The International Journal of Psychosocial Rehabilitation

Wisconsin: Leading the Way to Person-Centered
Planning in Community-Based Health       

Diane Grieder, M.Ed

Gerald Theis, LCSW

Grieder D & Theis G  (2008). Wisconsin: Leading the Way to Person-Centered Planning in
 Community-Based Health   International Journal of Psychosocial Rehabilitation. 12 (2), 111-114

A person-centered approach is reshaping practice throughout behavioral healthcare with its emphasis on the individual who has strengths, talents, and interests rather than a person as a case or a diagnostic label. Person-Centered Planning (PCP) incorporates the person’s right to fully participate in all aspects of their recovery planning; their right to make decisions and choices about their treatment, while ensuring important aspects of their culture also be documented in the service plan itself. This collaborative process empowers and provides an opportunity through a psychosocial rehabilitative model for the person to inherently find their own path to recovery.
It is now widely recognized that people with mental illness can participate actively in their own treatment and can become the most important agents of change for themselves. Person-Centered Planning skills, along with Evidence-based Practice (EBP) interventions, such as Wellness Management and Recovery, ranging from greater knowledge of psychiatric illness and its treatment to coping skills and relapse prevention strategies, play a critical role in people's recovery from mental illness.

It is anticipated that EBP will be a key intervention in PCP recovery outcomes. For example, Wellness Management and Recovery (WMR) aims to empower consumers with severe mental illness to manage their wellness, define their own recovery goals, and make informed treatment decisions by teaching consumers the necessary knowledge and skills. WMR strongly emphasizes that consumers determine and pursue personal goals and implement action strategies (objectives) in their daily living to achieve them. The program employs interventions to help consumers improve their ability to overcome the effects of mental illness on social and role functioning.

PCP encourages people receiving services and their supporters to focus on goals aimed at increased functionality and community integration rather than solely on reduction of symptoms and decreased use of hospitalization. It helps people to focus on increasing the quality of their lives and look to a better future with more meaningful activities and social relations. The barriers to success resulting from the person’s disability are identified and the plan is an effort to explain to everyone concerned how those barriers will be overcome while enhancing the person’s chances of successfully achieving the agreed upon goal.

In the State of Wisconsin, under the Bureau of Mental Health & Substance Abuse, the State has been awarded a one year grant (the “CMS Real Choice Award”) to bring recovery based; Person-Centered Planning (PCP) to Wisconsin’s community -based mental health programs beginning in 2008. A precursor to this grant was a previously awarded grant to implement recovery-based Evidence-based Practices (EBP) under a new statue called, Comprehensive Community Services, (CCS), and technical assistance, as requested by Alice Mirk, (Chief, Integrated Services Section, Bureau of Mental Health & Substance Abuse Services, Wisconsin Department of Health & Family Services from NTAC (National Technical Assistance Collaborative) which is part of NASMHPD (National Association of Mental Health Program Directors).

In 2004, Wisconsin created a new statute called Comprehensive Community Services (CCS) to administer a comprehensive service array for persons with severe mental illness. The statute establishes a scope of psychosocial rehabilitation services with standards for certification and criteria for determining need under Medicaid rules. The emphasis is on recovery, measured by decreases in dysfunctional symptoms and increases in level of health, well being, stability, self-determination, and self-efficacy.
Five counties initially applied for CCS and implemented the components of CCS. These same five counties were then selected by the Bureau to be offered two full-day s and three months of on-going technical assistance via follow-up phone calls on person-centered planning (PCP) as part of the NTAC consultation. Each of these counties use the Mental Health Functional Screen in their programs and agreed to use the SAMHSA Recovery Oriented Systems Inventory (ROSI) for surveying consumer satisfaction, prior to and after applying the PCP approach.
The Division of Quality Assurance and the Division of Health Care Financing also participated in these training sessions to ensure that PCP would be integrated into the regulatory and reimbursement environment in Wisconsin. PCP is one of the new criteria in the proposed Center for Medicaid and Medicare Services (CMMS) rule on psychosocial rehabilitation (Notice of Proposed Rule Making: Coverage for Rehabilitative Services 42 CFR Parts 440 and 441). PCP is considered critical to the advancement of system transformation.

