Virginia’s
Person-Centered Planning Process
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Rebalancing
Grant
Office of the
Governor
Office of Inspector
General
DMHMRSAS
Vision
Systems
Transformation
Grant
Person-Centered
Planning Leadership
Team
Team 6
Goal 2
Team 5
Money
Follows the
Person
Initiative
Implementation
Team
PCP Field Test
Person-Centered Plan
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Person-Centered Leadership Team
~ Team 6
Daun, Tim, Chris, Lisa, Christina
Website:
http://www.vcu.edu/partnership/disability_advocacy_ind_fam.html
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A Good Life
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•
•
•
•
•
•
•
•
•
•
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
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Guiding Principles
1. Listening
2. Self-Direction
3. Community
4. Abilities
5. Responsibility
“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.”
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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
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A Good Life
Building my community…
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Family
Friends
Relationship
map for:
___________
Providers
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A Good Life
My Planning Partner
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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.
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Partner Roles:
Greet and meet.
Share something that made you smile.
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Partner Roles:
Facilitator = Sarah + SC
Recorder = Any partner
Timekeeper = Any partner
Reporter
= Planning partner
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Individual Support Plan (ISP)
Components
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•
•
•
•
•
Essential Information
Personal Profile
Plan
Agreements
Support Instructions
ISP Change Note
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I. Essential Information
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I. Essential Information
Needed for Medicaid supports & services
What?
•
•
•
•
•
Contact information
Relevant history
Back-up and discharge plans
Legal, advocacy, access concerns
Assessment summaries
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SIS Part 4
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I. Essential Information
Who?
• Completed by the Support Coordinator with
partner input
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I. Essential Information
•SC shares annually
When?
•Partners provide updates to SC
quarterly
•SC notifies partners as needed
during the year
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Personal Planning
begins with…
Sarah
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How do we get to know
Sarah better?
We ask questions.
We ask Sarah, and we ask the
people who know Sarah best.
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II. Personal Profile
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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”
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II. Personal Profile
Partners discuss a good
life, talents and
contributions
Taken from everyone’s
perspective
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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
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II. Personal Profile
Partners review “important
to” items on the ISP
Taken from the Personal
Profile
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Home
home Sarah lives in a Vida Residential group home,
with 3 other women, she calls “friends.” She
moved into the home in 1994, has her own room
that she chose to paint yellow several years ago.
She has a television that she likes to watch in the
evenings, a radio and a small desk for art projects.
She likes to help cook dinner and spends a lot of
time in the living room in her home, talking with
whoever’s home at that time.
Sarah watches Martha Stewart on
occasion and wants to try some of
her ideas to jazz up her bedroom. It
has been awhile since it was last
painted, and she might want
something different. Sarah also talks
about going out more – she loves
sporting events and festivals.
routines Sarah likes coffee in the morning and usually
likes to have toast and eggs for breakfast. She likes
going to the same grocery store (Food World) each
week.
independence No. Sarah likes the help she receives to Sarah has talked about wanting to learn
be only for those things she absolutely needs, and
how to drive her power wheelchair
for it to be provided subtly around others. She does
on her own, especially in grocery
not complain, but we know she wants to do more
stores and shopping malls.
on her own.
privacy More privacy is needed for Sarah.
safety in my home Sarah says that she feels safe in her
home.
We think that Sarah would like more
privacy and independence with her
personal care, but she doesn’t want
to talk about it in front of everyone.
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II. Personal Profile
Home
Ideas
Drive power wheelchair in community
Do more for herself
Privacy with personal care
Coffee in the morning
Help cook dinner
Food World
Festivals
Sporting events
Talking with others
Redecorate bedroom
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Community and Interests
community Sarah lives in Vida a small community in Sarah doesn’t know many of her
Central Virginia. She lives near a strip mall that
neighbors. It would be nice if we
has a Chinese restaurant, a grocery store, a
could find a way for her to meet some
department store and a bank. There is a larger
of them.
shopping mall about 15 minutes away, where
Sarah likes to go shopping the most. Sarah enjoys
walks through the neighborhood when the weather
is nice.
safety in my community Sarah says that she feels safe
in her community.
things I enjoy Sarah enjoys shopping, bowling,
painting and spending time with other people.
