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Life Planning Guide: For Home Sharing Providers in British Columbia
This guide establishes a scalable framework to ensure each person supported has a current, structured, and actionable life plan. The content is designed to streamline information management, reduce service risk, and support integrated decision making across the care ecosystem.
Section 1
Personal Profile and Socio Emotional Information
Purpose
Enable providers and professionals to maintain situational awareness of the person’s preferences, routines, community connections, support requirements, and indicators of emotional wellbeing.
Enable providers and professionals to maintain situational awareness of the person’s preferences, routines, community connections, support requirements, and indicators of emotional wellbeing.
Key Inputs
• Preferred name
• Cultural identity and community affiliations including Indigenous nation and urban Indigenous supports
• Communication style and preferred approach
• Strengths and interests
• Triggers and early warning indicators
• De escalation strategies
• Community involvement
• Personal goals
• Important relationships
• Spiritual or cultural practices including end of life considerations
• Preferred name
• Cultural identity and community affiliations including Indigenous nation and urban Indigenous supports
• Communication style and preferred approach
• Strengths and interests
• Triggers and early warning indicators
• De escalation strategies
• Community involvement
• Personal goals
• Important relationships
• Spiritual or cultural practices including end of life considerations
Key Questions
• Have there been changes or updates needed
• Who needs to be aware of this information
• Who would the person like to share the information with
• Has documentation been updated across all service partners
• Have there been changes or updates needed
• Who needs to be aware of this information
• Who would the person like to share the information with
• Has documentation been updated across all service partners
Section 2
Health Information
Purpose
Support continuity of care and enable rapid access to health intelligence for emergency teams, acute care, primary care, and transition planning.
Support continuity of care and enable rapid access to health intelligence for emergency teams, acute care, primary care, and transition planning.
Core Data Requirements
• BC Personal Health Number
• Doctors including primary care, specialists, nurse practitioners
• Health history summary
• Current diagnoses including mental health and neurodevelopmental conditions
• Health records including hospital discharges, consult letters, testing
• Ongoing conditions and care responsibilities
• Medication list with dosage and administration instructions
• Immunizations
• Supplements and herbal supports
• Assistive devices (including contacts for wheel chair)
• Allergies and adverse reactions
• Health authority affiliation and care team contacts
• Pharmacy information
• Dental care provider
• Vision care provider
• Hearing supports including audiologist
• First aid and rapid response considerations
• Infection control needs
• BC Personal Health Number
• Doctors including primary care, specialists, nurse practitioners
• Health history summary
• Current diagnoses including mental health and neurodevelopmental conditions
• Health records including hospital discharges, consult letters, testing
• Ongoing conditions and care responsibilities
• Medication list with dosage and administration instructions
• Immunizations
• Supplements and herbal supports
• Assistive devices (including contacts for wheel chair)
• Allergies and adverse reactions
• Health authority affiliation and care team contacts
• Pharmacy information
• Dental care provider
• Vision care provider
• Hearing supports including audiologist
• First aid and rapid response considerations
• Infection control needs
Key Questions
• Are the important records together and organized
• Are updates required due to medication changes, behavioural presentation shifts, or new diagnoses
• Are all professionals aware of current information
• Were updates completed across primary care and CLBC systems
• Are the important records together and organized
• Are updates required due to medication changes, behavioural presentation shifts, or new diagnoses
• Are all professionals aware of current information
• Were updates completed across primary care and CLBC systems
Section 3
Legal and Decision Making Information
Purpose
Ensure alignment with provincial legislation and confirm clarity on who is authorized to make decisions, what limitations apply, and where critical documents are stored.
Ensure alignment with provincial legislation and confirm clarity on who is authorized to make decisions, what limitations apply, and where critical documents are stored.
