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How to complete ITP and Progress Monitoring, DHS-7109

For more information about the EIDBI service, see EIDBI – ITP development and progress monitoring.

Page posted: 2/17/17

Page reviewed: 11/22/17

Page updated: 2/9/18

Legal authority

CMS-approved state plan amendment (PDF), Minn. Stat. §256B.0949


Individual Treatment Plan (ITP) and Progress Monitoring, DHS-7109: The person-centered, individualized written plan of care. The ITP incorporates the person and family information from the comprehensive multi-disciplinary evaluation (CMDE) for a person who meets medical necessity for the EIDBI benefit. The qualified supervising professional (QSP) uses the ITP form to document the person’s initial plan of care and progress monitoring updates.

Medical necessity determination: A decision made by a qualified professional about whether a person with autism spectrum disorder (ASD) or a related condition has a medical need for and, therefore, is eligible to receive EIDBI services.

Person-centered services: Services that:

  • • Respond to the identified needs, interests, values, preferences and desired outcomes of the person or the person’s legal representative
  • • Respect the person’s history, dignity and cultural background
  • • Allow for inclusion and participation in the person’s community.
  • Overview

    This page provides guidance on how to complete ITP and Progress Monitoring, DHS-7109. Attach additional sheets to DHS-7109 if you need more room for answers.

    The qualified supervising professional (QSP) must:

  • • Always open a new form when starting a new authorization request to ensure you are using the latest version (never print or save the online forms)
  • • Complete all required fields
  • • Submit the form to DHS when completed
  • • Save the form as a PDF and submit for authorization (see MHCP EIDBI Provider Manual – Service Authorization).
  • Section A. Child’s personal information

    In section A, document the person’s and parent/primary caregiver’s information.

    Section B. Provider information

    In section B, document the EIDBI provider agency and QSP information.

    Section C. EIDBI service authorization request

    In section C, provide an overview of your treatment recommendations for the person.

    For each EIDBI service you request for authorization, identify the:

  • • Intensity, frequency and setting requested
  • • Treatment modality or modalities the provider team will use with the person to meet his/her goals and objectives (include percentage of time you will be using the modality).
  • In section C, you must also document how often the provider team will monitor the person’s progress. If you recommend progress monitoring to occur more frequently than every 6 months, you must provide clinical rationale.

    Section D. EIDBI service authorization request details

    In section D, provide specific information about the services you request for authorization, including:

    1. Service name (e.g., individual and/or group intervention, observation and direction, family/caregiver training and counseling, ITP progress monitoring, telemedicine and travel)

    2. Modifiers to indicate the level of EIDBI provider who will implement the service

    3. Start date and end date of services, total units per week and total units per six months

  • • Note whether the units are 15 min. or 30 min. and adjust requested units accordingly
  • • Use the EIDBI Billing Grid for service limits.
  • Recommended treatment intensity should match the amount of units requested for each service.

    You must base your requests on the person’s medical necessity determination and CMDE recommendations. A service included in the ITP must meet all applicable requirements for medical necessity and coverage (see EIDBI – Medical necessity criteria).

    Section E. Child and family person-centered planning

    In section E, describe:

  • • Person and family’s strengths and primary concerns/areas in which they need help
  • • Family goals and expectations
  • • How the person’s symptoms and needs impact the family’s home life and his or her ability to participate in the community
  • • Specific, targeted skills to teach the person (i.e., skills related to functional communication, reciprocal social interaction, imitation, attention, motivation, executive function, adaptive behaviors)
  • • Parent/primary caregiver goals and strategies he/she wants to work on
  • • Parent/primary caregiver’s preferences for type, amount and focus of training and counseling services.
  • Section F. Functional Behavior Assessment (FBA)

    In section F:

  • • Document if the person received a functional behavior assessment (FBA)
  • • Describe his or her behavioral intervention plan (if needed).
  • DHS recommends the provider completes and documents a FBA if the provider uses positive supports, restrictive procedures or develops an intervention plan to target interfering behaviors.

    Section G. Primary EIDBI treatment goals

    In section G, define and describe the person’s targeted goals and objectives and how the provider team will measure progress.

    The person’s goals and objectives must:

  • • Be attainable, measureable (i.e., quantifiable) and observable
  • • Be functional and developmentally appropriate
  • • Be medically necessary (see EIDBI – Medical necessity criteria)
  • • Be person-centered (see DHS – Person-centered practices)
  • • Be written objectively
  • • Clearly define observable behavior
  • • Consider other services the person currently receives
  • • Coordinate with but not include or replace academic goals and objectives provided through the person’s individual education plan (IEP) or individual family service plan (IFSP)
  • • Focus on maintenance
  • • Focus on the generalization of skills across people, environments and stimuli for the person’s optimal participation in home, school and community life.
  • Long-term goal

    In the “long-term treatment goal” subsection:

  • • Summarize the person’s overall treatment goal and how the family will support goal attainment
  • • Identify criteria for goal attainment.
  • Developmental domains

    In the “development goal domains” subsection, identify specific objectives according to developmental domain. You do not need to complete an objective for each domain.

