Building the Path to Home

Individual support planning

Individual support planning is a process used in the developmental services sector in many programs. It refers to the regular planning and monitoring needed to ensure that a person's needs are being met. A comprehensive individual service support plan looks at all areas of support identified in the Support Services section.

Many people and organizations may be involved in helping a person find housing and in supporting a person while he or she waits for housing. Someone has to take the lead to co-ordinate the individual support plan. This will likely be the case manager, if the person has one.

The planning format we have provided (Integrated Support Planning Tool) suggests that someone needs to be responsible for each identified activity.

Both developmental services and mental health agencies prepare individual support plans, but they use different names to describe them:

• hospitals call them "treatment plans"
• shelters call them "case plans"
• community agencies call them "support plans," "recovery plans," "rehabilitation plans" or "community support plans."

A person who receives services from a program or worker in the developmental services sector—such as a day program, residential program, adult protective service worker or family support worker—will have an individual support plan. Ask about it.

An individual support plan should include a crisis plan (Crisis Prevention and Management Tool).

Organizing a planning session

An individual support planning session is an open process of identifying needs and support requirements, negotiating roles and clarifying mutual expectations. You may want to include:

• at least one family member
• a friend or a past worker
• a housing support worker
• a mental health support worker
• a developmental services support worker
• a specialized dual diagnosis support worker
• a legal or financial worker
• a doctor or nurse practitioner
• a member of a the person's community (e.g., a cultural or disability group), if appropriate
• a member of the person's faith community, if appropriate.

Work with the person to make a list of trusted friends, family members, and past and current support people.

Identify which areas of need/functioning are covered and which are not. Think about:

• mental health assessment/monitoring (outpatient or community caseworker, psychiatrist)
• community/adaptive functioning (developmental service worker)
• housing supports (family, group home worker, shelter worker)
• crisis supports (Griffin Community Support Network or a mobile crisis team)
• medical needs (nurse or doctor)
• other clinical issues (psychologist, behaviour therapist, speech and language therapist, occupational therapist)
• day activities (vocational worker)
• community supports (case manager, staff from a club or recreation program)
• social supports (family, friends).

Depending on your role in this group, decide who should call the meeting. For example, if you need to make sure there is clinical or psychiatric input, you might call on a health care worker, rather than a family member or shelter worker, to co-ordinate the meeting. You want those who attend to be able to make decisions on behalf of their agency and commit to specific roles and activities agreed upon by those at the session.

Ask people to share their experiences of working with the person and their perspectives on the issues. Use the Personal Information Sheet to record past strategies and relevant information.

Develop a clear meeting agenda with a statement of the issues, needs and outcomes that you want to discuss. Identify a facilitator who can keep the discussion on track.

Make sure that there is a specific strategy in place to support the current housing and support situation and/or move along the path to stable housing. You may need to consider an interim plan (e.g., encouraging the person to join a day program while he or she is living in the shelter or boarding home to increase daily structure and develop relationships during the waiting period). Use the waiting period to get the person ready for a change in housing.

Use the Integrated Support Planning Tool to make sure each person is clear about what he or she has agreed to do. Send everyone a copy of the completed form. (Make sure the person, or his or her substitute decision maker, agrees to this.) Arrange a follow-up meeting. Identify people who can provide any additional expertise/support you will need at this meeting.

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