so that wecan hear about the individual’s preferences from someone who has first hand knowledge.



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After gathering information, the next part of the sequence in completing the Outcome Sectionof the ISP is developing an Outcome Statement in the Outcome Summary.

There has been a great deal of training on developing a person centered outcome statement. Ifyou are a new team member or would like a refresher, view the 2014 Outcome Statements(Professional Development) webcast available on the Information Centers.

But now, based on previous training and your own work, tell us what you know about creating awell developed outcome statement.



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In the blue box, type in three components of a well developed person centered outcomestatement. When you are done, click <submit>.



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The next series of slides provide a list of nine components to be included in a welldeveloped person centered outcome statement. Did you have these items on your list?

Developing an outcome statement that includes all of these components will meet ODP’srequirements and standard of practice. For each component, I will also provide anunderstanding of the reason why this is an important piece of the outcome statement.

1. Outcome statements include the Person’s first name to promote and reflect a personfirst focus and puts the spotlight specifically on who are we talking about.



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2. Write outcome statements in the present tense in order to identify the expected result; not whatwill happen or what should happen.

This has been a challenge for some team members for whom it does not make sense how this ispresent tense if it is not happening now?

Here is something that might help you and other team members to better understand why outcomestatements are written in the present tense.

Think about that organizational mission statements are written in present tense as this is what is tobe achieved; look at ODP’s mission as an example.

The following is from Power of Ted, Empowerment Dynamic by David Emerald. It was written todescribe outcomes outside of the disabilities field.

“Desired Outcomes are Stated in Present Tense – Outcomes are statements of vision. When weenvision something, we see it as complete, whole, finished – to the best of our ability. Some visionsare clear and concrete, while others may be more vague with only a sense of direction to guide us.Yet, we need to step “into” that vision and state as if it were already here.”

Writing an outcome statement in the present tense answers the question – How will I know when Ihave created it?



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3. Outcome statements reflect something Important To the person.

This is the core principle of developing an outcome statement. It is what matters most tothe person and is how he or she defines their quality life for themselves.

From the Annotated ISP – Outcome statements “represents what is currently important tothe individual, what needs to be maintained for the individual, or what needs to bechanged.”



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4) Outcome statements identify action and use action verbs in order to describe what ishappening, what the person is doing. There needs to be action in order to help the personachieve what is important to him or her.



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5) Describe the positive impact on the person’s life in the outcome statement. It answersthe questions:

How will the outcome make a difference?What will the person gain by having this outcome statement achieved?What will be maintained that is working well?



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6) Outcome statements balance Important To and Important For. Outcome statementsmust include what is important to the person and may include what is important for theperson. If the outcome statement contains Important For information, what is ImportantFor the person may be present in the statement as well, but if it is, it must be in the context(connected to) something the person considers important to.



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Here are the last three components.

7) There is no reference to or named paid service in outcome statements. Services are notincluded in the outcome statement. Services are included in Outcome Actions – Whatactions are needed? ODP has been providing direction on this since 2009; however namedservices in outcome statements were found through the 2014 2015 AE OversightMonitoring process.



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8) One statement or one sentence should be developed for the outcome statement. Usingone sentence keeps it simple and clearer to understand. The rest of the outcome sectionprovides great detail.



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9) Use people first language in developing an outcome statement to be consistent withODP’s values.Put the person before the disability.Does not diagnose or label the personDescribes what the person has, not what the person is (for example: a person has autism,

not person is autistic)



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As we explore the Outcome Summary; I will be providing examples based on a man namedIsaac. If you have not already printed out Isaac’s One Page Description, please do so now.Supports Coordinators, you may remember that we got to know Isaac during the RiskMitigation training in the fall of 2014.

We are using this One Page Description to get to know Isaac. As you know, a one pagedescription is a snapshot, we know the information is limited. This is for training purposesto help you to get to know Isaac. We are not using Isaac’s one page description to plan orevaluate. We are using the description to get to know him enough to consider how hisOutcome Summary might be developed.



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In addition to the one page description, here is a little more background on Isaac.

Isaac lives at home with his mother and sister who provide most of his care and support.He is 21 years old and his current diagnoses include autism, a mood disorder, and a mildintellectual disability. At time he displays self injurious behaviors and can be aggressivetoward others. Isaac is also known to get up in the middle of the night and wander. Isaactells his long time habilitation support staff person that he wants to see a country musicperformance.



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Okay, let’s think back on what we learned about developing a person centered outcomestatement. On the slide is an outcome statement for Isaac. Does this meet ODP’srequirements based on the nine components we described? What should be changed?



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In this original outcome statement for Isaac; licensed home and community habilitationservice is named. Outcome statements should not include named services so this shouldbe removed.

Here is how the revised outcome statement should be written.



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Let’s continue to develop the Outcome Summary part of the Outcome Section. Afterdeveloping the Outcome Statement, the other parts of the Outcome Summary provideperson centered information to better understand the desired outcome statement.Remembering that sequence matters, what comes next?

