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Person Centered Planning
Kit O’Brien Cota and Andrea MedleyDepartment of Human Services
Division of Developmental Disabilities
January 2018
Federal Regulations Impacting DDD Waiver Services
• Centers for Medicare and Medicaid Services (CMS) Home and Community Based Services (HCBS) Regulations
• Published in January of 2014
• Effective March 2014
• Impacts all 1915c HCBS Waivers
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Division of DD 1915c HCBS Waivers
• Children’s In Home Support Waiver
• Children’s Residential Waiver
• Adult Waiver
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HCBS Regulations Addresses 3 Broad Areas
1) Conflict of Interest Free Case Management
2) Person Centered Planning
3) Settings
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Based on the HCBS Regulations, What Has Changed for People in a DD
Waiver
• Individual Service Plans
• Service planning based on Active Treatment
• Provider agency as case manager
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Conflict of Interest Free Case Management
CMS requires States to separate case management from service delivery functions.
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What does Conflict of Interest Free mean?
Case Management must be done by someone other than a relative of the person served
Case Management must be done by someone other than a direct provider of service
Case Management must be done by someone who does not have a financial interest in a provider or is not employed by a provider
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Conflict of Interest Free Case Management
Prior to July 1, 2017
• QIDP at the provider agency served as the case manager & developed the ISP
• QIDP at the provider agency coordinates all services for the person. According to CMS, this is a conflict of interest.
As of July 1, 2017• ISC is recognized as the
case manager & develops the Personal Plan
• ISC coordinates services; the provider agencies implement services conflict of interest free
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The Role of the Case Manager
• To determine eligibility
• To develop the Personal Plan
• To assist with identifying the providers of choice
• To monitor the Plan
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Person Centered Planning
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Person Centered Planning
• Identifying the balance between what is important to a person and what is important for a person.
• It is a way to identify & document strengths, preferences, needs and desired outcomes of a person.
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Person Centered Planning
• Is directed by the person receiving Wavier services.
• Includes persons chosen by the individual.
• Assists people to achieve outcomes in the most integrated setting which is chosen by the individual.
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Person Centered Planning
• Ensures services are delivered in a manner that reflects personal preferences and choices.
• Reflects cultural considerations.
• Includes strategies for solving disagreements within the process.
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Person Centered Planning
• Must identify risk factors and measures to minimize risk.
• Must include opportunities to seek employment & work in competitive integrated settings if desired.
• Documents must be developed in plain language that can be understood by the person who receives services.
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Person Centered Planning
Implementation Strategy
Personal Plan
Discovery Process
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The Discovery Tool & Process
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The Discovery Process
• Is designed to gather information on what is important to and what is important for the person.
• Will be completed by the Independent Service Coordination (ISC) agencies who will record what they learn in the Discovery Tool.
• Is not a one-time event or meeting. The ISCs will gather information over a period of time.
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The Discovery Process• Should begin with the individual.
• Must include the guardian.
• Must include others chosen by the individual.
• Current providers must also be included.
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The Discovery Process will Consist of
• Discussions: face to face, phone, and/or electronic.
• Observations.
• Review of existing records.
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The Discovery Process
Information Gathered:• Must be updated at least annually, but can
be updated anytime there is a change in preferences or needs.
• Is used to develop the Personal Plan.
• Will become a part of the referral packet sent to provider agencies.
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Sections of the Discovery Tool• Self-Description • Home • Important Relationships• Career and Income• Health and Wellbeing• Communication• Life in the Community• Recreation/Interests/Hobbies• Choice and Decision-Making• Future Plans
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The Personal
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The Personal Plan
• Single & integrated personal vision for a person’s life.
• Focuses on the desires, strengths, preferences, and needs of a person.
• Is developed by the Independent Service Coordination agency in conjunction with the individual and guardian and based on the Discovery information.
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The Personal Plan will identify:
• The outcomes that the person desires in their life.
–There must be at least 1 outcome present.
• The strengths, preferences and supports needed of the person.
• Risk factors and plans to minimize risk.
