Disability policy and practice focus on the human rights of people with disabilities, their quality of life and their exercise of choice and control. It places people with disabilities at the centre of decision-making about their lives, recognising their strengths, preferences and personal goals. Many countries have adopted person-centred approaches to service planning and delivery which individualise and organise service systems to maximise choice and control of the services and support received. Increasingly individualised funding mechanisms such as direct payments and personal budgets are used to allocate government funding directly to individuals so that they can purchase services based on their own desired outcomes and support needs.

Individualised funding and person-centred approaches require a significant change in the roles of all professionals involved in disability services and the way services are delivered and evaluated. Disability practice must shift away from professional assessments and judgements about the services a person needs to live a good life. Rather professionals and service providers must strive for greater collaboration with the person with disability and others who know them well, to understand their support needs and preferences. Collaborative meetings of all the experts about a person’s life including the person themselves and the people who know them in different ways and from different perspectives should lead to responses tailored to meet the unique needs and preferences of a person across different life domains.

The processes of support planning are fundamental to person-centred services and individualised funding. Through a collaborative process, support planning aims to identify what is most important to and for a person to live a good life, explore resources in their environment, and make decisions about the nature and quantity of services and supports needed to assist in having a good quality of life.

Support planning has become a primary task of the disability workforce. However, service providers, policymakers and people with disabilities themselves are often confused about the purpose and processes of support planning and what constitutes best practice. For example, research shows that planning is often mistaken for a short meeting with professional experts which aims to produce a static plan or planning is conceived to be a one-off meeting between the person, their significant others and a service provider. Such misunderstandings can mean key stakeholders underestimate the time, effort and skills necessary to effectively support people with disability to live the life they want (O’Brien & Lovett, 1993; Robertson et al., 2007; Taylor & Taylor, 2013).

This chapter aims to review the purposes of support planning, the different types of plans, the common principles and processes of good planning and to consider some of the complexities of putting these principles into practice to ensure plans are implemented and inform action. In the rest of the chapter, the term “professional” primarily refers to the service provider responsible for coordinating the planning processes and developing the support plan.

Support Needs and Support Planning

Contemporary disability practice has two basic assumptions. First is that people with disabilities have the same human needs as the general population (such as needs for information, health, housing, meaningful personal relationships, active engagement, choice and control). Second is that the quality of life and daily functioning of people with (and without) disabilities is significantly influenced by the availability of supports to meet their needs (Thompson et al., 2009; Thompson et al., 2002; van Loon et al., 2010).

Supports are defined as resources (such as skills, money, technologies and time) and services that aim to promote personal growth, interests, capabilities and opportunities for a person to function and live a good life (Thompson et al., 2002; Thompson et al., 2009). Supports can be provided by natural supporters (such as family, friends and community members), mainstream services (such as health, mental health education and justice), specialised services designed specifically for an individual (such as drop-in support) or specialised services designed for a specific group of service users with disability such as a social club, day centre or group home.

The need for supports is not unique to people with disabilities: everyone in their day-to-day life relies on a variety of supports and services (such as those provided by the education system, healthcare, housing and employment). However, for many people with disabilities, supports available from mainstream services are insufficient to realise the opportunities that life presents and they may require additional or different types of support to participate in society and to have a good quality of life. People with intellectual disabilities may need additional help to meet their needs; this help is often only available through specialist disability services, such as support to access and use mainstream services, or to make decisions or participate in their community.

Current disability practice aims to understand peoples’ support needs. This means understanding how a person wants to live their life, what they want to do, what is and who are important to them, and what a person needs to stay safe and healthy. The depth and breadth of understanding sought about a person’s support needs varies considerably depending on where support needs planning occurs. For example, it may only be superficial when the purpose of planning is the allocation of funding but may be very detailed and specific when the purpose of planning is to guide the direct provision of support to meet a person’s aspirations to build social connections. It is widely acknowledged that every person’s support needs are unique and reflect the gap between their characteristics and abilities, the available opportunities in their environment and how they want to live their life. Understanding a person’s support needs, planning with them and providing the right type and amount of supports to them may bridge this gap and result in positive outcomes such as improved functioning, greater independence, better quality of life and social inclusion (Thompson et al., 2009).

