When we refer to an ISP or Individual Service Plan, we are talking about the document used by your agency and support team to define the agreement between you and the person receiving services as to what services and support will be provided to meet specified goals and objectives for a set period.


“A test for something being person-centered is that it works for humans.” Michael Smull

The final HCBS rule specifies that service planning for individuals must be developed through a person-centered planning process that addresses health and long-term services and support needs to reflect individual preferences and goals. Using a person-centered approach when developing an ISP increases the engagement of the person receiving services which creates a partnership that increases the likelihood of achieving desired outcomes.  A person-centered ISP…

  • is highly individualized.
  •  aims to bring the person more fully into their community, increase their quality of life, and leave them in more positive control.
  •  emphasizes the gifts and abilities of the individual as well as the needs identified by both them and others on the support team.
  • reflects cultural consideration and uses universal, respectful, and easily understood language.
  • creates a shared vision with meaningful outcomes for the identified period.
  • captures the hopes and dreams of the individual.

Some mistakes to avoid in person-centered ISP work include assuming you as the professional already know what is best for the individual, not allowing enough time to discover what matters most to the individual and their circle of support, fostering dependence by not encouraging self-reliance and positive control and not striking a balance between what is important TO the persona and what is important FOR them.

Funding Source Requirements

While we rightly focus on the individual’s preferences and needs first when developing an ISP, there are likely components required by the entity funding your services that need to be included in the final written document.  Examples of possible funding source required ISP components include a statement of progress on previous objectives, clearly defined and measurable goals, and objectives, baseline status, and barriers to achievement.  Your funding source may also require objectives related to certain trends or need areas such as emergency and disaster planning, financial stability, health and wellbeing, or access to generic resources.  In addition, there may be requirements for specific formatting, signatures, and timelines for submission.

Roadmap for Success

The ISP serves as a roadmap for the team.  In some cases, it is the only document used to capture essential information about the person receiving services, but it may also be the only written guide for how to achieve the shared definition of success for the individual during the reporting period.  A person-centered roadmap builds on the strengths of the individual rather than perseverating on deficits.  An effective ISP contains not only the goals and objectives agreed upon with the individual, but also details what success looks like, the steps necessary, who is responsible for what, and any supplies needed.  A person-centered road map balances the concepts of important To and important for.  Ideally, the team will be referring to the ISP frequently for direction.  Here is an example of a person-centered roadmap:

Important for Becca: 

Insulin use, diabetic diet, blood sugar monitoring

Important to Becca: 

Feeling good


Becca follows diabetic care each day so that she feels good.

Steps to get there: 

  • Preparing diabetic-friendly meals and snacks, taking insulin as prescribed, monitoring blood sugar, comfort check-ins 
  • Effective support Instructions detail how the support will be provided, under the individual’s needs and preferences, and how the individual will participate in the provision of supports. For the example above there could be additional support instructions such as these
  • Staff conducts finger sticks every morning according to ’s diabetes protocol (attached).
  • Staff gently reminds Becca that “it is time.” That is all that needs to be said, and she will know. Saying “finger stick” upsets her.
  • Becca chooses where to sit; some days she prefers being on her bed, and some days she prefers being on the lounge chair in the living room.
  • The staff puts smooth jazz music on the radio or tells a joke or a story to distract her during the finger stick.
  • If upon testing, Becca’s blood sugar is lower than 80 mg/dl or higher than 120 mg/dl, take health and safety steps described in her protocol (attached).

Information for Years to Come

Keep in mind that writing any written report with information about a person receiving services, especially an ISP, is part of the person’s permanent record and in most cases is considered a legal document.  You have likely both heard and said, “If it isn’t written down, it didn’t happen”.  Well, the converse is true that when it is written and submitted, it is considered true.  Take the time to review ISPs for accuracy and professionalism.  This is especially important when someone else has submitted a draft to you for approval.  Be sure to look for copy-and-paste errors. Verify dates and numbers that can be easily transposed on accident, of course, check grammar.  I can’t tell you how many times I have discovered incorrect information in a report that had already been submitted which meant I then had to send a corrected report.