Virginia’s Person Centered Planning Process. The Five Steps of Planning Sharing Information: Listening Choosing Partners: Community Planning Together:

Virginia’s Person Centered Planning

Process

The Five Steps of Planning

Sharing Information:

Listening

Choosing Partners:

Community

Planning Together: Abilities

Keeping Track:

Responsibility

Getting ready: Self-direction

Sharing Information

Listening

Sharing Information

and your actions.with your words

to what you tell us

We listen

We listento those who

know you best.

Sharing Information

Essential Information

Identifying Information

Address: 198 Evergreen Way Sex: M F Marital Status: S M

City/Zip: Any town, VA 24088 DOB: 09/05/1962

Home phone: 703-889-1258 SSN #: 215-58-9985

Cell phone: N/A Type of residence: Group Home

Work phone: N/A Primary language: English

Race: African American Caucasian Hispanic origin Hispanic Asian Other:

Emergency Contacts/Representation Phone: Fax: Email:

Guardian: N/A

address:

Family Member: Gloria Citizen703-664-

9887N/A [email protected]

address: 1008 Elm Street Any town, VA 24088

Authorized Representative: N/A

address:

Power of Attorney: N/A

address:

Emergency contact: Marshall Green703-889-

1258703-889-

[email protected]

address: 198 Evergreen Way Any town, VA 24088

Other:

address:

Needed to receive paid supports in Virginia.

Needed for assuring individuals health and safety.

Collected and maintained by a support coordinator.

Sharing Information



Sharing Information

Profile

Profile Questions Agenda Questions

What gifts and talents would you like to use more? share with others?

Home Living

2. What is your home like? What changes are needed and what other changes Might improve your living arrangement?

Would you like more or less independence? How?

4. Do you think that you have enough privacy?

Would you like more or less privacy? What would you like to change about your privacy?

5. Do you feel safe where you live? What changes might help you feel safer?

Community Living

What would make your community life better?

1. What are your gifts, talents and strengths?

Please provide a description of a good life for you.

Profile

3. Do you think that you have enough independence?

6. Tell us about the community where you live.

The Profile begins with your The Profile begins with your description of a good life.description of a good life.

Please provide a description of a good life for you.

Profile

Ask if someone who supports you has Ask if someone who supports you has training in person-centered thinking. training in person-centered thinking.

Tools are available to help us think in Tools are available to help us think in different ways, and to help us better different ways, and to help us better

understand.understand.

There are sample questions that can help.There are sample questions that can help.


Sharing Information

Profile questions help to describe you, your life and how you feel about it.

Agenda questions help to think about what needs improvement and better support.

Anyone you choose can help you complete your profile.

Profile

Home Living

Community LivingRelationships

Work and Alternates to Work

Contributions

Money

Transportation

Health and Safety

Learning

Focuses on our vision of what’s Focuses on our vision of what’s needed for a good life:needed for a good life:

Choosing Partners


Community

Profile

Choosing Partners


Partner List

Profile

Choosing PartnersThe people I want to help me plan: Contact information:

My Planning Partner:

Things to do with my planning partner:

Chosen support team and contact information.


Planning Partner

Partner List

Choosing Partners

Profile

My Planning Partner:

Things to do with my planning partner:

The Planning Partner.

Choosing Partners


Profile

A friend, family member or support provider to help you with the planning process.

Help with completing the profile, planning and arranging team meetings, checking in for changes.

Partner ListPlanning Partner

Getting Ready


Partner ListPlanning Partner Self-

direction

Profile

Getting Ready


Agenda


Profile

AgendaAgenda ItemsDecided before planning meeting.

Action TakenDecided during planning meeting.

New experiences, successes and profile updates.

Personal Goals/Outcomes

1.

2.

3.

4.

5.

Additional Topics:

6.

7.

Developed based on what the individual wants to accomplish and talk about.

Getting Ready

You choose the topics from your Profile.

Include improvements you need or want to make.

Additional topics to discuss with your team.


