Person Centered Care Planning

The Affordable Care Act mandates “person-centered” delivery of LTSS, an approach to care planning which recognizes that beneficiaries are not merely passive recipients of medical care, but the individuals who can best determine what it means to be well and what is needed to achieve wellness.  Person-centered planning recognizes that the person receiving services is the primary expert in his or her own goals and needs.  In order for this to be more than an empty slogan, it must be accompanied by substantive standards, including a comprehensive person-centered functional assessment.  Furthermore, while MCOs must meet baseline standards for LTSS services available within the managed care benefit package, specific delivery of LTSS should be customizable according to the needs and preferences of the individual.

A person-centered approach is not limited to health status, but also encompasses values of independence, control, and autonomy. It begins by identifying the strengths, preferences, needs (clinical and support), and desired outcomes of the individual. Counselors’ (options counselors, support brokers, and others who are administratively independent from MCO employees who ultimately authorize the individualized service plan) role in the person-centered process is to enable and assist LTSS consumers to identify and access a personalized mix of paid and non-paid services. The individual’s  personally defined outcomes, preferred methods for achieving them, training supports, therapies, treatments, and other services needed to achieve those outcomes become part of a written person-centered services and support plan.  The person-centered plan also supports individuals’ ability to self-direct services. (See discussion of Self Direction).

  • Individuals must be offered choices with respect to their services and supports, and must hold decision-making authority over which of the available services and supports to employ and which of the available providers to work with.  Enrollees should not face any penalty or reduction in benefits for exercising freedom of choice.
  • Individuals must have control over who is included in the planning process.
  • Individuals must have choices about the extent of involvement of their personal care provider(s) in their individual care team and appeal processes (ranging from no involvement to acting on individual’s behalf for all care decisions).
  • Individuals must have the right to choose to designate someone (e.g. a trusted family member or friend) to serve as their representative for a range of purposes or time periods.  If a representative is needed at a point in time when an individual is too impaired to make a choice, the representative should be someone who has a history of close involvement with the person.
  • Care planning meetings must be held at a time and place that is convenient and accessible to the individual.
  • MCOs must provide information that allows individuals to understand and make informed decisions about service options, including providing information aboutOlmstead rights to all individuals who use LTSS.
  • Mechanisms must be in place to minimize conflict of interests in the facilitation and development of the plan.
  • States and MCOs should develop appropriate standards, requirements and guidance to ensure quality services and outcomes, but should also allow informed consumers to opt-out of general requirements where appropriate.  For instance, an individual who is skilled in instructing his or her providers should be allowed to waive prior training or certification requirements for care providers.
  • States and CMS must jointly establish requirements for the person-centered plan itself.  For instance:
    • The person centered plan should integrate all elements of needed medical, clinical, and community living supports. An integrated care team with both clinical and LTSS expertise will have responsibility for developing and implementing the plan.
    • The plan must be prepared in person-first singular language and be comprehensible to the consumer and/or representative.
    • In order to be strength based, the positive attributes of the individual must be documented at the beginning of the plan.
    • The plan must identify risks and the measures taken to reduce risks without restricting the individual’s autonomy to undertake risks in order to achieve goals.
    • Goals must be documented in the individual’s and/or representative’s own words, with clarity about the amount, duration, and scope of services and supports that will be provided to assist the individual to achieve his/her goals.
    • Specific person(s) and/or any provider agenc(ies) responsible for delivering services and supports must be identified.
    • The plan should include a discussion of acute care preferences and anticipate care transitions needed for a return to the community from any temporary emergency room, hospitalization, or nursing home admission, as well as transitions requested by any individual who desires and is capable of a less restrictive community placement.
    • Other non-paid supports and items needed to achieve the goal must be documented.   The plan must include the signatures of all people with responsibility for its implementation, including the individual and/or representative, and a timeline for plan review.
    • The plan must identify the person and/or entity responsible for monitoring the plan and everyone involved (including the beneficiary) must receive a copy of the plan.
    • The plan should include strategies for resolving conflict or disagreement within the process, and include clear conflict-of-interest guidelines for all planning participants, as well as a method for the beneficiary to request revision of a plan, or appeal the denial, termination, or reduction of a service.
  • MCOs must have procedures in place to monitor and follow up implementation of individual’s person-centered plans.  This process includes mechanisms to ensure that paid and unpaid services and supports are delivered, and that integrated care teams monitor progress toward achieving individuals’ goals, and review the care plan according to the established timeline.  The MCO must also provide a feedback mechanism for the individual to report on progress, issues and problems.
  • CMS and states must ensure that the time it takes to do adequate person-centered planning is considered in setting reimbursement rates, and must consider the quality of person-centered planning when evaluating MCO performance.
  • States, CMS and MCOs must incorporate person-centered principles in their policy, mission/vision statements and operations documents.
  • States, CMS and MCO staff and leadership must receive training in the principles of person-centered planning.

A process for monitoring person-centered planning activities by plans must be implemented at the federal and state level and incorporated as an integral component of quality improvement activities.  This monitoring information must also be available to the independent ombudsman office. (See discussion of Independent Ombudsman).

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