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Person-Centred Plans from the Perspective of Persons-Supported in a Community Care Setting: A Qualitative Study

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Title: Person-Centred Plans from the Perspective of Persons-Supported in a Community Care Setting: A Qualitative Study
Language: English
Authors: Gillian Young (ORCID 0009-0005-7120-219X), Maria Mathews (ORCID 0000-0002-5174-104X), Leslie Meredith (ORCID 0009-0007-1338-6474), Shannon L. Sibbald (ORCID 0000-0002-4328-6489), Dana Ryan (ORCID 0000-0001-7949-8849)
Source: Journal of Applied Research in Intellectual Disabilities. 2025 38(3).
Availability: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
Peer Reviewed: Y
Page Count: 8
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Foreign Countries, Community Health Services, Planning, Models, Integrated Activities, Caregivers, Client Characteristics (Human Services), Individualized Programs
Geographic Terms: Canada (London)
DOI: 10.1111/jar.70084
ISSN: 1360-2322
1468-3148
Abstract: Background: In partnership with PHSS, a community care agency in London, Ontario, we describe the person-centred planning model. Person-centred plans (PCPs) are mandated in the community care sector and created annually through discussions with the person-supported, staff, family/friends and community members. PCPs are individualised, integrated into daily activities and contribute towards larger goals. Methods: We interviewed 18 persons-supported and one family member. Participants were individuals with developmental, medical, or complex physical needs and supported by PHSS. We explored goals, accomplishments, the individualisation of PCPs, experiences with the process, and supports/barriers. Results: PCPs are tailored to the person-supported's needs and preferences, linked to daily activities, and guide larger goals. PCPs are facilitated by the person-supported's goals and capacity and organisational factors (e.g., funding, staffing). Conclusions: This study evaluates person-centred planning from the perspectives of persons-supported, providing insights to enhance these processes within community care settings.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1475041
Database: ERIC
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  Value: <anid>AN0186163447;e0301may.25;2025Jun27.04:03;v2.2.500</anid> <title id="AN0186163447-1">Person‐Centred Plans From the Perspective of Persons‐Supported in a Community Care Setting: A Qualitative Study </title> <p>Background: In partnership with PHSS, a community care agency in London, Ontario, we describe the person‐centred planning model. Person‐centred plans (PCPs) are mandated in the community care sector and created annually through discussions with the person‐supported, staff, family/friends and community members. PCPs are individualised, integrated into daily activities and contribute towards larger goals. Methods: We interviewed 18 persons‐supported and one family member. Participants were individuals with developmental, medical, or complex physical needs and supported by PHSS. We explored goals, accomplishments, the individualisation of PCPs, experiences with the process, and supports/barriers. Results: PCPs are tailored to the person‐supported's needs and preferences, linked to daily activities, and guide larger goals. PCPs are facilitated by the person‐supported's goals and capacity and organisational factors (e.g., funding, staffing). Conclusions: This study evaluates person‐centred planning from the perspectives of persons‐supported, providing insights to enhance these processes within community care settings.</p> <p>Keywords: community care; intellectual and developmental disabilities; person‐centred care; person‐centred plans; qualitative research; social care</p> <p></p> <ulist> <item> This study offers insights into the effective implementation of PCPs in community care settings, which can be used to inform policy and practice in person‐centred approaches.</item> <p></p> <item> Findings address a gap in the literature around the creation and implementation of PCPs from the perspective of persons‐supported and provide insight into the ways PCPs can shape individual capacities and lifestyle.</item> <p></p> <item> PCPs empower individuals by focusing on their strengths, interests and personal goals, promoting autonomy and self‐determination.</item> <p></p> <item> PCPs contribute to a stable and supportive environment, potentially mitigating turnover issues among support staff and enhancing continuity of care.</item> </ulist> <p>Summary</p> <hd id="AN0186163447-2">Introduction</hd> <p>Community care sector organisations use person‐centred planning to identify and organise services and supports for people with intellectual and developmental disabilities living in the community to create a person‐centred plan (PCP) to guide care delivery (Administration for Community Living, [<reflink idref="bib1" id="ref1">1</reflink>]). PCPs are created through discussions with the person‐supported, staff, family/friends and community members and serve to integrate larger goals into daily activities. Several North American jurisdictions require annually updated PCPs for people with intellectual and developmental disabilities receiving care from community care organisations (Crisp and Lawrence [<reflink idref="bib6" id="ref2">6</reflink>]; Government of Manitoba [<reflink idref="bib13" id="ref3">13</reflink>]; Government of Ontario [<reflink idref="bib14" id="ref4">14</reflink>]; Terrell [<reflink idref="bib27" id="ref5">27</reflink>]). Despite this requirement, there is no clear consensus on the definition of person‐centred planning, and no universal approach to PCP creation (Claes et al. [<reflink idref="bib4" id="ref6">4</reflink>]). There is substantial variation in clinical and demographic characteristics of the populations that receive support from community care organisations, including individuals with intellectual and developmental disabilities and complex medical needs (Lin et al. [<reflink idref="bib19" id="ref7">19</reflink>]).