The Clearwater CountiesJune 2015

PERSON-CENTERED PLANNINGFOR PROVIDERS

The system is based on transparency, honesty, communication and teamwork;

This is a TEAM effort, not the SSA in isolation or the PROVIDER in isolation;

Explorations (assessments) are a TEAM effort, the SSA has the lead in completing the exploration with input from the other members of the team;

Day and residential services are partners in supporting the person to have a full and WHOLE life; we are looking for outcomes where BOTH locations contribute to meeting the outcome;

Outcomes are a TEAM effort, no-one should be coming to the ISP meeting with the outcomes already built.

THE OPERATIONAL PRINCIPLES

Alan Watts

THE ONLY WAY TO MAKE SENSE OUT OF CHANGE IS TO PLUNGE INTO IT, MOVE WITH IT AND JOIN THE DANCE.

Exploration: gathering assessment information;Identifying risks;Integrating exploration information into the My Vision

Plan (ISP);Developing outcomes;Noting routine services and supports in the Level of

Support section;The Commencement of Services;Documenting;Celebrating the person!

THE CORE COMPONENTS

Underlies the entire need for Person-Centered Planning;

Understanding the themes of the Supports Model will make developing person-centered discovery tools and outcomes easier.

THE SUPPORTS MODEL

OLD Programs Based on needs Facility-based

NEW

Array of supports from which person chooses

Based on needs AND desires

Community-based

THE SUPPORTS MODEL

WHEN learning occurs:During the typical day at times appropriate for the

content of the Outcomes, Support Considerations and Action Steps;

BUT we still include frequency, duration and scope!!!

Measurability is still a value!!!

Person-centered doesn’t mean vague!

NEW MODEL (SUPPORTS)

EXPLORATION: THE ASSESSMENT PROCESS

SSA Rule: The assessment shall identify supports that promote:

•Rights

•Self-determination

•Physical well-being

•Emotional well-being

•Material well-being

•Personal development

•Interpersonal relationships

•Social inclusion and community participation

THREE EXPLORATION TEMPLATES

Children’s;Transitioning Youth; andAdults.

The tool that records pertinent information about the person from the person’s perspective as well as from contributing Team members who know and care about the person. Exploration triggers My Vision Plan discussion and leads to the identification of outcomes and services and supports.

WHO PARTICIPATES IN DEVELOPING THE EXPLORATION TOOL?

Adults The person SSA Family/Guardian Residential provider Employment/Day

provider Others identified by

the person and SSA

Children & Transitioning Youth The person SSA Family/Guardian Residential provider Others identified by the family and SSA

GATHERING PERSON-CENTERED INFORMATION

The Exploration tool tracks the SSA Rule and asks:

What is important TO the person; What is happening in the person’s life

right now; What is important FOR the person; What would enhance the person’s life;

and Balancing important to and important

for.

THE EXPLORATION PROCESS

Gather certain information on the Exploration tool prior to the My Vision Plan meeting.

Records information from: from person’s perspective;from people who know and care about the person;

Facilitated by the SSA;The Exploration triggers discussion for the My

Vision Plan meeting;The updated Exploration tool is distributed to providers, along with the completed ISP, 15 days prior to the ISP start date.

IDENTIFYING RISK

A LIST OF RISKS TO EVALUATE

Fatal Four risks: Aspiration/ChokingConstipationDehydrationSeizures

Financial Exploitation Behavioral challenges Medical (e.g., medication sensitivities,

allergies)

IMPORTANT TO AND IMPORTANT FORTHE RISK BALANCING ACT

What’s Most Important

to the person

Written Instructions

to support risks

INTEGRATING EXPLORATION INTO THE MY VISION PLAN (MVP)

Integrating the Exploration information into the MVP

For each topic, discuss the person’s preferences and decide:

• What does this person want to develop and/or change?

• Are there any obstacles to address?

• Does the person indicate an interest in pursuing other available services, providers, and/or staff?

Integrating Exploration into the MVP

For each topic, discuss the person’s preferences and decide:

• Are there opportunities to enhance the person’s independence, community membership and productivity?

• Are there differences between what this person and the team want to develop and/or change?

• Does the person choose a recurring or one-time support?

• Is an outcome needed?

TAKING TO AND FOR INTO THE MVP

What does the individual choose to do when no one else is around?

What preferences does the individual demonstrate throughout the day?

What would the individual most like to do?

What skills does the individual need to accomplish what they would most like to do?

What does the individual spend his/her free time doing?

How does the individual indicate his/her dislikes?

What seems to motivate the individual?

How does the individual learn new tasks?

• What activities are completed independently or help the individual to be more independent?

• Will the outcomes increase the individual’s independence or improve his/her quality of life?

• What is critical to maintaining the individual’s health, safety and quality of life?

• Does the outcome relate to what the individual wants to be doing/learning now?

• Does the outcome enhance opportunities to develop friendships and social support networks?

OUTCOMES

The MVP:An acknowledgement between the person with disabilities, the County Board and the provider for the valued life OUTCOMES toward which services and supports are aimed;Reflects what is important to and for the person and helps everyone identify and support the person’s hopes and dreams; andSpecifies the routine services and supports the person will receive to keep them healthy, safe and active in their community.

THE MVP

1. If you wouldn‘t write it for yourself, an adult member of your family, or an adult friend, don’t write it for a person you support.

