Treatment Planning MATRS. Jennifer Wyatt, LMHC, MT-BC, CDP: Northwest Addiction Technology Transfer Center (ATTC)

Transcription

1 Treatment Planning MATRS Jennifer Wyatt, LMHC, MT-BC, CDP: Northwest Addiction Technology Transfer Center (ATTC) Rev Apr 2015

2 The ATTC Network Ten Regional Centers Four National Focus Area Centers SBIRT Hispanic and Latino Native American- Alaska Native Rural and Frontier

3 Handouts Mobile phones ATTC Consent forms & evaluations

4 Training split into 4 sections Mon, May 4 in The Summit 10:15-11:45am 1:15-2:45pm 3:15-4:45pm Tues, May 5 in The Summit 10-11:30am Please bring handouts to each section and attend all parts.

5 Participant Introductions Name Agency Job Experience with assessment and treatment planning What is your favorite thing to do outside of work?

6 Training Expectations Identify characteristics of a program-driven ( old method ) and an individualized treatment plan ( new method ) Understand how individualized treatment plans improve client retention and ultimately lead to better outcomes Discuss the importance of language and words we use Practice formulating treatment plans and develop: Problem Statements Goals based on Problem Statements Objectives based on Goals Interventions based on Objectives

7 Treatment Plans are... Meaningless & time consuming Ignored Same plan, different names

8 We re going on a road trip... Let s play the Car Game.

9 Positive aspects of Treatment Planning Negative aspects of Treatment Planning

10 Treatment Planning Process Conduct assessment. Collect client data and collateral information. Identify problems and strengths. Prioritize problems; write problem statements. Write goal statements to address problems.

11 Treatment Planning MATRS Measurable T Attainable Time-limited Realistic Specific

12 Overview of your work for today: 1. Read the case scenario. 2. List the problems and strengths. 3. Write problem statements. 4. Prioritize concerns to be addressed in your treatment plan; no more than Develop goal statements for the 3 primary concerns. 6. Create objectives (what the client will do) and interventions (what the counselor/agency will do) to resolve the problems. 7. Note completion dates and methods to evaluate progress.

13 Take a look at ASAM. How can this placement information be used in conjunction with your assessment data to create successful treatment planning? Could it guide the treatment priorities and assist in decreasing the level of care needed?

14 ASAM Dimensions Acute Intoxication and/or Withdrawal Potential Biomedical Conditions & Complications Emotional, Behavioral, or Cognitive Conditions & Complications Readiness to Change Relapse, Continued Use, or Continued Problem Potential Recovery/Living Environment

15 The What, Who, When, & How of Treatment Planning What is a Treatment Plan? What should it do? Why do we have one?

16 What is a Treatment Plan? A written document that: Identifies the client s most important goals for treatment Describes measurable, time-sensitive steps toward achieving those goals Reflects a verbal agreement between the counselor and client Center for Substance Abuse Treatment, 2002

17 At its best, the treatment plan is an incremental road map for client success detailing where the client is going and how we will support them in getting there.

18 Who Develops the Treatment Plan? Client partners with treatment providers (ideally a multi-disciplinary team) to identify and agree on treatment goals and identify the strategies for achieving them. Should others, such as family members, prescribers, or POs contribute to a treatment plan?

19 When is the Treatment Plan developed? At the time of admission Continually updated and revised throughout treatment Reviews are required every 30 days for the first 90 days of treatment, and then every 90 days thereafter. When might you conduct an additional treatment plan review?

20 How does the Assessment guide treatment plan development? The assessment provides initial information to begin the process of treatment. It should be comprehensive and indicate multiple areas of concern from the client s perspective.

21 Update Assessment Information The Assessment should represent the presenting issues and identified problems at the time of admission to treatment. Note that the information may need to be updated to reflect the willingness of the client to share more information after they have developed a relationship with the primary counselor.

22 Designing Effective Treatment Client Assessment ASAM DSM GAIN Individualized Treatment Plan Referral Group Indiv. session Collateral Information Group

23 Components in a Treatment Plan 1. ASAM Dimensions & Problem Statements 2. Goal Statements 3. Objectives 4. Interventions 5. Completion Dates

24 Treatment Plan Components: Problem & Goal Statements Problem statements Based on information gathered in the assessment and updates Goal statements Based on problem statements Reasonably achievable during active treatment

25 Treatment Planning Essentials Measurable T Attainable Time-limited Realistic Specific

26 Let s get started.. Get into groups of 4-5. Read the case scenario. List all Problems, Strengths, & Questions. Prioritize no more than 3 problems to address in your treatment plan. Decide on levels in ASAM Dimensions (0-4); no need for specifics, just a general level. Choose overall level of care (0-4). We will discuss as a large group before moving on. You have 20 minutes.