</p> <p>There are a limited number of studies examining the effectiveness of person‐centred planning (Dong et al. [<reflink idref="bib7" id="ref8">7</reflink>]). In addition, historically, people with intellectual and developmental disabilities have been excluded from research (Hollomotz [<reflink idref="bib15" id="ref9">15</reflink>]). Previous research has found that incorporating person‐centred planning improves overall person‐supported satisfaction, expands social networks and may improve health outcomes (İsvan et al. [<reflink idref="bib17" id="ref10">17</reflink>]; Wigham et al. [<reflink idref="bib30" id="ref11">30</reflink>]). In Ontario, Canada, the person‐centred planning process in community‐care organisations is influenced by the types (social vs. medical care) and nature (e.g., duration, intensity, community vs. residential) of services, organisational values and needs, and characteristics of the population served (Idrees et al. [<reflink idref="bib16" id="ref12">16</reflink>]). Given the breadth of organisations and services in the sector, person‐centred planning can greatly vary. We examine the development and implementation of PCPs from the perspective of persons‐supported at PHSS Medical and Complex Care in Community (PHSS), a non‐profit community‐care organisation in southwestern Ontario. We use person‐first and identity‐first terminology (person‐supported) to refer to individuals who receive services (Dunn and Andrews [<reflink idref="bib9" id="ref13">9</reflink>]).</p> <p>We examine PHSS in a single case study because of its reputation as a leader in person‐centred planning (Dong [<reflink idref="bib8" id="ref14">8</reflink>]). PHSS supports more than 250 individuals in over 60 locations and provides 24‐hour residential supports, day and overnight respite, specialised complex medical care, recreational programs, and support for individuals living at home with their families (PHSS, [<reflink idref="bib25" id="ref15">25</reflink>]). PHSS develops PCPs annually with each person‐supported to help plan the supports and services for each individual receiving care from the organisation (PHSS, [<reflink idref="bib25" id="ref16">25</reflink>]). PCPs are also used to help the person supported access support and necessary resources in education and employment, healthcare, community and social activities, and recreation (PHSS, [<reflink idref="bib25" id="ref17">25</reflink>]). This study addresses the gap in knowledge on approaches to implementing PCPs and fulfils a recommendation given by the authors of a systematic review on the effectiveness of person‐centred planning for people with intellectual disabilities to provide clearer descriptions of PCP and its components (Ratti et al. [<reflink idref="bib26" id="ref18">26</reflink>]). Work has begun in some jurisdictions to develop competencies and standardise the implementation of the PCP process (Tondora et al. [<reflink idref="bib28" id="ref19">28</reflink>]). Describing a high‐functioning example of person‐centred planning provides insight into how the intervention influences expected outcomes and informs future evaluation research.</p> <hd id="AN0186163447-3">Methods</hd> <p></p> <hd id="AN0186163447-4">Design</hd> <p>As part of a multi‐phase mixed methods study (Creswell [<reflink idref="bib5" id="ref20">5</reflink>]) we conducted qualitative interviews with persons‐supported by PHSS and/or their family members. The larger project used an integrated knowledge translation approach (Kothari et al. [<reflink idref="bib18" id="ref21">18</reflink>]) wherein university researchers partnered with PHSS to develop and design a study to examine the use of PCPs at PHSS and in the community care sector.</p> <hd id="AN0186163447-5">Procedure</hd> <p>We recruited participants with the assistance of PHSS administrative staff. Administrative staff reached out to program or residential site coordinators who asked the persons‐supported if they were interested in taking part in an interview with researchers. PHSS staff then coordinated the timing and location of interviews with research staff. It was important to involve PHSS in recruitment, as many individuals in the target populations did not have the resources or ability to reach out to researchers independently. To be eligible for the study, participants had to be a person‐supported by PHSS residential homes and/or day programs or their family member, and consent or assent to an interview.</p> <p>Using a semi‐structured interview guide, we asked participants to describe their goals, how they accomplish their goals, the goal setting (PCP) process, and major accomplishments. We also collected information on participants' ages and gender. We adapted interview questions to account for different communication abilities and capacities of persons supported. In line with previous qualitative studies and guidelines on conducting interviews with people with intellectual and developmental disabilities or who are non‐verbal, we used visual aids as concrete reference tools, adjusted the depth of questioning, used secondary confirmatory sources, allowed participants to choose the location for their interviews, adjusted question format and wording and allowed participants to communicate in the way they were most comfortable (Cambridge and Forrester‐Jones [<reflink idref="bib3" id="ref22">3</reflink>]; Emerson et al. [<reflink idref="bib10" id="ref23">10</reflink>]; Hollomotz [<reflink idref="bib15" id="ref24">15</reflink>]; Mitchell et al. [<reflink idref="bib22" id="ref25">22</reflink>]). Participants received a $25 gift card of their choosing for taking part in an interview.