Revision 13-2; Effective September 3, 2013

 

I. Overview of Discovery

Discovery is the process of listening to people and learning about what they want from their lives. It is getting to know people so that their personal outcomes, preferences, choices and abilities are understood, documented and form the foundation of planning their services and supports. Discovery is the basis for the Person-Directed Plan (PDP) and service delivery. It is an ongoing process that occurs each time the service coordinator talks to the person or those who know the person best. It is necessary to record the information learned so that it can be used when developing or updating the PDP. The service coordinator leads the discovery process, acting on behalf of the person whose services and supports are being planned.

The following core values guide the development of community supports and services for people with intellectual and developmental disabilities. These values form an essential foundation for the discovery process and service selection:

  • Self Determination. People should make decisions about things that affect their lives. The service coordinator supports the person in making choices. People should have information about directing their own services and supports and opportunities to do so.
  • Community Inclusion. People receiving services should have opportunities to lead a satisfying life – making friends, participating in preferred activities, and being involved in and valued in their community. The service coordinator recognizes the need for people to belong and examine opportunities for supporting connections.
  • Meaningful Relationships. People receiving services need opportunities to develop close relationships with others, maintain the relationships they have, and form new associations with persons and groups with similar interests and purposes. The service coordinator explores and advocates for ways the person may develop relationships and associations beyond staff and other existing relationships, based on the person’s interests and desires. Barriers to creating bonds with others should be addressed.
  • Maintaining Non-waiver Supports. Discovery includes identifying existing natural supports, such as supports provided by friends, family or others that are not to be replaced by paid services. The loss of these supports could leave the person without meaningful relationships or community connections. Non-waiver supports also include generic services and resources (e.g., the Department of Assistive and Rehabilitative Services (DARS), public education, Day Activity and Health Services, the Comprehensive Care Program, state plan Medicaid services, etc.) that must be used prior to accessing waiver services.

Building a trusting relationship is the means by which the service coordinator discovers what is important to the person. The following should be demonstrated when building relationships:

  • A caring attitude, interest in the person and respect for the wishes of the person and family.
  • Willingness to spend time with the person. When first supporting someone, the service coordinator often sees the person at least once a month to give sufficient time to get to know him/her.
  • Finding the positive and building on talents. Everyone wants to be liked for who they are. The service coordinator should not always focus on the person’s needs, but rather build the person’s confidence and self-esteem.
  • Ability to be trusted. Following through with promises is important to people and their families. Honor the individual’s request not to share private information. Trust will help the person to open up and talk about his/her life.
  • Willingness to admit mistakes.

Communication, listening and observation skills are indispensable for a service coordinator. These skills are needed when conducting discovery, facilitating meetings and when interacting with people receiving services, their families, providers and other community organizations (including the service coordinator’s own agency).

The best environment for a conversation about a person is a comfortable place without noise and distractions. Privacy must be maintained when discussing personal information. When the person is present, speak directly to the person. When other people are engaged in the conversation (including interpreters), be sure to look at the person who receives services so that you can see his/her reaction to the discussion through his/her facial expressions and body language.

It is important to engage different people in different ways to accommodate individual ways of communicating. Learning about a person’s communication abilities, including whether a person uses a communication device, is important when arranging a time to talk. It is also important to allow enough time to accommodate a person who communicates slowly or may require frequent breaks to remain engaged. Identifying preferences ahead of time, such as convenient times or days, may help guide successful questions and conversation.

  • Starting Conversations. Introduce yourself and explain the purpose of the visit (as obvious as this seems, it is often overlooked). Conversations with people receiving services can be started in many ways, depending on the interests and preferences of the person. Sometimes it may be necessary to start a conversation about an activity the person is interested in or participated in recently. A conversation may be started by asking about an item that belongs to the person or is present in his/her environment. Avoid immediately diving into questions that could seem too abrupt or too personal. Possible ways to start a conversation:
    • Tell me about yourself.
    • Tell me about your day.
    • What would you like me to know today?
    • You look so happy today. What put that smile on your face?
    • You look upset. Do you want to talk?
    • I see a lot of pictures in your room. Can you tell me about them?
    • What do you like to do?

If a person does not want to communicate, loses interest or does not have the tools necessary to communicate, ask if it would be better to come back later.

  • Gathering Information. Ask permission before asking personal questions. Questions should be centered on the concerns or interests of the person. You will not be able to get all important information immediately.

    Many people respond to opening requests, such as:
    • Tell me about your family.
    • Tell me about your friends.
    • I’m interested in knowing more about you.
    • Tell me about your favorite things.
    • Tell me about things you don’t like.