Required Documentation
• Identification including BCID or drivers license
• Social Insurance Number
• Passport
• Representation Agreement including Section 7 or Section 9 where applicable
• Enduring Power of Attorney
• Power of Attorney
• Temporary Substitute Decision Maker
• Public Guardian and Trustee involvement if applicable
• Committee of Person and Committee of Estate (where court appointed)
• Wills and estate planning
• Legal guardianship orders
• Medical Orders for Scope of Treatment
• Advance Care Plan including goals of care designations
• Greensleeve information (Vancouver Coastal and Island Health)
• Palliative care instructions
• Funeral, burial, cremation instructions
• Digital assets and online account access plan
• Identification including BCID or drivers license
• Social Insurance Number
• Passport
• Representation Agreement including Section 7 or Section 9 where applicable
• Enduring Power of Attorney
• Power of Attorney
• Temporary Substitute Decision Maker
• Public Guardian and Trustee involvement if applicable
• Committee of Person and Committee of Estate (where court appointed)
• Wills and estate planning
• Legal guardianship orders
• Medical Orders for Scope of Treatment
• Advance Care Plan including goals of care designations
• Greensleeve information (Vancouver Coastal and Island Health)
• Palliative care instructions
• Funeral, burial, cremation instructions
• Digital assets and online account access plan
Key Questions
• Have the documents been signed and remain legally valid
• Has anything changed in decision making authority
• Who needs copies for compliance and operational readiness
• Are all professionals working with current versions
• Have the documents been signed and remain legally valid
• Has anything changed in decision making authority
• Who needs copies for compliance and operational readiness
• Are all professionals working with current versions
Section 4
Financial Information
Purpose
Mitigate risk, maintain fiduciary compliance, and support transparent financial stewardship.
Mitigate risk, maintain fiduciary compliance, and support transparent financial stewardship.
Required Information
• Banking information
• Credit card information
• CPP and OAS details
• Pension details
• Disability assistance information
• Registered Disability Savings Plan
• Trust fund information
• Education Savings Plan if applicable
• Inventory of belongings and valuables
• Insurance policies
• CRA tax filings and disability tax credit status
• Budgeting supports
• Allowance or spending plan
• Accounting or trustee information
• Banking information
• Credit card information
• CPP and OAS details
• Pension details
• Disability assistance information
• Registered Disability Savings Plan
• Trust fund information
• Education Savings Plan if applicable
• Inventory of belongings and valuables
• Insurance policies
• CRA tax filings and disability tax credit status
• Budgeting supports
• Allowance or spending plan
• Accounting or trustee information
Key Questions
• Has there been changes or updates needed
• Who needs visibility into financial authority and restrictions
• Are documents up to date and reconciled
• Do supports need to be added to increase financial safety
• Has there been changes or updates needed
• Who needs visibility into financial authority and restrictions
• Are documents up to date and reconciled
• Do supports need to be added to increase financial safety
Section 5
Emergency and Critical Notification Information
Purpose
Provide rapid deployment readiness for emergency response, transitions, and crisis stabilization.
Provide rapid deployment readiness for emergency response, transitions, and crisis stabilization.
Contacts Required
• Local emergency contacts
• Out of province emergency contacts
• Next of kin
• Church or spiritual community
• Spiritual advisor
• Utilities including phone, power, cable, internet
• Lawyer, trustee, or Public Guardian
• Bank with card and PIN information in sealed format
• Trust fund or RDSP manager
• CLBC analyst and facilitator
• Health authority case manager
• Mental health or crisis clinicians
• Pharmacy
• After hours emergency line
• Local emergency contacts
• Out of province emergency contacts
• Next of kin
• Church or spiritual community
• Spiritual advisor
• Utilities including phone, power, cable, internet
• Lawyer, trustee, or Public Guardian
• Bank with card and PIN information in sealed format
• Trust fund or RDSP manager
• CLBC analyst and facilitator
• Health authority case manager
• Mental health or crisis clinicians
• Pharmacy
• After hours emergency line
Key Questions
• Who must receive immediate updates
• Are contact lists current and accessible
• Are emergency protocols documented and understood
• Who must receive immediate updates
• Are contact lists current and accessible
• Are emergency protocols documented and understood
Section 6
Care Planning and Goals of Care
Purpose
Anchor the planning process around the person’s values, preferences, and long term vision.
Anchor the planning process around the person’s values, preferences, and long term vision.
Core Planning Components
• Person centered plan
• Annual support plan
• Behaviour support plan
• Safety plan
• Crisis response plan
• Cultural safety plan
• Identity and belonging plan
• Transition plans for medical events
• Transition plans for aging
• End of life considerations
• Person centered plan
• Annual support plan
• Behaviour support plan
• Safety plan
• Crisis response plan
• Cultural safety plan
• Identity and belonging plan
• Transition plans for medical events
• Transition plans for aging
• End of life considerations
Advance Care Planning Requirements
• Diagnosis, prognosis, risks, and treatment options reviewed with a physician or nurse practitioner
• Goals of care designations written as a Medical Order
• Documented preferences for location of care
• Instructions for when the person can no longer speak for themselves
• Review cycle: annually or following a major health change
• Diagnosis, prognosis, risks, and treatment options reviewed with a physician or nurse practitioner
• Goals of care designations written as a Medical Order
• Documented preferences for location of care
• Instructions for when the person can no longer speak for themselves
• Review cycle: annually or following a major health change
Section 7
Information Sharing Protocols
Purpose
Support governance, compliance, and high confidence information flow across the service network.
Support governance, compliance, and high confidence information flow across the service network.
Key Requirements
• Identify who needs the information including CLBC, health teams, families, and community partners
• Confirm preferred communication channels
• Maintain version control for all documents
• Review information at least quarterly or when major changes occur
• Retire or destroy outdated documents
• Confirm alignment with privacy legislation including FOIPPA
• Ensure cultural safety considerations are embedded in all information sharing decisions
• Identify who needs the information including CLBC, health teams, families, and community partners
• Confirm preferred communication channels
• Maintain version control for all documents
• Review information at least quarterly or when major changes occur
• Retire or destroy outdated documents
• Confirm alignment with privacy legislation including FOIPPA
• Ensure cultural safety considerations are embedded in all information sharing decisions
Section 8
Annual Review Framework
Purpose
Provide a standardized refresh cycle to maintain operational discipline and ensure the life plan remains current.
Provide a standardized refresh cycle to maintain operational discipline and ensure the life plan remains current.
Annual Workflow
• Validate all sections with the person and their network
• Update all health, legal, financial, and emergency documentation
• Reconcile professional contacts
• Confirm representation authority
• Re align personal goals
• Audit data storage and security
• Confirm all copies distributed to the correct partners
• Document unmet needs or escalation requirements
• Validate all sections with the person and their network
• Update all health, legal, financial, and emergency documentation
• Reconcile professional contacts
• Confirm representation authority
• Re align personal goals
• Audit data storage and security
• Confirm all copies distributed to the correct partners
• Document unmet needs or escalation requirements
Aging & Transitions
1. Clinical and Functional Baseline Refresh
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Complete an updated functional assessment to capture current cognition, mobility, self care, communication, and medication adherence.
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Document changes with objective indicators to create a data-driven baseline for future shifts.
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Identify areas where decline may impact safety, decision making, or daily living within the home sharing environment.
2. Medical and Wellness Planning
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Trigger a primary care review to validate current diagnoses, rule out reversible conditions, and stabilize emerging ones.
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Confirm medication reconciliation, vision and hearing checks, fall risk screening, and chronic condition management plans.
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Establish a coordinated care plan with allied health (OT, PT, nursing) as required.
3. Advance Planning and Legal Readiness
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Ensure all legal and planning instruments are up to date:
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Representation agreements
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Power of attorney
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Advance care planning
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Medical Orders for Scope of Treatment
-
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Confirm that the individual and their personal network understand these tools and their implications.
4. Home Environment Optimization
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Conduct an environmental safety scan to determine modifications that will extend safe aging in place.
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Plan for adaptive equipment, fall mitigation, routine monitoring practices, and contingency supports.
5. Provider Capacity and Support
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Assess the home sharing provider’s ability to meet evolving needs.
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Identify required skill upgrades, respite expansion, or additional hours to maintain service stability.
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Document stress points or sustainability risks that CLBC needs to be aware of.
What to Communicate to CLBC
1. Change in Health Status
Provide a concise, evidence-informed summary:
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Recent functional decline indicators
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Medical findings
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Impact on safety, mobility, and decision making
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Service implications and projected future needs
2. Risk and Mitigation Framework
Outline:
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Immediate risks
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Mitigation measures already in place
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Gaps that require CLBC resourcing or approvals
3. Capacity and Sustainability Outlook
Clarify:
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Provider’s ability to continue
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Anticipated need for increased respite, additional staffing, or transition planning
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Long range considerations for complex care or assisted living pathways
4. Funding and Resource Requests
Position requests using a business case format:
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What is required
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Why it is required
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Expected impact on stability and quality of life
What to Communicate to Health Partners and Others
1. Primary Care
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Updated observations of cognitive or physical decline
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Medication concerns
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Fall or confusion events
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Requests for diagnostics, allied health, or geriatric consultation
2. Community Health
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Need for home support, nursing, OT or PT
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Need for equipment and home modifications
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Requests for ongoing monitoring
3. Family or Representative
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Clear updates on status
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Navigation support for planning documents
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Agreement on goals of care and preferred future pathways
Required Documentation
Maintain an integrated file that includes:
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Updated assessments
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Health summaries
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Care plans
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Risk assessments
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Incident reports
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Communications with CLBC and health providers
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Planning documents (representation agreement, MOST, power of attorney, advance care plan)