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 an individual's
inherent value and the way to think about and discover an individual's
unique preferences and personal life outcomes.
- Person-centered
planning
is the process of developing an individual's plan based on the philosophy
of person-centered thinking. Person-centered planning is a way to assist
individuals 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 individual's needs and be integrated into the
greater community.
- Person-centered
practice is the alignment of service
resources that gives individuals 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 an individual, with assistance (if needed, or if the individual 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 an individual's life based on life choices
to include his or her social role, individual dreams and inclusion in the
community;
- identifies and
highlights an individual's unique talents, gifts, and capabilities; and
- organizes around
the individual 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 individuals 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 individual.
- "Important
to"
is used to describe things based on personal preferences or choices about
what makes individuals happy and what makes them feel good about
themselves. General examples of things that are "important to"
all individuals could be preferred daily schedules created using personal
preferences, favorite types of food, and hobbies. "Important to"
is based on an individual's unique preferences.
- "Important
for"
is used to describe basic needs and health and safety needs. Examples of
things that are "important for" all individuals include oxygen,
food, water, sleep, shelter and health. Examples of what is
"important for" specific individuals could be insulin for those
who have diabetes or hearing aids for individuals 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 individuals are seen as valued and
contributing members of their communities.
Note: For
an individual who may not use words to communicate, in order to gather
information on what is "important to" the individual, have a
conversation with persons who the individual enjoys having fun with and who
know the individual best.
"Important To" vs. "Important
For" (cont.)
The
chart below contrasts some examples of "important to
" and "important for
" statements. Carefully review
these to help prepare for the activity on the next page.
Danielle's
"What, When, Who and How" Questions
Please scroll down on this page to
review information gathered using "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.
Important To
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Important For
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It is important to
Francis to talk about cars with his friends because it makes him happy.
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It is important for Francis to have
transportation to the doctor's office.
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It is important to
Danielle to watch her favorite soap opera at noon on weekdays.
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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.
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It is important to Jared
to get a job of his own choosing, doing something that he likes.
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It is important for Jared not to
leave his home for a job interview looking unkempt.
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It is important to
Francis to see his friend a few times a week in the afternoon between 3 and 4
p.m.
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It is important for Francis to be
on a diabetic diet because he's a person who has diabetes.
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Person-Centered
Planning vs. Traditional Planning
The
focus on what's "important to" an individual is also clear
when you compare person-centered planning to traditional service planning. In person-centered
service planning:
- the individual
receiving services will lead the person-centered planning process, when
possible;
- the plan must
reflect supports and services that are "important to" the individual
with regard to preferences, as well as what is "important for"
the individual 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 needed needs; and
- the individual's
legally authorized representative (if applicable) and team members have a
participatory role, with planning driven by the individual.
In
traditional planning, service coordinators, case managers, QIDP/QDDP,
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 individuals 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
Please scroll down to review all
content on this page.
To
complete our overview, let's identify the values essential to 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. Please scroll down and carefully
review each of these values.
Respect
of Self-Determination
- Self-determination
means respecting the life choices and decisions an individual makes based
on their preferences and interests with a focus on the whole person, not
just on their physical and mental disability.
- Choice and
personal control are central to creating quality in the individual's life.
Person-centered planning supports the person to have positive control over
his or her life choices.
Dignity
- This is the
right of an individual to be treated with respect and as a valued member
of his or her community, as afforded to any individual in the larger
community.
- The individual
is recognized as having capacity to exercise his or her rights unless
limited by law or court order.
Community Inclusion
- Community
inclusion means all individuals, 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 individual can contribute to society in a meaningful
way.
- Optimism is the
belief that each individual has the potential for a great life.
Diverse Populations of Individuals
Benefiting from Person-Centered Planning
Please
scroll down to review all content on this page.
Finally, it's important to
note that person-centered planning can benefit diverse populations of individuals.
Individuals
receiving supports and services who would benefit from person-centered planning
include but are not
limited to the following:
-Individuals who are aging
-Individuals residing in
nursing facilities
-Individuals recovering from
traumatic brain injuries
-Military veterans
-Children, in all settings
-Individuals who have visual
or hearing impairment
-Individuals receiving
hospice or home health services
-Individuals receiving
medical care and treatment from their primary care physician or who receive
care from medical hospitals
-Individuals receiving
in-patient or outpatient behavioral health care
-Individuals who have
intellectual and/or developmental disabilities
Note: All individuals 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.
