Virginia’s Person Centered Planning Process. The Four Phases of Planning Sharing Information...

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


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 Questions Agenda 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


ProfilePlanning Partner


Once the essential information and the profile are complete, it’s time to get ready

for planning.




An Agenda


ProfilePlanning PartnerAgenda

AgendaAgenda ItemsConsider 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 TakenDiscussion 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:



ProfilePlanning PartnerAgenda

The Personal Topics List

Personal Topics

Personal Topics

Topics not for the meetingConsider each specific point identified in the Profile that

will NOT be on the agenda.

Action TakenDiscussion 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:


Now that the agenda and personal topics

list are complete, it’s time to schedule

planning.

Planning Together


AgendaPersonal Topics

If needed, your planning partner can help you to schedule

your meeting.

Planning Together




Once the meeting is set, you invite others

including friends, family and all

providers.

Planning Together




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




From the agenda the team chooses one of four options for their

response.

Planning Together




routine supports or

health and safety supports or

action plans or

the discussion record

Action Plan for Achieving GoalsPlan begin date: ___________________Plan

Desired Outcome:

What would it take for anyone to achieve this outcome?

Supports currently in place:

Supports needed:

Support or Action StepsWho 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




Action PlanDiscussion

Record

Individual and Team

Planning Questions

Yes NoIndividual 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?

Yes NoTeam 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 AgreementProfile


Planning Partner



RecordPlanning Questions

Plus absent

contributors

Agreement

Agreement PageSignatures of team members who agree to help me with my plans as decided this day:

Individual Date

Case Manager Date

Guardian/ Authorized Representative Date

Team Member Relationship Date





Names of team members who contributed to my plans and were not here for planning

Comments:

Planning Together

The Support Summary





Record

AgreementPlanning Questions

Support Summary

Provider Support Summary Plan Dates: _________to_______ Provider: ___________ NPI: ____________ Date Revised:_________________

Support provided How to provide supports When? days

How longper day?

Weekly totalminutes or hours

Routine Supports

Health and Safety Supports

Achieving Goals

Total weekly hours Total additional hours if approved Grand Total

______hours______hours______hours

Action Plan

Keeping Track



Discussion RecordPlanning

QuestionsAgreementSupport

Summary


Now that the plan is ready, your team works together to help you stay on

track with achieving your goals.

Action Plan





Summary


Keeping Track

The Support Summary Checklist

Support Summary Checklist

Provider Support Summary ChecklistMonth: ___________ Year: _________ Provider: _________________ NPI: ___________ Date Revised ____________

Plan

How Often?

Routine Supports

Health and Safety Supports

Achieving Goals

Key:x = support providedn = not provided by DSPc = chose not to participatea = absent o = incident (see supporting documentation)Support Provider Signatures and initials:___________________________________________ ________ _____________________________________ ________

___________________________________________ ________ _____________________________________ ________

Action Plan





Summary


Keeping Track

Support Summary Checklist

The Plan Change and Quarterly Review Tool

Plan Change and Quarterly

Review Tool

ISP Changes and Quarterly Review ToolProvider: ___________ NPI: ___________

Plan Dates: Review Dates:

Is this being completed for a ISP change or quarterly review?

Check one: ISP Changes or Quarterly Review 1st 2nd 3rd 4th

Description of the person:

Health update (medications/appointments):

Significant events (celebrations/struggles):

Review of desired outcomes for health and safety and achieving goals

Desired outcomes Outcome 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





Summary


Keeping Track

Support Summary ChecklistPlan Change and Quarterly

Review Tool

The Daily and

Learning Logs

Daily and Learning Logs

Learning LogDate What 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 ____________________________Date Event

*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?

Date post:	01-Jan-2016
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Virginia’s Person Centered Planning Process. The Four Phases of Planning Sharing Information...

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