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Writing Person-Centered Plans

VIEWS: 37 PAGES: 86

  • pg 1
									Writing Person-Centered
Plans
                        The 2008 Version

  OPC Area Program
  Paula Newman, LPC

  Senga Carroll, LCSW

  Kathy Kershaw, LPC
Person-Centered Plans (PCPs)
 There has been ongoing evaluation of
  the PCP since its inception, in 2006.
  Subsequently, it has been revised
  several times.
 It is very important that you keep up
  with the revisions and use the most
  recent PCP form/template
Person-Centered Plans (PCPs)
 Person-centered planning is an
  ongoing, interactive, team process
   The day you sit down to develop the
    PCP with the client should not be the
    only day for the next year, that you
    look at the plan.
   The plan should be reviewed, revised,
    and updated on a regular basis. Even
    if it‟s just for the purpose of adding
    strengths or newly identified informal
    supports.
Person-Centered Plans (PCPs)
    Best Practice tells us that a good
    “Plan” is actually a “DESCRIPTION”
    of the client/family. The description
    tells us:
   What their life looks like now
   What needs to remain the same
   What needs to change
   Where they see themselves in the future
    and the support needed to get there
Person-Centered Plans (PCPs)
 Person-Centered Thinking is a
  prerequisite for writing good Person-
  Centered Plans
 Person-Centered Thinking requires us to
  focus on the person and those who love
  him/her and consider them the primary
  authorities on the person‟s life direction.
 Person-Centered Thinking is a way of
  thinking about people that respects their
  interests, hopes, dreams, and desires.
Writing PCPs- THE PROCESS
 The Qualified Professional (QP) or Licensed
  Professional (LP) from any service designated
  as the clinical home is responsible for
  developing the PCP.
 The process begins with Information Gathering,
  which includes dialogue with the client, the
  guardian, and others identified as important to
  the client
   Dialogues may be formal or informal
     meetings, telephone conversations, any
     discussion used to gather information
   Information may also be gathered from
     written reports, letters, etc.
Writing PCPs- THE PROCESS
 Dialogue/meetings should include information
  about aspirations and goals.
 Dialogue/meetings should include information
  about best practice and evidence- based
  treatment modalities which may be used to
  address symptoms of diagnoses.
 Decisions are made by the
  individual/family/legally responsible parties and
  professionals working together to determine
  services, supports, and treatments, including
  natural and community resources, that can
  best meet the person‟s identified desires and
  needs.
         Introductory PCP
 An Introductory PCP is an initial plan which is
  used for someone who is new to services (not
  just new to your agency)- or, anyone who has
  been completely discharged from services and
  has not had services for 60 days or longer.
 An Introductory PCP allows the provider to
  quickly gather the information needed for an
  initial authorization.
 A comprehensive clinical assessment must
  be completed prior to writing the Introductory
  PCP and prior to providing services.
Comprehensive Clinical Assessment
 A Comprehensive Clinical Assessment
  may include but is not limited to:
     T1023- Diagnostic Assessment
     90801- Clinical Evaluation/Intake
     96101- Psychological Testing
     96110/96111- Developmental Testing
     96116- Neuropsychological Exam
     H-0001- Alcohol &/or Drug Assessment
     H-0031- Mental Health Assessment
     Required Content for the
        Introductory PCP
 Identifying Information- Name, Date
  of Birth, Medicaid number, Medical
  Record number, Address, Telephone
  number, and Date of the Plan
 Action Plan that includes a long range
  outcome that is desired by the
  individual; current status of this
  outcome; and, two (2) short range goals
    Required Content for the
       Introductory PCP
 Crisis Prevention/Crisis Response-
  Contact/Continuation page, only.
   Contact information for the first responder,
    legally responsible person, natural/community
    supports, and professional supports.
   Advanced Directives information (Living Will,
    Health Care Power of Attorney, or Advanced
    Instruction for Mental Health Treatment)
   Emergency Contact or Next of Kin- address,
    relationship, and telephone numbers
   Crisis Plan Distribution List names
    Required Content for the
       Introductory PCP
 Summary of Assessment/Observations
   Axis I through V information- DSM Code,
    Diagnosis, and Diagnosis Date
   Information about all current
    medications- Name of the medication,
    dose, frequency, reason for change, date
    prescribed, and pharmacy (Update and
    revise anytime there is a change)
   List all known allergies (Update and revise
    anytime there is a change)
    Required Content for the
       Introductory PCP
 Signatures
   Licensed Professional
   Qualified Professional (for CAP-
    MR/DD, Medicaid Targeted Case
    Management, or state-funded
    services
   Person Receiving Services
   Legally Responsible Person
   Person Responsible for the PCP
   Other Team Members
    Required Content for the
       Introductory PCP
 Signatures- The Licensed Professional
  must:
   Confirm medical necessity for the
    services requested
   Confirm/verify that they have had direct
    contact with the client
   Confirm that they have reviewed the
    client‟s comprehensive clinical
    assessment
      Required Content for the
         Introductory PCP
 Signatures-If the client is less than 21 and is
   actively involved with Department of Juvenile
   Justice (DJJ) or Adult Criminal Court:
   The person responsible for the PCP has to
   include the date of the CFT met, or the date of
   the scheduled CFT meeting; or, the date that
   the client was assigned a TASC Care Manager;
   AND, an attestation that they conferred with
   the clinical staff at the LME to conduct care
   coordination.
   Check boxes left blank on this page will
   result in the PCP being returned as
   incomplete by the service authorizer.
Introductory PCP

