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New Ways to Think About Person Centered Goals and Objectives
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MELISSA SKAGGS
VICE PRESIDENT
TBC SERVICES AND PROVIDER RESOURCES GROUP
PERSON CENTERED PLANNING
OUTCOMES AND OBJECTIVES
AGENDA
DEFINING PERSON CENTERED PLANNING PRINCIPALS OF PERSON CENTERED PLANNING MYTHS OF PERSON CENTERED PLANNING THINKING OUT OF THE BOX – THE QUESTIONS
DEFINING OUTCOMES AND OBJECTIVES HOW TO CHOOSE AND PRIORITIZE OUTCOMES WRITING CLEAR OUTCOMES AND OBJECTIVES THAT CAN
BE IMPLEMENTED WHAT HAPPENS WHEN THE OUTCOME OR OBJECTIVE
DOESN’T WORK
PERSON CENTERED PLANNING
PERSON CENTERED PLANNING HAS BEEN DEFINED BY CMS AS…..
A PROCESS, DIRECTED BY THE FAMILY OR THE INDIVIDUAL WITH LONG TERM CARE NEEDS, INTENDED TO IDENTIFY THE STRENGHS, CAPACITIES, PREFERENCES, NEEDS AND DESIRED OUTCOMES OF THE INDIVIDUAL
PARTICIPANTS OF THE PLANING PROCESS ENABLES AND ASSISTS THE INDIVIDUAL TO IDENTIFY AND ACCESS A PERSONALIZED MIX OF PAID AND NON-PAID SERVICES AND SUPOPRTS THAT WILL ASSIST THEM IN ACHIEVING PERSONALLY-DEFIND OUTCOMES IN THE MOST INCLUSIVE SETTING
PRINCIPALS OF PERSON CENTERED PLANNING
COMMUNITY PRESENCE CHOICE
COMPETENCE
RESPECTCOMMUNITY
PARTICIPATION
COMMUNITY PRESENCE
SHARING ORDINARY PLACES THAT DEFINE COMMUNITY LIFE
CHOICES
THE EXPERIENCE OF AUTONOMY(freedom) IN BOTH SMALL EVERYDAY MATTERS (IE..WHAT TO EAT OR WHAT TO WEAR)
.AND IN LARGE, LIFE-DEFINING MATTERS ( IE..WHO TO LIVE WITH OR TYPE OF WORK TO DO)
COMPETENCETHE OPPORTUNITY TO PERFORM FUNCTIONAL AND MEANINGFUL ACTIVITES WITH WHATEVER LEVEL OR TYPE OF ASSISTANCE REQUIRED
RESPECT
A VALUED PLACE AMONG A NETWORK OF PEOPLE AND VALUED ROLES IN COMMUNITY LIFE
COMMUNITY PARTICIPATION
THE EXPERIENCE OF BEING PART OF A GROWING NETWORK OF PERSONAL RELATIONSHIPS THAT INCLUDES CLOSE FRIENDS
MY PARENTS ALWAYS HAD A DREAM FOR MY BROTHER AND SISTER WHEN THEY GREW UP, BUT NOBODY HAD A DREAM FOR ME, SO I NEVER HAD A DREAM FOR MYSELF. YOU CAN NEVER HAVE A GOOD LIFE IF NOBODY EVER HAS A DREAM FOR YOU, UNLESS YOU LEARN TO HAVE A DREAM FOR YOURSELF
CONNIE MARTINEZ
Person Centered Planning….. Sees the individual as the expert in his or her life Includes significant others and/or peers Identifies hopes, capabilities, interests, preferences, needs and
abilities Maximizes community connections Encourages responsible risk taking Sees set-backs as an opportunity for growth and learning
Myths to Person Centered Planning
Myth – The individual is not interested in participating
Reality – Need to communicate to the individual that they can and should be doing this. Their life can be different. Assess how do engage the individual in stages.
Myth – Our current plan and assessment tools needs to change
Reality – Your current tools and plans can still work, you just ask the same questions in a different way. The plan will still work, you just write it in a different way
Myth – No real role for the provider in the planning process
Reality – A LARGE but CHANGED role for the provider. The provider becomes a…o Collaboratoro Mentor/Consultanto Skill Builder/Supporter
Getting Started…….The Questions
What do you want for the future?
What kind of help will you need?
Who will support you best? Who knows what is best for
you? Is it you or someone else?
Can you ask for what you really want?
