The Life Plan
The Life Plan development is driven by the person, with input and participation of all members of the care-planning team. It is crucial that all members of the care-planning team are included, engaged and working together towards the ultimate outcome of a comprehensive person-centered service plan that meets the needs, overarching safeguards and life goals of the person.
About The Life Plan
The Life Plan is a document that outlines a person's:
- Goals and desired outcomes
- Habilitation goals
- Strengths and preferences
- Clinical and support needs (paid and unpaid) identified through their assessment
- Services and provider
- Safeguards including individual back-up plans and strategies
This document changes as the needs of the person change.
Who Is Involved?
Care Managers at the Care Coordination Organizations assist people with developmental disabilities to access services that support healthy, well–rounded and fulfilling lives. Care Managers work with the person and their family member, and bring together health care and developmental disability service providers to develop an integrated Life Plan for each person that includes developmental disability, medical, behavioral health, community and social supports, and other services.
Habilitation providers are often best positioned to know the clinical, medical and health status of those they support and are responsible for communicating that information to the Care Manager and care planning team at the time of the Life Plan meeting. This will ensure that the most current information regarding the person’s clinical, medical/health, safeguard needs, habilitation needs, etc. are integrated into the Life Plan by the Care Manager.
It is the responsibility of the habilitation provider to share relevant and pertinent information with the Care Manager prior to, during, and/or after the Life Plan meeting to support development of a comprehensive, person-centered Life Plan by the Care Manager. The care-planning team establishes the timeframe in which all needed and/or requested information or documents are to be shared/distributed, as well as who else within the care-planning team should have this information.
Ensuring that all members of a person’s care planning team have the necessary information to effectively participate in the person-centered planning process and in the development of the individual’s Life Plan to support comprehensive care planning is essential to effectively meeting the needs of persons receiving habilitation services. Establishing cooperative and collaborative relationships and agreements between habilitation providers and care managers is critical to achieving this outcome.