Office of the Governor Office of Inspector General Rebalancing Grant DMHMRSAS Vision Person-Centered Planning Leadership Team Systems Transformation Grant Money Follows the Person Initiative Team 6 Team 5 Goal 2 Implementation Team PCP Field Test Person-Centered Plan 2
Person-Centered Leadership Team ~ Team 6 Daun, Tim, Chris, Lisa, Christina Website: http://www.vcu.edu/partnership/disability_advocacy_ind_fam.html
A Good Life • Joy and happiness • Dreams for my future • People I want in my life • My own place and belongings • Do things I enjoy • A car or transportation • Stay healthy and safe • Own money, checking account & bank card • Contribute to family and community • Learn new things • Work! Person-Centered Practices Leadership Team 6
Guiding Principles “I am listened to. I have a voice. I listen to others” “I have choices. I am responsible for my choices” “I have friends and family whom I see often. I am part of my community. I have found groups, organizations and social activities that interest me. “I am able to contribute to family and community. I learn new things. I am respected. People are nice to me. I respect others. I am nice to others.” “I am responsible for my choices. I receive quality supports.” 1. Listening 2. Self-Direction 3. Community 4. Abilities 5. Responsibility
Changes in Language Client/Consumer = Individual Case Manager=Support Coordinator Service Plan=Support Plan Training = Learning Assistance = Supports Specialized Supervision=Safety Supports Interventions/Strategies = Support Instructions
Building my community… A Good Life
Family Friends Relationship map for: ___________ Providers
My Planning Partner A Good Life
What is a Planning Partner? A friend… family member… support provider… someone who helps with: -completing the profile, -arranging planning meetings, -contacting partners, -identifying off-limit topics, -communicating with SC.
Partner Roles: Greet and meet. Share something that made you smile.
Partner Roles: Facilitator = Sarah + SC Recorder = Any partner Timekeeper = Any partner Reporter = Planning partner
Individual Support Plan (ISP)Components • Essential Information • Personal Profile • Plan • Agreements • Support Instructions • ISP Change Note
I. Essential Information Needed for Medicaid supports & services What? • Contact information • Relevant history • Back-up and discharge plans • Legal, advocacy, access concerns • Assessment summaries
SIS Part 4 Under Revision
I. Essential Information Who? • Completed by the Support Coordinator with partner input
I. Essential Information When? • SC shares annually • Partners provide updates to SC quarterly • SC notifies partners as needed during the year
Personal Planning begins with… Sarah
How do we get to know Sarah better? We ask questions. We ask Sarah, and we ask the people who know Sarah best.
II. Personal Profile What? A living description of the individual. • A good life, from “my” perspective • Talents, gifts and contributions • What’s working & not working in 8 areas of life • “Important to” and “Important for”
II. Personal Profile Partners discuss a good life, talents and contributions Taken from everyone’s perspective
II. Personal Profile Who? • Individual with someone he or she chooses • Partners, from their perspectives • Support Coordinator maintains final When? • Shared annually by the SC and kept current by partners as they learn about the individual
II. Personal Profile Partners review “important to” items on the ISP Taken from the Personal Profile
II. Personal Profile Home Ideas Drive power wheelchair in community Do more for herself Privacy with personal care Coffee in the morning Festivals Help cook dinner Sporting events Talking with others Food World Redecorate bedroom
II. Personal Profile Community and Interests Ideas Baseball Meeting neighbors Dances Bowling Walking Movies Social groups Taking a trip Clubs Crafts Sitting on the back porch each morning Jewelry Painting Travel
II. Personal Profile Relationships Ideas Talk with family Write letters to family Baking cookies for gifts Holiday Parties
II. Personal Profile Partners review “important for” items on the ISP Taken from the Personal Profile, SIS and Risk Assessment
II. Personal Profile • Individual shares profile, with support as desired • Partners share profile updates with SC • SC reviews, maintains and shares profile information • TOs and FORs items are shared and discussed
III. Plan What? The shared planning tool Includes: • Desired Outcomes • Shared Actions and Supports • Who, how often and when
III. Plan Who? • Completed by all partners at planning When? • Completed annually and updated by partners during the year
III. Plan • Outcomes are NOT services. e.g., “Sarah receives residential services.” • Outcomes ARE related to what services provide.e.g., “Sarah lives in her own apartment with the privacy she wants.” • Outcomes ARE written as if they’re happening now.e.g., “Sarah has a paid job she likes.” • Outcomes can be “I statements” from the individual. e.g., “I ride a horse.”
III. Plan • Outcomes are NOT meaningless to the individual or full of clinical jargon e.g., tooth brushing, tying shoes, receives suctioning, etc. • Outcomes might be written with words like: goes, travels, moves, lives, learns, has, gets. • Outcomes can be seen and counted. • Outcomes are Sarah’s, not her partners’. • Outcomes are drawn from what’s identified in the profile.
Planning for health, safety and well-being All important for items must be addressed in planning under the final outcome: “To be healthy and safe.”
III. Plan Important to: “I want to cook.” Cooking means classes and meals Sarah…? Outcomes are written as if they are happening…what is Sarah’s vision?
III. Plan Quality of Life Outcomes Home Sarah drives her own wheelchair in her home and community. Community and Interests Sarah is an active member of the Bluegrass Club and Meets new friends who like music. Relationships Sarah writes letters to her family each week.
Action planning A Good Life
III. Plan Importantto I want to cook Describe what this means to the individual Going to cooking classes and making her own dinner at home Important for Diabetes Describe what this means to the individual outcome Diabetic diet 5 outcome statement Sarah attends a monthly cooking class and cooks dinner at home at least once each weekend. Supports Enrolling in a cooking class. Groceries and cooking dinner Reviewing diabetic recommendations Going to cooking classes
III. Plan # 5 Sarah learns how to prepare meals by attending a monthly cooking class and cooking dinner at home at least once each weekend. Supports are shared noting how often, by whenandhow long. The supports are shared between partners. The outcome number is also added.