Practical guide · Person-centered planning
Person-centered plan examples for adults with IDD.
Published 2026-10-28 · Updated 2026-10-29
A person-centered plan describes a person's life the way they want it and the support they need to live it. Medicaid HCBS rules set what the plan must contain, but the best plans read like they were written with the person, not about them. The examples below use an invented person, Alicia, and show sections many agencies use. Your state's form may name or order them differently.
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Key points
The short version.
- The person leads the plan; federal rules set what it contains.
- Start with a one-page profile anyone can read.
- Balance what is important to and for the person, with their agreement.
- Explain how the person communicates and their routines.
- Pair each risk with a support the person agreed to.
- Review at least every 12 months and when things change.
01 · Person-centered planning
What the plan must include.
Federal HCBS rules (42 CFR 441.301(c)(2)) require the person-centered service plan to reflect the items below, commensurate with the person's needs. The planning process is led by the person, with people they choose, and the plan is reviewed at least every 12 months and when needs change or the person asks.
- The setting the person chose to live in.
- Strengths and preferences.
- Clinical and support needs from an assessment of functional need.
- Goals and desired outcomes the person identified.
- Paid and unpaid services and supports for those goals.
- Risk factors and measures to reduce them, including backup plans.
- Plain language the person understands, and who monitors the plan.
- Informed consent in writing, signed by the people responsible for carrying it out, and copies to those involved.
02 · Person-centered planning
Example: a one-page profile.
Many plans open with a one-page profile that anyone can read before working with the person.
What people like and admire about Alicia: "Funny, great memory for birthdays, loyal friend, hard worker at the bakery." What's important to Alicia: "Her Saturday phone call with her mom; her cat, Pepper; country music while getting ready; working mornings, not afternoons." How to support Alicia well: "Give her a heads-up before plans change; let her choose her own clothes; speak to her, not to staff about her; remind her about her inhaler before walks, quietly."
03 · Person-centered planning
Example: important to and important for.
Person-centered practice separates what is important to the person, what makes their life good from their view, from what is important for them, such as health and safety. A good plan finds a balance the person agrees with instead of letting one replace the other.
Important to Alicia: "Coffee with sugar at the bakery break." Important for Alicia: "Keeping her blood sugar in the range her doctor set." Balance in the plan: "Alicia chose to switch to one sugar and to walk to the bakery; staff track her readings as her doctor asked and share them with her each week."
04 · Person-centered planning
Example: how Alicia communicates.
A communication chart helps new staff understand the person quickly.
"When Alicia goes quiet and holds her necklace, it usually means she is anxious; we should ask if she wants a break and offer her headphones." "When Alicia says 'later' to an activity, it usually means no; we should accept that and offer it again another day."
05 · Person-centered planning
Example: routines and preferences.
Describe a good day in the person's own order, so staff support it instead of replacing it with a house schedule.
"Alicia wakes at 6:00 a.m. without an alarm, feeds Pepper first, then showers. She likes to pick her outfit the night before. She takes the 7:15 bus to work and texts staff when she arrives."
06 · Person-centered planning
Example: a risk with the support that reduces it.
Name each risk, the support that reduces it and how it respects the person's choices.
"Risk: Alicia has asthma, and cold air and long walks can bring on attacks. Support: Alicia carries her inhaler in her bag; staff quietly check she has it before outings. If she has trouble breathing, staff follow her asthma action plan from her doctor and call 911 if her rescue inhaler does not help. Alicia agreed to this support."
07 · Person-centered planning
Example: unpaid supports and a backup plan.
List the people and resources in the person's life, not only paid services, and what happens when a support is not available.
"Unpaid supports: her mom calls every Saturday; her neighbor drives her to church on Sundays. Backup plan: if her ride to church is unavailable, staff offer a bus trip with support or a video-streamed service, and Alicia chooses."
08 · Person-centered planning
Write it with the person.
Use plain language and the person's own words where you can. Write "Alicia wants" rather than "the consumer will." Avoid jargon and labels, and read the plan back to the person before it is signed.
Any limit on the person's rights in a provider-controlled home is not a preference or a routine. It belongs in the plan only with the documentation the HCBS settings rule requires.
09 · Person-centered planning
How do you run a person-centered planning meeting?
You run it as the person's meeting: they choose who comes, when and where it happens and what gets talked about first. Federal rules say the process should be timely and happen at times and places convenient to the person. Most of the real work happens before and after the meeting itself.
Before the meeting, ask the person what they want to talk about, who they want there and who they do not. Gather what is working and not working from the person, their family and staff. Share any paperwork early, in plain language, so nobody sees it for the first time at the table.
During the meeting, start with what people like and admire about the person and what is going well. Let the person speak first on each topic and give them time to answer. Write goals in their words, and when the team disagrees, come back to what the person wants and what would make it possible.
After the meeting, read the draft back to the person, fix what they say is wrong and collect signatures from the people responsible for carrying it out. Share copies, train staff on what changed and set a date to check how it is going.
- Before: the person picks the people, time, place and topics.
- During: strengths first, the person speaks first, goals in their words.
