I Goal Setting Policy

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HEALTHY FAMILIES MASSACHUSETTSGoal Setting and IFSP Policy

September 2011

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HEALTHY FAMILIES MASSACHUSETTSPOLICIES & PROCEDURES

GOAL SETTING and the INDIVIDUALIZED FAMILY SUPPORT PLAN

In the HEALTHY FAMILIES MASSACHUSETTS (HFM) program home visitors have the opportunityat each visit to identify family strengths and assist families in using those strengths to set andachieve goals, thus building the parents self-esteem. The process of formalizing the familysgoals, strengths, and concerns helps them plan for the future, supports their progress, andmodels planning, decision making and coping mechanisms. Home visitors workcollaboratively with families to develop goals and an Individualized Family Support Plan(IFSP). The written IFSP allows the family to focus their skills and resources and provides homevisitors a guide for the content of their work with families. Goal setting refers to theprocess ofdeveloping goals, while the IFSP refers to the form used to document this process.

The HFM goal setting and individualized family support plan policies and procedures isdivided into the following sections:

The process of goal setting; Timeline for developing the IFSP; Identifying goals; Documentation of goalsthe IFSP; IFSP documentation and review; and Using goal and the IFSP to guide service delivery.

Attached to this policy are the following appendices: Appendix A: HFM IFSP forms Appendix B: HFM ISFP form instructions

I. THE PROCESS OF GOAL SETTING

A. Home visitors establish a trusting relationship with participants through the deliveryof strengths-based services. This includes using non-judgmental, supportivetechniques to gather information about the family, such as using the Family Profile and

guided conversations with the family.

B. Home visitors explain the importance of setting goals, as well as making the processmanageable by assisting participants with breaking goals into action steps. This mayinclude using language or terms for the goal setting process that are more accessible orfriendly for individual families.


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C. Home visitors help participants articulate goals they have for themselves and theirfamily. This can be through conversations or activities that help them identify thesegoals. Examples of such activities include the Family Profile, goals/values clarificationworksheets, etc.

D. Home visitors clarify participant goals and action steps to achieve those goals,connecting participant goals to the parameters of the five HFM goals. These five goalsare: To prevent child abuse and neglect by supporting positive, effective parenting skills To achieve optimal health, growth, and development in infancy and early childhood To promote increased educational attainment, job, and life skills To reduce repeat teen pregnancies To promote optimal parental health and wellness

E. Home visitors assist participants in developing and organizing their goals into awritten HFM IFSP (form Appendix A) containing agreed upon family and programgoals that reflect the current/ongoing needs and interests of the participant.

II. TIMELINE FOR DEVELOPING THE IFSP

A. When introducing the program to newly referred participants, home visitors shouldexplain that goal setting and the IFSP process is an integral component.

B. The identification of participant goals and the development of the initial IFSP mustoccur within 60 calendar days of a participants first home visit. Informationgathered during the Family Profile process must be used to inform the initial IFSP (seeHFM STANDARDIZED ASSESSMENT AND INFORMATION GATHERING POLICYfor further information). If the process for completing any IFSP takes place outside ofestablished timelines, reasons for this must be documented in supervision and

participant records.

NOTE: The sooner the initial IFSP is developed, the better planning for service deliverybecomes. The HEALTHY FAMILIES MASSACHUSETTS Implementation Team (HFMIT)recommends that the initial IFSP be developed within 30 calendar days.

C. After the initial IFSP is developed, home visitors, supervisors, and families update itin six months. The update process must assess progress and help them decide tocontinue or discontinue goals, identify goals achieved, develop new goals, and compilenew and continuing goals into the subsequent IFSP.

D. All subsequent IFSPs are then updated every six months based on the most recentIFSP. Reviews and revisions to the IFSP may occur at any time. In instances whencompletion of a participants IFSPs are delayed, s/he may have fewer than six months tocomplete the final IFSP when s/he is nearing graduation. Home visitors should takethis possibility into account when completing the final IFSP.


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F. As stated above, programs must use the Family Profile to identify family strengthsand concerns that are then translated into IFSP goals. Linkages between goalsidentified through the Family Profile process must be noted in the Participant DataSystem (PDS).

