person centered planning for cap/c case managers · person centered planning is a process that...

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Person Centered Planning for

CAP/C Case Managers

Kimberlee Hyman, MS

HCBS Provider Education and Support Specialist

The Carolinas Center for Medical Excellence1

Participant Learning ObjectivesParticipant Learning Objectives

Participants will be able to describe three outcomes of person centered planning.

Participants will be able to discuss the principles of person centered planningperson centered planning.

Participants will be able to define the phases of the person centered planning framework.

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I. Defining Person Centered Planning

Training Outline:

g g

II. Person Centered Thinking

III. Person Centered Principles

IV. Putting PCP into Practice


Training Outline:

e g e so Ce te ed a g




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Person Centered Planning (PCP) Definition

Person-centered planning is a process, directed by the

family or individual intended to identify the strengths,

capacities, and preferences, needs and desired

outcomes of the individual.

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• Person‐centered planning attempts to identify d hi hli ht th i t l t ift dand highlight the unique talents, gifts and

capabilities the recipient.

• Explore and discover where in the “real” world these gifts can be shared and appreciatedthese gifts can be shared and appreciated

01/09/2009

• The family identifies planning goals to achieve l tpersonal outcomes

• Engaging in active listening to the child and caregiver, learning what is important to them, and lending time and energy to support themand lending time and energy to support them

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1. The child and caregiver feel welcomed and heard

2. The child and caregiver have authority to plan and pursue their own vision

3. CAP/C Assessment of needs is fair and accurate

4. CAP/C Assessment and discovery identify personally defined quality of life

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1. The child and caregiver feel welcomed and heard

• Feel welcomed listened to and supported in their pp

decisions

• Are not pre-judged

• Staff use a speaking pace, volume and rhythm that

enables the person to fully understand

• The child and caregiver are allowed to share how they

are doing and their interests

1. The child and caregiver feel welcomed and heard.

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2. The child and caregiver have authority to plan and

pursue their own visionp

• The caregiver is in the best position to know what the

child wants and needs

• The caregiver, and the child, if able, have the control and

influence in the decision processes

• Person has support to express his or her needs, wants,

likes and dislikes about his or her life

• Planning should begin with the person’s own priorities,

what changes he or she would like to see for the future.

3. CAP/C Assessment of needs is fair and

accurate

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3. CAP/C Assessment of needs is fair and accurate

• Fair, valid and reliable.

• Provides information that enables the coordination of identified and needed support and services.

• Used to identify individual assets, capabilities and needs.

4. CAP/C Assessment and discovery identify personally defined quality of lifepersonally defined quality of life

• The discovery process includes conversation and sharing coupled with a comprehensive assessment.

• The discovery process integrates information concerning the family’s quality of life outcomes.

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4. CAP/C Assessment and discovery identify personally defined quality of lifepersonally defined quality of life

• A good assessment process helps people make choices that support their quality of life choices.

• Assessment helps individuals families, communities and friends to join together to encourage and support the child and the caregiver.g

Monitoring questions should be asked

repeatedly, not just at the time of assessment:

– Did needs change?

– Did assets change?

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M it i ti h ld b k dMonitoring questions should be asked

repeatedly, not just at the time of assessment:

– Did capabilities change?

– Are existing services meeting child’s needs?

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System Centered

• Focuses of placement and

Person Centered

• Focuses on quality of life• Focuses of placement and filling slots

• Emphasizes technologies and clinical strategies

• Organized to please funders, regulators, policies and rules

• Focuses on quality of life

• Emphasizes dreams, desires & meaningful experiences

• Organized to respond to h hild d ipolicies and rules the child and caregiver

• Discussions of the future contain specific concrete examples of positive activities, experiences and life situation to increase goal attainment

• Plans will reflect the unique interests, gifts and qualities of the person and their unique characteristics

E h i ti t f th d l t d• Emphasize creative ways to focus on the development and deepening of personal relationships.

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Bradley is a 12 year-old boy with severe cerebral palsy and

developmental delay. He lives with his parents and 2 younger siblings.

Case Study

He needs assistance with all ADLs and is mobile around the house

using a motorized wheelchair. He needs to be lifted by his father,

since his mother has a back injury and can no longer manage his

weight. Both parents work long hours outside of the home. Bradley

enjoys playing video games, going for “walks” downtown and in the

park, and reading (his parents read to him). Due to their work

schedules and the time required to manage Bradley’s care hisschedules and the time required to manage Bradley s care, his

parents have been unable to take the family to church on Wednesday

nights or to spend much leisure time with Bradley. Bradley’s mother

hopes that he will one day graduate from high school and become

actively involved in a church on his own.


Training Outline:




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Person Centered Thinking Activity

• I know it’s going to be a good day when I arrive to work

and……..

• I know it’s going to be a bad day when I arrive to work

and……..

• Here’s what can make my good days better and my bad

days less bad……..

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Person Centered Thinking Activity

What makes the

Here’s what could make my What makes the

difference between a good

and bad day?

I know its

yday better or

worse

going to be a good day

when?

