HEALTHY FAMILIES MASSACHUSETTS POLICIES & PROCEDURES

GOAL SETTING and the INDIVIDUALIZED FAMILY SUPPORT PLAN

In the HEALTHY FAMILIES MASSACHUSETTS (HFM) program home visitors have the opportunity at each visit to identify family strengths and assist families in using those strengths to set and achieve goals, thus building the parents self-esteem. The process of formalizing the familys goals, strengths, and concerns helps them plan for the future, supports their progress, and models planning, decision making and coping mechanisms. Home visitors work collaboratively 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 home visitors a guide for the content of their work with families. Goal setting refers to the process of developing 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 is divided 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 delivery of strengths-based services. This includes using non-judgmental, supportive techniques 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 process manageable by assisting participants with breaking goals into action steps. This may include using language or terms for the goal setting process that are more accessible or friendly for individual families.
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C. Home visitors help participants articulate goals they have for themselves and their family. This can be through conversations or activities that help them identify these goals. Examples of such activities include the Family Profile, goals/values clarification worksheets, 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 goals are: 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 a written HFM IFSP (form Appendix A) containing agreed upon family and program goals 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 should explain that goal setting and the IFSP process is an integral component. B. The identification of participant goals and the development of the initial IFSP must occur within 60 calendar days of a participants first home visit. Information gathered during the Family Profile process must be used to inform the initial IFSP (see HFM STANDARDIZED ASSESSMENT AND INFORMATION GATHERING POLICY for further information). If the process for completing any IFSP takes place outside of established 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 delivery becomes. 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 it in six months. The update process must assess progress and help them decide to continue or discontinue goals, identify goals achieved, develop new goals, and compile new and continuing goals into the subsequent IFSP. D. All subsequent IFSPs are then updated every six months based on the most recent IFSP. Reviews and revisions to the IFSP may occur at any time. In instances when completion of a participants IFSPs are delayed, s/he may have fewer than six months to complete the final IFSP when s/he is nearing graduation. Home visitors should take this possibility into account when completing the final IFSP.

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NOTE: In order for HFM services to be family-centered, establishing trust with the family must be a priority. The successful development of the IFSP will follow the building of a trusting relationship. Taking this into consideration, families should set the pace for IFSP development, which may occur sooner or later, as trust is established.

III. IDENTIFYING GOALS A. When identifying goals and developing the IFSP, the focus should be on the goals of the primary participant, although the participants goals may benefit/impact the extended family as well. B. The role of the home visitor is to support families in identifying and clarifying their goals. This exploration includes conversations with families to determine what is important to them, observations of the family, asking questions, the use of different curricula, and the Family Profile. Examples of questions that home visitors may ask to help families begin to think about their goals include: What do you want to accomplish? Why is this important to you? What strengths and resources do you have that will help you accomplish your goals? What could get in the way of you achieving this? NOTE: The examples above are not all-inclusive and, therefore, may not list all of the possible activities and tasks that may be involved in the process of goal setting and developing an IFSP. Please contact the HFMIT for Technical Assistance (TA) regarding this policy via the TA Help Desk at CTF_TAhelpdesk@massmail.state.ma.us C. Part of the home visitors role is to help families distinguish between short- and longterm goals. This is important, as long term goals may be built on the accomplishments of several short-term goals. Though the family may have goals that they may achieve over a longer period of time, goals and action steps written in the IFSP should be achievable during the six month time period each IFSP covers. D. Home visitors will assist families in setting clear and attainable goals that are achievable in the six-month timeframe of the current IFSP. Home visitors should start with family strengths, ensure clarity about role assignment, help the family to establish realistic time frames for completing goals and action steps, and make both goals and actions steps into measurable behaviors or concrete actions. E. Home visitors must respect the family-centeredness of the program and ensure that goals reflect what the family wants to achieve, while aligning the focus of their work with families within the HFM mission and goals.
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F. As stated above, programs must use the Family Profile to identify family strengths and concerns that are then translated into IFSP goals. Linkages between goals identified through the Family Profile process must be noted in the Participant Data System (PDS). IV. DOCUMENTATION OF GOALSTHE IFSP A. Once goals and action steps are identified, staff and families must record these on the HFM IFSP form. See Appendix A HFM IFSP form and Appendix B-HFM IFSP form directions. 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 the participant record in the PDS. SEE APPENDIX O: PDS USERS MANUAL OF THE PROGRAM ADMINSTRATION POLICY CREATING AN IFSP. D. Initial IFSPs must have at least one identified goal. HFM acknowledges that this process can be unfamiliar and overwhelming for some families. One goal may be all the family is capable of focusing on initially. E. Subsequent IFSPs should have more than one goal identified because participants are more familiar with the goal setting process, and ideally, have a strengthened relationship with the home visitor. Spotlight on Supervision: Guiding parents through goal setting can be challenging for home visitors. Reviewing with home visitors their strategies to engage parents in goal setting 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, the participant, the home visitor, and the home visitors supervisor sign it (including the date 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 to continue 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 placed in the familys paper record. The date of IFSP completion, that is, the date that the participant 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 in the 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 the date 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 the participant to see their successes and next steps needed as well as to decide whether to continue to work towards any goal not yet achieved. The participant, home visitor and supervisors signatures are required, although the supervisor does not have to be present 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 USERS MANUAL, 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 family discontinuing a goal because it is no longer relevant to them. All revisions to the IFSP follow the same process for collaborative development as described above. NOTE: Revisions to the IFSP must be noted in writing, and disseminated as described above. 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 toward the achievement of goals are the primary focus of home visits. As new topics or issues emerge, they can be addressed in home visits either as they relate to the family attaining their goals or in addition to (but not exclusion of) the work of the family in attaining their goals. New information or family plans may influence the relevance of already established goals. 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 new circumstances. PDS NOTE: Ongoing work on goals during home visits should be documented in the home visit 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, interests and needs are to be ignored, especially in a crisis, if activities would not be part of meeting goals on the current IFSP. The occurrence of frequent crises may indicate that the IFSP needs to be reviewed and/or revised. Check with participants in this situation to assess if they 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 stated goals. 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 in attaining their goals. Spotlight on Supervision: Having the IFSP available at case review can help home visitors 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 asking questions 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 at CTF_TAhelpdesk@massmail.state.ma.us

