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Person centered plan

This document provides an introduction to person-centered planning. It defines person-centered planning and contrasts it with traditional planning. Person-centered planning prioritizes what is "important to" the individual rather than just their needs. The document outlines federal regulations regarding the person-centered planning process and service plans. It also describes how the "What, When, Who and How" questions can be used to gather information to identify the seven components of person-centered planning and develop an individualized plan. The goal is for the planning process and resulting services/supports to be driven by the individual's preferences.

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Introduction to Person- Centered Planning
 Welcome to Introduction to Person-Centered Planning. The purpose of this presentation is to provide you with an introduction and overview of person- centered practices, services and planning.  The information in this presentation is used to improve the quality of lives of those we serve and to continue the philosophical shift in services to become more "person-centered."
Organization of Content  Module I: Overview reviews the definition of person-centered planning, person-centered planning concepts such as "important to" vs. "important for," the core values of person-centered planning, diverse populations benefiting from person-centered planning, and contrasts person-centered planning to traditional planning.  Module II: Federal Regulations reviews the federal regulations relevant to the person-centered planning process and person-centered plan.  Module III: Foundations of Person-Centered Planning builds a foundation for person-centered planning by explaining how "What, When, Who and How" questions can be used to gather information, by defining seven components of person-centered planning and by outlining a planning sequence.  Module IV: Examples of Person-Centered Planning shows how information gathered using "What, When, Who and How" questions can be used to identify the seven components of person-centered planning for two sample individuals
Objectives  After successfully completing this presentation, you will be able to:  describe person-centered planning, person-centered planning concepts such as "important to" vs. "important for" and the core values of person-centered planning;  identify diverse programs that serve a variety of people that benefit from person-centered planning;  describe differences between person-centered planning and traditional planning;  understand federal regulations relevant to the person-centered planning process and person- centered plan;  define seven components of person-centered planning;  outline a person-centered planning action sequence; and  identify person-centered planning components in individual examples of person-centered plans
Module I: Overview  This module will review the definition of person-centered planning, person- centered planning concepts such as "important to" vs. "important for," the core values of person-centered planning, diverse populations benefiting from person- centered planning and contrast person-centered planning to traditional planning
Person-Centered Planning Concepts  Several concepts are important to understanding person-centered planning:  Person-centered thinking is the philosophical foundation of person-centered planning. It is the core belief about a person's inherent value and the way to think about and discover a person's unique preferences and personal life outcomes.  Person-centered planning is the process of developing a person's plan based on the philosophy of person-centered thinking. Person-centered planning is a way to assist people needing services and supports to construct and describe what they want and need to bring purpose and meaning to their lives. Services and supports should meet the person's needs and be integrated into the greater community.  Person-centered practice is the alignment of service resources that gives people access to the full benefits of community living and ensures they receive the services and supports outlined in their plan.
Person-Centered Planning is Required  Through several sets of federal regulations, the Center for Medicare and Medicaid Services (CMS) now requires person-centered planning and services for Medicaid Home and Community-Based Services programs (HCBS), intermediate care facilities (ICF), nursing homes, Community First Choice (CFC) services, and home health services. The legal framework for person-centered planning in Medicaid HCBS was established in the Home and Community-based Settings rule of March 2014, which applies to the following:  1915 (c) waivers (Home and Community-based Services, Texas Home Living, Deaf Blind with Multiple Disabilities, Community Living Assistance and Support Services, Medically Dependent Children Program, and the Youth Empowerment Services program)  1915 (i) state plan services (HCBS Adult Mental Health)  1915 (k) state plan services (Community First Choice)  1115 (STAR+PLUS and STAR Kids)  STAR Health, the managed care program for children in state conservatorship
Person-Centered Planning Defined Person-centered planning:  is a process by which a person, with assistance (if needed, or if the person has a legally authorized representative), identifies and documents his or her preferences, strengths and needs in order to develop short-term objectives and action steps which ensure personal outcomes are achieved in the most integrated setting by using identified supports and services;  is an approach that helps create a vision for a person's life based on life choices to include his or her social role, dreams and inclusion in the community;  identifies and highlights a person's unique talents, gifts, and capabilities; and  organizes around the person to help put paid, unpaid and natural supports and resources in place that will assist him or her in achieving personal outcomes. Person-centered planning prioritizes what is "important to" a person as well as what is "important for" a person.  In summary, person-centered planning is a process to help people identify their strengths, preferences, and needs (clinical and support); achieve personally defined outcomes in the most integrated setting; and ensure delivery of services in manner that reflects personal choices, dreams and life aspirations.
"Important To" vs. "Important For"  Person-centered planning prioritizes what is "important to" a person as well as what is "important for" a person. Person-centered planning also seeks a "balance" between "important to" and "important for" that is unique to the person.  "Important to" is used to describe things based on personal preferences or choices about what makes people happy and what makes them feel good about themselves. General examples of things that are "important to" all people could be preferred daily schedules created using personal preferences, favorite types of food, and hobbies. "Important to" is based on a person's unique preferences.  "Important for" is used to describe basic needs and health and safety needs. Examples of things that are "important for" all people include oxygen, food, water, sleep, shelter and health. Examples of what is "important for" specific people could be insulin for those who have diabetes or hearing aids for people who have hearing impairment. "Important for" is aligned with basic needs, not always preferences. In addition, "important for" identifies what is necessary to ensure that people are seen as valued and contributing members of their communities.  Note: For a person who may not use words to communicate, in order to gather information on what is "important to" the person, have a conversation with those who the person enjoys having fun with and who know the person best
"Important To" vs. "Important For" (cont.)  It is important to Francis to talk about cars with his friends because it makes him happy.  It is important to Danielle to watch her favorite soap opera at noon on weekdays.  It is important to Jared to get a job of his own choosing, doing something that he likes.  It is important to Francis to see his friend a few times a week in the afternoon between 3 and 4 p.m.  It is important for Francis to have transportation to the doctor’s office  It is important for Danielle to stay inside between 11 a.m. and 4 p.m. when the temperature is above 85, because she could suffer heat stroke if exposed to too much heat.  It is important for Jared not to leave his home for a job interview looking unkempt.  It is important for Francis to be on a diabetic diet because he's a person who has diabetes.
Person-Centered Planning vs. Traditional Planning  The focus on what's "important to" a person is also clear when you compare person-centered planning to traditional service planning. In person-centered service planning:  priorities in service delivery shift to a person-centered approach;  the person receiving services will lead the person-centered planning process, when possible;  the plan must reflect supports and services that are "important to" the person with regard to preferences, as well as what is "important for" the person to meet the needs identified through a face to face assessment of functional, clinical, and support needs that assess for risk factors and measures to minimize risks, to include backup plans and strategies when neededneeds; and  the person's legally authorized representative (if applicable) and team members have a participatory role, with planning driven by the person.  In traditional planning, service coordinators, case managers, DDP, nurse managers, program managers, agencies, and professional staff determine needs and services based on assessments, observations, and interviews. Plans are developed and often do not include any input from people receiving services.
Person-Centered Planning vs. Traditional Planning (cont.) According to the chart below, person-centered planning can be contrasted from traditional planning in a few other ways. Please carefully review these differences now.
Core Values of Person-Centered Planning It can be said that person-centered planning is based on four core values: respect of self-determination, dignity, community inclusion, and optimism and belief. Respect of Self-Determination  Self-determination means respecting the life choices and decisions a person makes based on preferences and interests with a focus on the whole person, not just on physical and mental disability.  Choice and personal control are central to creating quality in the person's life. Person-centered planning supports the person to have positive control over his or her life choices. Dignity  This is the right of a person to be treated with respect and as a valued member of his or her community, as afforded to any person in the larger community.  The person is recognized as having capacity to exercise his or her rights unless limited by law or court order. Community Inclusion  Community inclusion means all people, regardless of their abilities, disabilities, or health care needs, have the right to be included and appreciated as valuable members of their communities, like all others.  The Council on Quality and Leadership (CQL) states that quality of life definitions should be driven by life expectations common to everyone in society regardless of their labels or need for extra support. Optimism and Belief  Belief is trusting that each person can contribute to society in a meaningful way.  Optimism is the belief that each person has the potential for a great life.
