Individualized Service Planning

Navigating The Journey

Short-term goals include the WHAT and the BY WHEN, but not the HOW. The HOW action steps belong in the Individualized Service Plan (ISP). In other words, the goal is the desired achievement, and the steps are the sequence of actions leading to the goal.

Below are a few excellent examples of ISPs that meet the SMARTS criteria:

Short-term Goal (WHAT and BY WHEN): Xavier will receive his High School Equivalency diploma by May 30th.

Action Steps (HOW):

Xavier will attend HSE classes every Monday, Wednesday, and Friday at Bronx Community College starting January 15 and finishing March 15.
Case manager and Xavier will meet weekly to discuss progress from January-June.
Xavier will meet twice per month with HSE tutor for support.

Short-term Goal (WHAT and BY WHEN): Ms. Diaz will secure a part-time sales job in Brooklyn with an income of at least $250 per week by March 30th.

Action Steps (HOW):

Case manager and Ms. Diaz will work together to identify at least 15 job opportunities by March 1st.
Ms. Diaz will complete job applications for at least eight jobs by March 15th.
Ms. Diaz will secure flexible childcare options for her two children by March 1st in order to make it possible for her to take on a part-time job.
Ms. Diaz will follow up with each job application submitted within a week of applying.

Short-term goals and action steps need to be reassessed and updated regularly, noting in the progress notes which milestones have been achieved and any barriers to progress. Updated goals must be entered in the documentation system, noting the date of the change and supporting documentation to justify the adjustment to the goals.

Tips and Strategies

Short-Term and Long-Term Goals

The Three Cs for Motivation…

Systems of Care

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Celebrations and rituals for case closure

Rituals and celebrations are a part of life! For some participants, marking of transitions in a positive and intentional way may be a luxury they have not often experienced. What traditions does your program have, or could create? Here are some examples that program participants could practice:

Opening the encouraging letters written to themselves earlier in the program
Going out for a meal with a case manager
Creating a “wall of appreciation”
“Toasting” virtually or in person (raising a glass of a favorite beverage, reflecting on best memories)

What ideas have you used in your program?

Words Matter

Can you think of a time when you had a positive experience bringing a service relationship to a close, either as a participant or a provider? If this is difficult, consider asking a friend or a colleague. When describing the experience, what were the words used to describe the transition?

Even when we use the term “case management,” no one wants to feel like a “case.” Be creative in considering the words you want to use to communicate your belief in the participant you have been working with! For example, alternative terms to “case closure” or “follow-up planning,” might include “success assessment,” a “launch event,” or a “transition celebration.”

Consider discussing with your team at work to find ways of framing transitions that mirror your desired positive program culture.

Ego Integrity vs. Despair: Adults in this stage begin reflecting on their accomplishments and develop integrity if they feel they have led meaningful lives. If they see their lives as having been fruitless, feel guilty about past situations, or feel they have not accomplished their life goals, they become displeased with life and anguished, often leading to depression and hopelessness.

Generativity vs. Stagnation: Adults give back to society through a variety of generative activities and engagements, such as by raising children, working, and getting involved with community activities and organizations. If adults are not able to pursue generative activities fully they can become idle and feel lifeless.

Intimacy vs. Isolation: As they mature, adults begin to seek relationships which lead to long-term commitments with someone other than a family member. Completion of this stage leads to enjoyable relationships, a sense of commitment, safety, and care within a relationship. When an adult avoids intimacy and fears commitment they can suffer from isolation, loneliness and sometimes depression.

Identity vs. Role Confusion: Throughout adolescence youth examine their independence and sense of self. Children who are encouraged and reinforced in their personal examination will emerge from this stage with a strong sense of self and a feeling of independence and control. Children who continue to be unsure of their beliefs and desires can feel apprehensive and puzzled about themselves and their futures.

Industry vs. Inferiority: Children establish self-confidence in their achievements. They begin tasks, finalize them, and feel good about their accomplishments. If this initiative is not encouraged, children start to feel inferior and doubt their abilities.

Initiative vs. Guilt: Children who are successful in this stage feel adequate and capable to direct others. Those who fail to acquire these abilities possess feelings of guilt, self-doubt, and lack of initiative.

Autonomy vs. Shame and Doubt: Children become mobile and develop physically at this age. They proclaim their independence by walking away from their caregiver, choosing toys to play with, and by choosing what they like to wear, to eat, etc. It is crucial for parents/caregivers to allow their children to explore their capabilities in an encouraging environment while at the same time protecting them from continuous failure. The aim of this stage is to develop self-control without losing one’s self-esteem.

