golden thread training powerpoint - m. thornton

Spokane RSN Golden Thread Training

Consultation

• Focus on RSN responsibility in two areas: ▫ Payment for medically necessary covered services

Includes meeting key requirements for claims/encounter submission

Includes meeting requirements for the logic of service delivery, i.e. the golden thread

▫ High quality services and desired clinical outcomes resulting from the use of recovery based principles in planning for and delivering services.

• Products: ▫ Clinical Monitoring Tool

▫ Service Delivery Tool

Consultation

• Tools: why two not one combined?▫ Critical that providers not mix up quality with basic

compliance External federal or state auditors look at claims, not

medical records

High positive scores that don’t adequately reflect audit risk

Too many variables to allow adequate focus

Audit or review teams can differ allowing for a more intense focus on areas of vulnerability

Consultation• Tools: why two not one combined?

▫ Service Delivery Tool –ensures that encounters will meet all

basic CMS requirements. This tool measures the “floor”.

Focus is on the linkage of documents in the medical record to

one another so that the logic of service delivery is evident to an

outside auditor.

There are requirements in this tool that go beyond the encounter

validation reviews –specifically treatment plans

Very little evaluation of the “content” of the documents - except

for determination that the content of the service described is

actually a covered service and is the service billed.

Consultation• Tools: why two not one combined?▫ Clinical Review Tool: reflects the initial set of “quality”

criteria the RSN wants you to focus on as a part of a “shaping” process to improve both the quality of services and the documentation of those services. Build on Janis Tondora training

Very few issues are focused on the “floor”

RSN wants to partner over a longer period of time for improving quality in its network – criteria chosen for recovery were the base on which additional criteria will be built

Consultation• Tools: why two not one combined?▫ Inter-rater reliability

Great deal of attention paid to making sure you understand how to succeed. Maintenance of yes/no answers requires more attention to the

questions

Scoring is different: Service tool: pass/fail – you either meet all required criteria or you

don’t. Multiple errors are documented and included in your scoring report.

Clinical tool: percentage scoring is allowed. Scores are not weighted in this iteration.

Medical Necessity and Golden Thread

Medical Necessity

• Regardless of your clinical approach to service

delivery – all services must meet the requirement

that the service be medically necessary.

▫ This may require at least a limited amount of jargon

▫ It is usually a pass/fail test – there are no services that

are partially medically necessary

▫ The primary link in medical necessity is between the

diagnosis of the individual and the service code

ICD 10 and DSM 5 code sets

CPT/HCPCS Code set

Definition in WA

• There is a federal definition in Medicare for medical necessity▫ Services must be "reasonable and necessary for the

diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member"

• There is not a federal definition of medical necessity in Medicaid▫ Each state is allowed to adopt their own

▫ Some states more than other emphasize local practice

▫ Generally they follow certain guidelines because they must be approved by CMS

Definition in WA

• 1915(b) Waiver

▫ Medical necessity or “medically necessary” – See

handout page 11.

▫ Key requirements: note ability to provide services for

a number of different reasons – diagnosis, cure,

amelioration, stabilization, prevention of deterioration

– should be clear in treatment plan what your intent is.

This may be an overall macro plan or may be specific

to certain outcomes only.

Definition in WA

• Key Criteria in WA Definition of Medical Necessity: ▫ Mental illness covered by Washington State for public mental

health services Federal auditors as well as RACs are looking closely at these on the

medical side. ICD 10 and DSM 5 challenges A and B

▫ Individual’s impairment and needs must be the result of a mental illness - concern about CD, DD, ID and other medical conditions that are not covered services but contribute to clinical picture

▫ Interventions are reasonable: this includes an assumption that services are specific and effective for the diagnosis or its effects on functioning AND that they are “generally accepted practice”.

Definition in WA

• Key Criteria in WA Definition of Medical Necessity:

▫ The individual is expected to benefit – go back to

listing of service purpose AND add in capability of the

individual to benefit AND willingness to engage

▫ Other formal or informal systems of support cannot

address unmet needs

Medicaid is required to be the payer of last resort

What else?

Skilled vs “unskilled” interventions

Medical Necessity:

Who Cares?• Isn’t this something only a

doctor can determine?