That’s right, next is the Reason for the Outcome. In this part we will find information tobetter understand why the outcome is important to the individual. The reason describeshow achieving this outcome statement will make a difference in the person’s life.



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Knowing the reason for the outcome will help ensure that we are helping the personachieve what is important to him or her. I might have the same outcome statement as youdo but my reason for wanting this outcome statement present in my life may be differentthan yours.

Let’s think about why people work. Someone recently told us that they work in order tosave money to retire. Someone else may work to save money for vacation. And someoneelse may work to be able to buy lots of shoes or to overall feel like a contributing memberof the community. More basically, most of us work to pay for where we live and to buyfood. In fact, it may be all of these things or different things at the same time. What isimportant here is that understanding the reason tells us what will be gained. If I work butdon’t save money to retire or go on vacation or buy lots of shoes or have money to pay forwhere I live; then I have not achieved the result I wanted.

In completing this section of the Outcome Summary, there is no need to repeat in detail orfully describe information that is contained in other sections of the ISP. It is fine to statethe basics and identify other sections for the details.



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This is the information provided in Isaac’s Outcome Summary that describes the reason forthe outcome.

Is the information clear enough to determine how and why the Outcome Statement isimportant to Isaac? Is there any information in this section that does not belong here? Isthere any information that is missing?



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There is information provided here that does not belong because it does not giveinformation about why this outcome statement is Important To Isaac.

Isaac’s interest in having a girlfriend is not part of the intent of this outcome statement andshould be removed. While his one page description identifies that it is important to Isaac tohave a girlfriend; as far as we know this is not the reason for this outcome statement.

If Isaac wants to begin to explore relationships and dating, it would make sense for theteam to work on a separate outcome statement in order to help Isaac learn about dating.



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The fact that Isaac goes into the community to a variety of places provides context for thisoutcome statement but does not provide information on the reason going to a countrymusic performance is important to him. This should be removed.

Isaac needing assistance when he travels in the community is a concern related to theoutcome. This is something that someone on the team might voice as a worry, barrier orchallenge. As this is not a reason, this sentence should be removed.

Here is how the revised reason for the outcome part should be written.



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And after we understand the Reason for the Outcome, the next part of the OutcomeSummary to complete is Concerns Related to the Outcome.

Identifying concerns is a step to help the team to begin thinking about what actions areneeded. But before we come up with solutions or actions, we need to know what are all ofthe concerns. The key to helping team members to voice concerns is to establish anenvironment where all voices can be heard with no judgement. All concerns should beheard and documented without asking the next questions – is this real and is this somethingthat the team needs to consider in planning.



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Questions that will prompt team members to identify concerns are:

What barriers prevent the outcome statement from being achieved now?What worries do team members have including:

what team members say are important FOR the person while the outcome statementis being worked on?potential risks to the individuals health and safety?

In thinking about concerns, the team will also include what has been tried in the past but hasnot worked, what the individual’s team has tried to figure out, or other concerns any teammember may have.

So, what are some of the reasons why it is important to identify the concerns before takingaction?



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Identifying concerns:Point out areas of health and safety that need to be addressed (people are happy AND

healthy and safe)Increases buy in of all team members; helps to find common ground and signify a shared

commitment to take actionSpotlights areas of risk and need for support; helps the person take a big stepPinpoints what has been tried and what might be done differently andDetermines likeliness (chance of it happening) and seriousness (potential risk of harm) of

the concern

We encourage you to take the time to identify and dig in on concerns and certainlyremember the sequence – identify concerns before coming up with solutions and takingaction. As you move from concerns to actions, also think about providing individuals with achance to try something. We all try things to determine if it suits us, if we like it andsometimes the answer is no. But we tried, learned something new and maybe somethingelse good came along.

Please remember that the 2014 webcast, Outcomes: A Bridge to Action, is still available asprofessional development.



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This is the information provided in Isaac’s Outcome Summary that describe the concernsrelated to the outcome.

Has the team identified possible barriers or other things that the team may be worriedabout? Is there any information in this section that does not belong here? Is there anyinformation that is missing? Any information that is inconsistent with what we know aboutIsaac’s need for support?



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These are all of the concerns that were identified by the team. The list was not edited andno judgement was made as to whether the concern was likely to occur and/or if there wasreal potential for harm. No changes need to be made to this list; it is fine just how itappears.

Notice that the third concern listed was the one that was previously identified as a reasonfor the outcome. This concern is now documented correctly.

One way to determine the likeliness and seriousness of the concern is to reviewinformation found in relevant assessments. We will look at that next.



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To this point in the sequence, we have developed an outcome statement, identified thereason for the outcome, and concerns about the outcome.

Before thinking about the actions, it is important to identify any assessments related tothis outcome statement that can give us more information to consider about the person’sstrengths, needs and abilities. Assessments help the team to identify an individual’sneeds, strengths and abilities.

