Transcript DMHDDSAS’ PCP Guidelines - Western Highlands Network

An Introduction to Writing
Effective Person-Centered Plans
Person-Centered Planning Starts
with Person-Centered Thinking
DRAFT: For review, feedback and revision
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Course Outline
Orientation to the PCP
PCP Planning Models
Engaging Consumers in PCP Planning
Process
Overview of PCP Elements
How to Write a Goal
Hands-On Writing Goals
Natural Supports
Getting Service Authorization Requests
Approved by the LME
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Learning Objectives
 Participants will learn to use several
methods to engage consumers or
families in the person-centered
planning process, including cultural
preferences.
 Participants will learn to use several
strategies to help consumers/families
define baseline behaviors and
functional outcomes.
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Learning Objectives
 Participants will learn to write
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measurable goals.
Participants will learn to translate
outcomes into service requests.
Participants learn to write step-down
plans and crisis plans.
Participants will learn to include
natural supports and other
community resources in PCPs.
Participants will learn key techniques
to ensure that their PCP and service
authorization request is approved by
LMEs.
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PCP Definition
A process focused on learning about an
individual’s whole life, not just issues
related to the person’s disability. The
process involves assembling a group of
supporters selected by the consumer
who are committed to supporting the
person in pursuit of desired outcomes.
Planning includes discovering strengths
and barriers, establishing time-limited
goals and identifying and gaining access
to supports from a variety of community
resources prior to utilizing the
community MH/DD/SA system to assist
the person in pursuit of the life he/she
wants.
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PCP Definition
Person-centered planning results in a
written plan that is agreed to by the
consumer and that defines both the
natural and community supports and
services being requested from the public
system to achieve the consumer’s
desired outcomes. The plan is used as a
basis for requesting an authorization for
services.
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Writing Effective PCPs
Often done as a perfunctory process
We Just want to get services authorized
Person-centered planning is a clinical
process (tip: use quotation marks on
goals)
PCPs can be used to make
interventions more effective
You do not need a PCP for outpatient
services only
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State’s Mandate
LMEs approve plans, not just discrete
services
PCPs are the lever for consumer-driven
services
DMHDDSAS’ PCP Guidelines are on the
their website,
www.dhhs.state.us/mhddsas (Bulletin
#034)
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Highlights of DMHDDSAS’
PCP Guidelines
Person-centered planning is a
foundation of system reform
A process determining real-life
outcomes and developing strategies to
achieve those outcomes in partnership
with the individual/family
Supports strengths and recovery, and
applies to everyone in the system
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Highlights of DMHDDSAS’
PCP Guidelines
The individual/family direct the process
and share authority and responsibility
with system professionals
Builds on strengths, gifts, skills, and
contributions
Supports consumer empowerment, and
provides meaningful options to express
preferences and make informed
choices
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Highlights of DMHDDSAS’
PCP Guidelines
Honors goals and aspirations for a
lifestyle that promotes dignity, respect,
interdependence, mastery and
competence
Supports a fair and equitable
distribution of system resources
Creates community connections
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Highlights of DMHDDSAS’
PCP Guidelines
Sees individuals in the context of their
culture, ethnicity, religion, and gender
Supports mutually respectful and
partnering relationships,
acknowledging the legitimate
contributions of all parties
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Key Features of the Recovery Model
A holistic view of mental illness that
focuses on the person, not just the
symptoms
Recovery is not a function of one’s
theory about the causes of mental
illness
Recovery from severe psychiatric
disabilities is achievable
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Key Features of the Recovery Model
Recovery can occur even though
symptoms may reoccur
Individuals are responsible for the
solution, not the problem
Recovery requires a well-organized
support system
Consumer rights, advocacy, social
change
Applications and adaptations to issues
of human diversity
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Essential Elements of PCPs
The Person-Centered Plan is a unified
life plan
It is the umbrella under which all
planning for treatment, services and
supports occurs
Real life outcomes are described and
related to life domains
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Essential Elements of PCPs
The planning team is at the core of the
PCP
The individual/family identifies who will
participate in the planning process,
how, and to what extent. Those
individuals will comprise the planning
team
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Essential Elements of PCPs
The extent to which the planning team
assists the individual with describing
his/her goals, preferences and needs
