Service Planning
Comprehensive Program Policy, P3.01 Comprehensive Service Plan Development and Transition Planning, outlines the information needed to effectively develop a service plan and service planning goals. Class Members in the CCMTP must have an established Comprehensive Service Plan (CSP) that details the Class Member’s individual high impact needs, risks, strengths and preferences and, how the Prime will support the Class Member in meeting their needs.
- The first service plan is to be completed and finalized within 45 days of receiving the referral from Maximus in AssessmentPro. This plan is referred to as the initial plan.
- All community moves must have an updated service plan finalized within 30 to 60 days preceding the transition date to the community (referred to as the transition plan).
- All Class Members who reach 17 months in the community must have a service plan completed within the 30 days preceding the 18-month milestone (referred to as the termination CSP).
- Throughout the transition continuum, all Class Members must have a service plan no older than 180 days old. Therefore, a new service plan must be reviewed, updated, and finalized every 180 days, or as clinically indicated, throughout pre- and post-transition activity periods.
The CSP should prioritize and reflect both individual choice and high impact/ high risk safety needs. In doing so, the CSP will outline a plan of care that respects the Class Member’s autonomy, while supporting them in maintaining their safety and well-being. CSPs should be developed in collaboration with the Class Member and their supports, in a language the Class Member understands.
CSPs must be developed using the Comprehensive Program Service Plan tool in the WebApp. The process for entering this information in the WebApp is described in detail in the required Orientation Module, T3.1 Service Plan, located in the Orientation Courses tab of the Colbert & Williams training website.
The Comprehensive Program requires review of the Class Member’s CSP by the University of Illinois at Chicago College of Nursing (UIC CON) for quality. Policy P3.06, Service Plan Quality Review, outlines the components of a proficient CSP. Service plan quality review rubrics are linked below and available in the WebApp library.
- CCMTP Service Planning Orientation Module (Updated February 12, 2025)
- Webinar: Best Practices in Service Planning
Presented by UIC CON on September 4, 2025
Recorded webinar | Slides - Webinar: Best Practices for Supporting Individuals Transitioning from Long-Term Care into the Community
Presented by UIC CON on April 4, 2024
Recorded webinar | Slides | Timeline Cheat Sheet - Webinar: Identifying and Addressing High-Risk Behavior
Presented by UIC CON on February 2, 2023
Recorded webinar |Slides - Webinar: Collaboration with Medical Teams and Coordination with Providers
Presented by UIC CON on January 4, 2023
Recorded webinar | Slides
Supporting Documents for Service Planning
- Service Plan Quality Review Rubrics:
- Service Planning Tip Sheet
- Fillable Comprehensive Service Plan (Download as a Word document to use fillable fields)
- High Risk Medications Handout
- CSP Example: Fictional Class Member moving to non-PSH setting with high-risk needs (Currently in development)