Diverse Populations Benefiting from Person-Centered Planning  Finally, it's important to note that person-centered planning can benefit diverse populations.  People receiving supports and services who would benefit from person-centered planning include but are not limited to the following:  -people who are aging  -People residing in nursing facilities  -People recovering from traumatic brain injuries  -Military veterans  -Children, in all settings  -People who have visual or hearing impairment  -People receiving hospice or home health services  -People receiving medical care and treatment from their primary care physician or who receive care from medical hospitals  -People receiving in-patient or outpatient behavioral health care  -People who have intellectual and/or developmental disabilities   Note: All people in the support and service groups listed above will have their own unique vision of what really matters and is important to them; their life choices and personal outcomes are not defined by a group.
Diverse Populations Benefiting from Person-Centered Planning(cont.)  Regardless of the supports and services people may need, we must ensure person- centered planning is used to help:  -with self-determination;  -consumer directed services be discussed and reviewed;  -teach independence and promote community integration regardless of where they live;  -life recovery oriented care or person-centered care used in settings to support behavioral and/or medical health care;  -discussion of informed consent and decision-making; and  -those living in environments with shared or participatory decision-making (i.e. spouse, adult children, or other family members asked by the person to provide the needed supports).
Module II: Federal Regulations  This module will review the federal regulations relevant to the person-centered planning process and person-centered plan.
Federal Regulations for the Person- Centered Planning Process (cont.)  Now that you have gained a basic introduction to person-centered planning, it is time to review the legal requirements for the person-centered planning process found in the Code of Federal Regulations (CFR) and guidelines. The CFR rules require that the person-centered planning process:  is driven by the person;  includes people chosen by the person to serve as members of his or her planning team;  provides necessary information and support to ensure the person directs the process to the maximum extent possible, and is enabled to make informed choices and decisions;  is timely (frequency) and occurs at times (hour, day, week) and locations of convenience to the person and his or her legal authorized representative;  reflects cultural considerations of the person and is conducted in plain language and in a manner accessible to persons who may have limited English proficiency;
Federal Regulations for the Person- Centered Planning Process (cont.)  According to the CFR, the person-centered planning process also:  includes strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all participants;  offers choices to the person regarding the services and supports the person receives and from whom;  includes a method for the person to request updates to the plan, as needed; and  records the alternative home and community-based settings that were considered by the person.
Federal Regulations for Person-Centered Service Plans  The CFR also contains rules for person-centered service plans. According to the CFR, the person-centered service plan must reflect the services and supports that are important to the person to meet the needs identified through an assessment of functional, assessment, clinical and support needs, as well as what is important to the person with regard to preferences for the delivery of those services and supports. Additionally, according to the CFR, the person-centered service plan must:  reflect that the setting in which the person resides is chosen by the person, includes access to the greater community, includes opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community to the same degree of access as people not receiving services (any modification to the settings requirements needed by a person must be supported by a specific assessed need and justified in the person-centered service plan);  include documentation of the specific and individualized assessed need, positive interventions and supports used prior to modification, less intrusive methods tried, and description of the condition that is directly proportionate to the specified need; and  reflect the person's strengths and preferences.
Federal Regulations for Person-Centered Service Plans (cont.)  According to the CFR, the person-centered service plan must also:  reflect clinical and support needs as identified through an assessment of functional need; include individually identified goals and desired outcomes;  reflect the services and supports, paid and unpaid (to include natural), that assist the person and providers to achieve identified goals, including natural supports;  reflect risk factors and the measures in place to minimize their impact, including individual back- up plans and strategies when needed, i.e. Emergency Response Services;  be understandable to the person receiving the services and supports and those supporting him or her by being written in plain language, to assure those who are limited in English proficiency understand, and in a manner that is accessible to persons with disabilities; and  identify the person and/or entity responsible for monitoring the plan.
Federal Regulations for Person-Centered Service Plans (cont.)  According to the CFR, the person-centered service plan must also:  be finalized and agreed to with informed consent of the person in writing and signed by all people and providers responsible for its implementation;  be distributed to the person and other people involved in the plan;  include those services, the purchase or control of which the person elects to self-direct using the Consumer Directed Services program;  prevent unnecessary or inappropriate services and supports from being provided;  document any modifications of additional conditions that must be supported by specific assessment and justified in the plan; and  be reviewed, and revised upon re-assessment of functional need when circumstances or needs change every twelve months, when the person's circumstances or needs change significantly and at the request of the person.
Module III: Foundations of Person- Centered Planning  In this module, we will build a foundation for person-centered planning by explaining how "What, When, Who and How" questions can be used to gather information, by defining the seven components of person-centered planning and by outlining a planning sequence.
"What, When, Who and How" Questions  The following four questions underscore the federal regulations cited above for the person-centered planning process and the need for the person to control the process.  What is important to and for the person? The answer to this question is a prelude to understanding and identifying the person's preferences and outcomes.  When should planning and services take place? This question acknowledges and identifies the person's unique preferences related to their daily routine and timing of events, include the timing (day/hour) of planning meetings, and also considers the preferences of the legally authorized representative, if applicable.  Who should attend planning meetings and/or be on a person's planning team? This identifies the people that know the person well and need to be participants in planning meetings, as chosen by the person.  How is a person-centered service plan developed? This identifies the need for the person to have access to viable options from which to choose services or supports (paid, unpaid and natural), the existence of an approach for group decision-making and conflict resolution, and the potential to identify central strategies to achieve outcomes chosen by the person.
"What, When, Who and How" Questions (cont)  "What, When, Who and How" questions should be answered and used by professional and support personnel to get to know the person and help them to actively support the person to control his or her planning process.
"What, When, Who and How" Questions (cont’d)
Person-Centered Planning Components
Person-Centered Planning Components (cont’d)  Preferences and outcomes are the central components of the service plan. The face to face conversations identify strengths, needs, and services, and assist the person in obtaining his or her preferences and outcomes. Preferences and outcomes then "drive" the contents of the written plan document. They also determine services, supports, action steps, short-term objectives, and the way the personal outcomes are to be monitored and measured.
 Preferences and Outcomes are the driving considerations of the person-centered service plan. A preference is a choice a person makes for one option over others. For instance, people have preferences on where they would like to work, eat, live and who to live with. An outcome is what a person wants to do, achieve, change, maintain, or experience that is important to them. Example: Preference - Joel wants to live in an apartment with friends instead of with his parents Outcome - Joel lives in an apartment
 Strengths are qualities, traits, talents or abilities that a person has demonstrated in the past. Example: Misti paints with watercolors and her paintings have been purchased by others.
 Needs are things that the person must have in order to ensure his or her safety, health, and successful integration into the community. Needs are often what is "important for" the person as found in functional and clinical assessments. Example: Robert ambulates with the use of a motorized wheelchair.
Supports are any forms of paid, unpaid, or natural assistance that are available to a person and any other member of the community. Example : Phil's brother brings Phil grocery shopping once a week. Services are any programmatic or professional resources recommended in the functional and/or clinical assessments which are available to anyone within the community and used to meet personal outcomes. Example :The Deaf Blind and Multiple Disabilities (DBMD) program provides Sue access to speech hearing and language therapy Action steps and short-term objectives refer to combined activities that enable each personal outcome to be achieved. In developing action steps and short-term objectives in the person-centered service plan, you may want to think about the SMART Principles:  S - Specific  M - Measurable  A - Attainable  R - Relevant  T - Time-bound Example : In order for Mike to spend more time outdoors as he prefers, he will visit a public park next weekend.
To accomplish monitoring and measurement, the person, in collaboration with his or her planning team, determines:  when and/or if the outcome has been accomplished;  the size, amount, and/or degree of measurement for action steps/short-term objectives;  how the steps are to be monitored and measured to help reach the outcome;  when (frequency) the steps/short-term objectives have been accomplished to assist in reaching the outcome; and  who is responsible for monitoring and measuring the success towards the desired outcome Example: Every two weeks, the job coach will evaluate Bob's progress at learning the new skill required in his job.