IV. DOCUMENTATION OF GOALSTHE IFSP

A. Once goals and action steps are identified, staff and families must record these on theHFM IFSP form. See Appendix A HFM IFSP form and Appendix B-HFM IFSP formdirections. The HFM IFSP form is available in English, Spanish or Portuguese.

B. Should participants prefer languages other than English, Spanish, or Portuguese,programs may translate the HFM IFSP forms for those participants.

C. Home visitors must complete documentation of the IFSP in the PDS in English.

PDS NOTE: The content of the IFSP must be recorded in the IFSP section of theparticipant record in the PDS. SEE APPENDIX O: PDS USERS MANUAL OF THEPROGRAM ADMINSTRATION POLICY CREATING AN IFSP.

D. Initial IFSPs must have at least one identified goal. HFM acknowledges that thisprocess can be unfamiliar and overwhelming for some families. One goal may be all thefamily is capable of focusing on initially.

E. Subsequent IFSPs should have more than one goal identified because participants aremore familiar with the goal setting process, and ideally, have a strengthenedrelationship with the home visitor.

Spotlight on Supervision: Guiding parents through goal setting can be challenging forhome visitors. Reviewing with home visitors their strategies to engage parents in goalsetting can be a rich topic for individual and group supervision.

F. When the IFSP form is complete, with all sections of the forms filled out, theparticipant, the home visitor, and the home visitors supervisor sign it (including thedate of signature). One copy is given to the family and this demonstrates that the goals

and plans to meet these goals are the familys plans and may encourage the family tocontinue to think about their goals and how they may be achieved.


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V. IFSP DOCUMENTATION AND REVIEW

A. After the IFSP is completed, reviewed, and signed by all parties, the original is placedin the familys paper record. The date of IFSP completion, that is, the date that theparticipant has signed the form, is recorded in PDS as the IFSP date.

B. The goals must then also be documented in the PDS, in the designated IFSP form.Activities completed and other progress made toward the achievement of goals,including discussion about the progress on goals, should be documented in the PDS inthe appropriate activities section of the home visit record for the participant.

C. The standard, minimum schedule for IFSP updates requires that the participant,home visitor, and supervisor update the IFSP at least every six (6) months after thedate of the initial IFSP. All goals must be reviewed and progress toward achievement

should be discussed with the participants. This will give the opportunity for theparticipant to see their successes and next steps needed as well as to decide whether tocontinue to work towards any goal not yet achieved. The participant, home visitor andsupervisors signatures are required, although the supervisor does not have to bepresent when the participant and home visitor sign the form.

PDS NOTE: Progress toward goals, including final achievement of goals, as it occurs,should be documented in the goal follow-up section in the PDS. SEE THE PDS USERSMANUAL, SECTION 7 , OF CREATING IFSPs.

D. During the six-month life of an IFSP, reviews and revisions may occur. Reasons for

review and revision may be: completion of goals, addition of goals, or the familydiscontinuing a goal because it is no longer relevant to them. All revisions to the IFSPfollow the same process for collaborative development as described above.

NOTE: Revisions to the IFSP must be noted in writing, and disseminated as describedabove. Revisions must also be noted in the PDS.

VI. USING GOALS AND THE IFSP TO GUIDE SERVICE DELIVERY

REMINDER: If the parents are driving the car, then the IFSP is their roadmap.

IFSPs guide the content of service delivery. Home visitors should ensure that steps towardthe achievement of goals are the primary focus of home visits. As new topics or issuesemerge, they can be addressed in home visits either as they relate to the family attainingtheir goals or in addition to (but not exclusion of) the work of the family in attaining theirgoals. New information or family plans may influence the relevance of already establishedgoals. This allows rich discussion between home visitor and family about how to maintain


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focus on larger goals in the midst of distractions, or how to adapt plans based on newcircumstances.

PDS NOTE: Ongoing work on goals during home visits should be documented in the homevisit record, by selecting the Linked to IFSP check box under the appropriate topic text box.

SEE THE PDS USERS MANUAL, SECTION 2 OF CREATING A HOME VISIT.

This focus on goal achievement does not mean that the familys current situation, interestsand needs are to be ignored, especially in a crisis, if activities would not be part of meetinggoals on the current IFSP. The occurrence of frequent crises may indicate that the IFSPneeds to be reviewed and/or revised. Check with participants in this situation to assess ifthey would like to change or revise their current goals.

