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A Step by Step Guide 




The following chart outlines the five major steps in the person-centered services approach. This process assumes an individual is eligible for services from SCDDSN. Each step is explained in detail on the following pages.

Step 1: Determining the need for services and supports

Step 2: Developing the person-centered plan.

Step 3: Implementing the person-centered plan.

Step 4: Evaluating the effectiveness of the person-centered plan, including the consumer’s and family’s satisfaction with the plan and the services.


Step 1: Determining the Need for Services and Supports

Once eligibility for SCDDSN services is determined, there are several steps that are followed. Identifying individual resources applies to new consumers since all current consumers with be "grandfathered in" at their current resource levels.

To determine the kinds of assistance or support individuals want and need, we must first gather information on:

  • where and with whom the person lives.
  • what he/she can do independently.
  • what is being done or needs to be done for the person.
  • who provides support.
  • what kind of work, if any, the person can or wants to do.
  • how and with whom he/she spends time, etc.

This information helps identify any gaps between how the person is living now and how he/she would like to live. We can then help determine the kinds of services and supports the individual wants, needs and requires to live as he/she chooses.

SCDDSN gets this information through the Inventory for Client and Agency Planning (ICAP) and the South Carolina Supplement (SCS).

The SCS documents information about personal relationships and natural supports available from family, friends, church members or other community contacts.

Step 2: Developing the person-centered plan.

There are many approaches to developing an effective person-centered plan. The expected result is a plan that focuses on how services and supports with the person’s life goals as it addresses needs. It builds on strengths while affording choice in how needs are met.

Family involvement is a very important part of developing an effective plan. The person-centered planning process strongly emphasizes the participation of the individual as well as family members and other close persons. They help identify a person’s hopes and aspirations, set future goals and develop a plan for achieving those goals. To do this, they must know the individual well. They must listen to him/her frequently and use this knowledge to adjust services and supports as needs and goals change over time.

Two features of the person-centered planning process -- the circle of support and the plan facilitator -- can be extremely helpful to the consumer in developing a plan and selecting services and supports.

The circle of support is a group of people chosen by the consumer and/or family. The members of this group help the consumer develop and monitor the plan of support. They are usually family, friends, co-workers, neighbors, church members, or service coordinators. They agree to meet on a regular basis to help the person identify and achieve personal aspirations and goals. Members of the group participate because they care about the person and want to work together to help overcome obstacles and open doors to new opportunities.

Circle members provide personal support and may take action on behalf of the individual. If a consumer has no family or close personal supports, the circle may be comprised primarily of staff members who know him/her well. Consumers and families have the option not to use a circle of support.

Consumers also will choose their plan facilitator. The facilitator guides the individual and the circle of support through the process of planning for the immediate and long-term future. The facilitator makes sure that the ideas and needs identified by the individual and the circle of support are addressed and included in the person’s plan.

The role of facilitator may be performed only by persons or organizations that do not provide direct services to individuals with disabilities. Because facilitators are independent of SCDDSN and service providers, their focus is exclusively on the consumer.

Facilitators must undergo special training, demonstrate competency in a variety of skill areas and meet other SCDDSN qualifications to be placed on an approved list. The consumer/family chooses the facilitator they want from the list, and there is no cost to the individual or family. Individuals may facilitate their own plan, but a trained facilitator must be present at the planning meeting to make sure the meeting follows the person-centered planning process.

Steps in The Planning Process

There are several steps involved in the person-centered planning process:

  • Before the planning meeting, the service coordinator gives the individual and/or family a list of trained facilitators.
  • The individual/family selects a facilitator, a date for the planning meeting, and the people he or she wishes to attend the meeting (the circle of support). The service coordinator may assist the consumer/family in identifying members of the circle of support.
  • The service coordinator contacts the selected facilitator, makes meeting arrangements and sends invitation letters to members of the circle of support.
  • The service coordinator attends the meeting and serves as a liaison between the individual, family members, service providers and members of the circle of support.
  • At the planning meeting, the facilitator guides the individual and the circle of support in addressing immediate and long-term goals and needs. Information on identified needs from the ICAP and the SCS, as well as knowledge of and information from the consumer are used to identify the individual’s preferences, talents, interests, and hopes for a meaningful life both now and in the future. The team helps the individual identify specific goals and develop a plan of supports, activities, services and resources needed to realize these goals. The plan includes supports that may or may not cost money.
  • The facilitator records information from the planning meeting in the Life Plan Worksheet and Plan of Supports.