More on Outcomes  All of the components of person-centered planning are essential, but outcomes are the key to person-centered planning. Every person has a life that looks different and unique based on his or her own personal definition of quality of life. Personal outcomes are clarified in the planning process and drive the objectives and steps outlined in the plan document. An organization can only design and provide needed services and supports after it has determined how the person defines his or her outcomes. Please review the following additional facts about outcomes:  "When services and supports do not produce outcomes, they become ends in themselves. The means to an outcome becomes confused with the outcome itself." (CQL - The Power of Personal Outcome Measures)  The process for identifying and defining outcomes is based on access to a range of options and meaningful choices grounded in real life experiences.  The plan is based on what outcomes are most important to the person at that present moment, with the understanding that change is natural and expected.  There is no standard definition for any outcome that applies to a group of people. It is unlikely that any two people will define an outcome in the exact same manner.  Two important outcome questions: Is the outcome as defined by the person currently happening in his or her life? Are individualized supports present in the person's life to assist him or her to attain this outcome?
Action Sequence of Person-Centered Planning The service planning team should follow the following general action sequence to create a person-centered service plan. Please review it carefully to prepare for an activity on the next page. 1. Engage in multiple conversations with the person; identify strengths, preferences, needs, services, supports, personal preferences and desired outcomes. This will also prevent unnecessary or inappropriate services and supports from being provided. These conversations will help the person identify members of the planning team and help the person set the agenda of the planning meeting. 2. Complete face to face assessments of functional, clinical, and support needs that assess for risk factors and measures to minimize risks, to include backup plans and strategies when needed. 3. Meet with the person and his or her team to develop the service plan. Further clarify personal outcomes and identify specific supports and services. Address and resolve any disagreements and identify resources and barriers, with the understanding the person directs choice in outcomes. Establish accountability for action. 4. Finalize service plan document based upon team discussions about personal outcomes and short-term action objectives to achieve those outcomes. Document the accountability of "who, what and when" for all action steps. 5. Monitor and measure the service plan's progress based upon the person's input and change service plan as needed.
Module IV: Examples of Person-Centered Planning  In this module, first we will show how information gathered using "What, When, Who and How" questions is used to identify the seven components of person- centered planning for two sample people, Francis and Danielle. After this, you will be asked to complete an activity about person-centered planning components for a third sample person.
Person-Centered Planning Examples In our two examples, we will begin by reviewing information about Francis and Danielle that was previously gathered using "What, When, Who and How" questions, and then show how this information is used to identify the seven person-centered planning components.
Person-Centered Planning Example #1 In our first example, the service coordinator, case manager, QIDP/QDDP, and nurse manager engaged in conversations with Francis and discovered the following:  Francis is a person who loves cars and talking about them with his friends.  He loves managing his money and eating at his favorite restaurant, Olive House, on the weekends after cashing his paycheck.  He does not hear as well as others and uses a wheelchair for mobility. Next, they gathered additional information about Francis by asking "What, When, Who and How" questions, which are presented on the next two slides
Francis' "What, When, Who and How" Questions What is important to and for Francis?  Francis told his team during his person-centered planning meeting that finding a job that has something to do with cars is most "important for" him. However, his team believed he should focus on developing more skills by continuing with school and job training. Since Francis is in charge of his planning process, all agreed that he should work on his personal life choices. When should Francis' person-centered planning meeting be held to identify and develop the outcomes?  Francis wakes up by 5 am almost every morning. He watches television game shows and naps in the afternoons since he is not working therefore, he has asked if services, supports and person-centered planning meetings be provided to him in the morning. Who sets the agenda and determines who should attend Francis' person-centered planning meetings?  Although she doesn't work directly with Francis, Louanne knows him well and visits him most weekday mornings. Francis invited Louanne to serve on his person- centered planning team. Therefore, Louanne will be invited to all of his person-centered planning meetings. Also, Francis agreed to add a job coach to his team to help him find a job working with cars. How should Francis' person-centered service plan be developed?  Francis' person-centered service plan focuses on ways to support his personal life choice of finding a job in a local mechanic's shop. Francis will enlist the help of a job coach for this goal. The job coach will provide Francis a list of available jobs working with cars so Francis has options to consider for this important decision.
Francis' Person-Centered Planning Components Through the face to face conversations, functional and clinical needs assessments, Francis was able to identify what is important to him and for him through the use of the "What, When, Who and How" questions. After careful review, Francis and his planning team identified the following within the components of Francis' person-centered plan. Please scroll down and review each of them now. You may select the images at left to review the definition of each component, if needed. Note how each component is unique, and how each plays an important role in the overall person-centered service plan. The following preferences were identified by Francis, shared with his planning team, and added to his plan:  Francis enjoys his collection of vintage model cars, showing them to friends, staff and visitors.  Francis would like to have a job working on cars.  Francis likes to eat at his favorite restaurant, Olive House, on the weekend.  Francis likes waking up at 5:00 AM and has asked if services, supports and person-centered planning meetings be provided to him in the morning.  Francis wants to become more independent. The desired outcomes identified by Francis include the following: Francis has a job working with cars. (Outcome #1) Francis manages his own money. (Outcome #2) Francis eats at the restaurant of his choice with the money he earns. (Outcome #3)
Francis' strengths include the following: Francis is amazing when it comes to his knowledge of makes and models of vintage cars. Francis has successfully lived for several years in a home with his friends using various support services of his choosing. Francis is very friendly and outgoing, which will help him make new friends in his new job.
Francis' needs were identified and added to his person-centered service plan:  Francis needs assistance with maintenance and repair of his hearing aids, lift and wheelchair.  Francis' home phone must have a feature that changes voice to text/text to voice.  Francis' cell phone should have the app that changes voice to text/text to voice, if he needs to use it.  Francis needs assistance getting into his lift when transferring into or out of his bed and favorite chair.  Francis needs assistance with transportation to complete his life choices.  Francis needs assistance with increasing his money management skills, i.e. use of debit card, learning to pay his bills on line, etc.  Francis needs his home to be accessible to maximize his independence, i.e. needs a ramp to enter his home.  Francis needs periodic reassessment of clinical and functional needs.
The following supports were identified and added to his person-centered service plan:  Francis' family helps him get into and out of his favorite chair using his lift when they come to visit and go with him on activities of his choosing within the community.  Francis' family and friend often assist Francis in changing over from the voice to text/text to voice feature on his home phone, if their assistance is requested by Francis.  Francis' family and friends meet him on routes that allow him to use public transportation to go out to eat, visit friends, and to go shopping.
These services were identified and added to his person-centered service plan:  Francis receives transportation and support services from program staff to see his doctors/audiologist as needed for medical care, treatment and for follow up as needed.  Francis will have a job coach to serve him by providing training and assistance for transportation related to job applications, interviews and coaching within the new job.  Francis will continue to receive Community Living Assistance and Supports Services (CLASS) to help him maintain his independence.
Francis' person-centered service plan includes the following action steps and short-term objectives, identified for each of his desired outcomes:  Francis has a job working with cars. (Outcome #1)  The job coach will provide Francis with a list of available jobs working with cars so he may choose which job to pursue.  The job coach will assist Francis with transportation, completing job applications, preparing for interviews and coach him as he learns new job tasks. Francis manages his own money. (Outcome #2)  Program staff will transport Francis to the bank and provide assistance to set up online banking and then coach Francis at home as he learns how to use online banking.  Program staff will coach Francis on how to develop a list of all bills with amounts owed, so he may pay his bills on-line and on time.  Program staff will provide transportation, coaching and support to Francis after the banking staff teaches Francis how to use a debit card.  Program staff will provide supports needed for Francis to become more independent in shopping at the grocery store. Francis eats at the restaurant of his choice with the money he earns. (Outcome #3)  Program staff will provide coaching, assistance and training on transportation options to support Francis going to the restaurant he chooses.  Program staff will coach Francis on how to use his debit card to pay for his food at the restaurant.
Francis' person-centered service plan will be monitored and measured as determined by Francis in collaboration with his planning team. His three outcomes will be monitored and measured as explained below: Francis has a job working with cars. (Outcome #1)  Francis and his work colleagues report his continued satisfaction with his job and his love of cars. The job is stable and achieves Francis' personal outcome at this time.  Francis' job coach continues to assess and measure the progress of Francis' job skills and phases out the daily job coaching support. Francis manages his own money. (Outcome #2)  Francis' money management skills allow him to spend his money as he chooses by eating out once a week at his favorite restaurant.  Francis continues to use his debit card without incident as he pays for purchases.  Francis continues to pay his bills using online banking without incident. Francis eats at the restaurant of his choice with the money he earns working. (Outcome #3)  Francis' money management skills allow him to spend his money as he chooses by eating out once a week at his favorite restaurant.  Francis uses public transportation to go out to eat weekly.