Regardless
of the supports and services individuals 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 individual to provide the needed
supports).
Module II: Federal
Regulations
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
individual;
- includes people
chosen by the individual to serve as members of his or her planning team;
- provides
necessary information and support to ensure the individual 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 individual and their legal authorized representative;
- reflects
cultural considerations of the individual 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 individual regarding the services and supports the individual
receives and from whom;
- includes a
method for the individual to request updates to the plan, as needed; and
- records the
alternative home and community-based settings that were considered by the
individual.
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 individual to
meet the needs identified through an assessment of functional, assessment,
clinical and support needs, as well as what is
important to the individual 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 individual resides is chosen by the individual,
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 individuals not receiving
services (any modification to the settings requirements needed by an
individual 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
individual'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 the
individuals important in 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 individual in writing and signed by
all people and providers responsible for its implementation;
- be distributed
to the individual and other people involved in the plan;
- include those
services, the purchase or control of which the individual 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 individual's circumstances or needs
change significantly and at the request of the individual.
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 individual to control the
process
.
- What is important to and for the individual?
The answer to this question is a prelude to understanding and identifying
the individual's personal preferences and outcomes.
- When should planning and services take place? This question
acknowledges and identifies the individual'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 an individual's planning team? This identifies the people that know the individual
well and need to be participants in planning meetings, as chosen by the
individual.
- How is a person-centered
service plan developed? This identifies
the need for the individual 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
individual.
"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 individual and help them to actively support the
individual to control his or her planning process. Please select each images below to
review these questions again now
Person-Centered Planning Components
In person-centered planning, all information
gathered about an individual should be used to identify the seven
person-centered planning components displayed in the diagram
below. Understanding how an individual's
information fits into these components provides an important foundation and
starting point for person-centered planning.
Person-Centered Planning Components
Please
scroll down to review all content on this page.
Preferences and
outcomes are
the central components of the service plan. The face to face conversations
identify strengths, needs, and services, and assist the individual 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. Please
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Preferences and Outcomes are the driving considerations of
the person-centered service plan. A preference
is a choice an individual makes for one option over others. For instance,
individuals 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.
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Strengths are qualities, traits, talents or
abilities that an individual has demonstrated in the past.
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Needs are things that the individual
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 individual as found in functional and clinical assessments.
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Supports are any forms of paid, unpaid, or
natural assistance that are available to an individual and any other member
of the community.
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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.
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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
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To accomplish monitoring and measurement,
the individual, 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.
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scroll down and review each of the seven
components below to prepare for a matching activity on the next page. For each
component, first read the definition on the right, and then hover your mouse over the
component image on the left for a brief example of that component.
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 individuals.
It is unlikely that any two individuals will define an outcome in the
exact same manner.
- Two important
outcome questions: Is the outcome as defined by the individual currently
happening in his or her life? Are individualized supports present in the
individual'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 individual; 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 individual identify members of the planning team
and help the individual 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 individual 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 individual
directs their 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 individual's input and change service plan as
needed.
- The planning team engaged in multiple conversations
with the individual.
- Planning team members completed face to face
assessments of functional, clinical, and support needs.
- The planning team met with the individual to develop
the service plan.
- The team finalized service plan document based upon
individual's input and discussions with team.
- The team monitored and measured the plan's progress
based on the individual's input.
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 individuals,
Francis and Danielle. After this, you will be asked to complete an activity
about person-centered planning components for a third sample individual.
Information
gathered using "What, When, Who and How" questions is used to
identify the seven components of person-centered planning.
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: Francis
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 pages.
Francis' "What,
When, Who and How" Questions
Please scroll down on this page to
review information gathered about Francis using "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
On
this page, select the images on the left to
review the definition of each person-centered planning component, and then
review how Francis' information fits into each component. Please scroll down
to review all seven 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.
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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)
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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.
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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.
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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.
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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.
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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.
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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.
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Person-Centered
Planning Example #2: Danielle
The service coordinator,
case manager, QIDP/QDDP 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 Person-Centered Planning
Components
On
this page, select the images on the left to
review the definition of each person-centered planning component, and then
review how Danielle's information fits into each component. Scroll down to
review all seven components.
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.
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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)
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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.
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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.
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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.
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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.
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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.
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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.
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In conclusion, remember that
person-centered planning will be most successful when:
- the individual
and team participate in the planning process;
- the individual,
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 individual 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.
Additional Resources
For
additional person-centered thinking, planning and practices resources, please
visit the following websites: