Resources for Person Centered Planning (PCP)

The purpose of this webpage is to provide a quick reference to resources available for Managed Long Term Care (MLTC) plans and Social Adult Day Cares (SADCs) on Person Centered Planning (PCP). This webpage will provide links to resources, found in the New York State (NYS) Department of Health (the Department) resource library, that provides guidance and information for PCP completion and execution.

SADC/SADS Person Centered Service Plan Template

Description:The Department has developed a care plan template to be utilized at the SADC to define member activities, preferences, goals and needs during SADC participation. When completed entirely the Person Centered Service Plan (PCSP) ensures that the member will have a Home and Community Based Services (HCBS) Final Rule complaint care plan document.

SADC/Social Adult Day Service (SADS) Person Centered Service Plan Template User Guide

Description:This reference guide created by the Department, is intended to be used as a resource to assist SADC and SADS programs with completing the SADC/SADS PCSP Template.

Resource Library

Description:The Person Centered Planning and Practice Resource Library is a collection of free resources on person centered care planning and practice across all HCBS sectors in New York State. There are materials available such as leading research papers, policy guidance, and training webinars which are organized in a user-friendly manner.

The resource library is intended to support the development and understanding of person centered thinking, planning and practice skills, and concepts.

PCP Statewide Training Initiative

Description:The Department's PCP Statewide Training Initiative is a webpage that provides information and resources. It offers information on how to register for live training sessions,

access to recorded topic webinars, resources and learning support materials to help persons who deliver and oversee person centered services such as SADC providers and MLTC plans.

The Art & Science of Creating SMART Person Centered Goals

Description: This resource, presented by the Health Plan Collaborative Workgroup on October 26, 2018, offers an overview of how to use SMART goals in the PCP process. The Health Plan Collaborative Workgroup is a self-initiated group of health plans from Minnesota that began working together in February of 2007. It explains the SMART acronym and how to apply it in care planning practice, how to convert identified needs into SMART person centered goals, and how to identify common pitfalls when creating SMART person centered goals.

Thinking Differently About Person Centered Planning

Description:This webpage from the Department's website covers a brief look at the history of PCP within the HCBS Final Rule. SADC providers and MLTC plans will learn about the five steps of the PCP process, the differences between traditional care planning and PCP, and how to integrate PCP into the community based service system.

SMART Goals and Mental Health

Description:This article from the Mental Health and Developmental Disabilities (MHDD) National Training Center covers goal setting as a mental health tool and emphasizes SMART goals. SADC providers and MLTC plans can use this resource as a baseline for creating quality goals.

Promoting Meaningful Person Centered Practices in Home and Community-Based Service Delivery

Description:The National Center on Advancing Person-Centered Practices and Systems (NCAPPS) is an initiative from the Administration for Community Living (ACL) and the Centers for Medicare & Medicaid Services (CMS) that helps States, Tribes, and Territories implement person-centered thinking, planning, and practice in line with U.S. Department of Health and Human Services policy. In this webinar, hosted by the NCAPPS, September 22, 2022, panelists who receive or have received HCBS, share their experiences with person centered supports and services. SADC providers and MLTC plans can learn from the discussion on topics related to rights, choice, and control and how these critical elements can be improved and fully integrated into service delivery practices.

Person Centered Thinking and the HCBS Final Rule

Description: The Department presented a two-hour long training on Person Centered Thinking and the HCBS Final Rule. This recorded training provides an overview of the HCBS Final Rule and its application to NYS services and supports. The training helps MLTC plans and SADC providers identify the expectations of the HCBS Final Rule for performing PCP, it describes the process for making modifications to the additional standards of the HCBS Final Rule and explains the difference between what matters to someone and what is good for them.

Goals to Care: How to Keep The Person In "Person Centered"

Description:This report, from the National Committee for Quality Assurance, May 31, 2018, equips SADC providers and MLTC plans with tips and tricks for coordinating goal-based care to individuals with complex needs. It also contains examples from organizations experienced in providing person centered care.

Fact Sheet Person Centered Planning and The Home and Community Based Services (HCBS) Rule

Description:A fact sheet from the Department, designed to provide an overview of the person centered care planning requirements for HCBS Final Rule.

Electronic Dementia Guide for Excellence (EDGE) Project: Strength Based Care Planning

Description:The EDGE Project's webpage of the Department is dedicated to individuals diagnosed with dementia. It will equip SADC providers and MLTC plans with comprehensive information on care planning for members experiencing dementia. Additionally, it offers tools and worksheets to help develop strength-based care planning skills.