▫ No Every state has rules as to who

Assessment: diagnosis

Treatment plan: services

• See WA reply on treatment planning

▫ See Federal regs on pg 12 Handouts

▫ Once initial case made, continuing confirmation is found in progress notes and other documentation – the entire treatment team participates as long as there is a reasonable connection between the service and the approved, current plan.

Copyright Mary Thornton & Assoc, Inc

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Medical Necessity:

Who Cares?• What about individual choice?

▫ They can choose to receive services that are not medically

necessary

Those services must be paid for by the client or by alternate

available resources

“The individual’s choices and preferences shall always be honored

and considered, if not always granted.” –MI Person Centered Planning

▫ Billing for non-medically necessary services will result in

encounter denied/reversed/paybacks or rate impacts


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What are they looking for? Documenting

Medical Necessity

1. It treats a mental health/substance abuse condition/illnessand the symptoms an/or functional deficits that are the result of the mental illness.

2. It has been authorized if necessary AND ordered or prescribed in a treatment plan – credentials critical

3. The service should be generally accepted as effective for the mental illness being treated and is a covered service

4. The individual must be willing to participate in treatment

5. The individual must be able to benefit from the service being provided

6. There must be active treatment

Copyright: Mary Thornton

What are they looking for in medical

necessity• Assessments: should result in a diagnosis but

requests for assessments can be solely based on

concern, reasonable guess, curiosity about whether

or not an individual has a mental illness

Medical Necessity: What’s It Mean?

Treating: • Client must have a reimbursable diagnosis▫ A and B criteria ▫ Mental health vs substance abuse or mental health and substance

abuse▫ You need to include the substance use diagnoses – often missing

in cases we reviewed. ▫ DSM 5 vs ICD 10▫ No more axes BUT

Medical diagnoses increasingly important for risk based pricing/care coordination/ med management

Axis IV requires additional codes in ICD 10 Axis V – GAF – DSM suggests:

APA guidance on suicidality for risk assessment Diagnoses for severity of symptoms ( severity scales are not

always available) WHODAS 2.0 for functioning

Mary Thornton & Associates, Inc

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Diagnostic Coding

• DSM 5 or ICD 10 CM diagnosis▫ Dx alone is not enough

Dx + Signs/Symptoms Dx + Functional Status Dx + Signs/Symptoms and Functional Status

▫ Current signs/symptoms and functional status is critical to medical necessity

▫ Acuity/other clinical information available in many of the codes

▫ Each service must be directed toward an appropriate diagnosis


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Treatment Planning

• Services must be provided according to an

individualized service plan

▫ Every service must be ordered

▫ Service orders cannot be backdated

▫ Require a certain level of credential to sign

• Authorizations are not evidence of medical necessity

– documentation in the medical record, not the

authorization request is required.

• See WAC and Federal Regulations (page 12)


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Treatment Planning

• Remember the goal and measurable outcomes must

be achievable.

▫ Services must be delivered at an appropriate intensity

for the individual presentation of the client

Be concerned with too little and too much

Meds only clients: remember outpatient is a voluntary

level of care

Frequent no shows and Non-compliance – golden thread

would require a revisiting of goals.


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Generally Accepted as Effective

• Looking for specificity and effectiveness in relation to the diagnosis + ▫ E.g. general parenting services

Movement towards delineating appropriate matches, not just mismatches e.g. MST or CBT

▫ Under-diagnosing in either kids or adults can create problems in defending medical necessity

▫ Watch inappropriate psychotherapy; treatment for very young; others.

• Services should not be experimental• Similar concerns with treatment planning – are services

being provided at appropriate intensity, etc. • Service must be covered – the auditor must be able to

recognize that a covered service was performed ▫ No “still life” notes or status reports –see Case I - page 7 and 8.


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Willing and Active Participant

• Client must be active participant ▫ These are usually voluntary services

Under LRA’s providers have different documentation concerns having to do with clinical risk.

▫ Documentation must be clear about client’s participation in treatment Involvement in planning – not just quotes either.

Besides being present- what else? Non-compliance

Diagnoses that may prevent participation

Signing treatment plans, progress notes in concurrent documentation


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Willingness to Participate

• FAQs from MN regs:

“Hopefully, the provider will have another and more

flexible source of funding that would cover

repeated efforts to build trust with the consumer

and eventually lead to the consumer accepting

needed services. MA cannot be billed for services

that the recipient does not want.”


