Developmental Services - Developmenatal Services - Case Management

Action Plan Procedures 10/02    

Person-Centered Planning is a process that assists and supports each person in creating a vision for how to live in and be a part of the community. Through the pre-planning and planning process, the planning team works with the person to articulate and identify specific Needs and Desires within the larger framework of the person's vision for the future. All Needs and Desires shall be addressed in Action Plans in accordance with the following procedures.

A "Need" is something identified by the consumer/guardian and the team that is required to maintain or improve a person's quality of life and should to be met within a specific time frame. Examples are housing, employment, day services, medical, and other professional services, respite, leisure, family support, transportation.

A "Desire" is anything else the person wishes to achieve/have/obtain, which is not a Need. Whether a goal is categorized as a Need or a Desire will, at times, depend on the person's circumstances. A Desire for one individual may be a Need for another person.

The team with the consumer/guardian leading is responsible for deciding what is identified as a Need, and what is identified as a Desire. These determinations are not final and irrevocable and what is identified initially as a Desire may, with a change in circumstances, later be reclassified as a Need. In this process, the team should be mindful that Person-Centered Planning is driven by the person.

Once identified and articulated, all Needs and Desires shall be recorded in the Person-Centered Plan without regard to whether they are reasonably achievable or presently capable of being addressed.

All Needs and Desires must then be recorded in an Action Plan attached to the Person-Centered Plan. Within the Action Plan the team must identify the following: 1) specific action steps required to meet the Need or Desire; 2) time frames for each action step, for reporting on progress, and for ultimately meeting the Need or Desire; and 3) persons responsible for action steps and reporting. The team shall monitor the person's Needs and Desires on an ongoing basis in accordance with the Action Plan. Desires will be addressed in the Action Plan process in the same manner as Needs except as stated in paragraph 8 below.

It is expected that, when the required resources are available to the team, most Needs shall be met within 90 days. It is also understood that for some Needs, such as housing and employment, a time frame of 90 days or less may be unrealistic even when all required resources are available to the team. Whenever the team identifies a time frame greater than 90 days, it must provide an explanation in the Action Plan for why the Need cannot be met within 90 days despite the availability of all necessary resources. Time frames may be adjusted only when necessary, due to the consumer's inability or unwillingness to participate.

A Need will be identified and treated as an "Unmet Need" when it has not been met within the time frame set by the team or whenever the team has determined, at any point in the process, that a resource required to address the Need is not available.

Once an Unmet Need is identified, the team must prepare an Interim Plan for providing services and supports that come as close as possible to meeting the Need in the interim while the team pursues the required resources for meeting the actual, identified Need. Within the Interim Plan, the team must identify action steps, time frames, and persons responsible for action steps and reporting. The Interim Plan becomes an adjunct to the Action Plan.

The team is obligated to conduct interim planning for Desires within the Action Plan. If the team determines that a resource required to address a Desire is not available, the team must develop action steps within the Action Plan that address the Desire as nearly as possible in the interim while the team pursues the unavailable resource. 

These guidelines are designed to empower the team in supporting the person regarding Needs and Desires. Person-Centered Planning is driven by the person or the person's guardian. The person and/or guardian provide the direction to the team. Other members of the team provide input, support, and guidance to the person regarding Needs and Desires and the planning process in general. If there are divisions between the person and team members, then the person's request should be honored to the extent possible except for reasons of health or safety. Team members always have the choice to not support the conclusions of the team by not signing the Plan. If there is a division between the person and the guardian or family members that cannot be resolved then mediation support is a suggested way of attaining resolution. When team members cannot reach consensus on an issue and the person or guardian has not expressed a preference on the matter, a majority vote of team members will control.

If a person or the person's guardian is dissatisfied with any part of the Plan or the planning process, they have the right to appeal in accordance with the Department's appeal procedures. The person or guardian may obtain assistance from the Disability Rights Center to file or pursue the appeal.

The Case Manager shall be responsible for ensuring that the Person-C entered Planning process is conducted in accordance with these procedures and shall be responsible for monitoring the planning process in accordance with the Case Management Manual.

See Person Centered Planning Preparation/Procedure Guide