Ready, Set, Goal: Goal-Setting from Start to Finish - NAMI

Ready, Set, Goal: Goal-Setting from Start to Finish - NAMI
Ready, Set, Goal:
Goal-Setting from Start to
Finish
New York City
Family Resource Centers
May 13, 2016
Agenda

Session I: Uncovering Family Needs

Review of March Learning Collaborative
 Approach
 Assessment
 Understanding
 Prioritization
Session II: Translating Needs Into Parent/Youth's Vision, and More!
 Parent/Youth's Vision
 Strengths and Concerns/Needs
 SMART Goals
 Action Plans
 Outcomes

Review of March’s Learning Collaborative

Effective outreach is a strategic process!

A plan that is the same for every family is not an effective plan; a
pitch that is the same for every audience is not an effective pitch.

Select the right organization, identify the right person, and
include the right content.

Pitches should be brief, specific, and genuine.

Focus on values, needs, and goals.
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Descriptions of programs and services can be found in your
folder.
Purpose of the Workshop

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To provide you with the support and tools
necessary to assist a family in translating
their needs into a concrete vision.
To learn how to use the overarching
parent/youth's vision to plan SMART goals,
SMART action steps, and create desired
outcomes for families.
Question

How do we make goal-setting meaningful for
you and the families you serve?
Key Elements of Person-Centered
Recovery Planning
Out
comes
Action Plans
SMART Goals
Strengths and Concerns/Needs
Parent/Youth's Vision
Prioritization
Understanding
Assessment
Approach
Approach
Out
comes
Action Plans
SMART Goals
Strengths and Concerns/Needs
Parent/Youth's Vision
Prioritization
Understanding
Assessment
Approach
Principles of the Approach
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Mutual Respect
Shared Listening
Wise Decision-making
Courageous Conversation
3 Methods of Communicating
The Power of Language
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Language shapes how we see the world.
The words we choose and the meanings we attach to them
influence our feelings, attitudes, and beliefs.
We choose the words we use to describe ourselves, others,
and the world around us.
These choices have a powerful effect on how we view mental
health and people with mental health conditions.
People-first language means we literally put ourselves and
others first in a sentence.

Instead of calling someone “mentally ill,” the more appropriate,
respectful phrase is “a person living with a mental illness.”
Active Listening

In the workplace, listening is used at least 3
times as much as speaking, and four to five
times as much as reading and writing.
What is the Difference between HEARING and
LISTENING?

Hearing: the physical ability

Listening: a skill. Listening allows one to
make sense of and understand what another
person is saying. Listening is active. It
means being alert to and understanding the
meaning behind the speaker’s words.
Barriers to Listening
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Noise
Language differences or accents
Worry, fear, or anger (our emotional
response)
Lack of attention span
Talking over the person
Planning your response
Bias or judgment
How to put the ACTIVE in Active
Listening
1.
2.
3.
4.
5.
Pay attention
Show that you are listening
Provide feedback
Defer judgment
Respond appropriately
Paying Attention
Give the speaker your undivided attention, and
acknowledge the message. Recognize that nonverbal communication also “speaks” loudly.
 Look at the speaker directly.
 Put aside distracting thoughts. Don’t mentally
prepare a response.
 Avoid being distracted by your involvement.
 “Listen” to the speaker’s body language.
What does their body language say to you?
Using Body Language
Humans have more than 700,000 forms of
body language.
Show that You are Listening
Use your own body language and gestures to
show your attention.
 Nod occasionally
 Smile and use other facial expressions
 Note your posture and make sure it is open
and inviting
 Encourage the speaker to continue with short
verbal comments like ‘yes’, and ‘uh huh’.
Reflective Listening
Our personal filters, assumptions, judgments, and
beliefs can distort what we hear. As a listener, your
role is to understand what is being said. This may
require you to reflect back and ask questions.

