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 to those who know you best.

Sharing Information Essential Information Identifying Information Address: 198 Evergreen WaySex: M F Marital Status: S M City/Zip: Any town, VA DOB: 09/05/1962 Home phone: SSN #: 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/RepresentationPhone:Fax: Guardian: N/A address: Family Member: Gloria Citizen address: 1008 Elm Street Any town, VA Authorized Representative: N/A address: Power of Attorney: N/A address: Emergency contact: Marshall Green address: 198 Evergreen Way Any town, VA 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 Essential Information

Sharing Information Profile Profile QuestionsAgenda 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 description of a good life. Please provide a description of a good life for you. Profile

Ask if someone who supports you has training in person-centered thinking. Tools are available to help us think in different ways, and to help us better understand. There are sample questions that can help.

Essential Information 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 Living Relationships Work and Alternates to Work Contributions Money Transportation Health and Safety Learning Focuses on our vision of what’s needed for a good life:

Choosing Partners Essential Information Community Profile

Choosing Partners Essential Information Partner List Profile Choosing Partners The 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.

Essential Information Planning Partner Partner List Choosing Partners Profile My Planning Partner: Things to do with my planning partner: The Planning Partner.

Choosing Partners Essential Information 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 List Planning Partner

Getting Ready Essential Information Partner List Planning Partner Self-direction Profile

Getting Ready Essential Information Agenda Partner List Planning Partner Profile Agenda Agenda Items Decided before planning meeting. Action Taken Decided during planning meeting. New experiences, successes and profile updates. Personal Goals/Outcomes Additional Topics: 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. Essential Information Profile Agenda Partner List Planning Partner

Getting Ready Essential Information Agenda Personal Topics Partner List Planning Partner Profile Personal Topics Topics not for the meeting Consider 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 Taken Discussion 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 Essential Information Agenda Personal Topics Partner List Planning Partner 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 Essential Information Agenda Personal Topics Partner List Planning Partner Profile A team planning process. Selected and invited by you, with help from your planning partner and support coordinator.

Essential Information Planning Together Agenda Personal Topics Partner List Planning Partner Abilities Profile

Essential Information Profile Partner List Planning Partner Agenda Personal Topics Planning Together

Essential Information Profile Partner List Planning Partner Agenda Personal Topics Agenda Agenda Items Decided before planning meeting. Action Taken Decided during planning meeting. New experiences, successes and profile updates. Personal Goals/Outcomes Additional Topics: 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 Essential Information Agenda Personal Topics Partner List Planning Partner Profile

While some supports may not change from year to year, how they are provided will change based on your changing preferences. Planning Together Essential Information Agenda Personal Topics Partner List Planning Partner Profile

For each agenda item, the team chooses at least one of four options for each response. Planning Together Essential Information Agenda Personal Topics Partner List Planning Partner Profile

routine supports or health and safety supports or action plans or a discussion record

Routine Supports Agenda Agenda Items Decided before planning meeting. Action Taken Decided during planning meeting. New experiences, successes and profile updates. Personal Goals/Outcomes 1. HaircutsRoutine Support 2. TransportationRoutine Support 3. Walking and falling 4. YMCA 5. Lock on door Additional Topics: 6. Drive own car 7. ShoppingRoutine Support

Health/Safety Supports Agenda Agenda Items Decided before planning meeting. Action Taken Decided during planning meeting. New experiences, successes and profile updates. Personal Goals/Outcomes 1. HaircutsRoutine Support 2. TransportationRoutine Support 3. Walking and fallingHealth/Safety 4. YMCA 5. Lock on door Additional Topics: 6. Drive own car 7. ShoppingRoutine Support

Action Plan Agenda Agenda Items Decided before planning meeting. Action Taken Decided during planning meeting. New experiences, successes and profile updates. Personal Goals/Outcomes 1. HaircutsRoutine Support 2. TransportationRoutine Support 3. Walking and fallingHealth/Safety 4. YMCAAction Plan 5. Lock on door Additional Topics: 6. Drive own car 7.ShoppingRoutine Support

