The Individual Service Plan (ISP) is a formal, individualized document that functions as a roadmap for individuals receiving support services in settings like long-term care, developmental disability services, or behavioral health programs. This plan details the specific supports an individual needs to achieve their personal life goals and maintain health and safety within their community. Its purpose is to ensure that all services are coordinated, appropriate, and delivered in a manner consistent with the person’s preferences and desired outcomes. The ISP effectively serves as a contract between the individual, their support team, and the funding or authorizing agency.
Person-Centered Focus
The defining characteristic of an Individual Service Plan is its foundation in person-centered planning (PCP), a philosophy that places the service recipient at the center of the process. This approach moves beyond simply addressing deficits or medical needs to focus on the individual’s strengths, preferences, dreams, and desired quality of life. The individual is empowered to have maximum choice and control over the services they receive, making their personal vision the driving force for the entire plan.
The planning process works to identify what is “important to” the individual, such as their relationships, community involvement, interests, and culture, alongside what is “important for” them, which includes health, safety, and necessary supports. When possible, the individual directs the planning process, and their preferences guide the entire team. The team, which may include family, friends, advocates, and various professionals, is chosen by the individual to ensure a comprehensive understanding of their life and goals.
The focus extends to ensuring services are provided in the most inclusive setting possible, promoting community integration and independence. This philosophy also emphasizes identifying a person’s capacity and strengths, rather than dwelling only on challenges or disabilities, to build a plan that supports a fulfilling life. The individual’s right to make informed choices, including taking appropriate risks, is honored throughout the planning process and documented in the final ISP.
Defined Goals and Service Specifications
The philosophical input gathered through the person-centered planning process is translated into the mandatory written components of the ISP, which must be clearly structured and highly detailed. The goals within the ISP must be measurable, observable, and time-bound to allow for objective tracking of progress. Professionals often use criteria similar to the Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) framework to ensure goals are meaningful and clearly defined.
A well-written goal will specify the conditions under which a skill will be demonstrated, the target behavior, and the criteria for acceptable performance, such as achieving 90% accuracy over three consecutive trials. For example, instead of a vague statement like “improve communication,” the ISP will specify, “The individual will verbally request a preferred activity once daily for four consecutive weeks”. This level of detail ensures all support staff understand what success looks like and how to document progress consistently.
The service specifications section of the ISP outlines every service, support, and activity required to achieve the goals. This documentation includes the frequency and duration of the service (e.g., “3 hours of community support per week”), the location where it will be delivered, and the specific provider or agency responsible for its delivery. The written plan also includes a mandatory risk assessment that identifies potential health, safety, or environmental risks, along with corresponding mitigation strategies.
Required Review and Revision Cycle
The Individual Service Plan is characterized as a “living document” that requires frequent and mandatory review to remain relevant to the person’s current life. Regulations typically require a formal, comprehensive review and re-authorization of the entire ISP at least once every twelve months, often referred to as the annual review.
Beyond the annual cycle, the ISP requires regular monitoring, often mandated every quarter or semi-annually. The individual’s support coordinator is responsible for continuously monitoring the appropriateness of services and ensuring that desired outcomes are being met. The plan must be formally revised whenever circumstances change significantly, such as when a person’s health condition shifts, a goal is met, or the team determines a service is ineffective.
Revisions are necessary to update the plan’s components, which may involve modifying the type or amount of services provided. The review and revision process is essential for maintaining compliance with funding and regulatory requirements. Documentation of these reviews, even if no changes are made, must be signed and dated and retained in the individual’s record.