1 an introduction to writing effective person-centered plans person-centered planning starts with...

11

An Introduction to WritingAn Introduction to WritingEffective Person-Centered PlansEffective Person-Centered Plans

Person-Centered Planning StartsPerson-Centered Planning Startswith Person-Centered Thinkingwith Person-Centered Thinking

DRAFT: For review, feedback and revisionDRAFT: For review, feedback and revision

22

Course OutlineCourse OutlineOrientation to the PCPOrientation to the PCPPCP Planning Models PCP Planning Models Engaging Consumers in PCP Planning Engaging Consumers in PCP Planning ProcessProcessOverview of PCP ElementsOverview of PCP ElementsHow to Write a GoalHow to Write a GoalHands-On Writing GoalsHands-On Writing GoalsNatural SupportsNatural SupportsGetting Service Authorization Requests Getting Service Authorization Requests Approved by the LMEApproved by the LME

33

Learning ObjectivesLearning Objectives

Participants will learn to use several Participants will learn to use several methods to engage consumers or methods to engage consumers or families in the person-centered families in the person-centered planning process, including cultural planning process, including cultural preferences.preferences.

Participants will learn to use several Participants will learn to use several strategies to help consumers/families strategies to help consumers/families define baseline behaviors and define baseline behaviors and functional outcomes.functional outcomes.

44

Learning ObjectivesLearning Objectives Participants will learn to write Participants will learn to write

measurable goals.measurable goals. Participants will learn to translate Participants will learn to translate

outcomes into service requests.outcomes into service requests. Participants learn to write step-down Participants learn to write step-down

plans and crisis plans.plans and crisis plans. Participants will learn to include Participants will learn to include

natural supports and other natural supports and other community resources in PCPs.community resources in PCPs.

Participants will learn key techniques Participants will learn key techniques to ensure that their PCP and service to ensure that their PCP and service authorization request is approved by authorization request is approved by LMEs. LMEs.

55

PCP DefinitionPCP DefinitionA process focused on learning about an A process focused on learning about an individual’s whole life, not just issues individual’s whole life, not just issues related to the person’s disability. The related to the person’s disability. The process involves assembling a group of process involves assembling a group of supporters selected by the consumer who supporters selected by the consumer who are committed to supporting the person in are committed to supporting the person in pursuit of desired outcomes. Planning pursuit of desired outcomes. Planning includes discovering strengths and includes discovering strengths and barriers, establishing time-limited goals barriers, establishing time-limited goals and identifying and gaining access to and identifying and gaining access to supports from a variety of community supports from a variety of community resources prior to utilizing the community resources prior to utilizing the community MH/DD/SA system to assist the person in MH/DD/SA system to assist the person in pursuit of the life he/she wants.pursuit of the life he/she wants.

66

PCP DefinitionPCP Definition

Person-centered planning results in a Person-centered planning results in a written plan that is agreed to by the written plan that is agreed to by the consumer and that defines both the consumer and that defines both the natural and community supports and natural and community supports and services being requested from the public services being requested from the public system to achieve the consumer’s system to achieve the consumer’s desired outcomes. The plan is used as a desired outcomes. The plan is used as a basis for requesting an authorization for basis for requesting an authorization for services.services.

77

Writing Effective PCPsWriting Effective PCPsOften done as a perfunctory processOften done as a perfunctory processWe Just want to get services We Just want to get services authorizedauthorizedPerson-centered planning is a clinical Person-centered planning is a clinical process (tip: use quotation marks on process (tip: use quotation marks on goals)goals)PCPs can be used to make PCPs can be used to make interventions more effectiveinterventions more effectiveYou do not need a PCP for outpatient You do not need a PCP for outpatient services onlyservices only

88

State’s MandateState’s Mandate

LMEs approve plans, not just discrete LMEs approve plans, not just discrete servicesservices

PCPs are the lever for consumer-driven PCPs are the lever for consumer-driven servicesservices

DMHDDSAS’ PCP Guidelines are on the DMHDDSAS’ PCP Guidelines are on the their website, their website, www.dhhs.state.us/mhddsaswww.dhhs.state.us/mhddsas (Bulletin (Bulletin #034)#034)

99

Highlights of DMHDDSAS’ Highlights of DMHDDSAS’ PCP GuidelinesPCP Guidelines

Person-centered planning is a Person-centered planning is a foundation of system reformfoundation of system reformA process determining real-life A process determining real-life outcomes and developing strategies to outcomes and developing strategies to achieve those outcomes in partnership achieve those outcomes in partnership with the individual/familywith the individual/familySupports strengths and recovery, and Supports strengths and recovery, and applies to everyone in the systemapplies to everyone in the system

1010


The individual/family direct the process The individual/family direct the process and share authority and responsibility and share authority and responsibility with system professionalswith system professionalsBuilds on strengths, gifts, skills, and Builds on strengths, gifts, skills, and contributionscontributionsSupports consumer empowerment, and Supports consumer empowerment, and provides meaningful options to express provides meaningful options to express preferences and make informed preferences and make informed choiceschoices

1111


Honors goals and aspirations for a Honors goals and aspirations for a lifestyle that promotes dignity, respect, lifestyle that promotes dignity, respect, interdependence, mastery and interdependence, mastery and competencecompetence

Supports a fair and equitable Supports a fair and equitable distribution of system resourcesdistribution of system resources

