PersonCentered Support Plan PCSP

1
Person-Centered Support Plan (PCSP)
DSPDs Process For Tracking Eligibility
,
Planning and Services
Assessing
Planning
Intake and Waiting List
Dis
-
Enrollment
Evaluating
Implementing
2
Purpose

• Understand changes, why these change why now.
• Learn how to link assessments to plans.
• Learn the parts of the comprehensive Action
  Plans.
• Clarify expectations of contracted providers in
  the process

3
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!

4
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

5
Accomplishments continued

• Link assessments directly to the plan
• Assessments strengthened
• multi-method
• multi-source
• multi-occasion
• Emphasize personal goals and address quality of
  life issues
• 8 Health and safety addressed in the context of
  the persons life

6
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

7
PCSP Outline Part I.

• Part I. Identifying Information and Background
• A. Background
• B. Person-Centered Profile
• C. Review of Previous Year
• Goals, Paid Services, and Support Strategies
• D. Assessments
• TO/FOR Lists

8
PCSP Outline Parts II - IV.

• Part II. Action Plan
• A. Personal Goals
• B. Additional Supports and Services
• C. Purchased Services
• Part III. Budget
• Part IV. Signatures

9
DSPD Assessments

• OT, PT, Speech
• ABI specific assessments
• CBIA
• ICAP
• Monthly Summaries
• Essential Lifestyle Plan
• Informal questioning / interviewing
• Education
• Voc Rehab
• Person-Centered Profile (new)

• Functional Behavior Assessments
• Rights Assessments
• Supports Intensity Scale
• Risk Assessment
• Social History Summary
• Psychological Evaluation
• Developmental Assessment
• Psychiatric Mental Health
• Medical evaluations

10
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

11
Person-Centered Profile

• 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

12
Person-Centered Profile Handout (outline)

• 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

• Introduction
• Likes/dislikes
• Communication style/preferences
• Contributions/ Relationships
• Hopes/Dreams/Fears and Personal Goals

13
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.

14
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)

15
Michael Smull

• Balance between important TO and FOR
• Balance between Choice and Responsibility
• Happy and dead are incompatible, alive and
  miserable is unacceptable

16
(No Transcript)
17
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)
  

18
B. PCSP Meeting1. Review the summary of
assessments

• Quick brief review of key issues including
• Person-Centered Profile
• Last years 1) goals, 2) purchased services, 3)
  support strategies, and
• 4) other supports
• Others critical changes and events

19
B. PCSP Meeting2.      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!

20
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

21
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

22
Personal GoalWhat makes it personal?

• Personal is
• What the person wants
• What is important to the person
• What is the persons 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

23
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 persons life
• The Goal is not
• the process (supports and services)
• the result of the Support Strategy

24
Personal Goal focus

• Maintain something good
• Avoiding something bad
• Accomplishing something good

25
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

26
 
Selecting and Writing Goals List of Current
Goals that are Most Important TO The Person
       
Jackies 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  
27
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.

28
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 hasnt already happened
• might include items from the FOR list

29
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

30
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 Work Who Is Providing The Support? Job
coach Start Date 4/1/2007 End Date
4/31/2008 Details Teach Jackie how to
independently assess task completion and quality.
Is this a Paid Support? Yes Provider Jobs R
Us Service Code/Description SEI Support
Strategy Yes Monthly Summary Yes For
Item(s) 7   Support Item 2 Work Related
Social Skills Who Is Providing The Support? Job
coach Start Date 4/1/2007 End Date
4/31/2008 Details Train Jackie to successfully
deal with criticism from coworkers. Is this a
Paid Support? Yes Provider Jobs R Us Service
Code/Description SEI Support Strategy No
Monthly Summary Report problems as
needed For Item(s) s 1 4
31
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

32
B Additional Supports and Services (Not Goal
Related)    
X
 
X
 
 
Standard Supports  
  Support Medical Treatment Who Is Providing
The Support? Dr. Imadoctor, IHC Start Date
4/1/2007 End Date 4/31/2008 Details 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 4/31/2008 Details Provide coordination
with supports and services, eligibility
evaluation, and other things as needed. X Is this
a Paid Support? No
33
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

34
Whats changed?

• Standardized process document
• Help with Person Centered Profile
• Goal Personal Goal (not day/residential)
• Action Plan expanded
• Do not come to the meeting with the answer (goal
  supports)
• Come to the meeting with good information about
  the person and as a team member, use creative
  problem solving, to address quality of life and
  health/safety

35
Guiding principle

• The best (most effective efficient) way to
  address a persons needs is in the context of
  trying to provide the life they want
• Whats next?
• Practice with mentor over next 6 weeks
• Apply PCSP process in USTEPS

36
the end