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These Person Centered Planning (PCP) process guidelines are intended to assist the individual (i.e., the person receiving the services), his/her family members and friends, service coordinators/case managers, and state and local service providers who participate in life planning. The purpose of this document is to guide the team in making the choices and developing strategies that comprise the support plan based on the individual’s desired lifestyle rather than the traditional remediation and deficit approach.

The person centered planning process is a core component of quality service delivery. Person centered planning should not be viewed as an "add-on" to the current planning process. Instead, person centered planning replaces the deficit-based assessment that traditionally has driven the Individual Service Plan.

The individual is the central driving force in determining his or her future vision, goals, supports and services. The planning process requires that family members, friends, and professionals to:

• listen to the individual;
• attend to the details;
• be open and sensitive to situations that can be difficult and confusing;
• encourage dreams and desires of the individual and to contribute to those dreams and desires; and
• identify and support what really matters to the person.

The person centered planning process requires a shift in traditional thinking, actions, and way of doing business. The individual directs the services and supports.

I. Definition of Person Centered Planning

Person centered planning is a process whereby persons with disabilities, with the support of families, direct the planning and allocation of resources to meet their own life vision and goals. This planning process:

• is based on a person’s preferences, dreams, and needs;
• understands how a person makes decisions;
• understands how a person is and can be productive;
• discovers what the person loves and dislikes;
• encourages and supports long-term hopes and dreams;
• is supported by a short-term support plan that is based on reasonable costs given the person’s support needs;
• includes the individual’s responsibilities;
• includes a range of supports including funded, community and natural supports; and
• should be conducted based upon the needs of the individual, but at least annually.

1. Discovery process: the process of identifying the strengths, preferences, and desires of an individual. It is an information gathering process that provides the foundation for developing/updating an individualized support plan. This occurs on an ongoing basis.
2. Facilitator: the person who leads the team through the person centered planning process, which includes developing an individualized support plan. The facilitator is anyone chosen by the individual. The facilitator gets people to share ideas and efficiently leads them through the process. He or she involves the individual and assures understanding of the discussion. The facilitator must be a good listener, check understanding regularly, observe themes, and guard against immediate or old solutions. He or she prepares for the meeting(s), maintains focus and redirects concerns unrelated to the plan development.
3. Individual: a person with a disability seeking or receiving services.
4. Informed Choice: the ability to make a voluntary decision based upon options presented to the individual. The individual will engage in a variety of experiences to identify preferences and choice.
5. LAR (legally authorized representative): is a person authorized by law to act on behalf of an individual and who may include a parent or guardian of a child, or a guardian of an adult.
6. Natural Supports: supports that occur naturally within the individual's environment. These are not paid supports, but are supports typically available to all community members. Natural supports should be developed, utilized and enhanced whenever possible. Purchased services should supplement, not supplant, the natural supports. Some examples of natural supports are the family members, church, neighbors, co-workers, and friends.
7. Open-ended questions: questions that do not suggest an answer, e.g. not simply yes/no or multiple choice questions.
8. Service Coordinator/ Case Manager: an individual employed by (Service Coordinator) or contracted by (Case Manager) FSSA who provides assistance to the individual in identifying and accessing medical, social, residential, employment, educational, behavior, and other appropriate services that will help an individual achieve a quality of life and community participation acceptable to the individual (and LAR on the individual's behalf) as follows:
   1. crisis prevention and management-locating and coordinating services and supports to prevent or manage a crisis;
   2. monitoring-ensuring that the individual receives needed services; evaluating the effectiveness, relevancy, and adequacy of services; and determining if identified outcomes are meeting the individual's needs and desires as indicated by the individual (and LAR on the individual's behalf).
   3. assessment-identifying the nature of the presenting problem and the service and support needs of the individual; and
   4. service planning and coordination-identifying, arranging, advocating, collaborating with other agencies, and linking for the delivery of outcome focused services and supports that address the individual's needs and desires as indicated by the individual (and the LAR on the individual's behalf).
9. Support Team: the team established by the individual that typically includes his/her legally authorized representative (if applicable), close family members/advocates, the case manager, providers, a BDDS Service Coordinator, and others identified by the individual as being important in his/her life.