The person may have a specific issue that is dominating the conversation. Go with it and let the person feel and express himself. It helps the person to speak at his own pace. Learn to be silent, as this can also be a way to connect. If the conversation shifts away from the person, redirect the focus back to the person. If necessary, be persistent in keeping the person the center of conversation. Be careful not to ask too many questions and observe nonverbal communication to determine when the conversation needs to take a new direction.

  • Listening. Listening well can sometimes be challenging, but it is a critical skill in discovery. It is how we learn about people. Let people know you are listening.
    • Talk to the person, not around the person, if the person is not alone.
    • Ask the right questions. Avoid questions with yes or no answers that are not exploratory and do not provide opportunities for people to express themselves.
    • Allow adequate time for the person to respond.
    • Reflect back the last statement you heard.
    • Paraphrase and sum up what you have heard during the conversation
  • Observing and Nonverbal Communication. If a person is able to effectively communicate through conversation, discovery is often easier. However, a great deal can also be learned through nonverbal communication.
    • Body language often provides information about what a person is thinking or feeling.
    • Some people may use gestures, behavior or other means of getting their point across. Help may be needed from family or others who know and care about the person to interpret and learn from what he/she is saying.
    • Conversation can distract from nonverbal communication of feelings and emotions.
    • Some behavior may be a request for help or attention.
    • Facial and eye expressions provide much information – trust, affection, disapproval, sadness, pain, discomfort, fear, awareness, interest, joy, concern.
    • Eye contact is important communication and shows respect.
    • Clothing, grooming, and environment may tell a lot about the person’s life. It is especially important to visit people at their home and in other environments.

Identifying personal outcomes is the focus of service planning and must be informed by meaningful discovery. It is important for everyone to make plans in order to achieve the outcomes they desire. People need to dream about their future and how they can achieve what is important to them. When talking with a person or gathering information:

  • Allow the person to dream big. Don’t discourage the person from dreaming about his/her future, but explain how to break dreams into attainable short-term outcomes.
  • The person’s outcomes must be clearly identified so that service providers and natural supports can assist the person to achieve them.
  • Barriers should be recognized and the service coordinator should help the person identify ways to resolve or work around the barriers.
  • When a service coordinator learns about outcomes, he/she should think about possible methods of achieving these outcomes. Outcomes may be met with assistance from family members, friends, community resources, generic service agencies or waiver services. The service coordinator is responsible for looking for alternative solutions, in addition to considering waiver services.
  • Be positive. Reflect the outcomes in positive ways. Represent the person.
  • Ensure health and safety. The service coordinator should gather existing information necessary to identify safety or health issues. The service provider should assist the person with addressing those needs. Health and safety outcomes must not be ignored and the person should be assisted in understanding the importance.
  • The service coordinator asks permission from the person or legally authorized representative to include service providers in the discovery process. The provider may have day-to-day experience with the person and should be considered a significant source of discovery information to identify outcomes.
  • Involve other allies identified by the person.
  • Recognize that the outcomes may change as the service coordinator learns more about the person.

II. Using the Discovery Guide

This Discovery Guide is intended to support learning about what is important to the person and what others need to know to support the person for each person who receives services and supports. It is designed as a guide for exploration. The service coordinator supports a meaningful discovery process by helping people to speak for themselves, each in his or her own way about his or her own dreams and outcomes. The service coordinator encourages those present to listen and learn about what people want.

Examples offered in the Discovery Guide are intended to inspire thinking about the types of information that are important in creating true PDPs. They are only examples and while some may be relevant to a particular individual, information gained from the person and those close to the person will yield individualized results.

Gathering important information for those who support and assist the person. The service coordinator documents information that will be helpful for the service provider to know when providing services and supports to the person. This includes a broad profile of the person and important matters in his/her life based on observations, discussions and other relevant information. This information includes:

  • The people, places and things that give the person happiness, contentment and satisfaction, in the present and in outcomes and dreams for the future.
  • What people like and admire about the person. Sometimes this may take effort to learn because people are not always accustomed to talking about attributes. Notice the good things about the person and encourage him or her to recognize his or her own strengths and positive attributes.
  • Background experiences that affect the present. Record events such as milestones, celebrations, institutionalization, losses, trauma, etc. that affect the person today.
  • Who helps the person make important decisions? Who is a reliable source of information? Who does the person feel closest to? Who else does the person want to have involved in discussions and decisions? If the person is isolated or only talks about staff, it may be a sign that the person needs other relationships and connections. If the person has a guardian, ask if he or she is included in decision making and how.
  • Preferences for social inclusion and alone time. Don’t assume that every person wants to be social all the time. Some people like having many friends; others prefer only a few close relationships. Personal relationships are very important to most people.
  • Safety issues. Think beyond just supervision, even though that is important. Evaluate whether the environments where a person spends his/her time are healthy and safe. Observation is as important as asking questions. Consider what supports the person needs to be safe, e.g., adaptive aids, caregiver capacity, preparation for emergencies, etc.
  • Health issues. Document health issues that concern the person. Detailed health information will be reflected in the health assessments completed by the provider.