Person-Centered Planning Example #2: Danielle The service coordinator, case manager, DDP and nurse manager engaged in conversations with Danielle and discovered the following:  Danielle came to the United States ten years ago to live with her sister and has helped raise her nieces, who are both now studying to become nurses. Danielle has become fluent in speaking English and shared she would like to learn to read and write in English, as it would "help me to feel like I belong here."  Danielle loves spending time with her family and wants to move closer to her family. She sees the supports offered by her family as a way to maintain her independence.  Danielle is a person who has an intellectual disability and beginning signs of memory loss.  Next, they gathered additional information about Danielle by asking "What, When, Who and How" questions. This information is displayed on the next two pages.
Danielle's "What, When, Who and How" Questions What is important to and for Danielle?  Danielle wants to learn to read and write in English to "help her feel like she belongs here." Danielle recognizes she needs more supports to maintain her independence and wants to move closer to her family for their support. When should Danielle's person-centered planning meeting be held to identify and develop the outcomes?  Danielle likes to sleep "in" most mornings. She told her team during the planning meeting that she wants all of her appointments and person-centered planning meetings to be after lunch. Because sleeping in is important to Danielle, her team addressed her preference and listed her request under supports with the directive to always asks doctors, dentists, or any other needed appointments be scheduled in the afternoon. All planning meetings will be held after lunch. Danielle expressed her desire to work at a job that does not start until later in the day and is located closer to her family. Her choice was honored by directing her job coach to identify potential employers who are located closer to her family and who hire people to work the afternoon and evening shifts at a job of Danielle's choosing. Danielle wants to move closer to her family when her lease is up, in two months. Who sets the agenda and determines who should attend Danielle's person-centered planning meetings?  Danielle's niece, Rhonda, visits her every Tuesday and Thursday night after she attends nursing classes at a nearby community college. Danielle asked Rhonda to help her make decisions and communicate to her planning team her desire to learn to read and write in English. Rhonda understands Danielle's personal life choices and preferences very well. Rhonda plans to support her aunt by attending all planning meetings and serving on her planning team. Her family, church friends and job coach will assist Danielle in identifying places to live and work close to her family. How should Danielle's person-centered service plan be developed?  Danielle's team considered her personal life choice of learning to read and write in English. Planning meetings will be conducted so she and her family can have a full understanding of what is being discussed. Translation or interpreter services will be used as needed. With Danielle's participation as team lead, the team identified how to best support her by finding available volunteer literacy programs offered in the area where she wants to live and additional supports she needs to reach her outcomes of learning to read and write in English and live closer to her family. Examples might be unpaid supports such as obtaining rides from classmates, or paid supports to assist Danielle in learning to ride the bus, learning to set up MetroAccess Service, and program staff to assist and support her efforts to practice her reading and writing assignments. Thus, Danielle was given options to enable her to make informed decisions related literacy programs and additional supports.
Danielle's Person’s Preferences and Outcome Through the face to face conversations, functional and clinical needs assessments, Danielle was able to identify what is important to her and for her through the use of the "What, When, Who and How" questions. After careful review, Danielle and her planning team identified the following within the components of Danielle's person-centered plan. Please scroll down and review each of them now. You may also select the images at left to review the definition of each component, if needed. Note how each component is unique, and how each plays an important role in the overall person-centered service plan. The following preferences were identified by Danielle, shared with her planning team, and added to her plan:  Danielle wants to find a new place to live, which is closer to her family.  Danielle wants her appointments after lunch.  Danielle wants to start work later in the day, in the afternoon or evening shifts. The following desired outcomes were identified by Danielle:  Danielle moves closer to her family to ensure family supports and maintain her independence. (Outcome #1)  Danielle works at a job of her choice in the afternoon. (Outcome #2)  Danielle learns to read and write in English. (Outcome #3)
Danielle’s Strengths Danielle's strengths include the following:  Danielle speaks English well as her second language.  Danielle has successfully lived independently with supports for over ten years.  Danielle knows the area in which she wants to live.  Danielle has many friends from her church.  Danielle's family supports her desire to move closer to them.
Danielle’s needs Danielle's needs were identified and added to her person-centered service plan. Danielle needs:  a walker to assist in preventing her from falling;  a home with minimal or no stairs and access to Emergency Response Services;  assistance with transportation to get to work since she cannot walk long distances;  assistance packing, lifting boxes and moving when she finds her new home;  financial supports to assist with paying rent and supporting her move; and  periodic reassessment of clinical, functional and personal needs.
Danielle’s Supports The following supports were identified and added to Danielle's person-centered service plan:  Danielle enjoys spending time with her family and friends and is very grateful for them taking her to the grocery store and providing her with rides to church on Sundays and Wednesdays.  Danielle's church friends have offered to help her pack her things and move her to her new home.  Danielle's volunteer literacy program is an important support.
Danielle’s Services These services were identified and added to her person-centered service plan:  Danielle receives transportation and support services from program staff to see her doctor as needed for medical care, treatment and for follow up as needed.  Danielle has a job coach who will continue to serve Danielle when she moves to her new home and provide training, coaching and transportation related to job applications, interviews and coaching within the new job.  Danielle receives Home and Community-based Services to help her to maintain her independence.
Danielle’s action steps and short-term objectives Danielle's person-centered service plan includes action steps and short-term objectives identified for each of her desired outcomes. Danielle moves closer to her family to ensure family supports and maintain her independence. (Outcome #1)  Program staff will provide Danielle with assistance in locating resources to help her find a new home closer to her family.  Program staff will provide Danielle assistance with going to visit potential new homes that are closer to her family.  Program staff will provide assistance reading legal documents and with writing when it comes to applications and lease agreements for the place she wishes to live. Danielle works a job in the afternoon. (Outcome #2)  Danielle's job coach will provide her with a list of jobs she may like that are available for her to work in the afternoon and evening shifts, near her family..  The job coach will assist Danielle with transportation, completing job applications, assist with interview preparations she may have, and coach her as she learns new job tasks. Danielle learns to read and write in English. (Outcome #3)  Danielle's support staff will find a volunteer literacy program near her new home that Danielle may attend on a regular basis.  Danielle will complete her reading assignments and practices her English writing exercises with the assistance of program staff.
Danielle’s monitoring and measurement Danielle's person-centered service plan will be monitored and measured as determined by Danielle in collaboration with her planning team. Danielle moves closer to her family to ensure family supports and maintain her independence. (Outcome #1)  Danielle continues to say she is pleased with her new place of residence.  Danielle's family assists her with weekly grocery and shopping trips. Danielle has increased visits to her family's home.  Danielle continues to use her walker daily as seen with no reported falls.  Danielle has not needed to use the Emergency Response Service. Danielle works at a job of her choice in the afternoon. (Outcome #2)  Danielle and her work colleagues continue to report her satisfaction and progress in her job and the "fit" of her work hours for her energy and attention.  Danielle's job coach continues to assess and measure the progress of Danielle's job skills and phases out the daily job coaching support, yet continues to monitor her weekly progress. Danielle learns to read and write in English. (Outcome #3)  Danielle maintains her consistent attendance and participation in the literacy program and she reports her continued desire to improve her English reading and writing skills.  Danielle chooses every week to complete 100% of her English assignment with assigned and scheduled assistance and monitoring from program staff.
Keys to Success  In conclusion, remember that person-centered planning will be most successful when:  the person and team participate in the planning process;  the person, with the support of the team, determines the personal outcomes and identifies services and supports to achieve those outcomes;  the plan is understandable to the person receiving services and supports and those providing the supports;  the team develops both paid, unpaid and natural supports needed to reach the desired outcomes;  the plan identifies those responsible for implementing and monitoring the plan; and  follow-up and follow-through on the plan is guaranteed, including changes and updates as needed.

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Person centered plan

  • 1.
  • 2.
     Welcome toIntroduction to Person-Centered Planning. The purpose of this presentation is to provide you with an introduction and overview of person- centered practices, services and planning.  The information in this presentation is used to improve the quality of lives of those we serve and to continue the philosophical shift in services to become more "person-centered."
