Transcript Person-Centered Planning 1

PERSON-CENTERED PLANNING 1:
THE APPROACH
Person-Centered Approach
The Approach
A person-centered approach is used to assist the client with using his own capacity and potential for
constructive action to realize his goals.
Staff act as facilitators rather than directors, offering respect, acceptance, and understanding to the
client to help empower him to realize his own potential.
The provider uses this approach when working with any client, particularly when planning for and
working on goals from the individual’s Support Plan.
The provider uses a person-centered process to assist the client with:
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choosing and achieving goals
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exercising choice and rights
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experiencing social inclusion
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experiencing dignity and respect
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maintaining and improving health
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using the environment
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experiencing continuity and security
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finding satisfaction with services and life situation
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In order to help the client obtain and achieve goals that are most important to him while also meeting
the needs of the client, staff must:
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get to know the client
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determine what goals are important to the client
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provide services needed to help the individual achieve his goals
To get to know the client and his significant others, staff use:
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Client-Specific Training
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Topics
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Status/Medical Update
To determine what goals are important to the client, staff use:
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Person-Centered Planning: Annual Summary
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Support Plan Update
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Through work with an individual, staff provide services needed to achieve goals by providing
opportunities:
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for relevant training and education such as obtaining knowledge about new things, learning a
skill, and increasing abilities in areas important to the individual
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to become exposed to new situations the individual has never experienced such as looking
at the moon, driving by a bird sanctuary, thinking about a homeless person seen on the
street
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to expand life experiences such as meeting and interacting with new people, looking at the
moon through a telescope, going to a planetarium, visiting the bird sanctuary, volunteering at
a homeless shelter at Thanksgiving
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When a client starts with the provider, staff use a Client-Specific Training form to get to know the
individual, including characteristics such as likes/dislikes, hobbies, strengths an weaknesses, health
and safety issues, routines, special needs, and medication requirements.
Throughout the year, quarterly, staff use the Topics and the Status/Medical Update to go over areas
of importance to the individual, such as:
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rights and responsibilities
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dignity and respect
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achievements of special note
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health and safety issues
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and health information
Before the Annual Report which is due in the 3rd Quarter, staff assist the client with coming up with
goals to work on for the upcoming year using the Person-Centered Planning: Annual Summary
form.
The Annual Summary is provided to the WSC during the 3rd Quarter meeting with the WSC, before the
Support Plan meeting.
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For the Annual Report the client comes up with goals as he sees them and staff are encouraged to
write the goals in the client’s own words when developing the goals that are important to the individual
using the Person-Centered Planning form.
Developing person-centered goals occurs during the Person-Centered Planning meeting BEFORE the
Annual Report is written and submitted to the WSC BEFORE the Support Plan meeting.
Once the Support Plan is completed by the WSC, the Implementation Plan is developed based on the
goals on the Support Plan.
The goals the client decides on for the Annual Report should be the same as the ones in his Support
Plan, but the reality is that they often are not.
If they are the same, then staff will go over the goals again on the Person-Centered Planning
and make sure this is what the client wants.
If they are not the same, staff will complete the Support Plan Update showing additions,
deletions, and/or changes, and contact the WSC to update the Support Plan.
In all cases, for the client to be empowered in his own life, staff must encourage anyone who works
with the individual to listen to what the client says and assist with developing meaningful goals in his
life.
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Person-Centered Planning
The Approach
During the Person-Centered Planning process, staff plan with the client what he wants his goals to be,
how he will work on the goals, which staff and how staff will help, time limits and frequency for each
goal, how progress will be assessed, and how the client will know he has accomplished his goal.
For each goal, staff are encouraged to help the individual come up with an action plan for achieving
his goals by covering:
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Performance - what the client will do (activities, tasks, etc) to work on the goal
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Strategies/Assistance - what staff will do to help the client to achieve the goal
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Training Methods - most appropriate for the client and the goal (demonstrate, verbal prompts,
physical prompts, repetition, explanation, pictures)
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Frequency - how often staff will provide help/support the client
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Time Limit - how long the client wants to work on the goal/when he should be finished
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Assessment - how progress will be measured, including how the client will know he is making
progress on the goal, his satisfaction with the goal, and the projected results of the training
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This plan of action for each goal, as determined by the individual, is used in the Implementation Plan
once the Support Plan has been received and the Support Plan Update has been completed, if
necessary.
Throughout the year, staff use the Implementation Plan to provide training strategies to assist the
client in achieving his goals as well as exploring and providing opportunities for expanding life
experiences.
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How does all of this relate to:
– person-centered planning
– the goals and supports and services on the Support Plan
– the goals on the Implementation Plan
– “givens”
– documentation
– getting paid
– getting audited
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Person-Centered Planning
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The client, his the circle of support, and the staff come up with goals in the Person-Centered
Planning meeting during the 3rd Quarter Review. This occurs at least 1 month BEFORE the actual
Support Plan meeting. This meeting provides staff with guidance for how to work with the
individual on things that are important to him, things he needs to work on, and dreams he has.
