DDD Scoop Articles Providing Additional Guidance on the Person Centered Planning Process

Below are a list of articles that have been published in the DDD Scoop regarding the Person Centered Planning process.  While these are not the sole source of direction, they do provide additional guidance based on questions received in the Division.  The articles are listed by date in ascending order.

5-5-17, Life Choices Update

The link below contains a webinar titled Overview of Life Choices. This webinar is the first in a series and introduces you to upcoming changes regarding the Person Centered process. The webinar was designed for all stakeholders in the Developmental Disability system and is for information purposes only. No Continuing Education Credits will be awarded. Please feel free to share this or the companion PDF with others who may not have access.

Other webinars in this series will include an overview of the Person Centered process, the Discovery and Personal Plan processes, and the Implementation Strategies. These webinars will be presented and available the last half of May. The Division will post notification of each webinar as they become available.

Currently ISC agency staff is being trained in the Discovery and Personal Plan development process. These trainings are specific to the upcoming changes and the enhanced role the ISC will play in developing the Personal Plan. Approximately 200 ISC staff were trained as of April 30, 2017. The remaining 270 ISC staff will be trained by June 28, 2017.

The Division is reviewing and revising the Discovery Tool and the Personal Plan that will be utilized beginning July 1, 2017. These documents along with related guidelines will be posted on the DHS website allowing for a public comment period. These documents will be posted this month.


5-19-17, A Glance at the Person Centered Process in Illinois

In order to provide greater clarity of our expectations relative to the development of the personal plan, we offer the following descriptions of critical elements of Illinois' Person Centered process:

The Person Centered process can be described as finding the balance between what is important to a person and what is important for a person. It is a way to identify strengths, preferences, needs (both clinical and support needs and desired outcomes of a person. Person Centered Planning includes 3 main components: 1) the Discovery Tool and process, 2) the Personal Plan, and 3) Implementation Strategies.

Discovery is the information gathering component of Person Centered process. The Discovery process is designed to gather information in order to capture what is important to the person and what is important for the person. The Independent Service Coordination (ISC) agencies will be responsible for facilitating the Discovery process and documenting what they gather in the Discovery Tool. The information captured during this process is used to develop the Personal Plan. The sections in the Discovery Tool include: Self-Description, Home, Important Relationships, Home, Career and Income, Health and Well-being, Communication, Life in the Community, Recreation/Interests/Hobbies, Choice and Decision Making, and Future Plans.

The Personal Plan is the single, integrated personal vision for a person's life. It focuses on the individual's strengths, preferences, needs and desires in each of the sections listed in the Discovery Tool. The Independent Service Coordination (ISC) agencies will be responsible for developing the Personal Plan in conjunction with the individual, guardian, family and current provider(s). The Personal Plan will contain the outcomes that the person desires in his/her life and document choice of qualified providers. In addition, it will reflect what is important to the person regarding delivery of services in a manner which ensures personal preferences, health and welfare. The Personal Plan also includes risk factors and plans to minimize them.

The Implementation Strategies are then developed by provider agencies. Provider agencies will provide services and supports that will assist the person to pursue the outcomes identified in the Personal Plan. The Implementation Strategy describes how the provider agencies will support the person to achieve his/her desires and needs. Provider agencies can design their own tool, but it must at least contain the requirements detailed below:

  • Outcomes identified in the Personal Plan
  • A description of how supports and services assist the individual to engage in community life and maintain control over personal resources
  • Opportunities to seek employment and work in competitive integrated employment if desired
  • Functional goals/training areas and methods to measure progress
  • Documentation that services and supports are linked to individual strengths, preferences and assessed clinical and support needs
  • Risks included in the Personal Plan and any others subsequently identified; strategies that will be used to mitigate risk and identify who is responsible for implementing these strategies
  • All services and supports to be provided regardless of provider or funding source, including type, methods if applicable, frequency, duration and staff assigned if applicable justification for any restriction(s) or modifications that limit the person's choice, access or otherwise conflict with HCBS standards
  • Basic descriptive, diagnostic, demographic and medical information
  • Documentation for any situation where a person lives in a residential setting owned or controlled by a service provider and modifications to the expectations of community settings are requested Provider Implementation Strategies must reflect ongoing review, monitoring and updating if necessary by the Provider Agency. It must also be updated to reflect changes in the Personal Plan at least annually and more often if warranted by circumstances, a change in functional status or at the request of the individual.

