Substance Abuse Treatment Record Review Presentation

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1 Substance Abuse Treatment Record Review Presentation January 15, 2015 Presented by Melissa Reagan, M.S.W., L.S.W., Quality Management Specialist & Rebecca Rager, M.S.W., Quality Management Specialist Please mute your phone once you join the conference. Thank you!

2 Treatment Record Review Overview As required by the HealthChoices program, treatment/service record reviews are completed in order to monitor adherence to service record standards and to assist in improving the overall quality of clinical treatment. The treatment/service record review schedule will be linked with the PerformCare credentialing cycle. This means that providers will receive an onsite review or desk review when recredentialing with PerformCare is scheduled to occur. Reviews will occur, at one time, for all levels of care. In addition, there may be times that PerformCare will complete a review at the request of stakeholders, or when concerns arise. 1

3 Treatment Record Review Process PerformCare staff will outreach to the provider at least a month prior to when the Treatment Record Review (TRR) will need to be completed. The PerformCare staff will either request records be submitted or will provide options for dates that PerformCare staff is available to come on-site to complete the review. At least two weeks prior to the review, PerformCare will fax the list of Member names that will be included in the review. 2

4 Treatment Record Review Tools TRR tools are created by reviewing OMHSAS bulletins, state and federal regulations, PerformCare Policy & Procedures, Service Descriptions and best practice documents for each level of care. In addition, PerformCare Psychologist and Psychiatrist Advisors review tools and may make recommendations for indicators based on their knowledge of best practices and research within their field. The PerformCare Reviewer will score each indicator on the tool as a 0 (information not present in record), 1 (information is present in the record), or as a N/A, if this indicator is not applicable for the record. In addition to completing the TRR tool during the review, the PerformCare reviewer may identify Corporate Compliance concerns or Quality of Care concerns and will make internal referrals as needed.

5 Components of the Substance Abuse TRR Tools A section by section review of indicators

6 Intake, Assessment and Referral Section

7 Intake, Assessment & Referral Are relevant medical conditions and medications (including frequency and amount) listed? If there are none, please be sure to mark this. If it is left blank, it will be scored as a 0. Are allergies including medication allergies/adverse reactions listed? If there are none, please be sure to mark this. If it is left blank, it will be scored as a 0. Does the record reflect past and present psychiatric symptoms (including past and present suicidal/homicidal ideation or self injurious behavior) and past/present mental health treatments? If there are none, please be sure to mark this. If it is left blank, it will be scored as a 0. Was a psychosocial evaluation completed? Was a level of care assessment completed (Pennsylvania Client Placement Criteria (PCPC) or American Society of Addiction Medicine (ASAM))? Must be documented within the chart that it was completed. Does the record reflect past substance abuse (SA) history (current use, last use), withdrawal/dt/seizure history, and past and present SA treatment? If no history, please mark this in the record; if left blank would be scored as 0. Does the record contain evidence of a trauma assessment having been completed; and if trauma is identified, is it addressed in treatment, or is appropriate referral made? If trauma is identified, be sure to document offering the member a referral to address this; and if member accepts/declines.

8 Treatment Planning Section

9 Treatment Planning Are the treatment plan goals specific and measurable? Are the target dates for completion individualized and specific to each goal and objective? Are therapeutic interventions/modalities listed? Does the treatment plan include discharge criteria and clear aftercare plans? Discharge criteria should define what the member needs to complete to discharge from this level of care; aftercare plan should include what services or community/natural supports the member will use after discharge. Was an assessment completed on member strengths and then incorporated into the treatment plan? 8

10 Treatment Planning (continued) Does the treatment plan include measurable baseline information? The baseline measure should match the measurable goal or objective. Does the record identify any past periods of sobriety/abstinence? Does the treatment plan or aftercare plan incorporate skills or supports that were present during this period of sobriety/abstinence? For members with ongoing symptoms that are NOT evidencing improvement, does the record indicate that the treatment team has made changes as appropriate (i.e. assessed effectiveness of interventions, re-evaluated medications, changes to treatment plan, involvement of family/external providers, treatment team meetings, etc.)? 9

11 Treatment Planning (continued) Additional question on the Substance Abuse Outpatient Therapy (SA OP) tool: Does the record indicate justification for individual or group therapy? Additional question on the Substance Abuse Partial Hospitalization Program (SA PHP) and Substance Abuse Nonhospital Rehabilitation tool: Does documentation support assisting member in obtaining supportive services when necessary? (medical/dental, psychiatric, legal, economic, educational, vocational, recreational/social) 10

12 Relapse Prevention Plan Section (if documented that member refuses to complete, this entire section will be scored as N/A)

