Posted on May 19, 2020

By Elizabeth Sites, CQL Quality Enhancement Specialist

Discovery is about getting to know a person, learning about what makes them the person they are. It’s having open, honest conversations. It’s observing people, watching verbal and non-verbal cues, talking to others who know the person well. It’s finding out what people want. People learn what they like and don’t like through education, experience and exposure. These “3E’s” are an important piece of the Personal Outcome Measures® (POM), which is an internationally-recognized tool used to discover personally defined outcomes for people.

The Personal Outcome Measures® Discovery Process

The Personal Outcome Measures® is a person-centered discovery process, exploring the presence, importance, and achievement of outcomes, along with the supports that help people achieve those outcomes. In a POM interview, 21 indicators are used to gain valuable insight into the lives of youth, adults, and older adults with intellectual and developmental disabilities, and psychiatric disabilities.

The interview covers a variety of topics, including choice, health, safety, social capital, relationships, rights, employment, and more. For decades, the internationally-recognized tool has been an effective avenue for improving individual quality of life, while creating a valid and reliable data set.

Choosing Goals In Person-Centered Planning

By Carli Friedman, CQL Director of Research

People choosing their own goals is key to person-centered planning, and we find that people with disabilities who choose their goals have a better overall quality of life – more outcomes present. In our 2019 sample of Personal Outcome Measures® interviews with 1,250 people with disabilities, people who did not choose their goals had an average of 41% of quality of life outcomes present, whereas people who did choose their goals had 67% of quality of life outcomes present (see figure).

Impact of Choosing Goals on Overall Quality of Life

Choosing goals not only improves overall quality of life, it also has a significant impact on every different area of quality of life. For example, people who chose their goals were 2.7 times more likely to interact with other member of the community, 2.8 times more likely to be treated fairly, 3.1 times more likely to be respected, 3.5 times more likely to realize goals, and many more.

And yet, despite the positive impact choosing goals can have, and the fact that people with disabilities are entitled to person-centered planning, only 54.1% chose their goals (outcome present) in 2019. Moreover, only 48.1% had organizational supports in place to facilitate choosing goals.

Choosing Goals: Organizational Supports

Our research indicates organizational supports can play a key role in facilitating goals and choice. For example, when organizational supports are in place, people with disabilities are 39 times more likely to choose their goals! Organizations should be supporting people to choose their goals, which includes using the Personal Outcome Measures® to help direct person-centered planning.

Putting Outcomes Into Action

By Elizabeth Sites, CQL Quality Enhancement Specialist

The Centers for Medicare and Medicaid Services (CMS) state in the Home and Community Based Services (HCBS) Settings Rule Guidelines “that service planning for participants in Medicaid HCBS programs under section 1915(c) and 1915(i) of the Act must be developed through a person-centered planning process that addresses health and long-term services and support needs in a manner that reflects individual preferences and goals. This planning process, and the resulting person-centered service plan, will assist the individual in achieving personally defined outcomes.” Beyond this being the rule for waiver services, it is best practice for all service types.

Discovering personally defined outcomes is the essence of the Personal Outcome Measures®. CHI Friendship is a human services provider based in North Dakota that has achieved CQL’s Person-Centered Excellence Accreditation, With Distinction, and has integrated POM interviews into their organization. “The POM interview is the springboard to developing the plan. This is the springboard to all future planning,” says Dori Leslie, President of CHI Friendship. “A relaxed and thorough interview helps the person and his/her team to discover what is of utmost personal importance.”

Developing A Person-Centered Plan

Organizations around the world have developed tools that are used in conjunction with the Personal Outcome Measures® interview for information gathering, which can then help direct the person-centered plan. Brothers of Charity Services in Galway, Ireland, developed a POM Information Gathering Workbook based on the 21 quality of life indicators. While it certainly doesn’t constitute a full POM interview, it is a way to capture some valuable information that can be used in planning.

Ray Graham Association, based in Illinois, developed and uses an All About Me document “that represents each person’s most current priorities and preferences.” The form can be used ‘as is’ or personalized however the person prefers – everything from edits to the color and font to full format changes. Some people receiving services have made scrapbooks, photo albums, power points, and even artwork to represent some of the sections within the All About Me document. It is intended to be updated as the person’s desires and preferences change, and as support staff learn new information about the person.

However the information is gathered, the focus should be entirely on the person, never the system. Maired Vaughan and Mary Seale from Brothers of Charity Services in Galway, Ireland, state that “Once the information gathering process has been completed, each person is supported to identify their unique hopes and dreams along with their priorities for the coming year.”

Once all the information has been gathered and priorities have been identified, what now? First, obtain consent from the person to share this information. Some people may not want every detail shared with others and that must be respected. Identify with the person their priorities and what pieces of the information will be brought to their support team. This information can be shared in different ways – prior to the plan meeting so that team members can come prepared with ideas for supporting the person’s priorities and dreams or at the plan meeting with all those in attendance. No matter how the information is shared, there must be a spirit of collaboration amongst the team members.

There is a lot of information gathered during the Personal Outcome Measures® process and not every dream and idea that is generated will become part of the formal planning document. Information will most likely need to be sorted out by priorities, themes, what is important TO the person and what is important FOR the person. Some of these pieces will be actionable items that can be put into place right away. Other pieces can be added as supports or learning objectives. Dori Leslie from CHI Friendship states that “these pieces also provide clues as to what the person may need to work on to achieve an improved quality of life.”

All that is learned through the Personal Outcome Measures® process does not necessarily have to be developed into formal goals. However, the person’s priority outcomes must be clearly identified in the plan and shared with all team members to drive conversations on how to best support the person to achieve those outcomes. If not a formal goal, the organization should define methods for routine check-ins on progress towards the priority outcomes.

Ensuring The Person-Centered Plan Is Understandable

Since it is essential that the plan includes the person’s priority outcomes, it is equally imperative that the person’s plan be in a format that is meaningful and understandable to the person. No one wants a written plan full of words that have no meaning to them. Providers have a responsibility to ensure that people’s plans are in a format that makes the most sense to the person. Different formats might include pictures, braille, audio or video. They could be developed using different platforms such as PowerPoint, scrapbooks, computer apps, Quik, etc.

One such template was developed by CQL and funded by the Illinois Council on Developmental Disabilities. This template uses ‘Easy Read’ concepts and photos, through the program Microsoft Publisher. Remember – personal plans are not just about the funding that comes along with them, they represent people’s lives and dreams and people should have a version of the plan that fits them.

Focus On The Person

“The QIDP ensures that the information gathered for the All About Me is shared with the person’s Independent Service Coordinator (ISC),” says Sharon Anderson from Ray Graham Association. “This collaboration has ensured that what truly matters to people is communicated and becomes part of the person’s plan.”

No matter who is responsible for developing the written plan, all members of the team are responsible for the implementation of the supports. If collaborative efforts prove to be difficult, it is imperative that provider organizations respectfully advocate for the person and their defined outcomes and dreams. Again, at the very core of everything, the focus needs to be on the person.

Ensuring that these processes occur for every person that receives services will help all the pieces come together for successful achievement of outcomes. The expectation within all services should be one of listening, discovery, communicating, and support for what really matters most to the person receiving the services.