Profile

Agenda


Getting Ready


AgendaPersonal Topics


Profile

Personal TopicsTopics not for the meetingConsider each specific point identified in

the Profile that will NOT be on the agenda. Also consider what topics might be considered inappropriate or embarrassing for anyone in a group discussion and list below.

Action TakenDiscussion record, added to routine supports, plan

for achieving goals or health and safety supports.

Personal topics not added to the Planning agenda and how resolved:

Builds privacy into the process based on individual preference and common social norms.

Getting Ready




Profile

Provides the option to do some planning with partners you want to support you with

personal topics.

Privacy with the issues you choose.

Getting Ready




Profile A team planning process.

Selected and invited by you, with help from your

planning partner and support coordinator.


Planning Together


Partner ListPlanning Partner Abiliti

es

Profile


Profile

Partner ListPlanning PartnerAgendaPersonal Topics

Planning Together

Planning Together


Profile

Partner ListPlanning PartnerAgendaPersonal Topics

Agenda

Agenda ItemsDecided before planning meeting.


New experiences, successes and profile updates.Personal Goals/Outcomes

1.

2.

3.

4.

5.

Additional Topics:

6.

7.

The first task at every planning meeting.

Planning Together

Providers who know your routine and

health and safety support needs based on

your essential information can come

with a list of supports to discuss.

Planning Together




Profile

While some supports may not change from

year to year, how they are provided will

change based on your changing preferences.

Planning Together




Profile

For each agenda item, the team

chooses at least one of four options for

each response.

Planning Together




Profile

routine supports or

health and safety supports or

action plans or

a discussion record

Routine Supports





1. Haircuts Routine Support

2. Transportation Routine Support

3. Walking and falling

4. YMCA

5. Lock on doorAdditional Topics:

6. Drive own car

7. Shopping Routine Support

Health/Safety Supports







3. Walking and falling Health/Safety

4. YMCA


6. Drive own car


Action Plan








4. YMCA Action Plan


6. Drive own car


Action Plan Plan begin date: ________________ Action Plan #__________

Desired Outcome:

What would it take for anyone to achieve this outcome?

Supports currently in place:

Supports needed:

Support or Action StepsWho will do what to achieve this outcome?

Who’s Responsible How Often or By When

Comments:

Written as if it were happening and uses “anyone” as the standard.

Supports needed are then shared among team.

Action Plan

Discussion Record








4. YMCA Action Plan

5. Lock on door Discussion RecordAdditional Topics:

6. Drive own car Discussion Record


Discussion Record (Completed for an agenda item when a plan may not be necessary)

Topic:

Discussion:

Decision:

A discussion record may or may not lead to a plan.

Discussion Record








4. YMCA Action Plan

5. Lock on door Discussion RecordAdditional Topics:

6. Drive own car Discussion Record


All responses are recorded on the agenda at the meeting.

Planning Together


AgendaPersonal TopicsAction Plan

Discussion RecordPlanning

Questions

Planning Partner

Partner List

Profile

Yes No

Individual Planning Questions

Does my plan match - (If any item is marked no, discuss at

the meeting).

What makes me happy?

My dreams?

People that I like?

Where I want to live?

Things I like to do?

Ways to travel?

Having my own money?

My checking account?

How I contribute?

New things I want to learn?

My work?

Support I need?

People who support me?

Yes NoTeam planning questions If any item is marked yes, please address at the planning meeting.

Are there any unfinished tasks from my plan that are not yet completed?

Are there any current actions and supports that are in conflict with what’s most important to me?

Are there any conflicts in my plan that create a health and safety concern?

Does any team member have an objection to any actions or supports in my plan?

Do I need financial planning or benefits counseling in order to maximize resources?

Am I at risk of exceeding financial resource limits?

Team Planning Questions

Planning Together

Profile




QuestionsAgreement


Agreement PageSignatures of team members who agree to help me with my plans as decided this day:

Individual Date

Case Manager Date

Guardian/ Authorized Representative Date

Team Member Relationship Date





Names of team members who contributed to my plans and were not here for planning

Comments:

Planning Together

The Support Summary


Profile


Discussion Record

AgreementPlanning Questions

Support Summary


Home Living Start/End Provided by

How Often?