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Voluntary Services NY Regs:

821.3 Chemical Dependence: “All patients shall be informed that admission is on a voluntary basis and that a patient shall be free to discharge himself or herself from the service at any time. For patients under an external mandate, the potential consequences for premature discharge shall be explained, but this shall not alter the voluntary nature of admission and continued treatment. This provision shall not be construed to preclude or prohibit attempts to persuade a patient to remain in the service in his or her own best interest.”


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Ability to Benefit

• Sufficient cognitive ability to benefit

▫ Watch for:

Very young children

Dementia – all kinds – fight if you think it is appropriate

at early stages of disease

Mental retardation – except for mild and sometimes

moderate

Autism

Other clients who cannot benefit – e.g. intoxicated

▫ A part of the willingness conversation as well


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Effectiveness and Progress in BH

Medicare Hospital Manual – Outpatient Services

▫ “For many other psychiatric patients, particularly

those with long-term, chronic conditions, control of

symptoms and maintenance of a functional level to

avoid further deterioration or hospitalization is an

acceptable expectation of improvement..”


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Medicare Hospital Manual – Hospital Outpatient

Services

• “"Improvement" in this context is measured by

comparing the effect of continuing treatment versus

discontinuing it. Where there is a reasonable

expectation that if treatment services were withdrawn

the patient's condition would deteriorate, relapse

further, or require hospitalization, this criterion is

met.”


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Medicare Hospital Manual – Hospital Outpatient

Services

• “Services are non-covered only where the evidence

clearly establishes that the criteria are not met; for

example, that stability can be maintained without

further treatment or with less intensive treatment.”


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Service Delivery Tool: Primarily

Focused on Medical Necessity • Questions 1-3: Treatment plan – there, signed, current? ▫ Treatment plan because it has been reviewed and signed means

that someone is certifying that the plan for treatment if followed is medically necessary for the individual. It: Flows from the assessment, Contains measurable goals and objectives that will result in the

individual realizing their recovery and treatment goals, Only provides for generally accepted treatment that the individual

agrees with and can benefit from

• Questions 4-11: Progress notes – is it there but in question 10 a what is there question▫ Active treatment that flows from treatment plan

Continued ability to participate and willingness to do so Generally accepted

Clinical Monitoring Tool

• Question 1: ▫ Intake assessment and strengths:

Best practice: they are specifically listed in body of assessment; re-addressed in terms of their use in treatment in clinical formulation

There is a discussion recorded with individual about their strengths and how they will assist in recovery, e.g. good at sports – what does that mean for treatment?

There is a discussion recorded with individual about how they have used these strengths in past to assist with recovery

▫ Credit for: list of strengths even if not correlated with specific or potential uses in treatment -see Hal –intelligent, smart, good at math vs. Joan – has aides coming into her house 49 hours per week.

Context of Change

• Current Life Situation-Emotional/mental status of the person, financial/educational resources, intellectual ability, coping skills

• Beliefs and Attitudes-Beliefs about how things should happen, self, religion, G-D, family)

• Interpersonal Relationships-Interactions with key people, such as spouses, friends, etc.

• Social Systems-Person’s family system, social network, work system.

• Enduring personal characteristics-Basic personality characteristics (ex. Impulsivity)

DiClemente, C: Stages of Change and Addiction. The Clinical Innovator Series. Hazelden Foundation, 2004


• Question 2:

▫ Treatment plan incorporates strengths (from

assessment) into goals, objectives or interventions

Best practice:

Strengths specifically linked to a specific goal, objective or

intervention

▫ “ Individual will” , “family will”

▫ Specific linkage of strength to a type of intervention or outcome

Credit for: listing strengths in the treatment plan

Even if not in assessment


• Question 3: ▫ Progress note describes a treatment modality listed on the

treatment plan Best practice:

Modality listed in narrative on progress note (not just the code)

Modality provided is listed on the treatment plan AND the content of the service is specifically directed towards the goal or objective for which the modality is listed.

Credit for: match of modality either listed or coded to that listed on the treatment plan Note if plan lists modalities specifically for each objective/goal

AND the goal/objective is listed on the progress note, there must be a match to content of service.


• Question 4:

▫ Interventions on plan include at least one self-directed

action step by individual or supports

▫ Best practice:

At least one self-directed/supports intervention is listed

for each objective in addition to skilled interventions

The self-directed/supports intervention clearly builds off

of the individual’s strengths which are also listed

▫ Credit for: at least one intervention that describes an

action to be taken by the individual or their supports


• Question 5: ▫ Primary MH diagnosis that is chief reason for encounter is

listed.▫ Best practice:

Diagnosis listed in progress note is listed on claim or encounter by the providing clinician.

If more than one diagnosis listed, the first listed is the primary reason for the encounter

If an evidence-based practice that is specific to certain diagnoses or diagnostic groupings is provided, one of these diagnoses is listed in the progress note as the primary reason for the encounter

▫ Credit for: listing a diagnosis on the progress note ( pulling over multiple diagnoses is not acceptable )


• Question 6: ▫ Treatment plans are developed collaboratively with

individual and there is evidence of this in the medical record

▫ Best practice: A progress note that details discussion and outcome of

meeting(s) with individual and others, if appropriate, on the development of the treatment plan is included in medical record.

With children, their voice is clearly heard in planning and in actual treatment plan -See Chart 3 goals/objectives page 8

▫ Credit for: quote from individual in treatment plan; signature of individual/family on treatment plan


• Question 7: ▫ Evidence that a copy of the treatment plan is given to

the individual in their preferred language

▫ Best practice: Documentation in a progress note or on treatment plan

itself that individual given a copy of the final plan

If language is other than English, a copy of the plan actually given to the individual must be included in the medical record

▫ Credit for: documentation that plan given to individual in progress note or on treatment plan or other


• Question 8: ▫ Clinical record indicates consultation tailored to specific

needs, values and preferences of the individual ▫ Best practice:

Use of APA CFI or other recognized tool for determination of cultural issues that may impact treatment

Documentation with individual/family, if appropriate, of clinical specialist resources and benefit to individual and determination if individual would like to use

Inclusion in treatment plan of agreed upon consultation

▫ Credit for: documentation in treatment plan of consultation OR if assessor is the clinical specialist recommended for the individual there is an assumption that an extra specialist consultation is not medically necessary.

Review Cases

• I: John Doe – 45 year old male

• II: Joan Jett – 68 year old female

• III: Hal Swingline – 7 year old male

Documentation Issues

• Cloning and “cutting and paste” –see Medicare Doc page 9. See also “volume” page 9.

• Excessive quotes – where is the clinician? ▫ What can be done concurrently and what needs some

thought and quiet?

• Don’t make up your own stuff if it explicit in regs or guidance from payer – e.g. modalities

• Have both goals and objectives – you need short term steps to monitor progress – consider some sort of benchmarking. See handouts page 6.

The Golden Thread-Connecting the

Dots• Each piece of documentation must flow logically from one

to another such that someone reviewing the record can see the logic

• The assessment must lead to the treatment plan and be coherent and cohesive and establish medical necessity –please be careful about inconsistencies – See Case 3 – page 6

• The progress notes must flow from the treatment plan and document the services provided and the individual’s response to treatment (both encounter and goal/objective-based)

• The progress notes lead to the treatment plan review/update that lead to the progress notes, etc.


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What Breaks the Golden Thread?

• Addressing specific clinical issues in the assessment,

assessment update or the treatment plan reviews that

are not addressed, deferred or referred to another

provider.

• Writing progress notes that do not link easily to goals

and objectives from the treatment plan. See State

Medicaid Manual in handouts – page 12 and 13

• Developing goals and objectives that are not

individualized based on assessment, reassessment, or

treatment plan review –watch out for drop down boxes

What Breaks the Golden Thread?

• Failure to change the treatment goals, objectives or

overall clinical strategy when the individual is not

progressing.

• Failure to update the treatment plan when new high

priority issues are identified or current objectives

are resolved.

Assessments

• There are different types of assessments that may

be completed to determine an Individual’s needs

during the treatment episode

▫ Clinical assessments

▫ Psychiatric assessments

▫ Functional assessments – WHODAS, CAFAS DLA

or other domain based assessments

▫ Case management assessments

▫ Vocational assessments


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The Clinical Diagnostic Assessment

• Usually the first piece of documentation in the

record (with the exception of crisis services or

rehab case mangement )

• Should be completed before the individual begins

treatment and on-going services are provided

• Includes targeted treatment needs and

recommendation for level of care

• Includes all confirmable diagnoses and relevant rule

outs


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Clinical Diagnostic Assessment

• To be completed prior to the development of the treatment plan

• The treatment plan based on this assessment must be completed according to agency policy and payer rules

• The assessment should be reviewed and updated as necessary –agency policy should address ▫ B diagnosis criteria must be continuously met – may want

some agency policy on review▫ State high priority criteria for uninsured ▫ Young children▫ Emergence of new diagnoses▫ Inpatient admissions


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Major Elements of the Assessment

• Presenting Problem▫ Reason for coming to treatment (Why Now?)▫ Comprehensive, chronological story of what has happened

that led to seeking treatment OR Interval history (ASSESSMENT UPDATES)

• Functional assessment (may be an addition for certain individuals depending on diagnosis)

• Data Gathering▫ Should be only pertinent information and should emphasize

most recent information▫ Should be gathered and documented in such a way that it

provides useful information


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Major Elements of the Assessment

• Mental Status/Risk Assessment – current observations of the individual –completed by someone trained or with credentials

• Clinical Formulation: an analysis of all other information in the assessment


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Presenting Problem and Chief

Complaint – Initial Assessment• Statement from the individual as to the nature of the

problem – chief complaint – usually in “quotes”

• The reason for seeking services now- history of the present illness▫ Initial assessment: should include information about when

the problem started, how it progressed, situations in which it is worse, self-help that has been tried, what has worked in past if this is a recurrence, major symptoms, significant impact on the person’s life, impact on ability to function

▫ This should not be a series of loosely connected quotes.

▫ See also Chart 2 – page 1- significant pieces of information missing/no chronology, etc.


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Complaint - Reassess

• Interval History: sufficient information so the reviewer can determine: ▫ Why originally entered treatment: Very briefly, level of

symptoms, functionality issues. Baseline

▫ Description of how moved away from baseline or, if desired, remaining at baseline

▫ How long current episode of care: reviewer wants to be able to place the last year within the context of the episode of care – e.g. 3rd of 6 years, 1st year, etc.


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Complaint - Reassessment

• Interval History: sufficient information so the

reviewed can determine:

▫ Services received

▫ Current plan for moving forward

▫ Estimate of remaining length of stay


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Interval History

Example: Child DD

Demographics, primary diagnosis, why entered

treatment, length of stay: Daniel is a 12 year old male

who was admitted to services at age 6 because of

problems with verbal and physical aggression at home and

in school. His diagnoses of mild mental retardation and

ADHD have been consistent since admission.


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Interval History

Improvement and how measured: Daniel has

significantly improved his school attendance and

participation this past year. This is a marked improvement

from the beginning of the year when he received numerous

citations for inappropriate behavior. He continues, however,

to have problem with behaviors at home where his parents

report 4-6 episodes per week of aggression particularly

against his younger sister.


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Interval History

Current plan for moving forward, estimate of

length of stay still needed: Daniel’s medications were

changed 6 months ago. He and parents both pleased

with Daniel’s response. He has also been involved in an

after-school group focused on managing triggers and

CM services were used to coordinate care among his

treatment team and school and to assist parents with

Daniel’s benefits. He is expected to remain in treatment,

with same level of services, for at least one additional

year with a renewed focus on helping Daniel manage his

behaviors at home while maintaining his gains at school.


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Data Gathering: Relevant and Mostly

Current

• Psychological/psychiatric treatment history

(should also include substance abuse

treatment history as well): length of time

client has been ill; should include client

assessment of outcomes and length, if any, of

period of stability; should also include client

assessment of their compliance with

treatment


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Data Gathering• Family history: relevant medical and psychiatric

• Educational history: relevant client history, not all grades – short description of major components of IEP including any CM provided by VBMHC

• Relevant medical background: more emphasis on current issues that may be relevant to diagnosis/TX

• Employment/Vocational history: relevant client history; indication of periods of stability or reduced symptoms; indication of functional baseline


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Data Gathering

• Legal history: emphasis on current history

• Alcohol/Drug use history: emphasis on current

use or patterns; assessment of level of risk if

currently in recovery

• Military service history: indication of periods of

stability or baseline functioning; may be relevant

diagnostically


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Medical Issues: ALWAYS

• Date of last physical exam

▫ Refer if not recent

• Ask the individual if their Primary Care Physician

(PCP) can be contacted

• Coordination with medical care providers plan

should be discussed, e.g. our agency policy is that ….


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Mental Status Exam

• Only completed by those with proper credentials,

training and experience

• This is a required portion of the clinical and

psychiatric assessment - not necessary for an annual

reassessment of need for services

• Must be accurate and complete


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Risk Assessment

• Should only be completed by those with

proper credentials, training, and experience

• Usually considered to be an addendum to the Mental

Status Exam so part of requirements for clinical and

psychiatric assessment

• Considers: suicide, homicide, self- harm, harm to

others, grave disability, etc.


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Identifying Needs

• One of the primary outcomes of all assessments is

identification of needs, concerns, deficits, behaviors or

other issues that may need to be addressed in the

treatment episode

•Supports: key supports only make sense in light of

treatment needs – look back once needs determined to

figure out relevancy – this should help decrease need for

services

▫ Take needs and subtract supports = what’s left for you to do.


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Identifying Needs

• Some issues may need to be addressed in subsequent levels

of care – you do have ability to defer

• The individual and provider may disagree about what is a

priority issue and can defer the issue for future discussion

(always leave the door open), e.g. substance use


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Identifying Symptoms/

Behaviors/ Problems with Functioning

• Needs can be focused on:

▫ Symptom reduction –think treatment services

▫ Functionality – think skill building

▫ Needs for services and supports – think case

management.


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Diagnostic Assessment

• Analysis: ▫ Diagnosis and symptoms or behaviors that support the diagnosis; list of rule

outs and strategy for gathering additional assessment or diagnostic information.▫ What are Individual/family’s goals and commitment to treatment (able and

willing)? ▫ Prioritized problem list: what will be addressed or deferred at the current level

of care or in initial treatment period Symptoms or behaviors Functional deficits or skill deficits Services and supports that the Individual/family cannot access on own

▫ Description of decision-making process and a recommendation for a level of care: including short discussion of what has or not worked in past and how this impacts decision.

▫ Individual/family strengths and supports that will be used in treatment or will support treatment.


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Clinical Formulation

• What are the individual’s goals, in their own words,

and commitment to treatment (able and willing).

▫ This may need to include the willingness of supports to

commit as well

▫ These can be quotes but should usually be the result of

multiple questions.


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Examples: Clinical FormulationChild MH

• Primary diagnosis of Bi-polar Disorder continued in

most recent medical review. PTSD is secondary on

Axis I with no Axis II per (DLA/Therapist/MD). GAF

score is ___ points higher reflecting a reduction in

vegetative symptoms. Axis IV stressors are the same.

No medical co-morbidities at this time per PCP.


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Examples: Clinical Formulation

Child MH

• Her recovery goal continues to be to live with her

brother and sisters. Her grandmother, primary

caretaker, would like Leisha to be able to make local

friends and be happy about living with her

grandmother. Although both are committed to

treatment they are discouraged about medications

and their side effects. There is some concern about

medication compliance.


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Examples: Clinical FormulationChild MH – information from therapist

• Leisha continues to be very anxious about school. She needs more effective coping skills and to recognize when to use them.

• Grandmother needs additional education about medications in order to help make choices and to partner better with MD.

• Leisha needs social skills to help with her peer relationships in school.

• Leisha needs to continue regular visits with sibs.


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Child MH – information from therapist

• Recommendation is that Leisha continue with her

home-base intensive treatment team. She and her

grandmother relate well to the team-based approach

and transportation barriers would prevent compliance

with multiple visits to the clinic each week. The focus of

treatment has to be her ability to manage her school

environment.


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Examples: Clinical FormulationChild MH – information from therapist

• Leisha’s grandmother continues to be her primary

support. Leisha does feel her brother and sisters are

really helping her as well. She has not identified any

valued supports in school although she states that she

“likes’ her teacher. She is bright and quite engaged when

she is at home. She likes to engage in problem-solving

games and spends a great deal of time playing outdoors.


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Treatment Planning

• Documentation of the treatment planning process includes the treatment plan AND a progress note describing as your agency requires: ▫ Description of the development of the plan▫ Who was there▫ Individual’s level of participation/family involvement

– critical for children▫ Outcomes: plan completed, goals set, etc.

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Content of the Treatment Plan

• Must flow from the mental health assessment or

treatment plan reviews

• Must address current prioritized problems/needs

• Must describe treatment goal(s) and objectives that

are measurable and address prioritized problem

areas preventing the individual from reaching their

recovery goal

▫ Focus on the desired outcome

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Treatment Plans: Purpose

• Treatment Plans results in:

▫ The priority list of needs/problems/ issues being matched now to specific services and outcomes

▫ Timeline negotiated with Individual/family

▫ Intensity of services negotiated with Individual/family

▫ How: group, individual, family – negotiated with Individual/family

▫ Combined these equal your treatment strategy

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Documenting Treatment Plans

• How many goals and objectives?