• Choice of providers.24
Sections of the Personal Plan
• Important Things to Know• Home• Important Relationships• Career and Income• Health and Wellbeing• Communication• Life in the Community• Recreation/Interests/Hobbies• Choice and Decision-Making• Future Plans
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Summary of Services & Supports page of the Personal Plan:
• Is completed by the ISC.
• Must include all Medicaid Waiver services that are or will be provided (i.e. Int. CILA).
• Will not contain the details of services (i.e. provide assistance eating).
• Will include prioritized outcomes.
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Provider Signature Page of the Personal Plan
• This page is complete by each provider agency that will provide any service.
• Provider agencies will document the outcome(s) they will address and service(s) they will provide.
• After receipt of the Personal Plan, provider agencies have 10 calendar days to sign & return this page.
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Provider Signature Page of the Personal Plan
• It is not necessary for provider agencies to document the details of their services on this Page; details will be outlined in the Implementation Strategy.
• Provider agencies must ensure that all services being billed are identified in the Personal Plan.
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Moving from Goals to Outcomes!
“goals, outcomes, it’s all the same thing, just different words…..” right?
WRONG
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Goals vs. Outcomes: The BIG Difference
Goals and outcome statements are NOT the same
• Goals are passive, hopeful, but not definitive.
• Outcomes are about the results that are desired.
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Outcomes
• It is what the person expects.
• Describe the ultimate or end result.
• Identify what the person will GAIN from the supports and/or services provided.
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Outcomes
• May reflect something the individual desires or prefers that is not currently present.
• May reflect something the individual desires or prefers that is already present and they want to maintain.
• Are not supports or services.
• May have to be prioritized by the individual and guardian.
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Writing Outcomes:• Begin with the aim of the outcome: Using the
person’s name followed by an action verb or phrase.
• It is helpful to complete the statement with how it will make a difference; use the phrase “so that” or “in order to”.
• The outcomes developed should make sense for a person without a developmental disability.
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Outcomes (#1) vs. Goals (#2)
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1. Laura exercises in Zumba Class at the Springfield YMCA so that she meets new friends and stays fit.
2. Laura will exercise three times a week with verbal prompts for 6 consecutive months by 12/31/17.
Services Are Not Outcomes!
Examples that are NOT outcome statements: • I want a day program.• I want to go to physical therapy.• I want speech therapy.• I want to be in the workshop.
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In Conclusion, the Personal Plan:
• Must be signed by the individual, guardian and ISC. The Plan is considered complete with these signatures.
• Provider agencies sign the Provider Signature Page of the Plan.
• Must be updated annually but can be done more often if needs or desires change.
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Implementation Strategy
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Implementation Strategy
• Developed by provider agencies that will Provide a serviceProvide a service and work toward an
outcome
• Describes how the provider agency will support the person to achieve their desires and meet their needs.
• Designed by the provider agencies; must at least contain basic components.
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Implementation Strategy
• Must be completed within 20 calendar days from the date of the provider signature on Personal Plan.
• Must be updated to reflect changes in the Personal Plan at least annually and more often if the person’s needs or desires change.
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An Implementation Strategy Must Include:
• Basic descriptive, diagnostic, demographic and medical information.
• Outcome(s) identified in the Personal Plan that the provider agreed to assist with.
• A description of how supports and services assist the individual to engage in community life and maintain control over personal resources.
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An Implementation Strategy Must Include:
• Plans to seek employment and obtain competitive integrated employment if desired.
• Documentation that services and supports are linked to an individual’s strengths, preferences and assessed clinical and support needs.
• Risks and strategies to minimize risk.
• Justification for any restriction(s) or modifications that limit the person's choice or access.
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DD Communication on Person Centered Planning
Person Centered Planning Process For Medicaid Waiver Services Manual http://www.dhs.state.il.us/page.aspx?item=96986
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Federal Information
Medicaid, Home & Community Based Serviceshttps://www.medicaid.gov/medicaid/hcbs/index.html
Federal Registerhttps://www.federalregister.gov/d/2014-00487
Fact Sheet- Settings Final Rulehttps://www.medicaid.gov/medicaid/hcbs/downloads/hcbs-setting-fact-sheet.pdf
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