13 Relapse Prevention Plan Does the plan identify antecedents and triggers to a potential relapse for the member? External factors that may effect the member. Does the plan identify early warning signs of what could be a crisis/relapse for the member (i.e. specific feelings or actions the member may exhibit prior to a relapsing)? Does the plan include steps the member can take in order to prevent a potential relapse (i.e. connect with sober supports, use of coping skills to deal with cravings, attend a meeting, call sponsor, etc.)? Does the plan actively incorporate member strengths and interests as a means to prevent a potential relapse? 12

14 Relapse Prevention Plan (continued) Are contact numbers to be used in relapse situations present (i.e. natural supports, community supports, identified sober supports, etc.)? Does the plan outline steps natural supports can take to assist a member when showing signs of relapse (i.e. call sponsor, help the person get to a meeting, remove persons, places, things, remind them to use coping skills, etc.)? Does the record contain evidence that, following a relapse, the treatment team has reviewed the relapse prevention plan for effectiveness, and made changes as appropriate? This would only be scored if a member had a relapse while in treatment. If not, the reviewer would mark this as N/A for the record. 13

15 Progress Notes Section

16 Progress Notes Does each progress note clearly document what occurred during the session (i.e. the data/facts of what happened in the session)? Does each progress note reflect which goals and objectives from the treatment plan are addressed? Does each progress note clearly document which interventions were used during the session? Does the clinician provide an assessment/analysis of the effectiveness (or lack of effectiveness) of treatment/interventions that occurred during the session? Do the progress notes reflect the member s response to treatment/progress towards goals? 15

17 Progress Notes (continued) Do the progress notes include a risk assessment which assesses suicide risk, homicide risk, and psychotic symptoms? This indicator will only be scored for a member if they are diagnosed with a cooccurring Mental Health disorder, in addition to their Substance Abuse diagnosis. If the member is only diagnosed with SA, this will be marked N/A. Does each progress note clearly document the plan for future sessions/treatment (score as 0 if it only notes the date of next session)? Additional indicators on the SA PHP tool: Do the progress notes demonstrate that individual counseling is being provided at least twice weekly? Do the progress notes demonstrate that group counseling is being provided, at least twice weekly? Do the progress notes demonstrate that family and/or couple counseling is being provided, as appropriate? 16

18 Recovery Orientation Section

19 Recovery Orientation Does the record contain evidence of person-centered language (i.e. avoiding use of client or patient ; including member and family names; record is individualized)? Does the record contain evidence of shared decision making (i.e. treatment meets needs of member rather than fit member into existing structure; evidence of collaboration/discussion between member and treatment provider)? Does the record contain evidence that progress is defined by the member/family (i.e. goals should be developed and assessed by the member/family, in collaboration with the provider; member/family empowered to advocate for themselves)? Does the record contain evidence that efforts were made to strengthen natural and community supports (i.e. supports used in treatment; suggestions made for increasing natural supports; review of the member s social role or strengthening involvement with community supports; linking to peer run support group in community)? 18

20 Recovery Orientation (continued) Does the record contain evidence that efforts were made to identify any cultural preferences of the member/family? Be sure to mark none if member notes none. If left blank, will be scored as zero. Does the record contain evidence that efforts were made to be respectful to cultural preferences, in order to provide culturally competent care? This will be marked as N/A if the member does not identify any cultural preferences that need to be respected during treatment. Does the record contain evidence that the focus is not only on symptom reduction but also addresses quality of life factors such as improving skills, relationships, living arrangements, participation in social or recreational activities, or the use of community resources? 19

21 Coordination and Continuity of Care Section Does the treatment record reflect continuity and coordination of care with other treatment team members/ providers, when applicable? If member declines to sign releases for other treatment team members or providers, this will be marked as N/A. 20

22 Discharge/Aftercare Section

23 Discharge/ Aftercare Does the record contain evidence that plans for aftercare began at entry into program? Does the record contain efforts to alleviate barriers to achieving and maintaining recovery (i.e. financial, medical, emotional, social)? Does the record contain evidence that attempts were made to strengthen community and natural supports throughout treatment (including linking to peer-based supports groups, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA)? Does the record contain evidence that there was collaboration with all aftercare providers (as appropriate and with member s agreement)? 22

24 Discharge/ Aftercare Does the discharge summary include the reason for termination of treatment? Does the discharge summary include name of aftercare provider, upcoming appointment dates for all providers, and contact information for all aftercare resources (including natural, community, and peer-based supports such as AA,NA)? Additional question on SA OP Tool: Does the record contain evidence that aftercare plans were actively initiated at least 30 days prior to discharge? 23

25 Physical Health-Behavioral Health Coordination and Continuity of Care

26 Physical Health-Behavioral Health Coordination and Continuity of Care Does the record contain evidence that discussion and support was provided related to nutrition and physical activity (i.e. provided educational materials, discussed healthy food choices, discussed increasing physical activity and wellness, etc.)? For members who do not currently have a Primary Care Physician, does the record contain evidence that the provider attempted to link the member/family to a Primary Care Physician? Does the record contain evidence that the member s tobacco use was assessed, and if appropriate, provided with tobacco use cessation information? Does the record contain evidence that the treatment team is monitoring medication adherence (i.e. asking member/family on regular basis, adding as treatment plan goal, discussing during sessions, and coordination with psychiatrist), if applicable?

