Leading Practice Guidelines

Person Centred Planning & Discovery

Type: Voice

Guideline: The organization uses creative, flexible and inclusive methods to identify a person’s strengths, needs, goals and aspirations. The planning process is driven and guided by the person.

The plan is based on an exploration of the persons’ desired personal outcomes and needs and the goals and activities that would lead to the attainment of those outcomes. A timeline to achieve these goals and the people that are needed to help are part of the plan.

A person centred planning process is conducted at least annually. This process feeds updates to the Support Plan. A person centred plan is developed with each person in advance or shortly (~3 months) after service begins.

The organization monitors and is accountable for the commitments made during the planning process.

What does this look like?

The organization has a consistent and documented process to ensure that planning with people served occurs. Essential features of this process include:

• Planning is a regular and ongoing activity that brings people together who love and support the person to help them:
  • Describe their desired future
  • Identify how they could achieve this desired future
  • Explore what’s getting in the way and how to reduce or eliminate barriers
  • Identify who they need help from to make progress
  • Identify a personalized mix of paid and non-paid people, services and supports to achieve their desired outcomes.
  • Create a plan and get commitment from those they need
  • Evaluate, revise plan and repeat
• The process is driven by the person, includes whomever the person chooses (number and specific people) and the format, location and topics are as guided by the person. The use of person centred planning tools such as PATHS, MAPs, Personal Outcome Measures, Person Centred Thinking Tools, etc., is offered to and directed by the person.
• The planning occurs in an accessible manner that is understandable to the person. The person has required communication support and any meetings associated with the planning process occur in the language they are most comfortable in (English, French, American Sign Language (ASL), use of symbols, etc.)
• The planning occurs within a safe space with ground rules that ensure positive, respectful and collaborative discussion among those that the person trusts.
• Ongoing planning acknowledges that the person can change their mind. There is direction on how and when the plan is revised and how this is communicated.
• When a person does not identify personal goals, desires or preferences, efforts are made to expose the person to new opportunities that are thought to be interesting, enjoyable and meaningful.
• There are a variety of tools and methods that can be used to assist planning and facilitate meaningful discussion. Such as:
  • Relationships/friendships
  • Reviewing what is working/not working,
  • Exploring specific aptitudes, skills, and abilities,
  • Walking through what is a good day/bad day for the person,
  • Talking about what is important to/important for the person,
  • Discuss what the person does and does not want in significant areas of life such as:
    • Learning/education
    • Employment/meaningful activities
    • Retirement
    • Fun
    • Health goals
  • Identify characteristics of people who support the person best.
  • Identify what people like and admire about the person.
  • Use relationship maps.
  • Use communication charts explaining communication style and best ways to communicate.

Staff are trained and competent in person centred planning and understand the expectations of follow up, evaluation and ongoing planning.

People receive the training and support they need to participate actively in the planning process to the extent that they are interested.

Follow up on actions committed to during planning is done consistently and in a timely fashion.

While a written support plan may be developed or updated following planning with the person, the support plan itself does not in and of itself shape or dictate the process. Updates to the support plan and any other required documentation is a likely action stemming from each planning session.

How would you know this is happening? (Evidence)

What you see in systems:

• The organization has a written, consistent process on how it facilitates regular planning with people they support.
• Written document is available that captures the planning process. These documents are live, dynamic plans that are referenced and updated regularly and shape the way that the organization provides services to people.
• The plan is documented and shared as directed by the person.
• There is evidence of follow up and progress on expressed plans of people served.

What you see in actions:

• Staff within the organization use people’s planning documentation as a road map for how they wish to be supported and what they want to achieve. They are accountable for the commitments made during the planning process and follow up to be sure that others are accountable for their part of the plan.
• People supported along with their support network feel that the planning process is a powerful, empowering process that allows them to direct and plan how they wish to be supported, what they want to achieve and who they need help from to succeed.
• The routine and tasks of the person, as supported by the organization, reflect the person’s wishes and their person-centred plan.