1. Person-Centered Planning Overview for Providers & Case Managers
PLANNING IS A WAY OF FIGURING OUT WHERE SOMEONE IS GOING AND WHAT KIND OF SUPPORTS THEY NEED TO GET THERE
2015

2. Goals for Today Review of person centered planning cornerstones.
Discussion of caseworker and provider roles and responsibilities in the PCP process.
Learn about the process from start to finish.
Quickly cover the 5 service accomplishments – the cornerstones
Any questions before we get started?

3. Purpose of Planning & What to Remember
It’s about…
discovering peoples capacities
creating a vision for a future
developing the supports
building community connections and relationships
increasing valued roles
PRESENCE, CHOICE, COMPETENCE, RESPECT, COMMUNITY PARTICIPATION
Lisa Slide -Person centered thinking – a commitment to know the person and seek to understand, willingness to be guided by the person, flexibility, creativity, about what
might be possible- what brings out the good in the person?

4. Person-Centered Planning Regulatory Requirements
Required planning process for adults receiving developmental services in Maine.
Meets regulatory requirements, addresses resource allocation, communicates changes, and ensures consistency and accountability.
Involves identifying and describing needs, goals and support services for person to live meaningful and self-directed life.
Individual and their families direct the person-centered planning process.
Goals are person-focused and personally defined.
See Statue 34 B
§5470-B. Personal planning
1. Right to personal planning.  Every adult with an intellectual disability or autism who is eligible for services must be provided the opportunity to engage in a personal planning process in which the needs and desires of the person are articulated and identified.
MaineCare Section 21 & 29 also require a planning process in order to be given authorization to bill for providing services– Waiver applications are in the process of a rewrite
- includes information on components of the plan and what the plan needs to contain
Section 13 Targeted Case Management also refers to required planning

5. Who is the PCP Process For?
The PCP process must be used for all …
WAIVER Section 21 and Section 29 members and people on those wait lists.
ADW members receiving DS case management.
Non-waiver people who only receive DS case management.
Limited Benefits or Non-MaineCare people who only receive DS case management (state cm only.)
Adults with ID/MH receiving Mental Health or Children’s case management and getting Section 21/29 Waiver.
ADW = Adults with Disabilities Waiver

6. Who is this NOT for? People who reside in … ICF/IID Nursing Group
Anyone who resides in a Nursing Facility
The Plans will be done by the facility they live in
ICF IID – at this point some have received training in the new PCP process- their caseworkers may choose to use the new process or an enhanced version

7. Case Managers as Plan Coordinators
PCP process has been streamlined with a refocus on the person…
Case Managers coordinate the process and ensure requirements are met.
Provider Agencies are MaineCare Service Planners (home, community, employment/career.)
Plans are entered into EIS as an assessment, providing ease of access and continuity of where items are tracked.
The PCP process was changing and with it OADS has had to adapt how the plans are supported by caseworkers.

8. Why CMs as Plan Coordinators?
Center for Medicare and Medicaid Services
Conflict Free Case Management
Need for informed choice and control by the person
No conflict between PCP and being paid for a service
Talk thru these bullets
Including current coordination by an agency

9. Person-Centered vs. System-Centered by Dr. Beth Mount
As you plan remember the inherent tension between systems and people…
Acknowledge the tension and remember that people come first…
Watch the 2 minute video by Dr. Mount and ask people to remember throughout the day that there will be a tension in the work we do

10. Case Management is… A “key” or “linchpin” service
Case managers act as an agent of the state human service system and an agent of the individual (first) and family.
The “system” needs case management to keep the world running.
The individual and family rely on case management to help them build and sustain lives.
Robin Cooper, NASDDS
Robin E. Cooper, NASDDS, April 2013 – this information comes from Robin Cooper
Another way would be to think of yourself as a representative vs. an agent…

11. Who is Involved in Planning?
Who might be there?
Person
Guardian, family, friends
Correspondent (OAB)
Caseworker (MANDATORY)
Agency staff
community, work/career and home
Professionals involved – OT, PT, therapist, doctor
DRC Advocate can be invited if Person wants
The Person chooses who to invite, when and where to meet, who facilitates, what’s on the agenda.
The person may choose to not attend but must be involved in service planning- it is the caseworker and service responsibility to work with the person to feel comfortable in their own meeting- make it a meeting they want to attend

12. Your Role in the PCP Process… Robin Cooper, NASDDS
For the person and family all providers….
Engage in high quality, person-centered planning that keeps the full focus on the person
Provide information, assistance and navigation of community resources
Provide knowledgeable and thoughtful strategies to assist people with what is important to and important for them on behalf of…
Be the front person for solving system problems of outcomes and quality on behalf of…
Acknowledge the workload of case workers, the need to seek Supervisor and clerical support as you are able.