The Division will host a live webinar regarding Implementation Strategies, as a part of the Person Centered process webinar series, no later than the first week of June 2017. An invite will be forthcoming to register for the webinar.


6-5-17, (No title)

As July 1, 2017 approaches, Division staff are receiving many calls and emails from those who have questions about expectations moving forward. Although information has been shared in an ongoing fashion since November 2013 (the "birth" of our Life Choices Initiative), as the deadline for implementation draws near, it is clear that all information has not reached all stakeholders and that many questions remain. We want to offer the following summary and assurances:

  1. Beginning July 1, 2017 ISCs will assume case management responsibilities for all waiver participants as the participants' "annual review" date approaches. The transition from provider-based QIDPs to ISC case management will be gradual and continue throughout fiscal year 2018. As a result, two systems will be occurring simultaneously - the "old" system (with Individual Service Plans and QIDP case management) for those who have not yet had their annual review and the "new" system (with person-centered planning and ISC case management) as annual reviews occur between July 1, 2017 and June 30, 2018.
  2. ISCs will begin the "new" person-centered planning process and ISC case management with persons new to waiver services (through PUNS selection or crisis) after July 1, 2017.
  3. All stakeholders should continue to operate in the same fashion as the current fiscal year (FY17) until notice is provided through the DDD Scoop, Division Information Bulletins, or other official channels from IDHS Division of Developmental Disabilities.

Watch the Division's website for more information and use this email address to send questions: DHS.DDD.Life.Choices@illinois.gov


6-19-17, Life Choices Webinar Availability

The recorded webinar titled "Life Choices System Transformation: Implementation Strategies" is now available on the DHS website at this link:

https://attendee.gotowebinar.com/recording/3082111795715083526

This two hour webinar provides an overview of the coming system changes associated with case management and provides detailed information about the portion of the person-centered planning process for which providers will be responsible. This webinar was presented on June 5, and is now available to all who were unable to attend as well as for those interested in re-watching.

A number of associated handouts are available during the webinar (look on the Handouts section of the webinar control panel after the webinar starts). These handouts are also available on the website: http://www.dhs.state.il.us/page.aspx?item=81882. Please visit the Recorded Webinars page and scroll down to the Life Choices options to find the handouts and the link to the webinar.


7-14-17, Transition to the Personal Centered Planning Process & Clarification on Implementation Strategies

Transition to the Personal Centered Planning Process

As we transition to Person Centered Planning, we continue to be reminded of the need to be flexible through the transition process yet remain compliant with the Waiver requirements. For each person in a DD Waiver, there must be a current Individual Service Plan (ISP), Addendum to the ISP or Personal Plan in place to guide the provision of services. Current continues to mean on or before 365 calendar days from the previous Plan. By June 30, 2018, all individuals in a DD Waiver must have a Personal Plan. Because of the volume of individuals receiving DD Waiver services, the ISC agencies must strategize their workload with this added responsibility of the Person Centered Planning process. If the ISC agency is able to complete a Personal Plan within 365 days of the ISP, this is ideal. In the event that this is not possible, the ISC agency might use one or more of the following approaches to transition to the Person Centered Plan process.

  • Scenario 1: ISC staff can shift their caseloads within the agency allowing their peers to conduct all or a portion of the Discovery and Personal Plan process. This allows the date of the Personal Plan to be within 365 days of the date of the Individual Service Plan.
  • Scenario 2: Where possible, some ISC staff began the Person Centered Planning process in the spring of 2017 to accommodate at least a portion of the ISPs that are due in July and August.
  • Scenario 3: If an Individual Service Plan becomes due prior to the date the Personal Plan can be developed, the ISC, provider agency, individual and family should work jointly to review the current Plan and ensure that all aspects continue to be relevant and the ISP will remain in place until the Personal Plan can be developed. This would constitute an acceptable process for the addendum to the current ISP.
    • The ISC must communicate to the provider agency the need for an ISP Addendum.
    • The addendum should be completed on or before 365 days from the most recent ISP.
    • The provider agency develops the ISP Addendum. It is not necessary to convene an Interdisciplinary Team meeting.
    • The team discusses the individual's current goals and objectives; discusses edits as appropriate
    • and adds new goals and objectives as needed.
    • ISC must identify the date and month, prior to June 30, 2018, that the Personal Plan will be
    • developed.
    • Provider agency updates the ISP with all the above information.
    • The individual, guardian, provider agency, and ISC are still required to review and sign the
    • addendum.
    • The date of the Personal Plan will reset the 365 day requirement for completing the Personal
    • Plan. All persons new to DD Waiver services must have a Personal Plan or preliminary
    • Individual Service Plan in place prior to entering services, with the exception of crisis cases.
    • When possible, the ISC should complete the Discovery and Personal Plan prior to the person
    • entering services. It is also acceptable, between July 1 and September 30, 2017, for the
    • residential provider agency to continue to develop a preliminary ISP prior to initiating services.
    • In this case, the preliminary ISP will remain in place and the ISC agency would then complete
    • the Discovery and Personal Plan process within 30 days of service.