Creates community connectionsCreates community connections

1212


Sees individuals in the context of their Sees individuals in the context of their culture, ethnicity, religion, and genderculture, ethnicity, religion, and gender

Supports mutually respectful and Supports mutually respectful and partnering relationships, partnering relationships, acknowledging the legitimate acknowledging the legitimate contributions of all partiescontributions of all parties

1313

Key Features of the Recovery ModelKey Features of the Recovery Model

A holistic view of mental illness that A holistic view of mental illness that focuses on the person, not just the focuses on the person, not just the symptomssymptoms

Recovery is not a function of one’s Recovery is not a function of one’s theory about the causes of mental theory about the causes of mental illnessillness

Recovery from severe psychiatric Recovery from severe psychiatric disabilities is achievabledisabilities is achievable

1414

Key Features of the Recovery ModelKey Features of the Recovery Model

Recovery can occur even though Recovery can occur even though symptoms may reoccursymptoms may reoccur

Individuals are responsible for the Individuals are responsible for the solution, not the problemsolution, not the problem

Recovery requires a well-organized Recovery requires a well-organized support systemsupport system

Consumer rights, advocacy, social Consumer rights, advocacy, social changechange

Applications and adaptations to issues Applications and adaptations to issues of human diversityof human diversity

1515

Essential Elements of PCPsEssential Elements of PCPs

The Person-Centered Plan is a unified The Person-Centered Plan is a unified life planlife plan

It is the umbrella under which all It is the umbrella under which all planning for treatment, services and planning for treatment, services and supports occurssupports occurs

Real life outcomes are described and Real life outcomes are described and related to life domainsrelated to life domains

1616


The planning team is at the core of the The planning team is at the core of the PCPPCP

The individual/family identifies who will The individual/family identifies who will participate in the planning process, participate in the planning process, how, and to what extent. Those how, and to what extent. Those individuals will comprise the planning individuals will comprise the planning teamteam

1717


The extent to which the planning team The extent to which the planning team assists the individual with describing assists the individual with describing his/her goals, preferences and needs his/her goals, preferences and needs will vary with circumstanceswill vary with circumstancesAll good plans are done in partnershipAll good plans are done in partnershipThe planning team includes The planning team includes participation by professionals and participation by professionals and paraprofessionals that have been paraprofessionals that have been involved with the individualinvolved with the individual

1818


The planning process honors the The planning process honors the schedule and comfort of the schedule and comfort of the individual/familyindividual/family

Information gathered is communicated Information gathered is communicated in a way that is understoodin a way that is understood

1919


The PCP includes goals and strategies The PCP includes goals and strategies to meet desired life outcomesto meet desired life outcomes

Meeting the treatment, and primary Meeting the treatment, and primary service and support needs in order to service and support needs in order to insure health and safety is a primary insure health and safety is a primary focus of the planning processfocus of the planning process

2020


The individual/family must be fully The individual/family must be fully informed of the rationale, evidence and informed of the rationale, evidence and risks of specific service support and risks of specific service support and treatment optionstreatment options

2121


The following avenues should be The following avenues should be explored for ways to contribute to the explored for ways to contribute to the accomplishment of life goals: a) accomplishment of life goals: a) personal resources, b) natural personal resources, b) natural supports, such as family, neighbors, supports, such as family, neighbors, co-workers, and friends, and c) co-workers, and friends, and c) community resourcescommunity resources

2222


The PCP addresses health and safety The PCP addresses health and safety needsneeds

Health and safety needs are identified Health and safety needs are identified as part of the planning process in as part of the planning process in partnership with the individual/familypartnership with the individual/family

Supports to maintain health and safety Supports to maintain health and safety must be developed within the context of must be developed within the context of the individual’s preferred lifestyle, as the individual’s preferred lifestyle, as much as possiblemuch as possible

2323


The PCP reflects the preparation for a The PCP reflects the preparation for a potential crisispotential crisis

The planning process identifies early The planning process identifies early known warning signals of an impending known warning signals of an impending crisis and the necessary interventions crisis and the necessary interventions to ensure health & safetyto ensure health & safety

Provides proactive plans to prevent Provides proactive plans to prevent crisis from occurring as well as reactive crisis from occurring as well as reactive planning and crisis contingenciesplanning and crisis contingencies

2424


Provides proactive plans to prevent Provides proactive plans to prevent crisis from occurring as well as crisis from occurring as well as reactive planning and crisis reactive planning and crisis contingenciescontingencies

2525


Individual/family disagreement with the Individual/family disagreement with the planplan

Good person-centered planning will Good person-centered planning will usually result in a plan of consensus by usually result in a plan of consensus by all partiesall parties

If preferences and choices are not If preferences and choices are not accepted and provided, there is access accepted and provided, there is access to an appeals/dispute processto an appeals/dispute process

2626


Changing the planChanging the plan

The individual/family is provided with The individual/family is provided with opportunities to refine and change the opportunities to refine and change the evolving planevolving plan

There are ongoing opportunities to There are ongoing opportunities to provide feedback regarding the provide feedback regarding the services, supports and/or treatment services, supports and/or treatment received and progress toward received and progress toward achieving outcomesachieving outcomes

2727

What If There Is A What If There Is A Disagreement?Disagreement?

