Person Centered Planning is a CMS HCBS Regulation that addresses the balance between what is important to a person and what is important for a person in service planning. The Person-Centered Planning process focuses on outcomes identified by the person receiving services in collaboration with their guardian, if applicable, and family. The ISC will document those desired outcomes, assist in identifying the barriers that currently prevent the outcomes, and assist the individual and/or guarding, if applicable, to locate and select agencies willing and qualified to provide the needed supports.
Person Centered Planning within the DD Waivers includes three main components: The Discovery Process, the Personal Plan and Implementation Strategies; each of these are described in detail in this section. Person Centered Planning is required for individuals funded through DD Waiver services only. Person Centered Planning does not mandate goals in independence in daily living, economic self-sufficiency, community integration or self-administration of medication. The planning process outlined in this manual is for individuals who are or who will be enrolled in a DD Medicaid Waiver service.
Discovery is the first component of Person-Centered Planning. The Discovery process is designed to gather information about a person's preferences, interests, abilities, preferred environments, activities, and supports needed. The ISC agencies will be responsible for facilitating the Discovery process and documenting what they gather in the Discovery Tool. The Discovery process is not a one-time event, but a series of information gathering activities. The ISC will gather information through discussions (face to face, phone, and electronic), observations, and record reviews (evaluations, assessments, case notes). This process should begin with the individual and then include the guardian, if applicable, advocate or family, and others chosen by the individual. It must also include current providers. The information captured during this process is used to develop the Personal Plan which summarizes key and critical areas of the person's life.
- Independent Service Coordination (ISC) Agencies Responsibilities in the Person-Centered Planning Process:
- The ISC is responsible for the completion of the Discovery Process and Tool. This must be done in conjunction with the person and/or their guardian, if applicable.
- The ISC must complete the Discovery process for:
- Children and adults currently enrolled in a DD Waiver. This should be done as a part of Individual Service and Support Advocacy (ISSA).
- Children and adults newly transitioning to a DD Waiver, including Ligas Class members. This does not include individuals in Crisis.
- The ISC must continue to complete and submit the Crisis Transition Plan and Funding Request form for individuals who are considered to be in Crisis (homeless, abusive situation or neglectful situation). The ISC then has 30 calendar days after the date the person begins DD Waiver services to complete the Discovery process and develop the Personal Plan.
- The ISC should not complete the Discovery Process for:
- Individuals who are Bogard class members living in an ICF/DD. These individuals are not involved in the Person-Centered Planning process and will continue to have an Individual Service Plan developed by the ICF/DD provider.
- Individuals who are 100% State funded.
- The Process
- In preparing for the Discovery Process, consider the individual's desired preference for the manner, location(s), and time(s) to gather this information.
- The ISC must facilitate the Discovery Process and complete the Discovery Tool.
- The ISC should ask the individual who they want to participate in the initial discussions. They should consider inviting people who know, support, and respect them.
- If possible, the Discovery Process should include a face-to-face discussion with the individual and guardian, if applicable. In situations where the guardian is unable to be present, the ISC must document how information was received from the guardian.
- The ISC must obtain information from provider agencies currently serving the individual.
- The ISC can also obtain information from family members, Personal Support Workers, teachers, therapists, friends, childcare providers, and others who know the person well.
- The Discovery Process is fluid and should be conducted over a period of time instead of in a single meeting.
- The completion date of the Discovery Process cannot be more than six (6) months from the date of the Personal Plan.
- The Discovery Tool should be updated at least annually but can be updated more often if the individual and guardian, if applicable, request changes.
- Sources of Information
- The questions in the Discovery Process are meant to guide conversations. It is not necessary to ask every question in each section, but it is necessary to address each section of the Tool.
- Prior to talking to the individual, the ISC should consider what supports may be needed to promote the person's full participation (visual aids such as graphics/pictures to understand concepts, pen, paper, sign language interpreter, etc.).
- The ISC can obtain information in various ways: conversations (face to face, phone, e-mails), record reviews, assessments/evaluations, provider agency notes and summaries.
- If the individual is currently enrolled in a DD Waiver service, the ISC agency must obtain information from the current provider agency(ies).
- Provider agencies must send the ISC requested information/documents within 14 calendar days of receiving a request.
- If information will be obtained face-to-face, the ISC staff must ensure agency staff has the appropriate authorization to leave their work responsibilities to participate.