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During the person-centered planning meeting, the client, his circle of support, and staff brainstorm
to come up with the goals the client wants to work on in the upcoming year. During this meeting
everyone involved helps the client decide what he wants to do, how he wants to do it, who he
wants help from, how he wants help, when he wants to work on goals, where he wants to work on
goals, and even why he wants to work on specific goals. From this brainstorming session staff
can develop these goals on the Person-Centered Planning form and submit the projected goals to
the WSC on the Annual Summary for inclusion in the Support Plan.
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The goals, along with other individual specific information, are provided to the WSC during the 3rd
Quarter Review 1 month BEFORE the support plan meeting to ensure the Support Plan contains
the goals the client wants. Staff use the Person-Centered Planning form and the Annual Report
to specify what goals the client wants to work on. This completed information is submitted to the
WSC in order to write the Support Plan.
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The Support Plan
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You should receive the Support Plan from the WSC BEFORE it is effective; however, you may
receive it during the month it is effective. As soon as you receive the Support Plan, you must write
the Implementation Plan. You have 30 days, but it should be done immediately.
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When you receive the Support Plan from the WSC, it should contain the information YOU
provided to the WSC, including characteristics of the client, projects he is working on,
medications, health, problems, issues, housing checks, and other information.
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In addition, the Support Plan should contain the goals provided to the WSC along with any
information needed for the individual to work on those goals.
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Remember, you are using a person-centered approach to establish goals for the individual to work
on throughout the year. The client is the one who decides what he wants to work on, who he
wants help from, how he wants to work on goals, how often to work on them, and how he will be
successful. THE CLIENT steers this vehicle – NOT you, NOT the WSC, NOT any of the circle of
support. The circle of support helps the client with developing goals to work on, provides
encouragement, suggestions, information, clarity, and reality checks.
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If the person-centered planning is done correctly, the Support Plan you receive should have the
exact goals that those involved in the planning came up with.
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If the Support Plan does not have the goals the individual came up with that were submitted to the
WSC, then staff may use the Support Plan Update form to request corrections to the Support
Plan.
The Implementation Plan
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When you receive the Support Plan, you write the Implementation Plan. The first page of the
Implementation Plan is the Signature Page and provides basic information about the client, dates,
supports, a signature area, a description of staff and natural supports, health and medical issues,
home and community safety needs and supports, and other supports/services needed.
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For each goal there is a Goal/Action Plan Page. If you did the person-centered planning correctly
and in depth and the Support Plan has the same goals you submitted to the WSC, then this is the
easy part. From the Person-Centered Planning form, you write the person-centered goal, the
supports/services needed, identify the circle of support that will assist the client with the goal, and
the current status. This section of the Implementation Plan also contains the Action Plan and the
Assessment.
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The Action Plan includes the parts you identified on the Person-Centered Planning form covering:
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Service:
which staff will assist the client with working on each goal (SERVICE)
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Performance:
what the client will do to work on each goal (TASKS)
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Strategies/Assistance:
what staff will do to assist the client with working on each goal
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Training Methods:
how staff will assist the client with reaching each goal
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Frequency:
how often to work on each goal (FREQUENCY)
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Time Limit:
how long the individual wants to work on each goal
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Assessment:
how progress will be measured for each goal
More than one Service may work with an individual on a specific goal. The tasks will be different and
staff should ensure there is no overlap in service provision.
Tasks include the things the client will do to work on successful completion of a goal.
Strategies are the things the staff will do to assist the client in working on a goal (accompany, locate,
help, explain, assist, etc.
Training Methods include such techniques as reminders, physical or verbal prompts, examples,
repetition, explanations, charts, tables, task cards, lists, pictures, diagrams, sound, music, dance, etc.
Frequency covers how many times a week or month or year the individual wants to work on a goal
and the Time Limit is the total length of time the client will work on the goal
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Assessment
Assessment provides a way for the client and staff to measure progress for each goal. A clear
statement of expectations for progress will help the individual know whether he is showing progress
while working on a specific goal. Progress does not mean the final achievement of a goal – it is the
work done toward the achievement of a goal. In other words, a client might want to ultimately “make
dinner for my sister”. Progress on this goal would be the work he does to learn how to do this
throughout the year. There are many variables that will affect the progress a client makes on any
specific goal:
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the current state of his skills
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the degree of his involvement in the goal
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the degree of his interest in the goal
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how often he works on the goal
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the manner in which the client wants to succeed at the goal
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effective training techniques
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staff
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One client may already be able to use a stove, set a timer, set the table, select and heat vegetables,
select fruit, etc. He may, however, not know how to make proper portions, understand the food
pyramid, know how to cook meat, understand what goes in a salad, and so on. He may not care about
being able to “independently” prepare a meal, but wants staff to help with certain things.
Another client may only be able to get out pots and pans staff point to, point to canned items he likes,
and stir a dish. This individual would work on a different set of skills than the previous individual.
Progress would be described differently.
