Introduction

Person-directed Care Planning is a process for continual listening and learning, focusing on what’s important to the individual now and in the future, and acting upon this in alliance with the individual’s family and friends.

This type of care-planning gives the individual positive control over their life. It allows them their choice of treatment, activities and daily care. It's a way of assisting the individual to determine what they want and when they want to do it. By developing person-directed care plans the person with dementia and family members are treated with respect and dignity.

Imagine two scenes:

• Imagine you are living in community care. You were not hungry at your scheduled 6:55 a.m. breakfast. But it is now 10:00 a.m. and you are hungry. You request a bowl of soup. The CNA seeks out a nurse to ensure the unscheduled snack is not contraindicated. The nurse says your blood sugars have been fluctuating widely and delegates checking it to the certified medical assistant (CMA). The CMA reports back that the result was within normal limits, and the nurse approves the snack. It is now 11:00 and almost time for lunch. You no longer want the soup.
• Now imagine the second scene. You awaken in the morning and get up when you want. You order and eat breakfast when you want. If you are hungry later, you request soup and a CNA gives you two choices and prepares the soup. Your medical diagnosis would inform, not dictate, your request. The CNA would have the authority to support your choices.

Which experience above would you prefer? As a person receiving care? As a caregiver?

Traditional Care versus Person-Directed Care

In the first scene above, fulfilling the request became a medical task related to the individual's diagnosis, and the individual was not engaged about the request or even asked what soup she preferred.

The second scene was more person-directed. Take a moment to compare the two models of care planning.

Person-Directed Planning Process

In person-directed thinking, the person is at the center. It is rooted in the principles of shared power and self-determination. People using person-directed planning make a conscious commitment to sharing power.

Here are the stages of the planning process:

• Preparation - Understanding the person and their situation, gathering information, encouraging others who know the person to contribute their perceptions and ideas
• Pre-planning - Working with the person/guardian to review information, set priorities, determine an agenda, and invite people to join in the planning process
• Action Planning - Identifying needs and desires and developing action steps to accomplish goals. Action planning is often done in a team meeting. Action planning can also be done through a series of conversations with different people
• Quality Assurance - Making sure the documentation meets standards and requirements
• Implementation and Monitoring - Following through on action steps, checking progress, and revising the plan as necessary

Key Components to Person-Directed Planning

Person-directed planning puts people in the context of their family and their community. Persons receiving care can choose to involve other family members and friends as partners in planning. Consequently, the plan reflects what is important to the person, their capacities, and the support they require.

Here are some tips:

Focus on capacities.

The focus of professional effort has traditionally been on the person’s impairment. People are channeled into different services depending on the category of their impairment; for example, by learning difficulty, sensory impairment, or loss of mobility. This leads to a process of assessment, which analyses and quantifies the impairment and its impact on the person’s ability to undertake a range of tasks.

Identify supports.

Person-directed planning assumes that people with disabilities are ready to do whatever they want as long as they are adequately supported. A person-directed plan clearly records what support someone requires, on his or her own terms.

Have a shared understanding – rethinking the role of the professional.

People using person-directed planning assume that the person is the first authority on his or her life. A dialogue with other people-family, friends or service-workers can build on this. Therefore, professionals are no longer in charge of collecting and holding information and making decisions about the person's life. Instead, individuals and the people who care about them take the lead in deciding what’s important, which community opportunities should be taken or created and what the future could look like.

Discover what’s important to the person.

Person-directed planning, therefore, focuses on the person’s capabilities, know their disabilities, and looks at what supports they need rather than assuming that people need to change. This shared understanding about the person will reflect what's important in their day-to-day life and in the future they desire.

The Roles of Individual’s Input into the Service, Support, and Care Plan

Individual

The individual is in the driver's seat of service, support and care planning. His or her input about the choices that are made for his or her life must be guided by him or her.