Occasionally a professional cannot Occasionally a professional cannot support the individual/family’s choices, support the individual/family’s choices, including the amount of service that is including the amount of service that is needed or that it can be funded. The needed or that it can be funded. The individual/families have access to a individual/families have access to a dispute process to address and resolve dispute process to address and resolve disagreements and to ensure fairness disagreements and to ensure fairness and equalityand equality

2828

A Tactic to AvoidA Tactic to AvoidUnnecessary ConflictUnnecessary Conflict

Agreeing to Agreeing to principlesprinciples versus specific versus specific servicesservices

2929

Person-Centered Thinking: The PCP Person-Centered Thinking: The PCP is a “Wholistic” Approachis a “Wholistic” Approach

Individual (biological; psychological)Individual (biological; psychological)

FamilyFamily

NeighborhoodNeighborhood

School / WorkSchool / Work

CommunityCommunity

3030

Use the PCP in 4 WaysUse the PCP in 4 Ways

To maintain focus on the consumer’s To maintain focus on the consumer’s progress toward goal attainmentprogress toward goal attainment

To track changes in needs and challengesTo track changes in needs and challenges

As a framework for identifying and As a framework for identifying and organizing needed resourcesorganizing needed resources

To measure growth and changeTo measure growth and change

3131

When Should You Update a PCP?When Should You Update a PCP?

Preferably every 6 months. Longer time-Preferably every 6 months. Longer time-frames do not communicate a message of frames do not communicate a message of hope and changehope and changeTarget datesTarget datesIntervals established by regulatory Intervals established by regulatory agenciesagenciesAt transitions and dischargesAt transitions and dischargesTo evaluate benefit/outcome of servicesTo evaluate benefit/outcome of servicesWhen the IPRS target population changesWhen the IPRS target population changes

3232

PCP UpdatePCP Update

Is there new information to inform any of Is there new information to inform any of the plans elementsthe plans elements

Any significant changes in key domainsAny significant changes in key domains

Goals or transition/discharge criteria Goals or transition/discharge criteria changedchanged

New strengths or resources emergedNew strengths or resources emerged

New or different barriersNew or different barriers

New concerns or needsNew concerns or needs

3333

PCP UpdatePCP Update

Impact of services provided. Have they Impact of services provided. Have they helpedhelped

Should target dates need to changeShould target dates need to change

New or different objectivesNew or different objectives

3434

AxiomsAxioms

Services should be time-limitedServices should be time-limited

The goal is to help the consumer function The goal is to help the consumer function in the natural support system, without in the natural support system, without services, not to provide services until they services, not to provide services until they will never be needed againwill never be needed again

Services may be needed in the same way Services may be needed in the same way that we use an attorney—from time to time that we use an attorney—from time to time in lifein life

Consumers may have to come back Consumers may have to come back periodically for helpperiodically for help

3535

AxiomsAxioms

Goals should be expressed in the words of Goals should be expressed in the words of the consumerthe consumer

Goals should be reflective of informed Goals should be reflective of informed choicechoice

Goals should reflect cultural factorsGoals should reflect cultural factors

3636

Cultural FactorsCultural Factors

What is the individuals cultural identity What is the individuals cultural identity (race, ethnicity, gender, sexual orientation, (race, ethnicity, gender, sexual orientation, religion, spirituality, disability status and religion, spirituality, disability status and other self-defining issues)other self-defining issues)

Are there possible cultural explanations of Are there possible cultural explanations of the problemthe problem

3737

History of Person-Centered PlanningHistory of Person-Centered Planning

1968-Ecological Assessment and 1968-Ecological Assessment and Enablement Plan (Nick Hobbs)Enablement Plan (Nick Hobbs)1980-Individual Service Design (Jack 1980-Individual Service Design (Jack Yates)Yates)1980-Individual Habilitation Plan (Willie 1980-Individual Habilitation Plan (Willie M.)M.)1987-Personal Futures Planning (Beth 1987-Personal Futures Planning (Beth Mount)Mount)1988-Child and Family Teams (CASSP)1988-Child and Family Teams (CASSP)

3838

History of Person-Centered PlanningHistory of Person-Centered Planning

1989-MAPS and Circles of Support 1989-MAPS and Circles of Support (Marsha Forest & Evelyn Lusthaus)(Marsha Forest & Evelyn Lusthaus)1992-Essential Lifestyle Planning 1992-Essential Lifestyle Planning (Michael Smull & Susan Burke (Michael Smull & Susan Burke Harrison)Harrison)1995-PATH (Jack Pearpointt, John 1995-PATH (Jack Pearpointt, John O’Brien & Marsha Forest)O’Brien & Marsha Forest)1990-Wraparound (VanDenBerg & 1990-Wraparound (VanDenBerg & Dennis)Dennis)

3939

Which PCP Model Should be Used?Which PCP Model Should be Used?

