Person-Centered Plans from the Perspective of Persons-Supported in a Community Care Organization

Background: Person-centred plans (PCPs) are widely used in community care organizations and required for service providers in many jurisdictions, but there are very few guidelines, evidence, or formal evaluations of PCP creation and implementation practices. PHSS is a non-profit community-care organization in a large urban city in Ontario, Canada. Objective: To describe person-centred planning and implementation practices from the perspective of individuals with intellectual and developmental disabilities and/or complex medical issues supported by community care organizations. Methods: We are an interdisciplinary team of researchers from Western University who partnered with PHSS. Our project team included community-care providers from PHSS and academic researchers. We involved PHSS staff at all stages of the study design, and persons-supported by PHSS were interviewed as part of the study. As part of a larger study evaluating the PCP process, we interviewed 18 persons-supported and 1 family member of a person-supported by PHSS. We asked participants about their goals, accomplishments, and experiences with the PCP process. We asked about the process used to create PCPs; examples of how the PCP is tailored to the individual; perceived benefits and challenges; and supports or barriers that facilitate or hinder the PCP process. Results: We identified three overall areas of the person-centred planning: 1) the process of creating a PCP, 2) PCP implementation, and 3) factors that support the creation and implementation of PCPs. PCPs are created annually with check-ins after 6 months. They are created through discussion with the person-supported, the staff who support them, friends, family, and community members. The PCP is shaped by the person-supported’s attributes including their likes, dislikes, and goals. PCPs could include different types of goals such as health-related goals, goals for daily living, and goals for hobbies and interests. The PCP goals are tracked both formally and informally. The process of creating the PCP is individualized and adaptable and centers the person-supported. The PCP creates a blueprint for daily activities with staff assisting persons-supported to participate in activities that align with goals and match preferences, personalities and capacities. Factors that facilitate the success of the PCP process include the nature of the person-supported’s goals, the person-supported’s capacity (i.e., physical and mental health status), and the organizational capacity (i.e., funding, staffing, organizational culture, and organizational infrastructure). Conclusions: This project offers a description of person-centred planning to improve standards of care and health equity for persons-supported by community-care organizations. Our next steps are to integrate findings from this study with findings from the other components of our project and to disseminate findings through knowledge translation strategies appropriate to the PHSS organization, other relevant community organizations, and policy stakeholders. Our findings will inform PCP process design and implementation for community care organizations both within Canada and globally. This project provides evidence for how person-centred planning can incorporate different types of goals and how those goals are translated into everyday supports for persons-supported in community care.