Introduction to Person Centered Planning

1. Introduction to Person Centered Planning June 2011 Neal Adams MD MPH California Institute of Mental Health

3. Learning Pyramid

4. Warm Up List typical goals found on current service plans Write 3 goals/areas of meaning you have for yourself on a piece of paper Hand that paper to the person sitting next to you

5. person-centered / directed care …it’s not a straight path from here to there…

6. Definition of a Recovery Plan • A recovery plan is a document, co-created by the person receiving services and the provider, to outline the steps needed to achieve a particular goal or outcome.

7. The Recovery Plan • It is the work/social “contract”, created by the person and provider.

8. A Person-Centered Approach to Service Planning • Collaboration and partnership. • The plan prioritizes the person’s desires while including a provider perspective.

9. PCP…Don’t we already do this?? • Making progress but… we DON’T “already do this.” • Not according to consumer/survivors… • “old wine…new bottles” • and not if you take a close look at concrete implementation strategies • Review your current records/plans Treatment Plan Recovery Plan

10. The Nature of the Problem • 24% of sample (N=137) report NEVER having a treatment plan • Of those who had experienced a treatment plan, half felt involved only “a little” or “not at all”. • Only 21% of participants report being “very much” involved • Only 12% of people invited someone to their last treatment planning meeting • Over half were not offered a copy of their plan • People aren’t even in the car, let alone the driver’s seat!

11. It Works! • For example, WNYCCP has achieved the following outcomes: • 55% decrease in ER visits • 58% decrease in inpatient days • 66% decrease in suicide attempts • 52% decrease in harm to others • 18% decrease in arrests • Cost-effective • Over a 3 year period, Medicaid costs per participant decreased 10% compared to an 8% increase for the general population

12. The Comprehensive Person-Centered Plan Incorporates Evidence-Based Practices Maximizes Self-Determination & Choice Encourages Peer-Based Services Informed by Stages of Change & MI Methods Promotes Cultural Responsiveness Respects Both Professional & Personal Wellness Strategies Focuses on Natural Supporters/Community Settings Consistent w/ Standards of Fiscal & Regulatory Bodies, e.g., CMS, JCAHO

13. PDP is… • Person Directed Planning is a planning process that • is controlled by the person receiving services (family for children) • results in a recovery plan that details the issues important to the person • managed in all important aspects by that person with freely chosen support when necessary • spells out what will constitute both quality in the execution of the plan as well as specific outcomes 13

14. Being Person-Centered in Practice The consumer as a whole person Sharing power and responsibility Having a therapeutic alliance The clinician as person 14

15. Fundamental Principles of PDP Adheres to the “person-first” concept Applies to ALL people Views the recovery process as flexible and non-linear Promotes self-determination to the maximum extent possible Focuses on capitalizing strengths Demands transparency and equal access to information Facilitates natural supporter involvement

16. The Road to Recovery... • Person-centered planning • is a collaborative process resulting in a recovery oriented treatment plan • is directed by consumers and produced in partnership with care providers for treatment and recovery • supports consumer preferences and a recovery orientation Adams/Grieder

17. Use of Person-first Language Not a diagnostic label Person with schizophrenia, or addiction not “a schizophrenic” or “an addict” Not “front-line staff” who are “in the trenches” direct care staff providing compassionate care Focus on strengths, successes, talents Self-determination as a right Communicate a consistent message of hope 17

18. Serving Two Masters Person-centered Recovery Community integration Core gifts Partnering Supports self-direction Regulation Medical necessity Diagnosis Documentation Compliance Billing codes Understanding Outcomes and Goals 18

19. Medical Necessity Doing the right thing, at the right time, for the right reason Standard of service and quality Five elements Indicated Appropriate consider issues of culture Efficacious Effective Efficient 19

20. Example Goal Decrease depression Objectives Assess medication needs Improve finances Develop appropriate vocational goals 20

21. Goal Maintain psychiatric stability Objectives Attend appointments with PCP Donna will attend psychiatric appointments Example 21

22. Goal Life long sobriety and abstinence Objectives Attend all classes and groups on substance abuse education Complete 4th step by November 2008 Attend 5 NA/AA meetings per week Weekly individual therapy Example 22

23. Plan Development Acquired skill / Art form Not often taught in professional training Often viewed as administrative burden and paper exercise Requires flexibility Opportunity for creative thinking Integrates information about person served Derived from formulation and prioritization Information transformed to understanding Strategy for managing complexity 23

24. Service Plan Functions Specifies intended outcomes / transitions / discharge criteria Clearly elaborates expected results of services includes perspective of person served and family in the context of the person’s culture Promotes consideration and inclusion of alternatives and natural supports / community resources Establishes role of person served and family in their own recovery / rehabilitation Assures that services are person-centered Enhances collaboration between person served and providers 24

25. Service Plan Functions continued Identifies responsibilities of team members--including person served and family Increases coordination and collaboration Decreases fragmentation and duplication Coordinates multidisciplinary interventions Prompts analysis of available time and resources Provides assurance / documentation of medical necessity Anticipates frequency, intensity, duration of services Promotes culturally competent services 25

26. Service Plan Functions continued Supports utilization management Services authorization, communication with payers and payment for services Allocation of limited resource A contract with the people we serve! 26

27. The Plan…Must it be a heavy burden? “Apparently, Smith’s desk just couldn’t withstand the weight of the paperwork we piled on his desk.”