Person centered planning is based on a variety of approaches or "tools" to organize and guide community change and life planning with people with disabilities, their families and friends. All approaches or "tools" have distinct practices, but share common beliefs. Although FSSA does not require the use of a specific "tool", the elements listed below must be evident in the planning process.

1. Person centered planning process is based on a framework that describes five essential accomplishments: 1) community presence, 2) community participation, 3) choice, 4) respect, and 5) competence.
2. Individual differences and differences in family dynamics and composition are respected and accepted.
3. Person centered planning requires that it is the individual who defines what is meaningful in his/her life and what really matters most to him/her.
4. All individuals have the opportunity to make informed choices and need to exercise control of their lives. Sometimes in order to do this effectively they must be supported by others and have a variety of experiences, either in their natural environment or from within the system.
5. Individuals must have choice among flexible, dependable services that meet their immediate needs and support their goals and aspirations for a lifestyle that affords personal control, informed decisions, dignity and respect.
6. Person centered planning process builds on an individual's strengths, gifts, skills, talents, and contributions.
7. Person centered planning processes encourage the "building of community" around individuals. They help develop supports to facilitate relationships with people within the individual's community.
8. Individuals should fully and actively participate in making the decisions that affect their lives.
9. Solutions to obstacles and issues that emerge during the person centered planning process are negotiated to ensure that resulting activities are consistent with the individual's preferences and goals.
10. The individual partners with the support team to explore creative options to meet the preferences and goals expressed by the individual.
11. Resources to support the individual are based on identified needs that the individual may have and are available in the community and/or in an agency. Natural resources presently available in the community are used first, then the agency resources. In instances where generic resources may not exist, they may need to be developed within the community.
12. All strategies and resources used must support the desired outcomes and identified needs of the individual. Strategies are developed to increase the likelihood that individuals will increase control over their lives, participate in community life and develop relationships.
13. Person centered planning is a dynamic, rather than a static process. The individualized support plan is revised as new opportunities and obstacles arise or when significant changes occur in the individual's life.
14. A person's cultural background is acknowledged and valued in the planning and decision-making process.

Person centered planning is an interactive planning process which brings together the people who live with the concerns and issues daily and who are committed to learning together to respond to the situation. Specifically, the differences are:

1. Listen, acknowledge, and discover the personal goals, preferences, choices, and abilities of the individual directing the plan:
   1. A person centered planning process occurs only when the individual is present.
   2. Prior to the planning meeting, the facilitator goes over the issues to be discussed with the individual or family/primary caregiver. They identify those issues that will be discussed in a larger group (public issues) and those that are to be discussed more privately (private issues).
   3. The facilitator asks open-ended questions to elicit information from the individual or family/primary caregiver in order to discover the preferences, choices, goals and abilities of the individual.
   4. The discovery process may or may not occur in a planning meeting with a large group of people. It can occur separately with the individual, family/primary caregiver and those that know him/her well.

      The discovery process solicits information based on the individual’s strengths, capacities, gifts, skills, talents, and contributions.

      All the information collected from team members (within or outside of the person directed planning meeting) during the discovery process must be confirmed with the individual to ensure accuracy before documenting it.

      The individual's goals and preferences are constantly evolving; therefore, person centered planning is ongoing and not a one time/annual planning process. Question-asking, listening and discovering the preferences of the individual is on-going.

      Every effort must be made to ensure that the individual is fully informed to make responsible choices based upon options presented.