NOTE: The IFSP should be used in a crisis to pivot services back to the familys statedgoals. For example, you could ask in a crisis home visit, How has your recent eviction

affected the amount of time you spend with your baby?

Programs are strongly encouraged to develop ways to acknowledge a familys success inattaining their goals.

Spotlight on Supervision: Having the IFSP available at case review can help homevisitors stay focused on the familys goals, and role models use of this living document.Supervisors can role model the importance of goals guiding service delivery by askingquestions that connect case review to the familys goals and their IFSP.

Please contact the HFMIT for TA regarding this policy via the TA Help Desk [email protected]
mailto:[email protected]:[email protected]:[email protected]


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Our Healthy Families Plan

Parents name: _____________________________________

_____________________________________

IFSP Start Date: ____________________________________

IFSP Label #: ____________________________________

Current Service Level: _______________________________

Next IFSP Due: ____________________________________

Things that are working well and are strengths for my family and me:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Things that my family and I would like help with, or would like to know more about:

____________________________________________________________________________________

____________________________________________________________________________________

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Parents Name(s): ______________________________________________________________

Goal Start Date: ______________ Goal #: ______________ IFSP Label #: _____________

Goal I want to Achieve: _________________________________________________________

Date I want to Achieve this goal: _________________________________________________

People/agencieswho can help meachieve this goal:

Date(s)I reviewedthis with myhome visitor:

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Steps to work toward goal:

What is the result of the goal?

I achieved this goal Date:_______I want to continue to work on this goal.I do not want to keep working on this goal.

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I/ we have selected these goals and developed this plan to achieve these goals with my/our

home visitor. We will use these goals to guide our work together.

Parents signature: ________________________________________ Date: ____________________

Parents signature: ________________________________________ Date: ____________________

Home visitors signature: __________________________________ Date: ____________________

Supervisors signature: ____________________________________ Date: ____________________


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Nosso Plano de Healthy Families

Nome dos pais: ____________________________________

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Data do inicio do IFSP: ______________________________

Nmero de etiqueta do IFSP: _________________________

Actual nvel de servio: ______________________________

Prxima data do IFSP: _______________________________

Coisas que functionam bem e meus pontos fortes to quanto os pontos fortes da minha famlia:

____________________________________________________________________________________

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Coisas que eu e a minha famlia gostariamos de ter ajuda, ou sobre qual assunto gostariamos de ter maisconhecimentos:

____________________________________________________________________________________

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Nome dos pais: ________________________________________________________________

Data do inicio da meta: ______ Nmero da meta: _____ Nmero de etiqueta do IFSP: _____

Meta que eu quero alcanar: ____________________________________________________

Data que quero alcanar a minha meta: __________________________________________

Pessoas/agencias quepodem me ajudaralanar a minha meta:

Data(s)Eu revisei o meu planocom o meu assistentede apoio famlia: :

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Passos que preciso tomar para alcanar a minha meta:

Qual o resultado da minha meta?

Eu alcanei essa meta. Data:_______ Eu quero continuar trabalhando para alcanar essa meta.

Eu no quero mais trabalhar prar alcanar essa meta.

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Eu/ns selecionamos esses objetivos e desenvolvemos este plano para alcanar-los com o meu/nosso assistente familiar. Usaremos esses objetivos da minha meta para orientar o nosso trabalharjuntos.

Assinatura da me: _______________________________________________ Data: ___________

Assinatura do pai: ________________________________________________ Data: ___________

Assinatura do assistente de apoio famlia: __________________________ Data: ___________

Assinatura do supervisor: __________________________________________ Data: ___________


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Nuestro Plan de Healthy Families

Nombre del Padre/Madre/: _________________________

__________________________________________________Fecha de inicio del plan IFSP: ________________________

Nmero de etiqueta de IFSP: _________________________

Nivel de servicio actual: _____________________________

Fecha de vencimiento para el prximo IFSP: ____________

Cosas que funcionan bien y que son fortalezas para mi familia y para m:____________________________________________________________________________________

____________________________________________________________________________________

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Cosas en las cuales mi familia y yo quisiramos ayuda o quisiramos ms informacin:____________________________________________________________________________________

____________________________________________________________________________________

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Nombre del Padre/Madre: _________________________________________________________

Fecha de inicio de meta: __________ Meta #: ________ Nmero de etiqueta de IFSP: ______

Meta que quiero alcanzar: _____________________________________________________

Fecha en que quiero alcanzar mi meta: __________________________________________

Personas/organizacioneslas cuales me pueden ayu-dar a alcanzar esta meta:

Fecha(s)Repas estos pasoscon mi visitantedomiciliario

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Pasos para trabajar hacia mi meta:

Cul fue el resultado de esta meta?