The literature does not support one The literature does not support one model over anothermodel over another

For children and youth with mental For children and youth with mental health needs, the Division does health needs, the Division does recommend that the System of Care recommend that the System of Care Child and Family Team process be Child and Family Team process be usedused

4040

Common Beliefs inCommon Beliefs inPerson- Centered PlanningPerson- Centered Planning

It is a means for uncovering what is It is a means for uncovering what is already there: the essence, gifts and already there: the essence, gifts and capacities of a person…it is about capacities of a person…it is about sharing life with one another…sharing sharing life with one another…sharing power and giving up control over power and giving up control over another personanother personAssumes the person, and those who Assumes the person, and those who love the person are the primary love the person are the primary authorities on the person’s life authorities on the person’s life direction, and the person drives the direction, and the person drives the processprocess

4141

Common Beliefs inCommon Beliefs inPerson- Centered PlanningPerson- Centered Planning

It is the beginning of the journey of It is the beginning of the journey of ongoing learning through shared actionongoing learning through shared action

Intends to shatter myths about people with Intends to shatter myths about people with “labels” and fosters an inclusive “labels” and fosters an inclusive communitycommunity

Relies on skilled facilitation in developing Relies on skilled facilitation in developing and moving the plan forwardand moving the plan forward

Requires systems to respond in flexible Requires systems to respond in flexible and meaningful ways and meaningful ways

4242

Introduction to DifferentIntroduction to DifferentPerson- Centered Planning ModelsPerson- Centered Planning Models

www.ilr.cornell.edu/ped/tsal/pcpwww.ilr.cornell.edu/ped/tsal/pcp

4343

Consumer/Family Member StoryConsumer/Family Member Story

Nancy BakerNancy Baker

4444

Examples of Ways to Engage Examples of Ways to Engage Consumers/Family Members in the Consumers/Family Members in the

PCP ProcessPCP Process

Identify an immediate, practical Identify an immediate, practical concern that can be addressedconcern that can be addressed

Don’t us “professional” language; use Don’t us “professional” language; use common termscommon terms

Participants brainstorm others . . . .Participants brainstorm others . . . .

4545

PCP Cheat SheetPCP Cheat Sheet

Each goal must have a creation date Each goal must have a creation date (top of goal pages on the left).(top of goal pages on the left).

Each goal must have current target Each goal must have current target dates that do not exceed 12 months.dates that do not exceed 12 months.

Axis I, II, and III must be addressed.Axis I, II, and III must be addressed. Front page of PCP (diagnosis, Front page of PCP (diagnosis,

supports/strengths, preferences, supports/strengths, preferences, problems/needs sections) must be problems/needs sections) must be completed and dated.completed and dated.

4646


Problems/needs must be addressed Problems/needs must be addressed within the PCP goals and interventions.within the PCP goals and interventions.

Client name and number should be on Client name and number should be on all pages of the PCP.all pages of the PCP.

PCP should identify goals, service type, PCP should identify goals, service type, and intervention, along with frequency.and intervention, along with frequency.

Client/guardian signatures are required Client/guardian signatures are required for all created goals, changes to PCP, for all created goals, changes to PCP, additions, etc.additions, etc.

4747


If signatures cannot be obtained on If signatures cannot be obtained on creation or change date, then a written creation or change date, then a written specific explanation should be included specific explanation should be included for the lack of a signature and the for the lack of a signature and the signature should be obtained at the next signature should be obtained at the next face-to-face visit.face-to-face visit.

All changes to PCP must show a review All changes to PCP must show a review date, status code, and justification.date, status code, and justification.

4848

PCP Cheat SheetPCP Cheat Sheet CBS step-down plans (required with 3 CBS step-down plans (required with 3

or more hours of daily CBS service) or more hours of daily CBS service) must be specific and reflect a system must be specific and reflect a system for reducing hours based on targeted for reducing hours based on targeted behavioral/adaptive improvements (See behavioral/adaptive improvements (See “Documentation Requirements” in CBS “Documentation Requirements” in CBS definition).definition).

4949

PCP Cheat SheetPCP Cheat Sheet Goals in the PCP must be measurable, Goals in the PCP must be measurable,

with the baseline behaviors defined in with the baseline behaviors defined in the goal as well. (We will be evaluating the goal as well. (We will be evaluating consumer outcomes by looking at consumer outcomes by looking at progress on each goal.)progress on each goal.)

All requested services (on the Service All requested services (on the Service Authorization Request form) must be Authorization Request form) must be addressed in the PCP.addressed in the PCP.

All services, including natural supports All services, including natural supports and other community services & and other community services & resources also should be included on resources also should be included on the PCP, per Division’s PCP guidelines.the PCP, per Division’s PCP guidelines.

5050

Can I See Examples of Good Can I See Examples of Good PCPs?PCPs?

Consult Consult Adams, N., & Grieder, D. (2005). Adams, N., & Grieder, D. (2005). Treatment planning for person-Treatment planning for person-centered care.centered care.

5151

GoalsGoals

If you don’t know where you are going, If you don’t know where you are going, how will you know when you get there?how will you know when you get there?

5252

What is a Goal?What is a Goal?

A goal communicates an intended A goal communicates an intended resultresult

5353

Goals should be:Goals should be:

SSimpleimple

MMeasurableeasurable

AAttainablettainable

RRealisticealistic

TTime-famedime-famed

5454

A Well-Written Goal Will A Well-Written Goal Will Communicate 3 Pieces of Communicate 3 Pieces of

InformationInformation

What the person will do (behavior)What the person will do (behavior)

Under what conditions the Under what conditions the performance will occur (condition)performance will occur (condition)

The acceptable level pf performance The acceptable level pf performance (criteria)(criteria)

5555

BehaviorBehavior

What the person will do refers to the What the person will do refers to the behavior, performance, or action of the behavior, performance, or action of the person for whom the goal is written. In person for whom the goal is written. In services for people with disabilities, services for people with disabilities, especially in the context of person-especially in the context of person-centered services, behavioral goals centered services, behavioral goals should be stated in positive, affirmative should be stated in positive, affirmative language.language.

