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Children’s Long-Term Support (CLTS) Provider Handbook

Section 7: Connecting With Participants and Families

Providers have an important role in supporting a participant’s needs, strengths, goals, and inclusion. Building collaborative partnerships with participants, families, and CWAs is necessary to ensure the best outcomes for participants.

Service planning

Providers play a supporting role in the participant service planning process. Participants and families seek providers who can work with a participant and family to deliver CLTS Program supports and services. They rely on providers to have the expertise and knowledge to deliver quality supports and services. Participants have a right to any qualified and enrolled providers available for the services the participant is authorized to receive, as listed in the statewide public CLTS Provider Directory.

Service Planning in the CLTS Program results in a document called an Individual Service Plan (ISP). As a CLTS Program provider, it is important for you to understand what an ISP is and what your role is with ISPs.

What is an individual service plan (ISP)?

An ISP:

  • Is a unique plan of supports and services that help a participant live at home in their community.
  • Is a flexible plan that changes as the participant’s goals and needs change.
  • Includes all CLTS-funded supports and services, as well as other services and supports that contribute to the participant’s outcomes.

The ISP contains five main components:

  1. Participant-informed rights and choices
  2. Participant outcomes: the strengths, abilities, and goals of the individual
  3. CLTS Program-funded supports and services (required billing codes, provider contact information, units of service, costs of services)
  4. Non-CLTS Program supports and services (school systems, medical providers, unpaid supports)
  5. Participant and family demographics

The ISP must include the supports and services being authorized, including the names of providers, frequency, and duration of supports and services, and the dates when supports and services will start and end. Services must be administered exactly as described in the ISP.

The complete ISP also:

  • Addresses the short-term and long-term goals of the participant and family.
  • Is a required document in the CLTS Program.
  • Has two parts: outcomes and detailed plan.

The CLTS Program uses the following documents or local forms that contain the same information:

Deciding Together (DT)

The CLTS Program requires a team approach to service planning called Deciding Together. The goal of Deciding Together is to create participant- and family-centered service plans that are meaningful, effective, and sustainable to help meet the child’s outcomes. Each family has a unique story and lived experience. Knowing and understanding their strengths, interests, hopes, dreams, priorities, and resources helps the team create an Individual Service Plan. Deciding Together supports transparent and shared decision making for families, support and service coordinators (SSCs), and other team members.

Who is part of the team?

  • The child (participant)
  • Family members
  • Support and service coordinator (SSC)
  • Service providers and health care professionals
  • Other important people included by the family

When is the ISP reviewed?

The team will review and update the ISP at least every six months. The team will also review and update the ISP whenever the participant’s needs or goals change or if a support or service is no longer needed.

Can an ISP change?

Yes. The ISP is flexible and should change if the planned supports and services are not working or if there are new outcomes. Service planning is a continuous process.

Participants, families, and the team will plan supports and services and create the ISP. This team approach helps everyone on the team understand how the plan is developed and why supports and services are chosen. The team makes decisions together and this makes sure team members work together to support the participant. Working as a team in the CLTS Program helps support better outcomes for the child.

Sharing the individual service plan (ISP) outcomes

The team will share the child’s outcomes with their CLTS Program service providers so they can support the child’s goals. This helps providers see themselves as part of the larger team supporting the participant and family. The CLTS Program requires that the team shares the child’s outcomes to make sure the child is achieving their goals. This is an important part of the Deciding Together and the ISP review.

There are three times when an SSC is required to share the ISP outcomes with authorized CLTS Program providers:

  1. When the ISP is first developed, the SSC sends copies of the ISP outcomes to essential service providers in the ISP. Each provider returns a signed copy. Essential service providers are defined as those who deliver waiver-funded services and have regular, direct contact with participants. (Find a list of essential service providers in Section 3: Provider Qualifications and Caregiver Standards.)
    • “Regular” means contact that is scheduled, planned, expected, or otherwise periodic.
    • “Direct” means face-to-face physical proximity to a participant.
  2. When an ISP is updated with a new service provider, the SSC sends a copy to the new provider and asks that they sign and return a copy.
  3. At the annual ISP review, the SSC sends copies to each of the service providers, so they know about any changes. Each provider once again returns a signed copy.

Connecting families to resources

CLTS Program providers may have more frequent contact with families and participants than other team members. It can be useful to have an idea of the other systems of support to help participants and families live in their community.
DHS has a list of community partners, resources, and newsletters to connect families to the supports they need: Helpful Resources for Families in Children's Services Programs, P-03036 (PDF).

Practice standards

There are essential expectations and considerations when working with participants and families as a CLTS Program provider. Using these standards helps ensure positive team collaboration and outcomes.

Your practice should be strength-based and participant- and family-centered, meaning you should:

  • Recognize and speak directly to the child.
  • Recognize families as the experts on their child’s needs, strengths, and goals.
  • Focus on the child’s abilities, interests, and potential.
  • Collaborate with families to ensure the services and supports they receive align with their values, hopes, and individual priorities. Practice active listening.

Practice cultural humility and responsiveness:

  • Demonstrate respect for cultural differences.
  • Avoid assumptions and seek to understand each family’s unique experience.
  • Always use inclusive and respectful language.
  • Arrange interpretation or communication supports if needed.

Practice trauma-informed care:

  • Approach interactions with empathy and care.
  • Prioritize emotional and physical safety in all settings.
  • Use predictable routines, clear expectations, and supportive communication.

Collaborate to ensure the participant is at the center of all decisions:

  • Work collaboratively with SSCs, CWAs, schools, therapists, and other service providers.
  • Communicate professionally and within a reasonable timeframe.
  • Work with families and CWAs to address challenges together.

Demonstrate consistency, professionalism, and reliability:

  • Arrive on time, prepared, and ready to provide services as authorized.
  • Promptly communicate schedule changes or concerns using the family’s preferred means of communication.
  • Provide services consistently.
  • Follow through on commitments and agreements.
  • Be timely and accurate with documentation and recordkeeping.
  • Ensure services align with the prior authorization and CLTS Program requirements.
  • Protect family privacy. Share information only with consent for authorized purposes.
  • Stay up to date on training, certifications, and licensure.

Rights and responsibilities for families

Participants and families in the CLTS Program have the right to:

  • Always be treated with respect and dignity.
  • Have their family’s culture, values, and beliefs respected.
  • Get clear and understandable information.
  • Take part in decisions, including being involved in planning services and supports.
  • Have personal and health information kept private.
  • File local county grievances or state fair hearing appeals.

You can find a copy of Participant and Family rights and responsibilities online at Participant Rights and Responsibilities Notification, F-20985.

Grievances and appeals

Contact the Wisconsin Department of Administration Division of Hearing and Appeals. Request for a Fair Hearing (PDF) from the Division of Hearings and Appeals.

Glossary