will vary with circumstances
All good plans are done in partnership
The planning team includes
participation by professionals and
paraprofessionals that have been
involved with the individual
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Essential Elements of PCPs
The planning process honors the
schedule and comfort of the
individual/family
Information gathered is communicated
in a way that is understood
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Essential Elements of PCPs
The PCP includes goals and strategies
to meet desired life outcomes
Meeting the treatment, and primary
service and support needs in order to
insure health and safety is a primary
focus of the planning process
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Essential Elements of PCPs
The individual/family must be fully
informed of the rationale, evidence and
risks of specific service support and
treatment options
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Essential Elements of PCPs
The following avenues should be
explored for ways to contribute to the
accomplishment of life goals: a)
personal resources, b) natural
supports, such as family, neighbors,
co-workers, and friends, and c)
community resources
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Essential Elements of PCPs
The PCP addresses health and safety
needs
Health and safety needs are identified
as part of the planning process in
partnership with the individual/family
Supports to maintain health and safety
must be developed within the context of
the individual’s preferred lifestyle, as
much as possible
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Essential Elements of PCPs
The PCP reflects the preparation for a
potential crisis
The planning process identifies early
known warning signals of an impending
crisis and the necessary interventions
to ensure health & safety
Provides proactive plans to prevent
crisis from occurring as well as reactive
planning and crisis contingencies
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Essential Elements of PCPs
Provides proactive plans to prevent
crisis from occurring as well as
reactive planning and crisis
contingencies
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Essential Elements of PCPs
Individual/family disagreement with the
plan
Good person-centered planning will
usually result in a plan of consensus by
all parties
If preferences and choices are not
accepted and provided, there is access
to an appeals/dispute process
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Essential Elements of PCPs
Changing the plan
The individual/family is provided with
opportunities to refine and change the
evolving plan
There are ongoing opportunities to
provide feedback regarding the
services, supports and/or treatment
received and progress toward
achieving outcomes
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What If There Is A
Disagreement?
Occasionally a professional cannot
support the individual/family’s choices,
including the amount of service that is
needed or that it can be funded. The
individual/families have access to a
dispute process to address and resolve
disagreements and to ensure fairness
and equality
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A Tactic to Avoid
Unnecessary Conflict
Agreeing to principles versus specific
services
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Person-Centered Thinking: The PCP
is a “Wholistic” Approach
Individual (biological; psychological)
Family
Neighborhood
School / Work
Community
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Use the PCP in 4 Ways
To maintain focus on the consumer’s
progress toward goal attainment
To track changes in needs and challenges
As a framework for identifying and
organizing needed resources
To measure growth and change
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When Should You Update a PCP?
Preferably every 6 months. Longer timeframes do not communicate a message of
hope and change
Target dates
Intervals established by regulatory
agencies
At transitions and discharges
To evaluate benefit/outcome of services
When the IPRS target population changes
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PCP Update
Is there new information to inform any of
the plans elements
Any significant changes in key domains
Goals or transition/discharge criteria
changed
New strengths or resources emerged
New or different barriers
New concerns or needs
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PCP Update
Impact of services provided. Have they
helped
Should target dates need to change
New or different objectives
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Axioms
Services should be time-limited
The goal is to help the consumer function
in the natural support system, without
services, not to provide services until they
will never be needed again
Services may be needed in the same way
that we use an attorney—from time to time
in life
Consumers may have to come back
periodically for help
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Axioms
Goals should be expressed in the words of
the consumer
Goals should be reflective of informed
choice
Goals should reflect cultural factors
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Cultural Factors
What is the individuals cultural identity
(race, ethnicity, gender, sexual orientation,
religion, spirituality, disability status and
other self-defining issues)
Are there possible cultural explanations of
the problem
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History of Person-Centered Planning
1968-Ecological Assessment and
Enablement Plan (Nick Hobbs)
1980-Individual Service Design (Jack
Yates)
1980-Individual Habilitation Plan (Willie
M.)
