The acronym ISP stands for Individualized Service Plan (or Individual Support Plan) within behavioral health, developmental services, and long-term care. This document functions as a personalized roadmap for individuals receiving services, outlining their specific needs, goals, and the support strategies required to achieve a desired quality of life. The ISP is a formal, federally and state-mandated document that guarantees the delivery of specific, agreed-upon services. It signifies a person-centered approach prioritizing individual preferences over standardized treatment models.
Defining the Individualized Service Plan
The Individualized Service Plan is a comprehensive, written plan that replaces or enhances traditional, clinically focused treatment plans. This shift emphasizes support and rehabilitation over solely treating symptoms, particularly for individuals with intellectual/developmental disabilities or serious mental illness. The plan coordinates all services an individual receives, ensuring they are integrated and working toward common, person-defined outcomes.
The ISP is used across various settings, including community support programs, residential facilities, and for individuals receiving home and community-based services (HCBS) waivers. It serves as an operational and fiscal document, providing prior authorization for the type, amount, and duration of funded services. Focusing on strengths rather than limitations, the ISP helps maximize functioning and life satisfaction. The plan ensures the individual has access to specialized support necessary to remain safe, healthy, and actively engaged within their community.
It is designed to be a “living document,” adapting to the individual’s changing goals, needs, and circumstances over time. This adaptability is essential because personal preferences, health status, and life aspirations naturally evolve. Built on person-centered planning, the individual’s choices and desires are the primary consideration in all decision-making. The ISP ultimately empowers the individual, allowing them to exercise greater control over their life and support journey.
Essential Elements of an ISP
The content of an ISP provides a detailed account of the individual’s path to achieving personal outcomes. The document begins with a comprehensive functional assessment that identifies the individual’s current status, including strengths, preferences, and support needs. This initial section provides context for all subsequent planning, often including medical history, communication styles, and existing support networks.
The core of the plan is the articulation of measurable goals and desired outcomes, which must align with the individual’s stated aspirations. These long-term goals are broken down into specific, short-term objectives that are actionable and time-bound. For example, a goal of “increasing independence” might be translated into the objective of “learning to prepare three simple meals per week within six months”.
Following the objectives, the ISP details the specific services, supports, and interventions provided to meet each goal. This includes formal services like therapeutic interventions, skills training, and behavior support consultation, as well as natural supports from family and community members. The plan specifies the frequency, duration, and provider responsible for delivering each service, creating a clear schedule of support.
The ISP also includes mandated components for health and safety, such as outlining significant health or behavioral needs and related maintenance plans. It must include provision for emergency back-up planning, identifying contacts and action steps to ensure continuity of care if a primary provider is unavailable. Finally, the document addresses the individual’s rights, choices, and decision-making capacity, ensuring preferences are respected and incorporated into their daily routine.
The Collaborative Process of ISP Development
The creation of an Individualized Service Plan is a collaborative, team-based process that puts the individual at the center of the discussion. This process begins with the initial assessment and information gathering, collecting input from the individual, family members, and other people who know them well. A dedicated service or support coordinator often guides this initial phase, ensuring all relevant life experiences, history, and preferences are considered.
The development involves an interdisciplinary team (IDT) that includes the individual, family members, clinical staff, direct support professionals, and other relevant specialists. The team meets to engage in shared decision-making, translating the individual’s aspirations into the formal goals and objectives of the written plan. This inclusive approach ensures the plan is comprehensive and culturally competent, reflecting a holistic view of the person’s life.
Once the plan is finalized and agreed upon by the team and the individual, it moves into the implementation phase where services and supports are put into action. The ISP is not static; it requires continuous monitoring and regular review to ensure its effectiveness and relevance. Reviews are often scheduled quarterly or semi-annually, with a new comprehensive ISP typically completed at least once a year.
The individual and their family have the right to request a team meeting and plan update at any time if needs or circumstances change. This ongoing evaluation is important for tracking progress on objectives and making necessary modifications to the services or goals. The success of the ISP relies heavily on this alliance between the professional team, the individual, and their caregivers.