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Reflect what has been said by summarizing what the
person is saying in your language, “What I’m hearing
is…” and “Sounds like you are saying…”
Ask questions to clarify certain points. “What do you mean
when you say…?” or “Is this what you mean…?”
Summarize the speaker’s comment every so often through
out the conversation.
Focusing Questions
Use focused questions to get a more definitive answer
than you would with an open-ended question.
Example:
Advocate: “Where do you spend most of your day?”
Youth/Parent: “I don’t know – it’s hard to say.”
Focused question: “Okay, let’s take yesterday. Was
that a regular day for you? What did you do in the
morning?”
Focusing Questions #2
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Advocate: What would you like to achieve
through our work together?
Youth/Caregiver: I don’t really know. I want to
do better? I’m just not really sure what you are
asking.
Advocate: Being better, if you were “better”
tomorrow, what would that look like? How would
you know that you are better?
Closed vs. Open-Ended Questions
Close-ended questions invite a yes or no answer.
They begin with Do, Does, Did, Is/Are, Was, Has,
Have, Could, Would, and Will.
Open-ended questions cannot be answered by yes
or no. They begin with: Who, What, When, Where,
Why, and How.
Practice:
Do you work?
Do you have any side effects from the medication you
are taking?
Tip!
If you find yourself responding emotionally to what
someone has said or is saying, say so.
Ask for more information:
“I may not be understanding you correctly, and
I find myself taking what you said personally.
What I thought you just said is…; is that what
you meant?”
Defer Judgment
Interrupting can be a waste of time. It frustrates
the speaker and limits full understanding of
the message.
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Allow the speaker to finish
Don’t interrupt with counter arguments
Sometimes it is appropriate to interrupt in
order to refocus the conversation or to clarify
what the speaker is saying.
Tip!
Interrupt to focus:
 Use the person’s name to get their
attention, and when he/she pauses,
redirect the conversation the issue at
hand.
 I really need to ask…
 Let me interrupt you for a just a
second...
 I think we need to focus on…
 Can we get back to…
 It would really help me to know more
about…
 Any clarifying question: “What do you
mean when you say…?” or “Is this what
you mean…?”
Respond Appropriately
Active listening is a model for respect and
understanding. You are gaining information and
perspective. You add nothing by attacking the
speaker or otherwise putting them down.

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Be open and honest in your response
But give these opinions in a respectful way.
Treat the other person as you would want to be
treated
Assessment
Out
comes
Action Plans
SMART Goals
Strengths and Concerns/Needs
Parent/Youth's Vision
Prioritization
Understanding
Assessment
Approach
Telling a Story Through your
Documentation

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Each record should tell a story about the care that’s
being provided.
Like any other story, the record has a particular
setting and a cast of characters that the “reader”
should understand in order to make sense of the
record.
Even when information is “stored” in various parts of
the record, the record needs to be consistent.
The record is a legal document and
should be a complete unit of information.
The Assessment Process: What Works?
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What is the purpose of the assessment?
What do we gain?
What is included in your assessment?
How do you approach family members during
assessment?
Purpose of the Assessment
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Get information that guides service planning.
Deepen your understanding of the whole person.
Identify areas for growth and opportunities for
change.
Identify strengths, talents, and gifts.
Identify valuable resources and those that haven’t
worked.
Create enthusiasm, confidence, and motivation for
goal achievement.
Reason for Seeking Services
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What brings you here today?
What would you like to change in your life?
What would you like to see happen as a
result of participating in these services?
What else?
Using the FES as a tool to Assess
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The FES is designed to give you some
jumping off points to identify areas that your
parent self-identifies as an area of
concern/need.
Allows you to have a conversation about their
strengths and resources.
Addresses many facets of parenting skills
and styles.
Understanding
Out
comes
Action Plans
SMART Goals
Strengths and Concerns/Needs
Parent/Youth's Vision
Prioritization
Understanding
Assessment
Approach
The Importance of Understanding
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Data collected in an assessment is by itself not
sufficient for planning – only identifies the “what.”
Data must be woven together, explored, and
interpreted in order to gain an understanding of the
person as a whole – identified the “why.”
True understanding is informed by:

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The individual’s understanding
Your professional opinion
An Example…
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The FES may indicate that the parent (Mrs. Bernard) does not
have a good understanding of her child’s problems.
The summary notes: “Mrs. Bernard does not understand her
son’s diagnosis or how the IEP fits in.”
This does NOT reflect true understanding; it merely re-states the
data/facts.
The task is to try to understand WHY Mrs. Bernard does not
understand her son’s problems.
This may take the plan in very different directions.
Let’s BRAINSTORM…
Determining Direction
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Mrs. Bernard is concerned that getting an IEP will label her son
as “different” from his peers, worsening bullying issues.
 Education on the IEP process, skills training in parent advocacy,
youth advocacy services to promote son’s social skills
development.
Mrs. Bernard doubts her son’s diagnosis because while he acts
up at school, he is cooperative and social at church and in the
home.
 Collaboration with faith-based or cultural organizations, education
on mental illness, family-based Action Plans.
Mrs. Bernard does not know how to talk to her son about his
mental health, fearing that he will feel blamed and stop
communicating with her.
 Peer support, communication skills training.
Take it to the Bridge
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Understanding means using the information gained
during the assessment process to come to a
consensus about the current situation.
Only by doing this can we determine what should
happen next.
“This is how I am seeing you and your situation at this
moment. Did I get it right?”
Stages of Change
Stage 1: Not Ready (Pre-Contemplation)
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The family member/youth doesn’t see a real need to change even if
others do.
Stage 2: Getting Ready (Contemplation)
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The family member/youth is beginning to think about and discuss
making a change BUT is not completely convinced that change is
needed.
Stage 3: Ready to Take Action (Preparation)
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The family member/youth understands that his or her issue is doing
more harm than good and determines steps to address issue.
Stage 4: Taking Action (Action)
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The family member/youth actively works to address issue.
Stage 5: Ready to Maintain Gains (Maintenance)
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The family member/youth is ready to take steps to keep from slipping
backwards.
Understanding a Family’s Readiness to
Change
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Assessing a family’s readiness
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Establish a rapport with the family
Understand if their resistance is internal and/or external
Meeting the family where they are
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Understand why a family is not ready to change
Ask yourself: How it has served them to stay in this
situation?
“People do not change because of logic. People only change when they have
an emotionally compelling reason.” – Author Unknown
Understanding Parent/Youth's Vision:
A Motivational Interviewing Approach
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Change occurs naturally and Motivational
Interviewing (MI) mirrors natural change.
When behavior change occurs it is usually within the
first few weeks.
Advocates have a significant influence on goal
dropout, sticking with the plan, and goal
achievement.
Using empathy regularly with your families improves
the family’s ability to change; the absence hinders
change.
Understanding Parent/Youth's Vision:
An M.I. Approach con’t….
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People who believe that they are likely to achieve their
vision do so. When advocates believe in families, families
can begin to believe in themselves!
What people say about change is important. Statements
that reflect motivation for and commitment to change do
predict achievement of their vision, goals and action plans.
Whereas, arguments against change (resistance) produce
less change.
You have the ability to CHANGE the conversation – to
replace argument with motivation.
Ambivalence:
The Dilemma of Change
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Example: “I want to move closer to my mother
and sister so that my children can be close to
their family, but I’m afraid that transferring
schools would be tough on the kids.”
For every goal, there are benefits to changing
and benefits to NOT changing.
Use the Decisional
Balance Sheet!
Rolling with Resistance