There are two types of assessments: formal and informal.

Some examples of formal assessments are: SIS, provider assessments, medical exams,communication assessments, physical therapy, and behavioral consults

Formal assessment Information can be found in: Know and Do, Health and Safety,Functional Information, Supervision Care Needs



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What are some informal assessments?

Direct observation, conversations with the person, family members, direct care staff orothers who know the individual well and also review of previous records.

Just a moment ago we talked about concerns and working to determine likeliness (chanceof happening) and seriousness (potential for harm). The information found in relevantassessment is one place to help figure this out.

Relevant assessment information may also be utilized as a baseline to determine if thecurrent action plan is effective. If the assessment provides information that the outcomeactions have not achieved the desired result, the team may want to consider changes tooutcome actions while the Outcome Statement remains the same.

To complete this part of the Outcome Summary, list the assessment name or source ofinformation and use a few words to summarize the relevant assessment information. Andremember this assessment information relates to the desired result in this one outcomestatement.



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On the slide is a list of the relevant assessments that you would look for or expect to find inIsaac’s ISP. Information found in these assessments will help the team to understand whatskills, strengths and needs the person brings to the work needed to achieve the outcomestatement.



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You may have noticed that we jumped over the first five fields in the Outcome Summary tobegin with the Outcome Statement. That was intentional as the outcome phrase, start andend dates are all determined after the outcomes statement, reasons and concerns aredeveloped and considered. To quickly review these fields:

Outcome Phrase: a non service word or phrase, a tag line, a keyword search that helpspeople to find this outcome statement.

Outcomes are not services and the Outcome Phrase is first identified in the OutcomeSummary. The outcome phrase is related to the desired result in the outcome statement; itidentify what the person wants in their life.

Example: Maria walks to the grocery store in order to buy diet soda and exercise. TheOutcome Phrase could be – grocery store, soda or exercise.



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Outcome Start Date: the date the activity will begin to work toward achieving the outcomestatement. The start date should be realistic to the specific outcome statement and desiredresult what will work for the person in their situation.

Outcome End Date: the estimated date of when the outcome statement should beaccomplished. This should be a best guess of when the team thinks the outcome statementwill be present for the person

Remember that outcome statements identify both the need for change and what is to bemaintained in the person’s life.

If something is working, and makes sense for the individual, the outcome statementremains in place to be sure that something Important To the person remains in thespotlight.

The end date is an estimate from the team on when the outcome statement will beachieved; this could be beyond the current plan year.



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This is additional clarification from ODP on start and end dates that is additional to theinformation provided in the live training.

In HCSIS/LMS (Job Aid for Creating Outcomes), the key terms (start and end dates) areidentified.

Outcome statements start and end dates do not necessarily match service detailsauthorization and annual review dates.



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The two last fields found at the top of the Outcome Summary are:

Actual End Date: the actual date the outcome was achieved. This is not a required field inHCSIS.

ODP further clarifies that if the person has achieved their outcome statement and nolonger wants support to maintain this outcome in their life, the actual end date (not arequired field) can be entered into the Outcome Section. At the time of the fiscal yearrenewal, when no services are no longer attached to the outcome phrase, the outcomestatement can be removed from the ISP.

Has the outcome been successfully accomplished (Yes or No)

Select "Yes" or "No" to indicate whether the outcome has been successfully accomplished.

Note: When initially creating outcomes, this field should be "No." When this field ischanged to "Yes," an Actual End Date should be entered for the outcome.

At the time of the Fiscal Year Renewal, when services are no longer attached to theOutcome Phrase, the Outcomes Statement can be removed from the ISP.



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Let’s look at one last part of the Outcome Summary for Isaac. On the slide is an outcomephrase to include in his ISP. Is there a key word that represents the outcome statement?



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An outcome phrase should be one or two words only. The revised outcome phrase wouldbe Country Music.



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This training started by talking about what matters and we will come back to that as weend.

This is about helping the individuals that you support to have what is important to them; tohave a better quality of life as they see it for themselves; to learn new skills and be healthyand safe.

The Outcome Section of the ISP is where the individual and team work together to makesure that what is important to the person is known and there is a plan in place to achieveand/or maintain the desired result.

Using precise language and following the sequence will assist all of us in the work neededto make it happen. Consistent application of ODP expectations will promote a sharedunderstanding and assist everyone in working more effectively and collaboratively.



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Now that you have completed Part 1, please remember to view Part 2, Outcome Actions inorder to complete this two part series.



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You can submit questions anytime to the Training Mailbox at the address on thisslide. While this mailbox was set up for SC Training questions, anyoneparticipating in this training can use this mailbox to ask a question about theOutcome Section of the ISP.



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This webcast was developed by the Pennsylvania Department of Human Services, Office ofDevelopmental Programs and produced by The Columbus Organization.

Thank you for participating in this lesson.



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