Identifying services to support outcomes. The service coordinator identifies services that support the person’s outcomes. Based on the information gathered during discovery, the service coordinator:

  • Identifies the services that will support the outcomes.
  • Explains the purpose and outcome of the service (what will the person gain from the service?).
  • Identifies what is important to the person and what others need to know and do to support the person so the program provider can use this information to design the implementation plan.

The examples below are meant to give service coordinators a general idea of how to use information gathered through the discovery process to identify services to support personal outcomes.

Example 1: Purpose/Outcome. What does the person want?

  • The person wants to join a choir.
  • The person wants to go to the singles class at church.
  • The person wants to take a class at the community college.
  • The person wants to take a vacation to Disneyland.

A possible support for these purposes/outcomes could be a person’s family or friends. An action plan is not needed unless a Home and Community-based Services waiver service is supporting the person to achieve the outcomes.

Example 2: Purpose/Outcome. What does the person want?

  • The person needs a safe place to be during the day.
  • The person enjoys being around other people and making friends.
  • The person wants to develop or reinforce a skill (educational skills, specialized therapies, socialization skills or other adaptive skills).

A possible waiver service to support these purposes/outcomes could be day habilitation.

The following information learned during the discovery process would be important to the provider of day habilitation services:

  • Important To. Information about preferences that are related to the service or the environment where the service will be delivered. This should help the provider to ensure a good experience for the person. Examples of areas related to quality of life issues:
    • The person wants to sit next to friends so he can visit with them.
    • The person wants to have frequent breaks so that he can walk around the building, get a drink of water and talk to people in other areas.
    • The person likes to eat meals at the same time each day.
    • The person likes to exercise.
  • What Others Need to Know and Do to Support the Person. Information about what others think is important for the day habilitation staff to know. Examples of information that often relate to communication or health and safety:
    • When the person starts to fidget, he often wants to take a break.
    • The person must take medication during the hours he receives day habilitation.
    • The staff must be trained to identify symptoms of high and low blood sugar.
    • The person does not have safety skills when working with equipment or machinery.
    • The person requires support to leave the building alone.
    • Transportation provider requires staff to be available to meet the van upon arrival to day habilitation services and to accompany the person to the van when leaving.

Example 3: Purpose/Outcome. What does the person want?

  • The person wants to get a driver license and needs help learning the Driver Handbook.
  • The family has requested assistance with the person’s grooming.
  • The person wants to explore recreational opportunities in his neighborhood and learn how to ride public transportation to these events.
  • The person needs transportation to attend classes.
  • The person wants to become her own payee and needs training on money management.
  • The person needs help to shop for groceries.
  • The person wants to improve abilities to do housekeeping tasks independently.

A possible waiver service to support these purposes/outcomes could be supported home living.

The following information learned during the discovery process would be important to the provider of supported home living services:

  • Important To. Information about what the person prefers about staff, schedules, criteria for providers to make a good match with staff, etc. Examples:
    • The person wants to work with female staff because she does not want a male to assist her with personal hygiene.
    • The person prefers that staff only come on Tuesday mornings because she is involved in other activities the rest of the week.
    • The person wants to interview and select any staff that will be coming to her home.
    • The person wants staff to call when they are on the way or if they are not able to make the appointment.
    • The person likes to be 10 minutes early to appointments.
  • What Others Need to Know and Do to Support the Person. Information about what is needed to ensure safety, health and well-being. Examples:
    • Due to the medication she takes, the person must drink plenty of water.
    • The person must have a backup plan if the assigned supported home living staff are unable to work to ensure the person receives adequate assistance during evening hours.
    • The person must be carefully supervised when crossing the street or in other non- safe environments.
    • The person needs supervision at all times when outside his/her home.
    • The person is unable to regulate water temperature and has been burned in the past when left to bathe without assistance.
    • The person will eat too fast if not prompted to eat slowly.

Example 4: Purpose/Outcome. What does the person want?

  • The person wants to eventually live alone but needs skills training in the areas of safety, money management and meal planning/preparation.
  • The person enjoys living with a family.
  • The person likes the foster/companion care (FCC) provider and wants to live with him/her.
  • The person wants to learn how to ride the public transportation system.

A possible waiver service to support these purposes/outcomes could be FCC.

