Module 5: Creating the plan through a team meeting
This module introduces the “nuts and bolts” of actually creating a plan with a focus on the team meeting and helping the individual to assure that all of the right people are involved in a quality person-centered process.
After completing this module, you should be better able to:
- describe the roles and responsibilities of team members;
- identify at least five key indicators of a well-run PCCP meeting;
- identify a wide range of both professional and community supports who can contribute to PCCP, including peer supporters.
A knowledge-learning assessment is included at the end of the module. If you are already familiar with the planning process, you may want to go to the end of this module and take the assessment test to see how much you know already. Then you can focus your learning efforts on the materials that are new for you.
The preplanning activities presented in Modules 3 and 4 offer critical information about how practitioners can help to elicit the individual’s goals, strengths, personal and cultural preferences, and network of supporters. These details should be organized and readily available to inform the subsequent planning meeting and its various steps and procedures, beginning with determining who should attend the planning meeting.
Practitioners should help the person to identify people who he or she believes will consider his or her best interest. In order to decide who should be invited to the meeting, practitioners should encourage the individual to think about the following:
- Who among your family and friends understand your pathway to recovery and what will help you to progress on your way? Who has offered helpful support in the past?
- Person-centered care plans (PCCPs) consider not only what you need from your team and the mental health system, but how you, in turn, can give back to others. Who knows your gifts and talents, and encourages you to use them to make meaningful contributions to the community, for example, through advocacy, employment, or volunteering?
- Who would feel comfortable speaking in the meeting in an honest and responsible way? Keep in mind that it may take time for some people to be active, vocal participants as their efforts to help in the past may have been rejected by you or other team members.
- Individuals who know the community and its resources and who are sensitive to your cultural identity can be very important contributors in the meeting. Have a conversation with these individuals to let them know why you would like them to be a part of your support network, what you know about the process, and what you believe will be expected of them. Ask them to play a part in your care planning process.
- You may use the Circle of Supports exercise (see Module 3) to identify the people you would like to invite to join your planning team. Remember, you may want to include friends, family, service providers, neighbors, the clerk at the store who helps you with your shopping each week, your teacher, or anyone else you choose.
- Remember that the team can, and often should, change over time based on how your goals change over time. For example, you may initially choose to have only a close friend and one direct service provider involved. Over time, you may find that your family has an important role to play. Or perhaps you have just returned to work and a job coach or a coworker might make helpful contributions. The composition of the team can change at any time. Not all decisions need to be made now!
Care planning can be far more successful if the individual involves people who are important in his or her life. One function of the practitioner can be to help the individual to identify these existing supports (through the kinds of questions noted above) or to help the individual to develop new ones in cases where such supports do not currently exist. For example, a care plan can include a fellow parishioner who offers to provide rides to Sunday services or to be a companion at a weekly Bible Study group. Creative use of community supports and spreading out support tasks are some of the highly desirable features of PCCPs. However, it is also possible that an individual may not wish to have others involved in the planning process due to personal or cultural preferences. People can be educated about the potential benefit of involving others, but this is always a matter of choice and is done only at the person’s request.
Ideally, these activities will lead to an initial meeting that involves people who know and care about the individual, including a mix of staff, advocates, family members, and friends. At this meeting, information regarding the goals and structure of the planning session will be reviewed and all attendees will have an opportunity to ask questions. This process builds on the pre-meeting orientation and education discussed in Module 3. Reviewing this orientation, at least briefly, is essential, as all meeting participants need to be clear on the purpose and format of the planning sessions.
Once the individual has some idea of who she or he would like to invite to be a part of the planning team meeting, the next step is identifying the time and location of the first (or next) meeting. A simple, yet powerful, strategy is ensuring that the individual has advance notification of this planning meeting as well as reasonable control over the meeting logistics, for example, what time the meeting takes place and who is invited to participate. All too often individuals arrive at their regular sessions or appointments and are notified that their treatment plan is overdue so “today is the day we need to get that on the books.” Given the importance of the decisions made in person-centered planning meetings, this lack of advance notice can place an unreasonable burden on the person to be prepared to launch into a discussion of their most valued hopes, dreams, and desires—as well as the difficult issues that may have been getting in the way. In such circumstances, it is not uncommon for the person to clam up, or for the practitioner and the person together to just default to a cookie-cutter, “business as usual” treatment plan that has little individualization and recovery focus. Wherever possible, giving people advance information, for example, “It is that time of year again when we will need to be updating your recovery plan together. If it’s OK with you, I’d like to try to schedule that for 2 weeks from now, and in the meantime, I’d like you to be thinking about what kinds of goals you’d like to focus on in the coming months and what kinds of steps we might need to take to help you reach those goals. And, of course, if there is anyone you’d like to invite—a family member, a friend—just let me know and we will do what we can to arrange a meeting time that works for everyone on the team.”
