Virginia’s Person Centered Planning Process

The Four Phases of Planning Sharing Information Getting ready for planning Planning Together Keeping Track

As a first step you share your “essential information,” which includes your standard assessment. This is completed by your support coordinator when you first seek paid supports in Virginia. Sharing Information Essential Information

Profile Essential Information Sharing Information The Profile questions help describe your life. The Agenda questions lead to your vision of the future. Anyone you choose can help to complete your Profile. Profile

Profile QuestionsAgenda Questions 1. What are your gifts and talents?What gifts and talents would you like to use more? share with others? 2. Tell us about the community where you live.What would make your community life better? 3. Tell us about the people you know.Are there any relationships you would like to change? Develop? 4. What is your home like?What changes are needed and what other changes Might improve your living arrangement? 5. Do you think that you have enough privacy?Would you like more or less privacy? 6. What things do you enjoy doing most?What would you like to do more often? 7. What things do you least enjoy doing?Which of these things would you like to change and how? 8. What do you do for fun and relaxation?What might improve your ability to have fun and relax (and with whom)?

The Planning Partner Sharing Information Essential Information Profile Planning Partner

Getting ready for planning Once the essential information and the profile are complete, it’s time to get ready for planning. Essential Information Profile Planning Partner

Getting ready for planning An Agenda Essential Information Profile Planning Partner Agenda

Agenda Items Consider what was identified with the agenda questions. Which topics do you want to discuss at the meeting? Leave out any items you do not wish to discuss at that time. Decided before planning meeting. Action Taken Discussion record, routine supports, achieving goals or health and safety supports. Decided during planning meeting. 1. Review of the profile, standard assessment and positive description of the person. 2. Personal Goals, change if needed. Additional Topics:

Getting ready for planning Essential Information Profile Planning Partner Agenda The Personal Topics List Personal Topics

Topics not for the meeting Consider each specific point identified in the Profile that will NOT be on the agenda. 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:

Essential Information Now that the agenda and personal topics list are complete, it’s time to schedule planning. Planning Together Profile Planning Partner Agenda Personal Topics

If needed, your planning partner can help you to schedule your meeting. Planning Together Essential Information Profile Planning Partner Agenda Personal Topics

Once the meeting is set, you invite others including friends, family and all providers. Planning Together Essential Information Profile Planning Partner Agenda Personal Topics

Your team reviews your essential information and profile to determine routine and health and safety supports. Your team will also work together in action planning. Planning Together Essential Information Profile Planning Partner Agenda Personal Topics

From the agenda the team chooses one of four options for their response. Planning Together Essential Information Profile Planning Partner Agenda Personal Topics

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

Action Plan for Achieving Goals Plan begin date: ___________________ 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 Responsible How Often or By When Date Completed Comments:

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

Planning Together Planning Questions Essential Information Profile Planning Partner Agenda Personal Topics Action Plan Discussion Record Individual and Team Planning Questions

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?

Planning Together The Agreement Profile Essential Information Planning Partner Agenda Personal Topics Action Plan Discussion Record Planning Questions Plus absent contributors Agreement

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 Planning Partner Agenda Personal Topics Action Plan Discussion Record Agreement Planning Questions Support Summary

Provider Support Summary Plan Dates: _________to_______ Provider: ___________ NPI: ____________ Date Revised:_________________ Support providedHow to provide supportsWhen? days How long per day? Weekly total minutes or hours Routine Supports Health and Safety Supports Achieving Goals Total weekly hours Total additional hours if approved Grand Total ______hours

Action Plan Keeping Track Profile Planning Partner Agenda Personal Topics Discussion Record Planning Questions Agreement Support Summary Essential Information Now that the plan is ready, your team works together to help you stay on track with achieving your goals.

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

Provider Support Summary Checklist Month: ___________ Year: _________ Provider: _________________ NPI: ___________ Date Revised ____________ PlanHow Often? Routine Supports Health and Safety Supports Achieving Goals Key: x = support provided n = not provided by DSP c = chose not to participate a = absent o = incident (see supporting documentation) Support Provider Signatures and initials: ___________________________________________ ________ _____________________________________ ________

Action Plan Profile Planning Partner Agenda Personal Topics Discussion Record Planning Questions Agreement Support Summary Essential Information Keeping Track Support Summary Checklist The Plan Change and Quarterly Review Tool Plan Change and Quarterly Review Tool

ISP Changes and Quarterly Review Tool Provider: ___________ NPI: ___________ Plan Dates: Review Dates: Is this being completed for a ISP change or quarterly review? Check one: ISP Changes or Quarterly Review 1 st 2 nd 3 rd 4 th Description of the person: Health update (medications/appointments): Significant events (celebrations/struggles): Review of desired outcomes for health and safety and achieving goals Desired outcomesOutcome achieved?Describe progress or changes: 1. Yes No 2. Yes No 3. Yes No Have any changes occurred during the past quarter? Yes No(If yes, briefly summarize changes). Are any additional changes needed or requested at this review? Yes No(If yes, include change notes with review and update provider summary and checklist). Does the individual continue to be pleased with all plans? Yes No Signatures Date: Individual: Guardian/Authorized Representative Case Manager: Initiating/Completing Provider:

Action Plan Profile Planning Partner Agenda Personal Topics Discussion Record Planning Questions Agreement Support Summary Essential Information Keeping Track Support Summary Checklist Plan Change and Quarterly Review Tool The Daily and Learning Logs Daily and Learning Logs

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? Daily Log for ____________________________ DateEvent

*Action Plan *Profile *Planning Partner *Agenda *Personal Topics *Discussion Record *Planning Questions *Agreement *Support Summary *Essential Information *Support Summary Checklist *Plan Change and Quarterly Review Tool *Daily and Learning Logs This concludes the planning process review. You may contact your Community Resource Consultant with any questions you have during the planning process. Keeping Track Any questions?