Worst case scenario is when WE advocate for change while our
parent/youth argues against it.
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So, if you don’t argue for change, what do you do?
 We do not oppose resistance, we roll or flow with it.
 Remember that ambiguity/resistance is a natural part of goal
setting and achievement.
 Avoid arguing for change.
 New perspectives are introduced but not forced.
 Let the family member/youth be the primary resource in finding
answers and solutions. At the end of the day, they know their life,
themselves, and their situation better than anyone else.
 If we offer solutions, we become the problem solver and the one
responsible for the improvements.
 Resistance is a signal that you need to respond differently.
Example of Rolling with Resistance
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Example:
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Advocate: You haven’t been coming to the parenting class.
I’m really concerned about you.
Parent: I know. The first two classes really helped me. I
know what I’m doing now.
Advocate: It may be that you find the classes take away
time from your life and kids. That the time spent on them
right now is more important than completing the course and
dealing with the consequences with ACS.
Parent: Well, I don’t know if it’s that important. I don’t want
to lose custody of my children or deal with any more issues
with ACS.
Tips for Staying Empathetic
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Understanding change is hard
Show warmth and caring
Try not to argue or be “pushy”
Show family members that you
understand their perspective
Be optimistic, supportive, and hopeful
Adapted from Jonathan Fader, 2014
Prioritization
Out
comes
Action Plans
SMART Goals
Strengths and Concerns/Needs
Parent/Youth's Vision
Prioritization
Understanding
Assessment
Approach
Balancing Priorities in the Plan
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People have multiple needs and goals – need to
PRIORITIZE.
Addressing too many things at one time can:
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Need to balance what is important TO the person
with what the provider thinks is important FOR the
person.
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Make the plan feel fragmented
Dilute efforts
Plan must make room for both perspectives.
Considering time-sensitivity or urgency of different
factors can assist in prioritizing efforts.
Finding the Right Balance
Neglect: Let
participant
do what
he/she wants
Control: Get
participant to
do what I
think is
needed
Parent/Youth's Vision
Out
comes
Action Plans
SMART Goals
Strengths and Concerns/Needs
Parent/Youth's Vision
Prioritization
Understanding
Assessment
Approach
Vision, SMART Goals & Action Plans
Vision
Goal 1
Action Step 1
Action Step 2
Goal 2
Action Step 1
Goal 3
Action Step 1
Action Step 2
Essential Features of Parent/Youth's
Vision
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They are broadly stated and reflect the big picture.
 In the language of your parent/youth
 Always expressed in person’s words using “I” statements.
 Is written in the notes.
 Moves toward the positive – “glass half full”
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Achieve rather than reduce – “glass half empty”
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“I want to have a better relationship with my kids.”
“I don’t want to argue with my kids.”
Parent/Youth's vision is linked to “discharge” criteria
 Identify the desired destination and what the destination looks
like.
Where the Vision Goes in eCOMPAS
Vision Development – It’s a Process!
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Not everyone can easily articulate their vision
– the process takes time!
It will unfold through reflective listening that
highlights what’s important to the person.
People are often ambivalent about their
vision.
Effective Parent/Youth's Vision
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Meaningful to the individual
Easily understood by any reader
Broad enough that all of the work you do together will fit into this
idea but not so broad that it will take years to achieve (similar
idea as prioritization).
 Example of Too Broad: “I want my daughter to become an
astronaut.”
 Example: “I want to be able to support my daughter to graduate
with her High School Diploma” (still working towards to idea of
becoming an astronaut but the first major vision in achieving that
overly broad vision).
 Example of not broad enough: “I want to support my daughter to
go to school every day next week”.
Strengths and Concerns/Needs
Out
comes
Action Plans
SMART Goals
Strengths and Concerns/Needs
Parent/Youth's Vision
Prioritization
Understanding
Assessment
Approach
Strengths and Concerns/Needs in
eCOMPAS
Strengths and Supports: What Works?
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How do you ask about strengths?
How do you identify strengths a family
member may not know they have?
Active Use of Strengths
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Strengths are not meant to “sit on a shelf”
How are strengths used in recovery
planning? For example:
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A youth who loves music might benefit from
listening to music with headphones as a way to
relieve anxiety on the subway.
A parent with strong family supports might have
family members assist her with grocery shopping
and learning to cook healthy meals.
Strengths and Supports
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“Tell me about the important people in your
life.”
“What are you good at?”
“What activities give you a sense of
accomplishment?”
What else could you ask?
Identifying Concerns/Needs:
What Works?
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How do you ask about concerns and needs?
Identifying Concerns/Needs
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“What has created challenges in achieving
your vision?”
“What have you tried in the past to address
these concerns?”
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Both what DID and DID NOT work
Ask yourself: What’s keeping them stuck?
Concerns/Needs
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Challenges/roadblocks experienced as a
result of family circumstances.
What is getting in the way of the person
achieving their goal?
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Why can’t they do it tomorrow?
Why can’t they do it themselves?
Why haven’t they already done it?
How are roadblocks getting in the way of
identifying and achieving your parent/youth's
vision?
Putting it Together