 A national behavioral health-consulting group, Alipar Inc, facilitated these training sessions and follow-up calls. The owner of AliPar, Inc. co-authored the book “Treatment Planning for Person-Centered Care: The Road to Mental Health and Addiction Recovery.”  In preparation for the bi-weekly teleconferences, each county team took turns preparing an Assessment, a Narrative Summary and a Person-Centered Plan of a consumer actively engaged in their mental health program. The documents were e-mailed to each of the other counties prior to the scheduled teleconference. The focus of the teleconference was on the use of PCP with its emphasis on the person’s assessed strengths, central theme of the person and their stages of change. The focus on the person-centered plan was on the use of the person’s own goals, strengths, objectives, and interventions applied by the providers. This process proved to be beneficial in the development of new skill sets. As a whole, the group determined defining objectives (as opposed to goals and interventions) was the most difficult part in the formation of the person-centered plan.

Since the Division of Quality Assurance and the Division of Health Care Financing participation in these training sessions, these entities were able to monitor and then later facilitate the progress made to ensure that PCP was being fully integrated into recovery planning and outcomes for these state regulated programs in Wisconsin. The monthly follow up teleconferences allowed for ongoing collaboration with each county technical training team. Through this process, each county team worked together building new skill sets while gaining a strategic advantage in this era of transformation. This process created an opportunity for each county to collectively apply their own unique circumstances towards a common goal.

 Together, these two approaches PCP and EBP are expected to enhance the service array and enhance a person-centered approach currently being offered by these five existing community-based mental health programs. Each of these counties will be at a strategic advantage towards demonstrating a recovery-oriented, evidence-based, person-centered model of delivery.

As a result of the PCP training these counties have already achieved the following objectives:

-Appreciation for the need for practice change (and just how difficult that is to do) in terms of conducting person-centered  treatment planning 
-Preparation for state and/or federal audits which focus on meeting  medical necessity criteria for services
-Identification of emerging new frameworks that will guide and develop the person-centered plan
-Understanding of the importance of a strengths-based assessment process
-Defining the key elements of a recovery plan
-Understanding how to apply a stages of change framework to engagement and person-centered planning
-Apply when indicated, Evidence-based Practice as a key intervention within the recovery/service plan
This group of providers agreed that the potential effect of PCP initiatives on their consumer’s with mental illness was significant. Although the benefits of learning how to plan to manage one's illness and make progress toward recovery are compelling, all agreed that recovery is hard work. The switch from being a passive recipient of care to an active partner is very challenging for many consumers. Providers note: 
  • Results of the training and the follow-up technical training phone calls were: Significant increases in PCP skills were documented.
  • County learning was given strong support by state staff.
  • County clinical and supervisory staff has additional skill development needs but are committed to the PCP process and are eager to refine their ability to engage consumers in PCP.


The State is hopeful that knowledge about PCP will be widely circulated and used in a variety of mental health specialties as providers begin to appreciate the need for practice change in the era of transformation. Those providers will be encouraged to expand these newly developed skill sets as they are tested and proven to be effective with the newly empowered consumers.

As providers focus on the individual who has strengths, talents, interest rather than theperson as a case or a diagnostic label our mental health recovery process will become a journey of healing and transformation for both providers and consumers.
Consumer ownership of their recovery plan allows providers to view the situation from the consumer’s perspective who is now perceived as a capable human being who is full of strengths and resources and the treatment approach is geared toward empowering consumer to achieve a desired future and meaningful life. This collaborative process results in a recovery-oriented plan that is directed by consumers and produced in partnership with providers.
By focusing in on the wisdom of consumers, providers will transition into a consumer- driven process that will assist consumers to enhance their resiliency and hope to the ravages of their illnesses.At the end of the day, providers who implement PCP will address consumer’s unique recovery needs by mapping their road to Recovery, Resilience and Wellness.

Copyright © 2008 Hampstead Psychological Associates, Ltd - A Subsidiary of Southern Development Group, SA.
All Rights Reserved.   A Private Non-Profit Agency for the good of all, published in the UK & Honduras