Purpose and Key Principles of Support Planning

In the broadest sense, support planning is a systematic process where the person with disability, significant people in their life and professionals work collaboratively to identify what is most important to and for the person (their goals and support needs) and then develop strategies to utilise resources to enable the person to live the life they want. This open and collaborative exploratory process should result in a support plan—a document that outlines a person’s goals and describes how these will be achieved through the involvement of people, services and resources (Sanderson, 2000).

An ideal plan explains clearly a person’s desired outcomes and details specifically what will be done, when and by whom, thus setting a clear work plan for all people and services involved. Of course, many plans look very different from this ideal type. The level of detail they include about goals, needs, strategies and resources depends on where in the service system support planning occurs. Indeed, in service systems with individualised funding a person’s initial support plan may simply deal with the allocation of funding. For example, in Australia’s National Disability Insurance Scheme (NDIS), planners in the National Disability Insurance Agency (NDIA) develop high-level plans with scant details other than the volume of allocated funding. Such plans then cascade down and are progressively developed with greater levels of specificity by support coordinators, the person themselves or service providers.

Support planning is carried out by different organisations, such as federal government agencies that allocate funds (such as the NDIA), by support coordinators or case managers who aim to find and coordinate services to meet the support needs identified by funding agencies, or by staff in services contracted to deliver specific supports to a person.

Thus, plans take many shapes and forms depending on the context, the type of organisation where the planning is done and the desired outcome. Some plans may focus on a specific life domain or life course transition, and others on all domains and the whole of a person’s life. For example, people with disability and their families might plan to address a particular life domain such as healthcare, education or leisure, or plan how to best support the person through certain life stages or transitions, such as starting or leaving school, or they may focus more comprehensively on a person’s aspirations for their future lifestyle.

Regardless of the particular type of planning and its specific purpose and context, all planning processes should involve the person and others who are experts about aspects of their life. The key principles of planning processes are that it is: person centred, collaborative, individualised, focused on personal outcomes and dynamic,

  • Person centred: planning processes focus on the person and how they want to live their life. The person is encouraged and supported to have as much choice and control over the planning process as possible and thus decisions about things that are important to them.

  • Collaborative: planning processes are collaborative where people with disabilities, significant others who know them well and professionals share power and make decisions about support needs and services.

  • Individualised: planning processes and plans reflect the unique circumstances of each person and their environment. All planning activities and decisions are tailored to the person’s individual characteristics, values, life experience, age, gender, culture, heritage and language.

  • Focused on personal outcomes: planning processes focus on understanding the person’s goals, wishes and capabilities, articulating what specifically will contribute to their quality of life in the present and future and how to make it happen. Planning is not about fitting people into existing service models and solutions. Outcomes should be clear and measurable but also realistic and available.

  • Dynamic: planning is a flexible, continuous, and dynamic process, designed to suit the person’s changing circumstances, goals and priorities over time. Monitoring and review of a plan is an essential part of the process which results in ongoing listening, learning and future actions. Importantly, the planning process is not a one-off event.

Collaboration and shared power between the person themselves, professionals and service providers are key to good planning. While in the past people with disabilities were passive recipients of care and professionals were the experts, current practice requires that the person themselves and, where appropriate, those who care about them drive decision-making about support. Shifting power away from professionals does not detract from their roles as subject matter or system experts and reliance on their knowledge and expertise in working with people with disabilities, families and services and building partnerships to articulate needs and initiate actions. Support planning brings together people with disabilities as experts on their own life and professionals as “experts of the process”. While all parties play an active role in planning processes, it is the responsibility of the professionals to build and sustain a collaborative approach and create a warm and safe environment to sustain effective processes.