</p> <p>Persons‐supported had a range of cognitive and communication abilities, so PHSS support staff were present for and assisted with the interviews as needed. PHSS staff support during the interviews included interpreting for the person‐supported or conveying their answers (e.g., sign language for deaf participants, interpreting communication boards for non‐verbal participants). In some interviews, PHSS staff would take a more active role, for example suggesting topics or ideas for the person‐supported to agree or disagree with by saying 'yes' or 'no' in cases where participants had limited verbal communication. PHSS staff also often provided visual aids to refer to during the interview, such as photos of past activities or the person‐supported's PCP to serve as reference aids.</p> <hd id="AN0186163447-6">Data Analysis</hd> <p>The interviews were approximately 30 min long. We conducted interviews in‐person or over Zoom (Zoom Video Communications Inc.). Interviews were audio‐recorded and transcribed verbatim. Three members of the research team independently read two transcripts to identify key words and codes, from which we developed a unified coding template. We used the unified coding template and NVivo 12 (QSR International) to code all of the transcripts and field notes. We resolved any coding disagreements through discussion and consensus.</p> <p>We pre‐tested interview questions with PHSS partners, confirmed meaning with participants in interviews, used an interviewer who had previous experience working with people with intellectual and developmental disabilities, and used an experienced transcriptionist (Berg [<reflink idref="bib2" id="ref26">2</reflink>]; Creswell [<reflink idref="bib5" id="ref27">5</reflink>]). In interviews conducted with the assistance of a PHSS support worker, we edited quotes (demarcated with square brackets) to appear in first person from the perspective of the persons supported expressing their own thoughts rather than the support worker acting as their intermediary. We conducted 15 interviews in person to observe participant body language and observed participants who indicated agreement with statements made by support staff on their behalf (e.g., nodding, smiling, etc.). Further, we often used visual aids such as a copy of the person supported's PCP or photos of activities the person‐supported had participated in to physically point to as a reference point for participants. We used these two additional sources of information to assess the degree to which support staff statements aligned with person‐supported sentiments. The level of support offered by the support staff during the interviews varied heavily between individuals. For many persons‐supported, support staff served exclusively in a communication capacity (e.g., using sign language with a deaf participant, saying words out loud from a non‐verbal participant who is using a communication tray). We recorded observations of the supports, interactions between support staff and participants, and participants' level of agreement in our field notes which we used to contextualise quotes during the analysis. Further, we used member checking to clarify meaning with participants (Creswell [<reflink idref="bib5" id="ref28">5</reflink>]); for example, the interviewer would verbally summarise or paraphrase participant answers, and ask whether the summary was correct. Quotes from participants who were assisted by a support worker during the interview are noted by an A (e.g., PS01A).</p> <hd id="AN0186163447-7">Ethics</hd> <p>There were unique challenges of conducting research with persons‐supported with intellectual and developmental disabilities; for example, obtaining informed consent, conducting interviews with non‐verbal participants, and confidentiality when staff members supported the interviews. Including persons‐supported with intellectual and developmental disabilities in our study aligns with the values of inclusivity, participation, and the 'Nothing About Us Without Us' principles of including and engaging persons with disabilities (United Nations [<reflink idref="bib29" id="ref29">29</reflink>]). We received approval from the relevant research ethics board associated with our institution. Prior to the interviews, we received informed consent from all participants. Interview data were stored securely, all sensitive documents were password protected, and all transcripts were de‐identified. Given the small number of persons‐supported by PHSS, we limited the demographic information collected and presented about participants to decrease the likelihood of participants being identified. Quotes from participants who were assisted by a support worker during the interview are noted by an A (e.g., PS01A).</p> <hd id="AN0186163447-8">Positionality</hd> <p>The authors are primary care and health services researchers, along with community care organisation executives and community care consultants. Using a pragmatic approach, we designed the study to understand the experiences of persons supported in person‐centred planning and how these plans are incorporated into their daily lives and support planning. We recruited participants from the organisation with various abilities and support needs and asked about their experiences with person‐centred planning in a community care setting. Through discussion of findings and their interpretation, we arrived at conclusions that reflect our individual views and data gathered from study participants.</p> <hd id="AN0186163447-9">Results</hd> <p>We interviewed 19 participants including 18 persons‐supported and one family member between June and September 2022. Persons‐supported were between 21 and 68 years of age. Fifteen of the interviews with persons‐supported (<emph>n</emph> = 78.9%) were facilitated by a support worker or had a support worker present. Nine participants were women (<emph>n</emph> = 47.3%). Two participants (<emph>n</emph> = 10.5%) attended the PHSS day program, while the rest were supported full‐time by PHSS. We describe three overarching themes: participants' experiences with the PCP creation process, linking goals to activities, and the documentation and tracking of goals. Based on post‐interview debriefings and review of field notes throughout data collection, we had reached data saturation (i.e., sufficient data had been collected to allow for rigorous analysis) (Berg [<reflink idref="bib2" id="ref30">2</reflink>]; Creswell [<reflink idref="bib5" id="ref31">5</reflink>]).