we promote opportunities and provide support for people with disabilities to lead self-determined...

We promote opportunities and provide support for people with disabilities to lead self-determined lives.

Person-Centered Support Plan (PCSP)

Intake and Waiting List

Evaluating

Assessing Planning

Implementing

Dis -Enrollment

DSPD’s Process For Tracking Eligibility, Planning and ServicesUtah System for Tracking Eligibility, Planning and Services


Purpose

Understand changes, why these change; why now.

Learn how to link assessments to plans.

Learn how to complete comprehensive Action Plans.

Learn how to meet all requirements in the Person Centered Support Plans.

Practice applying new content requirements prior to using USTEPS electronic tools.

Letter from the Division Director

George Kelner, Ph.D.


Introduction to the Person Centered Support Plan

Natural progression or maturing of the process

Person-centered planning is critical; not just a luxury

Vehicle for change, but it is up to you to make it work!


Accomplishments of the Redesigned PCSP Process

1. One integrated plan

2. One process for all situations

3. Person-Centered Planning Process while meeting waiver requirements and DSPD rules

4. Balance what is most important TO with what is most Important FOR a person


Accomplishments continued…

5 Link assessments directly to the plan

6 Assessments strengthened: multi-method multi-source multi-occasion

7 Emphasize personal goals and address quality of life issues

8 Health and safety addressed in the context of the person’s life


Accomplishments continued…

9. Plan includes state plan services, generic and natural supports in addition to DSPD funded supports (Waiver Services)

10. Direct link from the plan to the individual budget

11. Justify paid services with links to identified needs

12. Clarify Support Coordinator/Provider roles and responsibilities


Sample PCSP


PCSP Outline Part I.

Part I. Identifying Information and Background

A. BackgroundB. Person-Centered ProfileC. Review of Previous Year

Goals, Paid Services, and Support Strategies

D. AssessmentsTO/FOR Lists


PCSP Outline Parts II - IV.

Part II. Action PlanA. Personal GoalsB. Additional Supports and ServicesC. Purchased Services

Part III. BudgetPart IV. Signatures


Person-CenteredSupport Plan Process

Part I. Identifying Information and Background - Background - Person-Centered Profile - Review Previous Year Goals, Support Strategies and Paid Services - Assessments, To/For Lists

Assessment .


Handout: Role of Assessment Source: Adapted from “New Mexico –

Resource Guide for Independent Case Managers”

http://www.health.state.nm.us/ddsd/regulationsandstandards/Operations/CMOpsManBySec.htm

The Role of Assessment


The Role of Assessment

Assessments are an essential part of case management and the foundation of services for the individual. Current, valid and functional assessments help the Support Coordinator and team establish and maintain eligibility for funding and ensure team planning is thorough and person-centered.


DSPD Assessments

Functional Behavior Assessments

Rights Assessments Supports Intensity Scale Risk Assessment Social History Summary Psychological Evaluation Developmental

Assessment Psychiatric Mental Health Medical evaluations

OT, PT, Speech ABI specific assessments CBIA ICAP Monthly Summaries Essential Lifestyle Plan Informal questioning /

interviewing Education Voc Rehab Person-Centered

Profile (new)


Person-Centered Profile

First section of the Person-Centered Support Plan

Important information about the individual

Information that helps to know new people

Is a living document that grows with the person

The profile can include information from all those who know and support the individual


The Person-Centered Profile is initially completed by the Support Coordinator when a person transitions into services (may not have a lot of detail)

Most people in services have this type of information in their file as a good starting point

The Team provides the Support Coordinator with updated information on the Person-Centered Profile annually

The Person-Centered Profile is updated by the Support Coordinator when significant changes are noted or at least annually

Person-Centered Profile


Person-Centered Profile Handout (outline)

Introduction Likes/dislikes Communication

style/preferences Contributions/

Relationships Hopes/Dreams/Fears

and Personal Goals

Health and Safety Issues Legal/Rights Issues

Guardianship Court orders Rights restrictions

Other Considerations Emotional/self-esteem/

spiritual/cultural Other “Need to Know”

information Historical information Reference other

assessments


Linking Assessment to Planning

Intake and Waiting List

Evaluating

AssessingPlanning

Implementing

Dis-Enrollment

Person Centered Service PlanPerson-Centered Support Plan


Important TO

What the person tells us, either verbally or behaviorally, is “most” important TO the person.

What is important TO a person includes only what people are saying: With their words With their behavior

When what the person says is different from what they do, the bias is to rely on behavior.


Important FOR

What others tell us is important FOR the person to be successful

What is important FOR the person Issues of health or safety What others see as important to help the

person (the person may or may not agree)


Important FOR issues

Health and Safety Issues are NOT just concerned with “most” important FOR Concerned with issues that would be considered

“neglectful” if not included in the plan Waiver Language

Provide supports that are adequate to assure the general health and safety of waiver recipients

Maintain the health of individuals in waiver services sufficient to allow them to maintain their places of community residence


Michael Smull

Balance between important TO and FOR

Balance between Choice and Responsibility

“Happy and dead are incompatible, alive and miserable is unacceptable”

Assessment as “Learning/Describing” what is important TO and what is important FOR the person.