1987-Personal Futures Planning (Beth
Mount)
1988-Child and Family Teams (CASSP)
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History of Person-Centered Planning
1989-MAPS and Circles of Support
(Marsha Forest & Evelyn Lusthaus)
1992-Essential Lifestyle Planning
(Michael Smull & Susan Burke
Harrison)
1995-PATH (Jack Pearpointt, John
O’Brien & Marsha Forest)
1990-Wraparound (VanDenBerg &
Dennis)
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Which PCP Model Should be Used?
The literature does not support one
model over another
For children and youth with mental
health needs, the Division does
recommend that the System of Care
Child and Family Team process be used
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Common Beliefs in
Person- Centered Planning
It is a means for uncovering what is
already there: the essence, gifts and
capacities of a person…it is about
sharing life with one another…sharing
power and giving up control over
another person
Assumes the person, and those who
love the person are the primary
authorities on the person’s life
direction, and the person drives the
process
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Common Beliefs in
Person- Centered Planning
It is the beginning of the journey of
ongoing learning through shared action
Intends to shatter myths about people with
“labels” and fosters an inclusive
community
Relies on skilled facilitation in developing
and moving the plan forward
Requires systems to respond in flexible
and meaningful ways
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Introduction to Different
Person- Centered Planning Models
www.ilr.cornell.edu/ped/tsal/pcp
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Consumer/Family Member Story
Nancy Baker
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Examples of Ways to Engage
Consumers/Family Members in the
PCP Process
Identify an immediate, practical
concern that can be addressed
Don’t us “professional” language; use
common terms
Participants brainstorm others . . . .
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PCP Cheat Sheet
 Each goal must have a creation date
(top of goal pages on the left).
 Each goal must have current target
dates that do not exceed 12 months.
 Axis I, II, and III must be addressed.
 Front page of PCP (diagnosis,
supports/strengths, preferences,
problems/needs sections) must be
completed and dated.
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PCP Cheat Sheet
 Problems/needs must be addressed
within the PCP goals and interventions.
 Client name and number should be on
all pages of the PCP.
 PCP should identify goals, service type,
and intervention, along with frequency.
 Client/guardian signatures are required
for all created goals, changes to PCP,
additions, etc.
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PCP Cheat Sheet
 If signatures cannot be obtained on
creation or change date, then a written
specific explanation should be included
for the lack of a signature and the
signature should be obtained at the next
face-to-face visit.
 All changes to PCP must show a review
date, status code, and justification.
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PCP Cheat Sheet
 CBS step-down plans (required with 3
or more hours of daily CBS service)
must be specific and reflect a system
for reducing hours based on targeted
behavioral/adaptive improvements (See
“Documentation Requirements” in CBS
definition).
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PCP Cheat Sheet
 Goals in the PCP must be measurable,
with the baseline behaviors defined in
the goal as well. (We will be evaluating
consumer outcomes by looking at
progress on each goal.)
 All requested services (on the Service
Authorization Request form) must be
addressed in the PCP.
 All services, including natural supports
and other community services &
resources also should be included on
the PCP, per Division’s PCP guidelines.
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Can I See Examples of Good
PCPs?
Consult Adams, N., & Grieder, D. (2005).
Treatment planning for person-centered
care.
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Goals
If you don’t know where you are going,
how will you know when you get there?
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What is a Goal?
