PERSON-CENTERED PLANNING BLUE PLUS STYLE · 2017-10-11 · Confidential and proprietary. Blue Cross® and Blue Shield ®of Minnesota and Blue Plus are nonprofit independent licensees

Confidential and proprietary. Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.Confidential and proprietary.

PERSON-CENTERED PLANNING

BLUE PLUS STYLE

September 7th, 2017

Partner Relations Team

Presented by: Melinda Heaser and Kim Flom-Brooks

Confidential and proprietary.

Today’s presenters:

• Melinda Heaser, Partner Relations Consultant, Care Systems

• Kim Flom-Brooks, Partner Relations Consultant, SW Region

Input into today’s presentation also provided by:

• Jenna Rangel, Partner Relations Consultant, SE Region

WELCOME

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• Questions may be submitted via chat at any time. We will answer them at the

end as time permits. Q & A Summary will be emailed to all participants after the

presentation

• Attendance Log: Sign and return via e-mail to:

[email protected]

• Webinar will be available on the care coordination portal under ‘Access Training’.

HOUSEKEEPING ITEMS

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mailto:[email protected]


• Learn how to apply Person-Centered, Informed Choice and Transition

Protocol requirements to your assessments and care plans

• Learn the DHS audit protocol requirements for person-centered planning

• Learn Blue Plus' 2017 audit discoveries for person-centered planning

elements

• Have resources and tools to reference for future planning

OBJECTIVES

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• Introduction (7 minute video)

• Why person-centered?

• Person-Centered, Informed Choice and Transition Protocol

• DHS Audit Protocol: Review of Person-Centered elements

• Review of PCP elements in the LTCC

• Review of PCP elements in the Collaborative Care Plan

• Person-centered language

• What about those with Dementia?

• Resources

AGENDA

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Person-Centered Mat ters : mak ing l i fe bet ter for someone

l iv ing wi th dement ia

ht tps : / / you tu .be /OZXeXHJX_1A (7 minu te vers ion)

Full Video:

https://www.youtube.com/watch?v=5R3idi0e1eg (16 minute version)

PERSON-CENTERED MATTERS

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https://youtu.be/OZXeXHJX_1A

https://www.youtube.com/watch?v=5R3idi0e1eg


WHY PERSON-CENTERED?

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• Americans with Disabilities Act (ADA) and the Olmstead

decision

• Minnesota’s Olmstead Plan

• CMS Home and Community-Based Services Rules

• Minnesota Statute 245D

POLICY DRIVERS

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• Involves a deep respect for individuals and their equality

• A philosophy and approach which goes far beyond written care plans and

documentation

• A practice which results in quality of life for those individuals supported by our

systems.

PERSON-CENTERED PRACTICES

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• From health and safety to supported decision-making, addressing risk and choice

customized to the person’s individual preferences.

• Finding a balance between what is important TO the individual and what is

important FOR them.

SHIFTING OUR FOCUS

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DHS PERSON-CENTERED, INFORMED CHOICE &

TRANSITION PROTOCOL

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What is the transition protocol?

DHS PERSON-CENTERED PROTOCOL

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Discovery, Learning, & Assessment

Support & Action Planning

Implementation Quality Review

Part 1: Person Centered & Informed Choice

Part 2: Transition Requirements


When should the DHS person-centered protocol be referenced and used?

Any time support planning takes place:

• A person first requests services (assessment); or the first time a care plan is created

• There is a care plan review (monitoring/outcomes)

• There is a change in circumstances which effects changes to the care plan

• The person requests a re-visit to the plan

• The person is moving


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• Five effects of person-centered practice


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•How can we expand and deepen peoples’ relationships and connections with others?Grow in relationships

•How can we support people to contribute and help them discover and express their gifts and capacities?

Contribute to their community

•How can we help people experience choice and have positive control over their life?Make Choices

•How can we increase the number of valued ways people can contribute by having a valued role in their community?Dignity & Respect

• How can we increase the person’s participation in local community life?

Share ordinary places and activities


DHS AUDIT PROTOCOL:

REVIEW OF PERSON-CENTERED ELEMENTS

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Minnesota Department of Human Services

Managed Care (MSHO and MSC+) Elderly Waiver Care Planning Audit

(as required under 7.1.4.D., 7.8.3, and 9.3.7 of the 2016 MSHO/MSC+ contract)

2017 Audit Protocol

5. PERSON-CENTERED PLANNING - Assessment

Desired Outcome: The enrollee has an opportunity during assessment to identify what is

important to, and what is important for, them.

Method for measuring outcome achievement (met as determined by all of the

following):

For both initial assessments and reassessments:

DHS AUDIT PROTOCOL – PC ELEMENTS

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5.1 Opportunities for choice in the enrollee’s current environment are described.

a. There is a specific description of the enrollee’s opportunities to make meaningful choices in

their daily life (need to mention “choice” or a similar word), as identified in LTCC assessment

items. Items in ( ) are comparable items from DHS Form 3428A:

(1) E.4 (D.4)

(2) E.5 (D.5)

(3) E.8 (D.8)

(4) E.11(D.11)

(5) E.12-Housing) (D.12)

and

b. If there are areas in which opportunities for choice are limited, these are listed. (Person-

Centered Planning Comments, Sections E and I; in DHS Form 3428A, Sections D and F).