</p> <hd id="AN0186163447-10">PCP Creation Process</hd> <p>As part of the PCP creation process, participants described the PCP creation meeting, the people involved in the creation of the PCP, the goal‐setting process and the dynamic and flexible nature of the process.</p> <hd id="AN0186163447-11">PCP Creation Meeting</hd> <p>The PCP creation process is focused on the individual person‐supported's needs, starting with the initial meeting to create the plan. Referred to as a 'meeting' or sometimes 'celebration', the person‐supported meets with staff, family members and friends to list their strengths, qualities, likes and goals in order to create the PCP. One participant described the process:</p> <p>...that it's kind of like a party, a celebration ... [I] like that it's collaborative...[I] can have friends and family's input, but ultimately, it's like [my] decision as to where [I] want to go. ... We talk about...where [my] skills are and where [I] have all these gifts in certain areas ... And then sometimes people come up with different ideas based on their connections [to me] during those meetings. [PS11A]</p> <p>The PCP creation meeting is an opportunity not only to create a new PCP and establish new goals, but also to celebrate previous accomplishments and to look at what elements from the previous plan were accomplished or worked well:</p> <p>we kind of celebrated the things that [I]'ve already accomplished from years before. [I] kind of went through the things – And that was fun, talking about other goals that [I]'d already achieved. Yeah. And this year wasn't quite as exciting because we had COVID. So, [I] didn't have quite as many things that [I] could say or check off our list. [PS01A]</p> <p>Participants described the PCP creation meeting as an opportunity to celebrate their favourite things and their accomplishments. The meetings often include the person‐supported's favourite foods, and decorations that they choose. Several participants described the food they had at their PCP creation meetings, including one who took pride in the fact they made cupcakes: '<emph>And [I made cupcakes] for all [my] guests</emph>' [PS04].</p> <hd id="AN0186163447-12">People Involved</hd> <p>The PCP creation process directly involves people in the person‐supported's life. PCP creation meetings include the person‐supported's family members, friends, roommates, support staff and community members. Persons‐supported often had many people attend the PCP creation meeting; '<emph>[My] sister‐in‐law, ... my roommate. And [Name], my staff.... [My] friend [Name] who joined on Zoom...he couldn't be there but he says, "I'm not missing that. Get me on a Zoom"</emph>' [PS04]. Involving many people from the person‐supported's life in the PCP process helped to situate the person‐supported within their social network and community. Involving many people in the PCP process allowed them to provide input and to suggest ideas for the person‐supported to incorporate into their PCP:</p> <p>But typically, [I] would have close friends and family and whatever staff would like to attend. [We] would set that up and then it's kind of like a big party. And [I] have food and there's decorations and everything and it's kind of all about [me]...Everybody can input things [I] like. [I have] different connections from all over...[my] church friends... [and] they might be able to chime into and say, 'oh, you didn't want to do this goal' or 'hey, you really like to do this.' [PS07A]</p> <p>Including people outside the organisation in the PCP development process reinforces family and social connections and their investment in the process, so that they can help persons‐supported implement their PCP and achieve their goals.</p> <hd id="AN0186163447-13">Goal‐Setting Process</hd> <p>The PCP goal‐setting process can take different forms, but most commonly involves a facilitator who helps to direct the PCP creation meeting. The facilitator guides people attending the process to identify the person‐supported's passions, interests, gifts and talents: '<emph>... all of [my] passions we got together as a team and we went through ... all [my] gifts and talents</emph>' [PS01A]. Beginning with the person‐supported's interests, talents and gifts, the facilitator helps the person‐supported identify priorities and specific goals for the coming year. From there, the plan includes specific ways the person‐supported can achieve those goals:</p> <p>And then when we come up with [my] goals, [I] kind of say what means most to [me] and then [I] kind of prioritize what that list looks like. And then we come up with some action plans as to like, how to achieve those goals... when [I] say I want to play bocce again, what [are my] goals? Do [I] want to become a member of the club again? Do [I] want to travel [to play]? [PS10]</p> <p>The goals identified in the PCP creation meeting are then further developed to outline the steps needed to achieve them, and the ways in which these goals can be integrated into the person‐supported's everyday life. Staff as well as friends and family give input into this stage of the PCP creation process: '<emph>[in the meeting] it's not just [my] goals, it's 'how to make those goals happen'...And the people that could be involved... [my staff] helps [me] with those goals, helps [me] ‐develop them</emph>' [PS11].</p> <p>This highlights the importance of a skilled facilitator to assist in developing achievable goals, broken down into manageable steps, for each person‐supported. Broad goals or those lacking specificity could produce anxiety if they cannot be achieved.</p> <hd id="AN0186163447-14">Dynamic and Flexible Nature of the Planning Process</hd> <p>While each PCP is unique and tailored to the person‐supported, the PCP planning process itself is also dynamic, flexible, and tailored to the individual person‐supported's desires and needs. The PCP creation meeting usually involves a facilitator writing ideas on a big chart paper, but this can vary depending on the individual and the year:</p> <p>We talked about it, we wrote it and... we've had a [PCP facilitator]in the past where she's used the big [poster] paper or whatever you want to call it.... [we] didn't this year, we just kind of talked all about it and came up with different ideas and talked about what [I] wanted to do and what [I] wanted to work on. [PS12A]</p> <p>Not all persons‐supported choose to participate in a full PCP planning meeting. Instead, some persons‐supported prefer to create goals more spontaneously, while others choose to set their goals and annual plans in a smaller setting, without the formal structure of a full PCP creation meeting. One person‐supported who did not participate in a full PCP reflected on his reasons for changing the process:</p> <p>[I have] chosen not to do a full person‐centered plan. [I] prefer sitting down and having more of a one‐on‐one annually and, regarding goals, [I'm] fairly independent and [I] direct all of [my] own care. So, [I] will sit down with [my support worker] on an annual basis and talk about what [my] goals are for the next year and then we write them out and we talk to the staff team to try to help... obtain those goals. [PS10]</p> <p>Similarly, the person‐supported observed:</p> <p>[I]t feels a little bit remedial to [me] to have somebody up there artistically drawing, telling [me], hovering over [me] [and saying, 'here's your talents'... [I] prefer more of a [direct] approach. So, that's something that [I] would change about the process and [I] did change. [PS10]</p> <p>This individualised approach to the planning process allows for further autonomy, self‐determination and dignity for the persons‐supported.</p> <hd id="AN0186163447-15">Linking Goals to Activities</hd> <p>The types of goals included in a PCP are varied and can include anything from improving a person‐supported's health to travel plans. The three main categories of PCP goals were: health goals (e.g., improving mobility), goals for daily living (e.g., being active, help around the house) and goals for hobbies and interests (e.g., planning a trip, playing music). Some goals could be included in multiple categories.</p> <p>Health goals often included specific activities for the person‐supported to undertake on a day‐to‐day basis to improve their overall health, such as walking more, attending physiotherapy programs or attending doctors' appointments. One person‐supported identified recent accomplishments and goals specific to his health:</p> <p>So, a lot of [my] accomplishments as of late have been a little bit more health‐related. Getting back to doing more walking... then bloodwork and appointments are a little stressful for [me], and...[I've] worked really hard on being able to have a lot of that done in a shorter period of time. [PS03A]</p> <p>PCP goals for daily living included becoming more independent and doing more housekeeping, such as cooking, or putting laundry away. One person‐supported emphasised that they'd like to include more goals in their PCP related to things they do every day:</p> <p>What would [I] like included for everyday stuff? Like the stuff [I] do around [my] house or day‐to‐day things ... That's what [I'm] proudly doing independently, like [my] laundry and [my] cooking and carrying all that stuff around and helping put stuff away ... [I] get really pumped about being independent and doing that [myself]. [PS14A]</p> <p>Most PCP goals were exclusively for interests and hobbies, and many PCPs only included interest and hobby goals. These goals were often related to music, art, sports or volunteering. One person‐supported described their goals for singing and music, and the regular activities needed to realise these goals:</p> <p>[I] look for places that [I] can do karaoke. [I] look at some of the concerts that are coming up and some of the plays... [I'm] on [my] iPad every day researching.</p> <p>... in March, [I] came across this competition – I had a staff that was a student and [PHSS was] going to hire him. He has a guitar. [I] write music, so he was able to put music to [my] words. We recorded it and sent it in for the competition. [PS19A]</p> <p>Many goals did not fall into one specific category and were related to both interests and hobbies, as well as contributing to overall health. One person‐supported described many sports and activities that contributed to his goal of being active and improving his mobility:</p> <p>[My] goals are to be active. [I] like to be active, ... [I'm] very sporty in doing that kind of stuff and in the sense of being active, it would be like mobility, working on mobility and swimming, sports, baseball, that kind of stuff.... [I] really enjoy the outdoors and that kind of stuff as well, right? So, like, fishing day trips to [local beaches], nature hikes, [park], which is a local place just outside [city] where we go fishing weekly. [PS02A]</p> <p>PCP goals are integrated into daily activities, and a schedule depicting the person‐supported's average week is often included in the PCP. In this way, PCPs serve as a blueprint for staff in enacting the goals in regular planning. A single PCP goal, especially if it is broad, can have multiple activities associated with it. For example, a PCP goal of 'being active' can include a number of fitness and sports‐related activities the person‐supported participates in on a regular basis: '<emph>...[my] being active goal... [led to] the bike.... And – Zumba! ... [and] Spirit Club. That's fun. And then boxing with [Name]... The [YMCA], ... swimming</emph>' [PS01A]. Some PCP goals, particularly bigger ones, are broken down into steps to help track and ultimately achieve them. A person‐supported described the steps she took to fulfil her PCP goal of getting a cat: '<emph>one goal one year was to get a cat...