The Valued Outcomes section represents personal goals that participants would like to work toward achieving. These goals are identified during the initial interview and assessment process, as well as through a face-to-face meeting with each participant’s Interdisciplinary Team (IDT), which includes the participant and his or her representative, clinical team leader and participants primary provider(s) of DD services who have knowledge of their desired outcomes and service needs, as well as other people of his or her choosing (e.g., residential supervisors, friends, and others involved in the participant’s care).

Life Plans include long-term supports and services as well as any needed medical and behavioral health specialty referrals, referrals to community-based supportive services, habilitation and employment programs, transportation assistance, and other services the participant may need or prefer. Once finalized and approved by the participant and his or her authorized representative, all services and supports included in the Life Plan are documented in PHP’s electronic care management system and distributed to all applicable professionals responsible for delivering the services.

On an ongoing basis, PHP’s care management team monitors the participant’s well being and progress toward achieving the goals listed in the Life Plan and makes any needed adjustments or revisions in collaboration with the participant and his or her circle of support. Also at least every six months the care management team and IDT will conduct a formal Life Plan review to ensure that the plan remains responsive to the participant’s needs and preferences. Life Plan reviews may also take place in response to certain “triggering” events such as a change in caregiver or an inpatient hospital admission. PHP’s overarching goal is to do everything possible to assist participants in achieving their goals and valued outcomes in a manner that is consistent with their health, safety, well-being, and personal preferences.