Leading Practice Guidelines

Support Plan Documentation

Type: Voice

Guideline: The organization solicits and documents information from the person, their family and support and social network on the best way to support the person. This information is shared with those responsible for providing services so that they are equipped with and are guided by the wishes and needs of the person.

What does this look like?

The organization completes a personal or individual support plan for each person served that:

• Is built by and with the person, their family and support and social network
• Identifies the support needed by the person in a range of areas in order for them to be as independent and/or actively involved as possible.
• Captures the goals, preferences, needs, strengths, abilities, and wishes of the person on how best to support them going forward.
• Contains information that may have been received from health care providers, clinical consultants, etc., as guided by the person.
• Is informed by the results of person centred planning processes, personal outcome measure interviews and any specific assessments that the person may have received.
• Integrates information from other specific plans or protocols such as behaviour support plan, health care protocols, etc.
• Documents important historical milestones and events for the person so that key features of their story are not lost.
• For privacy or sharing purposes, the person may wish to break the document into specific areas or separate plans.
• Includes goals related to the person’s preferences and routines of daily living.

People are consulted with and participate in the development of a comprehensive support plan, in consultation with their families and support network. The written personal plan is kept in their personal file. These are prepared before people begin receiving services or as soon as possible after service begins. People served or the Substitute Decision Maker, along with those they delegate, receive a copy of the plan and provides ongoing input to ensure it remains up to date.

Personal support plan should include details about the needs, strengths and supports needed in the area to be as independent or actively involved as possible. While topics are guided by the unique circumstances surrounding each person and the types of supports the organization is providing to the person, the support plan should consider the following areas (in no particular order):

