Person-Centered Planning Process

Illinois Department of Human Services

Division of Developmental Disabilities

Information Bulletin

DD.22.012

Purpose:

This Information Bulletin informs Division of Developmental Disabilities (DDD) stakeholders of changes to the Person-Centered Planning process.

Background:

Person-centered planning using conflict-of-interest-free case management is a requirement for people receiving Medicaid waiver services. In 2017, Illinois transitioned the responsibility of writing the Personal Plan to Independent Service Coordinators (ISCs) which had previously been the responsibility of service providers. Service providers are responsible for writing Implementation Strategies which reflect what is written in the Personal Plan. In the spring of 2021, the DDD within the Illinois Department of Human Services (IDHS) contracted with the Institute on Disability and Human Development at the University of Illinois Chicago (UIC) to evaluate the person-centered planning process and make recommendations to improve the process for all stakeholders.

Person-Centered Planning Process:

The person-centered planning (PCP) process uses a Discovery Process to develop a person-centered plan (Personal Plan). The Discovery Process and development of the Personal Plan are to be completed by the ISCs. The service providers then use the Personal Plan to develop the Implementation Strategy. The process is directed by the individual, with assistance as needed or desired from a representative of the individual's choosing. It is intended to identify the strengths, capacities, preferences, needs, and desired measurable outcomes of the individual. The process may include others, freely chosen by the individual, who are able to serve as important contributors to the process. The PCP process empowers the individual by building on their specific abilities and skills, building a quality lifestyle that supports the individual to find ways to contribute to the community. The planning process must also include planning for contingencies such as when a needed service is not provided due to the support worker being out sick. The back-up plan must become a part of the individual's Personal Plan.

Discovery Process:

The Discovery process is designed to gather information about an individual's preferences, interests, abilities, preferred environments, activities, and supports needed. The ISCs are responsible for facilitating the Discovery Process with the individual 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, including face to face, phone and electronic meetings/visits, observations, record reviews, evaluations, assessments, and case notes. This process should begin with the individual (and other representatives the individual wants to participate) and advance as needed. It must also include input from current providers, if applicable. The provider(s) should be invited to the planning (face to face) meeting if the individual wishes to invite them. The information captured during this process is used to develop the Personal Plan which summarizes key and critical areas of the person's life.

The Discovery Tool was updated to reflect changes in HCBS Settings Rule expectations. This revision of the template allows for further changes to guide the discovery process in assisting the individual to identify their desired outcomes based on what is important to and for them in their life. The format of the template remains similar; however, questions were redesigned towards providing services that are in line with the Settings Rule expectations all providers are required to follow. Questions remain a guide to determining what is important to each individual within each critical life area. Not all questions need to be addressed; however, enough information should be gathered for all stakeholders to be able to determine how the individual wants to be supported.

Discovery Tool

  • The completion date of the Discovery Tool cannot be more than six (6) months from the date of the Personal Plan.
  • The Discovery Tool should be updated at least annually or as requested by the individual and/or guardian as applicable.
  • The Discovery Tool needs to be completed within 365 days from the previous tool. The official date of the Discovery Tool is the date the ISC signs the completed document, not the date of the face-to-face information gathering session.
  • 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.
  • At least one face-to-face visit must be conducted to complete the Discovery Process/Personal Plan.
  • In situations where the guardian is unable to be present, the ISC must document how information was received from the guardian. The ISC can also obtain information from family members, service provider staff, personal support workers (PSWs), teachers, therapists, friends, etc.
  • The ISC must address each section of the Tool. Although it is not necessary to ask every question in each section, it is important to gather enough information to determine the individual's preferences, abilities, support needs, barriers, and risk.
  • Barriers are factors that may prevent a desired outcome or make it difficult for something to be achieved. Barriers are only required for critical life areas that the individual has expressed a desire to work toward achieving an outcome.
  • Risks are factors that could be exposing someone to harm or danger in each critical life area; it is also the possibility that something bad or unpleasant is likely to happen if the individual is exposed to the situation.
  • The updated template for the PCP documents includes 10 critical life areas.

Personal Plan:

The Personal Plan is the single, comprehensive personal vision for an individual's life. It is developed using the information obtained during the Discovery Process, and within the Discovery Tool. This document is created through a person-centered approach and serves as a mechanism for sharing information with those who will be involved in supporting the individual to achieve their desired life. The Personal Plan provides the basis for receiving services, service monitoring, and quality evaluation. It focuses on the individual's strengths, needs, and desires. The Personal Plan will not only contain the outcomes that the individual requires in their life but also documents the choices of qualified providers and reflects what is important to the individual regarding the delivery of services in a manner that ensures personal preferences, health, and welfare. It includes risk factors, plans to minimize them, and any barriers that may prevent the individual from achieving their outcomes.