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5.2 The enrollee’s current rituals and routines are described.

a. There is a general description of the enrollee’s daily rituals and routines, which includes

quality, choice, preferences, and predictability, in general, as identified in:

(1) E.4 (D.4)

(2) E.5 (D.5)

(3) F.26 (L.26)

(4) F.27 (L.27)

(5) F.28 (L.28)

b. Enrollee has described the social, leisure, or religious activities s/he wants to participate

in. (E. 6-11 or D.6-11 on DHS Form 3428A);

and

c. There is a statement regarding how this information was gathered (E.1 or D.1)


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5.3 a. The enrollee’s decision about employment/volunteer opportunities has been

identified in: a. The enrollee’s decision about employment/volunteer opportunities has been

documented as identified in:

(1) D.12 (N.12 in DHS Form 3428A)

(2) D.12a (N.12a)

(3) D.13, and (N.13, and)

(4) D.14 (N.14)

Not met as determined by the following:

The above stated requirements are not met per each sub-element.


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13. COMPREHENSIVE CARE PLAN – Housing and Transition

Desired Outcome: The enrollee has a transition plan to support housing choice.

Method for measuring outcome achievement (met as determined by all of the following):

a. The LTCC assessment items related to housing choices and support are completed,

including follow-up questions; and

b. If the enrollee indicates they want assistance in exploring housing options, the transition

plan reflects a goal, steps to be taken, potential barriers; and

c. The transition plan is attached to the Care Plan.

Source of Evidence:

• DHS Form 3428: Section E: E.12, E.13, and E.13a; or DHS Form 3428A, Section D: D.12,

D.13 and D.13a.

• Preparation of transition plan that meets transition plan requirements (action steps).

• My Move Plan.


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8. COMPREHENSIVE CARE PLAN – Goals

Desired Outcome: The enrollee’s goals or skills to be achieved are included in plan, are

related to the enrollee’s preferences and how the enrollee wants to live their life, and there is

a plan to achieve their goals.

Method for measuring outcome achievement (met as determined by all of the

following):

a. Goals and skills selected by the enrollee to be achieved are clearly described;

Source of Evidence: Care plan and item F.9a related to training on assistive devices.

Provider care plan/summary.


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PCP ELEMENTS IN THE LTCC

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• DHS 3428 (DHS 3428A) Use the most current version

• Comments and Open Text Fields throughout the assessment

REVIEW OF PCP ELEMENTS ON THE LTCC

• Member’s decision about

employment/volunteer

opportunities has been

documented

Section D (N)

My Everyday Life

• Opportunities for choice

• rituals, routines, choice,

preferences and predictability

• Housing choice

• What’s important to the

person

• Future Plans/Goals

Section E (D)

Relationships and Community

Connections

Section F (L)

My Health

• Member’s health related goal

• Training on special

equipment/assistive devices

• Meal preferences

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Does the person want to explore opportunities for volunteer or work?

Section D (N) My Everyday Life

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• Input should be gathered from the member and/or family or other important people

in the member’s life. Paid providers are not allowed to participate in the LTCC.

Section E (D) Relationships and Community Connections

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• Use “choice” or similar language

• Your documentation should support that the member has opportunities for choice.

• If opportunities for choice are limited—describe this.

• Important To/For the person

• Remember to answer both questions

Audit tip: If either question is left unanswered, will be two audit findings.


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My Future Plans

Audit tip: If either question is left unanswered, will be two audit findings.


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Housing E.12 – E.14

• My Move Plan Summary DHS-3936


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Health Related Goals on LTCC

• Should be carried over to care plan goals

• Should be unique to the member

Audit tip: If a specific goal is documented in this section, the auditor will be

looking for it on the care plan.

Section F (L) My Health

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Meal Preferences

• Are nutrition needs being met?

• What are person’s preferences

• Support plan implications

What if the person is receiving Residential Services and all meals are provided?


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CL provides all meals



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• Assess need for training on

Special Equipment/Assistive Devices

• Carry over to CCP if any needs identified

Audit tip: Leave F.9a blank - at risk for two audit findings


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Enter the item(s) here. Additional

information can be provided in

the following Comments Section

and in the CCP.


• Document more detail in these areas

Person-Centered Planning Comments sections

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PCP ELEMENTS IN THE

COLLABORATIVE CARE PLAN (CCP)

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II. What’s Important to Me?