▫ Usually one goal – at most two

▫ Usually one to three objectives for each goal

▫ You and Individual/family must learn to focus

• Start where the Individual/family is and where the Individual/family wants to be – the goal for the Individual/family and for treatment may not be same.

▫ Devise a strategy that moves the Individual/family towards the goal with benchmarks or objectives that assist you in measuring both progress and success

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Treatment Goals

• Must relate directly to the diagnosis and the

presenting problem

• Describe the realization of a clinical outcome

▫ Individual’s Goal: “I want to move into my own

apartment.”

▫ Treatment Goal: The Individual will be able to manage

their symptoms and develop the social skills necessary

for managing independent living.

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Treatment Goals

• Usual content of a treatment goal:

▫ Behavioral description of what the individual will

accomplish in measurable terms

Do, finish, keep, stay in, live in, be successful at,

develop

▫ Within what environment

▫ Within what time frame

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Recovery and Treatment Goals – note

these were out of order

• “I want to be a part of my family again”

▫ NAME will be able to successfully manage symptoms and

behaviors in family interactions.

• “I want to get a job.”

▫ NAME will be able to demonstrate control of symptoms

and ability to use appropriate social skills that will allow him

to achieve on-going employment.

• “I want to go back to school and be a famous writer”

▫ NAME will be able to demonstrate ability to manage angry

outbursts so that he is not expelled from 5th grade.

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Developing Objectives

The objectives are the measureable steps by which

the client is working to achieve their discharge goal

▫ 2 or 3 at most for each goal

▫ Steps or benchmarks that will indicate progress

towards the goal

What can you see or hear about that is the desired

accomplishment

See chart on benchmarking –handouts page 6

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Interventions Based on Service Type:

Individual Treatment

• The Staff Member will:▫ Use CBT to assist individual in identifying relapse

triggers 1x/week for 6 months

▫ 1x/week for the next 6 weeks teach the individual self-calming techniques to use during high stress activities through discussion, modeling and role-play

• Note: need type of provider, intervention, frequency and duration

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Progress Notes

• Provide evidence a covered service was provided

• Provide evidence of the Individual’s continuing commitment to treatment through active participation

• Address objectives and progress towards meeting objectives as a means of measuring progress and benefit

• Measures progress against the recovery/treatment goals

• Revisit the estimated discharge date and discharge criteria for level of care in order to gauge progress

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Golden Thread• Progress Notes –see handout

▫ Take your treatment plans with you so you remember what you are doing and mean to accomplish

▫ Basic information: dates, signatures, name of service, name of client

▫ List goal/objective: favors objectives

▫ Presenting problem: statement of medical necessity

▫ List the interventions

▫ Describe client response

▫ Plan for next visit or visits

Progress Note Content

• State the reason for the visit: establish medical

necessity – should relate to a goal/objective

• List the interventions and describe specifically the

techniques you used in the session to get the clinical

outcomes you were looking for

▫ Should be specific to the type of service being

provided

Progress Note Content (cont.)

• Document the Individual’s response to the

interventions. This may include:

▫ Level and type of participation ( not alone)

▫ Were they able to demonstrate the skill or participate

in role playing or some other evidence

▫ Or did they not get it, refuse to participate, resist, etc.

Progress Note Content

• Statement of Individual’s progress and plan

▫ State progress in relationship to objectives or goal listed

▫ Homework or other tasks to complete before the next

visit

▫ Plan for next visit or visits – consider your observations

about the Individual’s response to your interventions

Clinical Formulation, Interval History


Adult MH – just to give you an idea of how much things must change

• Primary diagnosis of Major Depression continued in most recent medical review. Per (DLA/Therapist/MD) GAF score is ___ points higher reflecting a reduction in symptoms and better use of coping skills. Axis IV stressors have lessened with her primary support group now engaged in her recovery. She reports that she has been diagnosed with GERD and is taking OTC medication.


86


Adult MH

• Her recovery goal continues to be to return to

work. She states that feels strongly that her

treatment continues to help her reach this goal but

agrees that she can continue to move forward with

fewer professional supports right now.