The person-centered planning process results in a single plan that incorporates and ties together the various services and supports (housing/recreation, health services, employment, etc.) to ensure that they are coordinated in way that benefits the person. The plan includes time frames for completing goals and the results expected. It is intended to be practical, positive, realistic and based on achieving positive outcomes for the consumer.

The facilitator will develop an initial plan for each consumer. The completed plan is forwarded to a SCDDSN regional office for review and approval. The local DSN board is responsible for its implementation. As routine changes occur in the individual’s life situation, the service coordinator will update or change the Life Plan Worksheet and Plan of Supports, as needed.

SCDDSN is phasing-in person-centered services over a three-year period. All consumers will not have a person-centered plan facilitated during the first year of implementation. Local DSN boards/providers will implement plans for selected groups of consumers each year until person-centered plans are completed for all consumers.

Step 3: Implementing the person-centered plan.

Once the individual’s plan is approved by the SCDDSN regional office, the planning stage has ended, and it’s time to put the plan into action.

The service coordinator plays a vital role here. It is his/her job to be the link between the planning and the implementation stages. All involved -- the consumer/family, circle members and service coordinator -- share responsibility for implementing the plan. Service coordinators can assist families in identifying providers of services, and, in turn, assist providers in understanding the exact nature of the services needed by the individual and/or family. Members of the circle of support may also help either as paid service/care givers, or they may volunteer support to the person with a disability.

The agencies or service providers chosen by the consumer and/or family must follow the plan and provide supports as agreed on regarding what, how, when and where. SCDDSN, consumers and families evaluate service providers on the quality, efficiency and effectiveness; the consumer’s satisfaction with services and supports; and how well they help the consumer meet goals and produce desired results.

Step 4: Evaluating the Effectiveness of the Person-Centered Plan and the Services Provided

With the move to a person-centered approach, SCDDSN will also streamline procedures to ensure provider accountability and maintain quality services to consumers and their families.

SCDDSN continues to monitor and enforce regulations, and strict high standards of health and safety will continue to be top priorities at all times. The agency now focuses more on specific outcomes and results for consumers and families.

The principles of Continuous Quality Improvement guide SCDDSN in determining whether services and service providers are meeting expectations. The primary measure of quality will be how the person with the disability and the family view the responsiveness of the services. Service providers are required to design and modify supports and services to meet the expectations of the people who benefit from those services. To do this, they must continuously assess consumer satisfaction by collecting information from consumers and others, analyzing this information and making changes when needed.

SCDDSN will use a combination of oversight methods to evaluate the consumer’s plan and the service provider’s performance. They include:

  • licensing.
  • utilization review.
  • outcome assessment.
  • consumer satisfaction.
  • organizational outcome assessment.

An explanation of each of these methods follows.


State law requires licensing of programs and residential facilities. This licensing relates to the health and safety aspects of facilities and services. The law establishes standards for qualifications of staff, staff ratios, fire safety, medication management, facility size and construction, storage of hazardous liquids and health maintenance.

Previously, SCDDSN evaluated and licensed provider programs on standards related to the process of providing services rather than how well the services met consumers’ needs and how satisfied the consumer/family was with the services and the service provider. Since licensing is now only one of several methods for ensuring accountability, SCDDSN will license applicable programs on a three-year rather than an annual basis.

Utilization Review

SCDDSN conducts a periodic audit of records to make sure that services are being implemented as planned, that the consumer/family still wants and needs them, and that they comply with contract and/or funding requirements and best practices.

Personal Outcome Assessment

SCDDSN uses outcome assessments to determine how well the services and service providers are helping an individual achieve personal goals.

Consumer Satisfaction

Consumer satisfaction surveys are conducted periodically with consumers, families and other service agencies. SCDDSN and service providers will use this information to improve services and make them more responsive to consumers’ needs and wishes. If a consumer and/or family is dissatisfied with services received or with a service provider, SCDDSN has established a formal appeals process to be followed when decisions or concerns cannot be resolved through provider channels.

Quality Indicators

SCDDSN also collects and reports information on how well a provider is performing on quality indicators, including the health and safety of each person, dignity and respect, personal choice, participation in the community and attainment of goals. Other evaluation methods include:

  • comprehensive provider self-assessments.
  • service coordinator oversight.
  • peer reviews.
  • consumer/family monitoring.
  • local human rights committees.
  • family oversight.
  • circle of support contacts.

Information from these sources will be especially helpful to consumers and families in evaluating their plan and eventually in selecting and evaluating individual service providers.