Why is Person-Centered Planning Floundering?

Dialogue has been occurring across the country with respect to the under achievement and unfulfilled expectations of person-centered planning as it has emerged in rules and regulations.

As many readers will know, many years ago John O’Brien warned that once in rigid rule form, person-centered planning would be hijacked by the regulatory environment. There is a driving force for this phenomenon that may not be that obvious to those unfamiliar with the rule-making process.

What matters most to even the most enlightened and well-intentioned rule-makers is to stop “bad” things from happening or to address the “bad” things that have already occurred. The focus of the regulatory agenda is basically negative, even when the elements being addressed are a positive. For example, insisting that annual plan dates need to be rigidly held to instead of allowing the person or team to be more flexible in their planning.

As a result, there is a curtailment of creativity and an emphasis on forms and standardization. You often see this play out in residential state case management practices: “Everyone must be seen quarterly.” As a result, everybody gets the same number of visits, even those who need many more. The result is a victory of compliance over common sense.

The question in this regard has been asked many times by many people. “Why don’t you simply deal with the under-performing providers?” The truth is, that is more difficult and it’s easier just to write another rule or add one or two more bullet points to the current one than deal with difficult or politically connected providers.

Current person-centered planning rules will not bring about best practices. That comes from the dedication and commitment to quality from organizational stakeholders. You don’t create quality through rules; mostly you just get survey scores.

So, what has been identified across the country with respect to the following of rules based person-centered planning efforts? This is not to say that all of these deficiencies are present all of the time across all providers in all states. This list did not spring up because people had bad intentions, but rather because they began to focus on the wrong things.

This is the current list. What would you add?

• There is a very large number of people for whom plans “are written” who do not value their plan. Many in fact don’t even want a copy of the plan. Some actually say they hate their plan.
• Many plans are not implemented or only partially implemented.
• Many plans written are described with reference to person-centered planning requirements, but actually are written as individual support plans or care plans. They are staff documents, not a personal document.
• More and more goals, objectives and outcome statements are emanating from provider generated “PCP goal libraries” rather than being unique to the person.
• “Cutting and pasting” is becoming more fashionable and accepted as the means to crafting a person-centered plan. Another by-product is a much longer “plan” which is not to be compared with being a much better plan.
• Person-centered planning is becoming more of a scheduled event than the product of “a circle of supporters” meeting to help a person enjoy a greater quality of life. The following is not an example of an isolated instance—one staff member talking to another. “I’m going to try and bang out two PCPs before lunch.”
• Conflict-free case management, while well-intentioned, has resulted in greater fragmentation in the planning process. There is very little evidence that this conveyor belt initiative has improved the lives for those who it was intended.
• Many bad habits have sprung up during Covid that need to be addressed—deterioration in personal relationships, less people participating in the planning process, and the more frequently held conversation, often seen on Zoom or similar platforms an example of which follows.

“Hi, John. How are you doing? Well, it’s that time again when we have to do the annual review of your support plan.” I have your plan right here. Let me read you your current outcomes.” (The number which is decreasing over time)

“I see you are really making progress in recognizing your meds by color and shape. That’s great. And you’re remembering to do your laundry more frequently with fewer prompts—very good.”

“And I see that you are getting close to your goal of going out in the community at least two times a week. Very nice.”

“Is there anything you want to change or add?”

“Yes, I know you would like a new roommate. Why don’t we talk about that later, ok? I’ll email a copy to your team leader so you can sign it for me. Ok, have a great day, talk to you soon.”

• To our knowledge, there is no research that documents the effectiveness of all of the millions of dollars being spent on person-centered planning, or that people are living a better life as a result of it.
• Unfortunately, person-centered plans are buried in the midst of so many pages of the personal record that the importance and vitality of the plan is lost. Person-centered plans should be stand-alone documents that are important and valuable to the person for whom they are being developed.

We do not quarrel with the need for documentation or for having additional resource documents such as assessments, progress notes, health resumes or necessary legal information. Neither do we object to the use of care plans or behavioral support plans for those that need them.

Person-centered plans, however, are about deeper things. Those goals or desires that a person seeks to accomplish or experience in living their best possible life. The person-centered plan should be written for the focus person as the primary audience and be clear on what the person is doing or going to be doing in the future. And there needs to be reminders and check lists to direct the person in this pursuit.

Too many plans leave or allow the person supported to remain passive with diminished responsibility for achieving their own goals. What staff should be doing to assist the person in terms of the person-centered plan should be fleshed out and determined during the person-centered planning meeting and be shared with all staff as necessary and appropriate.