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Course Outline

An Introduction to Writing Effective Person-Centered Plans Person-Centered Planning Starts with Person-Centered Thinking DRAFT: For review, feedback and revision . Course Outline. Orientation to the PCP PCP Planning Models Engaging Consumers in PCP Planning Process

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Course Outline

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  1. An Introduction to WritingEffective Person-Centered PlansPerson-Centered Planning Startswith Person-Centered ThinkingDRAFT: For review, feedback and revision

  2. 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

  3. 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.

  4. Learning Objectives • Participants will learn to write 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.

  5. 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.

  6. 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.

  7. 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

  8. 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)

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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

  20. Essential Elements of PCPs • The individual/family must be fully informed of the rationale, evidence and risks of specific service support and treatment options

  21. 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

  22. 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

  23. 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

  24. Essential Elements of PCPs • Provides proactive plans to prevent crisis from occurring as well as reactive planning and crisis contingencies

  25. 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

  26. 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

  27. 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

  28. A Tactic to AvoidUnnecessary Conflict • Agreeing to principles versus specific services

  29. Person-Centered Thinking: The PCP is a “Wholistic” Approach • Individual (biological; psychological) • Family • Neighborhood • School / Work • Community

  30. 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

  31. When Should You Update a PCP? • Preferably every 6 months. Longer time-frames 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

  32. 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

  33. PCP Update • Impact of services provided. Have they helped • Should target dates need to change • New or different objectives

  34. 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

  35. Axioms • Goals should be expressed in the words of the consumer • Goals should be reflective of informed choice • Goals should reflect cultural factors

  36. 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

  37. 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)

  38. 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)

  39. 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

  40. Common Beliefs inPerson- 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

  41. Common Beliefs inPerson- 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

  42. Introduction to DifferentPerson- Centered Planning Models • www.ilr.cornell.edu/ped/tsal/pcp

  43. Consumer/Family Member Story • Nancy Baker

  44. 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 . . . .

  45. 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.

  46. 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.

  47. 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.

  48. 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).

  49. 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.

  50. Can I See Examples of Good PCPs? • Consult Adams, N., & Grieder, D. (2005). Treatment planning for person-centered care.

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