5656

ConditionCondition

Under what conditions the performance Under what conditions the performance will occur is the part of the goal that will occur is the part of the goal that describes the action of the staff person describes the action of the staff person or staff intervention. Specifically or staff intervention. Specifically address what assistance the staff address what assistance the staff person will provide, and/or what the person will provide, and/or what the staff person will do (if anything) to see staff person will do (if anything) to see that the behavior, performance, or that the behavior, performance, or action of the individual occurs.action of the individual occurs.

5757

Examples of Examples of Conditions/InterventionsConditions/Interventions

With assistance from a staff person . . . With assistance from a staff person . . . When asked . . .When asked . . .With suggestions from a team member . . With suggestions from a team member . . With physical assistance . . .With physical assistance . . .Given that Ellen has received instruction Given that Ellen has received instruction

5858

Examples of Examples of Conditions/InterventionsConditions/Interventions

Given that Jeremy has the phone book Given that Jeremy has the phone book in front of him . . .in front of him . . .Without any verbal instructions . . .Without any verbal instructions . . .Given that a staff person has shown Given that a staff person has shown Jose where the detergent is . . .Jose where the detergent is . . .With no suggestions or demonstrationsWith no suggestions or demonstrations

5959

CriteriaCriteria

Acceptable level of performance refers Acceptable level of performance refers to criteria. This means the goal must to criteria. This means the goal must include a description of how include a description of how “achievement” will be defined. In “achievement” will be defined. In writing this part of the goal, always writing this part of the goal, always consider how the person or the people consider how the person or the people who know the person will define who know the person will define success. Performance must be overt, success. Performance must be overt, that is, it can be observed directly.that is, it can be observed directly.

6060

Measurable GoalsMeasurable Goals

Measurable goals are most easily Measurable goals are most easily written by using words that are open to written by using words that are open to few interpretations, rather than words few interpretations, rather than words that are open to many interpretationsthat are open to many interpretations

6161

Words Open to Many Words Open to Many InterpretationsInterpretations

To knowTo know

To understandTo understand

To really understandTo really understand

To appreciateTo appreciate

To fully appreciateTo fully appreciate

6262

Words Open to Many Words Open to Many InterpretationsInterpretations

To grasp the significance ofTo grasp the significance of

To enjoyTo enjoy

To believeTo believe

To have faith inTo have faith in

To internalizeTo internalize

6363

Words Open to Fewer Words Open to Fewer InterpretationsInterpretations

To writeTo write

To reciteTo recite

To identifyTo identify

To sortTo sort

To solveTo solve

6464

Words Open to Fewer Words Open to Fewer InterpretationsInterpretations

To constructTo construct

To buildTo build

To compareTo compare

To contrastTo contrast

To smileTo smile

6565

Example GoalExample Goal

With staff assistance (With staff assistance (conditioncondition), ), Marsha will choose her clothing, based Marsha will choose her clothing, based on the weather (on the weather (performanceperformance), five out ), five out of seven days for the next three months of seven days for the next three months ((criteriacriteria).).

6666


Adam will identify places he can go in Adam will identify places he can go in his free time (his free time (performanceperformance), without ), without any suggestion from staff (any suggestion from staff (conditioncondition), ), each Saturday morning for the next each Saturday morning for the next three months (three months (criteriacriteria). ).

6767


With gentle, verbal encouragement With gentle, verbal encouragement from staff (from staff (conditioncondition), Charles will not ), Charles will not scream while eating (scream while eating (performanceperformance), two ), two out of three meals, for five minutes out of three meals, for five minutes each time, for the next two months each time, for the next two months ((criteriacriteria).).

6868


Given that Rosa has received Given that Rosa has received instructions (instructions (conditioncondition), she will call ), she will call her therapist to make her own her therapist to make her own appointments (appointments (performanceperformance), as ), as needed during the next four months needed during the next four months ((criteriacriteria).).

6969


With suggestions from a support team With suggestions from a support team member (member (conditioncondition), Henry will write a ), Henry will write a letter to his father (letter to his father (performanceperformance), once ), once a month for the next six months a month for the next six months ((criteriacriteria).).

7070

Why Do You Choose a Particular Why Do You Choose a Particular Target Behavior?Target Behavior?

Consumer/family is invested in itConsumer/family is invested in itSomeone else is invested in it (e.g., Someone else is invested in it (e.g., school)school)Easy behavior to show some initial Easy behavior to show some initial successsuccessBehavior is noxious; the family needs Behavior is noxious; the family needs something to happen.something to happen.Behavior ecologically affects other Behavior ecologically affects other behaviorsbehaviors..

7171

Tips for Making Goals MeasurableTips for Making Goals Measurable

You will find it more difficult to write You will find it more difficult to write clear and measurable goals if you have clear and measurable goals if you have not first written a clear and measurable not first written a clear and measurable level of performancelevel of performance

Measurable means you can count it or Measurable means you can count it or observe itobserve it

7272

Example: Making a Goal Example: Making a Goal MeasurableMeasurable

This goal uses the consumer’s This goal uses the consumer’s strengths as a lever of changestrengths as a lever of change

““Uncle Bob will increase the number of Uncle Bob will increase the number of times he intervenes with statements times he intervenes with statements that reflect the consumer accepting that reflect the consumer accepting responsibility for his behavior from responsibility for his behavior from none to 8 times per day”none to 8 times per day”

7373

How to Make Something How to Make Something MeasurableMeasurable

Specify a level of performanceSpecify a level of performance

Indicate a rate, for example 3 out of 4 Indicate a rate, for example 3 out of 4 times, 80% of the time, 5 minutes out of times, 80% of the time, 5 minutes out of every 10, 75% successevery 10, 75% success

Define the factors surrounding the Define the factors surrounding the behavior (e.g., when asked to work behavior (e.g., when asked to work independently, always after lunch)independently, always after lunch)

Identify the results of the behaviorIdentify the results of the behavior

7474

Measurable Goal ChecklistMeasurable Goal Checklist

What is the actual (measurable) starting What is the actual (measurable) starting point for this knowledge or skill?point for this knowledge or skill?

