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Supports for Adults

Individual Service Planning (ISP)



All individuals receiving funded services are required to have an individualized plan of care or individual support plan (ISP). Individual Support Plans provide the opportunity for enhancing the quality of life of each person by outlining his or her individualized services and supports. Standardized tools that are used for recording the process and outcomes of person centered planning in comprehensive and support services.

What is the Individual Support Plan (ISP)?

The ISP is the written details of the supports, activities, and resources required for the individual to achieve personalgoals. The Individual Support Plan is developed to articulate decisions and agreements made during a person-centered process of planning and information gathering. The general welfare and personal preferences of the individual are the key consideration in the development of all SPD funded care plans.

The individual and their team are responsible for developing the individual plan of support. ISP teams are composed of people who care about and know the individual. The team may also ask specialists, consultants or specific provider staff to contribute to the plan by completing evaluations, or by observing and collecting information that is basic to the preparation of the plan.

The ISP team is ultimately responsible for assessing and documenting each person’s:

  • Personal choices and preferences.
  • Significant health care, mental health or behavioral needs and related maintenance needs.
  • Safety and financial skills.

The ISP teams translate this information into goals and objectives, which are then contained within the written plan. The plan results in outcomes that maintain or change services or supports to reflect what is most important to and most important for the individual in their daily life.

What values are important in Individual Support Planning?

Choice and Control

The plan reflects an individual in terms of what’s important to and for them. Personal preferences should be evident in the goals, design strategies, and networks of support developed with the individual.

Health and Safety

Major health risks and safety issues in home and community environments are assessed. The plan may than identify professionals, protocols, and adaptations or supports that will address each risk identified. The planning process may also help be used to discuss issues and support an individual’s informed choice related to safety and lifestyle.


The ISP should help an individual and their team makes clear links with real life results. “I want to get a paid job” “I want to move to an apartment?” I want to see my family and friends”
The 1983 legislature directed the State of Oregon to identify the effectiveness of services for adults with developmental disabilities based upon the degree to which integration, independence and productivity and an enhanced quality of live are achieved.


What are the steps in the ISP process?

1. Gather person centered information

There are many tools for person centered planning. Oregon requires the use of “Person-Centered Planning Process ” to gather information that:

  • Helps an individual make and see their choices, needs and priorities;
  • Identifies a short and long term vision or direction:
  • Uses an individual’s strengths, relationships, and resources
  • Helps the individual and those significant to them to strengthen naturally occurring opportunities for support at home and in the community.

2. Identify health and safety risks

This is the assessment of what is important to remember for the individual to keep them healthy and safe. Different tools are use in comprehensive and support services to complete this assessment.

3. Get together, identify resources, and develop agreements

This portion of an ISP is an “action plan.” A written document identifies the most important goal(s) and activities or services needed to achieve them, who will be responsible for making sure they happen and how things will be checked on. The plan will also identify how assistance from family, friends, other agencies, and service funds will be used to achieve goals. Everyone who is a part of the plan signs it and gets a copy. Sometimes to implement the plan it may be necessary to develop job descriptions or agreements with people or organizations providing services in the plan.

4. Make it happen and keep it working

The plan will set a regular schedule for individual and team review to ask important questions like: Am I getting what I need? Am I satisfied? Does anything need to change?

SPD’s quality assurance standards and practices are designed to assure that ISP monitoring will occur in a standard manner across the state.

Service Providers and Community Developmental Disability Programs (or other case management authorities) are required to have policies and procedures in place that describes the process used in assuring that 100% of the ISP's for individuals are monitored and implemented.


What tools are used in the ISP process?

For individuals in 24-hour group homes and supported living settings

ISP requirements are outlined in the following administrative rules:

Training on the process, procedures and tools is available at Oregon Technical Assistance Corporation (OTAC). The material there will include:
  • ISP Handbook
  • Personal Focus Worksheet
  • Risk Tracking Record
  • Action Plans and Discussion records

For individuals with in-home services

ISP requirements are identified in the following administrative rules:

The tools available for person centered planning are:

For individuals in foster care

All residents in Foster Care Homes must have an Individual Support Plan (ISP) which is updated annually.

  • Download the Foster Care Individual Support Plan form in Word format.
For persons in comprehensive services, the Services Coordinator will help in the development of the ISP. For “private pay” residents, the Foster Care Home provider is responsible for the development of the ISP.