27 Physical Health-Behavioral Health Coordination and Continuity of Care (continued) Additional questions on the SA PHP and SA Non-hospital Rehabilitation Tools: For members diagnosed with a medication responsive disorder (i.e. ADHD, Bipolar Disorder, Depression, Schizophrenia, etc.), does the record contain evidence that provider discussed with the member/family exploring medication (e.g. discussion about member/family thoughts regarding medication, referral for psychiatric evaluation, etc.)? For members diagnosed with Schizophrenia or Bipolar Disorder who are using antipsychotic medications, does the record contain evidence that the psychiatrist has ensured diabetes screening has taken place? (N/A if psychiatrist is not affiliated with provider) For members with Cardiovascular Disease and a diagnosis of Schizophrenia, does the record contain evidence that the psychiatrist ensured member is receiving cardiovascular monitoring? (N/A if psychiatrist is not affiliated with provider) 26

28 Quality Indicators Section 27

29 Quality Indicators Does the record contain evidence that an assessment tool (related to evidence-based recovery-oriented services) is being completed and used to inform the treatment planning process? Does the record contain evidence that an outcome tool or measure related to evidence based recovery oriented services is being used? Does the record contain evidence that the outcome tool or measures were utilized to inform treatment planning and clinical decision making? Are empirically-based or evidence-based treatment packages being utilized? Can the provider show documentation to support that they are taking steps to improve outcomes (i.e. reminder calls for appointments, interactive web-based applications to support recovery, support groups, psychoeducation groups, etc.- only score once as not related to individual records)? This is only scored once (1 point) based on the documentation the provider can show to support this. 28

30 Completion of TRR and Exit Interview

31 Treatment Record Review Process Following the completion of the TRR, the PerformCare reviewer will conduct an exit interview with the provider. During the exit interview, the provider is given the opportunity to ask questions, provide clarifications, or produce additional information. The reviewer will detail the total score, as well as scores within the individual sections. Additionally, the reviewer may give feedback related to the individual records reviewed. The exit interview also allows the provider the opportunity to discuss additional concerns, feedback or suggestions regarding the TRR tools or TRR process. 30

32 Treatment Record Review Process PerformCare will collaborate with providers who do not meet a total score of 80% to implement Quality Improvement Plans (QIPs). Please note that the PerformCare reviewer will also be reviewing sections within the tool, and if a section score is below 80%, the provider will also be asked to provide PerformCare with a brief statement as to how they will address this. The provider is expected to reply with their brief statements within 30 days of the receipt of their letter. 31

33 Treatment Record Review Process The final results of all reviews will be communicated to providers in writing within 30 days of the review being completed. The results letter will note where the total score falls within the PerformCare Performance Goal Range, as noted below: %- Above standard documentation Provider will continue to be reviewed in accordance with the triennial re-credentialing cycle. High achievement will be noted on results letter, recorded during presentation at Credentialing meeting, and recognition will be noted within other PerformCare documentation %- Standard documentation Minimal opportunities for improvement are noted and the provider has achieved minimum network wide benchmark of 80%. No QIP required; provider will continue to be reviewed in accordance with the triennial re-credentialing cycle %- Below standard documentation Moderate number of opportunities for improvement noted; QIP is required. Annual review occurs until score is increased to 80% or above. 69% and below- Well below standard documentation Significant number of opportunities for improvement noted. Formal QIP required and a subsequent review will occur in 6 months and annually until score is increased to 80% or above. 32

34 Quality Improvement Plans If a Quality Improvement Plan (QIP) is required, it must be submitted to the PerformCare reviewer within 30 days of the receipt of results letter. The PerformCare reviewer will review the QIP and provide feedback within 30 days (reviewer may request additional information or could require revisions to QIP). The PerformCare reviewer will continue to follow up with provider on a quarterly basis on the implementation status of the QIP, as well as to provide any technical assistance that may be needed. 33

35 References of_drug_and_alcohol_programs/ l RECDEF.pdf

36 References s.aspx 35

37 Questions? Comments? Feedback? Thank you for your participation! Any additional feedback related to the Treatment Record Review process or tools can be submitted to: Melissa Reagan, M.S.W., L.S.W., Quality Management Specialist in the Capital region at Rebecca Rager, M.S.W., Quality Management Specialist in the Capital region at Maria Bakner, M.S., L.P.C., Quality Care Manager in the Franklin/Fulton region at Allison Krause, R.N., Quality Care Manager, Sr. in the Bedford/Somerset region at 36

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