What will I see this consumer doing What will I see this consumer doing when he/she reaches this goal?when he/she reaches this goal?

Did I avoid vague or unclear words or Did I avoid vague or unclear words or phrases?phrases?

7575

Most Common Errors on PCPsMost Common Errors on PCPs

The goals, objectives and interventions The goals, objectives and interventions are not specific, measurable, time-limitedare not specific, measurable, time-limited

The goals, objectives and interventions do The goals, objectives and interventions do not address symptoms, skills and not address symptoms, skills and resourcesresources

Each service provided is not necessarily Each service provided is not necessarily linked to a goal, objective or interventionlinked to a goal, objective or intervention

The diagnostic assessment is not linked to The diagnostic assessment is not linked to a goal, objective or interventiona goal, objective or intervention

7676

AvoidAvoid

Goals just requiring Goals just requiring attendance/participationattendance/participation

Goals that emphasize the absence of Goals that emphasize the absence of something; stress active, positive changesomething; stress active, positive change

7777

Dead-Man StandardDead-Man Standard

John will stop having temper tantrumsJohn will stop having temper tantrums

John would meet the objective of no John would meet the objective of no longer losing control of his anger if he longer losing control of his anger if he were dead!were dead!

John will remain calm when faced with John will remain calm when faced with frustrationfrustration

7878

Hands-On PracticeHands-On Practice

Here are some goals; try to “fix” them:Here are some goals; try to “fix” them:

Inadequate step-down planInadequate step-down planGoal not measurableGoal not measurableGoal too complexGoal too complexCrisis stabilization goalCrisis stabilization goalIntervention linked to best practiceIntervention linked to best practiceAdd natural supportsAdd natural supports

7979

Inadequate Step-Down PlanInadequate Step-Down Plan

The client's need for CBS The client's need for CBS paraprofessional will be reviewed for paraprofessional will be reviewed for medical necessity in 90 days.medical necessity in 90 days.

8080

Inadequate Step-Down PlanInadequate Step-Down PlanThe client's need for CBS-Pro will be The client's need for CBS-Pro will be reassessed monthly, & CBS services reassessed monthly, & CBS services reduced from 0-6 hours per day to 0-3 reduced from 0-6 hours per day to 0-3 hours per day once the client obeys hours per day once the client obeys rules 100% of the time, refraining daily rules 100% of the time, refraining daily 100% of the time from being disruptive 100% of the time from being disruptive and oppositional including but not and oppositional including but not limited to: fighting, arguing, instigating, limited to: fighting, arguing, instigating, being cruel to animals, running from being cruel to animals, running from supervision, property destruction & supervision, property destruction & sexual aggression.sexual aggression.

8181

Inadequate Step-Down PlanInadequate Step-Down Plan

Goal % compliance increases to 75% Goal % compliance increases to 75% CBS hours will be reduced to 20 CBS hours will be reduced to 20 hours/week per child and family team hours/week per child and family team review. Further improvement in behavior review. Further improvement in behavior to 90% compliance will reduce CBS to 90% compliance will reduce CBS hours to 10 hours/week.hours to 10 hours/week.

8282

Goal Not MeasurableGoal Not Measurable

Client will improve cooking skills as Client will improve cooking skills as evidenced by improving cooking skills.evidenced by improving cooking skills.

8383


Consumer will decrease audio Consumer will decrease audio hallucinations.hallucinations.

8484


Will complete requirements for DSS Will complete requirements for DSS plan re: substance abuse/dependence.plan re: substance abuse/dependence.

8585


Will learn how to avoid relapse.Will learn how to avoid relapse.

8686


Sincerity as evidenced by lack of fear Sincerity as evidenced by lack of fear of the futureof the future..

8787

Goal Too ComplexGoal Too Complex

As client is capable of improvement, As client is capable of improvement, he/she will obey rules 100% of the time he/she will obey rules 100% of the time in all settings, refrain from symptomatic in all settings, refrain from symptomatic behavior 100% of the time, including the behavior 100% of the time, including the avoiding the following: being avoiding the following: being disrespectful, having anger episodes, disrespectful, having anger episodes, being verbally and physically assaultive, being verbally and physically assaultive, not obeying rules in the home, in the not obeying rules in the home, in the school and in the community.school and in the community.

8888

Goal Too ComplexGoal Too Complex

Improve life domain functioning in the Improve life domain functioning in the home, community and school as home, community and school as evidenced by 1)compliance with adult's evidenced by 1)compliance with adult's directions by 3rd prompt 50% of the directions by 3rd prompt 50% of the time, 2) will earn behavioral plan time, 2) will earn behavioral plan rewards for school compliance 60% of rewards for school compliance 60% of the week, and 3) accept limitations and the week, and 3) accept limitations and consequence without being aggressive consequence without being aggressive or oppositional 50% of the time.or oppositional 50% of the time.

