Person-centered planning recognizes that people grow, change, and can realize personally valued goals. PCP focuses on the universally valued goal of living a good life as defined by the person we serve. All activities are focus on the person as a whole (not just their diagnosis or disability) and are informed by the person’s unique culture and identity. Our trained staff:

1. Demonstrates self-awareness and practices cultural humility. Person-centered practitioners must be cognizant of their own power and privilege, cultural assumptions, psychological development and temperament, personality dynamics, and prejudices to avoid imposing their beliefs on the process. Similarly, practitioners are aware of the values and cultural biases of the service system and recognize that the person’s values and culture may not align with the system’s values and culture.

2. Learns about a person’s cultural and linguistic preferences and experiences of trauma (personal or historical) and draws on this learning when partnering with the individual in the planning process. Recognizes cultural and linguistic factors such as individualism and collectivism, language and communication, values and beliefs, customs and rituals, relationships to authority figures, avoidance of uncertainty, relationships to time, and other cross-cultural differences that need to be understood and respected in the person-centered planning process and its goal of community inclusion.

3. Skillfully uses available person-centered tools to support goal discovery, visioning, and self-direction.

4. Conveys high expectations for meaningful outcomes across a broad range of quality-of-life areas valued by the person that go far beyond the management of a disability or diagnosis.

5. Creates a comprehensive, strengths-based profile with the person that helps them discover or rediscover themselves as a whole person with strengths and interests beyond their disability or diagnosis.

Planning facilitates linkages with both paid (professional) and unpaid (natural) supports. This requires understanding of the person’s relevant health or disability issues as well as knowledge of the array of systems the person may access. All activities seek to maximize connections to natural community activities and relationships in inclusive settings wherever possible and when consistent with the preferences of the person.

1. Understands the systems and supports a person may choose to access (e.g., LTSS) and facilitates linkages as appropriate, e.g., to health care, social services, entitlement programs, recreation and leisure, housing and employment supports, faith-based opportunities, employment resources, culturally specific resources, and safety net providers such as food pantries and clothing donations.

2. Understands basic issues related to different populations served, e.g., older adults and people with physical disabilities, intellectual/developmental disabilities, mental health challenges, brain injury, or Alzheimer’s disease or cognitive impairment.

3. Promotes the person’s connection to the valued natural community activities and relationships that matter most to them. Encourages a person’s experiences and activities beyond those provided in segregated environments designed only for people with disabilities or specific diagnoses.

4. Actively involves family caregivers and/or other supporters in collaboratively developing and executing the person-centered plan in accordance with the preferences of the person.

5. Supports the creation or maintenance of a meaningful life in the community (as defined by each individual) as a fundamental human right and not something that must be earned by the demonstration of “stability” or acts of compliance with professional recommendations. 

Relationships and planning activities are based on respect and the assumption that people are presumed competent and have the right to control decisions that impact their lives.

People are supported in
empowering themselves and discovering their voice in all aspects of plan co-creation and implementation. Practitioners are aware of and able to educate people (when necessary and desired) about the range of legal protections that promote both fundamental safety (i.e., the right to be free from abuse and neglect) and community inclusion (i.e., the right to be free from discrimination and the right to exercise freedoms).

1. Presumes competence. All people are presumed to have the capacity, and the right, to actively participate in the planning process.

2. Understands the concepts of dignity of risk and the right to fail. With the exception of some emergency situations, does not (directly or indirectly) place limits or restrictions on a person’s freedom or activities out of a desire to protect them or act in their best interest.

3. Provides basic education about one’s rights in services (including the right to receive conflict-free case management when supported by Medicaid-funded home and community-based services) as well as one’s right to be free from discrimination both within the service system and in the community at large. This requires a basic knowledge of the history and achievements of advocacy groups across disability and aging at the national level—including the passage of rights legislation such as the Americans with Disabilities Act (ADA), Olmstead, the Patient Self-Determination Act, etc.

4. Supports people to advocate for themselves (and/or advocates for them when appropriate and desired) when their preferences or values are not being honored in the person-centered planning process and during times of tension or disagreement with providers or supporters.

5. Practices supported decision-making, a series of relationships, interventions, arrangements, and agreements designed to assist a person to make and communicate to others decisions about their life, often around alternatives to guardianship and other legally sanctioned restrictions to freedom for people with disabilities.

6. Understands how to recognize abuse, neglect, and exploitation and the legal and administrative requirements related to the handling and reporting of such violations. 

Planning interactions and meetings are facilitated in a respectful, professional manner and in accordance with person-centered principles and the preferences of each individual. Ensures the
primary focus remains on the priorities and perspective of the person. Supports the person in expanding their team or circle as desired. Encourages all members to make meaningful contributions and facilitates the process in a way that is transparent and accessible to all parties involved.

1. Attends to language and respects the preferences of the person. Understands the nuances behind person-first vs. identity-first language.

2. Respects the person’s input regarding the planning meetings, including who the person would like to involve, preferences around logistics (location, schedule, etc.), priority areas for discussion, and preferences around facilitation (e.g., self-facilitated or supported).

3. Facilitates one-on-one or team meetings in a respectful, professional manner and works to ensure the person’s preferences shape the process. Meetings start on time; disruptions are minimized; the person is given the team’s full attention; the conversation follows the person’s lead; the person is never “talked about” as if they are not in the room, and conversations and questions are directed to their attention; the facilitator regularly checks in with the person during planning conversations to be sure they understand and to ask if they have questions; the person is always offered a copy of their plan and given a copy to review, edit, and suggest changes if it does not reflect their input.

4. Makes space for the contributions of all team members during person- centered planning meetings, with a particular priority of making sure the person’s voice is not lost in the dialogue and is given primary consideration.

5. Understands and knows how to help the person and their supporters identify and work through differences and conflicts. Able to facilitate agreement, or respectful disagreement, among all involved on course of action using tools and techniques such as conflict resolution and decision support.

6. Maintains a focus in the conversation on the person’s desired life goals and outcomes. 

The person-centered plan is co-created and captured in writing in a manner that adheres to established expectations around person-centered plan documentation. The plan is valued as a “living
document” that is revised as needed based on the person’s preferences and evolving situation. There is responsible follow-up and monitoring of the plan’s implementation.

1. Actively includes the person’s strengths, interests, and talents in their plan and its implementation.

2. Writes plans using the person’s preferred name and language and identity preferences throughout.

3. Frames goal statements using language that is clear and accessible while capturing what is important to the person in their own words wherever possible.

4. Reflects the services and supports (paid and unpaid) in plan documentation that will assist the person to achieve identified goals. If the person chooses coordinates efforts between paid and unpaid (natural) supporters during plan implementation.

5. Solicits ongoing feedback from the person and their supporters on progress and concerns and revises the plan as needed in an expedient manner.

6. Monitors and oversees the implementation of the plan to ensure that services are delivered both in accordance with the person’s preferences and in accordance with the type, scope, amount, duration, and frequency of supports as specified in the plan.