  • The Personal Plan should adhere to the culture, style, purpose, and vision of the individual.
  • The Personal Plan directly impacts the individual's quality of life.
  • The Personal Plan should address the challenges, risk factors, and rewards inherent for each individual to live life the way they choose.
  • The Personal Plan should outline any modifications identified in the rights a person has under the HCBS Settings Rule and must reflect an assessed need for modifications.
  • The current Plan must be completed within 365 days of the previous Plan.
  • The Personal Plan is considered complete when the individual and guardian approve the services, identified outcomes and supporting information in the Plan.
  • The individual, 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.

The ISC must develop a Personal Plan for children and adults currently funded through a Home and Community Based Services Waiver operated by the DDD. This should be done as a part of Individual Service and Support Advocacy (ISSA). They must also develop plans for children and adults newly transitioning to a DDD Waiver. This must be completed prior to initiating DDD Waiver services, with the exception of crisis cases*.

* For individuals who are considered to be in crisis, the ISC must complete the Crisis Transition Plan and Funding Request form. The ISC then has 30 calendar days after the date the individual begins DDD Waiver services to conduct the Discovery Process and develop the Personal Plan.

Revising/Editing the Personal Plan:

The Plan can be revised or edited if the individual's desires or needs change. Service providers who are aware of the need to revise or edit the Plan should notify the ISC.

Revisions to 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.
    • For example: individual changing/transitioning from AHBS to CILA, individual transitioning from CHBS to AHBS
  • On page one 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(s) and ISC.
  • The last signature date of the individual, guardian(s) 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.
    • For example: individual no longer wants to work at Wal-Mart, wants to try an animal shelter (edits).
  • The Discovery Tool should be reviewed and updated as needed (if discrepancies are identified).
  • On page one of the Personal Plan, under Check type of Plan, the ISC must select "Edit".
  • It is not necessary to obtain new signatures from the individual, guardian(s) or ISC when the Plan is edited.
  • An edit to the Plan does not require a new Provider Signature Page or a new Implementation Strategy, but the Implementation Strategy does need to be edited to include the information from the Personal Plan.
  • An edit to the Plan does not reset the annual renewal date.

Provider Selection:

  • Once the Personal Plan is completed, the individual/guardian directs the ISC to disseminate the Personal Plan to service providers they're considering as a possible service provider for the purpose of determining the organization's ability to meet the desired outcomes and/or provide services identified in the Plan.
    • Organizations that believe they can meet outcomes and/or provide services identified in the Plan can request additional information from the ISC (i.e. Discovery Tool, medical and social histories, psychological evaluation(s), etc.) and complete a Provider Signature Page to indicate a commitment to the individual. This must be done within 10 calendar days of receipt of the Personal Plan.
    • Once the provider has completed the Provider Signature Page and returned the document to the ISC, providers have 20 calendar days to develop a strategy for how the organization will implement the individual's Plan.
  • In cases where a current provider is unable or unwilling to assist the individual to work towards any desired outcome or provide services, the 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.

Outcomes:

  • Outcomes are directed by the individual to help them move toward a life they consider meaningful and productive.
  • It is expected that each individual in DDD Waiver services has at least 1 outcome.
  • Outcomes may reflect something the individual desires that is not currently present (such as learning a new hobby or skill) or it may reflect something that is already present that they want to maintain. Outcomes should not be tasks the individual needs to do to live, such as cleaning their bedroom or taking out the trash. Outcomes should be tied to the dreams or opportunities the individual wants to have in the future.
  • Outcomes can only be developed after identifying what is important to the individual.
  • The outcome statement should reflect "in order to" or "so that" to identify what is important to and for the individual.
  • Outcomes should be used to search out what is truly important to and for an individual and what capacities and skills that individual possesses.
  • Outcomes are values-based with the knowledge that every individual has unique capacities and skills.
  • Outcomes should focus on a positive vision for the future of the individual based on their strengths, preferences, and capacities for acquiring new skills, abilities, and interests. It focuses on what a person can do versus what a person cannot do.
  • These outcomes should make sense for someone without an intellectual/developmental disability.
  • Outcomes are not services and supports, nor are they meant to punish or control someone's behavior.
  • If there is no identified outcome in a critical life area, the ISC should still complete the remaining statements/questions of that life area, including completing the risk evaluation.
  • 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 individual to prioritize outcomes and select providers that meet the "top" priorities. The ISC should document the outcome(s) currently on hold and the reason why within the critical life area.

Back Up Plan:

  • The Back Up Plan is only required to individuals who are funded in the Home Based Support Services Program.
  • The Back Up Plan should address contingencies and emergencies, including the failure of a support worker to appear when scheduled to provide necessary services and the absence of the service presents a risk to the individual's health and welfare.
  • The Back Up Plan should be specific to the individual's needs and preferences. A sufficient Back Up Plan is not just to rely on calling 911, but rather one that utilizes other formal social service agencies, as well as family, neighbors, friends, and assistive technology devices.
  • Once complete, copies will be kept with the Personal Plan, provided to any service providers identified to provide services in the Back Up Plan, and with the individual.