Support planning processes are based on the notion that knowledge and understanding about support needs and effective solutions are created through an open and free dialogue. At the start of any planning process, neither the person nor the professional possesses all the knowledge required about needs and supports. Rather it is through purposeful engagement between the person, significant people in their lives and professionals that such knowledge is shared or created. This knowledge can then be used to reach informed decisions about desired goals and preferred supports necessary to formulate a plan. It is the professionals’ role to create a safe space and to allow sufficient time for a free exchange of ideas and exploration of different options and solutions.

Many years of research in human service practice generally, and disability in particular, shows that a trusting relationship between professionals and service users results in more realistic and sustainable plans which then yield better outcomes for the person and more effective resource allocation for the service system (Collings et al., 2018; O’Brien & O’Brien, 2002).

Support Planning Processes

This section sets out the generic processes of planning, recognising that the exact nature of each step and the plan itself is heavily influenced by its purpose and context. If plans are to be successfully implemented, the planning process should explore as deeply as possible the person’s situation, goals, support needs and strategies for meeting these. Good support planning addresses issues of capacity, functioning and health and safety. This requires a tailored process that includes:

  1. 1.

    Getting to know the person or pre-planning

  2. 2.

    Assessing support needs

  3. 3.

    Formulating the plan: setting goals, strategies and processes for monitoring and review

Support planning is a complex and iterative process, where the demarcation between each part is not always clear and which may involve moving backwards and forwards between different parts (Bigby & Frawley, 2010). Nevertheless, separating and describing each part of the process is useful for identifying the tasks and issues that each involves.

  1. 1.

    Getting to Know the Person or Pre-planning

The first part of the process is sometimes referred to as “pre-planning” and lays the foundation for the rest of the process. It is important for the professional to gain insight into how to communicate effectively with the person, who are the important people in the person’s life and the support the person needs to be involved and to participate in the planning process. This requires the professional to spend time gathering and analysing information from a variety of sources about how the person communicates (e.g. verbally, using communication aids, how to tell if they are happy or not, comfortable or not with someone or something), how they learn and process information, how they make decisions and who supports them in making choices or expressing preferences. This information enables the professional to tailor the planning processes to be as beneficial as possible to the person (Collings et al., 2016; Dowse et al., 2016).

Getting to know the person involves more than reading or recording information: it is about spending time together building a trusting relationship and making sure that everyone involved understands their role, the purpose of the planning and how the support plan will be used. Too often pre-planning is undervalued and neglected or constrained by inadequate allocation of time and other resources.

  1. 2.

    Assessing Support Needs

This part of the process provides time and space to explore the person’s goals and support needs in the context of their life. It seeks to garner evidence to inform decisions about desired outcomes and what support should be included in the plan to achieve these. It is important to understand that assessment is not a diagnostic process or an evaluation of whether the person is eligible for certain services (although exploring service options and issues of eligibility may be necessary as part of formulating a plan). Rather assessing support needs is about gathering and analysing information about the person, their environment, what is important to and for them to live a good life, and the supports required for them to maintain or improve their functioning and quality of life (Chenoweth, 2005; Rummery, 2002).

The scope and nature of information needed and the method of engaging in the assessment are determined by the purpose of planning and the mandate given to the professional. Nevertheless, even if a plan is focused on one area of a person’s life such as employment, it may also require supports in other areas of their lives (such as transportation) to be considered. Effective assessment of support needs is a holistic and dynamic process that seeks to understand the various elements that impact the person’s quality of life and functioning across multiple settings and environments.