Youth Workforce Development

Transitions for youth in workforce development programs may mean moving from supported job placement or career development activities, into “official” employment or an education program. Even when a participant is “placed” in employment or an education program, their lifetime career journey is seldom linear. In collaborating with youth to develop their follow-up plans when moving on from workforce development programs, important considerations include knowing your rights as an employee, how to access and enroll in further credentials that may be part of the follow-up plan, financial management skills, and reaching out for support when dealing with obstacles or challenges. These are all life-long skills that all adults need!

Foster Care

For some youth, transition out of programs happens around the same time as major life transitions. In New York City, youth in foster care “age out” between ages 18 and 21, according to their discharge plans with the Administration for Children’s Services. If the young person wishes, DYCD provider program staff can be valuable members of the young person’s transition planning team.

Therapeutic Relationships

The end of a formal case management relationship can bring up issues and concerns, for participants and for professionals, especially if the relationship has included counseling, psychotherapy, or emotional support (in other words, if the participant has taken the risk of trusting you with their feelings, sensitive information, or struggles). Consciously or not consciously, feelings or memories involving abandonment, anxiety, or failure can come up. This can affect communication and behavior.

Data (new information gathered):

Relevant information that may impact progress (examples: loss of stable childcare, recently got a new job, death of a loved one)
Additional obstacles or concerns shared by the participant

Plan:

Progress toward a specific goal (example: Jose shared that he has submitted three job applications.)
Next steps, including who is responsible for each step
Next meeting date and time

Assessment of the situation/individual:

Noted behavioral changes, concerns (examples: Participant was teary throughout the meeting, was more talkative than usual, has missed the last two appointments.)
Information about participant’s perspective (example: Participant stated that they are feeling motivated/frustrated.)

Objective account of the interaction:

Factual information about your observations of the interaction (examples: Participant arrived 15 minutes early, did not speak in group session, helped other participants while at the program.)
Use of nonjudgmental language with no assumptions

Strengths observed:

Qualities that support achievement of goals (examples: shows up on time, follows through with action steps, communicates transparently about progress and obstacles)
Skills, interests, and resources (examples: strong computer skills, utilizes resources offered, shows support and offers assistance to other participants)

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throughout the toolkit for quick access to practical techniques you can apply to your case management practice.

Reflection Corner: Take a moment to reflect on your approach to working with participants:

How do you demonstrate care and compassion for your participants from the moment you meet?
What strategies do you use to keep participants engaged and motivated toward reaching their goals?
How do you ensure that your progress notes are written in a timely manner and that they connect back to the participants’ goals and action steps?

Learn More: For a quick guide, or “cheat sheet” to all that is outlined in this toolkit, download the Case Management Standards desk guide here

Try This! Take a moment to assess the quality of your program, based on the stated requirements, expectations and outcomes for your program type. On a scale from 1-5, with 5 being excellent, 3 being satisfactory, and 1 being poor, how would you rate your program?

Like every other part of the case management journey, the transition phase is an opportunity to build awareness and skills in social-emotional learning, positive youth development, and resilience. See https://www1.nyc.gov/assets/ dycd/downloads/pdf/ Youth_Leadership_ Development_Framework.pdf.

Relate the transition plan to the participant’s individual service planning that has occurred throughout their time in the program. Transition is a part of life, and when participants see their own progress or reflect on their own lessons learned, they are building life-long skills.
Whenever possible, collaborate with the participant in developing their transition plan and their post-program plans. Knowing what to expect ahead of time makes it possible for the participant to express their voice and choice in the process.
Consider the participant’s sources of support (emotional, financial, educational, vocational, housing, etc.) and ensure that these are incorporated in the transition plan. In some programs, this may include involving members of the participant’s support system in planning meetings.

Some programs maintain a program-wide resource page (online or on paper) that can be shared with participants. In some cases, programs make sure participants know how to stay in touch with the program, for example by following social media accounts.

Making Effective Referrals

Tips based on the real-world experiences of case managers, to help your efforts in offering effective referrals:

Ask the participant’s permission before offering a referral. A simple question like, “Is it ok if I tell you about an organization that might be helpful?” can help keep the tone collaborative.

When there are multiple priorities, ask the participant what feels most urgent right now. They are the expert in their own life.