The Person Centered Planning Process (Refining the To’s and For’s List)

ü SISü P.C. Profileü Annual Reviewü Otherü Psychological

Assessmentü CBIAü Other

Pre-Planning Assessments

These feed the To’s & For’s Lists

To’s List

· T1: Having a relationship· T2: Getting a new job· T3: Continue living with

parents· T4: Going on vacation· T5: …...

For’s List

· F1: Eating· F2: Going to the Doctor· F3: Mental health· F4: Taking Medications· F5: Transportation to work· F6: …...

These can be added prior to or during the Meeting

To’s

Cu

rren

t G

oal

Fu

ture

Go

al

No

t A

pp

licab

le

Imp

ort

ant

Info

To

Item

T1

T5

XT4

XT3

XT2

X

X

For’s

Personal Goals

1. Dating (T1)

2. Living At Home (T3)

Future Goals

1. Getting a new job (T2)

Important Info

1. Overcome his depression (F3)

2. Going on Vacation (T4)

Non-Goal Related

1. Transportation (F5)

2. Needs help going to the Doctor (F2)

The Expanded, Inclusive, All-In-One ISP

Action Plan Action Plan Future Goals Important Info

This task is done during the meeting

In t

he

Pla

n

Imp

ort

ant

Info

Fo

r It

em

F1

XF4

XF3

XF2

No

t A

pp

licab

le

X

XF5

F6 X


Practice

Practice technique: Using assessment documents:

1. Use a RED pen,mark things that are important TO the individual

2. Use a BLUE pen, mark things that are important FOR the person

3. Record the source of the item important TO /FOR the individual.

Assessments Psychological ICAP CBIA Social History Person-Centered Profile


Planning Steps

A. Pre-meeting 1. Update TO/FOR List 2. Copy And Distribute B. PCSP Meeting 1. Review all assessments 2. Celebrate 6. Write Current Status of Goals 3. Add to TO/FOR List 7. Identify Supports and Services 4. Categorize TO/FOR List 8. Additional Supports and Services 5. Identify and Write Clear Personal Goal(s)


A. Pre-meeting

1. Update TO and FOR List

this is covered in assessment section…


A. Pre-meeting

2. Copy and Send

Copy select materials SIS Short Report, P-C Profile, Expanded

TO and FOR list Send out to Team prior to the

meeting Consumer, Guardian, Parent/advocate Provider(s)

Residential, Day/Work


B. PCSP Meeting

1. Review the summary of assessments

Quick – brief review of key issues including: Person-Centered Profile Last year’s 1) goals, 2) purchased

services, 3) support strategies, and 4) other supports

Others critical changes and events


B. PCSP Meeting

2. Celebrate !!!

Big challenge – even when the consumer accomplishes things, they still have a severe disability and a long list of needs to address.

The whole team needs to recognize accomplishments and take time to celebrate! This is not just added in for fun or to add a light

moment to the meeting. This is a critical component that requires a Support Coordinator with specific knowledge, skills and abilities. Practice!


B. PCSP Meeting 3. Add to To & For List

This is the same process as in A. 1. above.

This time it is with the whole team Add, combine, clarify, do not delete

anything


B. PCSP Meeting 4. Categorize TO & FOR List

TO: Current Goal Future Goal Important Information NA

FOR: Address in the Plan Important to know NA


5. Identify Personal Goals

Support Coordinator will identify personal goals based on assessments of what is Important TO the person with input from all team members (especially the consumer).It is imperative to start the process with what the person wants, what is most important to them, addressing their core values and passions.


Mission and Mandate

DSPD Mission and ValuesThe Mission of the Division of Services for People with Disabilities is to promote opportunities and provide supports for persons with disabilities to lead self-determined lives.

Medicaid Waiver Person-Centered Supports. Person-centered supports are those that are articulated by the person or that directly relate to a goal, preference, or outcome that the person has identified as important.


Personal GoalWhat makes it personal? “Personal” is:

What the person wants What is important to the person What is the person’s passions and values What brings the person pleasure and

enjoyment “Personal” is not:

What the person needs (habilitation, health & safety)

What is good for a person What others think the person should want


Personal Goal What makes it a goal?

The “Goal” is: The desired end result What we hope to accomplish this year Use “short-tem goal” if needed What we will see in the person’s life

The “Goal” is not: the process (supports and services) the result of the Support Strategy


Personal Goal focus

Maintain something good Avoiding something bad Accomplishing something good


Personal Goal(s)How many ?