  • 3.
    Organization of Content Module I: Overview reviews the definition of person-centered planning, person-centered planning concepts such as "important to" vs. "important for," the core values of person-centered planning, diverse populations benefiting from person-centered planning, and contrasts person-centered planning to traditional planning.  Module II: Federal Regulations reviews the federal regulations relevant to the person-centered planning process and person-centered plan.  Module III: Foundations of Person-Centered Planning builds a foundation for person-centered planning by explaining how "What, When, Who and How" questions can be used to gather information, by defining seven components of person-centered planning and by outlining a planning sequence.  Module IV: Examples of Person-Centered Planning shows how information gathered using "What, When, Who and How" questions can be used to identify the seven components of person-centered planning for two sample individuals
  • 4.
    Objectives  After successfullycompleting this presentation, you will be able to:  describe person-centered planning, person-centered planning concepts such as "important to" vs. "important for" and the core values of person-centered planning;  identify diverse programs that serve a variety of people that benefit from person-centered planning;  describe differences between person-centered planning and traditional planning;  understand federal regulations relevant to the person-centered planning process and person- centered plan;  define seven components of person-centered planning;  outline a person-centered planning action sequence; and  identify person-centered planning components in individual examples of person-centered plans
  • 5.
    Module I: Overview This module will review the definition of person-centered planning, person- centered planning concepts such as "important to" vs. "important for," the core values of person-centered planning, diverse populations benefiting from person- centered planning and contrast person-centered planning to traditional planning
  • 6.
    Person-Centered Planning Concepts Several concepts are important to understanding person-centered planning:  Person-centered thinking is the philosophical foundation of person-centered planning. It is the core belief about a person's inherent value and the way to think about and discover a person's unique preferences and personal life outcomes.  Person-centered planning is the process of developing a person's plan based on the philosophy of person-centered thinking. Person-centered planning is a way to assist people needing services and supports to construct and describe what they want and need to bring purpose and meaning to their lives. Services and supports should meet the person's needs and be integrated into the greater community.  Person-centered practice is the alignment of service resources that gives people access to the full benefits of community living and ensures they receive the services and supports outlined in their plan.
  • 7.
    Person-Centered Planning isRequired  Through several sets of federal regulations, the Center for Medicare and Medicaid Services (CMS) now requires person-centered planning and services for Medicaid Home and Community-Based Services programs (HCBS), intermediate care facilities (ICF), nursing homes, Community First Choice (CFC) services, and home health services. The legal framework for person-centered planning in Medicaid HCBS was established in the Home and Community-based Settings rule of March 2014, which applies to the following:  1915 (c) waivers (Home and Community-based Services, Texas Home Living, Deaf Blind with Multiple Disabilities, Community Living Assistance and Support Services, Medically Dependent Children Program, and the Youth Empowerment Services program)  1915 (i) state plan services (HCBS Adult Mental Health)  1915 (k) state plan services (Community First Choice)  1115 (STAR+PLUS and STAR Kids)  STAR Health, the managed care program for children in state conservatorship
  • 8.
    Person-Centered Planning Defined Person-centeredplanning:  is a process by which a person, with assistance (if needed, or if the person has a legally authorized representative), identifies and documents his or her preferences, strengths and needs in order to develop short-term objectives and action steps which ensure personal outcomes are achieved in the most integrated setting by using identified supports and services;  is an approach that helps create a vision for a person's life based on life choices to include his or her social role, dreams and inclusion in the community;  identifies and highlights a person's unique talents, gifts, and capabilities; and  organizes around the person to help put paid, unpaid and natural supports and resources in place that will assist him or her in achieving personal outcomes. Person-centered planning prioritizes what is "important to" a person as well as what is "important for" a person.  In summary, person-centered planning is a process to help people identify their strengths, preferences, and needs (clinical and support); achieve personally defined outcomes in the most integrated setting; and ensure delivery of services in manner that reflects personal choices, dreams and life aspirations.
  • 9.
    "Important To" vs."Important For"  Person-centered planning prioritizes what is "important to" a person as well as what is "important for" a person. Person-centered planning also seeks a "balance" between "important to" and "important for" that is unique to the person.  "Important to" is used to describe things based on personal preferences or choices about what makes people happy and what makes them feel good about themselves. General examples of things that are "important to" all people could be preferred daily schedules created using personal preferences, favorite types of food, and hobbies. "Important to" is based on a person's unique preferences.  "Important for" is used to describe basic needs and health and safety needs. Examples of things that are "important for" all people include oxygen, food, water, sleep, shelter and health. Examples of what is "important for" specific people could be insulin for those who have diabetes or hearing aids for people who have hearing impairment. "Important for" is aligned with basic needs, not always preferences. In addition, "important for" identifies what is necessary to ensure that people are seen as valued and contributing members of their communities.  Note: For a person who may not use words to communicate, in order to gather information on what is "important to" the person, have a conversation with those who the person enjoys having fun with and who know the person best
  • 10.
    "Important To" vs."Important For" (cont.)  It is important to Francis to talk about cars with his friends because it makes him happy.  It is important to Danielle to watch her favorite soap opera at noon on weekdays.  It is important to Jared to get a job of his own choosing, doing something that he likes.  It is important to Francis to see his friend a few times a week in the afternoon between 3 and 4 p.m.  It is important for Francis to have transportation to the doctor’s office  It is important for Danielle to stay inside between 11 a.m. and 4 p.m. when the temperature is above 85, because she could suffer heat stroke if exposed to too much heat.  It is important for Jared not to leave his home for a job interview looking unkempt.  It is important for Francis to be on a diabetic diet because he's a person who has diabetes.
  • 11.
    Person-Centered Planning vs.Traditional Planning  The focus on what's "important to" a person is also clear when you compare person-centered planning to traditional service planning. In person-centered service planning:  priorities in service delivery shift to a person-centered approach;  the person receiving services will lead the person-centered planning process, when possible;  the plan must reflect supports and services that are "important to" the person with regard to preferences, as well as what is "important for" the person to meet the needs identified through a face to face assessment of functional, clinical, and support needs that assess for risk factors and measures to minimize risks, to include backup plans and strategies when neededneeds; and  the person's legally authorized representative (if applicable) and team members have a participatory role, with planning driven by the person.  In traditional planning, service coordinators, case managers, DDP, nurse managers, program managers, agencies, and professional staff determine needs and services based on assessments, observations, and interviews. Plans are developed and often do not include any input from people receiving services.
  • 12.
    Person-Centered Planning vs.Traditional Planning (cont.) According to the chart below, person-centered planning can be contrasted from traditional planning in a few other ways. Please carefully review these differences now.
  • 13.
    Core Values ofPerson-Centered Planning It can be said that person-centered planning is based on four core values: respect of self-determination, dignity, community inclusion, and optimism and belief. Respect of Self-Determination  Self-determination means respecting the life choices and decisions a person makes based on preferences and interests with a focus on the whole person, not just on physical and mental disability.  Choice and personal control are central to creating quality in the person's life. Person-centered planning supports the person to have positive control over his or her life choices. Dignity  This is the right of a person to be treated with respect and as a valued member of his or her community, as afforded to any person in the larger community.  The person is recognized as having capacity to exercise his or her rights unless limited by law or court order. Community Inclusion  Community inclusion means all people, regardless of their abilities, disabilities, or health care needs, have the right to be included and appreciated as valuable members of their communities, like all others.  The Council on Quality and Leadership (CQL) states that quality of life definitions should be driven by life expectations common to everyone in society regardless of their labels or need for extra support. Optimism and Belief  Belief is trusting that each person can contribute to society in a meaningful way.  Optimism is the belief that each person has the potential for a great life.
  • 14.
    Diverse Populations Benefitingfrom Person-Centered Planning  Finally, it's important to note that person-centered planning can benefit diverse populations.  People receiving supports and services who would benefit from person-centered planning include but are not limited to the following:  -people who are aging  -People residing in nursing facilities  -People recovering from traumatic brain injuries  -Military veterans  -Children, in all settings  -People who have visual or hearing impairment  -People receiving hospice or home health services  -People receiving medical care and treatment from their primary care physician or who receive care from medical hospitals  -People receiving in-patient or outpatient behavioral health care  -People who have intellectual and/or developmental disabilities   Note: All people in the support and service groups listed above will have their own unique vision of what really matters and is important to them; their life choices and personal outcomes are not defined by a group.