Provide only one or two referrals at a time; don’t overwhelm with too many. Especially during times of stress, it is not realistic for anyone to hold a lot of information in mind at once.

Work as a staff team: share information and contacts. This can save you a lot of time!

Be familiar with what you offer. Do not send program participants or members of their circles of support to places where you are not aware of the availability or quality of services.

Don’t overpromise. In helping relationships, people generally value honesty and transparency, even when the news is not the best.

Let the program participant know what to expect. Help the program participant prepare, logistically and emotionally, by giving them an idea of the process and environment they will encounter. Include positives (for example, “The receptionist is friendly and speaks Spanish,” and negatives, “You will probably be on hold for a long time”).

Case Coordination and Case Conferencing

Do you currently practice case conferencing in your program? If no, what can you do to initiate it?
How often do you meet with your team to discuss the goals, challenges, and supports needed for individual participants?
How frequently do you meet with your internal team and external service providers to streamline communication and services for individual participants?
What would be the benefits to your participants if you enhanced your case conferencing capabilities within your program?
What might be some challenges of case conferencing within your program? Are resources (time, staffing) available to routinely practice case conferencing?

DYCD’s Family Engagement Toolkit

One great resource for engaging families as partners in the process of goal achievement can be found in DYCD’s Circles of Support Family Engagement Framework and Toolkit:

https://familyengagementdycdconnect.nyc/

Strong Words to Use When Writing Progress Notes

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Progress Note Practice

Next time you are writing a progress note, set a timer for ten minutes and use the SOAP-D acronym as a reminder of the standard for documentation. Include only the information that relates to the goals and progress of the participant. Proofread your note or read it out loud to ensure that it can be understood by another reader.

How to write effective progress notes:

Think about what you are going to write and formulate it before you begin.
Be thorough, yet concise.
Write notes immediately after you meet with the participant or complete an activity on their behalf.
Describe direct observations, not opinions.
Reflect on how the person is represented in your writing.
Use proper spelling, grammar, and sentence structure. Avoid shorthand.
Use respectful language and avoid slang.
Proofread.

Family Conferences

Individualized service planning helps participants to set their own goals, while family conferences help families make their own decisions. Family problems can be used to discuss problems that affect a family member or the whole family. Some examples might be adherence to house rules, conflicts between family members, lack of progress on a member’s goal such as employment or independent housing, substance abuse. When families are involved in the decision-making process, they are more invested in implementing the decisions. Typical steps for a family conference include the following:

Preparation: Family members decide where and when the meeting will take place, who will facilitate, what the ground rules will be, and who should attend. All those who will be affected by the decision should be invited.

Information Gathering: Information needed to make the decision is shared. A resource person may attend to provide information on services that can help to carry out the plan.

Discussion: All present share their thoughts and feelings regarding the issue.

Finalizing the Plan: The group comes to consensus on a plan to resolve the issue/problem discussed.

Monitoring: Family members may decide to have a follow-up meeting to check in on how the plan is working and make adjustments as necessary.

Suggested ground rules for a family conference:

Stay focused on the problem to be discussed.
Speak respectfully; everyone gets a turn to speak before someone speaks a second time.
Be honest; share how you think and feel and invite others to share their thoughts and feelings.
Practice confidentially; no one shares what has been discussed outside the group.
Do not belittle anyone’s ideas, blame, criticize, or name call.
Do not monopolize the discussion or interrupt,
Compliment others.

Motivational Interviewing

Motivational Interviewing (MI) is a technique for increasing motivation to change and has proven to be particularly effective with people who may be unwilling or resistant to change. Motivational interviewing aims to encourage the participant’s autonomy in decision making while the staff member acts as a guide, clarifying the participant’s strengths and aspirations, listening to their concerns, boosting their confidence in their ability to change, and collaborating with them on a plan for change.

To delve more deeply into the MI framework for supporting participants’ goal-setting, read more here:

https://positivepsychology.com/motivational-interviewing/

Written Short-term Goal Checklist

Take a look at one of your written short-term goals from a participant’s ISP and use this checklist to reflect:

Are goals clear and realistic?
Are tasks outlined within a timeframe?
Do we know who is responsible for what?
Are the participant’s strengths and resources integrated into the plan?
If you picked up this participant’s ISP, would you know exactly what the goals and action steps are to make that goal achievable?

