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Overview of the Life Plan and Integrated Care

The goal of PHP Care Complete FIDA-IDD Plan for adults with intellectual and other developmental disabilities (IDD) is to enable our participants to be as healthy, happy, and independent as possible. We integrate preventive and wellness services, medical and behavioral healthcare, personal safeguards and habilitation to  support each participant’s personal dreams in a state-of-the-art documentation system called the Life Plan. The Life Plan is an innovative approach to supporting persons with IDD.

The Life Plan incorporates two major components: “Personal Safeguards” and “Valued Outcomes.” The Personal Safeguards section lists all actions needed to keep our participants safe and healthy, including health care, nutrition, fire safety, and personal supports, among others. A participant may also choose a needed safeguard as a personal goal to increase independence, such as self-administration of medication or learning to travel safely within the community (e.g., ride the bus or subway).

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.


Participant and Family Participation

PHP believes that the active involvement of our participants and their families, caregivers, and circles of support is a vital component of the Life Plan. Whenever possible, we involve participants in the development of their Life Plan and include others who are important to them. This might include family members, friends, caregivers, residential supervisors, staff within their habilitation programs, and advocates.

Our Clinical Team Leaders and Care Managers will consult these individuals during all phases of the Life Planning process by telephone, in-home visits, or conferences and incorporate the input they receive into our participants’ Life Plans.


Revising the Life Plan

Each participant’s Life Plan is reviewed and updated at least every 180 days to make sure that it continues to address his or her needs and preferences. Additional reviews might take place after significant events or upon participant’s or provider’s request.  If the Life Plan is revised and approved by the participant/authorized representative, the updated version will be sent to all involved stakeholders and also made available to authorized persons via PHP’s secure web portal.


PHP Care Complete FIDA-IDD Plan has a Model of Care approved by the National Committee for Quality Assurance (NCQA), the New York State Department of Health, and New York State Office for People With Developmental Disabilities until 2018 based on a review of PHP Care Complete’s Model of Care.

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