PERSON-CENTERED PLANNING 2: THE PROCESS. 2-Person-Centered Planning - The Process 2 Remember,...

PERSON-CENTERED PLANNING 2:THE PROCESS

2-Person-Centered Planning - The Process

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Remember, person-centered planning is used to help the client use his own capacity andpotential for constructive action to realize his goals. Staff act as facilitators rather thandirectors, offering respect, acceptance, and understanding to the client to help empowerhim to realize his own potential. This approach is used when working with any client.

There are 4 steps involved in developing goals that are important to the individual. Meetwith the client, his circle of support, and staff BEFORE the individual’s support planmeeting to brainstorm what the individual wants to work on for the upcoming year.

1. Make a list of action statements or goals (called the STEM) and the SERVICES that will work with the individual on the goals.

2. Decide how often (FREQUENCY) the individual wants to work on a specific goal.

3. Decide on the TASKS the individual wants to work on and what he wants staff to do (what help he wants) to help him accomplish a specific goal.

4. Put it all together: Stem ----- Tasks ---- Frequency ---- Service


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Meet with the client and his circle of support BEFORE the client’s support plan meeting to talk abouthis future goals. Brainstorm to make a list of action statements that are important to the client. Askthe client what he wants to work on and who (what service) he wants to have help from. Decide howoften to work on the goal and the tasks involved to accomplish the goal.

1. Make a list of the goals in the client’s words, numbering each goal. The goal statement is called the STEM. It should be an “action” statement (I want to do something, learn something, see something, etc).

– Write the related SERVICE next to each goal statement.

– Discuss any goals that the client’s circle of support sees a need for and add these to the list with the Service.

– Examine the list and see if any can be combined. Make a list of the goals, combining when possible.

2. Discuss how often the client wants to work on these goals. Add the FREQUENCY to the list of goals.

3. Talk with the client about the TASKS he is willing to do for that goal. Make a list of the tasks related to each goal. These tasks include what the client will do and what the staff will do. This task list will become the objectives for each goal. Your task list will start with the word BY (how will the client do what he wants to do). You may discover that the client wants help from two or more services for one goal. We will look at an example for that situation in a moment.

7. Now, write the complete goal by putting the goal STEM together with the TASKS, adding the FREQUENCY, and putting the SERVICE that will help at the end in parentheses ( ).


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Let’s look at an example where the client wants to learn to dance once a week with help from his SLC.

STEM: I want to learn to dance

TASKS the client wants to work on: find a class, decide what kind of dancing to learn, see if I canafford a class, go to the class, practice the steps, staff will help me with these tasks and thenaccompany me to the class I choose

FREQUENCY: once a week

SERVICE: SLC

Now, put it all together:

I want to learn to danceby deciding what kind of dancing to learn, finding a class, budgeting for

theclass, going to class, and practicing the steps

with help once a week

(SLC).

You have a complete goal with STEM, TASKS, FREQUENCY, and SERVICE.

I want to learn to dance by deciding what kind of dancing to learn, finding a class, budgeting for theclass, going to class, and practicing the steps with help once a week (SLC).


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Now, let’s look at the whole process using goals that are important to the client.

STEP 1

Staff, the individual, and his circle of support meet and brainstorm this list of “action statements”. The

Service, who the individual wants help from, is added to each action statement.

This client has an SLC, an IHSS, and a Companion. He states:1. I want to make dinner (SLC)

2. I want to save my money (SLC)

3. I want to buy a tv (SLC)

4. I want to go to the movies and do fun stuff (Companion)

5. I want to go to Busch Gardens (Companion)

6. I want to volunteer with animals (Companion)

7. I want to go fishing (Companion)

8. I want to buy groceries and look nice (SLC-shopping, IHSS-look nice)

9. I want to make a memory book (IHSS)

The client’s circle of support suggests these action statements:a. help with health appointments (SLC)

b. help with chores (IHSS)

c. help with paying bills (SLC)


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Next, see if goals can be combined.1. I want to make dinner (SLC)2. I want to save my money (SLC)3. I want to buy a tv (SLC)4. I want to go to the movies and

do fun stuff (Companion)5. I want to go to Busch Gardens

(Companion)6. I want to volunteer with animals

(Companion)7. I want to go fishing (Companion)8. I want to buy groceries and look

nice (SLC-shopping, IHSS-look nice)


a. help with health appointments (SLC)

b. help with chores (IHSS)c. help with paying bills (SLC)

• Goal 1 does not seem related to any other goal

• Goals 2 and 3 are related to circle of support suggested goal c

• Goal 8 has 2 parts – financial and personal care

• So, part of Goal 8 is related to Goals 2 and 3 (financial)

