Revision 13-2; Effective September 3, 2013

 

I. Introduction

The Discovery Tool is not intended to serve as an interview tool. Discovery is an ongoing process rooted in supportive relationships developed between service coordinators and the people they support. This optional tool can be used to suggest exploration and organization of information critical to completion of Form 8647, Service Coordination Assessment – Intellectual Disability Services. While the prompts in this tool may be useful to the Person Directed Plan (PDP) Discovery process, it should not be considered all-inclusive, exhaustive or as a substitute meaningful discovery. While service coordinators generally use ongoing face-to-face discussions, record reviews and communications with family members and staff (who know the person best) to gather discovery information. Appendix III, Discovery Guide, offers information and instruction for carrying out a robust, ongoing discovery process.

Person’s Preferences for Planning Activities

Person’s Communication Style:

  1. How does the person communicate (gestures, sounds, facial expressions, adaptive equipment, etc.)? What is the best way to determine if the person is expressing satisfaction/happiness/comfort/agreement as opposed to dissatisfaction/unhappiness, discomfort/disagreement?
  2. Among those who know the person best, who seems better able to interpret what the person is trying to communicate?
  3. What is the best way for others to learn how to communicate effectively with the person?

Person’s Resources for Support Planning and Service Provision:

  1. Participants/Support Planning Team (SPT): Who does the person/legally authorized representative (LAR) wish to directly involve in support planning? Note: The person can be anyone, including provider staff.
Name Relationship to Person Contact Address and Phone Preferred Method for SPT Member
to Participate in the Person’s Planning
(personal availability, phone availability, etc.)
       
       
       
       
       
       
  1. SPT Involvement: What would be the person’s/LAR’s reaction to participating in meetings or group planning activities via phone or other remote methods?
  2. Service Coordinator Involvement: Is the person/LAR comfortable with the service coordinator independently contacting involved people to explore the person’s preferences and outcomes?
  3. Places: Where is the person/LAR most comfortable when participating in planning activities such as PDP reviews or Individual Plan of Care (IPC)/Implementation Plan (IP) reviews? What would be the person’s/LAR’s preference for an alternate or backup location?
  4. Times: What is the person’s/LAR’s preference regarding the time or day that he or she wants to participate in planning activities?

Information Specific to the Consumer Directed Services (CDS) Option

  1. What is the person’s/LAR’s understanding of his/her freedom to choose a comprehensive provider or to personally direct provision of certain specified services?
  2. What additional information does the person want about CDS?

Discovery Information Related to Completion of the Service Coordination Assessment

Preferences for Living Environment – Always include a summary of discovery information that justifies conclusions:

  1. Where and with whom does the person currently live?
  2. How closely does the current living situation align with the person’s priorities/wishes?
    • What location meets the person’s preference (city/locale)?
    • What kind of living environment does the person prefer (group living arrangement, alone, roommate, own apartment, with family, etc.)?
    • If group living is the preference, does the person like having his/her own bedroom or sharing with a roommate?
    • What factors does the person/LAR prioritize when considering the choice of a place to live (e.g., proximity to family/work/public transportation/shopping/school, availability of supports to teach the person critical skills related to living in his/her environment, affordability, etc.)?
  3. Are there any personal issues that might present risk for harm in the person’s living arrangement (e.g., daily rituals, threats of suicide or physical harm to self or others, inability to handle a personal crisis)? What supports are needed to address these risks (increased personal supervision, limited proximity, etc.)? Is the person currently receiving these supports?
  4. Does the person live, work and pursue leisure activities in integrated environments that are safe? If not, what are the specific issues presented to the person by these environments (e.g., sanitation issues within environments, physical hazards such as inaccessibility, toxic substances, hot water, lack of safety equipment such as fire extinguishers, smoke detectors, door peephole, inability to use safety equipment and pedestrian safety skills)?
  5. Does the person know how to respond in an emergency situation such as fires, hazardous weather, natural disasters, illness, injury or threat of bodily harm? Does the person need support to ensure safety in emergency situations?
  6. Does the person need any modifications to the living environment to ensure safety/health/access needs are met (e.g., ramps, doors, doorways, bathroom modifications, etc.)?
  7. Does the person need any additional equipment (personal or environmental) to support accessibility and safety within any frequented environment (e.g., mobility devices, switches, lifts, etc.)?
  8. Does the person require specialized therapies (dietary, occupational therapy, physical therapy, speech therapy, nutrition, postural supports, food-texture modifications, psychological counseling, behavioral supports, etc.) to support safe access to preferred activities and environments?
  9. When the person receives supports, are there any specific characteristics that must be considered to honor the person’s preferences (e.g., male as opposed to female staff for certain activities, a preferred staff person for implementing services, preference for adaptive equipment transfers as opposed to personal transfers, soft-spoken interaction as opposed to loud voices, information that should be given in advance regarding upcoming changes in the person’s routine, etc.)?

