Person-Centered, Informed Choice and Transition protocol

The purpose of the protocol is to ensure that lead agencies do service planning, implementation and quality review within a person-centered framework. It serves as a how-to guide for lead agency support planners to follow. 

The protocol provides guidance for support planners about what is good practice and what DHS expects. Going forward, all support plans must be based on person-centered principles and practices.

Regardless of their age or the program they participate in, the protocol applies to all children and adults who are eligible to receive support planning. Specifically, this includes the following people who use long-term supports and services: 

• Children and adults with disabilities
• Children and adults with mental illness 
• People older than 65 years old 
• Anyone from the above groups who also is transitioning from one residence to another.

(NOTE: This section is a clarification of Page 5 of the protocol (PDF) in the section "Who are the responsible parties?")

People at lead agencies (including contracted case managers) who plan supports and write support plans must follow the protocol. That includes:

• Adult mental health targeted case managers
• Children's mental health targeted case managers
• Developmental disabilities-vulnerable adult case managers
• Care coordinators 
• MnCHOICES certified assessors
• Relocation services coordinators
• Rule 185 case managers
• Waiver case managers.

DHS introduced the protocol March 4, 2016. The state intends for the entire system of long-term services and supports to be person-centered. 

Support planners must begin to use a person-centered approach to the planning they did and continue to do since the release of the protocol. Support planners should continue to develop plans at the times they normally would. All adults and children who receive services and supports can ask to update their plan when they want.

Support planners will need to learn more about person-centered practices and how to improve their skills. DHS expects the quality of plans to improve over time.

Mental health planning

DHS recommends lead agencies that provide children and adult mental health-targeted case management services integrate protocol standards into their policies, procedures and practices.

Lead agency review

During the lead agency review process, DHS reviews each lead agency’s case files for evidence of a person-centered approach. Beginning April 2017, DHS requires corrective action and remediation.  

Mental health process

The purpose of the review will be to provide technical assistance, consultation and to develop capacity to integrate protocol standards into policies, procedures and practices

Jensen class members

People who serve Jensen Class members already use person-centered plans. If, upon review, a class member’s plan does not meet person-centered planning standards, the respective lead agency must follow the requirements provided to them by the DHS Lead Agency Review team.

The protocol’s intent is not to add forms to the lead agency’s support-planning workflow. Rather, the intent is to incorporate a person-centered approach into the planners’ existing workflow. 

Part Two of the protocol does include one new requirement, however: The lead agency must work with a person who moves from one residence to another to create a move transition plan summary that clearly communicates key elements of the plan. DHS provides a template for this summary, My Move Plan Summary, DHS-3936 (PDF). 

See the "What resources exist for lead agencies?" section of the person-centered practices landing page for other optional tools for support planners.