 See mock Introductory PCP

 Model Completion of an
  Introductory PCP
       The Complete PCP
Writing the PCP
    Required Content for the
         Complete PCP
 Identifying Information
 Participants Involved in Developing
  the PCP
 Personal Interview
 Family/Legally Responsible
  Person/Informal Supports Interview
 Service Provider Interview
 Summary of Assessments and
  Observations
    Required Content for the
         Complete PCP
 Action Plan
 Crisis Prevention/Crisis Response
 Crisis Prevention/Crisis Response
  (Continuation)
 Signature Page
 Update/Revision Page
 Update/Revision Signature Page
Important “To” versus
Important “For”

 When completing the
 interviews, integrate the Person
 Centered Thinking skill of
 finding the balance between
 “Important TO” and “Important
 FOR” throughout the planning
 process.
Important “To” versus
Important “For”
  What is “important to” a person/family
   includes only what that person is
   “saying” with their words and with their
   behaviors. „Listen‟ to their behavior to
   help you decide what is really being said.
  What is “important for” people/families
   may include issues of health or safety;
   anything that others see as important for
   the person to be a valued member of
   their community (in relationships,
   school, work, etc.)
Informal Services/Supports versus
Formal Services/Supports
 Informal Services/Supports-
   Personal Resources: The person‟s own
    resources such as special skills,
    capacities, or attributes. Examine and
    include these in the plan.
   Natural Supports: Natural supports
    include family, neighbors, co-workers,
    and friends (of their choosing). Include
    existing supports in the plan and
    continue to explore new ones.
Informal Services/Supports versus
Formal Services/Supports
 Informal Services/Supports-
   Community Resources: Community
    resources are those that exist for
    community member‟s use. Examples
    include church or faith-based
    organizations, Boy‟s or Girl‟s Club, YMCA
    or YWCA, special interest or civic groups,
    sports or any other group available to
    other community members. These
    opportunities should be explored and
    offered.
Informal Services/Supports versus
Formal Services/Supports
 Formal Services/Supports- This is
  paid assistance provided by qualified
  professionals or paraprofessionals in
  the publicly funded system of
  services.
         Writing the PCP
Follow along using your copy of the PCP
Writing the PCP- Page 1
 _____________‟ s Person Centered Description/Plan:
  use the name the person prefers to be called
 Date of the Plan is the date the QP/LP (per the
  Service Definition) completes the PCP AND signs and
  dates the signature page.
 The first box under participants involved, is reserved
  for the client‟s participation
 Date of 1st Complete PCP if prior date was an
  Introductory PCP
 Facilitator of the Person Centered Planning (PCP)
  meeting or the Child and Family Team (CFT) meeting
Writing the PCP- Page 2
 Text entered in the header will appear on
  the remaining pages of the PCP (Click on
  “View” on the toolbar, the click
  “Header/Footer”, then insert your text):
  Name, DOB, Medicaid ID, MR#.
 Personal Interview
   What is working in your life right now?
   What is not working in your life now?
   Strengths: What are you talents/what are you
    good at/what do you like to do/what do you like
    most about yourself
Writing the PCP- Page 2
 Personal Interview
   What is “Important TO” me: What
    people/activities/things/places matter to you in
    your everyday life?
   Supports: What do others need to know or do
    to support you better in your relationships, in
    the things you like to do, in work or school, and
    in helping you remain safe- taking into account
    what is important to YOU.
   Long Term Outcomes: What are some things
    you would like to accomplish, personal goals you
