Person-Centered Planning and Community Inclusion


Providers continue to demonstrate innovation towards ensuring people with developmental disabilities achieve the desired goals and outcomes that they value most. There are several resources to support the planning process and the delivery of exceptional care in the most integrated community settings.

Strengths and Risk Inventory Tools

This Inventory is a tool that can help to generate meaningful conversations with a person regarding the possible risk areas in his/her life.

Person-Centered Planning 

Person-Centered Planning (PCP) is a process designed to ensure that everyone receiving services provided or authorized by OPWDD benefits from the most individualized supports and services possible. 

The Person-Centered Planning process should empower people with intellectual and/or developmental disabilities to have an active voice in the development of their Person-Centered Service Plan (PCSP) and in shaping their futures. It is an individualized approach to service planning, structured to focus on the unique values, strengths, preferences, capacities, interests, desired outcomes, and needs of the person. 

Person-Centered Service Plans are expected to change and to adjust with the person over time. Consequently, it is critical to revisit the plan as prescribed by OPWDD’s Administrative Directive Memorandum (ADM) #2010-03, in addition to whenever a person finds it necessary to revise or amend their service plan.

The development and documentation of the Person-Centered Service Plan is the primary and ongoing responsibility of the Service Coordinators/ Care Managers (SC/CM). Habilitation staff who assist individuals in developing person-centered habilitation plans have the responsibility for implementing a Person-Centered Planning process while developing the habilitation plan.

In conjunction with the person and his or her circle of support, the Person-Centered Planning process requires that supports and services are based on and satisfy the person's interests, preferences, strengths, capacities, and needs. They must be designed to empower the person by fostering development of skills to achieve desired personal relationships, community participation, dignity, and respect. 

The Person-Centered Planning process should also incorporate the following:

  • Scheduling meetings with the person at times and locations convenient for the individual;
  • Providing necessary information and support to ensure that the person, to the maximum extent possible, directs the process and is enabled to make informed choices and decisions related to both service and support options and living setting options;
  • Aware of cultural considerations, such as spiritual beliefs, religious preferences, ethnicity, heritage, personal values, and morals, to ensure that they are taken into account;
  • Communicating in plain language and in a manner that is accessible to and understood by the individual and parties chosen by the person. This includes providing information and plans in a language understood by the person, language interpretation during meetings if the person is limited-English proficient, explaining a document orally or in a language other than English, or providing it in an alternative format such as pictures or Braille;
  • Providing a method for a person to request updates to his or her plan, including who to notify and the means of notifying (phone or email) that person when a change is sought; and
  • Developing strategies to address conflicts or disagreements in the planning process, including a clear conflict of interest guidelines for people, and communicating such strategies to the person.

The Person-Centered Service Plan must include and document the following: 

  1. the person's goals and desired outcomes;
  2. the person's strengths and preferences;
  3. the person's clinical and support needs as identified through an OPWDD approved assessment (described in more detail in Assessments);
  4. the necessary and appropriate services and supports (paid and unpaid) that are based on the person's preferences and needs;
  5. any services that the individual elects to self-direct (described in more detail in Question 5);
  6. the providers of those services and supports;
  7. if a person resides in a certified residential setting, that the residence was chosen by the person after consideration of alternative residential settings (described in more detail in Roles and Responsibilities);
  8. the risk factors and measures in place to minimize risk, including person-specific staffing, back-up plans and strategies when needed (described in more detail in Roles and Responsibilities); and
  9. the person and/or entity responsible for monitoring the plan.

Once the Person-Centered Service Plan is completed and signed, the SC/CM is responsible for implementing and monitoring the plan as outlined in the OPWDD’s ADM #2010-03 and ADM #2010-04. This requires that the SC/CM ensure that all required attachments (e.g. habilitation plans, Individualized Plan of Protective Oversight (IPOP), documentation to support rights modifications, nursing plans, etc.) are received by service providers.

The SC/CM must follow up with the person, the circle of support or planning team, and habilitation providers to ensure that the plan is being properly implemented.

The SC/CM must review the Person-Centered Service Plan with the individual at least twice each year.  Additionally, the service plan should be reviewed when:

  • The capabilities, capacities, or preferences of the person have changed;
  • Requested by the person and/or parties chosen by the individual;
  • A determination that the existing plan (or portions of the plan) is/are ineffective; and/or
  • Reassessment of the person's functional needs.

Habilitation providers are responsible for all requirements as outlined in OPWDD’s ADM #2012-01, as well as all requirements and standards outlined in the Administrative Directive Memorandums for the specific service being provided. 

Habilitation providers are responsible for working with the individual and his or her circle of support to:

  1. develop any needed habilitation plan(s),
  2. schedule meetings at times and locations that are convenient to the person,
  3. sign the person-centered habilitation plan(s), and
  4. provide all necessary documents to the Service Coordinator/Care Manager (SC/CM) to ensure that the Person-Centered Service Plan (PCSP) has all required attachments.