13. Your Role in the PCP Process Robin Cooper, NASDDS
For the systems management Case Managers…
Are the front line on coordinating, monitoring, quality compliance, outcomes and health & safety
Uphold key Medicaid requirements
Ensure informed choice and freedom of choice
Assure rights are protected

14. The Four Phases to Planning
Phase One: Process Coordination Part 1
The Case Manager works with the person to:
Determine when and where meeting will occur, who will be invited, begin developing agenda, determine facilitator
Send out notices/invitations
Ask if the person wants a DRC Advocate, invite as decided

15. The Four Phases to Planning
Phase One: Process Coordination Part 1
The Case Manager will also:
Secure a meeting space
Ensure Service Planning & Goal Descriptions are entered by agency 30 days prior to plan meeting in EIS
Review Reportable events, IST, Safety Plan, Severely Intrusive Plan, if applicable
Begin working on the Face Sheet

16. The Four Phases of Planning
Phase Two: Service Planning
The Service Provider (home, community, work/career) MUST talk with the person to develop Service Descriptions and Goals for each MaineCare Service provided.
The Case Manager MUST talk individually with the person to develop Ancillary and Case Management Service and Goal Descriptions.
Service Planning comes from understanding the person’s capacities, needs, desires, interests and goals for the next year.
Based on conversations with the person and support staff the Service Providers will complete the required descriptions in EIS for MaineCare Services.

17. What is a Goal? An outcome the person wishes to achieve and is…
Written in plain language
Observable- you can “see” it
About what the person wants to do (important to the person not for the person)
A balance between detail and open-endedness
Gives meaning to the Person’s life
Connects to one of the 5 Accomplishments
Page 25 of PCP Instruction Manual

18. What a Goal is Not… It is not a Service Description…
or a “Hab Plan” or Plan of Care…
or to measure percentages of success or number of trials.
It is not always an activity that relates to the services described…
or a “program.”

19. The Four Phases of Planning
Phase Three: Process Coordination Part 2
The Case Manager….
Ensures EIS process and service/goal descriptions are complete.
Reviews Assessments/Forms for themes, conflicts, issues and resolve prior to plan meeting.
Completes Profile section of Personal Plan Narrative.
Meets with the Person/Guardian to review Service & Goal Descriptions submitted and ensure they reflect the Person’s informed choice of service provider, supports and meaningful goals.
Works with Person/Guardian to identify any sensitive issues and makes plan to address them outside of the plan meeting.
Finalizes meeting agenda with Person/Guardian.
Documents discussion and review of informed choice in the Personal Plan Narrative “Summary of Process Coordination.”

20. Reviewing Service & Goal Descriptions with Person & Guardian
The Case Manager…
Meets with the person (and guardian) without the agency present prior to the Plan Meeting to:
Discuss proposed Home, Community, Work/Employment, Career Planning, Ancillary, Case Management, Assistive Technology Service & Goal Descriptions (can print and bring Descriptions from EIS)
Discuss past year, what is important to and for the person
Discuss upcoming year, what they want and need to do
Review (and document) choice of services available to them through the Waivers and ensure they understand choice of providers, including case management
Cover required conversations and any pre meeting items, such as sensitive issues, agenda, time, place, facilitation, etc.

21. The Four Phases of Planning
Phase Four: Personal Plan Meeting
The Focus Person and their team meet to review proposed plan as a whole, discuss how to coordinate goals across service areas, and plan how to enhance opportunities for community inclusion.
Providers Role:
Attend meeting to participate in coordination of goals across service areas. Review the MaineCare Service Descriptions submitted for the Service Area(s) they cover.
Case Manager Role:
Facilitates meeting agenda (unless person chooses another facilitator or facilitates them-self, including items on Narrative.
Ensure any changes to Service & Goal Descriptions identified at the meeting are made in EIS (by the Provider of Service) prior to end of plan.

22. The Plan Meeting
The meeting is a time to put all the pieces together….
Review the pre-determined Agenda
Go over ground rules, time, housekeeping, facilitation & note-taking
Discuss Service Planning – agencies must attend and review goals and services (Home, Community, Work, Career)
Goals the person wants to achieve
Discuss required conversations
Employment, guardianship, health & safety, unmet needs, communication, coordination of goals and services across service areas, communication
What’s been proposed - does anything need to change?

