D. Development of the ISP
The development of the ISP is a complex process and a key responsibility of the SC. The development of the ISP begins upon acceptance of the applicant by his/her chosen Service Coordination provider.
All Service Plans must be person-centered and support the applicant's dignity, right to take risks and the right to fail while maintaining his/her health and welfare living in the community. Through direct interview and assessment, the SC must be able to acquire information needed to build an individualized and comprehensive plan. To accomplish this, multiple visits with the applicant by the SC may be required. The applicant may choose to include family, friends and others he/she selects to participate in the process. If the individual has a legal guardian he/she are present for the ISP development. (Refer to Section II -Becoming a Waiver Participant).
The Service Plan must reflect the applicant's strengths and abilities. It details all of the services and supports (e.g. informal supports such as family and friends) necessary to maintain the applicant in the community and prevent institutionalization, and the coordination of these services and supports. As information is collected for the Service Plan, the SC taking into account the efficiency of service utilization, must determine whether services are available through informal supports, non-Medicaid local, state and federally funded programs, Medicaid State Plan services, and/or waiver services.
The SC must collaborate with Local Department of Social Service (LDSS) staff to have an understanding of the applicant's history, if any, of participation in Medicaid State Plan community-based services or adult protective services. This collaboration will further the SC understanding of the strengths and needs regarding the applicant's health and welfare if he/she is approved for the NHTD waiver.
The SC discusses the need for non-waiver options with the applicant to assure appropriate referrals are made. If the applicant is already receiving non-waiver services with the anticipation of continuing them if approved for the NHTD waiver, the SC must obtain appropriate information from and regarding each of these services for inclusion in the ISP.
If the applicant's ISP indicates the need for Home and Community Support Services, Assistive Technology, Community Transitional Services, Environmental Modifications, and/or Moving Assistance the Service Coordinator must obtain, complete, and attach all applicable supporting documentation (e.g. HCSS assessment tools).
The SC works with the applicant to establish what services are needed. Upon selection of waiver service providers by the applicant, the SC is responsible to contact each waiver service provider to assure the availability and ability necessary to provide the service(s). In addition, the SC coordinates the inclusion of non-waiver services. The SC must work collaboratively with the applicant, NHTD and non-waiver providers and others to prepare the most accurate and complete Service Plan for submission to the RRDS. Open communication assists the SC in establishing a projected weekly schedule of all services (including days, times and who will provide) with input from the applicant. The schedule also includes the availability of informal supports.
Once the ISP is reviewed with/by the applicant, he/she is asked to sign the document indicating understanding of its contents and purpose as written. The SC then submits the completed ISP as part of the Application Packet to the RRDS for review (refer to Section II - Becoming a Waiver Participant).
Service Plans are expected to evolve as the participant experiences life in the community, requests revisions, experiences significant changes in his/her condition, or as new service options become available.