The way staff approach the information for each individual client is different and will ultimately affect
the progress the individual makes on each goal.
Progress for the first individual might include learning what the different groups are on the food
pyramid, learning to make a salad, finding a way to make sure that portions are adequate, learning to
cook a meat.
Progress for the second individual might include learning to use a can opener to open a can, to set the
table, to recognize the word “butter”, or to help put food on a plate with physical assistance.
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Both of these clients may want to “make dinner for my sister”, but the action plan for each is different
and how progress is defined and goal achievement is reached are also different.
If the first individual is able to learn even one food group, add carrots to a salad, scoop food onto a
plate, tell you that meat is done when it’s “not pink”, then he is showing progress.
If the second individual learns to use a can opener to open a can, set the table, and learns the word
“butter”, then he is showing progress.
For each of these individuals, successful achievement of the same goal may be different. For each
individual, the goal means different things. It may mean that staff does most of the work and the client
does only the tasks identified. Or it may mean that the client ultimately, independently, plans, budgets
for, purchases groceries for, and prepares a meal for his sister without any assistance from staff. It
may take years for that to be accomplished … or it may take months. Taking small steps on a goal
may ultimately be more important to the individual than a final success. Knowing he is making
progress on each small step toward a larger goal will provide the individual with pride, interest,
and ownership of the goal.
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“Givens”
“Givens” are tasks required to ensure an individual’s health, safety, and well-being. These are not
usually part of a goal, but may include, unexpected health and safety issues and situations that may
affect the well-being of the individual. These issues and situations may include, but are not limited to,
such things as an emergency room visit, doctor appointments the individual needs help with, an
overflowing toilet, a police- involved incident, etc.
Documentation
This is an essential part of any provider’s job. Documentation must be clear, objective, accurate,
complete, and on time. It is the staffs responsibility to ensure this is done. Once documentation is
completed, it is submitted to the office, reviewed, and filed in the client casebook. Once it is filed, the
company can bill for services completed. It must be available at all times to any state reviewer.
You MUST document any time you have contact with the client including phone calls and direct
contact and if you do anything on behalf of the client, such as contact a landlord. You can bill ONLY
for the direct contact, not for phone calls or contacts made on behalf of the client where the client is
not present. You also cannot bill for time with a client if the client is working with other staff. For
example, an SLC cannot bill for time if the client is working with his Companion.
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Getting Paid
Staff are paid for direct care work and corresponding paperwork completed. This includes working on
goals with the client, completing required paperwork such as quarterly reviews and annual reports,
and when necessary working on “givens”. This does NOT include phone calls, the time it takes you to
write your service notes or other required paperwork, transportation, or other non-direct contact tasks.
It includes only time that you are in direct contact with and working with the individual. If you bill for
time you did not work with an individual, it is Medicaid Fraud and you can be prosecuted. If your
paperwork does not reflect the scope of service you are supposed to be providing, the state will not
pay for the service … your company will not be paid … and you will not be paid.
Getting Audited
Once a year, or at the discretion of Delmarva, the company is audited. This audit includes a “desk
review” and client interviews. The desk review takes place so that the reviewer can examine all
aspects of the company’s business, including management plan, billing, policies and procedures, and
all documentation including client casebooks, personnel/staff, service logs, quarterly reviews, and
training.
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The company, and therefore staff, will be in a “pay back” situation to the state and may face being
closed down or even possible criminal prosecution for any:
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billing discrepancies or errors
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poor, incomplete, or missing documentation, including service notes and quarterly reviews
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fraud
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incomplete staff training
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incomplete or missing background screening
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anything determined by Delmarva to be an error
It is essential for staff to know the scope of the service you provide to any individual. If you provide
Companion services, then you cannot bill if you assist the individual with finding a job. You can help
the individual with finding a job, but you CANNOT bill for that service. Doing “above and beyond” the
scope of service is fine, but it would be on your own time. You probably have enough to do in
assisting the individual with working on his stated goals without adding to your work. You should help
the individual understand that you are there to assist him within the scope of your service. As an
Advocate for the individual you should also contact your supervisor if the client wants or needs things
that are not within the scope of service you provide.
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In summary, person-centered planning is used to plan out what the individual wants to work on
throughout his support plan year. Planning is used to assist the individual with using his potential
to identify and accomplish his goals. When the individual DIRECTS his own plan with staff as
ASSISTANTS, the individual will be empowered to realize his own potential.
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To assist the individual with identifying, working on, and accomplishing goals important to him,
staff must know the individual, understand what is important to the individual, and provide services
that will help him accomplish his goals through relevant training, exposure to new situations, and
expanding life experiences.
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Person-Centered Planning allows the individual and staff to have a plan of action for the support
plan year. Creating goals that are clear, thoughtful, and complete that the individual has planned
for himself not only helps the individual take charge of his goals, but also help staff know exactly
what is required when working with the individual as well as provide a guide when writing service
notes.
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In the next lesson, you will learn to use the information you gather during the individual’s personcentered planning to write clear, effective goals.
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