Personal Goal-setting

Think about a short-term goal that you have for yourself. Take a few minutes to write it down. Is it Specific, Measurable, Achievable, Realistic, Time-framed, and Strengths-based? If not, rewrite it to make sure it meets these criteria. Now, take a few more minutes to write three clear and concrete action steps that will help you to achieve this goal. You’ve created an Individualized Service Plan! Once you’ve done this, share it with someone, get some feedback, and get started making it happen!

Collaborative Goal-setting:

Remember, it’s our job to guide and encourage, allowing the participant to set their own goals and make their own decisions.

Actively listen.
Help participants identify their strengths and skills.
Help participants describe their challenges and desires and summarize what you have heard.
Clarify to make sure you understand.
Use prompting questions and help them prioritize needs by highlighting urgency.
Narrow down to one or two short-term goals, reinforcing what the program can help them achieve.

SMARTS Goals Templates

When working with participants, it can often be helpful to have a visual template to use while collaboratively setting goals. Offer options for completing the template on their own or completing it together, and then refer back to it frequently to check on progress.

SMARTS Goal Template doc

Reflection on Initial Assessment Checklist

As you think about your own experiences providing case management services in your program, it can be helpful to think about the process by which your program conducts initial assessments. Use the checklist below to reflect on how you implement initial assessments.

Was the initial intake assessment begun in conversation with the participant? If the participant is required to fill in any forms, were these explained to the participant in advance of their being asked to complete them?
Does it include contact information for the participant?
Does it include the required basic information needed to input in DYCD’s Participant Tracking System?
Does it describe why the participant is interested in joining the program at this time?
Does it describe the participant’s strengths as related to the reasons they are interested in joining the program?
Does it describe the participant’s current personal resources and support systems?
Does it describe the needs that the participant has at this time and barriers that could affect the participant’s ability to engage in the program?
Does it include any concerns that the participant may have about moving forward or their ability to achieve goals?

The Family Advocacy and Support Tool:

Participants often don’t recognize the many strengths and supports that they have. One way to help families gauge their own strengths is by using a family assessment. An example of such an assessment is the Family Advocacy and Support Tool (FAST). The FAST helps families identify their particular strengths as well as areas where they could benefit from additional supports. It focuses both on family/caregiver strengths as well as children and youth aged 0-21. This tool can be used to help support decision making, including identifying the level of care and service planning needs of families.

This tool is copyrighted by The John Praed Foundation (https://praedfoundation.org/about/) and is available for public use. You can find the FAST here: https://praedfoundation.org/tcom/tcom-tools/the-family-advocacy-and-support-tool-fast/. In addition to the tool itself, the Praed Foundation provides a reference guide to the FAST, which can be found here:

Download reference guide

To learn more about the FAST and to inquire about training, contact The Praed Foundation: https://praedfoundation.org/about/

Learn More: Three-minute animated video on the difference between empathy and sympathy and how to be effectively empathetic, by Dr. Brené Brown:

Strengths-based Engagement from the Start

Greet the participant by name. (“Welcome, Sarah! It’s so nice to meet you.”)
Introduce yourself, your role, and share what the program provides (and what it doesn’t).
Make the space inviting, with visuals representing participants’ cultural identities and languages. (Virtual adaptation: Be mindful of the physical or virtual background that you as staff show on video calls.)
Make intake a friendly conversation, not an interrogation. Avoid taking notes in the participant’s presence.
Ask about interests and skills. (“What do you enjoy doing when you’re not in school?)
Use open-ended questions. (“What brings you here today?”)
Actively listen without judgment.
Find out about the participant’s support systems. (“Who do you turn to when you need advice?”)
Offer choices for how to complete the intake process. (“Would you like to fill out the form and then talk, or would you like me to ask you some questions and complete it while we talk?”)
Point out the positives. (“Thanks for coming in on time today, Sarah.”)
Ask what the participant wants to get out of the program. (“What are you hoping we can help you to accomplish?”)

Instead of asking...

Instead of asking…	Try asking…
Are you married?	How would you describe your relationship status?
Do you get along with your family?	What’s your relationship like with your family?
You dropped out of school in 11th grade, right?	Tell me more about your experience in school.
Are you male or female?	With what gender, if any, do you identify? What gender pronouns do you use?

Active Listening

Create a listening atmosphere. Sit facing the participant, not behind your desk, and turn your phone to silent.
Look directly at the speaker (but be aware that some people are not comfortable with maintaining eye contact).
Listen and absorb what the speaker is saying (verbal and body language).
Stay mentally present and focused on the speaker.
Maintain a balance between listening and speaking. Use statements to encourage the participant, like “I’d like to hear more about that experience.”
Use open-ended questions.
Refrain from mentally preparing YOUR response.
Nod occasionally.
Smile and be aware of other facial expressions.
Use reflective listening, like “What I’m hearing is…”.
Ask questions for clarification.
Summarize the speaker’s comments periodically.
Remain nonjudgmental.
Do not interrupt!

