Changing or Updating the Life Plan

Care Coordination Organization (CCO) Care Managers are required to keep the Life Plan up to date and continually review the individual’s preferences, goals, need for supports and safeguards, effectiveness of the Life Plan and service delivery support strategies, etc. as part of comprehensive care management and monitoring of the implemented Life Plan.   

The ultimate purpose and goals for this activity is to ensure that the individual’s supports and services are meeting the person’s needs and contributing to a meaningful life for the person as he/she defines that through their chosen goals and that any health, behavioral, or other challenges and obstacles are being proactively addressed and monitored, and good health is promoted.   

The Life Plan must be revised whenever there are significant changes.

Significant changes include, but are not limited to:

  • A change in a goal;
  • Support changes;
  • Service changes;
  • Changes in the provider delivering a support or service;
  • Life event changes such as a move to a new setting or loss of a caregiver;
  • Changes in safeguard needs (e.g., medication administration, support services following hospitalization discharge, or other changes due to sites of care); and
  • Significant changes in a person’s condition.

The Life Plan must be reviewed and revised if ineffective per 14 CRR-NY 636-1.3 Person-centered Service Plan and standard number 11-9 of the PCR Manual. Changes must be made when the implemented Life Plan is not achieving the desired results for the person; when goals/supports are not effective and need revision in order for the person to make progress towards their goals.

Immediate Life Plan Update: 

The Life Plan must be revised prior to the next Life Plan review whenever there are significant changes to the individual’s Life Plan including but not limited to: 

  1. Significant change in condition (SCIC), that results in changes to a person’s functional status, as defined in the Comprehensive Assessment Section.
  2. A change in a safeguard
  3. Substantial change in a goal, support, or service.
  4. A change in the provider delivering a support or service.
  5. Sentinel events (unanticipated event) or life changing events, such as a move to a new setting or loss of a caregiver, that results in an immediate change to the person’s supports and services. 

In addition, the Care Manager must consider a person’s current services, supports or living situation to ensure review and updates of associated plans and assessments and any necessary referrals. 

As noted in the Comprehensive Assessment section, if the Care Manager determines that an SCIC has occurred, they must refer the person to OPWDD for reassessment with the OPWDD state-approved functional needs assessment (e.g., Child and Adolescent Needs and Strengths (CANS), Coordinated Assessment System (CAS), Developmental Disabilities Profile (DPP2)).

Updates at the Next Scheduled Life Plan Review: 

Circumstances that do not require an immediate Life Plan change and can therefore wait until the next formal Life Plan review include: 

  1. Short term events such as a temporary illness or temporary change to the person’s health, temporary location change, etc.
  2. A provider/natural support address or name change, Agency merger;
  3. If an element of the Life Plan is not achieving the desired results for the person;
    • meaning: when a goals/support is not effective and needs revision for the person to make progress. These updates should be made by the next review (annual or semi-annual).

These circumstances must be addressed immediately by the providers and communicated effectively to the Care Manager and care planning team and vice versa. However, they do not require an immediate Life Plan change and can therefore wait until the next formal Life Plan review if a Life Plan revision is necessary. Any changes or issues raised or addressed must be documented in the person’s care management record as part of the monitoring functions of the Care Manager.   

No Life Plan Update Needed:

Time limited events, such as sedation, flu, or brief illness, do not require a Life Plan change. However, brief changes may need to be communicated timely to the Care Manager, providers, and care planning team. These changes must also be documented in the care management record. 

Life Plan Updates Upon request:

The Care manager must revise the Life Plan, if necessary, at the request of the person/family/representative per the 14 CRR-NY Part 636-1.3 Person-Centered Planning Requirements. If the person requests a change to their plan the Care Manager must be responsive and work with the person/family/representative to determine if this is something that requires an immediate update or can wait until the next meeting. Ultimately, this is the person’s choice.