A goal communicates an intended
result
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Goals should be:
Simple
Measurable
Attainable
Realistic
Time-famed
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A Well-Written Goal Will
Communicate 3 Pieces of
Information
What the person will do (behavior)
Under what conditions the
performance will occur (condition)
The acceptable level pf performance
(criteria)
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Behavior
What the person will do refers to the
behavior, performance, or action of the
person for whom the goal is written. In
services for people with disabilities,
especially in the context of personcentered services, behavioral goals
should be stated in positive, affirmative
language.
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Condition
Under what conditions the performance
will occur is the part of the goal that
describes the action of the staff person
or staff intervention. Specifically
address what assistance the staff
person will provide, and/or what the
staff person will do (if anything) to see
that the behavior, performance, or
action of the individual occurs.
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Examples of
Conditions/Interventions
With assistance from a staff person . . .
When asked . . .
With suggestions from a team member . .
With physical assistance . . .
Given that Ellen has received instruction
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Examples of
Conditions/Interventions
Given that Jeremy has the phone book
in front of him . . .
Without any verbal instructions . . .
Given that a staff person has shown
Jose where the detergent is . . .
With no suggestions or demonstrations
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Criteria
Acceptable level of performance refers
to criteria. This means the goal must
include a description of how
“achievement” will be defined. In
writing this part of the goal, always
consider how the person or the people
who know the person will define
success. Performance must be overt,
that is, it can be observed directly.
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Measurable Goals
Measurable goals are most easily
written by using words that are open to
few interpretations, rather than words
that are open to many interpretations
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Words Open to Many
Interpretations
To know
To understand
To really understand
To appreciate
To fully appreciate
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Words Open to Many
Interpretations
To grasp the significance of
To enjoy
To believe
To have faith in
To internalize
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Words Open to Fewer
Interpretations
To write
To recite
To identify
To sort
To solve
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Words Open to Fewer
Interpretations
To construct
To build
To compare
To contrast
To smile
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Example Goal
With staff assistance (condition),
Marsha will choose her clothing, based
on the weather (performance), five out
of seven days for the next three months
(criteria).
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Example Goal
Adam will identify places he can go in
his free time (performance), without
any suggestion from staff (condition),
each Saturday morning for the next
three months (criteria).
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Example Goal
With gentle, verbal encouragement
from staff (condition), Charles will not
scream while eating (performance), two
out of three meals, for five minutes
each time, for the next two months
(criteria).
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Example Goal
Given that Rosa has received
instructions (condition), she will call
her therapist to make her own
appointments (performance), as
needed during the next four months
(criteria).
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Example Goal
With suggestions from a support team
member (condition), Henry will write a
letter to his father (performance), once
a month for the next six months
(criteria).
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Why Do You Choose a Particular
Target Behavior?
Consumer/family is invested in it
Someone else is invested in it (e.g.,
school)
Easy behavior to show some initial
success
Behavior is noxious; the family needs
something to happen.
Behavior ecologically affects other
behaviors.
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Tips for Making Goals Measurable
You will find it more difficult to write
clear and measurable goals if you have
not first written a clear and measurable
level of performance
Measurable means you can count it or
observe it
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Example: Making a Goal
Measurable
This goal uses the consumer’s
strengths as a lever of change
“Uncle Bob will increase the number of
times he intervenes with statements
that reflect the consumer accepting
responsibility for his behavior from
none to 8 times per day”
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How to Make Something
Measurable
Specify a level of performance
Indicate a rate, for example 3 out of 4
times, 80% of the time, 5 minutes out of
every 10, 75% success
Define the factors surrounding the
behavior (e.g., when asked to work
independently, always after lunch)
Identify the results of the behavior
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Measurable Goal Checklist
What is the actual (measurable) starting
point for this knowledge or skill?
What will I see this consumer doing
when he/she reaches this goal?
Did I avoid vague or unclear words or
phrases?
