Service and Support Planning


All Waiver services must be delivered according to the written Individual Support Plan (ISP). The ISP is based on information learned about the person, such as:

  • What is important to him/her in order to live his/her idea of a good life,
  • What is important for helping him/her stay healthy, safe and a valued member of the community,
  • What he/she is interested in doing,
  • What he/she does well, and
  • What he/she needs help with from the provider (support).

In some instances, a person may have difficulty communicating. In these situations, much of the information may be provided by the SC and/or family on behalf of the individual, particularly if he/she is new to a provider. Once a person is receiving supports, a great deal will be learned about the person from spending time with him/her in different settings, seeing what he/she can and cannot do, learning what he/she likes and doesn’t like, and by talking to him/her and others who know the person well.

You will be asked to participate in a team approach to providing supports, which may include answering questions, attending team meetings or actually completing an individual’s assessment. As a team member in providing supports, you will make contributions to the ISP – especially the “Personal Profile,” which is a personal description of the person to help the team focus on what’s important to the person, what needs to stay the same, and what needs to change for the person to have a good life.

Standardized Assessment for Virginia

Each person using Waiver services is assessed using the “Supports Intensity Scale” ® (SIS). This scale is completed every three years with the person and other people who know him/her well. This instrument gives service providers consistent information about the people they support. In addition, each person using Waiver services will have a “Risk Assessment” (which is part of the SIS) completed annually to determine health and safety needs and help plan supports for especially serious medical and/or behavioral issues. You may be asked questions about people you support in order to help complete one of these assessments.

The Individual Support Plan is person-centered and addresses what is important to and important for the person. Desired outcomes and supports in important life areas, including work, home, community, and recreation are identified and included in the plan.

Planning Team

The ISP is developed by a team with the person at the center of planning. Other members of the team include family members, guardian/authorized representative (if there is one), friends, SC, and service providers. The team must meet at least once a year to develop the ISP for the next year.

  • Meeting format: These meetings should be fun and informal, with all team members helping the person feel comfortable expressing his/her hopes, desires, and worries about services and supports. Team members (with permission from the person) present what they’ve learned and make suggestions related to his/her desired outcomes, preferences and supports to be provided in the upcoming year. Provider roles and responsibilities are decided upon and the shared plan is agreed to by all team members.

Planning Team image

Plan for Supports

Each provider develops a Plan for Supports with the person to address the outcomes that they agreed to at the meeting for their service area. In this way, the supports and activities that lead to reaching the desired outcomes are discussed and become a part of each Plan for Supports. A Plan for Supports is based on the role that each service fills in the person’s life. For example, a group home (or residential) provider might not help the person learn a job, but would help him/her to meet more people in the neighborhood or become a better cook. Each Plan for Supports becomes a part of the larger ISP.

Integrated Supports

This work is part of a larger overall effort pertaining to system redesign to improve services to people with DD in Virginia and will become a part of the overall planning process. Several of the concepts underlying the planning tool are inspired by LifeCourse principles and related work from the University of Missouri – Kansas City (UMKC). Many of the materials are available for download at

Person Centered (quarterly) Reviews

The Plan for Supports must be reviewed in writing once every three months to make sure it is still working for the person. This review looks at whether services are being delivered as described in the Plan for Supports, how well they support the person and whether the person is satisfied with the services. The person-centered review helps determine the appropriateness of the services and whether the supports being provided are moving him/her closer to achieving his/her desired outcomes. All Waiver providers’ person-centered reviews are sent to the SC for his/her review.


Each provider must maintain documentation that shows:

  • Supports were provided as described in the Plan for Supports;
  • What supports were provided and when;
  • That the Plan for Supports is being reviewed on a regular basis to determine status, movement or progress towards outcomes; and
  • That changes to the Plan for Supports are made as needed or desired by the person.

Formats and styles for this documentation vary from agency to agency. Recommended formats are available on the DBHDS website. Specific requirements for the agency where you work will be explained to you by your supervisor.