  • 15.
    Diverse Populations Benefitingfrom Person-Centered Planning(cont.)  Regardless of the supports and services people may need, we must ensure person- centered planning is used to help:  -with self-determination;  -consumer directed services be discussed and reviewed;  -teach independence and promote community integration regardless of where they live;  -life recovery oriented care or person-centered care used in settings to support behavioral and/or medical health care;  -discussion of informed consent and decision-making; and  -those living in environments with shared or participatory decision-making (i.e. spouse, adult children, or other family members asked by the person to provide the needed supports).
  • 16.
    Module II: FederalRegulations  This module will review the federal regulations relevant to the person-centered planning process and person-centered plan.
  • 17.
    Federal Regulations forthe Person- Centered Planning Process (cont.)  Now that you have gained a basic introduction to person-centered planning, it is time to review the legal requirements for the person-centered planning process found in the Code of Federal Regulations (CFR) and guidelines. The CFR rules require that the person-centered planning process:  is driven by the person;  includes people chosen by the person to serve as members of his or her planning team;  provides necessary information and support to ensure the person directs the process to the maximum extent possible, and is enabled to make informed choices and decisions;  is timely (frequency) and occurs at times (hour, day, week) and locations of convenience to the person and his or her legal authorized representative;  reflects cultural considerations of the person and is conducted in plain language and in a manner accessible to persons who may have limited English proficiency;
  • 18.
    Federal Regulations forthe Person- Centered Planning Process (cont.)  According to the CFR, the person-centered planning process also:  includes strategies for solving conflict or disagreement within the process, including clear conflict of interest guidelines for all participants;  offers choices to the person regarding the services and supports the person receives and from whom;  includes a method for the person to request updates to the plan, as needed; and  records the alternative home and community-based settings that were considered by the person.
  • 19.
    Federal Regulations forPerson-Centered Service Plans  The CFR also contains rules for person-centered service plans. According to the CFR, the person-centered service plan must reflect the services and supports that are important to the person to meet the needs identified through an assessment of functional, assessment, clinical and support needs, as well as what is important to the person with regard to preferences for the delivery of those services and supports. Additionally, according to the CFR, the person-centered service plan must:  reflect that the setting in which the person resides is chosen by the person, includes access to the greater community, includes opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community to the same degree of access as people not receiving services (any modification to the settings requirements needed by a person must be supported by a specific assessed need and justified in the person-centered service plan);  include documentation of the specific and individualized assessed need, positive interventions and supports used prior to modification, less intrusive methods tried, and description of the condition that is directly proportionate to the specified need; and  reflect the person's strengths and preferences.
  • 20.
    Federal Regulations forPerson-Centered Service Plans (cont.)  According to the CFR, the person-centered service plan must also:  reflect clinical and support needs as identified through an assessment of functional need; include individually identified goals and desired outcomes;  reflect the services and supports, paid and unpaid (to include natural), that assist the person and providers to achieve identified goals, including natural supports;  reflect risk factors and the measures in place to minimize their impact, including individual back- up plans and strategies when needed, i.e. Emergency Response Services;  be understandable to the person receiving the services and supports and those supporting him or her by being written in plain language, to assure those who are limited in English proficiency understand, and in a manner that is accessible to persons with disabilities; and  identify the person and/or entity responsible for monitoring the plan.
  • 21.
    Federal Regulations forPerson-Centered Service Plans (cont.)  According to the CFR, the person-centered service plan must also:  be finalized and agreed to with informed consent of the person in writing and signed by all people and providers responsible for its implementation;  be distributed to the person and other people involved in the plan;  include those services, the purchase or control of which the person elects to self-direct using the Consumer Directed Services program;  prevent unnecessary or inappropriate services and supports from being provided;  document any modifications of additional conditions that must be supported by specific assessment and justified in the plan; and  be reviewed, and revised upon re-assessment of functional need when circumstances or needs change every twelve months, when the person's circumstances or needs change significantly and at the request of the person.
  • 22.
    Module III: Foundationsof Person- Centered Planning  In this module, we will build a foundation for person-centered planning by explaining how "What, When, Who and How" questions can be used to gather information, by defining the seven components of person-centered planning and by outlining a planning sequence.
  • 23.
    "What, When, Whoand How" Questions  The following four questions underscore the federal regulations cited above for the person-centered planning process and the need for the person to control the process.  What is important to and for the person? The answer to this question is a prelude to understanding and identifying the person's preferences and outcomes.  When should planning and services take place? This question acknowledges and identifies the person's unique preferences related to their daily routine and timing of events, include the timing (day/hour) of planning meetings, and also considers the preferences of the legally authorized representative, if applicable.  Who should attend planning meetings and/or be on a person's planning team? This identifies the people that know the person well and need to be participants in planning meetings, as chosen by the person.  How is a person-centered service plan developed? This identifies the need for the person to have access to viable options from which to choose services or supports (paid, unpaid and natural), the existence of an approach for group decision-making and conflict resolution, and the potential to identify central strategies to achieve outcomes chosen by the person.
  • 24.
    "What, When, Whoand How" Questions (cont)  "What, When, Who and How" questions should be answered and used by professional and support personnel to get to know the person and help them to actively support the person to control his or her planning process.
  • 25.
    "What, When, Whoand How" Questions (cont’d)
  • 26.
  • 27.
    Person-Centered Planning Components (cont’d) Preferences and outcomes are the central components of the service plan. The face to face conversations identify strengths, needs, and services, and assist the person in obtaining his or her preferences and outcomes. Preferences and outcomes then "drive" the contents of the written plan document. They also determine services, supports, action steps, short-term objectives, and the way the personal outcomes are to be monitored and measured.
  • 28.
     Preferences andOutcomes are the driving considerations of the person-centered service plan. A preference is a choice a person makes for one option over others. For instance, people have preferences on where they would like to work, eat, live and who to live with. An outcome is what a person wants to do, achieve, change, maintain, or experience that is important to them. Example: Preference - Joel wants to live in an apartment with friends instead of with his parents Outcome - Joel lives in an apartment
  • 29.
     Strengths arequalities, traits, talents or abilities that a person has demonstrated in the past. Example: Misti paints with watercolors and her paintings have been purchased by others.
  • 30.
     Needs arethings that the person must have in order to ensure his or her safety, health, and successful integration into the community. Needs are often what is "important for" the person as found in functional and clinical assessments. Example: Robert ambulates with the use of a motorized wheelchair.
  • 31.
    Supports are anyforms of paid, unpaid, or natural assistance that are available to a person and any other member of the community. Example : Phil's brother brings Phil grocery shopping once a week. Services are any programmatic or professional resources recommended in the functional and/or clinical assessments which are available to anyone within the community and used to meet personal outcomes. Example :The Deaf Blind and Multiple Disabilities (DBMD) program provides Sue access to speech hearing and language therapy Action steps and short-term objectives refer to combined activities that enable each personal outcome to be achieved. In developing action steps and short-term objectives in the person-centered service plan, you may want to think about the SMART Principles:  S - Specific  M - Measurable  A - Attainable  R - Relevant  T - Time-bound Example : In order for Mike to spend more time outdoors as he prefers, he will visit a public park next weekend.
  • 32.
    To accomplish monitoringand measurement, the person, in collaboration with his or her planning team, determines:  when and/or if the outcome has been accomplished;  the size, amount, and/or degree of measurement for action steps/short-term objectives;  how the steps are to be monitored and measured to help reach the outcome;  when (frequency) the steps/short-term objectives have been accomplished to assist in reaching the outcome; and  who is responsible for monitoring and measuring the success towards the desired outcome Example: Every two weeks, the job coach will evaluate Bob's progress at learning the new skill required in his job.
  • 33.