[I] had to have money [to pay for] the cat [and supplies] ... then [I] had to go shopping for the cat supplies. [I] had to take the cat to the vet to make sure that he was up‐to‐date with shots</emph>' [PS12A]. PCPs include a variety of activities that combine goals and match them to a person‐supported's specific likes, interests and ambitions. For example, a person supported described how activities related to his love of sports were combined with a broader goal of getting out into the community: '<emph>...another one of [my goals ... would have been to go out into the community more, or let's say, to visit places I've never been.... So, it would be like, ... go to a [professional baseball team] game and whatnot</emph>' [PS07].</p> <hd id="AN0186163447-16">Goal Documentation and Tracking</hd> <p>PCPs are kept in a binder by PHSS staff coordinators who help facilitate PCP implementation, with a copy given to the person‐supported. This allows the staff and persons‐supported to be reminded of the goals and to work on implementing PCPs collectively ('<emph>we keep them in a binder and [they] give [me] a copy ...and we work on them together</emph>' [PS19A]) which facilitates accountability in both staff and persons‐supported for realising these goals. Some persons‐supported track their goals on boards in their houses, writing out PCP goals to have a highly visible daily reminder of what they were working towards. Goals were further broken down into categories or even seasons:</p> <p>[Me] and [my] roommate worked on the board and wrote down everything that [we] wanted to do like, for the year, but broke it down specifically for this summer... So [I] wrote down the beach. So, then [we] went to the beach. [PS04]</p> <p>PCPs are revisited at a formal check‐in point 6 months after the annual PCP creation meeting. This gives the person‐supported and their support staff the opportunity to revisit the plan, make changes and see what goals have not been achieved and need to be worked on. One participant described their check‐in as an opportunity to see if they wanted to change any of their goals:</p> <p>We do [a] check‐in, we kind of just discuss the goals to see where we're at. And then to see if we need to take any off or change them, because sometimes that happens too, where the goals change... And then, you know, maybe [I don't] want to move on [my] own, for example. Or maybe [I] want to do something different, then we change them at that time. [PS12A]</p> <p>Many persons‐supported reflected on the PCP process as a valuable tool for creating structure, ensuring accountability and facilitating goal attainment. They reflected that the PCP sets the foundation for achieving their goals:</p> <p>[The PCP] helps add structure and helping these things come to happen. So, like talking about the Blue Jay [baseball] game... [The PCP lays] the foundation stone for that to happen...[it] just keeps everybody on the same page. And it's [the PCP] something to refresh our minds...To go back to and be like, 'oh yeah, we haven't hit this yet, how can we make this happen?' [PS01A]</p> <hd id="AN0186163447-17">Discussion</hd> <p>Using qualitative interviews with persons‐supported, we describe how PCPs are created and linked to activities in persons‐supported's lives at PHSS. PCPs are holistic and can address multiple goals related to a person‐supported's health, daily functioning and personal preferences or interests. At PHSS, PCPs create a roadmap for staff and persons‐supported to organise regular activities and identify smaller steps that lead to the larger overarching goals. The activities and goals are tailored to the person‐supported's capacity, interests and preferences. Findings are consistent with the process and values identified by support staff at PHSS (Dong et al. [<reflink idref="bib7" id="ref32">7</reflink>]), with very little overlap in the support staff who participated in the study and those who supported persons‐supported during interviews.</p> <p>The meeting to create a PCP is an expression of the individuals themselves and which is reflected in the type of event (e.g., party), theme or food of the person's choice. The meeting and process itself takes many forms and incorporates the person‐supported's preferences. As seen in the data, the meetings and process can be formal or informal, involve many or few people, and document goals in a myriad of ways. It is also dynamic and regularly revisited and updated as goals are realised or re‐imagined. Consistent with the literature (Espiner and Hartnett [<reflink idref="bib12" id="ref33">12</reflink>]; Martin et al. [<reflink idref="bib20" id="ref34">20</reflink>]; Tondora et al. [<reflink idref="bib28" id="ref35">28</reflink>]), documentation and referral to the PCP serves to motivate and hold both persons‐supported and PHSS staff accountable for progress towards identified goals.</p> <p>Like other community care organisations (Espiner and Hartnett [<reflink idref="bib12" id="ref36">12</reflink>]; Idrees et al. [<reflink idref="bib16" id="ref37">16</reflink>]), PCP creation at PHSS involves not only the person‐supported but also their friends, family, support staff, broader community members and often, a facilitator. The inclusion of a variety of individuals who know the person‐supported is critical, especially for persons‐supported who may be non‐verbal or have mental health challenges such as anxiety or challenging behaviours (McCausland et al. [<reflink idref="bib21" id="ref38">21</reflink>]; Ottmann and Mohebbi [<reflink idref="bib23" id="ref39">23</reflink>]). For persons‐supported with these challenges, family members and long‐term support workers accustomed to non‐verbal cues play an important role in identifying their goals and interpreting their preferences (Idrees et al. [<reflink idref="bib16" id="ref40">16</reflink>]). The high turnover of support workers in the community care sector is a barrier to the implementation of PCPs (Engen et al. [<reflink idref="bib11" id="ref41">11</reflink>]; Idrees et al. [<reflink idref="bib16" id="ref42">16</reflink>]; McCausland et al. [<reflink idref="bib21" id="ref43">21</reflink>]). PCPs, however, have been suggested to promote staff retention by providing a means for staff to engage in meaningful work (Dong [<reflink idref="bib8" id="ref44">8</reflink>]).