28. Elements of a Recovery Plan • The person’s goal: what is the desired outcome of services? • Discharge/transition criteria—establishing and end point • How to overcome barriers? • Objectives – what are the steps to reduce barriers and attain the goal? • Proposed type(s) of interventions – who is going to do what to get there? • proposed duration– when will things be accomplished? • Purpose—what’s to be accomplished relative to the objective?

29. A Plan is a Road Map B C D A E “life is a journey…not a destination” • Provides hope by breaking a seemingly overwhelming journey into manageable steps for both the provider and the person served

30. Building a Plan Outcomes Services Objectives Strengths/Barriers Goals Prioritization Understanding Assessment Request for services

31. THE ASSESSMENT

32. Strengths • Environmental factors that will increase the likelihood of success: community supports, family/relationship support/involvement, work • Identifying the person’s best qualities/motivation • Strategies already utilized to help • Competencies/accomplishments • Interests and activities, i.e. sports, art • (Identified by the consumer and/or the provider)

33. Examples of Strengths Motivated to change Has a support system –friends, family Employed/does volunteer work Has skills/competencies: vocational, relational, transportation savvy, activities of daily living Intelligent, artistic, musical, good at sports Has knowledge of his/her disease Sees value in taking medications Has a spiritual program/connected to church Good physical health Adaptive coping skills Capable of independent living

34. Cultural Factors in Assessment Begin with cultural and demographic factors Clarify identity “how do you see yourself?” race, ethnicity, sexual orientation, religion, color, disability reference group Specify language fluency literacy preference 34

35. Barriers • What is keeping the person from their goals? • need for skills development • intrusive or burdensome symptoms • lack of resources • need for assistance / supports • problems in behavior • challenges in activities of daily living • threats to basic health and safety • Challenges / needs as a result of a mental / alcohol and/or drug disorder 35

36. Importance of Understanding Data collected in assessment is by itself not sufficient for service planning Formulation / understanding is essential Requires clinical skill and experience Moves from what to why Sets the stage for prioritizing needs and goals The role of culture and ethnicity is critical to true appreciation of the person served Recorded in a chart narrative Shared with person served 36

37. Interpretive Summary Bridge Informative findings based on assessment data and the subsequent recommendations Perception of the individual on his/her SNAP (strengths, needs, abilities and preferences) Perception of the provider on individual’s SNARF (strengths, needs, abilities, risk and functional status) Provider insight into contribution and impact of individual’s psychodynamic, cognitive, familial, environmental and personality traits on current status, service goals and treatment outcomes

38. Interpretive Summary, cont. Provider & individual’s understanding of how illness/condition impacts function Provider and individual’s speculation and understanding of previous treatment outcomes Groundwork for recovery vision and future goals Prioritization of needs for service planning Individual’s readiness and motivation for change

39. The 10 Ps • P ertinent history (brief) • P redisposing factors • P recipitating factors • P erpetuating factors • P resent condition / presenting problem • P revious treatment and response • P rioritization by person served • P references of person served • P rognosis • P ossibilites

40. Stages of Recovery and Treatment

41. The person is… over-whelmed by… giving in to… moving beyond… …the disabling power of the illness question- ing challeng-ing…

43. Vignette--Carmen 18 year old Latina High school senior preparing for graduation First generation parents monolingual Spanish speaking client bilingual observant Catholic family Lives in predominantly Anglo-American community 43 43

44. Vignette continued Excellent student Active in school and social activities Recently unable to attend school because of distress Graduation from high school and college attendance is core value for Carmen and family Recent physical problems Nausea, vomiting, dizziness, headaches Parents believe she is suffering from susto Treatment from curandero 44 44

45. Vignette continued Recent crisis Acute physical distress Admitted to hearing a baby cry while at school Reported feeling sad and blue Referred to mental health Embarrassed and resistant First family member to seek MH services 45 45

46. Vignette continued Assessment with Latina provider in Spanish Revealed she had a miscarriage a year ago Feeling increasingly guilty and troubled Wants to die and join her baby Relationship with parents has become distant and full of conflict father refusing to speak with her 46 46

47. Vignette Formulation Identity First generation Latina Bilingual Explanation of Illness What appeared to be a physical problem is a mental health problem somatization is idiom of distress shame, guilt and embarrassment are key themes Provider relationship Spanish preferred More open with Latina clinician 47 47

48. Vignette Formulationcontinued Psychosocial environment Lives with family, first generation Some degree of acculturation and distance from parents difficult and painful Diagnosis Consider possibility of culture bound syndrome susto Possible depression with psychotic features Understanding her beliefs may be key to treatment 48 48

49. Vignette Formulationcontinued Hypothesis Intergenerational issues of acculturation are a major factor Age appropriate issues of individuation and separation She is between contemplative and active stage—some ambivalence about help-seeking School completion and education opportunity and advancement are shared values /strengths to build upon Need to help her reconcile feelings of guilt and remorse Religious and spiritual factors may be significant 49 49

50. Definition of a Goal “The goal is a broad, general statement that expresses the individual’s and family’s desires for change and improvement in their lives, ideally captured in their own words.” Source: Adams, N. and Grieder, D. (2005) Treatment Planning for Person-Centered Care. Elsevier Academic Press.