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Initial Service Plans are extremely important. They are the global service plan that you create with your resident/member/client. Please be sure to reread the section of the Case Management Procedures that addresses ISPs, plus the Supplemental Notes on how to create an Initial Service Plan. Both are attached.

One way to think about Progress Notes is that they are a recap of your interview with the client (the PNs contain the “why” of what you are doing). They are followed up by your ISP, which contains the goals and actions (the “what”), “who” is responsible for each action, and the timeframe (the “when”).

ISPs are required to be created within the first 30 days of working with a client. If you did not create an ISP, you can write a retroactive ISP.  The best practice to follow is to write with a pen on the PN immediately following your assessment, “see ISP on ‘x’ date”. Clearly label the ISP “Initial Service Plan in your PNs, dating it the ‘x’ date you write it (not the date you should have written it). That way you’ll be able to find it in your case file. It helps to also highlight it with a highlighter.

5. Initial Service Plan

• The “initial service plan” is noted on the Progress Note as “Initial Service Plan” in a heading and attached to the initial Service Log and then printed for the paper case file copy.
• Service Logs, after the “initial service plan”, are only required to be printed and maintained in the paper copy file when a new ADL and assessment are completed or at least once a year when the annual “updated service plan” is done.
• The service plan identifies the tasks required to complete the plan, the person responsible for each task or step, a proposed time frame if appropriate, and specific follow-up that is required.
• The initial service plan will identify any ADL requiring assistance and address the plan for managing the ADLs, including who is helping the resident/client, what is the plan for those ADLs needing assistance as well as the plan to monitor the person’s care.
• The initial plan should also address any immediate needs identified by the applicant for service as well as any additional assistance that might be offered.

Supplemental Notes on Creating an Initial Service Plan and Updated Service Plan

These notes augment the procedures for the Initial Service Plan and Updated Service Plan contained in sections 5 and 6 of the Service Coordination Case Management Procedures.

For additional guidance on creating a service plan, please refer to the NASW Standards for Case Management found at http://www.socialworkers.org/practice/standards/sw_case_mgmt.asp

Creating an Initial Service Plan

1. Goals and Tasks of the Initial SP are based on:
   1. Client’s personal and capacity building goals
      1.                                                                i.      The SP must include an intervention (task/resource/goal) based on the primary reason the client chose to seek services from the Service Coordinator (SC).
      2.                                                              ii.      The SP may also include an intervention based on the highest priority need(s) the SC and Client have identified during the interview process.
2. The Client Assessment and ADL Assessment
   1.                                                                i.      If the Client has challenges meeting one or more activities of daily living (ADLs), the SP must identify the ADL requiring assistance and the planned intervention.
   2.                                                              ii.      The SP may also address interventions based on other needs/interests identified in the Intake and Assessment (ie increasing family supports, linking client with socialization opportunities, completing a Medical Directive or Will as appropriate, etc)
3. The SC’s professional selection (in concert with the client) of interventions
   1.                                                                i.      The SP will reflect the availability and appropriateness of the service network and resources within the client’s area.
   2. Responsibilities for achieving goals and tasks of the Initial SP include:
      1. All activities must include the person or entity responsible for completing them.
      2. Ideally the SP includes activities that the client is responsible for following through with in order to promote activities that encourage client self-sufficiency.
      3. If the client is frail or at risk as identified by their ADL Assessment, the plan must include who is responsible for helping the member with each of the identified ADLs needing assistance as well as the plan for monitoring the person’s care. This includes ADL assistance the client may have already been receiving prior to working with the SC. The SP may identify family, agency and assistive technology assistance the client will continue to receive, but then the SC will be responsible for monitoring that the client continues to receive the services and that they are adequately meeting the client’s needs.
      4. If the activity is the responsibility of the SC, it should be labeled as such.
      5. Time frame for completing goals and tasks of the Initial SP:
         1. Long term goals and tasks. This is the strength of the Initial SP, because this SP is the primary long term plan for the client/SC relationship. Examples of long term goals/tasks may be:
            1.                                                               i.      SC will work with client to monitor client satisfaction and needs addressed by home chore services on a monthly basis. This will be reassessed on an annual basis.
            2.                                                             ii.      SC will invite client to educational workshops related to chronic health conditions (approximately quarterly). Client will work to attend 2 per year.
            3.                                                           iii.      SC will work with client and daughter/guardian to mediate differences in how care is provided through quarterly and “as needed” family conferences.
4. Short term goals and tasks. These short term goals and tasks may include:
   1.                                                               i.      Finite goals, such as assisting client with applying for a new State ID within two weeks.
   2.                                                             ii.      Short term steps in achieving longer term goals, such as client will talk with daughter to find a mutually agreeable time within the next 10 days to meet with the SC regarding a disagreement in care.
   3. Changes and Updates to the Initial SP are covered in the Updated Service Plan.
      1. The SP is updated whenever there is:
         1.                                                                i.      A significant change of circumstances for the client
         2.                                                              ii.      A reassessment (ie after hospitalization or rehabilitation)
         3.                                                             iii.      Annually
5. Between Updated Service Plans, there should also be a “Plan” at the end of every Progress Note. This Plan will include the basic information contained in the Initial or Updated Service Plan (ie what the next step(s) are, who is responsible for them, and in what time frame), but can be limited to the direct issue the client is working on at the moment.