The most vital information comes of course from the person themselves. Knowledge about the person, their situation, and their goals and needs can be gained through purposeful conversation and observation with the person across multiple settings over time. It is unlikely to be enough to simply ask a person what they want or need, as many people, particularly those with intellectual disabilities, find it difficult to conceptualise and articulate their needs. Moreover, many people lack the confidence, knowledge or experience to make informed choices about things they want for themselves (Priestley, 1998). Therefore, it is important for the professional as an “expert on the process” to support the person to think about different areas of their life, ask questions and raise new ideas, opportunities and possibilities (Milner & O’Byrne, 1998; Rummery, 2002). For example, the professional can ask questions such as the following: “How do you want to spend the day?” “What do you want to learn to do?” “Where do you want to live and with whom?” “Where do you want to work?” “Who do you want to spend time with?”

Particularly, when planning with people with intellectual disabilities, it is important to also include other sources of information. This may include, for example, perspectives of family and friends who know the person well or in different contexts and settings. It may also be helpful to interview service providers and review case notes and documents such as prior assessments, health checks and service reports.

Most organisations provide frameworks to guide the domains to be covered in the needs assessment or require a review of specific documents as evidence. While some require a broad exploratory process, others call for the use of standardised tools, such as the Supports Intensity Scales (SIS) (American Association on Intellectual and Developmental Disabilities 2015–2018) or the Inventory for Client and Agency Planning (ICAP) (Bruininks et al., 1986) and the Instrument for the Classification and Assessment of Support Needs (I-CAN) (CDS, 2021).Regardless of the specific format, for an assessment to be effective it must consider three overlapping factors: the person, their environment and the supports. This stage of the process seeks to gain:

An understanding of the person:

  • Their current situation

  • Their personal characteristics (including personality, cultural background, health and impairment)

  • Their individual and family history and life circumstances (including developmental, social and cultural perspectives)

  • Their social networks and current community participation patterns (social relationships, involvement in employment, leisure or voluntary activities)

  • Their past experience using services, what has worked, what hasn’t worked and why

An understanding of the person’s environment:

  • The opportunities and resources in their environment

  • The accessibility and quality of these resources

An understanding of supports:

  • The scope and function of supports and services being used by the person including mainstream, specialist and informal support

  • Potential barriers and facilitators of supports

Next, it is important to gain insight into what is “important to” and “important for” the person. “Important to” the person is what matters to the person, their dreams and goals, and what it means for them to live a good life today and in the future (Sanderson, 2000). For example, where they would like to live and work, and what activities they want to participate in and with whom. Initially, in this part of the planning process, it is appropriate to support the person to explore their ideal vision, ensuring the discussion is not constrained by available resources or perceived barriers such as restricted funding or limitation in personal skills (O’Brien & O’Brien, 2002; O’Brien & Lovett, 1993). However, when engaged in the latter part of planning, making the best use of the available resources is clearly relevant.

In contrast, thinking about what is “important for” the person takes a more normative approach, focusing attention on what community standards might consider is necessary for a good life. For example, the plan could consider the person’s need for participation in the community, taking on valued social roles, and staying healthy and safe in their environment (Sanderson, 2000).

Information gathering is not an end in itself. To be of value, the information gathered from different sources must be analysed and interpreted to help understand the person’s goals, needs, risks and potential domains for change. This analysis provides the evidence on which decisions about goals, outcomes and potential strategies can be made. The assessment process also seeks to uncover and highlight potential challenges for implementation.

  1. 3.

    Formulating the Plan: Setting Goals, Strategies and Processes for Monitoring and Review

Support planning processes aim to formulate an optimistic but realistic support plan that sets out the person’s prioritised outcomes and specifies strategies and actions that will lead to these (Thompson et al., 2017). As already discussed the scope, nature and format of a plan are determined by its purpose, context and the mandate given to the professional. Regardless of any particular format, every plan should include three elements:

  1. 1.

    Goal setting: what will the plan achieve? The person’s goals and support needs phrased as valued outcomes: the things the person wants to achieve through the plan.

  2. 2.

    Identifying strategies: how goals are going to be met. Strategies to achieve goals, laying out specific activities and services to help the person meet their goals. This includes details about the types of support and services to be used, who will provide them, the amount required and who will fund them.