She also likes going to dances whenever she can.
Sarah likes sitting on the back porch and listening
to the birds early in the morning. She wants to
travel and talks about it frequently.
Sarah might enjoy some type of social
group or club. She likes bowling,
movies and baseball too. Sarah
doesn’t like sad music. She doesn’t
like being told that it’s time to go to
bed, if she’s not ready yet. Sarah
would like to have sitting on the back
porch a regular morning routine. We
can also help her plan a trip.
hobbies Sarah likes arts and crafts - especially giving
things she makes to others.
Sarah doesn't get to make enough crafts
and jewelry lately.
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Community and Interests
II. Personal Profile
Ideas
Meeting neighbors
Baseball
Walking
Dances
Bowling
Social groups
Movies
Clubs
Sitting on the back
porch each morning
Painting
Taking a trip
Crafts
Jewelry
Travel
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Relationships
family and friends Sarah has one brother (Glen) and
one sister (Addie). She talks with them on the
phone, usually on holidays. She lives with three
people at home and has good relationships with
all, but one of them (G.S.), which is occasionally
difficult. Sarah used to have contact with a teacher
from her occupational school, but hasn’t heard
from her since last year. Sarah also gets along
well with the people at her day support center and
at Vida County Parks and Recreation.
Sarah might like to talk with family
more often or write letters.
being understood by others: Those who support Sarah
understand when she is communicating her likes
and dislikes.
qualities of those who support Sarah likes people who
are patient and who listen to her.
Sarah does not like people with loud
voices.
culture, traditions Sarah likes celebrating the holiday
season and enjoys baking cookies to give as gifts
each year. She also likes to attend holiday parties
whenever she can.
religion, spirituality Sarah does not express any
religious preferences.
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Relationships
II. Personal Profile
Ideas
Talk with family
Write letters to family
Baking cookies for gifts
Holiday Parties
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II. Personal Profile
Partners review “important
for” items on the ISP
Taken from the Personal
Profile, SIS and Risk
Assessment
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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
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III. Plan
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III. Plan
The shared planning tool
What?
Includes:
• Desired Outcomes
• Shared Actions and Supports
• Who, how often and when
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III. Plan
Who?
• Completed by all partners at planning
When?
• Completed annually and updated by partners
during the year
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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.”
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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.
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Planning for health and safety
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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.”
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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?
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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.
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A Good Life
Action planning
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III. Plan
Important to
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
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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
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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 when and how long.
The supports are shared
between partners.
The outcome number is also added.
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IV. Agreements
What?
Demonstrates commitment to the individual
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IV. Agreements
Sign here…
And write
other
contributors
here…
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IV. Agreements
Who?
• Completed by all partners at the end of annual
planning
When?
• Completed annually and updated with new
providers during the ISP year
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After planning…
What?
Person-centered instructions for supports
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After planning…
Support Instructions
Who?
• SC and each provider
When?
• Annually by all providers
• Updated as we learn about the individual
during the year
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After planning…
Support Instructions
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After planning…
Support Instructions
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After planning…
A change to the shared ISP
What?
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After planning…
ISP Change Note
Who?
• Completed by all providers when changes are
made to the shared ISP.
When?
• As outcomes, actions and supports change
during the year
Travel out of state
Knitting
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After planning…
MR/ID Waiver
documentation
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After planning…
Ongoing notes
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After planning…
Ongoing learning
M. Smull
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After planning…
What?
Ongoing review and improvements
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After planning…
Person-Centered
Reviews
Who?
• Completed by all providers and SC
When?
• Provider shares new learning with
the individual
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This concludes the
planning process
review.
Questions?
Please check
http://www.dmhmrsas.virginia.gov/
For forms, updates and contacts.
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