Preferences for Financial Security – Always include a summary of discovery information that justifies conclusions:

  1. What financial resources are accessible to the person (review assets, sources of income as well as insurance coverage)?
  2. Does the person have adequate financial resources to meet his/her priority needs and preferences (food, shelter, medical and prioritized leisure activities)?
  3. What support does the person receive in managing his/her financial resources (e.g., parent/other serves as representative payee, a guardian appointed to manage financial affairs, etc.)? Include all supports: non-Home and Community-based Services (HCS)/natural or HCS.
  4. Describe any additional supports necessary to assist the person in addressing financial security/obligations.
  5. Is the person interested in acquiring additional knowledge, skills or abilities to increase control and choice regarding financial security? In which areas is he/she most interested?

Preferences for Physical/Emotional/Behavioral Health – Always include a summary of discovery information that justifies conclusions:

Physical/Emotional or Behavioral Health Concern (List all concerns, diagnoses, routine procedures, including dental.) Name/Specialty of Healthcare Professional Currently Addressing the Concern, if Applicable Thoroughly Describe the Intervention (medication, specialized therapy, frequency of visits, etc.) Who is Responsible (or needs to be responsible) for Ensuring this Concern is Addressed?
       
       
       
       
  1. What is the person’s/LAR’s preferences regarding the management of personal health?
  2. What issues impact the person’s ability to obtain necessary interventions (e.g., does not understand most medical issues and required interventions, is afraid of professionals, is combative during medical procedures, is uncooperative with taking medications as prescribed, etc.)?
  3. How does the person indicate physical distress or illness?
  4. Is the person/LAR satisfied with current supports?
  5. What change does the person/LAR wish to make with any of the supports currently provided?
  6. If the person takes medication, what assistance is required to ensure that they are taken as prescribed?
  7. If the person requires other interventions (e.g.,`positioning, nutritional management, etc.), what assistance is required to perform them?
  8. Does the person require medically necessary supplies? What are they and how are they obtained?
  9. Is the person interested in acquiring additional knowledge, skills and abilities that facilitate increased choice and control in meeting physical/emotional/behavioral health needs? Fully describe what the person is most interested in acquiring.

Preferences for Daily Living – Always include a summary of discovery information that justifies conclusions:

  1. What supports are necessary to assist the person in meeting physical needs (oral hygiene, physical hygiene, using the bathroom, eating assistance, positioning, shopping, cooking, etc.)?
  2. What supports are necessary to assist the person in maintaining possessions in the living environment (household tasks such as house cleaning, laundry, maintaining personal adaptive equipment, etc.)?
  3. What are the person’s preferences for his/her daily routine (includes the timing of daily events, the activities he/she does and the times in which he/she does those activities, the food he/she eats, etc.)?
  4. Is the person interested in acquiring additional knowledge, skills and abilities to increase control and choice regarding daily living? In which area is he/she most interested?