    would like to work on, hopes and dreams you
    have for yourself in the future?
Writing the PCP- Page 3
 Family/Legally Responsible
  Person/Informal Supports Interview
   What is working best in their life right
    now?
   What is not working in their life right
    now?
   Strengths: what do you consider to be
    some of the person‟s best attributes,
    talents, traits; what do you like or
    admire most about this person?
Writing the PCP- Page 3
 Family/Legally Responsible Person/Informal
  Supports Interview
   Who are the people; what are the
    activities/things/places that are “Important FOR” this
    person? What does the person what for their lives?
   Supports: What is important FOR the person? What
    do you think others need to know or do to support
    the person in their relationships, in things they like to
    do, in work or school and ways to stay healthy and
    safe?
   Long Term Outcomes: What do you think are some
    things the person would like to accomplish in the
    next year? What the persons‟ hopes and dreams for
    the future (as you know them)?
Writing the PCP- Page 3
 The QP should complete this page only after
  having compiled all of the information they
  received from any and all family members,
  church members, friends, neighbors, etc.
 The issues addressed in these interviews can
  include medical, psychiatric, social, and/or
  behavioral issues.
 If the client does not want family
  members involved and they are legally
  responsible for themselves, indicate that
  on this page and do not complete further.
Writing the PCP- Page 4
 Service/Support Providers Interview
   What do you as a qualified professional who
    has reviewed the comprehensive clinical
    assessment, think is working right now in
    the person‟s life? What is not working in the
    person‟s life right now?
   Strengths: Based on talking to, observing,
    and reading assessments regarding the
    person- what are the person‟s special
    talents/traits? What do people admire most
    about the person?
Writing the PCP- Page 4
 Service/Support Providers
  Interview
   What is “Important FOR” this person?
    Based on what you’ve gathered from
    the comprehensive clinical assessment
    and your knowledge about the needs of
    those experiencing symptoms of their
    diagnosis- who are some people you
    should access to help address the goals,
    what are some of the possible
    activities/things/places that could be
    accessed to help this person be
    successful in their everyday life?
Writing the PCP- Page 4
 Service/Support Providers
  Interview
   Supports: What is “Important FOR” this
    person? What do others need to know or do
    based on your clinical knowledge about
    their diagnoses and symptoms- to
    support this person in their relationships, in
    the things they like to do, in work or school
    and ways to stay healthy and safe?
   Long Term Outcomes: What are some of
    the things they want to accomplish in the
    next year? What are their hopes and
    dreams?
   Dialogues/Interviews
 Modeling
  Personal Dialogue/Interview
  Family/Legally Responsible
   Person/Informal Supports
   Dialogue/Interview
  Service/Support Providers
   Dialogue/Interview
Writing the PCP- Page 5
 Summary of
  Assessments/Observations
   List the comprehensive clinical assessments and
    evaluations that have been completed
   List the recommendations made for each
    completed assessment
   Enter the most recent completion date for each
    assessment
   If re-assessment is recommended, enter the
    projected due date for the reassessment. If re-
    assessment is not recommended, enter “N/A”
Writing the PCP- Page 5
  You can insert rows as needed into this table. Place
   your cursor on the table where you would like to
   insert the row, right click the mouse, click insert,
   click insert row above or below.