- When addressing risk, gather information from a variety of sources including the individual, guardian, if applicable, family, staff, record review, and observation. Use the information gathered to document why the concern currently presents a risk or when the concern has presented significant risk in the past.
- A separate risk assessment is not required but if an ISC chooses to use one, it must include the following domains: health/medical, safety at home, in the community and in the workplace, finances and behavioral supports.
- Guiding Conversations
When gathering information:
- Speak with the person using first person language and open-ended questions, such as "What do you…"
- Communicate with the individual, guardian, if applicable, and family using words that are easy to understand. Refrain from language only people working in the industry would understand and acronyms.
- If conducting a discussion with multiple people, ask the individual for input before asking others present to respond.
- Allow sufficient time for the individual to formulate thoughts and answer.
- Encourage/support multiple styles of communicating thoughts and ideas (pictures, drawing, symbols and words).
- The ISC should consider having a separate discussion with the individual prior to gathering information from other sources.
- If the individual is unable to communicate in a way for the ISC to understand, ISCs will have to rely on caregivers/those who know the person best to complete the discovery process. You may also rely upon caregivers when conducting the Discovery process with young children.
- Documenting the Information
- The Discovery Tool should be typed using the form provided. Using bullet points is preferred.
- The Discovery Tool must be completed by the ISC staff and therefore, will not be written in first person.
- The ISC should provide a copy of the Discovery Tool to the individual/guardian once the Discovery Tool is considered complete (each section addressed and with the ISC signature).
- The most recent copy of the Discovery Tool should be kept on file with the ISC.
- The ISC should provide a copy of the Discovery Tool, as a part of the complete referral packet, to the provider agency selected by the individual/guardian. This should occur after the person has selected the provider(s) and given consent to make a detailed referral for services. If the individual is remaining with a current provider, a copy should also be given to this provider.
- The ISC must complete the Discovery Tool at least annually but can update more often if the preferences, abilities or needs of the person change.
- The completed Discovery Tool will not require a review/approval from the Division of Developmental Disabilities.
B. Personal Plan
The Personal Plan is the single, comprehensive personal vision for a person's life. This document focuses on the individual's strengths, preferences, needs and desires. The ISC agencies will be responsible for developing the Personal Plan in conjunction with the individual, guardian, if applicable, family, and providers. The Personal Plan will not only contain the outcomes the person requires in their life, but also documents choices of qualified providers, reflect what is important to the person regarding delivery of services in a manner which ensures personal preferences, health and welfare. It must also include risk factors and plans to minimize them. This document is developed through a person-centered process and serves as a mechanism for sharing this information with others who are or will be involved in supporting the person to achieve his/her desired life. The Personal Plan provides the basis for receiving services, service monitoring and quality evaluation.
The Personal Plan should be developed only after the Discovery process (initial or updated) is complete, except situations when a Ligas Transition Service Plan (LTSP) is required. In these cases, the Personal Plan should be completed based on the LTSP instead of the Discovery Tool. Prior to the initiation of services or the expiration of the current Personal Plan, the ISC should complete the Personal Plan form based on what was learned during the Discovery or LTSP process.
- Developing the Plan
- The ISC is responsible for developing the outcomes and ensuring the completion of the Plan.
- The Personal Plan is based on information gathered during the Discovery process.
- The ISC must develop the Personal Plan for:
- Children and adults currently funded in a DD Waiver. This should be done as a part of Individual Service and Support Advocacy (ISSA).
- Children and adults newly transitioning to a DD Waiver. This must be completed prior to initiating DD Waiver services, with the exception of Crisis cases.
- For individuals who are considered to be in Crisis (homeless, abusive situation, or neglectful situation), the ISC must complete the Crisis Transition Plan and Funding Request.(PDF) (IL462-0140) form. The ISC then has 30 calendar days after the date the person begins DD Waiver services to conduct the Discovery process and develop the Personal Plan.
- The ISC will use the Personal Plan form as the official Plan. Alternative formats of the Plan may be generated and distributed to the individual and guardian, if applicable, as needed.
- The contents of the Plan must reflect the key aspects of a person's life as outlined on the form. If there is no outcome listed in a section, the ISC should still complete the remaining statements/questions of that particular section as appropriate.
- It should be recognized that some individuals will have multiple desired outcomes, all of which may not be addressed at this time. In such cases, the ISC should assist the person to prioritize outcomes and select providers who meet the "top" priorities. The ISC should document the outcome(s) currently on hold and the reason why.
- The ISC must ensure the Plan accurately reflects the outcomes, preferences, strengths and support needs of the individual.