This last element highlights the importance of the individual having a reasonable degree of input into the logistics of the planning meeting. Note the emphasis on the term “reasonable.” We are not suggesting that in person-centered planning, individuals can dictate that they can come, for example, only on the third Tuesday of the month at 3 pm as that is the only time their spouse is available! That would go beyond what would be considered “reasonable” input. However, consider how you make important medical appointments in your own life—particularly those where you might like the support of a family member or friend. In such cases, you might request, for example, “It’s very important to me that my husband be there with me to be a part of the discussion because he is a very important part of my decision making. So, if at all possible, if we can try to schedule the meeting later in the afternoon, that would make it much more likely that he will be able to be there to support me.” It is this type of courtesy in scheduling that we might expect in arranging our own health care appointments, and in person-centered planning, we work hard to honor this same accommodation.
The individual or plan facilitator (who may, or may not, be the primary clinical practitioner, see below) should notify the potential team members of the meeting date, time, place, and agenda well in advance. While efforts should be made to ensure that the focus person will be as comfortable as possible, the time and place of the meeting need to meet the convenience of other attendees as well. Some individuals prefer the meeting at their home, while some would rather have the meeting at a neutral place such as a room at an office. Team meetings can be held at diners or coffee shops if privacy can be assured. While there are no defined rules regarding the structure and logistics of the meeting, the overarching goal is to allow the person to set priorities and to have reasonable control over the date, time, and place of his/her PCCP meeting. The practitioner assists and supports the individual in making these arrangements.
While team-based planning should occur at a time most conducive to the maximum number of team participants being present, there will inevitably be times when an important person will not be able to attend. Practitioners should make every effort to adjust the schedules and times so that as many team members as possible can be included. It is vital to remember that a team member can be on the team and not in the meeting, if their input is solicited prior to the meeting and if they are briefed after the meeting. Sometimes team members also participate by phone or via a computer link.
There are some basic respectful practices in the treatment team process that we should be aware of as a starting point to ensure the PCCP meeting is maximally responsive to the person’s needs and preferences. These practices should be followed automatically though they are not yet a part of standard practice.
- Team members should arrive on time for the meeting as it can be disconcerting and disruptive for participants to be coming and going throughout the discussion.
- The meeting facilitator should ensure that all members introduce themselves and their role in the focus person’s life. This is particularly critical when new members, such as natural supporters, are joining the team for the first time.
- It is important to ensure that you are giving the person your full attention by turning off cell phones, not having side bar conversations, and not charting in their, or someone else’s, medical record, while the person is present and the team is engaged in conversation. Think of this as a fully protected time for the person in recovery!
- Be cognizant of the tendency to talk about the person (as if she or he is not in the room) rather than talking directly with them. Questions/comments should first be directed to him or her (e.g., asking them how they think their groups are going and if they are making progress) rather than soliciting this information only from the staff member/group leader. When teams are feeling pressured for time to get through all the necessary agenda items, it can seem easier and quicker to ask questions of staff; but remember, we are striving for more of a partnership and a balance of perspectives.
Each member of the care planning team has a unique role to fulfill in the planning and plan oversight process, but everyone involved is there to support the individual and his/her recovery priorities. Table 5.1  summarizes the roles of respective team members and additional information is provided here.
Table 5.1 Roles and Responsibilities of PCCP Team Members
|Focus Person (for whom the plan is being developed)||Facilitator||Family (as defined by individual) and other supports (including community representatives)|
|Has the leadership role in developing the plan.|
Has ownership of the plan.
May or may not select the facilitator for the planning process.
Is responsible for full participation in the process.
Thinks about and communicates his or her hopes, dreams, desires, needs, likes, dislikes, and so on as clearly as possible using whatever means appropriate to his or her abilities.
Expects the facilitator, practitioners, family members, and other natural supporters to work with him or her, not for him or her.
Builds relationships with planning team members.
Is willing to be creative and take responsibility and risks to achieve his or her stated goals.
Stays committed to the process.
|Embraces all responsibilities common to other attendees in addition to the following:|
Is an advocate for the focus person.
Is able to work with team members in an informal way.
Provides unconditional support to the person throughout the process. Adjusts the level of facilitation and support as needed based on the person’s preferences and current abilities.
Encourages the focus person to be as active and empowered as is possible and preferred.
Uses “person-centered” and “person-first” language and encourages others to do the same.
Helps clarify and communicate the person’s ideas to members of the team.
Encourages the person to be creative in his or her plan and to take action, responsibility, and responsible risks.
|Common responsibilities include:|
Believes in and values the person-directed planning process.
Listens to, understands, values, and respects the person in recovery and his or her supporters.
Is honest and open in communicating his or her own perspective.
Treats all members of the team with respect.
