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Person Centered Planning by 6195nl1


									Person Centered Support Planning

Planning Process Overview

 Tools to help us
  learn about the
 Formal and

                Personal Goals

 Use Assessments to
  identify PERSONAL
  goals based on what is
  important TO the
 The best way to meet a
  person’s needs is by
  addressing what they
                           Personal Goals
  want in life!
               Support Items
 Outlines the
  person’s goals
 Lists assignments
     Who
     What
     When              Support Items
     Where             Personal Goals
     (Why)              Assessments
 Detailed plan
  outlining a method
  to help achieve the
 Identifies what staff   Support Strategies
  will do to help the       Support Items
                           Personal Goals
 Summarize and
  evaluate the service
 Solicit the person’s   Monthly Summary
  perspective            Support Strategies
 Due by the 15th of       Support Items
  the following            Personal Goals
  month                     Assessments
        A Continuous Process

                        Personal Goals
                          Action Plan

Monthly Summary      Support Strategies
 Behavior Notes
         Prior to the PCSP Meeting

 Update TO/FOR list
     Add items from all assessments (not just SIS)
 Copy and distribute
     SIS short report
     Person Centered Profile
     Expanded TO/FOR list
 Annual Review from Providers
               PCSP Meeting Agenda
                             Review and Update
 Introductions               TO/FOR list
 Review Agenda              Categorize TO/FOR list
 Review Person Centered     Personal Goals
  Profile                         Write the goal
 Review last year’s plan         Current Status, Strengths,
      Goals
                                  List Supports
      Services
                             Non-Goal Related
      Strategies
 Celebrate!!                Amount Duration
                              Frequency of purchased
         Categorize TO/FOR Lists

 Most important TO     Most important FOR
     Current Goal          On the Plan
     Future Goal           Important Info
     Important Info        Not Applicable
     Not Applicable
                Personal Goals

 The focus of a Personal Goal
     Accomplish something good
     Maintain something good
     Avoid something bad

 “The best way to meet a person’s needs is by
  addressing what the person wants in life!”
               Personal Goals
            What makes it Personal?
 Start the process with what the person wants
 What is most important to them
 Address their core values and passions

 “Personal” is not…
      What the person needs (habilitation, health & safety)
      What is “good” for a person
      What others think the person should want
                Personal Goals
              What makes it a goal?
 The “Goal” is:
      The desired end result
      What we hope to accomplish in about a year
      Use “short-term goal” if needed
      What we will see in the person’s life (observable)

 The “Goal” is not:
      The process (services and supports)
      The result of the Support Strategy (objectives)
      The service itself
                     Action Plan

 Outlines the person’s goals
     Include current status of the goal
     Identify strengths and barriers
 Identify all supports and services
  necessary to accomplish the goal
 All parties should be clear on their
  assignments prior to leaving the planning
      Identify Supports and Services

   Medicaid State Plan Services
   Natural Supports
   One-time and Ongoing
   Behavior supports & Psychotropic Med Plans
   Specific Medical
   Skill Training, Opportunities, Relationships, etc.
   Formal/Written Support Strategies
         Non-Goal Related Supports

 Needed supports that are not related to Personal
      “FOR” items not already addressed
 Address health and safety issues
      from the “FOR” list that were categorized as “address in
       the plan”
 Address preferences and wants
      from the “TO” list that were categorized as other
       “important information”
               Support Strategies

 Follow the Support Items
 Detailed plan outlining what staff will do to
  accomplish the objectives
     Not what the person receiving services will do
      Who is Responsible for What?

 Providers                       Support Coordinators
     Write support strategies        Review
     Address their                   Critique
      assignments as outlined         Approve
      in the Action Plan              Send back for revision
     Send to Support
      Coordinator within 30
      days of the planning
             Components of a “good”
                Support Strategy
 How will the support be provided? How will the
  objective be met?
       Are there detailed guidelines or instructions indicating
        how to support the person?
   What is the purpose of the support?
   Who will provide the support?
   When will the support be provided?
   How will information be documented?
   What are the indicators of success?
   How will information be shared and supports
           Monthly Summary

 Due by the 15th of the following month
 Must summarize and evaluate the service
  provided during the month
 Solicit the person’s perspective
          Summarize and Evaluate

 Demonstrate that CMS requirements are
  being met
     What was done
     How funding was used
 Evaluate the effectiveness of supports
     Functions as an ongoing assessment to aid in the
      continual planning process

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