87


Adult MH – information from therapist

• Mary continues to have episodes where she is quite sad resulting in poor motivation and some isolating. She needs to recognize the early onset of symptoms and utilize coping skills early

• In anticipation of discharge her crisis plan needs to be reviewed.

• Consider transferring medication management to primary care MD.


88

Examples: Clinical FormulationAdult MH – information from therapist

• Based on her success in outpatient services, will

continue with reduced monthly sessions with therapist.

Mary will call if she experiences an episode of acute

sadness.

• Medication management services will continue for next

quarter with medical services attempting to move

prescriptions to PCP


89

Examples: Clinical FormulationAdult MH – information from therapist

• Mary’s reports that her younger sister meets with Mary

at least weekly to catch up on her progress and to

provide encouragement and praise. This has been very

helpful. In addition, Mary’s self-confidence re: her ability

to better manage her own illness has substantially

increased.


90


• Child DD: Primary diagnosis of ADHD with Mild

Mental Retardation continued per

(DLA/Therapist/MD). GAF score remains the same

because school functioning is better but more

problems at home. Axis IV stressors have increased

because father has lost job. No medical issues.


91


Child DD

• Family and child state continued goal of having Daniel

participate successfully in both band and in chess

club. Daniel knows that this depends on both his

behavior in school and now at home as well.


92

Examples: Clinical FormulationChild DD– information from therapist

• Daniel needs to be able to use the anger management

skills he is using so well in school in his home

environment as well.

• Daniel’s parents need additional information and skill

building in managing Daniel’s outbursts. They need to be

consistent and support each other’s efforts.

• Daniel needs social skills to assist him with peer

relationships in school activities and with sister.


93


• Recommend that Daniel continue with outpatient

services for medication management and with his group

at school.

• CM needs to coordinate with treatment team re: getting

referrals for parents skill building and psychoeducation.

• CM also needed to maintain Daniel’s benefits which are

crucial now that Dad has lost job.


94


• Daniel has two “best friends” at school. He likes his

group at school and his SPED teacher aide especially.

The aide is a key support for Daniel in his attempts to

control his behavior.

• Daniel and his parents are very close and he feels very

supported by them.


95

Interval History

Example: Adult MH


treatment, length of stay: Mary is a 60 year old woman

admitted 5 years ago for moderate symptoms of mood

disorder, nos. This diagnosis was upated 2 years ago to

Major Depression following a psychiatric hospitalization.


96

Interval History

Improvement and how measured: She has continued

to improve this past year. Her therapist reports and Mary

agrees that she has been able to positively utilize learned

coping skills and is on a medication regimen that keeps

most of her symptoms well controlled. (Could quote from

MD as well)


97

Interval History

Services received, current plan for moving forward, estimate of length of stay still needed: In the past year, she received weekly therapy, now decreased to monthly with an estimated date of discharge within 6 months. During the next treatment period services will focus on helping Mary maintain her coping skills as well as develop a plan for effectively using these skills to assist her in getting and maintaining a job. She will continue with therapy and medication management.


98

Interval History

Example: Child MH


treatment, length of stay: Leisha is a 8 year old female

who was admitted one year ago after a 2 month residential

stay with discharge to her maternal grandmother . She was

diagnosed with bi-polar disorder and PTSD, reconfirmed at

XXMHC. Her symptoms at admission included problems

with urinary continence, unwillingness to attend school,

frequent outbursts at home, poor grooming habits, and

reported sleep disturbances.


99

Interval History

Improvement and how measured: Leisha has experienced a moderate amount of improvement in grooming, urinary incontinence, and sleep. Gmother notes problems have decreased to no more than once every other week. She continues, however, to resist school attendance and is now frequently cited for behavioral outbursts and some physical aggression at school. Her behavior at home improved once regularly scheduled meetings with siblings were arranged.


100

Interval HistoryCurrent plan for moving forward, estimate of

length of stay still needed: Leisha and her grandmother

both complain about her medications – both their

complexity and effectiveness. This will be a focus in the

next 6 months. She will continue to be involved with the

intensive home team with individual therapy focused on

helping her cope with her anxiety re: school; family therapy

to focus on helping grandmother better understand and

support efforts to increase school attendance and the

importance of medication; case management to assist with

benefits, coordination of team with school, and continued

visits with sibs.


101

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