- The Plan must also discuss risk and strategies to minimize these risks.
- The current Plan must be completed within 365 days of the previous Plan.
- The Personal Plan is considered complete when the individual and guardian, if applicable, approve the services, identified outcomes and supporting information in the Plan. The individual and guardian, if applicable, and ISC must sign the Personal Plan. The last signature date of these three parties becomes the annual renewal date for the Personal Plan.
- If the individual is unable or unwilling to sign the Personal Plan, the ISC must document the reason why and the date the ISC reviewed the Plan with the person.
- If the guardian, if applicable:
- Is unable to sign the Plan, the ISC must obtain verbal approval from the guardian and document the method and date the approval was received.
- Is unwilling to approve and sign the Plan, the ISC must first work to resolve any disagreement(s) and document in the Plan how the disagreement(s) was addressed. If the guardian is still unwilling to approve and sign the Plan, the ISC must document the reasonable measures taken to obtain their approval/signature.
- Is unresponsive to requests for their approval and signature, the ISC must document the reasonable measures taken to obtain this information and the individual's guardian has failed to respond.
- Does not sign and date the Personal Plan, the last signature date of the individual or ISC becomes the annual renewal date for the Personal Plan.
- The completed Plan shall become a part of the individual's record.
- The ISC will update the Plan at least annually to ensure it continues to reflect the person's preferences.
- Individuals, guardians, if applicable, families or service providers who wish to revise or edit a Personal Plan should notify the ISC.
- The Plan can be revised or edited more often if the person's desires or needs change. Revisions and edits to the Plan must be done using the following guidelines:
- Revising the Personal Plan:
- If there is a significant change in the individual's wellbeing (medical or behavioral), the ISC must review and revise the Discovery Tool and Personal Plan to ensure these documents accurately reflect the current preferences, desires, abilities and support needs of the individual.
- On page 1 of the Personal Plan, under Check type of Plan, the ISC must select Revision.
- A Revision requires new signatures (and dates) from the individual, guardian, if applicable, and ISC.
- The last signature date of the individual, guardian, if applicable, and ISC becomes the annual renewal date for the Personal Plan.
- A new Provider Signature Page(s) should be completed along with a new Implementation Strategy.
- Edits to the Personal Plan:
- When the ISC becomes aware of the need to add or subtract an outcome or service, the Plan can be edited.
- The Discovery Tool should be reviewed and updated as needed (if discrepancies are identified).
- It is not necessary to obtain new signatures from the individual, guardian, if applicable, or ISC when the Plan is edited.
- An edit to the Plan does not reset the annual renewal date.
- Dissemination of the Plan and Provider Selection
- The individual and guardian, if applicable, directs the ISC to disseminate the Personal Plan to provider organizations that they're considering as a possible service provider for the purpose of determining organizations' ability to meet the desired outcomes and/or provide services identified in the Plan.
- Organizations who believe they can meet outcomes and/or provide services identified in the Plan, can request to be part of the provider selection process.
- If a provider in a certain geographic area cannot implement the outcomes identified in an individual's Personal Plan, the individual, guardian, if applicable, and family can decide if the service needs and desired outcomes are greater than their geographic desires.
- In cases where a current provider is unable or unwilling to assist the person to work towards any desired outcome or provide services: This provider should not sign a Provider Signature Page.
- The ISC should assist the individual to locate other qualified and willing providers. Until a qualified and willing provider(s) is located, the ISC should:
- Document its progress toward finding an appropriate service provider.
- Document the outcome(s) currently on hold and the reason(s) why.
- It is crucial for all stakeholders to understand the outcomes listed in the Personal Plan are those expressed by the individual through the Discovery process. Service providers who are aware of the need to change the Plan should notify the ISC of the person's need or desire to change their Plan.
It is expected that each individual in DD Waiver services has at least 1 outcome. This may reflect something the individual desires that is not currently present or it may reflect something already present, and they want to maintain it. When developing outcomes in the Personal Plan, remember that outcomes:
- Can only be developed after identifying what is important to the person through the Discovery process.
- Should include what is important for the person. The outcome statement should reflect "in order to" or "so that". See examples below.
- May have to be prioritized.
- Are not services and supports; see examples below.
- Should be understandable to a person without an intellectual/developmental disability.
- Must be written in present tense and plain language.
- Should not be written in first person.
- Outcomes should only be identified for sections the individual expressed a desire or preference.
