| Individualized Family Service Plan (IFSP) |
|---|
Child's Name: Jane Doe
Birthdate:
Age
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| Developmental Levels: |
| 15-18 months | Fine Motor | 12-15 months | Gross Motor |
| 15-18 months | Cognitive | 18-21 months | Language |
| 12-15 months | Self-Help | 18-21 months | Social/emotional |
Child Strengths and Needs:
Jane's developmental strengths are in her ability to communicate and interact with her mother, aunt, and brother and sister. Despite her many health problems, Jane's temperament is sunny, and her disposition makes it easy for her to get the adults around her involved with her.
Jane's physical health varies considerably as a result of her HIV infection and this affects her motor development, which is very uneven. Jane has persistent diarrhea and recurring ear infections. Jane is a fussy eater and sometimes throws food she doesn't like or want. She doesn't have many opportunities to play with or be around other young children, which would allow her to make the most of her good language and social skills. |
Family Strength s and Needs:
Theresa is deeply committed to keeping her family together and to caring for Jane at home as long as she can. Theresa's periods of being sick with HIV make it hard for her, at times, to manage the demands of taking care of Jane.
She has a lot of help from Yvonne and Julie, both of whom are great sources of support and can be relied o to help out whenever they are needed.
Yvonne goes grocery shopping fort he family, helps Julie with her school work, takes Jane and Theresa to medical appointments, and has made a home for Roger with her family. Because Theresa relies so heavily on Yvonne and because Yvonne disapproves of Theresa's drug use so strongly, Theresa wants to enter a treatment program again.
Julie is devoted to her little sister and helps out with her every chance she gets. Julie says she wants to be a very important part of Jane's IFSP team.
Right now, mealtimes are not good times at the Doe's.
Theresa is often too tired to cook dinner and then coax Jane to eat, but she worries about Jane not getting enough to eat and wants to see her grow stronger. Julie manages dinner whenever Theresa is too tired, but she isn't sure what she can make for dinner that Jane would like and want to eat. Theresa also wants some time alone during the day to rest when she isn't feeling strong, and she hopes Jane will have a chance to be around other young children. Theresa needs a stroller in order for her to be able to take Jane out of the house. |
Outcomes:
- Theresa wants to control her drug addiction in order to maintain her good relationship with her sister.
- Theresa wants Jane to be in day care, so that Theresa has some time during the day and so that Jane can have a chance to play with children her own age.
- Theresa and Julie want some help at mealtimes in order for Jane to learn how to eat more foods, be less fussy, and grow stronger.
- Jane will have physical therapy in order to increase her body strength and mobility and make it possible for Theresa and Julie to take care of her at home.
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Outcome: #1
Theresa wants to control her drug addiction in order to maintain her good relationship with her sister. |
Strategies/Activities:
- Theresa, Dolores (the WIN service coordinator), and Betty (Theresa's hospital social worker) will discuss Theresa's options for a drug treatment program.
- Theresa will choose the option she prefers and will call to refer herself within a week of the discussion.
- If there is a waiting list, Betty will arrange for Theresa to have a priority admission because of her illness.
- Theresa will complete the intake process for the treatment option she chooses and will go to treatment sessions as scheduled. Dolores or Betty will go with Theresa to her appointments whenever she asks.
- Betty, Dolores, and Yvonne will help and support Theresa, encouraging her efforts. Theresa will tell Dolores and Betty when she feels like using drugs, and they will tell Theresa whenever they think she is using drugs.
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Criteria/Timelines:
Theresa will determine if she is making progress overcoming her drug addiction. She suggested that she review her progress with Dolores every month. |
Outcome: #2
Theresa wants Jane to be in day care so that Theresa has some time to rest during the day and so that Jane can have a chance to play with children her own age. |
Strategies/Activities:
- Dolores will investigate day care centers within walking distance of the Doe's house and will talk over the options with Theresa.
- Theresa will make a choice from the options.