    More on Outcomes All of the components of person-centered planning are essential, but outcomes are the key to person-centered planning. Every person has a life that looks different and unique based on his or her own personal definition of quality of life. Personal outcomes are clarified in the planning process and drive the objectives and steps outlined in the plan document. An organization can only design and provide needed services and supports after it has determined how the person defines his or her outcomes. Please review the following additional facts about outcomes:  "When services and supports do not produce outcomes, they become ends in themselves. The means to an outcome becomes confused with the outcome itself." (CQL - The Power of Personal Outcome Measures)  The process for identifying and defining outcomes is based on access to a range of options and meaningful choices grounded in real life experiences.  The plan is based on what outcomes are most important to the person at that present moment, with the understanding that change is natural and expected.  There is no standard definition for any outcome that applies to a group of people. It is unlikely that any two people will define an outcome in the exact same manner.  Two important outcome questions: Is the outcome as defined by the person currently happening in his or her life? Are individualized supports present in the person's life to assist him or her to attain this outcome?
  • 34.
    Action Sequence ofPerson-Centered Planning The service planning team should follow the following general action sequence to create a person-centered service plan. Please review it carefully to prepare for an activity on the next page. 1. Engage in multiple conversations with the person; identify strengths, preferences, needs, services, supports, personal preferences and desired outcomes. This will also prevent unnecessary or inappropriate services and supports from being provided. These conversations will help the person identify members of the planning team and help the person set the agenda of the planning meeting. 2. Complete face to face assessments of functional, clinical, and support needs that assess for risk factors and measures to minimize risks, to include backup plans and strategies when needed. 3. Meet with the person and his or her team to develop the service plan. Further clarify personal outcomes and identify specific supports and services. Address and resolve any disagreements and identify resources and barriers, with the understanding the person directs choice in outcomes. Establish accountability for action. 4. Finalize service plan document based upon team discussions about personal outcomes and short-term action objectives to achieve those outcomes. Document the accountability of "who, what and when" for all action steps. 5. Monitor and measure the service plan's progress based upon the person's input and change service plan as needed.
  • 35.
    Module IV: Examplesof Person-Centered Planning  In this module, first we will show how information gathered using "What, When, Who and How" questions is used to identify the seven components of person- centered planning for two sample people, Francis and Danielle. After this, you will be asked to complete an activity about person-centered planning components for a third sample person.
  • 36.
    Person-Centered Planning Examples Inour two examples, we will begin by reviewing information about Francis and Danielle that was previously gathered using "What, When, Who and How" questions, and then show how this information is used to identify the seven person-centered planning components.
  • 37.
    Person-Centered Planning Example#1 In our first example, the service coordinator, case manager, QIDP/QDDP, and nurse manager engaged in conversations with Francis and discovered the following:  Francis is a person who loves cars and talking about them with his friends.  He loves managing his money and eating at his favorite restaurant, Olive House, on the weekends after cashing his paycheck.  He does not hear as well as others and uses a wheelchair for mobility. Next, they gathered additional information about Francis by asking "What, When, Who and How" questions, which are presented on the next two slides
  • 38.
    Francis' "What, When,Who and How" Questions What is important to and for Francis?  Francis told his team during his person-centered planning meeting that finding a job that has something to do with cars is most "important for" him. However, his team believed he should focus on developing more skills by continuing with school and job training. Since Francis is in charge of his planning process, all agreed that he should work on his personal life choices. When should Francis' person-centered planning meeting be held to identify and develop the outcomes?  Francis wakes up by 5 am almost every morning. He watches television game shows and naps in the afternoons since he is not working therefore, he has asked if services, supports and person-centered planning meetings be provided to him in the morning. Who sets the agenda and determines who should attend Francis' person-centered planning meetings?  Although she doesn't work directly with Francis, Louanne knows him well and visits him most weekday mornings. Francis invited Louanne to serve on his person- centered planning team. Therefore, Louanne will be invited to all of his person-centered planning meetings. Also, Francis agreed to add a job coach to his team to help him find a job working with cars. How should Francis' person-centered service plan be developed?  Francis' person-centered service plan focuses on ways to support his personal life choice of finding a job in a local mechanic's shop. Francis will enlist the help of a job coach for this goal. The job coach will provide Francis a list of available jobs working with cars so Francis has options to consider for this important decision.
  • 39.
    Francis' Person-Centered Planning Components Throughthe face to face conversations, functional and clinical needs assessments, Francis was able to identify what is important to him and for him through the use of the "What, When, Who and How" questions. After careful review, Francis and his planning team identified the following within the components of Francis' person-centered plan. Please scroll down and review each of them now. You may select the images at left to review the definition of each component, if needed. Note how each component is unique, and how each plays an important role in the overall person-centered service plan. The following preferences were identified by Francis, shared with his planning team, and added to his plan:  Francis enjoys his collection of vintage model cars, showing them to friends, staff and visitors.  Francis would like to have a job working on cars.  Francis likes to eat at his favorite restaurant, Olive House, on the weekend.  Francis likes waking up at 5:00 AM and has asked if services, supports and person-centered planning meetings be provided to him in the morning.  Francis wants to become more independent. The desired outcomes identified by Francis include the following: Francis has a job working with cars. (Outcome #1) Francis manages his own money. (Outcome #2) Francis eats at the restaurant of his choice with the money he earns. (Outcome #3)
  • 40.
    Francis' strengths includethe following: Francis is amazing when it comes to his knowledge of makes and models of vintage cars. Francis has successfully lived for several years in a home with his friends using various support services of his choosing. Francis is very friendly and outgoing, which will help him make new friends in his new job.
  • 41.
    Francis' needs wereidentified and added to his person-centered service plan:  Francis needs assistance with maintenance and repair of his hearing aids, lift and wheelchair.  Francis' home phone must have a feature that changes voice to text/text to voice.  Francis' cell phone should have the app that changes voice to text/text to voice, if he needs to use it.  Francis needs assistance getting into his lift when transferring into or out of his bed and favorite chair.  Francis needs assistance with transportation to complete his life choices.  Francis needs assistance with increasing his money management skills, i.e. use of debit card, learning to pay his bills on line, etc.  Francis needs his home to be accessible to maximize his independence, i.e. needs a ramp to enter his home.  Francis needs periodic reassessment of clinical and functional needs.
  • 42.
    The following supportswere identified and added to his person-centered service plan:  Francis' family helps him get into and out of his favorite chair using his lift when they come to visit and go with him on activities of his choosing within the community.  Francis' family and friend often assist Francis in changing over from the voice to text/text to voice feature on his home phone, if their assistance is requested by Francis.  Francis' family and friends meet him on routes that allow him to use public transportation to go out to eat, visit friends, and to go shopping.
  • 43.
    These services wereidentified and added to his person-centered service plan:  Francis receives transportation and support services from program staff to see his doctors/audiologist as needed for medical care, treatment and for follow up as needed.  Francis will have a job coach to serve him by providing training and assistance for transportation related to job applications, interviews and coaching within the new job.  Francis will continue to receive Community Living Assistance and Supports Services (CLASS) to help him maintain his independence.
  • 44.
    Francis' person-centered serviceplan includes the following action steps and short-term objectives, identified for each of his desired outcomes:  Francis has a job working with cars. (Outcome #1)  The job coach will provide Francis with a list of available jobs working with cars so he may choose which job to pursue.  The job coach will assist Francis with transportation, completing job applications, preparing for interviews and coach him as he learns new job tasks. Francis manages his own money. (Outcome #2)  Program staff will transport Francis to the bank and provide assistance to set up online banking and then coach Francis at home as he learns how to use online banking.  Program staff will coach Francis on how to develop a list of all bills with amounts owed, so he may pay his bills on-line and on time.  Program staff will provide transportation, coaching and support to Francis after the banking staff teaches Francis how to use a debit card.  Program staff will provide supports needed for Francis to become more independent in shopping at the grocery store. Francis eats at the restaurant of his choice with the money he earns. (Outcome #3)  Program staff will provide coaching, assistance and training on transportation options to support Francis going to the restaurant he chooses.  Program staff will coach Francis on how to use his debit card to pay for his food at the restaurant.
  • 45.
    Francis' person-centered serviceplan will be monitored and measured as determined by Francis in collaboration with his planning team. His three outcomes will be monitored and measured as explained below: Francis has a job working with cars. (Outcome #1)  Francis and his work colleagues report his continued satisfaction with his job and his love of cars. The job is stable and achieves Francis' personal outcome at this time.  Francis' job coach continues to assess and measure the progress of Francis' job skills and phases out the daily job coaching support. Francis manages his own money. (Outcome #2)  Francis' money management skills allow him to spend his money as he chooses by eating out once a week at his favorite restaurant.  Francis continues to use his debit card without incident as he pays for purchases.  Francis continues to pay his bills using online banking without incident. Francis eats at the restaurant of his choice with the money he earns working. (Outcome #3)  Francis' money management skills allow him to spend his money as he chooses by eating out once a week at his favorite restaurant.  Francis uses public transportation to go out to eat weekly.