Strengths-based Approach:

Compliance-focused approach	Strengths-based approach
Participant enters. Case manager: “You’re fifteen minutes early. I can’t meet with you right now. Wait here.”	Participant enters. Case manager: “It’s so great to meet you. Thanks for coming early–that’s going to be a useful skill in your job interviews. Let me finish up with this other participant. I’ll be with you in a few minutes.”
Meeting begins. Case manager: “Sit down. Fill out this form.”	Meeting begins. Case manager: “Welcome! It’s so nice to meet you. Have a seat. Can I get you some water?”
Case manager: “You didn’t fill out immigration status. You have to fill out the entire form or I can’t help you.”	Case manager: “You can fill this form out on your own or I can walk you through it. Fill out as much as you are comfortable sharing right now.”
Case manager: “Why are you here?” Participant: “Someone told me you can get me a job.” Case manager: “We don’t give away jobs, you’re going to have to do the work to find one. We just have connections.”	Case manager: “What brought you in today?” Participant: “Someone told me you can get me a job.” Case manager: “We can definitely help you with some skills and connections that will hopefully result in a job! Let me tell you more about what our program involves and then I’d like to learn more about your experiences and strengths.”
Case manager’s phone buzzes throughout the meeting. Occasionally, they look down to check it.	Case manager’s phone is on silent and put away. They’re attuned and responsive to the participant’s body language and eye contact.
Case manager: “Okay, based on what you wrote down, I’m going to assign you the following services…”	Case manager: “Thanks for sharing so much about yourself. Based on our conversation, what are some goals you have for yourself? What services that I mentioned are you most interested in?”

Trust vs. Mistrust: Children begin to learn the ability to trust others, established from the consistency of their caregivers. When trust develops well, the child achieves confidence and security in the world. Unsuccessful achievement of this stage can result in failure to trust, fear, anxiety, and an overall feeling of mistrust in the world.

A note about inclusive language:

When talking with program participants about barriers and resources, using person-centered, non-stigmatizing language is an important part of conversations that are strengths-based and nonjudgmental. Download a guide with easy-to-follow tips for keeping inclusion in mind at: https://advancementproject.org/resources/the-social-justice-phrase-guide/

Do’s and don’ts for professional boundaries:

Share only your professional contact information and let clients know your/the program’s available hours.
Do not lend or provide your own personal items, money, or cigarettes to clients.
Come to agreement with all staff in your program on boundary considerations so that participants can expect consistency.
Establish guidelines for when it may or may not be helpful for staff to share personal experience with clients. Sharing personal experiences or interests can be helpful in building relationship and demonstrating empathy, but be careful not to share experiences that take the focus away from the participant or make them feel responsibility toward the case manager.
Establish guidelines for accepting gifts from participants and for providing gifts or special incentives to participants.
Decide the times when exceptions to program rules may need to be made.

Strengths-based approaches to practicing cultural humility:

When greeting a participant by name, ask how their name is pronounced and be sure to pronounce it correctly throughout your interactions.
Follow the participant’s lead for body language and eye contact. For example, if you notice a participant does not like to make eye contact, you could take them on a walk which involves less eye contact.
Recognize and explore the participant’s cultural beliefs and realize that you are not there to change them.
Instead of asking “What gender are you,” you might consider asking “Do you identify with any particular gender?” or “How would you describe your gender identity?” and “What personal pronouns do you use?”
Create a meeting space that is welcoming to people of different cultures and abilities. This might look like having participant artwork on the walls, a diverse array of snacks, or fidgets on tables.
Ask open-ended questions. Instead of “Did you grow up in the United States?” you might say, “Tell me about where you grew up.”
Keep an open mind to the participant’s identity. If someone says, “I am the first in my family to go to college,” consider asking, “What is that like for you?” instead of making assumptions based on what society tells us that experience is like.
Explore strengths, supports, and talents. Lift up experiences that the participant might not recognize as valuable. For example, if they have several younger siblings, identify how they have been a mentor to those children.
Actively listen without attempting to “fix” or give advice.
Validate the participant’s key experiences and feelings.
Use a compassionate, not condescending, tone of voice.