Capitalizing on strengths and accounting for
concerns/needs illuminates how you will
achieve an identified goal, which leads to…
SMART Goals
Out
comes
Action Plans
SMART Goals
Strengths and Concerns/Needs
Parent/Youth's Vision
Prioritization
Understanding
Assessment
Approach
SMART Goals in eCOMPAS
SMART Goals
S = Simple, straightforward, specific
M = Measurable
A = Attainable, action-oriented
R = Relevant (to goal and stage of change)
T = Time-bound
Effective SMART Goals
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Meaningful to the individual
Easily understood by any reader
Effective in tracking progress
Encourage the person to try new skills
Contains ONE behavior that works toward
achieving the vision.
Formula for SMART Goals
Within [amount of time (time-bound)], [insert
name] will have improved [insert
documented concern/need (relevant)], as
evidenced by [insert a meaningful
change in functioning or behavior that is
related to the vision (measurable and action
oriented)].
Measurability
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The intended change should be obvious and
readily observed by the individual and the
family, as well as the staff.
It is acceptable to measure change by
observation, self-report, and/or completion of
an assignment.
Journals, behavior charts, etc.
SMART Goals Should NOT be Limited to
Service Participation
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Ann will attend the parenting class 1x weekly for 12 weeks.
 This is about service participation. People can participate in
services for years and not achieve the intended benefits.
SMART Goals are what the person hopes to change with the
assistance of services. Ask yourself the question: As a result of
attending the parenting class, how do you expect the parent’s
behavior/quality of life/status to change in a measurable way?
 Ann will apply communication techniques to reduce instances of
arguing with her son to no more than one time per week for four
consecutive weeks, as measured by self-report.
Sample SMART Goals
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Over the next 3 months, Kris will reduce his social anxiety by
attending at least one social event per week for 30 minutes with
a family member, as measured by self-report.
Over the next 30 days, Kris will experience a decrease in anxiety
when talking to people at social events, as evidenced by his
tracking of anxiety levels in his mood log.
Within the next 3 months, Kris will try 3 different types of social
events that fit his needs and report progress toward
independently meeting new people through his advocate’s
monthly report.
Common Mistakes When Writing SMART
Goals
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Describing what the advocate is expected to do instead of what
the individual is expected to do.
Including more than one expected behavior in a single SMART
Goal.
Using terms for performance that are subjected to many
interpretations, are not action-oriented, and are difficult to
measure.
Writing SMART Goals that do not relate to the vision.
Cluttering a SMART Goal by including unnecessary information.
Being too general and not clearly specifying the expected
outcome.
Using general verbs or action words such as “understand” –
instead, use concrete verbs such as “demonstrate,” “discuss,”
“participate,” etc.
Detail: SMART Goals
Make Goals SMART…
Specific
SMART Goals are more easily accomplished when
they are clearly stated. Answering the 5 W’s – who,
what, when, where, and why – is helpful in setting
specific goals.
Measurable
Establishing concrete criteria for measuring progress
can help motivate continued effort to achieving the
goal. How will we know when the goal is
accomplished?
Attainable
The goal should be reasonable and achievable.
Trying to do too much in too little time is not the best
way to succeed.
Realistic
A goal is probably realistic if the person believes that
it an be accomplished. To be realistic, a goal must
represent something a person is willing and able to
do.
Timely
Goals are more grounded when there is a time frame
attached to them. Identifying short-term steps within a
longer term goal can help to create hope and
momentum.
Practice, Practice, Practice

Turn these 3 Goals into a SMART Goal:
 Gloria will get an IEP for her daughter.
 Erica will argue less with classmates at school.
 Jesse will take a parenting class so that he is
closer to his family.
Within [amount of time], [insert name] will have
improved [insert documented concern/need], as
evidenced by [insert a meaningful change in
functioning or behavior that is related to the vision].
Action Plans
Out
comes
Action Plans
Objectives
Strengths and Concerns/Needs
Parent/Youth's Vision
Prioritization
Understanding
Assessment
Approach
Action Plans in eCOMPAS
Action Plans aka Services


Action Plans serve as a contract for who is
responsible for what actions, including the person
receiving services and natural supports, that is,
supports that they already have in place.
Action Plans include services which:

Are tailored to the stage of change/recovery

Are connected to a specific objective
Action Plans from natural supports are not services.


Describe medical necessity by clearly identifying how
recommended services can help the individual overcome
specific concerns
A Note from Our Sponsors…
 Medical Necessity
“…shall mean payment of part or all of the cost of medically necessary services, as
authorized by Medicaid, which are necessary to prevent, diagnose, correct or
cure conditions in the person that cause acute suffering, endanger life, result in
illness or infirmity, interfere with such person’s capacity for normal activity, or
threaten some significant disability and which are furnished to an eligible person
in accordance with this title and the regulations of the department.”
What????
In plain English, it means that your services have to be described in a way
that prove they should help your parent/youth achieve their goal while
also connecting with the overall vision.
Action Plans aka Services


Action Plans serve as a contract for who is responsible for what
actions, including the person receiving services and natural
supports, that is, supports that they already have in place.
Action Plans include services which:
 Are tailored to the stage of change/recovery
Describe medical necessity by clearly identifying how
recommended services can help the individual overcome
specific concerns
 Are connected to a specific objective
Action Plans from natural supports are not services.