2. Documentation of the information gathered during a person centered planning process is important
   1. All information should be written in a respectful manner. Information is to be communicated to the individual in a way that she or he understands.
   2. Document all the information gathered from the individual /family to ensure that it is available to all pertinent staff and/or providers (new and old). This helps reduce or eliminate the need to ask the same questions repeatedly by new staff to the individual or family members.
   3. All the information must be documented in the plan without changing the meaning that the individual/family attributes to it.
   4. The documentation should cover the individual's daily routines and desired goals. It should be descriptive, but concise, painting a picture of the individual. This picture should lead to the development of a meaningful day and activities for the individual. For example, identifying that the individual works 25 hours a week as a stocker for the hardware store, volunteers 5 hours a week at the senior center and works out at the community recreational center.
   5. The person centered planning process must include information relevant to any issues concerning the individual’s health and safety. Supports to maintain the individual's health and safety should be developed within the context of his or her preferred lifestyle so that it does not conflict with his/her preferences. Describing issues functionally provides a better picture of the individual's need for support. For example, when documenting a behavior such as verbal or physical aggression, a description of how it manifests and the situations in which it occurs must be included. Merely stating that the individual is verbally or physically aggressive may not provide sufficient information to determine the supports the individual may need. Example: Tom often grasps his hands and breathes heavily prior to becoming physically aggressive by hitting or pushing people near him.
3. The individual determines who is involved in the planning process:
   1. The individual chooses the members of the person centered planning team. The team may include the individual’s legally authorized representative, close family members/advocates, the case manager, providers, a BDDS Service Coordinator and others identified by the individual as being important in his/her life.
   2. The team members must respect, trust, and support the individual.
   3. If bringing together a team for the planning process is difficult, then developing one should become a priority. However, the planning process can be initiated while the team is being developed.
   4. The team members meet in a comfortable location, as defined by the individual. This may help the individual feel relaxed and open enough to share things that are important to him/her with the rest of the team.
4. Identify the existing supports (natural or paid), both used and unused, that are consistent with the individual achieving identified goals
   1. In most situations family members, friends, and the individual have the most knowledge about the preferences, capacities, and gifts of their children, friends, and themselves respectively. However, professionals usually have knowledge of resources available in order to provide appropriate supports and services for the individual. All members should play an active and collaborative role in order for the planning process to be effective.
   2. The individual, families and professionals recognize and document in the individualized support plan the existing supports in the individual’s life.
   3. Previously unexplored natural supports in the community are discovered during the process.
   4. Identified supports match the preferences of the individual.
   5. The planning process considers the supports that the individual may require for issues that may not be directly related to the outcome but influence the strategies and actions that are developed to achieve the outcome. For example, counseling for anger or stress management.
5. Other professionals not originally included by the individual in their planning teams are identified as consultants, when needed.
   1. All professional consultations, such as with a nurse or psychologist, occur in the presence, or with the permission, of the individual/LAR and are conducted in a manner respectful to the individual.
   2. The support team (i.e., individual, family and professionals) and other professional consultants are encouraged to have a trusting and collaborative relationship.
6. Issues of safety, health, rights, and freedom from abuse, neglect and exploitation are dealt with in the person directed plan

   The planning process includes a discussion of individualized health and safety issues in the context of the life desired by the individual. The process maintains a balance between rights (choice/control), responsibilities and risks (health/safety) experienced by all citizens.

1. To identify additional natural supports and negotiate needed service system supports
   1. Both natural and system supports are negotiated to develop the best possible support plan to achieve what is important to the individual.
   2. The individual determines his/her own supports by participating in selecting, evaluating, and when necessary, changing his/her activities and support staff.
   3. The support team members identify opportunities and activities to connect the individual to the community.
2. Implementation of the support strategies becomes the responsibility of the planning participants
   1. The individualized support plan includes i) outcomes, strategies and activities, ii) person/s responsible for the completion of the activity or strategy, and iii) the date by which it is to be completed. Including specific names of people responsible and timeframes facilitates the monitoring process.
   2. The goals and aspirations are prioritized by the individual.
   3. The most important goals and aspirations are addressed first.
   4. A support plan is more easily implemented if the team works on a few goals and aspirations at a time.
   5. The individual is supported to develop community connections.
   6. Preferences should not be considered to be the same as services and supports. Services and supports are used to facilitate the acquisition of the individual's preferences. For example, the individual may express a preference to work in a bank. However, he or she may require the support of a job coach to achieve the desired goal. The support of a job coach is not the expressed preference of the individual in this case. The job coach is the support needed to achieve a goal based on the expressed preference.
   7. In a case where there is a disagreement between the individual and their LAR, every effort should be made to negotiate and clarify conflicting issues. The facilitator must keep the individual's preferences and desires the main focus of the planning process and resolve the LAR's concerns to come up with the best compromise between the two.
   8. There must be a partnership between all the team members to implement the individualized support plan. No single team member should be responsible for its implementation.
3. When people choose outcomes that conflict with state/programmatic standards, the following strategies should be considered to meet people’s needs
   1. Identify goals/needs that can be achieved within the existing standards, rules and regulations within the FSSA system, while problem solving on how to accomplish the ones that are more difficult to achieve.
   2. Explore resources in other systems and programs serving people with disabilities and services available to all citizens, whether or not they have a disability, in the community to fulfill these needs.
   3. Use the existing system to its fullest potential and negotiate to create the best possible arrangement for the individual.
   4. Discover why a particular choice or the refusal of an alternative presented in place of the original choice is important to the individual.