27 Group reports Each group shares: Strengths All problems, including 3 priorities ASAM PPC across Dimensions 1-6 Overall recommended level of care for your treatment plan

28 Do you have questions you d like to ask Betsy? Info that might help? Each group can ask Betsy 3 questions: o Craft them carefully o Use your best MI skills: Remember openended vs close-ended questions Use: What, how, tell me about Avoid: Is, can, do, have

29 Remember Maslow s Hierarchy of Needs? 5 Self-actualization 4 Self-esteem 3 Love & Belonging 2 Safety & Security 1 Biological/Physiological

30 Biological and Physiological Needs Substance Use Physical Health Management Medication Adherence Issues 1 Biological/Physiological

31 Safety & Security Mental health management Functional impairments Legal issues 2 Safety & Security

32 Love & Belonging Needs 3 Love & Belonging Social & interpersonal skills Need for affiliation Family relationships

33 Self-Esteem 4 Self-Esteem Achievement and mastery Independence/status Prestige

34 Self-Actualization 5 Self-Actualization Seeking personal potential Self-fulfillment Personal growth

35 Take a minute to reevaluate your treatment planning priorities Has your group identified the most pressing issues from Betsy s perspective?

36 One size fits all Program Driven Plans

37 Program Driven Plans Created to serve the largest number of clients without individualizing treatment. Assume that something we do in our program will be beneficial to the client without special attention to individual needs.

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40 Program-Driven Plans Client has to fit into the standard treatment program. The client must fit or he/she is often determined not ready or inappropriate for treatment. Plan often includes only standard program components (e.g., group, individual). There is little difference between clients treatment plans. They appear to be cookie cutter.

41 Program-Driven Plans Goals are often written as: 1. Attend 3 AA meetings/wk 2. Complete Steps 1, 2, & 3 3. Attend group sessions 3x/wk 4. Meet with counselor 1x/wk 5. Complete 28-day program

42 Program-Driven Plans often Include only those services immediately available in agency. Do not include referrals to community services (e.g., parenting classes) Lack creativity

43 Individualizing Treatment Our goal is to identify the individual problems and needs of each client, and make every attempt to tailor the treatment to meet those needs.

44 Review of the Treatment Process Is treatment the same for everyone? Are there groups to meet the special needs of individuals in the program? Do the treatment groups address issues in the ASAM dimensions?

45 Let s Review the Treatment Plan Format. ASAM Dimensions Problem statements Goal statements Objectives Interventions Completion dates Signatures

46 What information is needed to individualize a Plan? Possible sources of information: Client Probation reports Screening results Assessment information Collateral interviews

47 The Old Method (Program-Driven) Problem Statement Alcohol Dependence Not individualized Not a complete sentence Doesn t provide enough information A diagnosis is not a complete problem statement.

48 Improved Problem Statement Examples Van: I am drinking every day and it takes more liquor now to get me drunk. Meghan: I am pregnant and need help with prenatal care. Tom: I have mental problems that get in the way of my recovery.

49 Tips on writing Problem Statements Include all identified problems, regardless of available agency services. A referral to outside resources is a valid approach to addressing a problem. List all problems, whether deferred or addressed immediately. Review and assess each ASAM domain. Avoid jargon. Use non-judgmental language. Use complete sentence structure.

50 Changing Language What do you think about these Problem Statements? Client has low self-esteem. Client is in denial. Alcohol dependent Client is promiscuous. Client is resistant to treatment. Client is on Probation because he is a bad alcoholic.

51 Changing Language - Examples Old language 1. Client has low self-esteem. New language 1. I don t feel good about myself. 2. Client is in denial. 3. Alcohol Dependent 2. I have two DUIs in the past year, but alcohol use is not a problem. 3. If I don t drink when I wake up in the morning, I get the shakes.