  • 46.
    Person-Centered Planning Example#2: Danielle The service coordinator, case manager, DDP and nurse manager engaged in conversations with Danielle and discovered the following:  Danielle came to the United States ten years ago to live with her sister and has helped raise her nieces, who are both now studying to become nurses. Danielle has become fluent in speaking English and shared she would like to learn to read and write in English, as it would "help me to feel like I belong here."  Danielle loves spending time with her family and wants to move closer to her family. She sees the supports offered by her family as a way to maintain her independence.  Danielle is a person who has an intellectual disability and beginning signs of memory loss.  Next, they gathered additional information about Danielle by asking "What, When, Who and How" questions. This information is displayed on the next two pages.
  • 47.
    Danielle's "What, When,Who and How" Questions What is important to and for Danielle?  Danielle wants to learn to read and write in English to "help her feel like she belongs here." Danielle recognizes she needs more supports to maintain her independence and wants to move closer to her family for their support. When should Danielle's person-centered planning meeting be held to identify and develop the outcomes?  Danielle likes to sleep "in" most mornings. She told her team during the planning meeting that she wants all of her appointments and person-centered planning meetings to be after lunch. Because sleeping in is important to Danielle, her team addressed her preference and listed her request under supports with the directive to always asks doctors, dentists, or any other needed appointments be scheduled in the afternoon. All planning meetings will be held after lunch. Danielle expressed her desire to work at a job that does not start until later in the day and is located closer to her family. Her choice was honored by directing her job coach to identify potential employers who are located closer to her family and who hire people to work the afternoon and evening shifts at a job of Danielle's choosing. Danielle wants to move closer to her family when her lease is up, in two months. Who sets the agenda and determines who should attend Danielle's person-centered planning meetings?  Danielle's niece, Rhonda, visits her every Tuesday and Thursday night after she attends nursing classes at a nearby community college. Danielle asked Rhonda to help her make decisions and communicate to her planning team her desire to learn to read and write in English. Rhonda understands Danielle's personal life choices and preferences very well. Rhonda plans to support her aunt by attending all planning meetings and serving on her planning team. Her family, church friends and job coach will assist Danielle in identifying places to live and work close to her family. How should Danielle's person-centered service plan be developed?  Danielle's team considered her personal life choice of learning to read and write in English. Planning meetings will be conducted so she and her family can have a full understanding of what is being discussed. Translation or interpreter services will be used as needed. With Danielle's participation as team lead, the team identified how to best support her by finding available volunteer literacy programs offered in the area where she wants to live and additional supports she needs to reach her outcomes of learning to read and write in English and live closer to her family. Examples might be unpaid supports such as obtaining rides from classmates, or paid supports to assist Danielle in learning to ride the bus, learning to set up MetroAccess Service, and program staff to assist and support her efforts to practice her reading and writing assignments. Thus, Danielle was given options to enable her to make informed decisions related literacy programs and additional supports.
  • 48.
    Danielle's Person’s Preferencesand Outcome Through the face to face conversations, functional and clinical needs assessments, Danielle was able to identify what is important to her and for her through the use of the "What, When, Who and How" questions. After careful review, Danielle and her planning team identified the following within the components of Danielle's person-centered plan. Please scroll down and review each of them now. You may also select the images at left to review the definition of each component, if needed. Note how each component is unique, and how each plays an important role in the overall person-centered service plan. The following preferences were identified by Danielle, shared with her planning team, and added to her plan:  Danielle wants to find a new place to live, which is closer to her family.  Danielle wants her appointments after lunch.  Danielle wants to start work later in the day, in the afternoon or evening shifts. The following desired outcomes were identified by Danielle:  Danielle moves closer to her family to ensure family supports and maintain her independence. (Outcome #1)  Danielle works at a job of her choice in the afternoon. (Outcome #2)  Danielle learns to read and write in English. (Outcome #3)
  • 49.
    Danielle’s Strengths Danielle's strengthsinclude the following:  Danielle speaks English well as her second language.  Danielle has successfully lived independently with supports for over ten years.  Danielle knows the area in which she wants to live.  Danielle has many friends from her church.  Danielle's family supports her desire to move closer to them.
  • 50.
    Danielle’s needs Danielle's needswere identified and added to her person-centered service plan. Danielle needs:  a walker to assist in preventing her from falling;  a home with minimal or no stairs and access to Emergency Response Services;  assistance with transportation to get to work since she cannot walk long distances;  assistance packing, lifting boxes and moving when she finds her new home;  financial supports to assist with paying rent and supporting her move; and  periodic reassessment of clinical, functional and personal needs.
  • 51.
    Danielle’s Supports The followingsupports were identified and added to Danielle's person-centered service plan:  Danielle enjoys spending time with her family and friends and is very grateful for them taking her to the grocery store and providing her with rides to church on Sundays and Wednesdays.  Danielle's church friends have offered to help her pack her things and move her to her new home.  Danielle's volunteer literacy program is an important support.
  • 52.
    Danielle’s Services These serviceswere identified and added to her person-centered service plan:  Danielle receives transportation and support services from program staff to see her doctor as needed for medical care, treatment and for follow up as needed.  Danielle has a job coach who will continue to serve Danielle when she moves to her new home and provide training, coaching and transportation related to job applications, interviews and coaching within the new job.  Danielle receives Home and Community-based Services to help her to maintain her independence.
  • 53.
    Danielle’s action stepsand short-term objectives Danielle's person-centered service plan includes action steps and short-term objectives identified for each of her desired outcomes. Danielle moves closer to her family to ensure family supports and maintain her independence. (Outcome #1)  Program staff will provide Danielle with assistance in locating resources to help her find a new home closer to her family.  Program staff will provide Danielle assistance with going to visit potential new homes that are closer to her family.  Program staff will provide assistance reading legal documents and with writing when it comes to applications and lease agreements for the place she wishes to live. Danielle works a job in the afternoon. (Outcome #2)  Danielle's job coach will provide her with a list of jobs she may like that are available for her to work in the afternoon and evening shifts, near her family..  The job coach will assist Danielle with transportation, completing job applications, assist with interview preparations she may have, and coach her as she learns new job tasks. Danielle learns to read and write in English. (Outcome #3)  Danielle's support staff will find a volunteer literacy program near her new home that Danielle may attend on a regular basis.  Danielle will complete her reading assignments and practices her English writing exercises with the assistance of program staff.
  • 54.
    Danielle’s monitoring andmeasurement Danielle's person-centered service plan will be monitored and measured as determined by Danielle in collaboration with her planning team. Danielle moves closer to her family to ensure family supports and maintain her independence. (Outcome #1)  Danielle continues to say she is pleased with her new place of residence.  Danielle's family assists her with weekly grocery and shopping trips. Danielle has increased visits to her family's home.  Danielle continues to use her walker daily as seen with no reported falls.  Danielle has not needed to use the Emergency Response Service. Danielle works at a job of her choice in the afternoon. (Outcome #2)  Danielle and her work colleagues continue to report her satisfaction and progress in her job and the "fit" of her work hours for her energy and attention.  Danielle's job coach continues to assess and measure the progress of Danielle's job skills and phases out the daily job coaching support, yet continues to monitor her weekly progress. Danielle learns to read and write in English. (Outcome #3)  Danielle maintains her consistent attendance and participation in the literacy program and she reports her continued desire to improve her English reading and writing skills.  Danielle chooses every week to complete 100% of her English assignment with assigned and scheduled assistance and monitoring from program staff.
  • 55.
    Keys to Success In conclusion, remember that person-centered planning will be most successful when:  the person and team participate in the planning process;  the person, with the support of the team, determines the personal outcomes and identifies services and supports to achieve those outcomes;  the plan is understandable to the person receiving services and supports and those providing the supports;  the team develops both paid, unpaid and natural supports needed to reach the desired outcomes;  the plan identifies those responsible for implementing and monitoring the plan; and  follow-up and follow-through on the plan is guaranteed, including changes and updates as needed.