Preferences for Work and/or School – Always include a summary of discovery information that justifies conclusions:

  1. What are the person’s preferences regarding work, education and volunteer opportunities in the community?
  2. For a person under the age of 22, are educational/school services being provided? Where? What prioritized supports are being provided by the school? (Note: The person’s parent, teacher and individual education plan are excellent resources.) Are the school’s services reflecting the person’s/LAR’s priorities?
  3. For a school-age person receiving educational services, explain how current HCS and non-HCS supports could enhance and support the person’s educational service.
  4. If the person is not school age, what does the person do during the day (work, adult learning, etc.)?
  5. What is the person’s understanding of available options in the community to address his/her preferences for work or education?
  6. If the person expresses a preference, does the person currently possess the necessary skills, knowledge and abilities to address preferences? If not, what does the person require?
  7. Describe the services that would best assist the person in obtaining work/educational preferences.
  8. If the person is not interested in volunteering, working or going to school, describe what the person would like to do?

Preferences for Relationships – Always include a summary of discovery information that justifies conclusions:

  1. Using discovery information, describe any close relationships in the person’s life (who is the individual, what is the nature of the relationship, how often does the person wish to see the individual, etc.).
  2. Who are the person’s friends?
  3. Is the person satisfied with the number and types of relationships in his/her life?
  4. Is the person satisfied with the type and frequency of contact with friends and family? How do you know?
  5. In what new types of relationships is the person interested in exploring?
  6. Is the person interested in acquiring additional knowledge, skills or abilities to increase control and choice regarding relationships? Fully describe what the person is most interested in acquiring.

Preferences for Social Inclusion – Always include a summary of discovery information that justifies conclusions:

  1. Is the person aware of available community-based activities? If not, describe how the person could become more aware of options.
  2. In what community-based activities does the person actively participate (ongoing community activities such as going to movies, church, festivals or participating in clubs or other community-based organizations)?
  3. Is the person satisfied with the type and frequency of participation in community-based activities? What other activities would the person like to do?
  4. What activities does the person specifically dislike?
  5. Is transportation a barrier to the person’s participation in community activities? What resources are available to assist the person with transportation?
  6. What supports would the person require to participate in community-based activities to his/her satisfaction?
  7. Is the person interested in obtaining new knowledge, skills or abilities related to social inclusion? Fully describe what the person is most interested in acquiring.

Preferences for Rights/Legal Status – Always include a summary of discovery information that justifies conclusions:

  1. What rights does the person exercise (e.g., freedom of movement, accessibility, opening mail, privacy, phone calls, personal possessions, voting, exercising chosen religion, etc.)?
  2. What rights are not exercised? If the person is not exercising those rights, what are the reasons?
    • Is the person choosing not to exercise those rights? How do you know?
    • If the right is being limited by support staff, describe the reason for the limitation(s).
    • Did the SPT consider the limitation(s) and find that it was necessary to protect the person?
    • If there are limitations, describe the supports that are in place/necessary to restore the person’s rights.
    • Does the person need someone to assist in the exercise of rights (guardian, power of attorney, advocate, etc.)? If applicable, describe the supports targeted toward obtaining assistance.
  3. Describe the person’s ability and desire to advocate for himself.
  4. Would the person like to learn more about self-advocacy? What supports are in place/necessary to help the person learn?
  5. Does discovery provide any evidence that the person has been abused, neglected or exploited?
  6. If the person is still experiencing personal distress from a previous occurrence of abuse, neglect or exploitation, describe the supports the person is receiving (or needs/wants) to cope with the distress.
  7. Is there any information regarding the person’s vulnerability to abuse, neglect or exploitation that should be shared with staff supporting the person?
  8. Is the person interested in obtaining new knowledge, skills or abilities related to exercising rights or preventing abuse, neglect or exploitation? Fully describe what the person is most interested in acquiring.

Preferences for Other Personal Outcomes Desired by the Individual – Always include a summary of discovery information that justifies conclusions:

Using the Discovery Guide or other means adopted by your center, identify other priority personal outcomes that should be a focus (purpose) of either HCS or non-HCS supports.