• The other part of Goal 9 is personal care, a separate goal

• Goals 4, 5, 6, 7 are related• Goal 9 does not seem related to

any other goal• Circle of support suggested goals

a-b are not related to any other goal

• Again, circle of support suggested goal c is related to goals 2, 3, and part of 8 (financial issues)


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From the original list …1. I want to make dinner (SLC)2. I want to save my money (SLC)3. I want to buy a tv (SLC)4. I want to go to the movies and do fun stuff (Companion)5. I want to go to Busch Gardens (Companion)6. I want to volunteer with animals (Companion)7. I want to go fishing (Companion)8. I want to buy groceries and look nice (SLC-shopping, IHSS-look nice)9. I want to make a memory book (IHSS)

a. help with health appointments (SLC)b. help with chores (IHSS)c. help with paying bills (SLC)

… it looks like there will be 7 goals…1. I want to make dinner (SLC)2. I want to pay my bills, save my money, and buy a tv (SLC)3. I want to do fun stuff (go to Busch Gardens, the movies, fishing) and volunteer with

animals (Comp)4. I want to look nice (IHSS)5. I want to do my chores (IHSS)6. I want to make a memory book (IHSS)7. I want to see my doctor when I need to (SLC)


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STEP 2Now, discuss how often the client would like to work on these goals and add the FREQUENCY to the list.

1. I want to make dinner (SLC)

2. I want to pay my bills, save my money, and buy a tv (SLC)

3. I want to do fun stuff (go to Busch Gardens, the movies, fishing) and volunteer with animals (Comp)

4. I want to look nice (IHSS)

5. I want to do my chores (IHSS)


7. I want to see my doctor when I need to (SLC)

twice a month

once a week

3 times a week

every day

once a week

once a month

when I need to


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Step 3Talk with the client about the TASKS he is willing to do for that goal. Make a list of the tasks related

toeach goal. These tasks include what the client will do and what the staff will do. This task list willbecome the objectives for each goal.

Your task lists will start with the word BY (how will the client do what he wants to do).

Let’s look at what the tasks for the first three goals might look like:1. I want to make dinner (SLC) twice a month

– By planning a menu, making a grocery list, buying the ingredients, making dinner– My coach will help me decide on a menu, write the grocery list, shop with me, and help me make dinner

2. I want to pay my bills, save my money, and buy a tv (SLC) once a week– By balancing my checking account, writing out my checks, putting some money in a “save” envelope,

buying a tv when I can afford it – My coach will help me by going through my check register and statement with me, write my checks so I

can sign them, help me put money in an envelope, and shop for a tv with me when I have enough money

3. I want to do fun stuff (go to Busch Gardens, the movies, fishing) and volunteer with animals (Comp) 3x a week

– By finding a place to volunteer, learning about volunteering there, volunteering at that place, planning some fun stuff, budgeting for some fun stuff, doing some fun stuff, getting a good job

WHOOPS! “Getting a good job” is not within the Companion’s scope of service. It is the job of aSupported Employment Coach. You would explain that to the client and move on with the next goal.


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When you have completed the tasks for each goal, complete the process with Step 4.

Step 4

This is where you put each action statement (the STEM) together with the TASKS, the FREQUENCY,

and the SERVICES.

These Goals will be used when you work with the individual. They will provide guidance for who does

what, what to do, how to do it, and when to do it.


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Let’s look at Goal #1.

Start with the action statement – I want to make dinner

Meet with the client and ask these questions:

How will the client make dinner? What does he want to do? What does he want you to do? Howoften? How long does the client want to work on the goal?

The client wants to plan 2 meals each month. He wants to make a grocery list for ingredients for hismeals. He wants to shop for his groceries. He wants to make the meals he planned. He wants to dothis two times a month with his SLC’s help. He wants to work on this goal for the entire year.

List the information you and the client and his circle of support came up with:

THE STEM I want to make dinner by:

THE TASKS - planning a menu each week- making a grocery list for ingredients- buying the groceries - making dinner

FREQUENCY twice a monthSERVICE SLC

Now, you have a complete goal:

I want to make dinner by planning a menu, making a grocery list, buying my groceries, and making dinner twice a month with help (SLC) THE STEM THE TASKS FREQUENCY SERVICE


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Assessment

How do you know when the client has successfully accomplished his goal? Look at the goal. If it is written correctly, you and the client will know when the goal has been completed successfully. In thisexample, your assessment is that the client will have successfully completed his goal when he makesdinner twice a month for 12 months.

I want to make dinner by planning a menu, making a grocery list, buying my groceries, andmaking dinner twice a month with help (SLC)

If the client works on this goal for 12 months, then he will have successfully completed his goal whenhe makes dinner 24 times.

Progress will be shown each time you work on the goal with the client. If he accomplishes the tasks,then he is showing progress. In this example, the client does not need to be able to cook dinner byhimself (independently), shop by himself, plan, or make a grocery list by himself.

