Scenario: Rosella Using the Integrated Supports STAR for Planning

Rosella is a 42-year-old woman living in a Personal Care Home. She is diagnosed with Bipolar Disorder, non-insulin-dependent diabetes, hypertension, and has a history of seizures. She also has a history of being exploited by others. She has a goal to move into her own apartment & gain employment at a local pet store.

Let’s work together. Open up a blank Support Star and complete on Rosella. The blank template can also be accessed on the Life Course website. You can either print the form and fill it out, or download it and complete it on your desktop.

Thinking about each section, what could you put in each heading? Click the boxes below for hints on what could be included.

Personal Strengths and Assets

List things that she is, has done, or can do.

She is friendly, determined, willing to ask for help, completed her GED, can cook with a microwave, and wants to manage her diabetes.
In the future, she will need to gain skills in meal planning, budgeting, administrating her medication, etc.

Technology-Based

List things that she knows how to use or already has.

Knows how to use the internet and basic computer skills.

Also list things that she needs.

A Smartphone to set reminders
Lose It app to track her meals which can show her the number of carbs, protein, and fiber she is eating
Internet to obtain information
A phone to make medical appointments and connect with friends.

Community-Based

List the things in the community that she currently utilizes and things in the community that she needs to support her.

Diabetes education classes through local health care providers
Cooking class at the local Cooperative Extension Office
Peer support through local Community Mental Health Center
Recovery/Support programs available through faith communities that don’t require joining in order to participate
Bus pass, and training which could be available if there is a public transportation system
National Alliance on Mental Illness (NAMI) chapter.

Eligibility Specific

There are mental health services that could be available to her through the local Community Mental Health Center.

The Office of Vocational Rehabilitation can provide employment support through the Individual Supports and Placement Program for people with significant mental health issues.

The nurse at the Personal Care Home could teach Rosella about medication administration.

Work Incentives Planning Assistance services are available to assist Rosella and Guardianship to understand the impact of work on Social Security Disability benefits.

Relationship-Based

These should be any unpaid people in her life that have an interest in her and her life and do not take advantage of her and any paid people who care and support her.

Family members
Friends, staff at the Personal Care Home who have helped her,
Former or current therapist
People who work at the pet store.

Team Member Roles

When completing the Integrated Services Star, it is important to understand the roles that everyone will play in creating and supporting Rosella’s goals.

Rosella’s Role:

To communicate with the team and work cooperatively towards this goal.
To work with her team on goal setting and eventual move.
To work on steps identified as part of a move-out plan.
To contact the Office of Vocational Rehabilitation and ask for an intake appointment

Guardianship State Service Worker (GSSW) Role:

To review the case history and determine any risk factors or barriers.
To communicate with Rosella and the team about any identified issues.
To support the planning process within the bounds of the guardianship court orders.
To set up the flow of funds to pay for things like classes, a bus pass, etc.
To sign needed consent documents/consent forms.

**In-Reach Team Role*:**

To assist with case history review and determine any risk factors or barriers
To assist with necessary evaluations and appointments for medical and psych services, if needed.
To facilitate the development of a detailed move-out plan, that includes the when, where, how & who is responsible for the tasks
To train Rosella and her staff on the final plan & assist her with the move out plan
To coordinate/facilitate ongoing meetings about the goal and how best to meet this desire

Personal Care Home Staff Role:

To support Rosella and her desire to move out.
To assist in her education about medications.
To assist with her desire to be out in the community.
To communicate with the team her progress and any issues that arise.

Supports Star with the word "job search" in the middle and images and logos used to represent ideas and resources under technology, relationship-based, community-based, personal strengths, and eligibility specific.

Click the image to view in larger detail.

Pictures can also be used instead of words, to create an Integrated Support Star. Here is an example of how you can use pictures for a job search.

*In-Reach is through the Community Mental Health Centers to help individuals who are moving into independent living in the community.