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Service Planning in Adulthood


The Developmental Disabilities Service System can seem complex to a newcomer. However, once you understand the different parts, how they work together, and in what order to access them, it can be easier to navigate. First, the individual or the person supporting them must contact the Developmental Disabilities office for the county in which they live to set up an intake appointment. To find your local County Developmental Disabilities Program (CDDP) office look here: Community Developmental Disabilities Program (CDDP) by County.

The intake includes gathering records and completing evaluations to determine eligibility. People are eligible for developmental disabilities services in the state of Oregon based on criteria related to IQ and adaptive skills challenges present prior to their 18th birthday. Once all of the documentation is gathered, the eligibility worker will review and compare it to the rule (Oregon Administrative Rule - OAR 411-320-0080) to see if you are eligible for our services.

Services Coordination (also known as Case Management)

Once an adult is deemed eligible, they will have the option of choosing who will coordinate their services. That office will connect the individual with Service Providers to get the support they need. There are two options for service coordination. The individual can choose to stay at their county office where their point person is called a Service Coordinator (SC). The other option is to choose a Support Services Brokerage where the point person is called a Personal Agent (PA). Here is a list of Brokerages by location.

Oregon is unique in that it is the only state with Support Services Brokerages. Back in 2003 a lawsuit established the brokerages to eliminate long waiting lists. Read more about the Staley Settlement here.

Whether the individual chooses a CDDP or a Brokerage, they will not get services there. The Service Coordinator at the CDDP or Personal Agent at the Brokerage will connect the individual with Service Providers and facilitate the transfer of funds on the individual’s behalf.

Creating an Individual Service Plan (ISP)

An Individual Service Plan (ISP) is a roadmap to the support an individual needs and chooses to implement in their life. Either the Service Coordinator (SC) or the Personal Agent (PA) (see Accessing Support Services) calls a meeting annually to create or update the ISP. The individual gets to choose who will attend. Anyone in the individual’s life whether paid or providing natural supports can be invited.

During this meeting the needs of the individual are assessed and identified through an interview. Options for resources are presented by the SC or PA, and the team brainstorms other possible ways to address unmet needs and/or continue ongoing supports. Supports may be related to housing, employment, finances, family and personal relationships, sexuality, mental health, physical health, recreation, and anything else that might support the individual in living a fulfilling life.

Support conversations often start with identifying the need for attendant care which includes Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs).

ADLs are about basic needs and include but are not limited to assistance with bathing, personal hygiene, dressing, eating, mobility (ambulation, transferring and positioning) bowel and bladder care, stand by support, cognition, memory care and behavior supports.

IADLs are more complex activities. They assure a person can live as independently as possible in the community and may include supports that assist a person to continue to productively work toward long range goals i.e. managing money, using technology, transportation to work or classes, or they may be related to maintaining independent living such as light housekeeping, laundry, meal preparation and chore services and medication management.

Around the time of the annual ISP, the Service Coordinator or Personal Agent will also ask the individual and one or more people who provide them direct support to participate in an Oregon Needs Assessment (ONA). This is an interview that determines the number of service hours available to help meet the goals identified in the ISP.