How Long?

Weekly Total

Morning Routine: Mark likes to wake up at 7:30am each morning by his alarm clock. He likes to shave before breakfast and needs physical support to do so. He…

01/01/08 Residential Provider

Daily 1 hour 7 hours

What have we learned or has changed with home living? 1

2

3

4

The Profile focus areas are found on the Support Summary and supports are based on the preferences and needs of the individual.


How Often? How Long?

Weekly Total




What have we learned or has changed with home living? 1

2

3

4

Providers record the start date and schedule.

Action Plan

Keeping Track

Profile



QuestionsAgreementSupport Summary


Responsibility


Action Plan

Profile





Keeping Track

The Provider Support Summary Checklist

Support Summary Checklist


The Provider Support Summary Checklist

Provider Support Summary ChecklistMonth: ___________ Year: _________ Provider: _________________ NPI: ___________ Date Revised ____________

Plan

How Often?

Routine Supports

Health and Safety Supports

Achieving Goals

Key:initials= support providedn = not provided by DSPc = chose not to participatea = absento = incident (see supporting documentation)

Signatures and initials of all responsible for providing supports:___________________________________ _________ ________ _____________________________________

________

___________________________________________ ________ _____________________________________ ________

Brief plan descriptions and plan numbers are copied from the Support Summary onto the checklist.

One per provider per month, updated when changes occur.

Action Plan

Profile





Keeping Track

Support LogSupport Summary Checklist


Support Log

Support Log for ____________________________Date Details

Support Log

When Supports are not provided as agreed, the reason is recorded on the Support Log.

Action Plan

Profile





Keeping Track


Learning Log


Support LogLearning Log

Learning LogDate What did the person do?

(what, where, when, how long?)What was there?(name of people supporting the person, friends and others)

What did you learn about what worked well? What did the person like about the activity? What needs to stay the same?

What did you learn about what didn’t work? What did the person not like about the activity? What needs to be different?

When changes are needed, the Learning Log helps team look more closely to identify what needs to change.

Action Plan

Profile





Keeping Track


The ISP Change NoteISP Change Note



Information

Individual:

Medicaid Number:

Provider:

Case Manager:

Start Date:Individual Support

Plan Dates: to

Instructions

1. Identify the desired outcome or outcomes that are changing.2. Indicate if the outcome was achieved.3. Describe changes needed or requested 4. Obtain signatures from the individual/guardian and all affected providers.5. Submit to case manager (with an ISAR if hours are changing) 10 days prior to start date. 6. Once signed by case manager, all affected providers update Provider Support Summary and Checklist.

Desired Outcome/s

Previous outcomes:Outcome Achieved? Changes/Additions (if any):

Mark is… Yes No

Mark is… Yes No

Describe changes:

ISP Change Note

Previous outcomes are replaced with newly chosen outcomes, an ISAR is included when hours change.

A team approach is needed.

Action Plan

Profile





Keeping Track


Quarterly ReviewsISP Change

Note



Quarterly Reviews


How Often?

How Long?

Weekly Total




What have we learned or has changed with home living?

1 Looking at all of Mark’s home living supports, we have learned that… 2

3

4

The quarterly review occurs directly on the Support Summary.


How Often?

How Long?

Weekly Total


01/01/08END 2/19/08

Residential Provider


What have we learned or has changed with home living?

1 Looking at all of Mark’s home living supports, we have learned that…


Daily 1.5 hours 10.5 hours

2

3

4If an ISP Change Note was approved during the quarter the box is checked and the totals are updated. Previous instructions are “ended.”

__________________________

M. Green 02/19/08

Action Plan

Profile





Keeping Track


ISP Change Note



This concludes the planning process review.

You may contact your Community Resource Consultant with any

questions you have during the planning process.

Any questions?

Quarterly Reviews

Documents

Virginia’s Person Centered Planning Process. The Five Steps of Planning Sharing Information: Listening Choosing Partners: Community Planning Together: