3000, Person-Directed Plan

Revision 19-4; Effective September 9, 2019

Local intellectual and developmental disability authorities (LIDDAs) are responsible for conducting person-directed planning as the foundation for service delivery for persons receiving general-revenue (GR) funded services, Community First Choice (CFC) and persons enrolling in the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) programs.

LIDDAs must use a person-directed planning process that is consistent with Texas Health and Human Services Commission (HHSC) Person Directed Planning Guidelines.

Person directed planning is an ongoing process that empowers the person, and the legally authorized representative (LAR) on the person’s behalf, to direct the development of a plan of services and supports that:

  • identify supports and services necessary for the person to achieve the person’s preferred outcomes;
  • identify natural supports available to the person and describe needed service system supports;
  • occur with the support of a group of people chosen by the person and the LAR on the person’s behalf; and
  • accommodate the person’s style of interaction and preferences regarding time and setting.

The result of person-directed planning must reflect the essential elements of the person’s desired life in sufficient detail, so the program provider understands how to provide services to meet the person’s outcomes.

HHSC approved Person-Directed Planning training is found online at Person-Centered Planning (PCP) Training for Providers.

3100 Discovering the Person

Revision 19-4; Effective September 9, 2019

The person’s strengths and needs are the basis for the entire process and must be involved in all aspects of the process, as well as the focus. The foundation of person-directed planning is to listen, acknowledge and discover the personal outcomes, preferences, choices and abilities of the person directing the plan. This activity is often called “discovery.” The local intellectual and developmental disability authority (LIDDA) service coordinator (SC) has the responsibility to facilitate the process of discovery as preparation for developing the Person-Directed Plan (PDP).

There are many ways to conduct discovery. The most common method is to have conversations with the person, legally authorized representative (LAR) and others who know and support the person, such as caregivers, close family members, current provider staff, friends and teachers. Effective discovery includes:

  • communicating and listening skills;
  • developing a relationship;
  • creating a distraction-free environment; and
  • identifying and acknowledging non-verbal communication cues.

The person-directed planning Discovery Guide and Discovery Tool are central resources to utilize when beginning the discovery process.

Documentation of the information gathered during discovery is important. The SC is responsible for documenting the information gathered from the person, family, provider and other participants.

Although person-directed planning is not a linear process, discovery is important preparation for developing the PDP.

3200 PDP

Revision 19-4; Effective September 9, 2019

Before developing the Person-Directed Plan (PDP), the service coordinator (SC) should discuss with the person and legally authorized representative (LAR) the importance of the provider being included when the person discusses his/her preferences and outcomes. Since the provider will be responsible for designing and providing the services to the person, understanding the person’s strengths, capabilities and desires is critical to providing services that are meaningful to the person. The SC should request permission from the person/LAR to invite the provider to the planning meeting to develop the PDP. The SC should also ask the person/LAR if they would like to invite anyone else to participate in the service planning process.

The SC is responsible for convening and facilitating a meeting to develop the PDP. There is not a single way to approach developing the PDP. It can be a brainstorming session where the purpose of services and desired outcomes are discussed while program services are decided upon. Or, it can be a meeting in which the discovery information is presented and clarified and then program services are negotiated.

The SC should have a thorough understanding of the services in the program so that connections can be made between what the person wants to have happen and the program service array. Reviewing the Program Billing Guidelines for Targeted Case Management, Home and Community based Services (HCS) and Texas Home Living (TxHmL), discussions with the person’s program provider and consultation with the LIDDA’s service coordination supervisor can support this understanding.

3210 Developing the PDP for Persons in GR

Revision 19-4; Effective September 9, 2019

If the designated local intellectual and developmental disability authority (LIDDA) determines a person is eligible for, and desires service coordination, the LIDDA must develop and implement policies and procedures related to enrollment into general revenue (GR) services that address:

  • developing a written plan of services and supports that uses a person-directed planning process that is consistent with the Person-Directed Planning Guidelines, including:
    • current services and supports, including existing natural supports;
    • outcomes to be achieved by the person and the GR services to be provided to the person;
    • an assessment to be conducted after enrollment;
    • the reason for each GR service to be provided; and
    • the amount and duration of each GR service identified in the plan; and
  • authorizing the provision of the GR services identified in the plan.

3220 Developing the PDP for Persons in HCS and TxHmL

Revision 19-4; Effective September 9, 2019

The Person-Directed Plan (PDP) has two elements plus instructions:

  • Form 8665-ID, Individual Data, completed by the SC at the time of enrollment and updated as necessary thereafter.
  • Form 8665, Person-Directed Plan, is the form used to document a person’s PDP.

The Service Planning Team (SPT) is responsible for determining whether a person’s program service is critical to meeting the person’s health and safety needs. The program provider must develop a written backup plan for each program service identified on the PDP as critical to meeting a person’s health and safety. Because Home and Community-based Services (HCS) program providers must ensure that trained and qualified staff are always available for the provision of residential support and supervised living, a backup plan is not needed for these services. Backup plans for host home must be documented in the service agreement the host home provider has with the program provider.

The SPT is responsible for documenting that the services on the PDP:

  • are necessary for the person to continue living in the community;
  • ensure the person’s health and safety;
  • prevent the need for institutional services;
  • meet each type of service component note in the PDP and is appropriate to meet desired outcomes or needs of the person;
  • does not replace existing supports for each service, natural supports or other sources for the service, such as Texas Workforce Commission, for funding of supported employment services; and
  • are cost effective.

For an enrollment PDP, the service coordinator (SC) is responsible for justifying both the need and the amount for each service type in the PDP.

For PDP renewals and PDP updates, refer to the Home and Community-based Services Handbook.