- Examples of Outcomes Statements:
- "Mary volunteers at a day care center so she gets to spend time with children and knows she is needed."
- "Bernice sings with the choir on Sundays, so she stays active."
- "Ron enjoys rock music while bathing so he can relax and feel refreshed."
- "Bree watches Animal Planet when she is assisted to stretch so she feels safe and relaxed during her exercise time."
- "John delivers mail at the hospital in order to gain job skills."
- When documenting risk in the Personal Plan:
- Provide narrative information (including brief overview of current skills as well as potential and known risks) sufficient to guide a provider.
- Consideration should be given to both the risks associated with current activities of the individual as well as potential risks which inhibit the individual from pursuing his/her goals and fully participating in integrated settings.
- All safeguards, supports, education and training necessary to mitigate identified risks should be included.
- Discuss with the individual and guardian, if applicable, if they are willing to accept some situations with risks to facilitate choice, independence, and community integration.
- Identify safeguards that are already in place to minimize identified risks and outline additional needed actions to reduce other risks which pose a real or potential threat to the individual's health, safety and/or welfare.
- Identify who will be responsible for each of the needed safeguards and actions.
If conflict arises during Personal Plan development, the ISC should:
- Determine what needs to change and what needs to remain the same for the person by considering what makes sense or is working as well as what doesn't make sense or isn't working in the individual's life.
- Allow each person to contribute their perspective.
- Use the information gathered as the basis of thought for the development of an outcome.
Ultimately, the decision-making authority rests with the individual and guardian, if applicable. The guardian has authority to make decisions on behalf of the individual as authorized by the State Probate Code, 755 ILCS5/ - Probate Act of 1975. The Division would expect ISC's and providers to work with the guardians and individuals when there is a conflict regarding the personal plan. This may include helping the guardian and individual to reach a compromise. If there is ongoing evidence that the guardian is not acting pursuant to the authority granted to them in the State Probate code then the ISC should refer the matter to the State Probate Court.
- Summary of Services and Supports Page
The Summary of Services and Supports page of the Personal Plan is to be completed by the ISC agency. The ISC must document all services, as applicable to each individual, on this page of the Plan under the column titled Service/Support. ISC agencies must ensure all Medicaid Waiver services to be provided to an individual (including the service's scope, amount, frequency and duration) must be listed in the individual's Personal Plan. This should include Individual Service and Support Advocacy. Billings and claims for any Medicaid Waiver service found during an audit and not included in the Plan will be voided. It is not necessary for ISC agencies to document the details of these services (i.e., provide assistance with meal preparation) on this page. Provider agencies who are aware of the need to change services (i.e., add Supported Employment), should notify the ISC to ensure this service is requested by the individual and guardian, if applicable, and included in the Personal Plan.
- Provider Signature Page
The Provider Signature Page of the Personal Plan should only be completed and signed by provider agencies who will render services or work toward outcomes listed on the Summary of Services and Supports page of the Personal Plan. Prior to delivering any services through the Medicaid Waivers, providers should ensure they have a copy of the final and completed Plan. The Summary of Services and Supports page of the Plan must contain the service(s) the provider will deliver. All paid services that are applicable to the individual must be identified on this page. Billings and claims for any Medicaid Waiver service found during an audit, not to be included in the Plan, will be voided.
- After receipt of a Personal Plan, provider agencies who will support any of the services or outcomes listed in the Plan should document the particular service(s) and outcomes they will address 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., providing assistance with hygiene) on this page. The details of how the service will be provided should be outlined in a provider's Implementation Strategy.
- A provider agency must not change the services or outcomes contained in the Plan. Provider agencies who are aware of the need to revise or edit the Plan, should notify the ISC.
- Provider agencies have 10 calendar days to complete, sign and return the Provider Signature Page. The completed and signed page becomes a part of the individual's Personal Plan.
- Back Up Plan
- An emergency back-up plan is only required for individuals who receive Home-Based Services (HBS) services to handle situations when:
- an employee, who is providing essential supports, is unavailable;
- the Employer of Record is not capable or available to manage employees; and
- handling other emergencies.
- A back-up plan may include friends, family or other natural supports, trained and qualified employees, or agency providers whom the individual can call for assistance.
- If back-up services are to be purchased from an agency provider, the individual/employer of record must consider such costs in the budget. In addition, any employees who are paid to provide back-up services must not be scheduled for over 40 hours per week.
- The Personal Plan must also address the back-up plan. All members of the individual's support team must be educated about the back-up plan and have information accessible.
