In Wisconsin's Children's Long-Term Support (CLTS) waiver, goals start with the child and family, not with a list of available services. The family is the expert on their own priorities, strengths, and needs. The state's team-based planning framework, Deciding Together, guides this process. A service plan cannot be written until outcomes are agreed on, so goal-setting is the work that comes first.

Table of Contents

  • [What makes a strong goal for a CLTS service plan?](#what-makes-a-strong-goal-for-a-clts-service-plan)
  • [Who should be part of the goal-setting conversation?](#who-should-be-part-of-the-goal-setting-conversation)
  • [How does the Deciding Together process work, step by step?](#how-does-the-deciding-together-process-work-step-by-step)
  • [What should goal-setting avoid?](#what-should-goal-setting-avoid)
  • [How do you tell the difference between proactive and reactive planning?](#how-do-you-tell-the-difference-between-proactive-and-reactive-planning)
  • [How can Abide Supportive Living support the goals your team chooses?](#how-can-abide-supportive-living-support-the-goals-your-team-chooses)
  • [How often should a CLTS service plan be reviewed or changed?](#how-often-should-a-clts-service-plan-be-reviewed-or-changed)
  • [Key Takeaways](#key-takeaways)
  • [References](#references)

What makes a strong goal for a CLTS service plan?

A strong goal describes a specific change the child and family want to see in daily life. In the CLTS program, outcomes are the specific steps that help participants meet their overall goals, according to the Wisconsin Department of Health Services Deciding Together Instructions.

Goals describe what the child and family want to change or achieve, not which services they want to receive. A goal might focus on building a skill, increasing independence, or improving a routine at home or in the community.

Goals are agreed on by the team before the plan is developed. The plan follows the goal, not the other way around. This means the team first clarifies what the family wants, then chooses supports that fit that outcome.

Goals belong to the child and family. The team's job is to support them, not assign them. The Deciding Together Guide states that the family is the expert on their goals, strengths, and needs.

Who should be part of the goal-setting conversation?

The goal-setting conversation should include the child, family members, the Support and Service Coordinator (SSC), service providers and health care professionals, and anyone else the family chooses to include. This is the Deciding Together team described in the Deciding Together Instructions.

The family decides who sits at the table. The Deciding Together Guide reinforces that the family is the expert on their own goals, strengths, and needs. No one else can determine what matters most to the child and family.

The SSC plays a distinct role. The SSC knows available programs, tools, and services that can help the family reach a goal. The SSC brings knowledge of the system, while the family brings knowledge of their own life.

Before service planning begins, the team must complete an assessment that captures strengths, challenges, interests, dreams, and priorities. This assessment creates the foundation for meaningful goal-setting, according to the Deciding Together Instructions.

How does the Deciding Together process work, step by step?

The Deciding Together process has five steps: Identifying Outcomes, Thinking Creatively, Weighing Options, Developing the Plan, and Evaluating the Plan. These steps are outlined in the Deciding Together Instructions.

In Step 1, the team identifies outcomes without offering solutions. The Deciding Together Instructions state clearly that the team does not offer solutions during this first step. Solutions come later, after the outcome is clear and everyone understands what the family wants.

Step 4 covers choosing supports and services, assigning roles and tasks, and deciding how often and when supports and services will happen. This is where the plan takes shape around the agreed-upon goals.

Step 5 is where the team talks about what is and is not working. This step keeps goals alive rather than fixed. The team can adjust the plan as the child grows and circumstances change.

What should goal-setting avoid?

Goal-setting should avoid starting with a service and then finding a goal to fit it. The Deciding Together Guide states that Deciding Together is not starting with a service and then finding a goal to meet that service.

Goal-setting should also avoid one team member deciding the goals or problems without family input. The Deciding Together Guide is explicit that this approach is not part of the framework.

Options are not limited to what CLTS pays for. Support can come from outside the program, in place of or alongside program services. The Deciding Together Guide notes that the team should consider supports beyond CLTS-funded services.

The cheapest option is not automatically the right one. The Deciding Together Guide clarifies that Deciding Together is not only considering the least expensive options. A plan is also not meant to be an unchanging "forever plan."

How do you tell the difference between proactive and reactive planning?

Proactive planning happens during initial plan development and at regular intervals throughout ongoing engagement with a family. Reactive planning typically occurs when a problem is presented to the team. Both are described in the Deciding Together Instructions.

Proactive goal-setting produces steadier progress and fewer crisis conversations. When the team plans ahead, goals reflect the family's long-term vision rather than immediate problems.

A practical prompt is to ask what the family wants the next six to twelve months to look like, not only what is going wrong today. This question shifts the conversation toward growth and possibility.

Reactive planning still has a place. When a problem arises, the team can respond. But a plan built mostly on reactive conversations will feel less stable and more stressful for the family.

How can Abide Supportive Living support the goals your team chooses?

Abide Supportive Living provides skill instruction and respite in Milwaukee, Waukesha, Ozaukee, and Washington counties. Abide does not provide housekeeping, personal care, or nursing. The focus is on teaching skills with people rather than doing tasks for them.

For children on the CLTS waiver, Abide offers CLTS Non-Medical Respite. This short-term respite gives families a planned break while their child stays engaged and supported.

For adults funded through IRIS, Abide offers Daily Living Skills Instruction, Life Skills Training and Education, Money and Planning Skills, and Community Access Skills. These services support goals related to independence, self-direction, and community participation.

The funding routes are plain: the Children's Long-Term Support (CLTS) waiver for children, and IRIS for adults. Abide's approach means progress belongs to the individual, not to the provider.

How often should a CLTS service plan be reviewed or changed?

A CLTS service plan should be reviewed at regular intervals, not just at the start. The Deciding Together Instructions state that proactive planning continues throughout ongoing engagement with a family.

Step 5 of the Deciding Together process, Evaluating the Plan, is the built-in checkpoint for asking what is and is not working. The Deciding Together Guide describes this step as the team talking about what is and is not working.

A plan is not designed to be permanent. Goals can be revised as skills grow and priorities shift. The Deciding Together Guide states that Deciding Together is not designing an unchanging "forever plan."

Families should raise a goal that no longer fits rather than waiting for the next scheduled review. Bringing concerns forward early keeps the plan aligned with the child's current life.

Key Takeaways

  • In Wisconsin's CLTS program, goals come from the child and family first, and the service plan cannot be developed until outcomes are agreed on.
  • Deciding Together is the state's team-based planning framework, with five steps: Identifying Outcomes, Thinking Creatively, Weighing Options, Developing the Plan, and Evaluating the Plan.
  • The Deciding Together team includes the child, family members, the Support and Service Coordinator, providers and health care professionals, and anyone else the family wants involved.
  • In Step 1, the team identifies outcomes without offering solutions yet.
  • Deciding Together is not choosing a service and then inventing a goal to justify it, and it is not limited to services CLTS pays for.
  • Support for a goal can come from outside the CLTS program, in place of or in addition to program services.
  • Abide Supportive Living offers CLTS Non-Medical Respite for children and adult skill instruction funded through IRIS in Milwaukee, Waukesha, Ozaukee, and Washington counties.

References

  1. Deciding Together Instructions, Wisconsin Department of Health Services
  2. Deciding Together Guide: What It Is and What It Isn't, Calumet County
  3. Children's Long-Term Support Program (CLTS), Green County