• One Page Profile – summarizing major points of Support Plan
• History/Story
  • What is the person’s story? What is the important history that shapes who the person is today?
  • Where did they live in the past? With whom?
  • Past struggles and joys that they want their support team to be aware of.
• Rights & Responsibilities
  • What awareness and knowledge does this person have of their rights and responsibilities?
  • What information and education do they need to enhance their knowledge and skills in this area?
  • Are any rights restricted? Why? What is the plan to eliminate or reduce this restriction? Include specific rights restriction review documentation if available.
• Decision Making
  • What support does this person need to make decisions, if any?
  • Who are the people who provide formal or informal support in this area?
• Self-Direction/Advocacy
  • How does the person express and advocate for themselves?
  • What support do they require to advocate?
  • Do they currently or want to in the future, access advocacy services or peer mentorship?
  • Name and contact information of advocate, if applicable.
  • Community resources used or needed.
• Relationships/Connection
  • Who is important to the person?
  • What is or where is the important information about these important people (i.e. contact information, birthdays, desired frequency of contact, etc.)?
  • What support and assistance does the person need to develop or maintain relationships?
  • Strategies to address barriers
  • Community resources used or needed
• Inclusion
  • Does this person know or want to know their neighbours? Do they need support to interact or connect with them?
  • How does the person access and participate in their neighbourhood, preferred communities or city/town? What support do they need to do so?
  • What community groups, special interest communities or organizations does this person want to be involved in? Do they require support to do so?
  • Strategies to overcome barriers
• Employment/Meaningful Contribution
  • What are and how is this person being supported to achieve their employment goals?
  • If employment is not their goal, how do they wish to contribute and spend their time (e.g. volunteerism, healthy lifestyle activities, etc.)?
  • What community resources or supports does the person use or need in this area?
  • Strategies to address barriers.
• Education and lifelong learning
  • Goals, dreams and wishes
  • Community resources used or needed
  • Strategies to address barriers
  • Transportation/Getting Around
  • How does the person get around their community? Are there barriers?
  • What support do they require to successfully access transportation?
  • Strategies to address barriers
  • Community resources used or needed
• Financial/Material Wellbeing
  • Supports required to be as independent or actively involved
  • Income/Expenses – does the person have enough income to meet their needs, and if not, what strategies could increase or reduce the gap between their needs/desires and the availability of funds to meet those needs?
  • Status of financial planning/budgeting – who does what?
  • Community resources used or needed
  • Strategies to address barriers
  • Communication/Language
  • How does this person communicate? What support do they require to maintain, enhance or initiate this?
  • What training or information do staff who support them require to understand, interpret or facilitate this communication?
  • Does the person use or want to use any assistive technology in order to enhance their ability to communicate.
  • Strategies to address barriers
  • Community resources used or needed
  • Fun & Recreation
  • What does the person like to do for fun, what do they not like to do
  • What support does the person require to participate in their preferred activities or to try new ones?
• Independent Living/Daily living
  • What support does the person need to get through their day?
  • How do they want that support to be provided?
  • How do they direct that support or communicate when they want changes to the way their day is going?
  • Does the person require personal or intimate care during bathing, dressing, toileting, or personal hygiene? How is this best done? Who, how and when do they prefer this is provided? What specific information or training do the staff providing this support require in order to do this respectfully and safely?
  • Does this person have any specific support needs to assist them to sleep well?
• Safety
  • What supports does the person require to be safe? What risks are present for the person?
  • Do they have information and skills to keep themselves safe from or to report if they are being mistreated, disrespected or hurt?
• Health and wellbeing
  • Acute and chronic health conditions
  • Allergies
• Medications and Treatments
  • Sensory needs
  • Mobility needs
  • Healthy lifestyle supports
  • Mental health supports
    • Counselling
    • Addictions support
  • Clinical supports (physiotherapy, occupational therapy, dietary, speech, nursing)
  • Food & Nutrition
  • How does this person communicate when they are not feeling well or in pain?
  • Reference or attach all health care protocols or plans (seizure or prn protocols)
  • Contact information for all members of the person’s health care team
  • Community resources used or needed
  • Strategies to address barriers
• Support required to be as independent or actively involved in all above areas
  • Spirituality
  • What spiritual practices does this person engage in/want to engage in?
    • Religious communities or practices
    • Cultural ceremonies or events
    • Meditation, massage or other self-care activities
  • What brings the person comfort when they are sad, upset or experiencing grief?
• Positive Behaviour Support
  • Does the person require any specific support around behaviour that is unsafe or gets in the way of their ability to be successful at home or in the community?
  • What strategies or supports are helpful and under what circumstances?
  • Refer to or include any behaviour support plans and safety plans.
• Technology
  • Does the person use technology for fun or assistance?
  • What support does the person require to use or access this technology?
  • What information or training will those that support the person need about the technology?
• Legal
  • What supports does or would the person require to address legal issues?
  • Who would help or support if this becomes a need?
  • How would the person’s rights be supported and protected?
  • What community resources would or could be accessed?
• End of life planning
  • Has or does the person wish to document their wishes for health care in advance of and arrangements following their death?
  • Does the person have or want to have a will or expression of wishes?
  • What support does the person need to execute these plans?
  • Where is required and relevant documentation kept in the event of serious illness or death?
• Support Team
  • Who are the key members of the person’s support team both in and outside the organization? Include contact information for all (this may include key staff, managers, social workers, EIA worker, clinicians, Substitute Decision Maker, etc.).
  • Who are the members of the person’s natural support network that could provide the required supports? Include contact information for all.
  • Are there specific roles and responsibilities that each fulfill in supporting this person successfully.

Each person has a copy of their support plan in an accessible format, if they wish.

Each person’s personal plan is reviewed annually or more frequently if there is a change in needs or circumstances. The review of the plan is guided by the person and informed by the person’s ongoing person centred planning process. While the person may not wish to involve everyone in this process, relevant changes to the support plan should be shared with those responsible for facilitating or implementing the support, with the person’s consent.

The organization has a method to ensure that all staff who are responsible for supporting the person have access to and are familiar with their support plan. Staff receive orientation prior to working with the person on the best ways to support them. Staff are trained to understand the purpose and importance of support plans and their role in providing the supports outlined.

Depending upon the scope or type of support the organization provides to the person, the support plan may be broad or very focused (i.e. employment support only). Where two (or more) organizations provide support to a person, it is imperative that there is collaboration and sharing to ensure that support is integrated. This is, however, guided by the person and there may be some information that they wish not to disclose to all service providers. When this happens, there needs to be discussion about any risks that this may create and a plan to mitigate or decrease these risks.

How would you know this is happening? (Evidence)

What you see in systems:

• Each person has a written support plan that outlines the supports the person needs to be successful.
• Training/orientation content and record of completion.

What you see in actions:

• Staff are aware of and guided by the wishes, preferences and needs of the person as documented in a comprehensive, thorough and dynamic support plan.
• People who the person relies on for support (either paid or unpaid) are aware of and committed to their role in helping the person be successful.
• People receive the support they require and desire.