C. Implementation Strategies
The information identified in the Personal Plan must be addressed and accounted for in the Implementation Strategy. An Implementation Strategy must detail the supports and services that will be provided on a day-to-day basis. Implementation Strategies are developed by provider agencies who have agreed to provide services. Implementation Strategies will be evaluated to assure consistency between the stated desires and provider-directed activities/support.
- Strategies developed by Provider Agencies
After the provider agency signs the Provider Signature Page of the Personal Plan, the provider agency will develop an Implementation Strategy that includes the details of how the service(s) will be provided. Prior to delivering any services through the Medicaid Waivers, providers should ensure they have a copy of the final and completed Plan. Billings and claims for any Medicaid Waiver service found during an audit not to be included in the Plan will be voided.
- Provider agencies who will develop an Implementation Strategy can determine their own tool/format, but it must at least contain the following information:
- Basic descriptive, diagnostic, demographic and medical information.
- Outcomes identified in the Personal Plan the provider has agreed to work toward.
- 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.
- All services and supports to be provided, regardless of provider or funding source, including type or methods, frequency, duration, and staff to be assigned, if applicable.
- Justification for any restriction(s) or modification(s) which limit the person's choice, access or otherwise conflict with HCBS standards.
- Documentation for any situation where a person lives in a residential setting owned or controlled by a service provider and modifications to the community settings are requested.
- When an individual is using the same provider agency for multiple services (i.e., CILA and CDS services) the provider agency is not required to develop two different Implementation Strategies. However, if the strategies for the services are significantly different and the provider determines separate Implementation Strategy documents would be more "user friendly" for the staff, the use of separate documents is acceptable. Regardless of whether the provider opts to use separate or combined strategies, each of the Implementation Strategy documents must contain all the necessary components described above. The provider should keep a copy in both service locations, so staff are aware of the supports and services they are to provide.
- Provider Agencies have 20 calendar days to develop their Implementation Strategy. The 20 calendar days begin with the provider's signature date on the Provider Signature Page of the Personal Plan.
- Provider agencies must provide the individual, guardian, if applicable, and the ISC a copy of the Implementation Strategy.
- Individual/guardians must review the proposed strategies. If approved, the individual and guardian, if applicable, is required to sign the provider's Implementation Strategy. The ISC will not sign or approve Implementation Strategies.
- Provider agencies must ensure all services being billed are identified in the Personal Plan. Provider agencies who are aware of the need to change services (i.e., add Supported Employment), should notify the ISC to ensure this service is requested by the individual and guardian, if applicable, and included in the Personal Plan.
- Implementation Strategies must reflect ongoing review, monitoring and updating when necessary. Implementation Strategies 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.
- Provider types listed below, who have agreed to render services and/or work toward outcomes, should develop Implementation Strategies as outlined below:
The following provider types are required to develop Implementation Strategies:
- Adult Day Care
- Agency-based Personal Support Worker (HBS only)
- Child Group Home
- Community Integrated Living Arrangement
- Community Day Services
- Community Living Facility
- Supported Employment Program
- Remote Support
The following provider types can develop Implementation Strategies OR use current Assessment/Treatment Documents:
- Behavior Services (Therapy, Counseling)
- Nursing (HBS only)
- Occupational Therapy
- Physical Therapy
- Speech Therapy
The following provider types are not required to develop an Implementation Strategy:
- Adaptive Equipment
- Assistive Technology
- Home Modifications
- Non-Medical Transportation (HBS only)
- Self-Direction Assistant (HBS only)
- Vehicle Modifications
- Individually hired Personal Support Worker
- Employer of Record Implementation Strategies
The Employer of Record should complete the Strategy. An individual, guardian, if applicable, and family can also hire a Self-Directed Assistant to assist or to complete the form on behalf of the individual, guardian, if applicable, and family.
The Employer of Record can be the HBS participant, guardian, if applicable, family, or close associate who is ultimately responsible for ensuring wages are paid and taxes are filed for individually hired Personal Support Workers (PSWs). The Employer of Record is also responsible for overseeing the services outlined in the monthly budget, signs Service Agreements, Service Authorizations, and time sheets. In addition, the Employer of Record may help with hiring, training, supervising and firing PSWs. Resources for this implementation strategy are: Employer of Record Implementation Strategy for Home Based Supports and services.(PDF) and Instructions for the Employer of Record Implementation Strategy for Home Based supports and services.(PDF).