New Ways to Think About Person Centered Goals and Objectives

1. MELISSA SKAGGS
VICE PRESIDENT
TBC SERVICES AND PROVIDER RESOURCES GROUP

2.  DEFINING PERSON CENTERED PLANNING
 PRINCIPALS OF PERSON CENTERED PLANNING
 MYTHS OF PERSON CENTERED PLANNING
 THINKING OUT OF THE BOX – THE QUESTIONS
 DEFINING OUTCOMES AND OBJECTIVES
 HOW TO CHOOSE AND PRIORITIZE OUTCOMES
 WRITING CLEAR OUTCOMES AND OBJECTIVES THAT CAN BE
IMPLEMENTED
 WHAT HAPPENS WHEN THE OUTCOME OR OBJECTIVE DOESN’T
WORK

3. PERSON CENTERED PLANNING HAS BEEN DEFINED BY CMS AS…..
 A PROCESS, DIRECTED BY THE FAMILY OR THE INDIVIDUAL WITH
LONG TERM CARE NEEDS, INTENDED TO IDENTIFY THE STRENGHS,
CAPACITIES, PREFERENCES, NEEDS AND DESIRED OUTCOMES OF THE
INDIVIDUAL
 PARTICIPANTS OF THE PLANING PROCESS ENABLES AND ASSISTS THE
INDIVIDUAL TO IDENTIFY AND ACCESS A PERSONALIZED MIX OF PAID
AND NON-PAID SERVICES AND SUPOPRTS THAT WILL ASSIST THEM IN
ACHIEVING PERSONALLY-DEFIND OUTCOMES IN THE MOST
INCLUSIVE SETTING

4. COMMUNITY PRESENCE CHOICE
COMPETENCE
RESPECT COMMUNITY PARTICIPATION

5. COMMUNITY PRESENCE
SHARING ORDINARY
PLACES THAT DEFINE
COMMUNITY LIFE

6. CHOICES
THE EXPERIENCE OF
AUTONOMY(freedom)
IN BOTH SMALL EVERYDAY MATTERS
(IE..WHAT TO EAT OR WHAT TO WEAR)
.AND IN LARGE, LIFE-DEFINING
MATTERS ( IE..WHO TO LIVE WITH OR
TYPE OF WORK TO DO)

7. COMPETENCE
THE OPPORTUNITY TO PERFORM
FUNCTIONAL AND MEANINGFUL
ACTIVITES WITH WHATEVER LEVEL OR
TYPE OF ASSISTANCE REQUIRED

8. RESPECT
A VALUED PLACE AMONG A NETWORK
OF PEOPLE AND VALUED ROLES IN
COMMUNITY LIFE

9. COMMUNITY PARTICIPATION
THE EXPERIENCE OF BEING PART OF A
GROWING NETWORK OF PERSONAL
RELATIONSHIPS THAT INCLUDES CLOSE
FRIENDS

10. MY PARENTS ALWAYS HAD A DREAM FOR MY BROTHER AND SISTER
WHEN THEY GREW UP, BUT NOBODY HAD A DREAM FOR ME, SO I
NEVER HAD A DREAM FOR MYSELF. YOU CAN NEVER HAVE A GOOD LIFE
IF NOBODY EVER HAS A DREAM FOR YOU, UNLESS YOU LEARN TO HAVE
A DREAM FOR YOURSELF
CONNIE MARTINEZ

11.  Sees the individual as the expert in his or her life
 Includes significant others and/or peers
 Identifies hopes, capabilities, interests, preferences, needs and abilities
 Maximizes community connections
 Encourages responsible risk taking
 Sees set-backs as an opportunity for growth and learning

12. Myth – The individual is not interested in participating
Reality – Need to communicate to the individual that they can and should be doing
this. Their life can be different. Assess how do engage the individual in stages.
Myth – Our current plan and assessment tools needs to change
Reality – Your current tools and plans can still work, you just ask the same questions
in a different way. The plan will still work, you just write it in a different way
Myth – No real role for the provider in the planning process
Reality – A LARGE but CHANGED role for the provider. The provider becomes a…
o Collaborator
o Mentor/Consultant
o Skill Builder/Supporter

13.  What do you want for the future?
 What kind of help will you need?
 Who will support you best?
 Who knows what is best for you?
 Is it you or someone else?
 Can you ask for what you really want?
 What’s important for me?
 What’s important to me

15. OUTCOMES ARE LESS
STRUCTURED
 SHOULD REFLECT PERSONAL
DESIRES
 BASED ON THE TEAM DIALOGUE
THAT INCLUDES THE
INDIVUDUAL
 STATES THE BIG PICTURE
 LONG TERM ITEMS THAT NEED
TO BE ACCOMPLISHED OR
FOCUSED ON
 DRIVEN BY THE ASSESSMENT
 MEASURABLE
 FOCUSED ON OUTCOMES
 MEANINGFUL TO THE
INDIVIDUAL
 ACHIEVABLE
 RELATED TO THE GOAL
 FUN AND INTERESTING
 CAN BE IMPROVED WITH
TECHNOLOGY AND CREATIVE
ACCOMODATIONS AS NEEDED
OBJECTIVES MORE
CONCRETE

16. MOST MEANINGFUL AND IMPORTANT
HARD TO STAY FOCUSED
SOMETHING THAT WILL BE
ACHIEVED OVER A LONGER PERIOD…
2 TO 3 YEARS FOR EXAMPLE