What’s important for me? What’s important to me
OUTCOMES ARE LESS STRUCTURED
SHOULD REFLECT PERSONAL DESIRES
BASED ON THE TEAM DIALOGUE THAT INCLUDES THE INDIVUDUAL
STATES THE BIG PICTURE LONG TERM ITEMS THAT
NEED TO BE ACCOMPLISHED OR FOCUSED ON
DRIVEN BY THE ASSESSMENT
MEASURABLE FOCUSED ON OUTCOMES MEANINGFUL TO THE
INDIVIDUAL ACHIEVABLE RELATED TO THE GOAL FUN AND INTERESTING CAN BE IMPROVED WITH
TECHNOLOGY AND CREATIVE ACCOMODATIONS AS NEEDED
OUTCOME –VS- OBJECTIVEOBJECTIVES MORE
CONCRETE
LONG TERM OUTCOMEMOST MEANINGFUL AND IMPORTANT
HARD TO STAY FOCUSED
SOMETHING THAT WILL BE ACHIEVED OVER A LONGER PERIOD… 2 TO 3 YEARS FOR EXAMPLE
SHORT TERM OUTCOMESHELPS TO MAINTAIN FOCUS
HELPS TO MAINTAIN A MORE POSITIVE ATTITUDE
SHOWS RESULTS FASTER
SOMETHING THAT WILL BE ACHIEVED IN LESS THAN A YEAR
LONG TERM OUTCOME
I WANT A JOB IN THE COMMUNITY THAT PAYS AT LEAST MINIMUM WAGE
TEAM FOUND THAT THE INDIVIUAL NEEDS SUPPORT TO INDENTIFY JOBS THAT MATCH SKILLS AND WILL REQUIRE ASSISTANCE IN FINDING TRANSPORTATION
SHORT TERM OUTCOME
INDIVIDUAL WILL APPLY FOR AT LEAST 10 COMMUNITY JOBS
INDIVIDUAL WILL LEARN TO USE PUBLIC TRANSPORTATION
OBJECTIVES WILL BE DEVELOPED TO ADDRESS BARRIERS TOWARDS REACHING THESE SHORT TERM OUTCOMES
CHOOSING OUTCOMES
SOME THINGS TO CONSIDER WHEN THINKING ABOUT GOALS
INDIVIDUALS AREAS OF INTEREST COMMUNICATION BEHAVIORS MOBILITY/ABULATION BASIC SELF CARE EDUCATION SELF-SUFFICIENCY EMPLOYMENT NEEDS LIFE DESIRES ENVIROMENT/LIVING SITUATION
PREFERENCES OF THE INDIVIDUAL AND/OR FAMILY ARE ADDRESSED
STRENGTHS, NEEDS AND PREFERENCES HAVE BEEN IDENTIFIED THROUGH THE ASSESSMENT PROCESS AND PERSONAL CONVERSATIONS AND OBSERVATIONS OF THE INDIVIUAL
RISKS HAVE BEEN IDENTIFIED
CURRENT SUPPORTS ARE DISCUSSED TO DETERMINE IF THEY ARE STILL NEEDED IN THE SAME WAY
BARRIERS TO ACHIEVEMENT OF GOALS ARE INDENTIFIED
OUTCOME FOCUSED
COMMUNTY INCLUSION NEEDS ARE REVIEWED AND MODIFIED AS NEEDED
SELF DETERMINATION SKILLS HAVE BEEN ASSESSED
EXAMPLE
ASSESSMENT FOUND THE THE INDIVIDUAL IS NON-VERBAL WITH LITTLE TO NO FUNCTIONAL COMMUNICATION. THE INDIVIDUAL ENJOYS GOING OUT TO EAT
OUTCOME AREA…….INDIVIDUAL WILL INCREASE INDEPENENCE IN THE COMMUNITY BY USING ALTERNATIVE STRATAGIES WHEN EATING OUT.
RISK IDENTIFY THE DANGERS TO HEALTH, SAFETY AND
WELFARE IDENTIFIED RISK NEED TO BE ADDRESSED IN THE ISP RISK SHOULD HAVE BEEN IDENTIFIED DURING THE
ASSESSMENT PROCESS
POTENTIAL AREAS OF RISK HEALTH AND MEDICAL SAFETY HOME COMMUNITY WORKPLACE/SCHOOL FINANCIAL BEHAVORIAL
HOW MANY OUTCOMES……..
There should be a direct correlation between the individuals strengths, needs and desires and the number of outcomes developed
The individual should have a say in the number of outcomes
There should be team discussion and team decisions as for the reasons of the selection of the outcomes for the ISP (its best practice to document this discussion within the ISP)
Outcome Writing Basics
At every step of the process keep the desires, interest and needs of the individual in mind
Think about who will be responsible for monitoring the outcomes
Determine what steps/objectives will be needed for the outcome to be achieved
Establish a deadline
Three questions that need answered What is being measured How is it being measured How will I know when the outcome has been
accomplished
Well Written Objective
Sequential
Related directly to the outcome
Measurable
Stated so that the behavior changed is observable
Singularly stated objective – no compound (multiple objectives)
Measuring AchievementUnderstanding what is the desired result of the objective
Poor Objective – Tommy will take out the trash
Good Objective – After dinner Tommy will take the trash to the dumpster with less than 2 verbal prompts 5 of 7 times for 4 consecutive weeks by March 31, 2014
Without a good objective there is no basis for making accurate judgments or determinations of achievement for the program being implemented
If the objective is not understood then you can have confusion and disagreements about what is expected not only of the individual but also the service provider
Make sure the outcome is clearly defined
Make sure there are not too many steps that need to be monitored or achieved in one objective
Think about objectives as a communication tool…..
HELP!!!!!
OUTCOME CAN’T BE OBTAINED
NOW WHAT?????
Was the outcome clearly understood by the service provider
Did the outcome have the ability to determine achievement
Was their proper training and communication with the service provider
Was this outcome truly something the individual wanted
Was discovery/assessment accurate
Were the objective clear and concise
Does it need to be re-written in a different way
Melissa SkaggsTBC Services and Provider Resources Group1616 Lancaster AvenueReynoldsburg, Ohio 43068800-995-0043mskaggs@tbcservices.netwww.tbcservices.netwww.providerresourcesgroup.net