  3. 3.

    Monitoring and review processes. Processes for monitoring and review, which sets out how the plan will be implemented, managed and monitored, by whom and when, as well as when, by whom and under what circumstances the plan will be reviewed.

Goal Setting: What Will the Plan Achieve?

Goals represent what the person wants to achieve to live the life they want. Goals should be phrased as the desirable outcome the person wants and articulate what exactly will change in their life circumstances as a result of implementing the plan. Goals are personal and tailored specifically to each person’s wants and needs, bringing together what is important to and for them in different life domains (see Chap. 2). The agreed set of goals should be phrased clearly and detailed in an observable and measurable way and set out a specific time frame for achievement.

A goal could be something that the person wants to do now or in the future, for example, participating in social and recreational activities: “In the next 12 months I want to go to the shopping centre by myself or with friends”, or “I want to join a social club”. A goal could be about relationships with others or social inclusion: “I want to have more friends”, or “I want to go for family dinners”. It could be something that the person wants to learn to do to build their capacity: “I want to be able to communicate more effectively with people”, or “I want to cook my own meals”. Or it could be something that would allow the person to be more independent and have more choice and control over their life: “I want to live in my own home”, or “I want to travel independently”.

Goals can be big or small, or short term or long term. Long-term goals usually involve complex changes that take time to achieve. Long-term goals often require more detailed planning, breaking big tasks into steps using short-term goals as stepping stones to larger goals.

Decisions about which goals are to be included in a plan require careful consideration and negotiation. The needs assessment process will have given an overall picture of the person and their vision for a good life but may have resulted in a long list of goals. It is unlikely that a support plan can efficiently include all the goals identified by the person or all areas of a person’s life. Therefore, at this stage of the process, the discussion should focus on prioritising goals to be included in the plan.

The person’s preferences should be the starting point for this discussion. As with the previous stage about envisioning a good life, it is important to remember that while some people are very clear about their goals, others may require help in identifying and articulating their priorities. It is the professional’s role to help a person explore different elements in their life and to think about the changes that would most help them to live the life they want. Setting goals needs to be realistic to avoid failure and requires careful consideration of the resources required to meet them. Therefore, it is crucial at this stage to consider the person’s capabilities as well as the availability of support services and resources in their environment.

Furthermore, sometimes the goals identified by the person are different from the needs seen by caregivers, families, friends and other professionals. For example, a person may aspire to participate in activities that may be seen by others as a risk to their health, safety and well-being or as unrealistic because of the person’s skills and capacities. When these issues arise, it is the professional’s role to support the person to articulate their needs and at the same time help family members voice their concerns. The professional helps the parties to balance the principle of dignity of risk with the duty of care. Then, the parties carefully work through their differences and reach a mutual agreement about goals and how the person can be best supported to reach them.

Negotiating goals requires open and genuine discussion about practical possibilities and constraints. A good planning process seeks to balance the person’s choice and what is realistic in a given context. For example, Mary’s goal is to “have a job and earn my own money”, but the needs assessment and family members recognise that she struggles to wake up in the morning on time. It is the professional’s role to lead an honest discussion about what it may take for Mary to find a job and reflect on how important it may be to improve her time management. If Mary agrees the importance of this and is willing to work towards it, the plan could include Mary’s long-term goals as “getting a job” broken into shorter-term goals such as “in the next 12 months I want to be able to manage my time better so I can be ready on time to go to my morning activities”.

Identifying Strategies: How Goals Are Going to Be Met

This part of the plan is closely aligned with the goals and is about the “how”. It sets out what services, supports and particular steps are required to achieve the person’s goals. Each goal usually has several strategies detailing the activities, services and supports (what would happen), responsibilities (who will do it) and time frame (when would this happen, for how long).