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Improving the Quality of Questions

Contrast these questions with…. More vision‐oriented, community‐lifequestions and approachesquestions and approaches

Ideal home:

Do you like your home? If you could make any changes to your home that would make daily life easier for you and your child would they be?

Ideal activities:

Do you want your child to be able to do activities?

If we were to see your child at school orplaying with friends what types ofactivities? playing with friends what types of activities would we see him/her doing?


Contrast these questions with…. More vision‐oriented, community‐lifequestions and approaches

Ideal home:Ideal home:

Do you like your home? If you could make any changes to your home that would make daily life easier for you and your child would they be?

Questions to considered when discussing the ideal home:

1. Does the structure/layout of the home support the child’s care needs? 2. Do the caregiver have options? 3 Does the environment promote a sense of comfort and security?3. Does the environment promote a sense of comfort and security?

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Contrast these questions with…. More vision‐oriented, community‐lifequestions and approaches

Ideal activities?Ideal activities?

Do you want your child to be able to do activities?

If we were to see your child at school orplaying with friends what types of activities would we see him/her doing?

Questions to consider when discussing the ideal activities:1. Consider the types of activities the family is involved in. Does the child enjoy

these activities?2. What does community mean to the family?3 Are there activities the caregivers would like to for the child to do that she or he is3. Are there activities the caregivers would like to for the child to do that she or he is

not currently doing?4. What type of support does the child receive while at school? Is the support

adequate?


Training Outline:




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Person Centered Principles

Community Presence

Choice

Competence

Respect

Community Participation


Community Presence

Sharing the ordinary places that define the

community life

Choice

Competence

R tRespect


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Community Presence


community life


Community Presence

E i t iChoice Experience autonomy in small everyday matters

Competence

R tRespect


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Community Presence

Choice

CompetenceOpportunities to perform

functional and meaningful activities

R tRespect



Community Presence

Choice

Competence

R t Perceived having a valuedRespect Perceived having a valued place and role in life


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Respect Perceived having a valued place and role in life

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Community Presence

Choice

Competence

R tRespect


Being a part of a network of personal relationships

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Community Presence


community life

Experience autonomy in Choice

p ythe small everyday

matters

CompetenceOpportunities to

perform functional and meaningful activities

R tPerceived having a l d l d l iRespect valued place and role in

life


Being a part of a network of personal

relationships

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How Person Centered is Your PCP?

• Did you help the caregiver to use this person-centered

process to assist in the planning for the child?

• Did the caregiver identify anyone else who they wanted

to assist in or facilitate the planning for the child?

• Did the desires and goals of the child and caregiver form

the foundation for the process?

How Person Centered is Your PCP?

• Was the process positive and respectful?

• Were the strategies used to gain the caregiver’s g g g

perspective respectful?

• Does the caregiver have a formal role in quality

assurance?

• Are the child and caregiver participating in all phases of

the process?

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Training Outline:



IV Putting PCP into PracticeIV. Putting PCP into Practice

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i d

Process

Person Centered Thinking

Revisions

Ongoing

Learning

Documentation

Required Content

Required Content

Process

Person Centered Thinking Person

Centered

Revisions

Ongoing

LearningDocumentation Thinking

Person Centered Thinking is a set of value‐based skills that:

• Change the way we see individuals/families

• Change the way we support individuals/families

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Required Content

Process


Process

Revisions

Ongoing

LearningDocumentation

Person Centered Planning is a process that enables people important to the person, as well as people that will provide supports and services to come together and discuss the who, what, when, and where of services.

Required Content

Process

Person Centered Thinking Required

Content

Revisions

Ongoing


Required content or documentation is required to be submitted toRequired content or documentation is required to be submitted to DMA for an applicant who is requesting CAP/C services or for an annual review:- Referral - FL-2- Assessment - Plan of Care- Physicians Request Form, as applicable

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Required Content

ProcessPerson Centered Thinking

Documentation

Revisions

Ongoing


Documentation of Person Centered Plan includes outlining medical and other services and activities put into place to meet the individual and family’s needs.

Required Content

Process


Ongoing Learning

Revisions

Ongoing


g

O i l i i l i d di i f thOngoing learning involves review and discussion of the goals and interventions documented on the plan of care.

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Required Content

Process


Revisions

Revisions

Ongoing


Revise the plan of care to change the things that need to be different based on the results of the ongoing learning.

Required

ProcessPerson Centered Thinking

Revisions

Ongoing

Learning

Documentation

Required Content

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Key Points

• It is important to remember that Person

Centered Planning is a starting point in a

process intended to promote self-guided positive

change. Is it not a one-time event.

Key Points

• Having information about the person’s aspirations, g p p ,

interests, preferences, and strengths all in one place

also can serve as a resource that can be reused and

updated as the person’s goals, interests, and

preferences change.

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Key Points

• Person centered planning outcomes should ensure that the child and caregiver feel welcomed and heard and have authority to plan and pursue their own vision

Key Points

• The CAP/C Assessment should be fair and accurate. The assessment process should assist the child and caregiver in discovering and identifying their personal definition of “quality of life”.

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