Revision 13-2; Effective September 3, 2013
Person-Directed Planning Guidelines
Person directed planning is an ongoing process that empowers an individual, and the legally authorized representative (LAR) on the individual's behalf, to direct the development of a plan of services and supports that:
- identify supports and services necessary for the individual to achieve the individual’s preferred outcomes;
- identify natural supports available to the individual and describe needed service system supports;
- occur with the support of a group of people chosen by the individual and the LAR on the individual’s behalf; and
- accommodate the individual’s style of interaction and preferences regarding time and setting.
The result of person-directed planning must reflect the essential elements of the individual’s desired life in sufficient detail so the Home and Community-based Services (HCS) provider understands how to provide HCS services to meet the individual’s outcomes. The Person-Directed Planning Guidelines on the Department of Aging and Disability Services (DADS) website provide a more detailed description of the principles of person-directed planning. See https://hhs.texas.gov/sites/default/files//documents/doing-business-with-hhs/providers/long-term-care/lidda/persondirectedplanningguidelines.pdf and www.learningcommunity.us.
Discovering the Individual
The individual and his or her needs are the basis for the entire process and must be involved in all aspects of the process, as well as the focus. The foundation of person-directed planning is to listen, acknowledge and discover the personal outcomes, preferences, choices and abilities of the individual directing the plan. This activity is often called “discovery.” The local authority (LA) service coordinator (SC) has the responsibility to facilitate the process of discovery as preparation for developing the Person-Directed Plan (PDP).
There are many ways to conduct discovery. The most common method is to have conversations with the individual, LAR and others who know and support the individual, such as caregivers, close family members, current provider staff, friends and teachers. Part I of Appendix III, Discovery Guide, provides guidance for effective discovery, including:
- Useful communicating/listening skills;
- Developing a relationship;
- Creating a distraction-free environment; and
- Non-verbal communication cues
Other methods of discovery are activities from:
- Appendix III, Discovery Guide;
- Appendix IV, Discovery Tool;
- Methods taught by The Learning Community for Person Centered Practices (TLCPCP); and
- Planning Alternative Tomorrows with Hope (PATH).
Discovery can be done using a combination of these methods.
Documentation of the information gathered during discovery is important. The SC is responsible for documenting the information gathered from the individual, family, provider and other participants.
Although person-directed planning is not a linear process, discovery is important preparation for developing the PDP.
Before developing the PDP, the SC should discuss with the individual and LAR the importance of the HCS provider being included when the individual discusses his/her preferences and outcomes. Since the provider will be responsible for designing and providing the services to the individual, understanding the individual’s strengths, capabilities and desires is critical to providing services that are meaningful to the individual. The SC should request permission from the individual/LAR to invite the HCS provider to the planning meeting to develop the PDP. The SC should also ask the individual/LAR if they would like to invite anyone else to participate in the service planning process.
The SC is responsible for convening and facilitating a meeting to develop the PDP. There is not a single way to approach developing the PDP. It can be a brainstorming session where the purpose of services and desired outcomes are discussed while HCS services are decided upon. Or, it can be a meeting in which the discovery information is presented and clarified and then HCS services are negotiated.
The SC should have a thorough understanding of the services in the HCS program so that connections can be made between what the individual wants to have happen and the HCS service array. This understanding can be supported by reviewing the HCS Program Billing Guidelines, discussions with the individual’s HCS program provider and consultation with the LA’s HCS service coordination supervisor.
Developing the PDP
The PDP has two elements plus instructions:
- Form 8665-ID, Individual Data, contains important data information about the individual that doesn’t change often.
- Form 8665, Person-Directed Plan, is the form used to document an individual’s PDP.
Form 8665-ID, Individual Data
This page is completed by the SC at the time of enrollment and updated as necessary thereafter. The SC is required to provide the program provider a copy of Form 8665-ID:
- at the time of enrollment;
- when the individual transfers to a new provider; and
- anytime information on Form 8665-ID is updated.
Form 8665, Person-Directed Plan
Pages 1, 2 and 3 are completed using the information gathered through the discovery process. These pages include:
- identifying information;
- method(s) of discovery;
- important information about the individual;
- a list of people in the individual’s life;
- frequency of service coordination;
- non-HCS services; and
- additional comments.
Page 4, Action Plan:
- identifies the services to be provided;
- identifies the individual's preferences for service delivery options;
- indicates if a backup plan is necessary for that service;*
- explains the purpose and outcome of the services which address the individual’s preferences revealed during discovery;
- describes the relevant background information that is important to understand about the individual receiving those services; and
- communicates why the services are important to and for the individual.
*Note: The service planning team is responsible for determining whether an individual’s waiver service is critical to meeting the individual’s health and safety. The program provider must develop a written backup plan for each waiver service identified on the PDP as critical to meeting an individual’s health and safety. Because HCS program providers must ensure that trained and qualified staff are available at all times for the provision of residential support and supervised living, a backup plan is not needed for these services. Backup plans for foster/companion care must be documented in the service agreement the foster/companion care provider has with the HCS program provider.
The Service Planning Team is responsible for documenting that the services on the PDP:
- are necessary for the individual to continue living in the community;
- ensure the individual's health and safety;
- prevent the need for institutional services;
- each type of service component in the PDP is appropriate to meet a desired outcome or need of the individual;
- each service component does not replace existing supports, natural supports or other sources for the service (such as Department of Assistive and Rehabilitation Services (DARS) for funding of supported employment services); and
- are cost effective.
Note: For an enrollment PDP, the SC is responsible for justifying both the need and the amount for each HCS service type in the PDP. For PDP renewals and PDP updates, the SC is responsible for justifying the need for each HCS service type in the PDP and the HCS program provider is responsible for justifying the amount of each HCS service type in the Implementation Plan (IP).
PDP Update for IPC Renewal
The PDP is treated as a new plan at the time of the individual plan of care (IPC) renewal. Although the current PDP may be used as a template for the updated PDP, the:
- PDP date is updated each IPC renewal year on the top of Page 1 and on the top of every Action Plan page; and
- entire document must be reviewed and updated, as appropriate, to the individual’s current situation and personal outcomes (e.g., an Action Plan that was discontinued in the previous IPC year is not included in the new PDP).
PDP Update Within the IPC Year
If an individual’s PDP must be updated within the IPC year, the SC must clearly indicate what was updated. The PDP date is updated at top of Page 1 and, if an Action Plan is also updated, then the new PDP date is included on the top of that Action Plan page.
New information is added at the beginning of the narrative on Page 1 (rather than at the end of the narrative). Begin the new information with the following notations:
- PDP Update;
- the date the new information was added to the PDP; and
- name of the SC who is updating the information.
Example: PDP Update, Jan. 22, 2013, Sarah Smith, SC
If it is necessary to add a new Action Plan page or change information on a current Action Plan page on the PDP within an IPC year, then the SC makes the following notations at the bottom of the Action Plan page that has been updated:
- checks the “changed” or “added” box and the date or the date of the decision to discontinue the service; and
- enters the SC’s printed name and signature.
The SC must send any new or updated page(s) of the PDP to the HCS provider in a timely manner. The HCS provider is responsible for creating or revising the individual’s IP to address the new information.