  Additional Assessments Recommended- if any of
   the assessments listed above indicate that other
   assessments would be beneficial, list them here. Note
   the reason for the recommendation- if you don‟t
   know, ask the recommending clinician. Approximate
   Due Date- date by when you plan to have this
   appointment scheduled. Date completed- come
   back and add this date once the assessment is
   completed.
Writing the PCP- Page 5

  Based on interviews, dialogues, and
   assessments, which
   Characteristics/Observations will
   result in Action Plans? Up to six (6)
   symptoms, behaviors, issues can be
   addressed.
    Examples: “hears voices”, “destroys
     property”, “is very angry”, “talks
     about wanting to get high”, etc.
Writing the PCP- Page 5

  List the Diagnoses- the code, the name,
   and the date the diagnosis was given
    Axis I: Major Mental Disorders;
     Developmental Disorders and Learning
     Disabilities
    Axis II: Personality Disorders; and
     Mental Retardation
    Axis III: (Non-Psychiatric) Medical
     Conditions
Writing the PCP- Page 5

    Axis IV- Psychosocial and Environmental
     Problems
      Economic Problems
      Housing Problems
      Occupational Problems
      Educational Problems
      Problems with Primary Support Group
      Problems Related to Legal
       System/Crime
Writing the PCP- Page 5

  Axis V- Global Assessment of Functioning
   (GAF) score based on a 100-point scale
   (p.34 in the DSM-IV-TR)
 _____________________________________
  All Current Medications- list the name of
   every current medication prescribed. This
   includes psychiatric medications and all the
   other medications the person is taking.
   (Update and revise this list as changes are
   made- hence, in the event of a crisis the
   information is correct. An update does not
   constitute a revision to the plan)
Writing the PCP- Page 5
 All Current Medications
   Dose: Enter the dosage of each medication.
    The amount of the medicine
    administered/taken.
   Frequency: Enter the dosage frequency- how
    often the medicine is administered/taken
   Reason for Change: Examples: New
    medication, terminated medication, new dose,
    new frequency, etc.
   Date: Enter the date of each initial prescription
    and each change.
   Pharmacy: Enter the Pharmacy name and
    phone # and the Healthcare Provider‟s phone #
Writing the PCP- Page 5
 List All Known Allergies
   Update and revise this list of
    allergies anytime there is a
    change.
   If none, enter “None”.
Summary of Assessments-
      Modeling


Review of Mock
Comprehensive Clinical
Assessment to Complete the
Summary of
Assessments/Observations
Writing the PCP- Page 6
 Action Plan
   Potential services, supports, interventions,
    and/or treatment options to meet the goals and
    needs are discussed with the individual/family,
    professionals, and other service providers.
    Everyone should participate.
   The individual/family must be fully informed of
    the rationale, evidence and risks of specific
    services, interventions, and treatment options-
    so that they can make responsible choices about
    their treatment
   Add additional copies of the Action Plan page as
    needed
Writing the PCP- Page 6
 Long Range Outcome- Based on all the
  information you have gathered, in
  measurable terms, state the outcomes
  the person/family would like to achieve
  within the year and/or into his/her future
 Where am I now in the process of
  achieving this outcome?- Based on the
  information you‟ve gathered briefly
  describe the person‟s current status, skills
  and abilities related to the identified long
  range outcome
Writing the PCP- Page 6
 Characteristic/Observation #: List the
  characteristics/observation from the
  Summary of Assessments/Observations
  page here, that supports the need for the
  short range goal below
   Use clinical judgment to recognize the
    relationships between the
    characteristics/observations and the short
    term goals.
   More than one goal may be developed for a
    single characteristic/observation if
    necessary to fully address the need.
Writing the PCP- Page 6
 Short Range Goal- Enter a person-
  centered measurable objective needed to
  achieve the long range outcome, based on
  the What‟s “Important TO” and “FOR” me
  sections of the interviews.
 Support/Intervention to Reach Goal-
  Define the supports, interventions, services
  required to achieve the short range goal
  based on the Supports sections of the
  interviews.
Writing the PCP- Page 6
 Who will Provide
  Support/Intervention/Service?-
  Identify the individual(s) who will be
  responsible for implementing and
  documenting progress toward the
  goal. When the responsible person is
  a paid provider, indicate the agency
  name and position of the person.
  When possible, include the name of
  the individual, as well.
Writing the PCP- Page 6
 Support/Service & Frequency- Identify
  the specific service/treatment to be used to
  address the goal and enter the frequency
  of that service.
 Target Date- Enter the date the team
  projects the person can achieve this goal. A
  target date may never exceed 12
  months from the Date of the Plan.
 Reviewed Date- Enter the date the
  progress towards the goal was reviewed.
Writing the PCP- Page 6
 Status Code- Based on the progress
  review, enter the status code
   R= Revised- you revised the goal or the
    intervention
   O= Ongoing- the goal remains the same; is
    still needed
   A= Achieved- the client has successfully
    achieved the goal
   D= Discontinued- the team has decided to
    discontinue the goal- it is no longer relevant,
    etc.
Writing the PCP- Page 6
 Justification for
  Continuation/Discontinuation of
  Goal- If a goal is not achieved at the
  time of review, provide information
  justifying the reason the team
  determines to revise, continue, or
  discontinue the goal.
    Action Plan- Practice