Assists the focus person to identify his or her strengths and needs, and to formulate his or her wishes, hopes, dreams, concerns, and so on.
Shares knowledge and perspective regarding what has worked and not worked well for the person in the past.
Uses “person-first” language.
Follows through on agreed-on tasks.
Helps to identify and/or pursue resources available to the person from the team or broader community.
|Guides the planning process, keeping everyone and everything focused on the person’s wants, needs, desires, dreams, and hopes for his or her life.|
Ensures that all perspectives are heard and given due respect.
Uses various tools to help individuals share their story of recovery.
Uses consensus-building skills.
Is able to use various means of conflict resolution to manage disputes and/or breakdowns in the planning process.
Maintains a record of the planning process.
Assists planning team to view and use upsets and disappointments as opportunities to be creative and try new strategies for goal attainment.
Reviews and evaluates the process in partnership with the focus person and others as appropriate.
|Views upsets and disappointments as opportunities to learn, grow, and try new strategies for goal attainment.|
Believes in the person’s ability to have a positive impact on others and suggests ways in which he or she may do so.
Stays committed to the process.
Community members also pledge to facilitate the person’s pathway to community activities of his or her choice by promoting welcoming and accommodating environments that encourage inclusion.
Adapted from Ref. .
What is a PCCP facilitator, and what role does the facilitator play? The “facilitator” is someone who is trained in, and committed to, the principles and practices of PCCP. In other disciplines and fields, such as the developmental disabilities field, there may be independent facilitators who act as the coordinator of the process. In the mental health systems with which we have worked, this setup has not been feasible because of time and fiscal pressures. Most commonly, the primary clinician or practitioner is the organizer and facilitator of the meeting. Therefore, in this document, we refer to the meeting leader as the clinician or practitioner. This is in no way to discount the role of the independent facilitator as it works in other PCCP models, but more so in recognition of the current practice of many mental health systems and the limited feasibility of having an outside facilitator.
An additional possibility is to have a peer specialist act as the coordinator or facilitator of the meeting. META Services Recovery Education Center of Phoenix, for example, employs “recovery coaches” as facilitators of PCCP meetings. A central function of the Recovery Coach is to assist individuals in completing a Self-Directed Recovery Plan and to provide peer support as the individual works on his or her plan for recovery. Expanding the role of peer specialist employees to include PCCP facilitation is a particularly promising practice, and research is underway to assess its effectiveness.
Within the PCCP meeting, the practitioner works to ensure that the values and steps of the process are delivered in a manner that is consistent with PCCP’s fundamental principles. The following list notes the essential skills for running such a meeting:
- Being able to listen to what people are “saying” (in overt verbal language as well as subtle body language).
- Being able to assist team members to listen to each other.
- Being able to listen below the surface to what is not being said.
- Being able to think, and assist others to think, beyond the formal service system to include a network of natural supports.
- Being able to assist the person receiving services and the planning team members to dream big!
- Being able to suggest large and small dreams, goals, and objectives.
- Being able to work with the team to tap into community supports and activities.
- Being able to solicit information from team members such as how to access culturally appropriate services.
- Being able to encourage the person receiving services to use gifts and skills to further his or her own recovery and to give back to team members or the community as a whole.
- Being able to use and to teach others to use person-first language.
- Being able to define and discuss all aspects of PCCP.
- Being able to use common language in place of professional jargon.
- Being able to assist team members to adhere to PCCP principles throughout the meeting.
- Being able to encourage the person receiving services to be an active participant in the meeting and in the action steps of the plan itself.
- Being able to solicit all viewpoints and to make sure all team members have an opportunity to provide inputs and be heard.
- Being able to build consensus among team members.
- Being able to deal with challenging team members, and to use conflict management skills to deal with conflict.
- Being able to engage team members and to reconvene the group over time as necessary.
- Being able to redirect team members from talking “about” the person receiving services to talking “with” him or her. In some instances, team members may slip into speaking about someone in the third person, almost as if the person is not there. It is the responsibility of the practitioner to redirect and refocus the meeting to be one of collaboration and inclusiveness for the person receiving care.
- Being able to contribute to the development of a collaborative atmosphere in which the focus person is encouraged to take on as much leadership as is preferred and possible.
- Being able to share clinical expertise regarding strategies that might assist the individual in reaching his or her goals.
- Being able to suggest clinical interventions as well as community resources that can potentially assist the individual in reaching important goals.
- Being able to assure compliance with state rules and regulations regarding the delivery of services and supports.
- Being able to attend to the funders’ requirements of medical necessity and to allowances under identified billing codes.
- Being able to document the focus person’s diagnosis after having a transparent discussion with the individual, soliciting his or her perspective, and providing clear explanation when necessary. This discussion can happen during, or prior to, the planning meeting depending on the person’s preference.
—Person in Recovery on her typical role in planning