COMPONENTS OF A LIFE PLAN
The Life Plan is a written “plan of care” that describes the individual’s personal goals and what they need for safety.
The Life Plan is developed by a person’s Inter-Disciplinary Team (IDT), also known as the Care Planning Team, and should be invited to the Life Plan meetings.
People who will participate in the person-centered planning process and the development of a Life Plan must be comprised of a team including the individual, their family or representative, the Care Manager, primary providers of developmental disability services and other providers as requested by the individual and/or their family or representative.
The Care Manager is required to ensure that the content of the LifePlan reflects the participant’s, the advocate’s and the service provider’s input. The I AM, CAS and/or DDP2 assessments may be utilized to reflect the preferences and needs of a person. This information will populate into the Life Plan Components.
Major Components of a LIFE PLAN
Section 1: Assessment Narrative Summary
This section is entitled “Introducing Me” which provides personal information such as interests, aspirations, activities, challenges, likes and dislikes. This section also includes where the individual lives, works and their key relationships.
Section 2: Outcomes & Support Strategies
This section includes measurable/observable personal outcomes which are developed by the individual and their circle of support/care planning team.
Section 3: Individual Safeguards & Plan of Protection
This section compiles all supports and services needed to ensure the individual remains safe & healthy across the various settings they receive service. Safeguard terminology should be person focused and consistent across all plans, including, Staff Action Plans, Travel Plans and Behavior Support Plans. Safeguards and Protection Plans must be updated in real time for access and use across all service providers.
Section 4: HCBS Waiver Services & Medicaid State Plan Authorized Services
This section lists all Home & Community Based Waiver Services (HCBS) and State Plan Services which have been authorized for funding.
Section 5: All other supports, services and natural community resources
This section provides a listing of the service providers, natural supports & community resources that support the person. The services in this section are not funded through Medicaid State Plan or HCBS.
Section 6: Final Section
This section provides a summary of the planning meeting including participants. It also includes the person’s diagnosis, medications, allergies and durable medical equipment needed. Upon completion of the development of the Life Plan, the document is signed by the participant, their advocate, the Care Manager and the Care Manager’s Supervisor. The participant, their advocate and the waiver habilitation service providers receive a copy of the signed Life Plan.
Life plans must be in place for everyone no later than December 31, 2019. Life plans result in development of Staff Action Plans that define goals and outcomes. Staff Action Plans will be embedded within the Life Plan and must be in place within 60 days of the service start date or Life Plan review date, whichever comes first.