Texas Health and Human Services (HHS) is creating person-centered models of care for people who receive services through Medicaid waiver programs. These minimum guidelines have been developed in conjunction with The Learning Community for Person Centered Practices. HHS is committed to working with our partners and contractor to ensure they can meet these standards and go beyond them.
To submit training for consideration to be approved by HHS, please send the complete training to PersonCenteredPlanning@hhsc.state.tx.us.
General Themes [Required]
- Using evidenced-based best practices.
- Focusing on person-centered skills, including understanding and supporting a person's preferences to the greatest degree possible.
- Addressing person-centeredness as the best model for delivering services.
- Allotting sufficient time for exercises, discussions after activities, and covering all required elements for an approved training.
- Addressing cultural considerations, including race, ethnicity, religion, gender and disability.
- Viewing people who get services as individuals, not a disability label. This includes their right to get services in the most integrated setting possible.
- Ensuring service plans focus equally on people with mental and physical health conditions to ensure concepts and skills learned in the training will be applicable to anyone.
- Understanding the concepts of and the difference between important to and important for.
- List words in order of probable importance to the client. For example "family and friends" should come before "support coordinators."
- Exercise(s) for trainees to reflect on how a lack of person-centeredness may lead to behavioral and mental health issues.
- Exercise(s) for trainees reflect cultural considerations specific to Texas or local populations.
Communication Competencies [Required]
- Overall communication concepts, such as a commitment to the person getting services and confidentiality.
- Communication skills with both verbal and nonverbal clients.
- Learn to identify the person’s strengths, goals and preferences.
- Conflict resolution strategies.
- Person-first language.
Examples / Exercises [Required]
A minimum of 2 examples plus 2 exercises, case studies or vignettes for each of the following:
- Identifying what is important to the client.
- Addressing conflict during person-centered planning meetings.
- A minimum of 1 example plus 1 exercise, case study or vignette for each of the following:
- Individual-driven identification of personal strengths.
- Individual-driven identification of supports.
- Individual-driven identification of preferences, goals & outcomes.
Actively listen to clients instead of managing clinical needs only.
Suggested Examples / Exercises [Recommended]
Apply active listening to identify outcomes and available services that can help the person reach small goals in pursuit of a larger goal.
- Define support systems, including who the person getting services would like to take part in planning and future updates.
- Include an assessment of functional needs and relevant history, such as medical records, objective functional assessments and eligibility. Assessment reflects both clinical and support needs as well as the person’s desires and long-term goals.
- Explore choices / options available and important to the individual. This can cover all aspects of their life, not just waiver services.
- Understand the timeline of person-centered planning meetings, follow-up, updates and addendums.
- How does someone ask for a plan update?
- Are the follow-up/progress notes detailed?
- Can a reader / reviewer understand what's working for the person getting services as well as what might need to be changed?
- Who is responsible for implementing and monitoring the plan?
- The importance of pets, exercise, sports, and other (non-traditional) supports.
- Outcomes assessments that include quality of life outcomes measures and regular collection and review of (subjective and objective) data.
- Natural support assessments to include if the natural supports are willing or able to provide the type and amount of support being asked of them?
- Pre-transition planning.
- Transition from multiple facility types.
- Using skills and tools to identify people who are at risk for being placed back into an institution such as Minimum Data Sets.
- Risk and risk mitigation that includes capturing the concerns of the person getting services.
- Positive versus toxic environments.
- Post-transition planning.
- Compare / contrast pre- and post-transition planning.
Examples / Exercises [Required]
A minimum of two examples plus two exercises, case studies or vignettes for EACH of the following:
- Person-centered meeting with people who are post transition
- People with mental illness, co-occurring mental illness, IDD and substance use disorders.
- People successfully transitioning with, no natural supports, complex medical conditions and preventing admissions and readmissions
- Children transitioning from a facility back into the community.
- Include age and developmentally-appropriate socialization.
- Address preventing post-transition isolation.
- Please include all tools and worksheets you will be using in your training.
- Please provide curriculum vitae for the trainers you have employed or with whom you have contracted.
Client-directed Services (CDS) Option
A Texas Appendix (if the training isn't specific to Texas) to support trainers educating Texan service coordinators and case managers. This appendix would include terminology frequently used in Texas's systems, intellectual and developmental disability (IDD) and mental health resources in Texas, such as HHS or the State Supported Living Center Ombudsman, health plan or local IDD authority service coordinators, Consumer Rights Office, Money Follows the Person, and Surrogate Decision-making committees.
If the training is Texas-specific, this information may be included within the text / training versus in a separate appendix.
Review an individual being presumed competent unless deemed incompetent by court of law; review alternatives to guardianship.