When considering strategies, it is important to explore potential formal and informal sources of support that may assist the person in achieving their goals. These could include:

  • The person’s skills, knowledge and strengths—what can they do by themself or with support

  • The person’s informal network, including family, friends, neighbours and volunteers

  • Existing and available paid support (disability-specific and mainstream services)

  • Existing and available technologies and possible environmental modification

  • Existing and available funding mechanisms

As with all other parts of the planning process, identifying strategies is a collaborative effort: the person, the professional and others the person wants to be involved in their life should be invited to contribute their expertise and knowledge in identifying ways to accomplish the person’s goals. The decision about what strategies to include must reflect the person’s preferences and the availability and accessibility of support and services (Bigby & Frawley, 2010). There are many different possible ways of reaching a goal. It is important to consider what might be the most effective pathway for the person at this point in time. For example, if Jim’s goal is “I want to learn how to cook my own meals”, strategies could be:

  • The NDIS will fund $300 to purchase some adaptive equipment such as a switch for the blender and a tipping kettle; Jim and his mother will liaise with the Independent Living Centre to explore available technology by the end of October.

  • Two hours of support every weekday (10 hours a week) will help Jim to cook lunch and dinner—the support coordinator will organise this with the local disability support service by November 14.

When describing the strategies, it is important to use clear, specific and objective language. Where possible, avoid ambiguity or the possibility of misinterpretation by giving measurable milestones or actions. For example, it’s better to say ‘twice a week’ than “regularly”.

This stage also requires the professional to facilitate an in-depth discussion about potential barriers to supports and how they will be addressed in the plan. This might involve considering the person’s motivation, past experiences and availability of resources and funding. This will ensure that any barriers stemming from limited funding and the availability of formal and informal supports and services are clearly recognised, addressed and resolved before the plan is implemented.

Monitoring and Review Processes

Planning processes must include discussion about the management of the plan, monitoring and review. The professional leading the preparation of the plan may not be the person responsible for its implementation and tasks such as finding and coordinating services or day-to-day plan management. This makes it crucial to identify who takes responsibility for organising and implementing strategies for every goal and who will have overall responsibility for coordinating strategies and monitoring progress.

Planning is an ongoing process; personal preferences, resource availability and social environments change over time. Reviewing the plan and evaluating its outcomes help to ensure that all actions, strategies and supports are revised if they are not effective or no longer meet the person’s needs and goals.

Conclusion

Support planning is a core component of policy and service provision for people with disabilities and their families. Supporting people to develop a plan is now a primary task of the disability workforce. In this chapter, we identified the core principles and processes of successful support planning.

It is important to remember that plans are merely means to an end and are meaningful only when they are implemented effectively and result in a better quality of life and choice and control for the person. Successful support planning requires professionals to build partnerships with the person and the important people in their life and services, to guide an open and genuine exploration of the person’s needs and goals, and to reach an agreement about how to meet them. This requires considering different perspectives about the person’s situation, resolving tensions, identifying priorities, negotiating resources and considering opportunities for change. It is only through this shared understanding that meaningful goals can be identified and prioritised, and realistic strategies can be planned and implemented.

Take Home Messages

  • Disability policy aims to enable people with disability to have a good quality of life and to exercise choice and control over the services and supports they receive.

  • Support planning aims to develop a shared understanding of a person’s support needs in the context of their life and identify the supports a person requires to live the life they want.

  • Support planning has various purposes, for example, determining funding, setting broad life goals and creating detailed blueprints for the delivery of specific supports.

  • Support planning is carried out by staff with differing roles and in a wide range of organisations: for example, central government agencies which allocate funding packages for support; support coordinators and case managers add more detail about needs and goals to funding plans and find and coordinate services to meet these; and staff in services contracted to deliver specific supports to a person who must plan for how these will be delivered.

  • Regardless of differences, processes of support planning are based on principles of being person centred, collaborative, individualised, focused on personal outcomes and dynamic.

  • Support planning has three core processes: getting to know the person or pre-planning, assessing support needs and formulating the plan.