Introduction to Person Centered PlanningIntroduction to Person Centered Planning

June 2011

Neal Adams MD MPHCalifornia Institute of Mental Health

Learning Pyramid

Warm UpWarm Up

• List typical goals found on current service plans

• Write 3 goals/areas of meaning you have for yourself on a piece of paper

• Hand that paper to the person sitting next to you

person-centered / directed careperson-centered / directed care

…it’s not a straight path from here to there…

Definition of a Recovery PlanDefinition of a Recovery Plan

• A recovery plan is a document, co-created by the person receiving services and the provider, to outline the steps needed to achieve a particular goal or outcome.

The Recovery PlanThe Recovery Plan

• It is the work/social “contract”, created by the person and provider.

A Person-Centered Approach to A Person-Centered Approach to Service PlanningService Planning

• Collaboration and partnership.

• The plan prioritizes the person’s desires while including a provider perspective.

PCP…Don’t we already do this?? PCP…Don’t we already do this??

Making progress but… we DON’T “already do this.” Not according to consumer/survivors… “old wine…new bottles” and not if you take a close look at concrete

implementation strategies Review your current records/plans

Treatment PlanRecovery Plan

The Nature of the Problem The Nature of the Problem • 24% of sample (N=137) report NEVER having a

treatment plan• Of those who had experienced a treatment plan,

half felt involved only “a little” or “not at all”.

o Only 21% of participants report being “very much” involved

o Only 12% of people invited someone to their last treatment planning meeting

o Over half were not offered a copy of their plan

o People aren’t even in the car, let alone the driver’s seat!

It Works! It Works!

• For example, WNYCCP has achieved the following outcomes:

• 55% decrease in ER visits• 58% decrease in inpatient days• 66% decrease in suicide attempts• 52% decrease in harm to others• 18% decrease in arrests

• Cost-effective• Over a 3 year period, Medicaid costs per

participant decreased 10% compared to an 8% increase for the general population

The Comprehensive Person-Centered Plan

Incorporates Evidence-Based Practices

Informed by Stages of Change & MI Methods

Encourages Peer-Based Services

Maximizes Self-Determination & Choice

Promotes Cultural Responsiveness

Focuses on Natural Supporters/Community

Settings

Respects Both Professional & Personal Wellness Strategies

Consistent w/ Standards of Fiscal & Regulatory Bodies,

e.g., CMS, JCAHO

PDP is…PDP is…

• Person Directed Planning is a planning process that is controlled by the person receiving services

(family for children) results in a recovery plan that details the

issues important to the person o managed in all important aspects by that person

with freely chosen support when necessary spells out what will constitute both quality in

the execution of the plan as well as specific outcomes

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Being Person-Centered in PracticeBeing Person-Centered in Practice

• The consumer as a whole person• Sharing power and responsibility• Having a therapeutic

alliance• The clinician as person

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Fundamental Principles of PDPFundamental Principles of PDP

• Adheres to the “person-first” concept• Applies to ALL people • Views the recovery process as flexible

and non-linear• Promotes self-determination to the

maximum extent possible• Focuses on capitalizing strengths• Demands transparency and

equal access to information• Facilitates natural supporter

involvement

The Road to Recovery...The Road to Recovery...

• Person-centered planning is a collaborative process resulting

in a recovery oriented treatment plan

is directed by consumers and produced in partnership with care providers for treatment and recovery

supports consumer preferences and a recovery orientation

Adams/Grieder

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Use of Person-first LanguageUse of Person-first Language

• Not a diagnostic label Person with schizophrenia, or addiction

• not “a schizophrenic” or “an addict”

• Not “front-line staff” who are “in the trenches”

direct care staff providing compassionate care

• Focus on strengths, successes, talents• Self-determination as a right• Communicate a consistent message of

hope

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Serving Two MastersServing Two Masters

Person-centered Recovery Community integration Core gifts Partnering Supports self-direction

Regulation Medical necessity Diagnosis Documentation Compliance Billing codes

Outcomes and GoalsOutcomes and Goals

UnderstandingUnderstanding

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Medical NecessityMedical Necessity

• Doing the right thing, at the right time, for the right reason

• Standard of service and quality• Five elements

Indicated Appropriate

o consider issues of culture Efficacious Effective Efficient

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ExampleExample

• Goal Decrease depression

• Objectives Assess medication needs Improve finances Develop appropriate vocational goals

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• Goal Maintain psychiatric stability

• Objectives Attend appointments with PCP Donna will attend psychiatric

appointments

ExampleExample

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ExampleExample

• Goal Life long sobriety and abstinence

• Objectives Attend all classes and groups on

substance abuse education Complete 4th step by November 2008 Attend 5 NA/AA meetings per week Weekly individual therapy

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Plan DevelopmentPlan Development

• Acquired skill / Art form Not often taught in professional training Often viewed as administrative burden and paper

exercise Requires flexibility

• Opportunity for creative thinking• Integrates information about person served

Derived from formulation and prioritization Information transformed to understanding

• Strategy for managing complexity

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Service Plan Functions Service Plan Functions • Specifies intended outcomes / transitions /

discharge criteria Clearly elaborates expected results of services

o includes perspective of person served and family in the context of the person’s culture

Promotes consideration and inclusion of alternatives and natural supports / community resources

• Establishes role of person served and family in their own recovery / rehabilitation Assures that services are person-centered Enhances collaboration between person served

and providers

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Service Plan Functions Service Plan Functions continuedcontinued

• Identifies responsibilities of team members--including person served and family Increases coordination and collaboration Decreases fragmentation and duplication Coordinates multidisciplinary interventions Prompts analysis of available time and resources

• Provides assurance / documentation of medical necessity Anticipates frequency, intensity, duration of

services• Promotes culturally competent services

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Service Plan Functions Service Plan Functions continuedcontinued

• Supports utilization management Services authorization, communication with

payers and payment for services Allocation of limited resource

• A contract with the people we serve!

The Plan…Must it be a heavy burden?The Plan…Must it be a heavy burden?

“Apparently, Smith’s desk just couldn’t withstand the weight of the paperwork we piled on his desk.”

Elements of a Recovery PlanElements of a Recovery Plan

• The person’s goal: what is the desired outcome of services?

• Discharge/transition criteria—establishing and end point

• How to overcome barriers?• Objectives – what are the steps to reduce barriers and

attain the goal?• Proposed type(s) of interventions – who is going to do

what to get there? proposed duration– when will things be accomplished? Purpose—what’s to be accomplished relative to the

objective?

A Plan is a Road MapA Plan is a Road Map

• Provides hope by breaking a seemingly overwhelming journey into manageable steps for both the provider and the person served

A E

B C D

“life is a journey…not a destination”

Building a PlanBuilding a Plan

Request for services

Assessment

Services

Understanding

Goals

Objectives

Outcomes

Prioritization

Strengths/Barriers

StrengthsStrengths• Environmental factors that will increase the

likelihood of success: community supports, family/relationship support/involvement, work

• Identifying the person’s best qualities/motivation

• Strategies already utilized to help• Competencies/accomplishments• Interests and activities, i.e. sports, art

(Identified by the consumer and/or the provider)

Examples of StrengthsExamples of Strengths• Motivated to change• Has a support system –friends, family• Employed/does volunteer work• Has skills/competencies: vocational, relational,

transportation savvy, activities of daily living• Intelligent, artistic, musical, good at sports• Has knowledge of his/her disease• Sees value in taking medications• Has a spiritual program/connected to church• Good physical health• Adaptive coping skills• Capable of independent living

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Cultural Factors in AssessmentCultural Factors in Assessment

• Begin with cultural and demographic factors Clarify identity

o “how do you see yourself?” o race, ethnicity, sexual orientation, religion,

color, disability reference group Specify language

o fluencyo literacyo preference

BarriersBarriers

• What is keeping the person from their goals?

need for skills development intrusive or burdensome symptoms lack of resources need for assistance / supports problems in behavior challenges in activities of daily living threats to basic health and safety

• Challenges / needs as a result of a mental / alcohol and/or drug disorder

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Importance of UnderstandingImportance of Understanding

• Data collected in assessment is by itself not sufficient for service planning

• Formulation / understanding is essential Requires clinical skill and experience Moves from what to why Sets the stage for prioritizing needs and goals The role of culture and ethnicity is critical

to true appreciation of the person served

• Recorded in a chart narrative Shared with person served

Interpretive Summary BridgeInterpretive Summary Bridge

• Informative findings based on assessment data and the subsequent recommendations

• Perception of the individual on his/her SNAP (strengths, needs, abilities and preferences)

• Perception of the provider on individual’s SNARF (strengths, needs, abilities, risk and functional status)

• Provider insight into contribution and impact of individual’s psychodynamic, cognitive, familial, environmental and personality traits on current status, service goals and treatment outcomes

Interpretive Summary, cont.Interpretive Summary, cont.

• Provider & individual’s understanding of how illness/condition impacts function

• Provider and individual’s speculation and understanding of previous treatment outcomes

• Groundwork for recovery vision and future goals

• Prioritization of needs for service planning• Individual’s readiness and motivation for

change

The 10 PsThe 10 Ps

• P ertinent history (brief)• P redisposing factors• P recipitating factors• P erpetuating factors• P resent condition / presenting problem• P revious treatment and response • P rioritization by person served• P references of person served• P rognosis• P ossibilites

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Stages of Recovery and TreatmentStages of Recovery and Treatment

Ohio VillageProchaska & DiClemente

Stage of Treatment

Treatment Focus

Dependentunaware

High risk/ Unidentified or Unengaged

Pre-contemplation

Engagement

• outreach • practical help• crisis intervention• relationship building

Dependent aware

Poorly coping/Engaged/not self-directed

Contemplation/preparation

Persuasion

• psycho- education• set goals• build awareness

Independent aware

Coping/Self responsible Action

Active Treatment

• counseling• skills training• self-help groups

Inter-dependentaware

Graduated or Discharged Maintenance

Relapse Prevention

• prevention plan• skills training• expand recovery

moving moving beyond…beyond…

challeng-challeng-ing…ing…

question-question-inging

giving in giving in to…to…

over-over-whelmed whelmed

by…by…

……the the disabling disabling power of power of

the the illnessillness

The person The person is…is…

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Vignette--CarmenVignette--Carmen

• 18 year old Latina High school senior

o preparing for graduation First generation

o parents monolingual Spanish speakingo client bilingualo observant Catholic family

Lives in predominantly Anglo-American community

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Vignette Vignette continuedcontinued

• Excellent student Active in school and social activities Recently unable to attend school because of

distress Graduation from high school and college

attendance is core value for Carmen and family

• Recent physical problems Nausea, vomiting, dizziness, headaches

• Parents believe she is suffering from susto Treatment from curandero

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Vignette Vignette continuedcontinued

• Recent crisis Acute physical distress Admitted to hearing a baby cry while at

school Reported feeling sad and blue

• Referred to mental health Embarrassed and resistant First family member to seek MH services

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Vignette Vignette continuedcontinued

• Assessment with Latina provider in Spanish Revealed she had a miscarriage a year

ago Feeling increasingly guilty and troubled Wants to die and join her baby Relationship with parents has become

distant and full of conflicto father refusing to speak with her

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Vignette FormulationVignette Formulation

• Identity First generation Latina Bilingual

• Explanation of Illness What appeared to be a physical problem is a

mental health problemo somatization is idiom of distresso shame, guilt and embarrassment are key themes

• Provider relationship Spanish preferred More open with Latina clinician

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Vignette FormulationVignette Formulationcontinuedcontinued

• Psychosocial environment Lives with family, first generation Some degree of acculturation and distance

from parentso difficult and painful

• Diagnosis Consider possibility of culture bound syndrome

o susto Possible depression with psychotic features Understanding her beliefs may be key to

treatment

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Vignette FormulationVignette Formulationcontinuedcontinued

• Hypothesis Intergenerational issues of acculturation are a

major factoro Age appropriate issues of individuation and

separation She is between contemplative and active stage

—some ambivalence about help-seeking School completion and education opportunity

and advancement are shared values /strengths to build upon

Need to help her reconcile feelings of guilt and remorseo Religious and spiritual factors may be significant

Definition of a GoalDefinition of a Goal

“The goal is a broad, general statement that expresses the individual’s and family’s desires for change and improvement in their lives, ideally captured in their own words.”

Source: Adams, N. and Grieder, D. (2005) Treatment Planning for Person-Centered Care.

Elsevier Academic Press.

Definition of a GoalDefinition of a Goal

• Goals express the hopes and dreams of the client.

• Goals identify the hoped-for destination to be arrived at through the services provided.

The Essential Features of Goals The Essential Features of Goals

• They are BIG Long term, global, and broadly

stated They are not necessarily measurable

• Written in positive terms built upon abilities / strengths,

preferences and needs embody hope/alternative to current

circumstances

Key Points about GoalsKey Points about Goals

• A good goal inspires the individual to reconnect to their dreams.

• Goal development is an essential part of engagement and creating a collaborative working relationship.

Collaboration and GoalsCollaboration and Goals

• Reaching agreement on the goal is essential The provider understands and appreciates

the importance of the goal. The goal has immediate meaning and

relevance for the consumer. The goal becomes a shared vision of

success.

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The Right BalanceThe Right Balance

Neglect Control

Let client do what he/she wants

Get client to do what I want

Recovery ZoneRecovery Zone

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Common GroundCommon Ground

• Clients should have the dignity of risk and right of failure

• Providers are advocates of client choice• Clients are not abandoned to suffer “the

natural consequences” of their choices• Provider or client not a failure if choice

results in failure• Use reinforcers to support client choice• Assure true choice over a wide range of

options

Pat Deegan

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Carmen’s Plan/Action StageCarmen’s Plan/Action Stage

• Goal “I want to graduate from high school”

BarriersBarriers

• What is getting in the way of the person achieving their goal Why can’t they do it tomorrow Why can’t they do it themselves

• Our focus is removing/reducing/resolving barriers that are a result of the mental illness

Recovery Happens In Small StepsRecovery Happens In Small Steps

• To be an effective road-map, plans need to clearly identify the smaller steps that get you to your destination.

• These markers along the way also offer opportunity to celebrate and acknowledge progress.

• Every gain made is additional fuel for the journey!

Defining ObjectivesDefining Objectives

• Objectives describe a significant and meaningful change that the individual can see or experience.

• Objectives are milestones – they designate the mini-goals along the way.

• Well-written objectives create opportunity for success, for seeing that the dream is really possible.

What Do Objectives Do?What Do Objectives Do?

• Take into account the culture of person served

• Divide larger goals into manageable tasks• Provide time frames for assessing progress • These are the action steps the person

takes toward their goal

Objectives and Medical NecessityObjectives and Medical Necessity

• Objectives address barriers to the goal.• They also describe changes in behavior,

function, or status. relate back to functional impairments

o how the work we are doing will reduce these barriers

identify key changes that the consumer wishes to accomplish

Keep it Focused!Keep it Focused!

• A maximum of two or three objectives per goal is recommended to create focus and reduce the chances of feeling overwhelmed.

Objectives Should Be SMARTObjectives Should Be SMART

• Simple or Straightforward• Measurable• Attainable• Realistic• Time-framed

How to Write an ObjectiveHow to Write an Objective

• Subject

• Verb/Action Word

• What

• When will it be done/timeframe?

• How will it be measured?

• Person receiving services

• Will demonstrate

• Ability to use three coping techniques to address anger

• Within one month

• As measured by therapist observation

Objectives Are Not InterventionsObjectives Are Not Interventions

• Objectives are the WHAT What is the next step towards the goal? What is the next significant milestone?

• Interventions are the HOW How are we going to get there? Interventions are the action steps taken to

achieve the objective.

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Carmen’s Plan/Action StageCarmen’s Plan/Action Stage

• Goal “I want to graduate from high school”

• Objective Carmen will return to class attendance

for 5 consecutive full days within a month as reported by Carmen / or support worker

InterventionsInterventions

• Actions by staff, family, peers, natural supports

• Specific to an objective• Respect consumer choice and

preference• Specific to the stage of

change/recovery• Availability and accessibility

of services may be impacted by cultural factors

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Five Critical ElementsFive Critical Elements

• Interventions must specify provider and clinical discipline staff member’s name modality frequency /intensity / duration purpose / intent / impact

• Clarifies who does what• Include a task for the family, or other

component of natural support system to accomplish

The 5 W’s of InterventionsThe 5 W’s of Interventions

• Who Which member of the team or support system will

provide it• What

specifically what service will be provided.• When

How often, how much time and duration• Where

Identify the location of service delivery• Why

Link the intervention back to the desired outcome

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Carmen’s Plan/Action StageCarmen’s Plan/Action Stage

• Interventions Psychiatrist to provide weekly to monthly

pharmacotherapy management visits for 3 months to relieve acute symptoms of anxiety and depression

Social worker to provide one hour of cognitive-behavioral psychotherapy twice a week for 4 weeks to help Carmen resolve feelings of guilt and loss

Support worker to meet with Carmen up to 3 hours / week for 4 weeks as required to coordinate / facilitate return to school with school counselors and mental health team

Carmen and family to attend weekly sessions with their parish priest to bring about forgiveness and family reconciliation.

Common MistakesCommon Mistakes

• Assessment Do not use all available information resources Not culturally appropriate / sensitive Not sufficiently comprehensive Lack adequate integration / understanding of the

person

Common MistakesCommon Mistakes

• Goals Not global Not directed towards recovery Not responsive to need Not strengths based Too many

Common MistakesCommon Mistakes

• Objectives Don’t support the goal Not measurable or behavioral Interventions become objectives Not time framed Too many simultaneous objectives

Common MistakesCommon Mistakes

• Interventions Purpose not included Frequency, intensity, and duration not

documented Too few Don’t reflect multidisciplinary activity

JaneJane

• Jane comes in to the mental health clinic for medications that help her with her depression and anxiety. In the past, she has been overwhelmed by sadness and would drink to “numb-out” and her drinking made it impossible for her to function at home or work. Feeling much better, Jane wants to get back into the workforce. She occasionally experiences relapses, but finds that she gets back on her feet more quickly now.