52 Changing Language - Examples Old language 1. Client is promiscuous. New language 1. I have sex with multiple partners. 2. Client is resistant to treatment. 3. Client is on Probation because he is a bad alcoholic. 2. In the past year, I started three different treatment programs but didn t finish any of them. 3. I have legal issues because of my drinking.

53 Vague terms to watch out for SAFE HEALTHY GOOD POSITIVE OR NEGATIVE APPROPRIATE What else?

54 Rate these Problem Statements: 1. I don t have a safe place for my children. 2. I have medical and substance abuse issues. 3. I don t have job skills. 4. I drink alcohol every day.

55 Rate these Problem Statements: 5. I have diabetes and a leg wound that won t heal. 6. The adults I live with drink alcohol. 7. I can t leave my kids to go to treatment. 8. I don t have a safe and drug-free place for me and my children to live.

56 Write Problem Statements for Betsy You have 20 minutes to develop problem statements for the three problems you have prioritized. THEN, I ll ask you to have a group spokesperson report on your work before we move on to the rest of the treatment plan.

57 The Old Method (Program-Driven) Goal Statement Will refrain from all substance use now and in the future Not helpful for treatment planning Cannot be accomplished by program discharge date

58 The Old Method (Program-Driven) Objective Statement Will participate in an outpatient program Not specific A level of care is not an objective.

59 The Old Method (Program-Driven) Intervention Statement Will see a counselor once a week and attend group on Monday nights for 12 weeks This sounds specific, but it really describes a program component.

60 Problem Problem and Goal Statements Betty: I have sex with multiple partners weekly. Goal Problem Goal I will learn sexual practices to protect me from HIV/STI. Thomas: I hear voices in my head and talk back to them. I will meet with a mental health provider for an evaluation.

61 Problem Problem and Goal Statements Edward: If I don t drink alcohol when I wake up in the morning, I get the shakes. Goal I will manage withdrawal from alcohol by going into a medical detox program. Problem Goal Marta: I have two DUIs in the past year, but alcohol use is not a problem for me. I will learn about alcohol use disorder.

62 Problem and Goal Statements Problem Goal Problem Goal Effie: I don t feel good about myself. I will learn about my personal strengths and skills. Damian: In the past year, I started three different treatment programs but didn t finish any of them. I will commit to completing a 4-week treatment group.

63 Why make the effort to individualize Treatment Plans? Leads to increased retention rates which are shown to improve outcomes Empowers the counselor and the client, and focuses counseling sessions Honors the uniqueness of each individual Recognizes multiple pathways to recovery

64 University of Washington Alcohol and Drug Abuse Institute: Retention Toolkit Research shows a direct correlation between remaining in substance use disorder treatment for at least 90 days and positive outcomes, including a reduction in substance use and criminal justice involvement. Website includes information on: Online training videos Cultural competence MI Motivational Incentives Family involvement

65 Goal Statement Examples 1. I will safely withdraw from alcohol, stabilize physically, and begin to establish a recovery program. 2. I will obtain safe care for my children when I go to residential treatment. 3. I will obtain medical treatment for my leg wounds. 4. I will eat better.

66 Objective Statement Examples 1. I will report any withdrawal symptoms. 2. I will begin activities on Monday that involve a substance-free lifestyle to support my recovery goals. 3. I will call Group Health to find a doctor to treat my leg wounds by I will consult three agencies to seek assistance for my child care needs by Thursday.

67 Intervention Statement Examples 1. Staff will assist Betsy in making an appointment with a primary care provider. 2. Staff will assist Betsy in finding child care services and help her to develop a dialogue for the phone conversations by role playing. 3. Staff will teach Betsy skills to cope with cravings for alcohol including using self-talk and urgesurfing. 4. Staff will assist Betsy in finding a sober support group for women.

68 Let s Create Goals, Objectives, and Interventions for Betsy Goal statements Resolution of the Problem statements Objectives Small incremental activities for the client to achieve the goals Interventions Activities the Counselor will complete to assist the client in achieving the goals

69 Check-in Discussion Are your treatment plan components Likely to be understood by the client? Free of clinical jargon? Clearly stated? Written in complete sentences? Attainable in active treatment phase? Agreeable to both client and staff?

70 Prep for the next exercise Each group will hand off their treatment plan to another group. Each group will point out strengths and share feedback. Please be sensitive. The treatment plan in front of you represents a group s best work today. First, let s go over a framework that will help you provide feedback.