</p> <p>PCPs provide a map for a person‐supported's activities. In contrast to traditional planning which focussed on addressing deficits (Persons with Developmental Disabilities Central Alberta Community Board [<reflink idref="bib24" id="ref45">24</reflink>]), PCPs at PHSS are capacity‐driven and focus on a person‐supported's talents, passions and personal goals. Health and daily living goals are identified by persons‐supported themselves and are enacted with the aim of increasing individual capacity and independence. Moreover, health and daily living goals are implemented within a holistic approach and are often layered with hobby and personal interest goals in alignment with the personality and preferences of the person‐supported. Rather than target specific behaviours, activities inform life arrangements. The PCPs lead to a set of interconnected, complementary and ongoing activities so that the person‐supported's lifestyle (i.e., the way in which the person lives) reflects their goals, personalities and capacity.</p> <hd id="AN0186163447-18">Strengths and Limitations</hd> <p>This paper has several limitations. We only interviewed persons‐supported at a single organisation in Southwestern Ontario, so results may not be typical of other organisations, particularly if they provide different types of support from PHSS. Furthermore, many interviews involved a PHSS staff member interpreting or answering on behalf of the person supported, which highlights the challenges of involving individuals with intellectual and developmental and/or physical disabilities in qualitative research. These methods required us to diverge from conventional approaches that assume that participants can independently access, understand, and respond to study invitations. These adaptations required us to negotiate procedures with the research ethics board that balanced principles of autonomy and confidentiality with inclusivity. Given the staff presence during many of the interviews, our findings may represent more positive examples or acquiescence of persons supported during the interviews (Hollomotz [<reflink idref="bib15" id="ref46">15</reflink>]). Staff‐mediated responses could influence person‐supported responses to be more positive, or to focus on themes and topics that the person supported may not have chosen themselves. Persons‐supported may not feel comfortable being critical of the PCP process, particularly since support staff are involved in plan creation and implementation. Notably, one person supported said they did not want a PCP and ended the interview. Future studies examining PCPs involving methods such as an institutional ethnography or observational components would be beneficial for a more comprehensive understanding of the effects of the person‐centered planning process.</p> <hd id="AN0186163447-19">Conclusions</hd> <p>This project described the PCP process at PHSS, a community care organisation based in London, Ontario, Canada. The PCP planning meeting involves persons‐supported and their friends, family, support staff, and broader community members who identify goals related to their health, daily functioning and personal preferences or interests. PCPs provide the blueprint for a person‐supported's activities and motivate and hold persons‐supported and PHSS staff accountable for progress towards identified goals. The study findings address the gap in the literature on the creation and implementation of PCPs from the perspective of persons‐supported and provide insight into the ways PCPs can shape their capacities and lifestyle.</p> <hd id="AN0186163447-20">Author Contributions</hd> <p>G.Y. was involved in the formal analysis, investigation and the writing of the original manuscript draft. M.M. conceived of the study, acquired funding, supervised the project, oversaw the methodology and the writing of the original manuscript draft. L.M. was involved in project administration, methodology and reviewed and edited the manuscript. S.L.S. acquired funding and reviewed and edited the manuscript. D.R. was involved in the curation of data, methodology and reviewed and edited the manuscript.</p> <hd id="AN0186163447-21">Acknowledgements</hd> <p>We would like to thank Donnie Antony, Ruth Armstrong and Brian J. Dunne for their important contributions to this project.</p> <hd id="AN0186163447-22">Disclosure</hd> <p>The funders had no role in the research process.</p> <hd id="AN0186163447-23">Ethics Statement</hd> <p>This study received approval from Western University's Health Sciences Research Ethics Board (Project ID 120382). All participants provided informed consent prior to participating in the study.</p> <hd id="AN0186163447-24">Consent</hd> <p>The authors have nothing to report.</p> <hd id="AN0186163447-25">Conflicts of Interest</hd> <p>The authors declare no conflicts of interest. PHSS was involved in the conceptualisation and design of the study, and recruitment of participants, but to limit their potential influence on study findings were not aware of participant identities or involved in the coding of transcripts.</p> <hd id="AN0186163447-26">Data Availability Statement</hd> <p>The data analysed during this study are not publicly available due to the need to maintain participant confidentiality; however, a portion of these data may be available from the corresponding author on reasonable request.</p> <ref id="AN0186163447-27"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Funding: This work was supported by the Canadian Institutes of Health Research (CIHR) (QAE 180992).</bibtext> </blist> </ref> <ref id="AN0186163447-28"> <title> References </title> <blist> <bibtext> Administration for Community Living. n.d. 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  Data: Person-Centred Plans from the Perspective of Persons-Supported in a Community Care Setting: A Qualitative Study