2. There’s only 24 hours in a day – if it is not important, drop it!

3. A person-centered outcome must relate to an important part of life.

PERSON-CENTERED OUTCOMES

James has autism, likes routines, likes repetition, has very short attention span

Old model: James will get rewards for increasing attention to task

New model: James is placed at a grocery store for a job. His job is stamping prices on cans. He wears ear buds and carries a CD player with his favorite music on it. Every 15 seconds, the music stops and a voice says, “James, stamp the cans.”

OUTCOMES IN THE SUPPORTS MODEL

• Outcome: An achievement that the person wants to accomplish.

• Support Considerations: Things that– The person does toward achieving my outcome; – Are necessary to help the person achieve their

outcome; and– Others (supports – paid/unpaid) to help me achieve my

outcome.• Action Steps:- Specific provider tasks to meet the Outcome;- NOT kept in the MVP;- Can and should change based on their effectiveness.

MVP FRAMEWORK

Outcome: A future end result and the reason why it matters to the person.

Support Considerations: Basic steps and tools that help meet the outcome.

Action Steps: The detail addressing the outcome, built to complement the ISP but not stored within it.

MVP FRAMEWORK

• OUTCOME: developed by the person and their team (based on what the person wants)

• SUPPORT CONSIDERATIONS: developed by team

• ACTION STEPS: developed by provider with assistance from the team as needed

FRAMEWORK FOR OUTCOMES

Outcome: My dog Oakley receives her Champion title in the show ring by March 1, 2016 so that I have more friends who share my interests.

Support Considerations: 1. I complete Handler Training;2. I get Oakley’s coat in shape.

FRAMEWORK IN MY LIFE

OUTCOME: I learn to dance by April 1, 2016 so that healthy activities are part of my life.

SUPPORT CONSIDERATIONS:

1. I take dance classes;

2. I go out dancing with friends.

FRAMEWORK IN LATOYA’S LIFE

OUTCOME: I vote in the February 2016 election so that I learn to exercise my rights.

SUPPORT CONSIDERATIONS:

1. I learn what voting mean;

2. I practice at a voting machine;

3. I vote in the February 2016 local elections.

FRAMEWORK IN STEVE’S LIFE

OUTCOME: I plan my own daily schedule by December 1, 2015 so that I make more decisions in my life.

SUPPORT CONSIDERATIONS:1. I learn the concepts of “before” and “after”;2. I cut out pictures of my daily activities from

magazines; 3. I paste the pictures on cardboard and hang

it in my bedroom;4. I tell staff what I am going to do.

FRAMEWORK IN GINA’S LIFE

OUTCOME: I volunteer at a soup kitchen by November 1, 2015 so that I am participating more actively in my community.

SUPPORT CONSIDERATIONS:1. I learn to serve food;2. I learn good hygiene around food; 3. I learn the names of foods;4. I am supported to find a soup kitchen

where I can work.

FRAMEWORK IN SAM’S LIFE

OUTCOME: I check out a self-advocacy group by July 17, 2015 so that I can make more friends.

SUPPORT CONSIDERATIONS:1. I call a variety of self advocacy groups to

find out when their next meeting is;2. Staff assist me to attend a meeting;3. I start a conversation;4. I decide if I would like to attend more

meetings.

FRAMEWORK IN JACKIE’S LIFE

OUTCOME: I learn to point to one of three offered items by September 30, 2015 so that I can communicate what I want.

SUPPORT CONSIDERATIONS:1. Staff will help me build a communication

chart with pictures of my preferred activities, preferred foods, etc;

2. I choose between things I like and I don’t.

FRAMEWORK IN KAREN’S LIFE

OUTCOME: I open a bank account in my name by June 30, 2015 so that I handle my own money.

SUPPORT CONSIDERATIONS:

1. I learn what banking is;

2. I get a name stamp;

3. I open an account and get checks;

4. Staff assist me in doing my banking as needed.

FRAMEWORK IN SUE’S LIFE

OUTCOME: I stay alone in my home for up to three hours at a time by July 1, 2016 so I can be more independent.

SUPPORT CONSIDERATIONS:

1. I learn safety themes for staying alone;

2. I learn about different things to do during my alone time.

FRAMEWORK IN SHARON’S LIFE

OUTCOME: I maintain a job by March 15, 2016 so that I learn the value of work.

SUPPORT CONSIDERATIONS:

1. Staff assist me to identify a job that matches my skills and interests;

2. I am supported at my job site.

FRAMEWORK IN TRACI’S LIFE

OUTCOME: I lose 12 pounds by June 23, 2016 so I am more fit.

SUPPORT CONSIDERATIONS:

1. I join a fitness club;

2. I find a substitute for sugared soda and ice cream drinks;

3. I identify other foods that I need to substitute;

4. I track my weight weekly.

FRAMEWORK IN BILL’S LIFE

Routine services and supports

Level of support:

Documentable, billable services not reflected in the outcomes and support considerations but essential to the person’s day to day life

THE COMMENCEMENT OF SERVICES

PROVIDER DOCUMENTATION

Relationships changeRelationships change

People learn to speak up People learn to speak up

Agencies collaborate in new waysAgencies collaborate in new ways

We learn to live in each others…We learn to live in each others…

CELEBRATING THE PERSON!