People First Supports Coordination | 855-PFSC-HELP



Locate, arrange for, and obtain services specified in the ISP. Including medical, Social, Habilitation, and Education. Community Services the individual needs to live at home or in the community.



Ongoing management of services and support stipulated in the ISP in collaboration with the individual, family, and providers of service.



Supports and services to assure that the ISP is implemented, that the ISP continues to meet the needs and desires of the individual, and that the health and safety of the individual is assured.



What is Supports Coordination -


Supports coordination is a critical service that involves the primary function of locating, coordinating and monitoring needed services and supports for individuals. Locating services and supports consists of assistance to the participant and his or her family in linking and obtaining and arranging services specified in an isp, including needed medical social, habilitation, education or other needed services.


Supports coordination also includes providing information and assistance in order to help participants decide whether to select participant directed services and assistance for participants who opt to direct services.




What does a monitoring include? Each Supports coordination monitoring activity with the individual will include a review of:


• Progress towards implementation of the ISP

• Individual’s health and well being

• Incidents

• Licensing citations of the residential home if applicable

• Individual’s satisfaction with services/supports

• Quality of services/supports and cost effectiveness

• Support outcomes and any barriers


What is an Individual Support Plan (ISP)-

In 2000, ODP recognized the need to standardize one plan to be used across the Commonwealth that would meet federal and state regulations. Using one plan allowed for the collection of consistent data. The ISP process involves collaboration between the individual, his or her family, guardian or advocate, and other people important in the individual’s life. The individual and his or her family drive the process if they choose to do so. During the information gathering process, it is important to have people present who know the individual best and will offer rich and detailed information about the individual and his/her needs. Information gathered should mirror the core values of everyday life and should reflect the individual’s personal preferences, such as communication needs, what’s important to him/her, and desired activities just to name a few. A completed plan should provide a means of achieving outcomes important to the person, integrating Natural Supports as well as funded supports. Needs must be met that effect health and welfare or, if absent, would cause the individual to not be supported in a community setting.


What is a Waiver-

Waiver is a shortened term for the Medicaid Home and Community Based Waiver Program which provides funding for mental retardation supports and services to help you to live in your home and community. The name Waiver comes from the fact that the federal government waives Medicaid rules for institutional care in order for the state to use the same funds to provide supports and services for people in the community. The state must make specific assurances to the federal government when requesting a Medicaid Waiver. Federal and state funds are combined in Medicaid Waivers.


The federal and state shares are not the same in each state and they are adjusted each year. In Pennsylvania it is generally a 50/50 split. In Pennsylvania, the Office of Developmental Programs (ODP), formerly the Office of Mental Retardation (OMR) operates three waivers: Consolidated Waiver, Person/Family Directed Support Waiver and Infants/ Toddlers and Families Waiver. Each waiver has its own unique set of eligibility requirements and service


What is Prioritization of Urgency of Need for Services -

The PUNS form is completed to inform the Administrative Entities (AEs)/County MH/MR Programs and the Office of Developmental Programs (ODP) of the number of people waiting for services and to plan for their needs. The PUNS also indicates the urgency of those needs. The PUNS is an important tool used to assist AEs/counties in developing the county plan and annual budget that is submitted to ODP. Budgets are developed two years in advance of the current year.


What Does PUNS stand for -

PUNS stands for Prioritization of Urgency of Need for Services for persons with mental retardation (MR). In addition to identifying the urgency of need for services and supports, the PUNS identifies the types of services an individual is currently receiving and services and supports that are needed. The urgency of need for services is identified in one of three levels:


Emergency Need: The Emergency need category on the PUNS is for individuals who need services within the next six months. Services needed may be in the home or out of the home. For example: When there is a death of a caregiver and there is no other family member available to provide support.

Critical Need: The Critical need category on the PUNS is for individuals who need support within the next two years. For example: When a person has an aging or ill caregiver who will be unable to continue providing support or there has been a death in the family that reduces the capacity of a caregiver to provide care.

Planning Need: The Planning need category on the PUNS is for individuals who need services more than two years from now but within the next five years. For example: When a person has expressed a desire to move, the person is living in a large setting and needs community services, or the person is “aging out” of another system (e.g. education).


What is SIS and the PA Plus-

The Supports Intensity Scale (SIS) and the Pennsylvania Plus is a standardized assessment for people with intellectual disabilities. Everyone who receives waiver services through the ID/MR System in Pennsylvania will be required to have a SIS and the PA Plus interview to evaluate the frequency, intensity and type of supports a person needs.