 Writing Goals and
  Interventions
   Use the MOCK PCP- See first
    2 goals. Develop Goal #3
Writing the PCP- Page 7
 Crisis Prevention/Crisis Response
   A Crisis Plan includes supports/interventions
    aimed at preventing a crisis (proactive) and
    supports/interventions to employ if there is a
    crisis (reactive)
     Proactive planning includes identifying health
       and safety risks and strategies to address them
       before they occur
     Reactive planning serves to avoid diminished
       quality of life during a crisis by having a plan in
       place
Writing the PCP- Page 7
 Health and behavioral concerns that
  may trigger the onset of a crisis
  (include lessons learned from previous
  crisis events).
   Include information on health and wellness
    issues- are there physical issues that
    contribute to a person’s vulnerability to a
    crisis?
   Include environmental factors that may
    contribute to the onset of crisis
   Incorporate information gathered from the
    interview sections
Writing the PCP- Page 7
 Crisis prevention and early intervention
  strategies (List everything that can be done
  to help this person avoid a crisis).
   List coping skills the person has learned or has
    used in the past
   Provide a detailed description of the strategies
    that will help the person avoid a crisis.
   Incorporate information gathered from the
    interviews.
   Include strategies that have been effective in
    the past. Include opportunities for the person to
    exercise self-soothing skills developed and
    calming strategies such as consciously breathing
    deeply
Writing the PCP- Page 7
 Strategies for crisis response and
  stabilization (Focus first on natural and
  community supports. Begin with least
  restrictive steps. Include process for
  obtaining back-up in case of
  emergency and planning for use of
  respite, if an option. List everything
  you know that has worked to help this
  person become stable).
   Provide a detailed description of strategies.
    Consider strategies the person employs in their
    day to day life and in previous crises.
Writing the PCP- Page 7
  Incorporate information gathered from the
   interviews
  Positive behavioral supports and approaches
   other than calling law enforcement (911) to
   deal with the crisis, should be sought. Law
   enforcement (911) should be called as a
   last resort only. If calling law
   enforcement is part of the plan, law
   enforcement should be involved in the
   plan development and their agreement
   obtained ahead of time.
Writing the PCP- Page 7
 Specific recommendations for
  interacting with the person receiving a
  Crisis Service.
   List specific details learned from close family
    and friends about what type of interaction and
    treatment is helpful during a crisis and what
    types of things need to be avoided.
   Your agency may use an on-call crisis service,
    where the staff is mostly unfamiliar with the
    client. What do they need to know or do
    immediately?
Writing the PCP- Page 7
 Strategies identified to be followed
  after a crisis to determine what
  worked and what did not work, and
  make changes to the PCP including this
  Crisis Plan.
   Identify activities ahead of time which will
    be followed after a crisis, to determine what
    worked and what didn‟t work during the crisis
   Talk to those involved in the crisis about the
    effectiveness or ineffectiveness of the strategies
   Update/revise the Crisis Plan based on
    information learned
Writing the PCP- Page 7
 Consents/Releases of Information (For
  individuals or agencies included on the
  Contact List)
   Consent/Releases of Information must be in
    each individual‟s service record before any
    information regarding a crisis, or distribution of
    the Crisis Plan can occur.
   Ensure that there are no individuals/agencies
    included on the Contact List for whom there is
    not a consent/release of information in the
    record.
Writing PCPs- Page 8
 Crisis Prevention/Crisis Response
  (Continuation)
   Contact List
     First Responder- Name and #
     Legally Responsible Person- Name, #,
      Attached copy of legal documents (i.e.
      Court-Ordered Guardianship, Power of
      Attorney, Loco Parentis document)
     Natural Supports- Name and #
Writing PCPs- Page 8
  Contact List
    Professional Supports- Name and #
    Primary Care Physician- Name and #
    Preferred Psychiatric Inpatient/Crisis
     Respite Provider- Name and #
    Other Professional Supports- Name
     and #
Writing PCPs- Page 8
 Advanced Directives
   Enter “yes” or “no” to the existence of a
    living will, health care power of attorney
    or advance directives for mental health
    treatment. If the person has any of
    these attach a copy. If the person
    does not have them- explain the
    options.
Writing PCPs- Page 8
 Advanced Directives
   Living Will: All competent adults have
    the right to make decisions in advance
    about issues such as life support when it
    is clear that death is imminent or a state
    of coma becomes permanent. With a
    living will in place, the legally responsible
    party can make sure that the person‟s
    wishes are honored.
Writing PCPs- Page 8
 Advanced Directives
   Health Care Power of Attorney- Also known
    as a durable power of attorney for health care,
    this document can be helpful when a person is
    unable to make medical decisions for
    him/herself. It may also be referred to as a
    health care proxy or medical power of attorney.
    It names someone who represents the person‟s
    wishes. Unlike the living will, which usually is
    limited to terminally ill patients, this document
    applies whenever the person is unable to make
    medical decisions.
Writing PCPs- Page 8
 Advanced Directives
   Advance Instruction for Mental Health
    Treatment- or advance instruction, is a written
    instrument signed in the presence of two
    qualified witnesses who believe the person to be
    of sound mind at the time of the signing, and
    acknowledge that before a notary public. In this
    document, the person gives instructions,
    information, and preferences regarding mental
    health treatment.
 Writing the Crisis Plan