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Most Common Errors on PCPs
The goals, objectives and interventions
are not specific, measurable, time-limited
The goals, objectives and interventions do
not address symptoms, skills and
resources
Each service provided is not necessarily
linked to a goal, objective or intervention
The diagnostic assessment is not linked to
a goal, objective or intervention
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Avoid
Goals just requiring
attendance/participation
Goals that emphasize the absence of
something; stress active, positive change
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Dead-Man Standard
John will stop having temper tantrums
John would meet the objective of no
longer losing control of his anger if he
were dead!
John will remain calm when faced with
frustration
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Hands-On Practice
Here are some goals; try to “fix” them:
Inadequate step-down plan
Goal not measurable
Goal too complex
Crisis stabilization goal
Intervention linked to best practice
Add natural supports
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Inadequate Step-Down Plan
The client's need for CBS
paraprofessional will be reviewed for
medical necessity in 90 days.
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Inadequate Step-Down Plan
The client's need for CBS-Pro will be
reassessed monthly, & CBS services
reduced from 0-6 hours per day to 0-3
hours per day once the client obeys
rules 100% of the time, refraining daily
100% of the time from being disruptive
and oppositional including but not
limited to: fighting, arguing, instigating,
being cruel to animals, running from
supervision, property destruction &
sexual aggression.
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Inadequate Step-Down Plan
Goal % compliance increases to 75%
CBS hours will be reduced to 20
hours/week per child and family team
review. Further improvement in behavior
to 90% compliance will reduce CBS
hours to 10 hours/week.
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Goal Not Measurable
Client will improve cooking skills as
evidenced by improving cooking skills.
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Goal Not Measurable
Consumer will decrease audio
hallucinations.
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Goal Not Measurable
Will complete requirements for DSS
plan re: substance abuse/dependence.
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Goal Not Measurable
Will learn how to avoid relapse.
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Goal Not Measurable
Sincerity as evidenced by lack of fear
of the future.
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Goal Too Complex
As client is capable of improvement,
he/she will obey rules 100% of the time
in all settings, refrain from symptomatic
behavior 100% of the time, including the
avoiding the following: being
disrespectful, having anger episodes,
being verbally and physically
assaultive, not obeying rules in the
home, in the school and in the
community.
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Goal Too Complex
Improve life domain functioning in the
home, community and school as
evidenced by 1)compliance with adult's
directions by 3rd prompt 50% of the
time, 2) will earn behavioral plan
rewards for school compliance 60% of
the week, and 3) accept limitations and
consequence without being aggressive
or oppositional 50% of the time.
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Crisis Stabilization Goal
If client becomes agitated or verbally
aggressive, then the following
interventions may be used: 1) Client
will be offered time out to calm self, 2)
client will be verbally redirected, 3)
client's therapist may be contacted. If
the client's behavior continues to
escalate and he/she becomes a danger
to him/herself and/or others, the
following therapeutic interventions may
be followed:
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Crisis Stabilization Goal
1) Non-violent physical crisis
intervention, 2)CPI restraint, 3) Client
will be monitored for vital signs and
emotional/behavioral response, 4) Law
enforcement and/or the mental health
agency will be contacted, and 5) client's
family/guardian will be contacted.
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Intervention Linked to Best Practice
Consumer will receive individual/family
therapy 1-4 times per month for
psychodynamic, reality, and CBT
therapy to stop symptoms.
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Intervention Linked to Best Practice
Consumer will participate in individual
therapy to develop a therapeutic
relationship with the therapist 0-4 times
per month.
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Add Natural Supports
Consumer will work with his uncle, who
is a farmer, this summer to 1) develop
work skills, 2) use exercise to diffuse
negative affect, and 3) to
have supervision and monitoring by
family in an environment and activity
that he prefers.
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Add Natural Supports
Consumer will play soccer for his high
school soccer team to 1) enhance
social skills, 2) practice team work, and
3) use physical exercise to assist in
alleviating depression.
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Natural and Community Supports
May be used as part of the overall plan
to achieve outcomes
Formal services should be transitioned
to natural supports as much as
possible over time
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Natural and Community Supports
Places, things and, particularly, people
who are part of our interdependent
community lives and whose
relationships are reciprocal in nature.