    For each applicable objective, document:

  • • Baseline data
  • • Projected date of accomplishment
  • • Start date
  • • Percent for mastery
  • • Progress monitoring (choose one if applicable): Percent mastery achieved, objective changed, objective discontinued or objective achieved.
  • Definitions of progress monitoring options

    In the “developmental goal domains” subsection, update goals by selecting one of the following options that best describes the progress for that goal:

  • • Percent mastery achieved: Goal mastered by achieving percent mastery criteria
  • • Objective changed: Goal carried over from previous plan but altered
  • • Objective discontinued: Goal discontinued
  • • Objective achieved: Use if goal mastered but percent mastery not met.
  • For more information, see the progress monitoring section.

    Section H. Summary of current services

    In section H, document all other services the person receives, such as case management, school, CTSS, HCBS waivers, speech therapy, occupational therapy, personal care assistance (PCA), home care, etc.

    Section I. Coordination of care

    In section I:

  • • Document if a coordinated care conference occurred
  • • Summarize conference outcomes (if applicable).
  • The coordinated care conference is a covered service under the EIDBI Benefit. For more information, see EIDBI – Coordinated care conference.

    Progress monitoring

    The QSP must submit an ITP progress monitoring update after each six months of treatment, or more frequently as determined by the CMDE provider or QSP. This is to determine if the person is making progress toward targeted functional and generalizable goals specified in the ITP.

    In the “progress monitoring” section, document the person’s progress toward ITP goals and objectives during each update. Your documentation depends on the progress monitoring option selected in the primary EIDBI treatment goals section. In the person’s initial ITP, the “progress monitoring” section will be blank.

    Adjusting the ITP based on progress monitoring

    Based on the results of the ITP progress monitoring, the ITP must be adjusted as needed and must document that the EIDBI service continues to be medically necessary for the person or the person is referred to other services. As a person makes progress toward his/her goals/objectives, the EIDBI provider team, in consultation with the person's parent/primary caregiver, must adjust the person’s ITP.

    As part of this adjustment, a QSP, Level I or Level II provider must perform an updated observation of the person. The adjusted ITP may also include input from licensed education staff or other licensed health care providers.

    The QSP documents all ITP adjustments in DHS-7109. These must include:

  • • Person’s current rate of goal/objective achievement, including when a goal is achieved, added, changed or discontinued
  • • Input from the person’s legal representative or primary caregiver
  • • Recommendations for continued EIDBI services based on his/her medical need
  • • Referral to other services
  • • Significant change in the person’s condition or family circumstances
  • • Transition or discharge planning
  • • Treatment modifications (e.g., modality, intensity, frequency and duration) and rationale for the change (this may include updates to family/caregiver training and counseling).
  • Transition and discharge planning

    In the “transition and discharge planning” section, the QSP must document the discharge criteria that will be used and a defined transition plan.

    The transition and discharge plan must include:

  • • Criteria the provider team will use to evaluate if it is medically necessary for the person to transition to other services and/or discharge from EIDBI services
  • • Plan for transitioning services (plan must meet the termination of services requirements)
  • • A description of how the person or the person’s legal representative will be informed of and involved in the transition (e.g., time allowed to make the transition).
  • Addendum A

    Once DHS-7109 is completed, the QSP, parent/legal representative(s) and the interpreter (if applicable), must sign Addendum A.

    The date the parent/legal representative(s) signs the ITP is the date the evaluation is considered complete. Signing Addendum A confirms understanding of and agreement with the treatment plan and service recommendations.

    Addendum B

    In Addendum B, identify everyone who participated in the ITP’s development or progress monitoring, including:

  • • Parent/legal representative(s)
  • • QSP
  • • Level I or II providers.
  • Addendum C

    When completing Addendum C, “A typical week in the life,” account for all of the hours in the week (i.e., complete all available boxes).

    The “week in the life” should reflect the recommendations in the ITP, including:

  • • Amount and type of EIDBI services
  • • Other services the person will continue to receive in addition to EIDBI services.
  • If the person does not have activities or therapy sessions scheduled, use a phrase such as “no activity scheduled” or “free time.”

    Additional resources

    DHS – Person-centered practices
    EIDBI – ITP development and progress monitoring

    EIDBI – Medical necessity criteria

    ITP and Progress Monitoring, DHS-7109

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