        Modeling
Use MOCK Crisis Plan for
Modeling the Development
of a Crisis Plan
Writing PCPs- Pages 9 and 10
 Signature Page
   I. Service Orders: Required for
    Medicaid funded services
     The Licensed Professional must:
       Confirm medical necessity for the services
        requested
       Confirm/verify that they have had direct
        contact with the client
       Confirm that they have reviewed the client‟s
        comprehensive clinical assessment
Writing PCPs- Pages 9 and 10
 If not ordered by a LP, a Qualified
  Professional (QP) must order CAP-
  MR/DD services and Medicaid funded
  Targeted Case Management (TCM)
  services. The signature confirms one
  or both of the following:
   The requested CAP-MR/DD services are
    medically necessary
   The requested Medicaid funded TCM
    services are medically necessary
Writing PCPs- Pages 9 and 10
 In all cases, signatures and the dates of the
  signatures are REQUIRED
 The signature is not authenticated until
  the designated professional signing
  enters the date next to their signature.
 The signature serves as the Service Order
 The provider may not bill Medicaid for
  services until the service order signature is
  acquired
 Do not present the signature page to
  the LP to sign if not attached to a fully
  completed and dated PCP
Writing PCPs- Pages 9 and 10
 Signatures
   II. Person Receiving Services
     The person receiving services is required to sign
       and date the PCP in Part II indicating
       confirmation and agreement with the services
       and supports detailed and confirmation of
       choice of service provider(s), if the individual is
       legally responsible for themselves.
     The person should not sign the signature page
       if it is not attached to the completed and dated
       PCP
     The provider cannot bill Medicaid for services
       until this signature is acquired
Writing PCPs- Pages 9 and 10
 Signatures
   MINORS-
     A minor may sign the plan for mental health
      services, initially, (NC General Statute 90-21)
      but once a legally responsible person becomes
      involved, the legally responsible person shall
      also sign the plan
     A minor receiving outpatient substance abuse
      services may sign the plan without parental
      consent when services are provided under the
      direction and supervision of a physician. When
      the services are not provided under the
      direction and supervision of a physician, the
      parent or guardian‟s signature is required (NC
      General Statute 90-21.5)
Writing PCPs- Pages 9 and 10
 Signatures
   III. Legally Responsible Person
     This signature confirms involvement in the
      development of the PCP and agreement
      with the services to be provided;
      understanding that he/she has the choice of
      service providers and may change
      providers at any time; and, for CAP-MR/DD
      services, only- an understanding that
      he/she has the choice of seeking care in an
      ICF-MR facility in lieu of CAP-MR/DD
Writing PCPs- Pages 9 and 10
 Signatures-
   IV. Person Responsible for the PCP- The
    QP/LP representing the person‟s clinical home
    and responsible for the PCP development signs
    and dates the plan confirming involvement and
    agreement with the services and supports
    detailed in the PCP.
     The signature and date of the signature is
       REQUIRED
     The date of the QP/LP signature should coincide
       with the Date of the Plan
Writing PCPs- Pages 9 and 10
  If the client is less than 21 and is actively
   involved with Department of Juvenile
   Justice (DJJ) or Adult Criminal Court:
 The person responsible for the PCP has to
 include the date of the CFT met, or the date of
 the scheduled CFT meeting; or, the date that
 the client was assigned a TASC Care Manager;
 AND, an attestation that they conferred with
 the clinical staff at the LME to conduct care
 coordination.
 Check boxes left blank on this page will
 result in the PCP being returned as
 incomplete by the service authorizer.
Writing PCPs- Pages 9 and 10
 Signatures
   V. Other Team Members- Other team
    members have the option to sign and
    date the PCP confirming participation and
    agreement with the services and
    supports detailed in the PCP
Writing PCPs- Supplemental Page 1
 PCP Update Revision-
   PCPs must be review if the person‟s needs
    change, if there is a change in provider,
    and/or based on assigned target dates
   In review that results in a new service being
    added or a new goal(s) being added, or
    anything that cannot be explained in the
    “Justification” space next to the Status
    Code- use the PCP Update/Revision
    page
   Anytime the Update/Revision page is used,
    the Update/Revision Signature page must
    also be completed.
Writing PCPs- Supplemental Pages
2&3
 PCP Update/Revision Signatures-
   For Medicaid funded services- When the
    Update/Revision includes a new service(s), a
    licensed physician, licensed psychologist,
    licensed physician assistant or licensed family
    nurse practitioner must sign and date the
    Update/Revision- indicating that the new service
    is medically necessary.
   For State funded services- the person
    responsible for the Plan may sign the
    Update/Revision form indicating medical
    necessity.
 Update/Revision