23. Required Discussions
Health & Safety (health risks, behavioral risks and personal safety)
Employment (plan for and potential barrier(s) to)
Guardianship (need, type and alternatives)
Coordinating goals across service areas
Communication (style and barriers to communication)
Unmet Needs (dental, housing etc.)
More info on required discussions can be found on page 16 of the PCP Instruction Manual

24. Required Timelines
Service Planning begins prior to date the Service & Goal Descriptions must be completed in EIS.
Completed Service & Goal Descriptions in EIS occurs at least 30 days prior to scheduled Personal Plan Meeting.
Personal Plan Meeting must be no more than 45 calendar days prior to the Effective Plan Date.
Effective Plan Date is a FIXED month and day (does not change) from year to year. PCP Plan is complete** and approved by Case Manager.
Waiver Reclassification Date – This is a FIXED month and day (does not change) from year to year. Complete** PCP must be received by the Resource Coordinator 30 calendar days prior to Re-class Date. The plan should be less than six (6) months old at the time of the member’s eligibility determination or redetermination.

25. Effective Date
The date upon which services described in the plan start is fixed and in force for 365 calendar days. The effective plan date is the same day each year.
The new plan cannot be more than 365 days from the current plan.
The planning meeting must be held no more than 45 calendar days prior to the effective plan date.
The Plan Meeting date is NOT the same as the Effective Plan date.
Waiver Re-class – plan cannot be older than 6 months from Waiver date.

26. Plan is Complete** when…
The Face Sheet, Personal Plan Narrative, Service Descriptions and Goal Descriptions are completed for each service and entered into EIS; and that all required signatures approving the plan have been obtained on the Face Sheet. The PCP must have been reviewed and approved by the Case Manager and documented in the Final Case Management Approval.

27. PCP Documentation The Home Supports Service and Goal Descriptions
The Service Provider is responsible for completing, in EIS, 30 days prior to the Plan Meeting….
The Home Supports Service and Goal Descriptions
The Community Supports Service and Goal Descriptions
Work/Employment/Career Supports Service Descriptions

28. PCP Documentation
The Case Worker is responsible for completing in EIS…
The Personal Plan Face Sheet
The Personal Plan Narrative
Case Management Service Description
Ancillary Service Description
Assistive Technology Service Description???

29. Where to Document an Unmet Need
A need (not a desire) will be identified and treated as an “unmet need” when…
A. It has not been met within the time frame set by the team, or
B. Whenever the team has determined, at any point in the process, that a resource required to meet the need is not available.
Document unmet needs on the Face Sheet, Personal Plan Narrative and Service Description Narrative, develop an interim plan in the Goal Description, and update the Services and Supports Assessment (V6) in EIS.
Page 27 of the PCP Instruction Manual

30. PCP Documentation
Before the Effective Plan Date the Case Manager will…
Finalize the Personal Plan Face Sheet.
Finalize the Personal Plan Narrative .
Finalize CM and Ancillary Service Descriptions.
Ensure Home, Community, Work/Career, Service Descriptions are accurate (if changes were decided on at time of the Planning Meeting.)
Print a copy of the entire plan for Person/Guardian to review and obtain required signatures on Face Sheet.
Complete Final CM Approval in EIS.
Send copy of signed Face Sheet to each provider and alert agencies that the plan is complete.
Provide signed copy of plan to Person and Guardian.

31. Assessing Focus Person Satisfaction w/ Personal Plan
Assessing satisfaction occurs throughout the planning process….
Case Manager and Service Providers ask the Person throughout the planning phases:
How was the planning process for you? What would you change and what did you like?
How is the plan going? Are you getting the supports to do the things you want and need? How satisfied are you with what you are receiving?
Are you accomplishing your goals?
Each Plan must include a description of how the Team will evaluate ongoing satisfaction.
Case Manager conducts a review of the PCP every 90 days, which may or may not be part of accessing satisfaction
See PCP Instruction Manual pages 18 & 19

32. Remember it’s all about the Person!
Ask Yourself
In Person-Centered Planning am I assisting people to...
Make and sustain connections, memberships and friendships?
Enhance their reputations?
Increase their active involvement in the life of communities?
Develop and invest their gifts and capacities?
Increase choice and control in their lives?
Remember it’s all about the Person!

33. Thank You for Being Here!
QUESTIONS?
Use the PCP Instruction Manual and Forms with Instructions online to help answer your questions.
Lean on your Supervisor and the PCP Groups/Forums for support.
Remember…It is one plan at a time!