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  Data: English
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  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Gillian+Young%22">Gillian Young</searchLink> (ORCID <externalLink term="https://orcid.org/0009-0005-7120-219X">0009-0005-7120-219X</externalLink>)<br /><searchLink fieldCode="AR" term="%22Maria+Mathews%22">Maria Mathews</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-5174-104X">0000-0002-5174-104X</externalLink>)<br /><searchLink fieldCode="AR" term="%22Leslie+Meredith%22">Leslie Meredith</searchLink> (ORCID <externalLink term="https://orcid.org/0009-0007-1338-6474">0009-0007-1338-6474</externalLink>)<br /><searchLink fieldCode="AR" term="%22Shannon+L%2E+Sibbald%22">Shannon L. Sibbald</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-4328-6489">0000-0002-4328-6489</externalLink>)<br /><searchLink fieldCode="AR" term="%22Dana+Ryan%22">Dana Ryan</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0001-7949-8849">0000-0001-7949-8849</externalLink>)
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Applied+Research+in+Intellectual+Disabilities%22"><i>Journal of Applied Research in Intellectual Disabilities</i></searchLink>. 2025 38(3).
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  Data: Wiley. Available from: John Wiley & Sons, Inc. 111 River Street, Hoboken, NJ 07030. Tel: 800-835-6770; e-mail: cs-journals@wiley.com; Web site: https://www.wiley.com/en-us
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  Data: 8
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  Data: 2025
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  Data: Journal Articles<br />Reports - Research
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  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Community+Health+Services%22">Community Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Planning%22">Planning</searchLink><br /><searchLink fieldCode="DE" term="%22Models%22">Models</searchLink><br /><searchLink fieldCode="DE" term="%22Integrated+Activities%22">Integrated Activities</searchLink><br /><searchLink fieldCode="DE" term="%22Caregivers%22">Caregivers</searchLink><br /><searchLink fieldCode="DE" term="%22Client+Characteristics+%28Human+Services%29%22">Client Characteristics (Human Services)</searchLink><br /><searchLink fieldCode="DE" term="%22Individualized+Programs%22">Individualized Programs</searchLink>
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  Label: Geographic Terms
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  Data: <searchLink fieldCode="DE" term="%22Canada+%28London%29%22">Canada (London)</searchLink>
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  Label: DOI
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  Data: 10.1111/jar.70084
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  Group: ISSN
  Data: 1360-2322<br />1468-3148
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: In partnership with PHSS, a community care agency in London, Ontario, we describe the person-centred planning model. Person-centred plans (PCPs) are mandated in the community care sector and created annually through discussions with the person-supported, staff, family/friends and community members. PCPs are individualised, integrated into daily activities and contribute towards larger goals. Methods: We interviewed 18 persons-supported and one family member. Participants were individuals with developmental, medical, or complex physical needs and supported by PHSS. We explored goals, accomplishments, the individualisation of PCPs, experiences with the process, and supports/barriers. Results: PCPs are tailored to the person-supported's needs and preferences, linked to daily activities, and guide larger goals. PCPs are facilitated by the person-supported's goals and capacity and organisational factors (e.g., funding, staffing). Conclusions: This study evaluates person-centred planning from the perspectives of persons-supported, providing insights to enhance these processes within community care settings.
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  Data: 2025
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  Data: EJ1475041
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        Value: 10.1111/jar.70084
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 8
    Subjects:
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Community Health Services
        Type: general
      – SubjectFull: Planning
        Type: general
      – SubjectFull: Models
        Type: general
      – SubjectFull: Integrated Activities
        Type: general
      – SubjectFull: Caregivers
        Type: general
      – SubjectFull: Client Characteristics (Human Services)
        Type: general
      – SubjectFull: Individualized Programs
        Type: general
      – SubjectFull: Canada (London)
        Type: general
    Titles:
      – TitleFull: Person-Centred Plans from the Perspective of Persons-Supported in a Community Care Setting: A Qualitative Study
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Gillian Young
      – PersonEntity:
          Name:
            NameFull: Maria Mathews
      – PersonEntity:
          Name:
            NameFull: Leslie Meredith
      – PersonEntity:
          Name:
            NameFull: Shannon L. Sibbald
      – PersonEntity:
          Name:
            NameFull: Dana Ryan
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 05
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 1360-2322
            – Type: issn-electronic
              Value: 1468-3148
          Numbering:
            – Type: volume
              Value: 38
            – Type: issue
              Value: 3
          Titles:
            – TitleFull: Journal of Applied Research in Intellectual Disabilities
              Type: main
ResultId 1