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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:

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Our Healthy Families Plan

Parents Name(s): ______________________________________________________________ Goal Start Date: ______________ Goal #: ______________ IFSP Label #: _____________

Goal I want to Achieve: _________________________________________________________ Date I want to Achieve this goal: _________________________________________________
People/agencies who can help me achieve this goal: Date(s)

Steps to work toward goal:

______________________________________________ 1 ______________________________________________

I reviewed this with my home visitor:

________________ ________________

________ ________

______________________________________________ 2 ______________________________________________

________________ ________________

________ ________

______________________________________________ 3 ______________________________________________

________________ ________________

________ ________

______________________________________________ 4 ______________________________________________

________________ ________________

________ ________

______________________________________________ 5 ______________________________________________

________________ ________________

________ ________

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.

Our Healthy Families Plan

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: ____________________

 Nosso Plano de Healthy Families

Nome dos pais: ____________________________________ ____________________________________ 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:

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Portuguese 12/09

 Nosso Plano de Healthy Families

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 que podem me ajudar alanar a minha meta:

Passos que preciso tomar para alcanar a minha meta:

Data(s)

_____________________________________________ 1 _____________________________________________

Eu revisei o meu plano com o meu assistente de apoio famlia: :

________________ ________________

________ ________

_____________________________________________ _____________________________________________

________________ ________________

________ ________

_____________________________________________ _____________________________________________

________________ ________________

________ ________

_____________________________________________ _____________________________________________

________________ ________________

________ ________

_____________________________________________

________________ ________________

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_____________________________________________

Qual o resultado da minha meta? Eu alcanei essa meta. Data:_______ Eu no quero mais trabalhar prar alcanar essa meta.

Eu quero continuar trabalhando para alcanar essa meta.

 Nosso Plano de Healthy Families

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 trabalhar juntos.

Assinatura da me: _______________________________________________ Data: ___________

Assinatura do pai: ________________________________________________ Data: ___________

Assinatura do assistente de apoio famlia: __________________________ Data: ___________

Assinatura do supervisor: __________________________________________ Data: ___________

 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: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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

Spanish 12/09

 Nuestro Plan de Healthy Families

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/organizaciones las cuales me pueden ayudar a alcanzar esta meta:

Pasos para trabajar hacia mi meta:

Fecha(s)

___________________________________________ 1 ___________________________________________

Repas estos pasos con mi visitante domiciliario

________________ ________________

________ ________

___________________________________________ ___________________________________________

________________ ________________

________ ________

___________________________________________ ___________________________________________

________________ ________________

________ ________

___________________________________________ ___________________________________________

________________ ________________

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___________________________________________

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Cul fue el resultado de esta meta? Alcanc mi meta. Fecha:_______ No quiero continuar trabajando hacia esta meta.

Quiero continuar trabajando hacia esta meta.

 Nuestro Plan de Healthy Families

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

Firmas
Padre/Madre : ___________________________________________________ Fecha: __________

Padre/Madre : ___________________________________________________ Fecha: __________

Visitante Domiciliario : _____________________________________________ Fecha: __________

Supervisor : _____________________________________________________ Fecha: __________

Statewide IFSP Instruction Sheet Cover Page Parents Name: Record the name of primary participant on the top line and the name of coparent, if applicable, on the second line IFSP Start Date: Record the date that the home visitor and participant(s) begin writing the IFSP together. 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 and participant(s) brainstorm some short statements about strengths. Remember, not every bullet needs to have a statement. Things that my family and I would like help with, or would like to know more about: Home visitor and participant(s) brainstorm some short statements about needs. Remember, not every bullet 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 #_____ IFSP Label #______: Record the above information on each goal sheet; in the event that a goal sheet becomes separated from the rest of the IFSP, this information will help to keep the participants file organized. Also, if the participant decides to add a new goal to his/her IFSP, the home visitor and participant will record a new goal start date here to show when they added this new goal to the IFSP. Goal I want to Achieve: Record the participants goal in the box below this statement. Home visitors should help participant(s) identify goals that are SMART (Specific, Measureable, Attainable, Relevant, and Time-limited)

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Date I want to Achieve my goal: Record the date the participant(s) feels s/he will be able to complete the goal (remember, if participant(s) selects goals that are attainable in less than six months, the IFSP should have additional goals that will carry it through the entire six-month period). Steps to help me work toward my goal: Record the action steps that break down the tasks to be completed to reach the goal. People/agencies who can help me work toward each step of my goal: Record the people or agencies 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 and participant(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 to goal 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 on both 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 their IFSPs. Signature Page Signatures: Participants and home visitors must sign the signature page on the date the IFSP is created, 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.

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