17. HELPS TO MAINTAIN FOCUS
HELPS TO MAINTAIN A MORE
POSITIVE ATTITUDE
SHOWS RESULTS FASTER
SOMETHING THAT WILL BE
ACHIEVED IN LESS THAN A YEAR

18. LONG TERM OUTCOME
I WANT A JOB IN THE COMMUNITY THAT PAYS AT LEAST MINIMUM
WAGE
TEAM FOUND THAT THE INDIVIUAL NEEDS SUPPORT TO INDENTIFY
JOBS THAT MATCH SKILLS AND WILL REQUIRE ASSISTANCE IN
FINDING TRANSPORTATION
SHORT TERM OUTCOME
INDIVIDUAL WILL APPLY FOR AT LEAST 10 COMMUNITY JOBS
INDIVIDUAL WILL LEARN TO USE PUBLIC TRANSPORTATION
OBJECTIVES WILL BE DEVELOPED TO ADDRESS BARRIERS TOWARDS
REACHING THESE SHORT TERM OUTCOMES

19. SOME THINGS TO CONSIDER WHEN THINKING ABOUT GOALS
 INDIVIDUALS AREAS OF INTEREST
 COMMUNICATION
 BEHAVIORS
 MOBILITY/ABULATION
 BASIC SELF CARE
 EDUCATION
 SELF-SUFFICIENCY
 EMPLOYMENT NEEDS
 LIFE DESIRES
 ENVIROMENT/LIVING SITUATION

20. PREFERENCES OF THE INDIVIDUAL AND/OR FAMILY ARE ADDRESSED
STRENGTHS, NEEDS AND PREFERENCES HAVE BEEN IDENTIFIED
THROUGH THE ASSESSMENT PROCESS AND PERSONAL CONVERSATIONS
AND OBSERVATIONS OF THE INDIVIUAL
RISKS HAVE BEEN IDENTIFIED
CURRENT SUPPORTS ARE DISCUSSED TO DETERMINE IF THEY ARE STILL
NEEDED IN THE SAME WAY
BARRIERS TO ACHIEVEMENT OF GOALS ARE INDENTIFIED
OUTCOME FOCUSED
COMMUNTY INCLUSION NEEDS ARE REVIEWED AND MODIFIED AS
NEEDED
SELF DETERMINATION SKILLS HAVE BEEN ASSESSED

21. ASSESSMENT FOUND THE THE INDIVIDUAL IS NON-VERBAL WITH
LITTLE TO NO FUNCTIONAL COMMUNICATION. THE INDIVIDUAL
ENJOYS GOING OUT TO EAT
OUTCOME AREA…….
INDIVIDUAL WILL INCREASE INDEPENENCE IN THE COMMUNITY BY
USING ALTERNATIVE STRATAGIES WHEN EATING OUT.

22.  IDENTIFY THE DANGERS TO HEALTH, SAFETY AND WELFARE
 IDENTIFIED RISK NEED TO BE ADDRESSED IN THE ISP
 RISK SHOULD HAVE BEEN IDENTIFIED DURING THE ASSESSMENT
PROCESS
POTENTIAL AREAS OF RISK
 HEALTH AND MEDICAL
 SAFETY
 HOME
 COMMUNITY
 WORKPLACE/SCHOOL
 FINANCIAL
 BEHAVORIAL

23. There should be a direct correlation between the individuals strengths,
needs and desires and the number of outcomes developed
The individual should have a say in the number of outcomes
There should be team discussion and team decisions as for the reasons of the
selection of the outcomes for the ISP (its best practice to document this
discussion within the ISP)

24. At every step of the process keep the desires, interest and needs of
the individual in mind
Think about who will be responsible for monitoring the outcomes
Determine what steps/objectives will be needed for the outcome to
be achieved
Establish a deadline
Three questions that need answered
 What is being measured
 How is it being measured
 How will I know when the outcome has been accomplished

25. Sequential
Related directly to the outcome
Measurable
Stated so that the behavior changed is observable
Singularly stated objective – no compound (multiple objectives)

26. Understanding what is the desired result of the objective
 Poor Objective – Tommy will take out the trash
 Good Objective – After dinner Tommy will take the trash to the dumpster
with less than 2 verbal prompts 5 of 7 times for 4 consecutive weeks by
March 31, 2014

27. Without a good objective there is no basis for making accurate judgments
or determinations of achievement for the program being implemented
If the objective is not understood then you can have confusion and
disagreements about what is expected not only of the individual but also
the service provider
Make sure the outcome is clearly defined
Make sure there are not too many steps that need to be monitored or
achieved in one objective
Think about objectives
as a communication tool…..

28. HELP!!!!!
OUTCOME CAN’T BE
OBTAINED
NOW WHAT?????

29. Was the outcome clearly understood by the
service provider
Did the outcome have the ability to determine
achievement
Was their proper training and communication
with the service provider
Was this outcome truly something the
individual wanted
Was discovery/assessment accurate
Were the objective clear and concise
Does it need to be re-written in a different way

30. Melissa Skaggs
TBC Services and Provider Resources Group
1616 Lancaster Avenue
Reynoldsburg, Ohio 43068
800-995-0043
mskaggs@tbcservices.net
www.tbcservices.net
www.providerresourcesgroup.net