Jane’s GoalJane’s Goal

• Goal: I want to work full-time.

Addressing Jane’s BarriersAddressing Jane’s Barriers• Objective 1

Jane will be clean and sober for 30 consecutive days as measured by self-report.

• Interventions: Sam Smith, LCSW, will provide dual recovery groups

once per week for one year to Jane so she can learn the tools to stay clean.

CM will discuss how meetings went with Jane once per week in the community, and reinforce active participation in the group to assist her in achieving sobriety for 3 months.

Jane will attend AA meetings 3 x per week for 3 months in order to develop a sober support system

• Objective 2 Jane will master two stress reduction skills within

the next 60 days as measured by her self report of successfully resolving conflicts/problems without self-defeating behavior .

• Interventions Peer specialist will meet with Jane every other

week in the community to practice stress reduction skills for 2 months

CM will provide skills training on stress management one hour/once per week for 60 days.

Addressing Jane’s BarriersAddressing Jane’s Barriers

Barriers / Excuses / RationalesBarriers / Excuses / Rationales

• Medicaid won’t let us do this! Medicaid won’t let us do this! OIG auditsOIG audits

• the forms don’t have the right fieldsthe forms don’t have the right fields• regulations prohibit itregulations prohibit it• consumers aren’t interested/motivatedconsumers aren’t interested/motivated• recovery isn’t realrecovery isn’t real

stigma among professionals stigma among professionals • lack of time/caseloads lack of time/caseloads

too hightoo high• ““my clients are sicker”my clients are sicker”

Barriers / Excuses / RationalesBarriers / Excuses / Rationales

• social control is our “true” missionsocial control is our “true” mission• professional boundariesprofessional boundaries• funding issuesfunding issues

getting paid for servicesgetting paid for services no Medicaid no Medicaid

reimbursementreimbursement dis-incentivesdis-incentives lack of Medicaid funding for EBP’slack of Medicaid funding for EBP’s

• ““we’re already doing this”we’re already doing this”

Provider Role And ContributionProvider Role And Contribution

• PerceptionPerception There isn’t much of a role for providers in the There isn’t much of a role for providers in the

person-centered worldperson-centered world

• RealityReality There is a large but changed role for providersThere is a large but changed role for providers

• providers of hope providers of hope • assessment / formulationassessment / formulation• knowledge of the system of care/communityknowledge of the system of care/community• knowledge of the disease and possible solutionsknowledge of the disease and possible solutions• teachers/trainers/coachesteachers/trainers/coaches

It’s Not Permitted / ReimbursableIt’s Not Permitted / Reimbursable

• Perception Medicaid regulations and state plans won’t allow for

person-centered planning• Reality

Most state plans for Medicaid reimbursement, be they option, clinic option or waiver, speak the language of individualized planning

the person directing the planning, and a strengths based approach to assessment and planning

Violates Professional BoundariesViolates Professional Boundaries

• Perception This isn’t how I was trained I’m not comfortable with this I know better My licensing board won’t let me do that

• Reality Providers have not received necessary training and

support Established appropriate professional model

Linking Planning With EBPLinking Planning With EBP

• Perception EBPs are not person-centered nor Medicaid re-

imbursable• Reality

Most evidence based practices / programs are constructed from smaller specific service interventions that can be individualized

“De-constructing” EBPs into specific billable services demonstrates medical necessity of each element

EBPs provide decision-support point in shared-decision making

IMR/IDDT/SE all closely related to PDP

Services Are Not Aligned With PCPServices Are Not Aligned With PCP

• Perception “programs” are not individualized

treatment/services and PCP doesn’t fit• Reality

There are opportunities within program structures to provide consumer-centered serviceso phases/stages of change approacho employing peers as facilitatorso budgeting needs to consider moving from

services to supports

Consumers Are Too Sick Consumers Are Too Sick

• Perception Consumers aren’t interested in

participating (“old timers”), are “delusional”, have no goals, etc.

• Reality Need to communicate a message of hope and a

belief that their life can be different, or education/training/tools on person-centered planning

Need to assess and plan for stage of change

“If you don’t know where you are going, you will probably end up somewhere else.”

Lawrence J. Peter