A. Types of Service Plans
The following is an explanation of the different types of Service Plans used in the NHTD waiver.
1. Initial Service Plan (ISP)
The ISP (refer to Appendix C - form C.1) is developed when an individual is applying to become a waiver participant. The ISP is a collection of personal, historical, medical/functional and social information about the applicant gathered through interview and assessment of the individual by the Service Coordinator (SC) and others. It is the primary component of the Application Packet (refer to Section II - Becoming a Waiver Participant). The ISP provides justification for the individual's participation in the NHTD waiver. It describes the reason NHTD services are needed to assure the individual's health and welfare while in the community.
The focus of the ISP is on the individual, reflecting his/her choices and needs that support the individual's health and welfare while in the community. This includes information regarding significant relationships, current informal and community supports, desired living situation, and recreation or community inclusion-time activities. The ISP must also contain a description of the individual's strengths and limitations, including any cognitive, behavioral or physical concerns.
The ISP also details services necessary to maintain the individual in the community. A description justifying why the services are needed to allow for transition from a nursing home into the community or to prevent nursing home placement from occurring is also included. For an applicant presently in an institution, the ISP must include current assessments and/or summaries of all services provided by the facility, including relevant medical reports.
2. Revised Service Plan (RSP)
The RSP (refer to Appendix C - form C.13) is developed through a collaborative effort between the participant, individual(s) selected by the participant to participate in the development of the RSP, the SC, current NHTD waiver service providers, non-waiver providers, and others as appropriate. The focus of the RSP remains on the individual, reflecting his/her needs and choice of services that continue to support safe and successful community living.
The RSP is required in the following situations:
- At least every six months, if the participant chooses to continue waiver services;
- When a participant is absent from the community (e.g. extended institutionalization) where upon return to the community the individual's needs have significantly changed, requiring revision of the Service Plan;
- Any time there is a need for a significant change in the level or amount of services (e.g. a decrease/increase in the participant's abilities, a change in the participant's living situation, a participant wants to make a significant change in his/her Service Plan, or there is a major change in the availability of informal supports); and
- When a participant relocates from one region to another.
The RSP must contain a review of the participant's previous months in the waiver and identify the plans and goals for the next six (6) months. The RSP details services necessary to maintain the individual in the community and prevent nursing home placement.
3. Addendum to the Service Plan
The Addendum to the Service Plan (refer to Appendix C - form C.15) is developed by the SC in collaboration with the participant and individual(s) selected to participate in the process and specific service provider(s) when there is only a minor change needed in the amount, type, or mix of waiver services to an existing Service Plan. (e.g. a participant wishes to increase/decrease the amount of time at a Structured Day Program)