The team has to decide 2 to 4 will work for most people May not have a goal at first for

someone new to DSPD services


Prioritizing Goals

What does the person want to focus on? What is most Important TO the person? What will make the biggest difference ? What is doable in the next year? What will require coordinated multiple supports on

the Action Plan? versus a single assignment

What is better to re-categorize as a Future Goal


Selecting Goals – Resolving Conflict

This process is Person-Centered

Parents and even guardians do not have the ultimate authority

All team members need to be given a chance to provide input into decisions


Selecting Goals – Resolving Conflict

Often provider staff have the most knowledge about what people want; however, the Support Coordinator needs to make the final decision with input from the whole team and special consideration as to what the person wants


Categorize TO and FOR listsLearning Exercise

1. Give case study with “TO” and “FOR” list and team will categorize and identify priority goals for the person.

Review Jackie & then practice with Happy.


Write A Clear Goal

Support Coordinator will write a clear,specific, measurable goal for eachPersonal Goal selected by the Team.

Review Jackie & practice with Happy.


Selecting and Writing Goals

List of “Current Goals” that are “Most Important TO The Person”To Item “Current Goal” Notes

1. Changing Job Assignments

Jackie wants to keep her current job. She really enjoys her job, the money she earns, and the friends at Work

2. Live on her own Jackie wants to live on her own and be more independent.

Jackie’s Goals

#1 Jackie wants to move into her own apartment within 2 years.

· Current Situation: Jackie lives with her parents. · Strengths: Jackie has a steady income with SSI and her job. She is responsible. She knows how to get help in emergencies. · Barriers: Jackie has trouble riding FlexTrans. She needs help getting to and from work. She is at risk for having seizures when alone. She has limited shopping,

cooking, and money skills. · To Item(s): #2


Personal Goals - Examples

Jackie Goal #1 Jackie wants to move into her own

apartment within 2 years. Goal #2 Jackie would like to keep her job and

keep making money.

Others- Bob will continue living with his parents.- Jane will go on at least one date a month.


6. Write the current status of goal

Current status of the Goal How close to the Goal? History? Keep it focused on the goal itself

Strengths: prerequisite skills, steps accomplished,

relationships Barriers:

If this is important, why hasn’t already happened might include items from the “FOR” list


Complete the Action Plan

Support Coordinator will complete the Action Plan, with input from the team, for each Personal Goal by adding the related supports under each goal


7. Identify supports and services

Formal/Written Support Strategies Medicaid State Plan Services Natural Supports One-Time and On-Going Behavior Supports & Psychotropic Med Plans Specific Medical Skill Training, Opportunities, Relationships,

etc…


Learning Exercise

1.We have complete first part of Action Plan by identifying Personal Goal(s) and

Current Situation, Strengths and Barriers.

2.“Goal Related” supports and services. Review Jackie & practice with Happy.


Goal #2 Jackie would like to keep her job and keep making money · Current Situation:

Jackie has worked as a janitor at the University of Higher Education for 11 years. · Strengths: Jackie is dependable and gets along well with her coworkers. Her brother provides transportation to and from work. She has completes most of her cleaning duties independently. · Barriers: Jackie can become upset with coworkers and supervisors. She needs prompts to complete tasks. She needs accommodations for her seizures. · To Item(s): #1

Support Item #1: Complete Quality WorkWho Is Providing The Support? Job coach Start Date: 4/1/2007 End Date: 4/31/2008Details: Teach Jackie how to independently assess task completion and quality. Is this a Paid Support? Yes Provider: Jobs R UsService Code/Description: SEISupport Strategy: Yes Monthly Summary: Yes For Item(s): #7 Support Item #2: Work Related Social SkillsWho Is Providing The Support? Job coach Start Date: 4/1/2007 End Date: 4/31/2008Details: Train Jackie to successfully deal with criticism from coworkers. Is this a Paid Support? Yes Provider: Jobs R UsService Code/Description: SEISupport Strategy: No Monthly Summary: Report problems as neededFor Item(s): #’s 1 & 4


8. List Additional Supports and Services

Not related to Personal Goals not already addressed

Address health and safety issue 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”


Learning Exercise

Give Personal Goal and supporting information and write a good example of a list of “Non-Goal Related” supports and services.

Review Jackie & practice with Happy.


X X

B: Additional Supports and Services (Not Goal Related)

Standard Supports

Support: Medical Treatment Who Is Providing The Support? Dr. Imadoctor, IHC Start Date: 4/1/2007 End Date: 4/31/2008Details: Dr. Imadoctor is the primary care doctor.X Is this a Paid Support? No Support: Support Coordination Who Is Providing The Support? Hamblin Gilbertson Start Date: 4/1/2007 End Date: 4/31/2008Details: Provide coordination with supports and services, eligibility evaluation, and other things as needed.X Is this a Paid Support? No


Complete the Person-Centered Support Plan

The last part of the Action Plan is the Purchased Services Copy and Paste Service Descriptions amount , duration, frequency)

Part III of the PCSP is the Budget Signatures


What’s next?

Practice with “mentor” Review first two PCSPs (Supervisor) Pass off PCSP Checklist Learn to apply PCSP process in

USTEPS

we promote opportunities and provide support for people with disabilities to lead self-determined...

Documents

selfdetermined lives

services slide

support strategies

person slide

person centered support

state plan services

sample pcsp slide

paid services