The Michigan Association of Community Mental Health requires an Individual Plan of Service to be completed at least once a year in accordance with the Michigan Mental Health Code. The creation of this plan can be billed to Medicaid. The Individual Plan of Service is created using Person Centered Planning techniques. The document that is created can be a powerful tool for reaching one’s housing dream. While the requirement is for one IPOS a year, it should be reviewed and updated regularly. The Individual Plan of Service and the Person Centered Plan will be referred to as PCP in the following explanation.
The PCP should be thought of as a living guide for the person served by Community Mental Health, developed by the individual with help from the supportive team that the individual identifies. The individual can solicit input from whomever they choose, to include friends and family, experts in a particular issue that the individual would like to work on, etc. For instance, if a person is interested in pursuing long term housing goals, they may ask a Housing Specialist to participate beginning in the preplanning stages of the development of the plan. This plan becomes a guide, with goals, objectives and strategies to reach the person’s desired outcomes for both the individual and for the people involved in this person’s life. While the plan holds weight, it is developed as goals and objectives and strategies, based on what is important to the individual and their unique strengths. It is also recognized that this plan can continue to evolve based on the person’s unique circumstances, what has been accomplished, and changes to what the individual would like to achieve.
Like the President’s job is to uphold the Constitution of United States, the Social Worker’s ultimate responsibility is to make sure that the PCP is followed and pursued by the individual, the supports, and the professionals involved. The IPOS that results from the PCP process is much more then a document as it is constantly evolving to meet the every changing preferences, needs and situation of the individual.
In the 1980’s, people in the mental Health system, would receive an inter-disciplinary team (I-team) meeting once a year. This I-team consisted of a doctor, nurse, dietitian, occupational therapist, case manger, a psychologist, and a recreational therapist. Each member of the I-team would do an assessment and provide their recommendations to the other professionals. The person and their supports attended the meeting to learn what the orders were from these professionals. The I-team then decided what type of housing was best for you and when you were allowed to move into different housing.
In the early 1990’s a revolution took place it Michigan. Medicaid still required an Individual plan of support but the I-team was replaced with the PCP concept. The professionals in the old I-team could only attend the PCP meeting if they were invited and the focus shifted to the interest of the individual and his/her identified circle of supports. Through a variety of different PCP techniques, the individual expresses his/her needs and preferences to develop the plan of action to achieve these desired goals. If the person has difficulty in expressing these desires, he or she may choose to ask for assistance, from those closest to them.
The PCP consists of a few stages: pre-planning, holding a meeting, and implementing the plan. The planning for the meeting stage is called pre-planning activities. This is where most of the housing work is done. This is where a person and those closest to the individual learn what kinds of housing would work best by asking questions such as:
- What is most important to this person, is it work; friends, church, family etc (see choices, choices, needs book)?
- What does this person need to live as independently as possible in the community?
- Are direct supports needed and how is this person going to get to work and to the store?
- What kinds of transportation options are available? Do they need a ride, can they use a bus system, or is special equipment needed?
Before the meeting, an exploration of the housing choices and the housing resources available needs to be done. This is when its best to contact CHN to review one’s desires and choices. CHN can review what housing services are currently available. The needs, the desires, and the housing resources will create the housing goal. This goal will be formed from an educated balance of ones needs, ones desires, and the resources available.
Somewhere in every PCP it will say this person is, or is not, living in the least restrictive environment. The more research that was done in the pre-planning activities then the more true the statement will be.
Every PCP needs to have a housing goal. The goal will be one of the following: about maintaining the current situation, obtaining a home that helps the person live more integrated in their community, or searching for the resources for the person to reach their dream home.
For More Information:
Related housing choices see CHN’s Housing Planning Library: Choices, choices, and needs, Getting My Own address, and Oakland Community Health Network – OCHN (formerly OCCMHA) – Intake, Services and Supports.
Informational sources used for this article: Beeman, Pat, Ducharme, George, and Mount, Beth (1989). One Candle Power: Building Bridges into Community Life for People with Disabilities. Manchester, CT: Communities.