8989

Crisis Stabilization GoalCrisis Stabilization Goal

If client becomes agitated or verbally If client becomes agitated or verbally aggressive, then the following aggressive, then the following interventions may be used: 1) Client will interventions may be used: 1) Client will be offered time out to calm self, 2) client be offered time out to calm self, 2) client will be verbally redirected, 3) client's will be verbally redirected, 3) client's therapist may be contacted. If the client's therapist may be contacted. If the client's behavior continues to escalate and he/she behavior continues to escalate and he/she becomes a danger to him/herself and/or becomes a danger to him/herself and/or others, the following therapeutic others, the following therapeutic interventions may be followed:interventions may be followed:

9090

Crisis Stabilization GoalCrisis Stabilization Goal

1) Non-violent physical crisis 1) Non-violent physical crisis intervention, 2)CPI restraint, 3) Client intervention, 2)CPI restraint, 3) Client will be monitored for vital signs and will be monitored for vital signs and emotional/behavioral response, 4) Law emotional/behavioral response, 4) Law enforcement and/or the mental health enforcement and/or the mental health agency will be contacted, and 5) client's agency will be contacted, and 5) client's family/guardian will be contacted. family/guardian will be contacted.

9191

Intervention Linked to Best PracticeIntervention Linked to Best Practice

Consumer will receive individual/family Consumer will receive individual/family therapy 1-4 times per month for therapy 1-4 times per month for psychodynamic, reality, and CBT psychodynamic, reality, and CBT therapy to stop symptoms.therapy to stop symptoms.

9292

Intervention Linked to Best PracticeIntervention Linked to Best Practice

Consumer will participate in individual Consumer will participate in individual therapy to develop a therapeutic therapy to develop a therapeutic relationship with the therapist 0-4 times relationship with the therapist 0-4 times per month.per month.

9393

Add Natural SupportsAdd Natural Supports

Consumer will work with his uncle, who Consumer will work with his uncle, who is a farmer, this summer to 1) develop is a farmer, this summer to 1) develop work skills, 2) use exercise to diffuse work skills, 2) use exercise to diffuse negative affect, and 3) to negative affect, and 3) to have supervision and monitoring by have supervision and monitoring by family in an environment and activity family in an environment and activity that he prefers.that he prefers.

9494

Add Natural SupportsAdd Natural Supports

Consumer will play soccer for his high Consumer will play soccer for his high school soccer team to 1) enhance school soccer team to 1) enhance social skills, 2) practice team work, and social skills, 2) practice team work, and 3) use physical exercise to assist in 3) use physical exercise to assist in alleviating depression.alleviating depression.

9595

Natural and Community SupportsNatural and Community Supports

May be used as part of the overall plan May be used as part of the overall plan to achieve outcomesto achieve outcomes

Formal services should be transitioned Formal services should be transitioned to natural supports as much as to natural supports as much as possible over timepossible over time

9696

Natural and Community SupportsNatural and Community Supports

Places, things and, particularly, people Places, things and, particularly, people who are part of our interdependent who are part of our interdependent community lives and whose community lives and whose relationships are reciprocal in nature.relationships are reciprocal in nature.

9797

Example Natural Support SystemsExample Natural Support Systems

Extended familyExtended family

NeighborsNeighbors

FriendsFriends

VolunteersVolunteers

Peer groupsPeer groups

ClergyClergy

Traditional healersTraditional healers

9898

Use of Natural SupportsUse of Natural Supports

Lessen dependence on professional Lessen dependence on professional servicesservicesSupport community integrationSupport community integrationReduce isolationReduce isolationOvercome stigmaOvercome stigmaIncrease motivation for recoveryIncrease motivation for recoveryPromote friendshipPromote friendshipSocial networkingSocial networking

9999

Natural SupportsNatural Supports

Help is most likely to have long-term Help is most likely to have long-term benefits if the help-giver promotes the benefits if the help-giver promotes the help-seeker’s acquisition of effective help-seeker’s acquisition of effective behaviors that decrease the need for behaviors that decrease the need for help. In other words, a primary goal is help. In other words, a primary goal is for the consumer to become more for the consumer to become more capable, competent, and independent. capable, competent, and independent. This goal, then, is the cornerstone of This goal, then, is the cornerstone of beneficial help-giving and help-seeking beneficial help-giving and help-seeking exchanges. exchanges.

100100

Natural SupportsNatural Supports

Carl Dunst’s research has shown that Carl Dunst’s research has shown that recipients of help become effectively recipients of help become effectively empowered only when they assume a empowered only when they assume a high degree of responsibility for high degree of responsibility for change.change.