RN

The RN is responsible for the coordination of care for the individual. They develop service, support and care plans guided by individuals' needs and preferences, educate individuals and their families at discharge, and facilitate continuity of care for individuals across settings and among providers.

LVN

LVNs complete focused assessments of individuals and participate in the development and modification of the ongoing service, support, and care plan.

CNA

CNAs know the details of individuals' day-to-day life, activities, and experiences that families are most interested to hear about at the care conference. They are ready to report needs and requests to the family. Having the CNA attend meetings honors the strong bond that the individual and family feel for a dedicated CNA. It communicates to the individual and family how much the organization values and trusts their CNA's skills and knowledge.

Dietitian

The dietitian evaluates the individual in person, at appropriate intervals, and develops a discipline-specific assessment of the individual's health and social status. At the recommendation of individual team members, other professional disciplines may be included in the comprehensive assessment process and in the planning of the individual's care.

Activity/Recreation Director

The activity/recreation director identifies the person's leisure/recreation needs, barriers, and potential, and provides interdisciplinary support, recreation interventions, and monitors and evaluates a person's response.

Therapist

The therapist establishes a rehabilitation diagnosis, creates individualized plans, establishes a treatment program, anticipated goals and expected outcomes, and any predicted level of improvement.

The "I" care plan

The "I" care plan is an individualized service, support, and care plan written from the individual’s perspective. This plan is written in words that the individual and his or her family use. Clarity is enhanced when we use the individual’s own words and phrases.

A 'problem' becomes a 'need' and the 'intervention' is changed to 'approaches.' This language reflects what an individual identifies as his or her goals.

An example "I" care plan based on mobility

Need

"I need to keep my left side strong."

Goal

• Long-Term Goal: "I want to return to my home for my birthday on June 1^st."
• Short-Term Goal: "I want to be able to go to the bathroom on my own."

Approaches

"I want to help the caregiver move each joint on my left side. Please remind me when dressing and undressing to move each joint on my left side."

"Remind me to reach for my tea, which is on my left side until I can use my right side."

"I need to strengthen my right side."

"I want caregivers to help me strengthen my right side."

"I want to help the caregiver strengthen the right side of my body. Please help me by moving every joint on my right side until I can begin to do it by myself."

(CNAs/N/OT)

"Please schedule my physical therapy early in the day when I am most energetic. I fade in the afternoon."

(PT/CNAs/N/OT)

"I topple over on my right side. This is very uncomfortable. Please put pillows and towels in place to support my right side so it looks like my left side when I sit in a chair. Then I can stay out of bed for an extra hour, until four every afternoon, and be up for supper at 6:00 p.m."

"My right hand feels better when I’m grasping a big rolled towel."

(CNA/N)

*CNA=Certified Nursing Assistant; N=Nursing; PT=Physical Therapy’ OT=Occupational Therapy; ST=Speech Therapy; D=Dietary

One-Page Profiles

There are many different tools that can be used to ensure person-directed care is provided to care recipients. Most of these tools require additional training to fully understand how to implement them. One of these tools is fairly easy to use and you can get started right away.

This tool is called the One-Page Profile. The One-Page Profile is a short introduction to a person that captures key information on a single page that will provide family, friends, and caregivers with an understanding of the person and how best to support them.

It’s not a person-directed plan, but more of a beginners guide. The One-Page Profile typically consists of a photo and three questions.

Here are the three questions:

• What’s important to me?

What’s important to the person? This can include people, places, possessions, rituals, routines, faith, culture, interests, hobbies, and work. They make the person who they are.

• What do others like and admire about me?

What do other people like and admire about the person? This can be collected by asking other people. You can send them prepared postcards for feedback (for example, "3 things I like and admire about you") or collecting these statements at the beginning of a review meeting on a poster, in a circle of support.

• How do you best support me?

Collect specific statement on how to best support the person. What kind of support is really helpful for the person? What does the person want and need? What kind of support does the person enjoy?