- If the publicly funded day centers are not available or are inappropriate for Jane, Betty will arrange for Theresa to get financial assistance from the Department of Social Services or the hospital to pay the fees.
- Dolores and Theresa will enroll Jane together as soon as possible.
Yvonne will try to get a friend to loan Theresa a stroller. If this doesn't work out, Betty will ask social services to buy a stroller so that Jane can go to daycare. - Theresa will take Jane every morning to the center when she is well enough to take her. Julie will pick Jane up in the afternoon.
Dolores will arrange for a home health aide or visiting nurse to help out during the day with Jane when either Jane or Theresa is not well enough to manage alone. - When Theresa and Jane are both well, Theresa will take Jane in her stroller to the park down the street once a week.
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Criteria/Timelines
The timelines are as listed above in the activities. Theresa will decide if she is satisfied with the way things are going and if her need has been met as specified in the outcome. |
Outcome: #3
Theresa and Julie want some help at mealtimes in order for Jane to learn how to eat more foods, be less fussy, and grow stronger. |
Strategies/Activities:
- Dolores will arrange for a home nutritionist or visiting nurse to come to the Doe's five evenings a week, beginning in two weeks.
- The home visitor will help Theresa and Julie make a list of several finger foods that are god for Jane and that she likes and is able to eat.
- The home visitor will show Julie how to make several easy to prepare dishes that Jane likes and is able to eat.
- John Bennett, the WIN occupational therapist, and Dolores will do a feeding evaluation of Jane next week, before the home visitor comes to determine if Jane has any special feeding problems and will develop a plan with Theresa, which would become a part of this IFSP, to remediate the problem if one exists. The evaluation will be done at home at a regular mealtime.
- Yvonne will continue to do the grocery shopping for the Doe's, now using a list that Julie has made for her.
|
Criteria/Timelines:
The timelines are as listed above in the activities. Theresa will decide if she is satisfied with the way things are going and if her need has been met as specified in the outcome. |
Outcome: #4
Jane will have physical therapy in order to increase her body strength and mobility and make it possible for Theresa and Julie to take care of her at home. |
Strategies/Activities:
- Charlene Cangelosi, the hospital physical therapist will visit Theresa and Jane at home once a week to monitor Jane's motor development for signs of loss of previously attained skills.
- Charlene will work with Jane on her balance and righting reactions.
She will show Julie and Theresa how to play with Jane in a way that gives her practice in these activities.
- When Julie plays with Jane, she will play in the way that Charlene is teaching her.
- Dolores will come to one of Charlene's sessions every month to learn how Jane is doing.
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Criteria/Timelines:
Jane's therapy will begin next week. Charlene will use clinical observation to judge Jane's progress or Jane's maintenance of previous motor skills, and will do a formal evaluation jointly with Dolores every three months to monitor Jane's motor development. |
Notes on the IFSP Process:
Betty Allain, Theresa's hospital social worker, referred Theresa and Jane to Project WIN. The WIN assessment staff planned a transdisciplinary arena assessment with Theresa, Yvonne, and Julie. Betty became part of the team for the assessment.
Following the assessment, Theresa decided to enroll in Project WIN with Jane. Betty is part of Theresa's IFSP team, along with the occupational and physical therapists from the project. Yvonne and Julie are on the team, and Dolores Doiren will work with Theresa as her service coordinator.
Because Theresa and Jane have HIV, they may need the services of many agencies other than the hospital and Project WIN. New members will be added to this transagency IFSP team by Theresa, or with Theresa's consent as the need arises.
Theresa was very clear about the kinds of support she needed and plans to tell Dolores any time she needs or wants a change in the IFSP for Jane, Julie, Roger, or herself. Because Yvonne may need to take over for Theresa at any time should she become too ill to care for her family, Theresa has asked that Yvonne be a full member of the team and have access to all the records relating to Jane and the Doe's IFSP. |
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