101101

Formal Helping System

Natural Therapy System

Impasse

102102

Empirically Supported TreatmentsEmpirically Supported Treatments

Clinical Trials (random design)Clinical Trials (random design)

Quasi-Experimental designsQuasi-Experimental designs

Pre/Post designsPre/Post designs

103103

Efficacy vs. EffectivenessEfficacy vs. Effectiveness

Efficacy – Works on a discrete problem Efficacy – Works on a discrete problem within a circumscribed population (typically within a circumscribed population (typically studied in a university environment)studied in a university environment)

Effectiveness – Works on diverse Effectiveness – Works on diverse problems with broad population (real problems with broad population (real world)world)

104104

Randomized Controlled TrialsRandomized Controlled Trials

Most control; most difficult and time-Most control; most difficult and time-consuming to doconsuming to do

Highest level of evidenceHighest level of evidence

105105

Quasi-Experimental DesignsQuasi-Experimental Designs

Compare naturally occurring groupsCompare naturally occurring groups

Done prior to random controlled trials; Done prior to random controlled trials; often have biased samplesoften have biased samples

106106

Pre-Post DesignsPre-Post Designs

Compare end of treatment to beginning Compare end of treatment to beginning of treatmentof treatment

Basis for much of the best/promising Basis for much of the best/promising practices literaturepractices literature

Nearly all interventions show positive Nearly all interventions show positive gains heregains here

107107

Hierarchy of EvidenceHierarchy of Evidence

Better/Best TreatmentsBetter/Best TreatmentsWell-Established/EfficaciousWell-Established/EfficaciousProbably Efficacious (2 studies Probably Efficacious (2 studies showing better than wait-list control; showing better than wait-list control; like well established, but not replicated like well established, but not replicated by 2by 2ndnd team) team)Evaluated, but unclearEvaluated, but unclearNot evaluated, but commonly usedNot evaluated, but commonly usedEvaluated, negative findingsEvaluated, negative findings

108108

Well-EstablishedWell-Established

At least 2 controlled group design At least 2 controlled group design studies or a large series of single-case studies or a large series of single-case design studiesdesign studiesMinimum of 2 investigatorsMinimum of 2 investigatorsUse of a treatment manualUse of a treatment manualUniform therapist training and Uniform therapist training and adherenceadherenceTrue clinical samples of youthTrue clinical samples of youth

109109

Well-EstablishedWell-Established

Tests of clinical significance of Tests of clinical significance of outcomesoutcomesFunctioning outcomes plus symptomsFunctioning outcomes plus symptomsLong-term outcomes beyond Long-term outcomes beyond terminationtermination

110110

What If the Consumer Doesn’t What If the Consumer Doesn’t Want EBP?Want EBP?

80% of intervention should be recognized 80% of intervention should be recognized EBPEBP

20% of interventions can be customized20% of interventions can be customized

111111

Standard CareStandard CareWhen a SAR is submitted to WHN, we When a SAR is submitted to WHN, we will clinically review the utilization will clinically review the utilization either either beforebefore or or afterafter the service is the service is provided.provided.

Most services will be reviewed after Most services will be reviewed after they are provided, however, we still they are provided, however, we still must authorize the service in order for must authorize the service in order for providers to be paid. To do that, an providers to be paid. To do that, an authorization technician will check to authorization technician will check to see if the SAR fits within standard care.see if the SAR fits within standard care.

112112

Standard CareStandard Care““grids” outline pre-established clinical grids” outline pre-established clinical standards for the services and amounts standards for the services and amounts of service that consumers typically of service that consumers typically need for four degrees of impairment, or need for four degrees of impairment, or as they are called, levels of care—A, B, as they are called, levels of care—A, B, C, and D.C, and D. We strongly recommend that you use We strongly recommend that you use the standard care grids to make a the standard care grids to make a request for services. In these cases, an request for services. In these cases, an authorization technician will authorization technician will automatically approve your request if automatically approve your request if your other documentation is in order.your other documentation is in order.

113113

Standard CareStandard CareApproval for standard care services Approval for standard care services does not constitute a cart blanche does not constitute a cart blanche approval to do anything you like. You approval to do anything you like. You still can only provide the service if it is still can only provide the service if it is medially necessary. The services will medially necessary. The services will be subject to random retrospective be subject to random retrospective audit.audit.

114114

Standard CareStandard CareIf your SAR falls outside of the If your SAR falls outside of the parameters of standard care or is a parameters of standard care or is a very high-end service (e.g., residential), very high-end service (e.g., residential), it will be passed for review from the it will be passed for review from the authorization technician to a clinical authorization technician to a clinical specialist.specialist.

If your SAR falls outside of standard If your SAR falls outside of standard care, we recommend that you include a care, we recommend that you include a detailed justification.detailed justification.

115115

Standard CareStandard CareWe revise the standard care grids from We revise the standard care grids from time-to-time, based on provider input, time-to-time, based on provider input, which is always welcome. Check the which is always welcome. Check the WHN website for the most current WHN website for the most current grids: grids: www.westernhighlands.orgwww.westernhighlands.org

In order for an authorization technician In order for an authorization technician to act on your SAR, you must complete to act on your SAR, you must complete the level of care (LOC) on the SAR the level of care (LOC) on the SAR form.form.

116116

ResourcesResources

Person-Centered PlanningPerson-Centered Planningwww.ilr.cornell.edu/ped/tsal/pcpwww.ilr.cornell.edu/ped/tsal/pcpTreatment PlannersTreatment Planners

www.wiley.com/WileyCDA/Section/id-8340www.wiley.com/WileyCDA/Section/id-8340.html.htmlAdams, N., & Grieder, D. (2005). Adams, N., & Grieder, D. (2005). Treatment planning for person-Treatment planning for person-centered care.centered care.

1 an introduction to writing effective person-centered plans person-centered planning starts with...

Documents

pcp pcp planning models

goals pcps

lme slide

revision slide

perfunctory process

discrete services pcps

service authorization

consumers desired outcomes