Guidance

Person-centered planning is a discovery process used to search out what is truly important to and about a person and what capacities and skills that person possesses.  To the maximum extent possible, the person directs the planning of their services and makes informed choices about the services and supports they receive. This process is meant to help service providers and others involved with the person understand how the person wants to live and guides the delivery of services and supports to maximize progress and drive positive outcomes in the areas of the person’s life that are most important to them.

The planning process must be designed to empower people by building on their skills and abilities and promoting a quality lifestyle that supports their desired community contributions.

Other factors that impact the person’s life, such as health and wellness, relationships, employment, and where a person wants to live, are also considered during the planning process. Exploring opportunities with the person to use their skills and abilities helps to set a direction while providing positive motivation and increasing the likelihood of achieving the outcomes that are most important to the person.

Person-centered planning is a collaborative and recurring process between the person, their family members or other supports and advocates, and the service provider(s) that comprise the Care Planning Team. The planning process must be adhered to during the comprehensive assessment process, at the time the Life Plan is developed, and during subsequent reassessments and reviews of the Life Plan.

The CCO/HH provider is accountable for engaging with the person in coordinating and arranging for the provision of person-centered services; supporting adherence to treatment recommendations; monitoring and evaluating the person’s needs, including prevention, wellness, medical, specialist and behavioral health treatment, care transitions, developmental disability, long term services and supports, and social and community services where appropriate through the creation of an individualized Life Plan.

In accordance with OPWDD regulations in NYCRR Part 636, the person-centered planning process requires:

  1. Supports and services are based on the person’s interests, preferences, strengths, capacities, and needs;
  2. Supports and services are designed to empower the person by fostering skills to achieve desired personal relationships, community participation, dignity, and respect;
  3. The person is satisfied with activities, supports, and services;
  4. Necessary information and support are provided to ensure that the person, to the maximum extent possible, directs the process and is enabled to make informed choices and decisions;
  5. The person chooses who works with them to develop their person-centered Life Plan and they can choose who they want to assist them in making decisions;
  6. The person-centered planning process involves parties chosen by the person, often known as the person’s Care Planning Team, Circle of Support, or Interdisciplinary Team (IDT). The members of the team, as chosen by the person, participate in the process as needed, and as defined by the person. The person may request the participation of anybody they think may be helpful to them in the planning process. This may include family members, advocates, or friends, or parties appointed by the person to support them in decision-making (e.g., a supporter under a supported decision-making agreement, an agent under a power of attorney, or a health care agent);
  7. The individual will be supported to make informed choices about what supports and services they want and need. This support may come from family, friends, staff, or someone who has legal decision-making authority in their life;
  8. The people chosen to assist the person in decision-making by, among other things, explaining issues to be decided, answering the person’s questions, encouraging them to actively participate in decision-making and, when necessary, assisting with communicating their preferences;
  9. It is up to the person who they would like to invite to participate, except to the extent that applicable decision-making authority is conferred on another person under State law. This means that a legal guardian with decision-making authority that covers the provision of relevant services must always be given the opportunity to participate in the planning process.  If the person has a guardian who has legal decision-making authority over relevant service planning, the guardian may always choose to be a part of the process and may choose to make decisions on their behalf, as long as it’s within the scope of their authority to do so;
  10. Scheduling times and locations of convenience to the person;
  11. Taking into account the cultural and linguistic considerations of the person and/or family member by providing information in plain language and in a manner that is accessible to and understood by the person and their chosen parties. Written and verbal information must be provided in a way that the person can fully understand it. For example, oral interpretation and written translation services are provided in the person’s primary language and/or using alternative forms of communication that works best for the person and their family. A person’s primary language should not be assumed. The primary language is decided by the person and/or their family/representatives.
  12. Providing a method for the person to request updates to the Life Plan as needed;
  13. Developing strategies that address conflicts or disagreements in the Life Plan process, including clear conflict of interest guidelines, and communicating such strategies to the person who is receiving services as appropriate;

For developing the HCBS Waiver service habilitation plans (i.e., Staff Action Plans), with the person and the people they have chosen to support them.

The person must also be made aware of their rights surrounding person-centered planning:

  1. Notice of the person-centered planning process and Life Plan
  2. The care manager must give notice to the person of their right to a person-centered planning process and of their right to object to services prior to the initiation of the person-centered planning process and development of the plan.
  3. Right to participate in a Person-centered planning process 

This means that:

  • the person-centered planning process is all about the person;
  • the person is in charge of the planning process
  • if there is conflict or disagreement when planning services and supports, there are ways to resolve them, and the person will be told about them.
  1. Right to a Person-Centered Plan of Services

The Person-Centered Life Plan must be clear to the person and their Care Planning Team. It must be provided in the person’s primary language and written in a way that is easily understandable to the person and their family/representatives. If needed, the Care Manager will utilize alternative methods of communication to review the Life Plan with the person and their family/representative. 

The person must sign their Person-Centered Life Plan to show that they agree with what the plan says. The Care Manager, who will make sure that everything in the plan happens, will also sign the plan. The person will get a copy of the plan. 

The person will review the Life Plan with their care manager at least twice a year, when something in the plan changes, or when the person wants to change something in their plan.

The right to a Person-Centered Plan of Services will be reflected in the person’s Life Plan and/or other associated plans and will include:

  • Goals and desired outcomes;
  • Strengths and preferences;
  • Needs based on an assessment;
  • Services and supports the person needs and who they have chosen to provide them;
  • Services the person chooses to self-direct;
  • Where the person lives and that they chose to live there or that they choose to move;
  • Things that might cause a risk of harm to the person and what will be done to make the risk smaller, including having a plan about what to do if something goes wrong;
  • Name of the person or agency the person has chosen to watch over their plan to make sure that everything in the plan happens as it should.
  1. Right to object to your Plan of Services

If the person is 18 years old or older, they may object to the whole plan of services, including their person-centered Life Plan, or any portion of it. In addition, the following people may object on their behalf: their chosen advocates (including the chosen family members from whom they receive support), their legal guardian, Mental Hygiene Legal Service, or the Consumer Advisory Board (if they represent them). If the person is capable of making their own decisions and they do not have a legal guardian, the person may prevent someone else from objecting on their behalf, except the Mental Hygiene Legal Service, which must always be given the opportunity to object, or the Consumer Advisory Board (if the person is fully represented by CAB).

If the person is under 18 years old, their parent(s) may also object to any plan of services for them. If the person doesn’t agree with them, they may choose someone to represent them, including legal counsel, to help resolve the objection.

If the person has an issue with something in their plan, they should tell their Care Manager or service provider that they wish to object to the plan. Providers must have policies and procedures to resolve an objection and must explain to the person what those policies are and assist them following the applicable procedures. If the person is unable to resolve their objection with the provider, they can request a formal hearing with OPWDD. Providers must explain to the person how to request a hearing from OPWDD. 

For more information please see 14 NYCRR Part 636 Person Centered Planning Requirements,