• Carry over from LTCC

Review of PCP elements in the Collaborative Care Plan

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III. My Strengths

• Include details gathered from Section E of LTCC

• Use detail and be specific


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IV. My Supports and Services

• Provide detail about what the person wants help with

• It doesn’t just have to be ADLs or IADLs

• Formal and informal supports


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VII. My Goals

• Goals are the member’s, not provider or Care Coordinator

• Use the person’s name or I statements when writing goals

• Interventions should be specific- whose going to do what by when (Target Date)


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PERSON-CENTERED (PC) LANGUAGE

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PERSON-CENTERED LANGUAGE

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System-centered Person-centered

Diagnosis Lives with…

Outing Goes to ____

Setting, environment, facility Lives with or at ____

Support staff People who support

Behaviors Person with shows X behaviors when experiencing X condition

Client/member Person’s name

Non-communicative, unable to have conversation

Communicates with eyes/hands/assistance from family, etc.



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Member

WillMust

Needs to Should


• What’s Important to Me? (living close to my family, visiting friends)


“Family”

“Church”

“Continue living at home”

John says the most important things to him

are to continue living at home with his wife

and spending time with this 5 children and 11

grandchildren. His Catholic faith and regular

attendance at church is also very important to

him.

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• My Strengths (skills, talents, interests, information about me)


Client is alert and oriented and makes

decisions independently. She is independent

in her mobility without an assistive device.

Has a positive attitude and is helpful to others.

Jane takes pride in that she is still able to

manage her own needs and cares and does

not want to be dependent on her family.

Despite having both knees replaced, she is

able to walk independently.

Jane has a positive attitude and enjoys

helping others including volunteering at the

local nursing home and in the youth program

at her church.

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• My Supports and Services (What do I want help with? Service and support I requested?

From Whom?)


Member will continue to reside in 24 hour CL

with assistance for ADL’s and IADL’s and med

management. She will continue to be seen by

her care team on a regular basis.

Or

“Customized Living Services at Main Street

Residence.”

Karl resides at Main Street Residence and

enjoys living there. He would like to receive

assistance with taking his medications and

some daily needs which include bathing,

housekeeping, and laundry service from the

residence staff. He would like to have

breakfast only prepared by the residence.

Karl wants his daughter, Kimberly, to continue

managing his finances.

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GOALS:

Examples of PC friendly language with goals.


Jane would like her

medications administered by

customized living staff.

I would like help with taking my

medications as they are

prescribed.

Member will have medications

administered by CL staff.

John would like to be injury free

and avoid falls this year.

I would like to be free of any

injuries or falls this year.

No falls. Continue to be pain free.

Joe would like help with

management of his pain

due to arthritis.

I would like help managing

the pain I have due to my

arthritis.

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WHAT ABOUT THOSE WITH DEMENTIA?

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• Treating the person with dignity and respect

• Understanding their history, lifestyle, culture and preferences including likes,

dislikes, hobbies and interests

• Provides opportunity to focus on the individual rather than their condition, and on

their strengths and abilities rather than their losses.

• Ensures they have a chance to try new things and take part in activities they

enjoy

PC APPROACH TO DEMENTIA

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Caregivers

Providers

Facility Staff

Member

Neighbors

Family

Church

members


From the LTCC

Not acceptable:


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Person-centered approach:


From the CCP


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Not acceptable:

Person-centered approach:


Care Plan Goals

Not acceptable:


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Care Plan Goals

Person-centered

approach:


PERSON-CENTERED RESOURCES

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DHS Person Centered Thinking 2-day Trainings (strongly recommended):

• https://rtc3.umn.edu/pctp/training/index.asp

DHS Person-Centered Practice rules & guidelines:

• https://mn.gov/dhs/partners-and-providers/program-overviews/long-term-services-and-

supports/person-centered-practices/

Positive Supports MN – includes examples, resources, & tools:

• https://mnpsp.org/pcp/

RESOURCES

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https://rtc3.umn.edu/pctp/training/index.asp

https://mn.gov/dhs/partners-and-providers/program-overviews/long-term-services-and-supports/person-centered-practices/


New landing page on the

Care Coordination Portal:

• Today’s training

• MCO training

• DHS resources

• DHS FORMS

• Sample care plan

RESOURCES

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• Person-Centered, Informed Choice and Transition Protocol: MN Department of Human Services,

January 2017

• From Theory to Practice: Making Our Practice Person-Centered: Age and Disabilities Conference, June

21, 2017

• Using Person-Centered Practices in Support Planning: Presented by DHS Disability Services and the

Lead Agency Review Team, May 22, 2017

Other resources, information and language taken from:

Positive Supports Minnesota site: https://mnpsp.org/

DHS Person-Centered Practices site: https://mn.gov/dhs/partners-and-providers/program-overviews/long-

term-services-and-supports/person-centered-practices/

REFERENCES LIST

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https://mnpsp.org/

https://mn.gov/dhs/partners-and-providers/program-overviews/long-term-services-and-supports/person-centered-practices/

Confidential and proprietary. Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.Confidential and proprietary.

THANK YOU.

Please contact your Partner Relations Consultant with any questions or email

[email protected].

Documents

PERSON-CENTERED PLANNING BLUE PLUS STYLE · 2017-10-11 · Confidential and proprietary. Blue Cross® and Blue Shield ®of Minnesota and Blue Plus are nonprofit independent licensees