The following information learned during the discovery process would be important to the provider of FCC services:

  • Important To. Information to help a provider in selecting the type of home, staff characteristics and supporting daily routine preferences. Examples:
    • The person likes to sleep late on weekends.
    • The person wants to remain close to his family’s home in the west part of the city.
    • The person does not like to be around people who smoke.
    • The person wants his own bedroom.
    • The person wants a long-term provider.
    • The person does not like animals.
    • The person wants a family that would allow him to keep his pet hamster.
    • The person wants to attend church.
  • What Others Need to Know and Do to Support the Person. Information about general health and safety issues. Examples:
    • The FCC setting should be within close proximity to the person’s family.
    • The staff should be fully aware of medical issues that are included in the Comprehensive Nursing Assessment.
    • The FCC provider should be available on-site any time the person is in the home.
    • The person has difficulty independently working kitchen appliances.
    • The FCC provider should receive training from the occupational therapists and physical therapists regarding how to support therapy.
    • The FCC provider should be aware of and follow behavioral guidelines prepared by the provider of behavioral supports.
    • The person’s blood sugar levels must be checked in the morning and evening.

Example 5: Purpose/Outcome. What does the person want?

  • The person wants to express his opinions without yelling.
  • The person wants to be able to calmly ask others to leave his room.
  • The person wants to continue living with his family.
  • The person wants friends and is finding it difficult to keep them.
  • The person wants a better relationship with his family.
  • The person wants to not feel lonely.

A possible waiver service to support these purposes/outcomes could be behavioral supports.

The following information learned during the discovery process would be important to the provider of behavioral supports:

  • Important To. Information to help staff understand what the person experiences as positive situations or negative situations. Examples:
    • The person likes to be asked (not told) to complete a task.
    • The person likes to be busy.
    • The person wants more friends and more fun.
    • The person likes privacy.
    • The person likes to take a break when faced with stressful situations.
    • The person does not like others taking or handling his possessions.
    • The person likes to be on time to his art class.
    • The person likes having friends and family, and likes to be in touch with them frequently.
    • When stressed, this person likes to talk to his best friend on the phone.
  • What Others Need to Know and Do to Support the Person. Information about supporting the person’s positive behavior. Examples:
    • The family has noticed that the person becomes more stressed when he is in a loud environment, is bored or the activity is too difficult.
    • Staff should remind the person to take deep breaths when trying to express his emotions.
    • Staff should remind others living in the home to knock on the person’s bedroom door before entering.
    • It is important for the person to have a safe place for his special belongings. He becomes very angry when they are lost.
    • Each morning, staff should tell the person what is planned for the day.
    • Staff must take the time to listen to what the person is trying to communicate.

Example 6: Purpose/Outcome. What does the person want?

  • The person wants to have supports at work.
  • The person needs to keep his job but needs some additional training. DARS is no longer available.

A possible waiver service to support these purposes/outcomes could be supported employment (SE).

The following information learned during the discovery process would be important to the provider of SE:

  • Important To. Information about preferences for how SE will be delivered. Examples:
    • The person likes to perform tasks as independently as possible.
    • The person would like to work mornings rather than evenings.
    • The person prefers to speak Spanish.
  • What Others Need to Know and Do to Support the Person. Information about supports necessary for success and well-being. Examples:
    • It is important for the SE staff to be aware of signs and symptoms of seizures.
    • It is important for the SE staff to support and reinforce the person’s work schedule.
    • It is important for the SE staff to arrive at the work site at the same time as the person.
    • It is important for the SE staff to ensure that the person takes his medication during the work day.
    • It is important for the person to arrive to work on time.
    • It is important for the SE staff to teach the person work-related conduct and expectations (e.g., call if you are ill or will be late, dress for the job, etc.).

The service coordinator develops the PDP using the information gathered from the discovery process.

Example 7: Purpose/Outcome. What does the person want?

  • The person wants to interact with others.
  • The person wants to be able to talk.
  • The person wants a mobile device to help him communicate.
  • The person wants the freedom to come and go without assistance.

A possible waiver service to support these purposes/outcomes could be adaptive aids.

The following information learned during the discovery process would be important to the provider of adaptive aid services:

  • Important To. Information about preferences that are related to the adaptive aids to be used should help the provider to ensure a good experience for the person. Examples of areas related to quality of life issues:
    • The person wants a small, lightweight speech device that is durable.
    • The person wants to choose the voice that the speech device uses.
    • The person wants access to the speech device at all times.
    • The person wants to go places whenever he wants without assistance.
  • What Others Need to Know and Do to Support the Person. Examples of information important for the staff to know:
    • It is important for staff to offer only the amount of assistance requested.
    • It is important for staff to be patient.
    • It is important that the speech device be received quickly and programmed according to the person’s wishes.
    • It is important that the speech device and electric wheelchair be charged and well maintained.

As a service coordinator gets to know a person, it will become apparent what is important to the person regardless of where he/she is, what he/she is doing, who is supporting him/her, and what others need to know and do to support him/her, regardless of the setting. The information that is not specific to a setting or a service are collected and included in the One-Page Profile of the PDP. The important to and the what others need to know and do to support the person information that is specific to a service is included in the Pertinent Information section of the PDP action plan for that service.