Alcanc mi meta. Fecha:_______ Quiero continuar trabajando hacia esta meta.

No quiero continuar trabajando hacia esta meta.

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Yo/nosotros hemos seleccionado estas metas y desarrollado este plan de trabajo con mi/nuestrovisitador domiciliario. Usaremos estas metas como gua de nuestro trabajo juntos.

Firmas

Padre/Madre : ___________________________________________________ Fecha: __________

Padre/Madre : ___________________________________________________ Fecha: __________

Visitante Domiciliario : _____________________________________________ Fecha: __________

Supervisor : _____________________________________________________ Fecha: __________


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Appendix B- HFM IFSP Form InstructionsSeptember 2010

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Statewide IFSP Instruction SheetCover Page

Parents Name: Record the name of primary participant on the top line and the name of co-parent, if applicable, on the second line

IFSP Start Date: Record the date that the home visitor and participant(s) begin writing the IFSPtogether.

IFSP Label#: Record the label number that the home visitor will enter in PDS.

Current Service Level: Record the participants current service level.

Next IFSP Update Due: Record the due date for the next updated IFSP; this date is 6 months

from the start date.

Things that are working well and are strengths for my family and me: Home visitor andparticipant(s) brainstorm some short statements about strengths. Remember, not every bulletneeds to have a statement.

Things that my family and I would like help with, or would like to know more about: Homevisitor and participant(s) brainstorm some short statements about needs. Remember, not everybullet needs to have a statement.

**NOTE** For initial IFSP home visitors should refer back to the My View form to help

facilitate a conversation about strengths and needs.

Goal Sheet

Parent Name: __________________Goal start date: _____ Goal #_____ IFSPLabel #______:Record the above information on each goal sheet; in the event that a goal sheet becomesseparated from the rest of the IFSP, this information will help to keep the participants fileorganized. Also, if the participant decides to add a new goal to his/her IFSP, the home visitorand participant will record a new goal start date here to show when they added this new goalto the IFSP.

Goal I want to Achieve: Record the participants goal in the box below this statement. Homevisitors should help participant(s) identify goals that are SMART (Specific, Measureable,Attainable, Relevant, and Time-limited)


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Appendix B- HFM IFSP Form InstructionsSeptember 2010

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Date I want to Achieve my goal: Record the date the participant(s) feels s/he will be able tocomplete the goal (remember, if participant(s) selects goals that are attainable in less than sixmonths, the IFSP should have additional goals that will carry it through the entire six-monthperiod).

Steps to help me work toward my goal: Record the action steps that break down the tasks to becompleted to reach the goal.

People/agencies who can help me work toward each step of my goal: Record the people oragencies for each action step that could help the participant(s) complete that step.

Dates I reviewed this goal with my Home Visitor: Record the dates when the home visitor andparticipant(s) review IFSP goals between six-month updates.

What is the result of this goal?: Complete this column at the end of the six month period and

use it to start the process of writing the next updated IFSP.

I achieved this goal: Check this box if the participant achieved this goal.

Date: Record the date the participant achieved the goal.

I want to continue to work on this goal: Check this box if the participant did not complete togoal but would like to continue to work towards this goal.

I do not want to keep working on this goal: Check this box if the participant did not complete

to goal and would like to stop work towards this goal.

**NOTE** To save paper and reduce the bulk of each participants IFSP, copy the goal sheet onboth sides of a sheet of paper. Also, home visitors should carry extra goal sheets with them at

all times to ensure they can accommodate all the desired goals participants have for theirIFSPs.

Signature Page

Signatures: Participants and home visitors must sign the signature page on the date the IFSP iscreated, and supervisors must sign and date at the next supervision session for the home visitor.

**NOTE**Enter the date of the Parents Signature as the IFSP date in PDS.

I Goal Setting Policy

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