Developing Person-Centered Service and Care Plans: Honoring Choice While Mitigating Risk

The purpose of this process is to support long-term care communities in their efforts to honor residents’ choices and preferences that influence quality of care and quality of life, while mitigating potential risks associated with those choices and preferences. This process is specifically aimed at care planning when an individual’s choice carries sufficient risk that the community is considering not honoring the person’s wishes. The documentation of this process is critical, as it is relied upon should an unforeseen event occur.  Having the documentation that shows all the steps taken, who was involved in the conversations, what options were discussed, which were or were not acceptable, and why is what regulators and others will want to see.  This document is a brief summary of the care planning/service plan development tool.  For the complete toolkit and documentation forms mentioned below, please go to PreferenceBasedLiving.com.

Step 1: Identify and Clarify the Person’s Choice and Preferences

The intent of this step is to Identify and clarify choices and preferences that are associated with risk.  Interview the person using the PELI and observe the person. Review the person’s history to obtain detailed information about the nature and extent of the choice that the person wishes to make. 

• Interview the individual and the staff who are most familiar with the individual.
• Identify the request.  Determine if the choice is a one-time request or a long-term preference.  Is it a repeated preference over time or perhaps a brief reaction to some other concern?
• Repeat back to the person your understanding of what she or he desires to choose or refuse, to confirm both parties understand each other.  
• Ask to involve the person’s representative in the discussion.  
• Record the nature and extent of the choice(s) the person wishes to make on the Documentation Form and place in the written or electronic medical chart or health record. 

Step 2: Discuss the Choice and Options with the Person

The intent of this step is for the team and person to explore options that might be mutually acceptable. This is an opportunity for the person and multidisciplinary care team to engage in dialogue so that the person can explain what is important to him or her.  

• Discuss with and educate the person about the potential outcomes, both positive and negative, of respecting and aiding the pursuit of her or his choices and preferences, as well as the potential negative or positive outcomes of preventing the person from acting on his or her choices. 
• Offer ways to accommodate the choice which also mitigate potential negative consequences as much as possible.
• After learning of and considering the potential consequences and positive outcomes, the person may decide not to take his or her initial requested action, to curtail its frequency, or to select an alternative with fewer potential adverse consequences, or may continue to desire the original choice.
• Explain why a requested choice cannot be honored if it poses significant danger to others. 
• Record the conversations with the person and representative on the Documentation Form and place it in the medical chart/health record. Describe the discussion of the risks and benefits and whether the person exhibited adequate decision-making capacity related to the choice in question. Provide a record in writing about what was presented to the person and what the person’s response was.   

Step 3: Develop the Plan to Honor the Choice and Preference

The intent of this step is to collaborate with the person to determine how the team will accommodate a choice to maximize the person’s well-being. Have a copy of the documentation forms from Steps 1 and 2, with the person’s most important preferences on hand for the meeting.

• Develop a detailed plan about how the person’s preference will be accommodated and who will take steps to ensure it is fulfilled.  
• Ensure the participation of the person, and, if desired, their representative, in every step of the care planning process and make sure the person is made aware of the steps of the plan.
• Ensure the participation and input of the direct care staff as they have the most contact with the person.
• Record the decisions reached and the steps the staff will implement to assist the person and mitigate potential negative outcomes and augment positive outcomes to the fullest extent possible. 

Step 4: Monitor and Make Revisions to the Plan

The intent of this step is for the team to work with the person to revise the plan as needed and desired by the individual. The interdisciplinary team will monitor the progress of the plan and its effects on the person’s well-being, as well as the ongoing desire of the person to continue with the plan as written. 

• Recognize that as a person changes over time, one’s needs and preferences and the way he or she expresses needs and choices will change.   
• Ensure that care and service plans are flexible, as people have the right to change their minds. 
• Do not limit monitoring to auditing forms or records. Monitoring plans generally need to include observing, assessing, and discussing with the person his or her response to the planned interventions at a frequency that is appropriate for the particular person and choice.
• Record the ongoing discussion in the care plan; the plan of care will be updated as needed to reflect these changes.

Considerations for Continuous Improvement

The Quality Assurance and Performance Improvement team should review trends related to resident choice, preferences, and safety, particularly when individuals are routinely denied requests, or when the team identifies patterns of community care practices that might be improved by performance improvement action plans. Areas that the team might consider for specific attention might include:

• Denial of requests on a routine basis for more than one person. Whenever the community denies honoring a choice or preference, it should be documented and reviewed for trends, the need to educate staff, and/or policy changes.
• Areas of community inability to accommodate individual’s preferences and action planning for future growth.  This may include planning for future changes to the physical environment or changes in resource allocation to better accommodate preference.
• Resident and/or family council feedback. If individuals feel their preference and choices are not being honored, a community-wide plan should be put into place that includes assessment using the PELI and staff training that focuses on learning how to offer safer alternatives that mitigate risk while honoring preferences.
• Perceived high-level risk activities, community responses, and risk management review.