In all cases, the Division is asking providers and ISC agencies to work together and coordinate the best possible transition to the Person Centered Planning process for participants in the DD Waiver.

Clarification on Implementation Strategies

Last month the Division held a live webinar regarding provider Implementation Strategies. If you have not viewed the webinar you can access the recording and related documents by clicking on the links below. After this presentation the Division received various questions regarding the development of Implementation Strategies and wanted to clarify the following. At this time, the Division is not requiring Service Facilitators, Self-Direction Assistants, or families in HBS to develop Implementation Strategies. The Division continues to discuss this issue, including when this will be required and how this will be communicated to all parties.


7-28-17, Waiver Services Billed Must be Included in the Personal Plan, Provider Attendance at Discovery/Personal Plan Meetings & Person Centered Planning Webinars

Waiver Services Billed Must be Included in the Personal Plan

Independent Service Coordination (ISC) agencies have been instructed to ensure that all Medicaid Waiver services to be provided to an individual (including the services' scope, frequency, and duration) must be listed in the individual's Personal Plan. Prior to delivering any services through the Medicaid Waivers, providers should ensure they have a copy of the final, approved Plan and that the Plan lists the service(s) the provider will deliver. Billings and claims for any Medicaid Waiver service found during an audit not to be included in the Plan will be voided.

Provider Participation in the Discovery/Personal Plan Process

ISC agencies must ensure opportunity for provider input into the Person Centered Planning process. We are pleased to see evidence that this is occurring as ISC agencies have finalized some of the first Personal Plans. We have, however, received comments that in some cases, ISC agencies have invited Direct Support Persons (DSPs) to Discovery meetings/discussion without consulting with or informing the appropriate provider agency management. While we welcome participation from DSPs, when the individual and guardian request it, ISC agencies must ensure a DSP has the appropriate authorization to leave their work responsibilities to provide such participation.

Person Centered Planning Webinars

A four part webinar series on Person Centered Planning is now available on the IDHS website. The webinars are for information purposes. No CEs http://www.dhs.state.il.us/OneNetLibrary/27896/documents/By_Division/DivisionofDD/LifeChoices/OverviewoLifeChoicesSeriesWebinar1042417.pdfor CEUs will be awarded for webinars 1, 2 or 3; two hours of CEs are awarded for webinar 4. Click on the titles below to view the webinars.

For additional information and materials (forms, guidelines and Frequently Asked Questions) visit the Person Centered Planning Process for Medicaid Waiver Services webpage


8-10-17, Person Centered Planning - Frequently Asked Questions

The Person Centered Planning Frequently Asked Questions document on the DHS website has been updated to reflect recent questions posed by DDD stakeholders. You can access the updated document by clicking on the link Frequently Asked Questions.

We will continue to update the FAQ with the most recent date reflected in the upper left hand corner just under the Note. The document is arranged in ascending order; scroll down the page to view the most recent. Please continue to submit your questions regarding Person Centered Planning to DHS.DDD.Life.Choices@illinois.gov


9-1-17, Clarification regarding Waiver Services Billed and the Personal Plan

In the July 28th edition of the DDD Scoop, we provided the following information under the heading Waiver Services Billed Must be Included in the Personal Plan. As a result, the Division has received many questions regarding the content of the Personal Plan and what must be recorded in order to allow for successful Waiver billing and claims. As such, we are providing the following guidance:

The ISC must document the services, as applicable to each individual, on the Summary of Services and Supports page of the Personal Plan under the column titled Service/Support. All paid services that are applicable to the individual, including Individual Service & Support Advocacy, must be identified on this page. (See services in chart below.)