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 Steps Who will do what to achieve this outcome? Who’s ResponsibleHow 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 Agenda Agenda Items Decided before planning meeting. Action Taken Decided during planning meeting. New experiences, successes and profile updates. Personal Goals/Outcomes 1. HaircutsRoutine Support 2. TransportationRoutine Support 3. Walking and fallingHealth/Safety 4. YMCAAction Plan 5. Lock on doorDiscussion Record Additional Topics: 6. Drive own carDiscussion Record 7. ShoppingRoutine Support

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

Agenda Agenda Items Decided before planning meeting. Action Taken Decided during planning meeting. New experiences, successes and profile updates. Personal Goals/Outcomes 1. HaircutsRoutine Support 2. TransportationRoutine Support 3. Walking and fallingHealth/Safety 4. YMCAAction Plan 5. Lock on doorDiscussion Record Additional Topics: 6. Drive own carDiscussion Record 7. ShoppingRoutine Support All responses are recorded on the agenda at the meeting.

Planning Together Essential Information Agenda Personal Topics Action Plan Discussion Record Planning Questions Planning Partner Partner List Profile YesNo 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?

YesNo Team 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 Essential Information Agenda Personal Topics Action Plan Discussion Record Planning Questions Agreement Partner List Planning Partner Agreement Page Signatures of team members who agree to help me with my plans as decided this day: IndividualDate Case ManagerDate Guardian/ Authorized RepresentativeDate Team MemberRelationshipDate Team MemberRelationshipDate Team MemberRelationshipDate Team MemberRelationshipDate Team MemberRelationshipDate Names of team members who contributed to my plans and were not here for planning Comments:

Planning Together The Support Summary Essential Information Profile Agenda Personal Topics Action Plan Discussion Record Agreement Planning Questions Support Summary Partner List Planning Partner

Home Living Start/EndProvided 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… 01/01/08Residential Provider Daily1 hour7 hours What have we learned or has changed with home living? The Profile focus areas are found on the Support Summary and supports are based on the preferences and needs of the individual.

Home Living Start/EndProvided 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… 01/01/08Residential Provider Daily1 hour7 hours What have we learned or has changed with home living? Providers record the start date and schedule.

Action Plan Keeping Track Profile Agenda Personal Topics Discussion Record Planning Questions Agreement Support Summary Essential Information Responsibility Partner List Planning Partner

Action Plan Profile Agenda Personal Topics Discussion Record Planning Questions Agreement Support Summary Essential Information Keeping Track The Provider Support Summary Checklist Support Summary Checklist Partner List Planning Partner

The Provider Support Summary Checklist Provider Support Summary Checklist Month: ___________ Year: _________ Provider: _________________ NPI: ___________ Date Revised ____________ PlanHow Often? Routine Supports Health and Safety Supports Achieving Goals Key: initials= support provided n = not provided by DSP c = chose not to participate a = absent o = 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 Agenda Personal Topics Discussion Record Planning Questions Agreement Support Summary Essential Information Keeping Track Support Log Support Summary Checklist Partner List Planning Partner Support Log

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

Action Plan Profile Agenda Personal Topics Discussion Record Planning Questions Agreement Support Summary Essential Information Keeping Track Support Summary Checklist Learning Log Partner List Planning Partner Support Log Learning Log

DateWhat 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 Agenda Personal Topics Discussion Record Planning Questions Agreement Support Summary Essential Information Keeping Track Support Summary Checklist The ISP Change Note ISP Change Note Partner List Planning Partner Support Log Learning Log

ISP 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 Agenda Personal Topics Discussion Record Planning Questions Agreement Support Summary Essential Information Keeping Track Support Summary Checklist Quarterly Reviews ISP Change Note Partner List Planning Partner Support Log Learning Log Quarterly Reviews

Home Living Start/EndProvided 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… 01/01/08Residential Provider Daily1 hour7 hours What have we learned or has changed with home living? 1 Looking at all of Mark’s home living supports, we have learned that… The quarterly review occurs directly on the Support Summary.

Home Living Start/EndProvided 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 END 2/19/08 Residential Provider Daily1 hour7 hours What have we learned or has changed with home living? 1 Looking at all of Mark’s home living supports, we have learned that… 02/19/08Residential Provider Daily1.5 hours10.5 hours If 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 Agenda Personal Topics Discussion Record Planning Questions Agreement Support Summary Essential Information Keeping Track Support Summary Checklist ISP Change Note Partner List Planning Partner Support Log Learning Log 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