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Example Natural Support Systems
Extended family
Neighbors
Friends
Volunteers
Peer groups
Clergy
Traditional healers
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Use of Natural Supports
Lessen dependence on professional
services
Support community integration
Reduce isolation
Overcome stigma
Increase motivation for recovery
Promote friendship
Social networking
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Natural Supports
Help is most likely to have long-term
benefits if the help-giver promotes the
help-seeker’s acquisition of effective
behaviors that decrease the need for
help. In other words, a primary goal is
for the consumer to become more
capable, competent, and independent.
This goal, then, is the cornerstone of
beneficial help-giving and help-seeking
exchanges.
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Natural Supports
Carl Dunst’s research has shown that
recipients of help become effectively
empowered only when they assume a
high degree of responsibility for
change.
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Formal Helping System
Impasse
Natural Therapy System
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Empirically Supported Treatments
Clinical Trials (random design)
Quasi-Experimental designs
Pre/Post designs
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Efficacy vs. Effectiveness
Efficacy – Works on a discrete problem
within a circumscribed population (typically
studied in a university environment)
Effectiveness – Works on diverse
problems with broad population (real
world)
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Randomized Controlled Trials
Most control; most difficult and timeconsuming to do
Highest level of evidence
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Quasi-Experimental Designs
Compare naturally occurring groups
Done prior to random controlled trials;
often have biased samples
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Pre-Post Designs
Compare end of treatment to beginning
of treatment
Basis for much of the best/promising
practices literature
Nearly all interventions show positive
gains here
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Hierarchy of Evidence
Better/Best Treatments
Well-Established/Efficacious
Probably Efficacious (2 studies
showing better than wait-list control;
like well established, but not replicated
by 2nd team)
Evaluated, but unclear
Not evaluated, but commonly used
Evaluated, negative findings
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Well-Established
At least 2 controlled group design
studies or a large series of single-case
design studies
Minimum of 2 investigators
Use of a treatment manual
Uniform therapist training and
adherence
True clinical samples of youth
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Well-Established
Tests of clinical significance of
outcomes
Functioning outcomes plus symptoms
Long-term outcomes beyond
termination
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What If the Consumer Doesn’t
Want EBP?
80% of intervention should be recognized
EBP
20% of interventions can be customized
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Standard Care
When a SAR is submitted to WHN, we
will clinically review the utilization
either before or after the service is
provided.
Most services will be reviewed after
they are provided, however, we still
must authorize the service in order for
providers to be paid. To do that, an
authorization technician will check to
see if the SAR fits within standard care.
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Standard Care
“grids” outline pre-established clinical
standards for the services and amounts
of service that consumers typically
need for four degrees of impairment, or
as they are called, levels of care—A, B,
C, and D.
We strongly recommend that you use
the standard care grids to make a
request for services. In these cases, an
authorization technician will
automatically approve your request if
your other documentation is in order.
112
Standard Care
Approval for standard care services
does not constitute a cart blanche
approval to do anything you like. You
still can only provide the service if it is
medially necessary. The services will
be subject to random retrospective
audit.
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Standard Care
If your SAR falls outside of the
parameters of standard care or is a
very high-end service (e.g., residential),
it will be passed for review from the
authorization technician to a clinical
specialist.
If your SAR falls outside of standard
care, we recommend that you include a
detailed justification.
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Standard Care
We revise the standard care grids from
time-to-time, based on provider input,
which is always welcome. Check the
WHN website for the most current
grids: www.westernhighlands.org
In order for an authorization technician
to act on your SAR, you must complete
the level of care (LOC) on the SAR
form.
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Resources
Person-Centered Planning
www.ilr.cornell.edu/ped/tsal/pcp
Treatment Planners
www.wiley.com/WileyCDA/Section/id8340.html
Adams, N., & Grieder, D. (2005).
Treatment planning for personcentered care.
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