Review Example
 MOCK Revision
Learning Log- Supplemental Page 4
Anytime there is a serious event or when a situation
   happens with the person that needs to be looked at
   closely, it is recommended that you complete the
   Learning Log to understand how to better support the
   person
 What did the person do?
 Who was there?
 What did you learn about what worked well? What did
   the person like about the activity? What needs to stay
   the same?
 What did you learn about what didn‟t work well? What
   did the person not like about the activity? What needs
   to be different?
Learning Log- Supplemental Page 4
 Provides a way for people to record ongoing
  learning
 Tells us what is important to and for the
  individuals
 Helps us focus more clearly on critical
  information
 Can be used to focus on someone‟s whole
  life or specific areas of their life, e.g. their
  health, how they like to spend their time
Did We Get It Right- Supplemental
Page 5
 In supporting evidence based practice on
  seeing the PCP as a “description” of someone‟s
  life, the following questions are designed as
  prompts to ensure commitment to the person
  centered planning process:
               Did We Get It Right?
   Does the plan describe who you are?
   Does the plan describe what you want to do in
    your life?
   Does the plan describe the support you need to
    do these things?
 OPC PCP Quantitative/Qualitative
            Review



         See handout
Review the questions on the form
Local Monitoring PCP Review
 Worksheet #4 Review
      Introductory PCP and
           Complete PCP
        Review Questions
         Writing PCPs

            Questions?
________________________________

MH/DD/SAS Person-Centered Planning
  Instruction Manual- 2008 Version

								
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