The Individualized Back Up Plan form.pdf is online.

Implementation Strategy:

Implementation Strategy (IS) describes how the service provider will support the individual to achieve their desired outcomes. The primary objective of the Implementation Strategy is to provide sufficient direction for direct support professionals and other direct care staff to support the individual safely and according to their needs, preferences, and risks. The information identified in the Personal Plan must be addressed and accounted for in the Implementation Strategy.

As a direct result of the evaluation UIC completed on the person-centered planning process in Illinois, a recommendation was made to develop a standardized template that all providers will use to develop the Implementation Strategy for each individual receiving DDD Waiver services. The goal of the template is to ensure all providers are supporting individuals within the expectations of the HCBS Settings Rule as well as to ensure waiver compliance.

  • Every service provider is required to start using this new template upon release.
  • The IS must contain outcomes identified in the Personal Plan that the provider has agreed to work towards.
  • The IS should also include a description of how supports and services assist the individual to engage in community life and maintain control over personal resources.
  • The IS must include opportunities to seek employment and work in competitive integrated employment if desired by the individual.
  • The IS may contain functional goals/training areas to learn or improve skills for the individual.
  • If any functional goals/training areas are identified within the IS, they should also include the methods to measure progress and what should happen when the individual learns the required skill.
    • Examples of functional goals/training areas could be, the individual will complete their laundry weekly, or the individual will complete physical therapy exercises three times a week.
  • The functional goals should be included within a monthly progress note but are not expected to be revised on a timeline. Providers should revise or discontinue any functional goals/training areas that are no longer necessary for the individual.
  • Risks should be included in the IS that are identified in the Personal Plan. A separate risk assessment is not required as long as the IS includes all risks, plans to mitigate the identified risk and identify who is responsible for implementing these strategies.
  • The IS should be completed within 20 calendar days of the provider's dated signature on the Provider Signature Page.
  • The IS needs to be approved by the individual receiving services before it can be implemented. Plans should then be sent to the guardian, if applicable, for approval.
  • Each critical life area must be completed. If there are no outcomes present for a specific life area, the following areas must still be completed.
    • Strength and Preferences
    • How the agency will maximum strength/preferences
    • Identified Risk
    • Strategy used to mitigate risks
    • Backup Strategy (Not for 24-hour CILA or CDS)
    • Progress on last year's outcomes (if the individual had an outcome in this critical life area during the previous plan year)
  • The language used in the plan should be person-centered and focused on the individual's abilities. Providers should avoid phrases that appear to control or restrict an individual, such as "allowed to" or "must do in order to." For example, phrases such as:
    • "The individual is allowed to request alternative meals." Should be replaced with: "The individual is encouraged to request alternative meal options if they do not like, or do not want the agreed upon meal."
    • "The individual is allowed to spend $20 on an outing." Should be replaced with: "The individual can make purchases as desired."
    • "The individual must tell staff X in order to be able to do Y." Should be replaced with: "The individual has 2 hours of time within the community alone. To ensure staff is aware of their plans, they are encouraged to communicate with staff where they plan to go and when they plan to return. If the individual does not wish to share details of the community trip, this should not limit or prevent their access to the community."

All Implementation Strategies should include the justification and documentation for any restriction(s) and/or modifications that limit the individual's choice, access or otherwise conflict with HCBS Settings Rule standards including:

  • Previous attempt to use positive interventions and support.
  • Documentation that less intrusive methods were attempted.
  • Includes a clear description of the condition that is directly proportionate to the specific assessed need. This should include a brief explanation for why the restriction and/or modification is being implemented.
  • Each modification/restriction should only be implemented based off the assessed need of the individual. At no time, should modifications and/or restrictions be implemented at the guardian's request without an identified need.
  • Description of data collection methods.
  • Timeframes for periodic review to determine if modifications remain necessary.
  • Informed consent of the individual.
  • Assurance that intervention(s) will not harm the individual.
  • All restrictions and/or modifications need to be reviewed by the agency Human Rights Committee.

Timeline:

  • Discovery Tool must be completed within 365 days of the previous Discovery Tool.
    • Discovery Tool date is the date the Tool is signed by the ISC.
  • Personal Plan must be completed (signed by all parties) within 365 days of the previous Personal Plan date.
    • Personal Plan date is the final date the Personal Plan is signed.
  • Provider signature page is due back to the ISC within 10 calendar days of receipt of the Personal Plan.
  • Implementation Strategy is due within 20 calendar days of the date the Provider Signature Page is signed by the QIDP.
    • Implementation Strategy date is the date the QIDP signs the plan.

Effective Date

October 1, 2022