Presentation on theme: "Person-Centered Planning Overview for Providers & Case Managers"— Presentation transcript:
1Person-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 THERE2015
2Goals 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 cornerstonesAny questions before we get started?
3Purpose of Planning & What to Remember It’s about…discovering peoples capacitiescreating a vision for a futuredeveloping the supportsbuilding community connections and relationshipsincreasing valued rolesPRESENCE, CHOICE, COMPETENCE, RESPECT, COMMUNITY PARTICIPATIONLisa Slide -Person centered thinking – a commitment to know the person and seek to understand, willingness to be guided by the person, flexibility, creativity, about whatmight be possible- what brings out the good in the person?
4Person-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 planning1. 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 containSection 13 Targeted Case Management also refers to required planning
5Who 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
6Who is this NOT for? People who reside in … ICF/IID Nursing Group Anyone who resides in a Nursing FacilityThe Plans will be done by the facility they live inICF 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
7Case 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.
8Why CMs as Plan Coordinators? Center for Medicare and Medicaid ServicesConflict Free Case ManagementNeed for informed choice and control by the personNo conflict between PCP and being paid for a serviceTalk thru these bulletsIncluding current coordination by an agency
9Person-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
10Case 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, NASDDSRobin E. Cooper, NASDDS, April 2013 – this information comes from Robin CooperAnother way would be to think of yourself as a representative vs. an agent…
11Who is Involved in Planning? Who might be there?PersonGuardian, family, friendsCorrespondent (OAB)Caseworker (MANDATORY)Agency staffcommunity, work/career and homeProfessionals involved – OT, PT, therapist, doctorDRC Advocate can be invited if Person wantsThe 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
12Your 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 personProvide information, assistance and navigation of community resourcesProvide 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.
13Your 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 & safetyUphold key Medicaid requirementsEnsure informed choice and freedom of choiceAssure rights are protected
14The Four Phases to Planning Phase One: Process Coordination Part 1The Case Manager works with the person to:Determine when and where meeting will occur, who will be invited, begin developing agenda, determine facilitatorSend out notices/invitationsAsk if the person wants a DRC Advocate, invite as decided
15The Four Phases to Planning Phase One: Process Coordination Part 1The Case Manager will also:Secure a meeting spaceEnsure Service Planning & Goal Descriptions are entered by agency 30 days prior to plan meeting in EISReview Reportable events, IST, Safety Plan, Severely Intrusive Plan, if applicableBegin working on the Face Sheet
16The Four Phases of Planning Phase Two: Service PlanningThe 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.
17What is a Goal? An outcome the person wishes to achieve and is… Written in plain languageObservable- you can “see” itAbout what the person wants to do (important to the person not for the person)A balance between detail and open-endednessGives meaning to the Person’s lifeConnects to one of the 5 AccomplishmentsPage 25 of PCP Instruction Manual
18What 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.”
19The Four Phases of Planning Phase Three: Process Coordination Part 2The 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.”
20Reviewing 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 personDiscuss upcoming year, what they want and need to doReview (and document) choice of services available to them through the Waivers and ensure they understand choice of providers, including case managementCover required conversations and any pre meeting items, such as sensitive issues, agenda, time, place, facilitation, etc.
21The Four Phases of Planning Phase Four: Personal Plan MeetingThe 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.
22The Plan MeetingThe meeting is a time to put all the pieces together….Review the pre-determined AgendaGo over ground rules, time, housekeeping, facilitation & note-takingDiscuss Service Planning – agencies must attend and review goals and services (Home, Community, Work, Career)Goals the person wants to achieveDiscuss required conversationsEmployment, guardianship, health & safety, unmet needs, communication, coordination of goals and services across service areas, communicationWhat’s been proposed - does anything need to change?
23Required DiscussionsHealth & 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 areasCommunication (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
24Required TimelinesService 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.
25Effective DateThe 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.
26Plan 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.
27PCP 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 DescriptionsThe Community Supports Service and Goal DescriptionsWork/Employment/Career Supports Service Descriptions
28PCP DocumentationThe Case Worker is responsible for completing in EIS…The Personal Plan Face SheetThe Personal Plan NarrativeCase Management Service DescriptionAncillary Service DescriptionAssistive Technology Service Description???
29Where 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, orB. 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
30PCP DocumentationBefore 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.
31Assessing 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 satisfactionSee PCP Instruction Manual pages 18 & 19
32Remember it’s all about the Person! Ask YourselfIn 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!
33Thank 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!