This client is not ready to do that yet. Perhaps he will be ready to accomplish this same goal stem but

with different tasks and different types of help from staff next year.

For a client who is able to cook, this goal may be too basic. In that case, you may need to modify theTASKS involved, but not necessarily the STEM.

For example, I want to make dinner by finding new recipes in cookbooks at the library and trying twoout each month with help (SLC).


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As noted previously, sometimes a client would like help from two services for one goal. Let’s look atthis same goal where the client wants both his SLC and his IHSS to help him.

Start with the action statement for Goal 1 – I want to make dinner

Meet with the client and ask these questions:How will the client make dinner? What does he want to do? What does he want you to do?

Howoften? How long does the client want to work on the goal?

The client wants to plan 2 meals each month. He wants to make a grocery list for ingredients for hismeals. He wants to shop for his groceries. He wants to make the meals he planned. He wants hisSLC to help him with making a grocery list and buying his groceries. He wants his IHSS to actuallyhelp him plan and prepare two meals each month. He wants to work on this goal for the entire year.

List the information you and the client came up with:

THE STEM I want to make dinner by:THE TASKS - planning a menu each week (IHSS)

- making a grocery list for ingredients (SLC)- buying the groceries (SLC)- making dinner (IHSS)

FREQUENCY twice a monthSERVICE SLC, IHSS


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Now, you have a complete goal but with two Services assisting the client with the same goal. Keep the stem, but write the tasks separately by Service:

THE STEM and FREQUENCY I want to make dinner twice a month with help by:THE IHSS TASKS a- planning a menu and preparing a meal (IHSS)THE SLC TASKS b- making a grocery list and buying my groceries (SLC)

Here is the complete goal:I want to make dinner twice a month with help by:a- planning a menu and preparing a meal (IHSS)b- making a grocery list and buying my groceries (SLC)

As with the previous goal, you can see when the client will have successfully accomplished his goal. In this example, your assessment is that the client will make dinner twice a month for 12 months.

As with the previous goal, you can see if the client works on this goal for 12 months, then he will havesuccessfully completed his goal when he makes dinner by planning and preparing a meal with hisIHSS 24 times and when he makes a grocery list and buys these groceries with his SLC 24 times.

Again, progress will be shown each time you work on the goal with the client. If he accomplishes thetasks, then he is showing progress. In this example, the client does not need to be able to cookdinner by himself (independently), shop by himself, plan, or make a grocery list by himself. The clientwants help from his IHSS and his SLC to accomplish the same goal, but with different tasks.

You can use any STEM with different tasks and services again and again.


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Now, let’s look at one of the other goals this client decided on.

The client’s original list of goals:1. I want to make dinner (SLC)2. I want to pay my bills, save my money, and buy a tv (SLC)3. I want to do fun stuff (go to Busch Gardens, the movies, fishing) and volunteer with animals

(Comp)4. I want to look nice (IHSS)5. I want to do my chores (IHSS)6. I want to make a memory book (IHSS)7. I want to see my doctor when I need to (SLC)

As we have seen, the client has decided on his first goal:1. I want to make dinner by planning a menu, making a grocery list, buying my groceries,

and making dinner twice a month with help (SLC)

Remember, the steps for writing a person-centered goal are:1. Meet, brainstorm, and make a list of goal action statements (STEM) with the SERVICE.2. Determine the FREQUENCY.3. Make a list of the TASKS related to each goal beginning with the word By.4. Put the goal STEM together with the TASKS, adding the FREQUENCY, and putting the

SERVICE that will help at the end in parentheses ( ).


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Let’s look at Goal #3 – I want to do fun stuff (go to Busch Gardens, the movies, fishing) and volunteerwith animals (Comp).

We have completed STEPS 1-2:1. Meet, brainstorm, and make a list of goal action statements (STEM) with the SERVICE.2. Determine the FREQUENCY.

I want to do fun stuff (go to Busch Gardens, the movies, fishing) and volunteer with animals (Comp) –once a week.

Now, let’s work on STEP 3 - Make a list of the TASKS related to each goal beginning with the word By

TASKS: find a place to volunteer at, learn how to volunteer at that place, volunteer at that place, go tothe beach, go out to eat, go to the movies, go fishing, go to Busch Gardens, go to the library, find ajob. I want to save money for special activities and have someone go with me on the activity.

Remember, “find a job” is not within the Companion’s scope of service. It is the job of a SupportedEmployment Coach. If the individual continues to express interest in a job, as an advocate you

shouldassist him with seeing if he can receive this service.