One of the key elements of the person centered planning process is a good facilitator. Good facilitators do not just run meetings. They must get to know and understand the individual and significant others in that person’s life. A skilled facilitator is one who clearly understands the change process and the corresponding values. Skillful facilitators have the ability to listen, concentrate, take directions from the individual, and be inquisitive to constantly search for capacities and areas for exploration.

A number of people can serve as a facilitator during the person centered planning process. No one person is excluded from being a facilitator, and no person is assumed to serve as the facilitator. However, whoever serves as the facilitator must have completed training by a BDDS approved training entity, have observed a facilitation and participated in at least one person centered planning meeting before facilitating independently. See Appendix A for considerations in choosing facilitators for the person centered planning process. See Appendix B for BDDS approved training options.

The quality of a person centered planning process is defined by the individual and is reflected in more personal outcomes being achieved. There will be a multi-level monitoring process to ensure the quality of person centered plans. The indicators of successful implementation of a person centered planning process are:

1. Evidence that the individual determines his/her preferences during the person centered planning process with the support of family/LAR, friends, and staff if necessary.
2. Evidence that the individual chose whether or not other persons should be involved and identified the people to be included in the person centered planning process.
3. Evidence that the individual chose the time and location of the person centered planning session.
4. Evidence that the individual chose his/her outcomes and support staff whenever possible.
5. Evidence that the individual's preferences and outcomes were seriously considered and in situations where it was difficult to implement his/her preferences and outcomes, the team arrived at a compromise acceptable to all.
6. Evidence that case managers/service coordinators ensure that support plans remain current at all times and are monitored on an ongoing basis for their effectiveness in achieving the outcomes identified by the individual with the support of his/her family/LAR. This is a critical element since an individual's goals and preferences are constantly evolving. It is important to keep asking questions, listening and discovering the preferences of the individual.
7. Quality improvement plans actively seek feedback from the individuals and families receiving services and supports regarding the opportunities they have to express needs and preferences and the ability to make choices.

   The Person Centered Planning Process Happens When . . .

   people work together to solve the challenges that arise
   when individuals live and work where
   and how they choose and strive to
   reach their dreams and goals.

Appendix A

Considerations in choosing facilitators for the Person Centered Planning process.

Appendix B

Bureau of Developmental Disabilities Services Approved Person Centered Planning Training Programs

(Please check https://webcms.in.gov/CMS/services/waivers.html for a current list of BDDS approved training entities.

• Essential Lifestyle Planning
• Personal Futures Planning
• McGill Action Planning Systems (MAPS)
• Planning Alternative Tomorrows (PATH)
• Lifestyle Planning
• Gwen Chesterfield training course
• Indiana Institute on Disability and Community training course
• John O’Brien training course
• Thriving in the Community

References

Dileo, D. (1994). Reach for the Dream: Developing Individual Service Plans for Persons with Disabilities. Florida: Training Resource Network.

Falvey, M., Forest, M., Pearpoint, J., & Rosenberg, R. (1994). Using the Tools: Circles, MAPS, and PATH.

Mount, B., & Zwernick, K. (1988). It’s Never Too Early, It’s Never Too Late. St. Paul: Minnesota Governor’s Planning Council on Developmental Disabilities.

O’Brien, J., Lovett, H. (1992). Finding a Way to Everyday Lives: The Contribution of Person Centered Planning. Pennsylvania Department of Public Welfare, Office of Mental Retardation.

Smull, M., Sanderson, H., & Harrison, S. (1996). Reviewing Essential Lifestyle Plans: Critieria for Best Plans. College Park, MD: Center in Human Services Development, University of Maryland.

Person Directed Planning and Family Directed Planning: Guidelines for Individuals Living in the Community (2000). Long Term Services and Supports (LTSS), Division of Texas Department of Mental Health and Mental Retardation (TDMHMR).

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