Person Centered Planning

This paper reports the outcome of focus groups, interviews and written surveys conducted in 2003 by a consultant working for the Northern Area Agency on Aging in Wisconsin under a contract with the Department of Health and Family Services. Groups of elders, family members and long-term care professionals were asked to address the question of how, when and why older people make the decisions they do about long-term care.

This group of presentations were offered around the state of Colorado in regional training sessions. The day focused on various aspects of consumer direction, including case managers, Medicaid options, and working with personal-care attendants. Other presentations include transitioning a child to consumer-directed health care and a presentation on the benefits, rights, and responsibilities of consumer direction.

Part of the Wisconsin QA/QI grant was to develop a framework to evaluate long-term care services. The framework was based on desired personal-experience outcomes. Once desirable outcomes were recorded, they were used as benchmarks for quality management and outcomes measurement.

This Request for Proposals (RFP) concerned the development of methods and training for assessing personal-experience outcomes for adults with developmental or physical disabilities and frail elders. The grant awardee would contract to develop a tool and related tasks to assess person-experience outcomes and quality of life for the above listed populations.

A publication that may be useful for legal guardians as they consider or prepare for a a transition planning process for the person they represent. This book guides the process in determining if a person can live in the community, and what that community living environment would need to look like. The purpose of this guidebook is to provide information about the variety of community residential options available to adults with developmental disabilities who relocate from State Centers.

This is a planning document developed by the Ozaukee County Aging Services Department that helps individuals gather thoughts and discuss them with their family by asking, What Do You Want? This document, subtitled “Your Personal Guide for Planning a Happy Healthy & Independent Long Life” helps individuals take an inventory of the values and preferences. The guide recommends recording what you want and reviewing the list periodically with those closest so they can carry out the plans.

This study was conducted as part of the Nebraska Nursing Facility Transition (NFT) Grant. The target population included children living in nursing facilities who meet the criteria for transition to home and community-based settings and children living at home identified as at-risk for nursing facility placement. The goals of this paper were to decrease the number of children in nursing facilities, identify risk factors, and to develop a plan to keep children in home and community settings.

The Consumer-Directed Supports Toolbox is a set of materials developed under the Community-Integrated Personal Assistance Services and Supports (CPASS) grant awarded to North Carolina in 2002. It was developed to support the implementation of consumer-directed options in North Carolina. The “toolbox” consists of 3 powerpoint presentations, a set of exercises to be used in conjunction with the powerpoints, a consumer-directed supports manual, brochures and other visual aids.

This series of worksheets provides examples of what the Michigan Nursing Facility Transition grant used in planning the transition from the nursing facility to the community. Review the worksheets for Daily Living, Employment Planning, Financial Planning, Health Planning, Housing Planning, Planning Template, Self-Determination, Social and Transportation Planning.

Michigan developed a six-part training on transition and diversion. Module 6, the final module in this series, is an overview of organizational impact and collaboration in nursing facility transition. This section provides information on how developing nursing facility transition capacity may impact an organization and team. It also provides information on “bringing all the resources” together. The Appendix is also included.