- After: read it back, sign, share, train staff and set a check-in.
10 · Person-centered planning
How do you include someone who doesn't use words?
You include them by learning how they already communicate and planning around it, not by talking about them in their absence. Everyone communicates something through behavior, expressions, sounds, signs, pictures or a device, and the plan should be built from what they show.
Spend time with the person before the meeting in places they enjoy. Ask the people who know them best what a good day and a bad day look like, what they reach for, what they push away and how they say yes and no. Write those observations down as evidence of preferences.
In the meeting, use whatever helps the person take part: pictures, objects, a communication device, short sessions or a familiar room. Watch their reactions to choices and record them. If the person leaves or shows they are done, that is information too.
Example: "Daniel smiles and leans forward when music starts and pushes the plate away when he is full. The team offered two day program options by visiting both; Daniel stayed and laughed at the art studio and asked to leave the other within minutes. The team chose the art studio and will check again in three months."
11 · Person-centered planning
What is the difference between a person-centered plan and a care plan?
A person-centered plan is built around the life the person wants, while a care plan is usually built around a clinical or health need. A care plan often lists a diagnosis, treatments and tasks for staff. A person-centered plan includes those needs but starts with the person's goals, strengths, preferences and relationships.
The two should work together. If someone has a nursing care plan for diabetes or a seizure protocol, the person-centered plan should point to it and describe how that care fits the person's routines and choices. A health task that ignores the person's preferences is more likely to be refused or done badly.
The term used in your state may differ, and some agencies call every plan a care plan. What matters is whether the person led it and whether it covers the items federal HCBS rules require.
12 · Person-centered planning
What mistakes make a plan less person-centered?
The most common mistake is writing the plan about the person instead of with them. Others creep in slowly, often because forms are copied from last year or written to satisfy a reviewer rather than the person.
A quick test helps: read the plan aloud to the person. If they would not recognize themselves in it, or if it would read the same for anyone else in the home, it needs more of them in it.
- Goals that are really staff tasks, such as "will take medications as prescribed."
- The same goals and wording copied year after year without asking the person.
- House rules written as if they were the person's preferences.
- Only paid services listed, with no friends, family or community supports.
- Risks that crowd out everything the person wants to try.
- Labels and jargon the person cannot read or would not use about themselves.
- A meeting held when and where it suits staff, not the person.
- A finished plan nobody shares with the staff who work with the person.
13 · Person-centered planning
How should staff use the plan day to day?
Staff should use the plan as a working guide for each shift, not a document they read once at hiring. The one-page profile, communication chart and routines tell them how to support the person today, and the goals tell them what to work on and write about.
Good habits help. Read the one-page profile before working with someone new. Check for changes at shift handoff. When writing a daily note, describe what the person did toward their goals and what they said or showed about how it went. Tell a supervisor when something in the plan no longer seems right.
Staff notice changes first. If the person keeps refusing an activity, makes a new friend or wants a different job, that should reach the planning team. Federal rules require the plan to be reviewed when needs change and when the person asks, and staff observations are often how that request starts.
14 · Person-centered planning
Keep the plan where support happens.
A plan only helps if the staff supporting the person know it. Keep it with the person's record, train staff on changes and connect daily notes to the goals in it.
LunahUP keeps the person's plan context, goals and supporting documents within reach of the staff documenting support. The person and their planning team decide what the plan says.
Questions people ask
Short answers.
What is the difference between a person-centered plan and an ISP?
They are names for the same kind of plan. States and agencies use ISP, individual service plan, person-centered support plan and other names for the plan Medicaid HCBS rules require.
Who leads a person-centered planning meeting?
The person leads, with support if they want it, and chooses who attends. A case manager or support coordinator usually facilitates and writes the plan with them.
Does a person-centered plan need signatures?
Yes. Federal HCBS rules require the person's informed consent in writing and signatures from the individuals and providers responsible for carrying out the plan.
How often is a person-centered plan updated?
At least every 12 months, when the person's needs or circumstances change significantly, and whenever the person asks.
Can family members be part of the plan?
Yes, if the person chooses. The planning process includes people the person chooses, and unpaid supports from family and friends belong in the plan.
Can the agency that provides services write the person-centered plan?
Usually not. Federal HCBS conflict-of-interest rules generally say providers of the person's HCBS may not develop their person-centered plan. A case manager or support coordinator usually does, and providers contribute what they know. Check your state's rules for any exceptions.
Where should a person-centered planning meeting be held?
Wherever suits the person. Federal rules say planning should be timely and happen at times and places convenient to the person. That might be their home, a cafe or a familiar program room, rather than an office chosen by staff.
What if the person disagrees with part of their plan?
Listen, record their view and revisit that part with them. Federal rules require a way for the person to request updates to their plan, and the plan needs their informed consent in writing. Your state's process explains how disagreements are resolved.
Sources
Check the official source.
Requirements change and differ by state. Confirm current rules with your state agencies and payers.
Keep the work connected
Related LunahUP workflows.
Start with one recurring task
Bring the plan your staff rarely open.
Inspect a fictional person record with plan goals, and a note prepared from staff facts against one of them.
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