After receipt of the Personal Plan, provider agencies that support or will support any of the services listed on Summary of Services and Supports page should document the particular service(s) they will provide on the Provider Signature Page of the Personal Plan. It is not necessary for provider agencies to document the details of these services (i.e. provide assistance with medication administration) on the Provider Signature Page. The details of how the service will be provided should be outlined in a provider's Implementation Strategy. Provider agencies must ensure that all services being billed are identified in the Personal Plan (See services in chart below.) Provider agencies who are aware of the need to change services (i.e. add Supported Employment), should notify the ISC to ensure that this service is requested by the individual/guardian and included in the Personal Plan.

24-Hour Stabilization Services

Adaptive Equipment

Additional Staff Support

Adult Day Care

Assistive Technology

At-Home Cay Program

Behavior Intervention & Treatment

Behavioral Services (Psychotherapy & Counseling)

Child Group Home

CILA - 24 Hour

CILA - Family

CILA - Host Family

CILA - Intermittent

Community Living Facility

Developmental Training

Emergency Home Response Services

Home Accessibility Modification

Individual Service & Support Advocacy

Non-Medical Transportation (HBS only)

Occupational Therapy

Out of Home Respite

Other Day Program

Personal Support

Physical Therapy

Regular Work

Self-Direction Assistance

Skilled Nursing (HBS only)

Speech Therapy

Supported Employment

Temporary Assistance

Training & Counseling Services for Unpaid Caregiver

Vehicle Modifications

Should you have any questions, please feel free to contact Andrea Medley at Andrea.Medley@illinois.gov or by phone at (217) 524 - 2520.


9-15-17, Person Centered Planning: Who Should Develop Implementation Strategies?

Developing Implementation Strategies is the third component of the DDD Person Centered Planning process. Implementation Strategies are developed by provider agencies and describe how the provider will support the person to achieve his/her desires and needs. The following guidance should be used when determining what type of provider should develop Implementation Strategies:

Community Integrated Living Arrangement, Community Living Facility, Child Group Home, Developmental Training, Supported Employment Program, Adult Day Care providers who have agreed to work toward an outcome and/or provide services should develop an Implementation Strategy.

Self-Direction Assistants (SDAs) will be required to develop an Implementation Strategy as of November 1, 2017, for individuals in HBS who have a Personal Plan developed on or after this date. SDAs can develop an Implementation Strategy prior to this date if they choose to or at the request of the individual/family.

Individuals, families and others serving as the Employer of Record in HBS will be required to develop an Implementation Strategy as of November 1, 2017. This will be for individuals in HBS who have a Personal Plan developed on or after this date. Prior to this date, the Division will provide a format for HBS Employers of Record to utilize.

Behavior Analyst, Counselors, Psychotherapist, Speech Therapist, Physical Therapist, Occupational Therapist and HBS Nurses can develop an Implementation Strategy or use their existing assessments and treatment documents to outline the supports and services they will provide. In either case, these services must be reflected in the Personal Plan. When these providers use existing documents for individuals in HBS, the services they provide must be included in the Employer of Record's Implementation Strategy.

Agencies that provide Adaptive Equipment, Home or Vehicle Modifications, Assistive Technology or HBS Non-Medical Transportation are not required to develop Implementation Strategies. These services must be reflected in the Personal Plan. For individuals in HBS, these services must be included in the Employer of Record's Implementation Strategy. DD Waiver providers that request Adaptive Equipment, Home Modifications or Assistive Technology, in order to meet the needs of the individual, must include these services in their Implementation Strategy.


9-29-17, Life Choices - Person Centered Planning Information - Correction & Bogard Class Members Living in an ICF/DD

Life Choices - Person Centered Planning Information - Correction

First and foremost, we'd like to make you aware of a change in the Frequently Asked Questions (FAQs) - Life Choices System Transformation dated August 2017. The answer indicated below has been corrected in the posting on the DHS Website:

  • Delineation of Duties
    • Question: Who will be responsible for completing the Specific Level of Functioning Assessment and Physical Health Inventory (SLOF) for individuals with a mental illness:
    • Correct answer: The provider agency should continue to complete the SLOF annually for people with a mental illness as stated in Rule 115.

Bogard Class Members Living in an ICF/DD

Second, we want to affirm that Bogard class members who live in ICF/DDs are required to receive ISSA services, as stated in the Bogard Consent Decree. As such, they need to continue to receive a minimum of 4 visits a year. They are not involved in the Person Centered Planning process; therefore, they will continue to have an ISP developed by the ICF/DD provider.