Client’s Vision:
“I want to create a better lifestyle
for my son and me.”
Goal 1:
Goal 2:
Within one month, Celia will improve her
chances of getting a full-time job by applying
to at least 5 jobs per week, as evidenced by
copies of completed and submitted
applications to her family advocate.
Within 3 months, Celia will improve her
relationship with her son by identifying at least
3 methods for setting healthy boundaries with
her son, as evidenced by report of Family
Advocate.
Action Plan:
Family Advocate will hold 15-minute
check-in calls once a week (in addition to
regular meetings) for the next month in
order to discuss job search, application
completion, and provide support.
Action Plan:
Celia will attend Emotional Fitness
Parenting Class once weekly for the next
12 weeks in order to learn new skills in
discipline and boundary-setting.
Activity!
Goal vs. Action Plan
Service Action Plans – 5 Ws

Must specify:

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WHO will provide the service, i.e. name and job title
WHAT: The NAME of the service, e.g., basic living skills
training, AND the modality in which the service will be
provided, e.g., individual sessions or in group
WHEN: The SCHEDULE of the service, i.e. the time and
day(s)
WHERE the service is being provided
WHY: The intent and purpose of the service/intervention
Tip


Read plan from the bottom to the top
Is it clear why THIS service is being provided
in response to THIS SMART Goal that
connects to achieving the Parent/Youth’s
Vision?
Examples

Examples of Service Action Plans:




Taking Parenting Class
Attending Youth Group
Participating in individual advocacy sessions
Examples of Self-Directed and Natural Support
Action Plans:


Asking trusted family member for assistance with child care
Gathering all documents and records needed to apply for
benefits
Common Documentation Errors

SMART Goals





Don’t support the vision
Not measurable or behavioral
Action Plans become SMART Goals
Not time-framed or generically time framed
Action Plans





Purpose not included
Frequency, intensity, and duration not included
Don’t reflect multidisciplinary activity
Don’t include natural supports
Don’t link to the goal
Quick Review




Parent/Youth's Vision:
 What the person would ultimately like to achieve
 The desired outcome
SMART Goals:
 What the person will do, change, or accomplish to achieve Vision
 Measurable changes the person will make and skills to be gained
Action Plans:
 Services and supports that help person achieve Parent/Youth's
Vision and SMART Goals
 Not limited to providers; may include actions by person, family
members, and support network
Remember, services are not SMART Goals!
Outcomes
Out
comes
Action Plans
Objectives
Strengths and Concerns/Needs
Parent/Youth's Vision
Prioritization
Understanding
Assessment
Approach
Outcomes




Identified and agreed-upon end point for services
Individual’s needs and likely destination at discharge plays a
critical role in determining the anticipated length of stay
 For example, someone who has just moved into a new apartment
might have a shorter length of stay than someone who has not
yet identified their options and preferences for housing
Anticipated discharge or transition shapes the individual’s plan
Shift from “complete the program” to “achieve Parent/Youth's
Vision”
Documenting Progress Over Time




Provides an opportunity for the family
member/youth and advocate to evaluate how
things are going on a regular basis and
document the continued medical necessity of
the services being provided.
Progress notes can be considered a mini
plan review
Contact notes are not progress notes
Service Plan reviews
Following up on Progress

Questions to ask the family when revisiting
Parent/Youth's Vision (Open-ended
questions are helpful)





Why did we set this goal?
What is keeping you from completing this goal?
What steps will it take to complete this goal?
Who can help you?
How can your FRC staff help you?
Next Learning Collaborative




We will be reviewing what we learned in this
LC.
Identify areas that were particularly
challenging and trouble-shoot as a group.
Plus: learn how to write effective progress
notes (documenting progress or lack of
progress over time).
Practice, Practice, Practice!

Documentation and role play practices
Thank you!
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