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Make a list of the information you have gathered:

STEM: I want to do fun stuff and volunteer with animalsTASKS: by budgeting for activities and doing the activity (Busch Gardens,

movies,fishing) by finding a place to volunteer, learning about that job,

volunteering atthat job

FREQUENCY: once a weekSERVICE: Companion

STEP 4 - Now, write the complete goal by putting the goal STEM together with the TASKS, adding the

FREQUENCY, and putting the SERVICE that will help at the end in parentheses ( ).

I want to do fun stuff (go to Busch Gardens, the movies, fishing) I am interested in by budgeting foractivities and doing the activity and volunteer with animals by finding a place to volunteer, learning

thatjob, and volunteering with help one time a week (Comp).


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Our goal looks like this:

I want to do fun stuff (go to Busch Gardens, the movies, fishing) I am interested in and volunteer withanimals by finding a place to volunteer, learning that job, and volunteering with help one time a week(Comp).

If the individual wanted to only “do fun stuff” once a month and “volunteer” once a week, then youcould write the goal like this:

I want to: a. do fun stuff (go to Busch Gardens, the movies, fishing) I am interested in by budgeting my

money and going on activities with help once a month (Comp)b. volunteer with animals by finding a place to volunteer, learning that job, and volunteering with

help once a week (Comp)

Or you could write the goal like this:

I want to do fun stuff (go to Busch Gardens, the movies, fishing) and volunteer with animals (Comp):a. by budgeting my money and going on activities I am interested in with help once a monthb. by finding a place to volunteer, learning that job, and volunteering with help once a week

You could also add in more of the “fun stuff” the client is interested in, such as going out to eat, goingto the beach, going to the library. This would provide you with even more information in the goal. Remember to always number your goals.


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So far, we have two goals:

From this information …..

1. I want to make dinner (SLC) twice a month– By planning a menu, making a grocery list, buying the ingredients, making

dinner– My coach will help me decide on a menu, write the grocery list, shop with me,

and help me make dinner

We got this goal…

1. I want to make dinner by planning a menu, making a grocery list, buying my groceries, and making dinner twice a month with help (SLC)


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From this information ….

3. I want to do fun stuff (go to Busch Gardens, the movies, fishing) and volunteer with animals (Comp) – once a week

– By finding a place to volunteer at, learning how to volunteer at that place, volunteering at that place, going to the beach, going out to eat, going to the movies, going fishing, going to Busch Gardens, going to the library, finding a job

– I want to save money for special activities and have someone go with me on the activity

We got this goal…

3. I want to do fun stuff (go to Busch Gardens, the movies, fishing) and volunteer with animals (Comp):

a. by budgeting my money and going on activities I am interested in with help once a month

b. by finding a place to volunteer, learning that job, and volunteering with help once a week


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Now, let’s try goal #2. We have the STEM, the SERVICE, the FREQUENCY, and the TASKS.Remember, you, the client, and his circle of support will come up with this information during thePERSON-CENTERED PLANNING meeting.

During the meeting, you brainstormed this STEM, with the SERVICE, and FREQUENCY:

2. I want to pay my bills, save my money, and buy a tv (SLC) once a week

Now, you come up with these TASKS describing how the client wants to work on his goal:– by balancing my checking account, writing out my checks, putting some money in a

“save” envelope, buying a tv when I can afford it – my coach will help me by going through my check register and statement with me, write

my checks so I can sign them, help me put money in an envelope, and shop for a tv with me when I have enough money

Now, let’s put it all together:2. I want to budget my money:

a. by balancing my checking account, writing out my checks, and putting money in a “save” envelope with help once a week (SLC)

b. by buying a tv when I have enough money saved (SLC)


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These are the remaining goals with STEM, SERVICE, FREQUENCY, and TASKS. See if you can

come up with the goals using the information provided here. Consider how you and the individual will

know he is making progress.

4. I want to look nice (IHSS) every day

– by making a list of things I have to do each day to look good, following that list

– My IHSS will help me with my shower routine and remind me to do the other things on my list

5. I want to do my chores (IHSS) once a week

– by making a chore chart, following my chore chart at least once a week

– My IHSS will help me make the chore chart and will remind me to look at it each day and do the chore for that day, my IHSS will help me with moving furniture when I vacuum

6. I want to make a memory book (IHSS) once a month

– by taking pictures, buying a memory book and some stickers, starting with 1 memory page at a time

– I will take my camera with me when I go out to take pictures, my IHSS will help me put pictures in my book

7. I want to see my doctor (SLC) when I need to

– by making an appointment for a physical, making appointments for blood work, making a dentist appointment, writing the appointments on my calendar

– My coach will go with me to my appointments


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Print the exercise for creating goals, complete the information, check your answers, and

submit to the office for credit on this lesson.

PERSON-CENTERED PLANNING 2: THE PROCESS. 2-Person-Centered Planning - The Process 2 Remember,...

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