Person-Centred Planning

INTRODUCTION- TMS recognizes that everyone has unique needs and abilities. Person centred planning is the foundation of the services we provide.

PURPOSE

The purpose of this document is to describe the policy and practices TMS has in place regarding person-centred planning.

POLICY

When developing support plans, TMS ensures that we respect the choices, beliefs and culture of the person we serve.  Depending on individual choices, circumstances and abilities, planning is done with input from: the person served, their family, support network and their health care team.

The planning process begins at intake and involves gathering as much information as possible to provide a complete, accurate and timely picture of an individual’s specific needs.  Information collection includes:

Intake Package

Before an individual receives services from TMS the Residence or Program Coordinator and/or Operations Manager meets with the individuals, their families and their support network to gather information about the individual being served. This is done by completing an intake package.

The intake document includes:

- Daily schedules, routines

- Medication information and health care plans

- Information about the individual’s culture, beliefs and traditions

- Support required for the individual to complete routines

- Contacts for the individual including health care team, family, friends

During intake, the individual will also receive information about TMS and the services we provide. Consent forms will be signed and completed prior to the individual receiving services.

Program Binder

Within three months of receiving services TMS will collaborate with the individual being served and their family/support network to create a program binder. This binder is individual specific and contains the following documents/information;

-       Daily schedules, routines & activity guides

-       Personal contacts and information about the individuals support network including information about visiting their family/friends or hosting their family/friends for visits

-       Nutrition information; food likes/dislikes, sensitivities and dietary requirements. If special diet requirements are necessary a referral to a dietician will be made.

-       Individual care plans for personal care routines, bathing/showering, brushing teeth, transportation, communication, telephone & technology usage.

-       If necessary a Behaviour Support Plan and Safety Plan will be developed (see behavior support plan policy)

Changes to Individual program binders are made as necessary throughout the year and a complete review is done annually.

Health & Medication Binder

Every person who lives in a residence supported by TMS has a health & medication binder.

 This binder is individual specific and contains the following documents/information;

-       Health profile/health care plans

-       Consent- permission to receive medical care

-       Medication information including medication administration record (MAR) and protocols,

-       Bowel care

-       Medical appointment record

-       Standing order form

Individuals with specific health or support needs that require staff intervention will have protocols completed by a professional. This includes, but is not limited to individuals with: seizures, eating difficulties, allergies, behavior and safety protocols or plans, personal care protocols. Where possible the protocols will be signed, and approved by the individual or those authorized by the individual or their family. 

Changes to Health & Medications binders are made as necessary throughout the year and a complete review is done annually.

Individual Documentation Binder

Every person who is supported by TMS has a documentation binder. This binder is completed by staff working with the individual. These records serve as a record for all activities of daily living completed each day. This binder is individual specific and contains the following documents/information:

-       Emergency information sheet

-       Personal funds record

-       Daily progress notes

-       Daily activity checklist/positive opportunity

-       Nutrition record/food intake

-       Behaviour record/baseline

-       Required charting- mood, bowel, sleep

-       Hygiene checklist/record

-       School records (if applicable) including any Individual Education Plan.

-       Family/friend visit & phone record

-       Appointment record

-       Incident reports

-       Injury report form

The individual documentation binder is updated each day the individual is receiving care/services by TMS. Monthly reports are compiled with information/data collected from the records in the individual’s binder. Each month the documentation records are taken to the administration office (see records policy)

My Plan

Every person who TMS supports is encouraged to participate in completing a “MY PLAN” workbook.  If the individual chooses, this document can also be shared with members of their support team. If necessary, support will be provided to complete the “MY PLAN”. This plan is typically updated throughout the year and it is suggested that it be reviewed annually before the individual service plans are completed/ reviewed.

“MY PLAN” is used to identify areas where individuals would like to improve/grow/learn. “My Plan” is also used to help gather information about the individual and their unique needs and abilities.

Individual Service (or Support) Plan (ISP)

Once sufficient data and information is collected TMS begins the process of creating an individual’s first ISP. The ISP reflects key elements of the data gathered in the documents above and the process will typically begin within 3-4 months of intake.

The process used to complete an ISP is developed based on the unique circumstances of each individual.  That process considers: personal choices/preferences, ability to facilitate their own process, involvement of other stakeholders (especially advocates or legal representatives). 

In all cases the Resident Coordinator will document the process that is agreed upon for the individual as well as the steps that are followed to complete the ISP.

Every person who TMS supports has an individual service plan that is updated annually and reviewed every six months.  The plan identifies the goals and objectives for the individual in a variety of areas, including:

·      Communication

·      Culture, religion, identity

·      Emotions & Behaviour

·      Friends & Family

·      Job & Education

·      Life Skills- Home

·      Physical health

Goals and objectives that are developed must be specific, measurable, achievable, reasonable and time-bound. Performance is tracked and measured to provide input for future plans.

Performance measures from ISPs are a key component of the corporate Performance Measurement System and help TMS ensure that we are satisfying the individual's needs and providing effective, efficient and economical service. 


Other resources:

Plain Language Planning Workbook (My Plan)