71 Treatment Planning Essentials Measurable T Attainable Time-limited Realistic Specific

72 Objectives & Interventions (It MATRS!) Measurable Achievement of objectives and interventions is measureable. Measurable indicators of client progress Assessment scales/scores Client report Behavioral and mental status changes

73 Objectives & Interventions (It MATRS!) Attainable Objectives and interventions can be achieved during the active treatment phase. The focus is on improved functioning. Identify goals that are attainable in Level of Care provided. Remember to revise goals when client moves from one Level of Care to another.

74 Objectives & Interventions (It MATRS!) T Time-limited Focus on goals and objectives that are short term. Objectives and interventions should be reviewed within a specific time period.

75 Objectives & Interventions (It MATRS!) R Realistic The client can complete the objectives within a specific time period. Goals and objectives are reasonable given the client s environment, supports, diagnosis, and level of functioning. Progress requires client effort and buy in. This is essential.

76 Objectives & Interventions (It MATRS!) Specific Objectives and interventions are specific and goal-focused. Address in specific behavioral terms how level of functioning or functional impairments will improve with the interventions.

77 Clinical Example Problem Statement: I have been in the emergency department three times for treatment in the last six months due to fights with my boyfriend when we were drunk. M R T A S

78 Clinical Example Goal Statement: I will develop a personalized Safety Plan. M R T A S Objective Statement: I will create a personalized Safety Plan by attending 6 Domestic Violence Awareness classes between and Intervention Statement: Staff will assist Betsy in contacting the Domestic Abuse Women s Network (DAWN) by

79 Do the examples pass the MATRS Test? Measureable: Yes, the counselor can evaluate how many classes attended. Attainable: Yes, the client has transportation to attend classes. T R S Time-Limited: Yes, the class runs for 6 weeks. Realistic: Yes, the client has the ability to attend classes. Specific: Yes, examples include specific activities.

80 The MATRS Test Measurable? Can change be documented? Attainable? Achievable within active treatment phase? Time-Related? Is time frame specified? Will staff be able to review within a specific period of time? Realistic? Is it reasonable to expect the client will be able to take steps on his or her behalf? Is it agreeable to client and staff? Specific? Will client understand what is expected and how program/staff will assist in reaching goals 80

81 Review of group Treatment Plans Does it pass the MATRS test? What are the strengths of the plan? What suggestions do you have that might improve the plan? M R T A S

82 What have you learned about your own treatment planning process as you ve listened to others work?

83 The Stages of Change Illustrated Adapted from Prochaska & DiClemente, 1982; 1986

84 Consider how the Stages of Change impact Treatment Planning 5. Maintenance 6. Relapse 4. Action 3. Preparation 2. Contemplation 1. Pre-Contemplation Adapted from Prochaska & DiClemente, 1982; 1986

85 Pre-Contemplation I don t have a problem. Person is not considering or does not want to change a particular behavior.

86 Maybe I have a problem, but I m not sure what to do about it. Contemplation Pre-Contemplation Person is thinking about changing a behavior.

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88 I ve got to do something. Preparation Contemplation Person is seriously considering changing a behavior by planning and taking steps toward change. Pre-Contemplation

89 Action I m ready to start. Person is actively doing things to change or modify behavior. Contemplation Pre-Contemplation Preparation

90 How do I keep going? Maintenance Action Preparation Contemplation Pre-Contemplation Person continues to maintain behavioral change until it becomes permanent.

91 What went wrong? Maintenance Relapse Action Contemplation Preparation Pre-Contemplation Person returns to the previous pattern of behavior that they had begun to change.

92 Client name/unique identifier Dated, Signed, Legible Start/stop time Credentials Basic guidelines of documentation Specific problems, goals & objectives addressed Add new problems, goals, & objectives Session content & client response Progress toward goals & objectives Interventions used to address problems, goals, & objectives

93 Documentation: Basic Guidelines Entries should include: Report on progress, or lack thereof, on the treatment goals, objectives and interventions, with specific references to each Any new developments or concerns The focus and content of the session Accomplishments or agreements

94 Documentation: Basic Guidelines Describes: Changes in client status Responses to, and outcomes of, interventions Observed behaviors Progress toward goals and completion of objectives

95 The Golden Thread

96 The client s treatment record is a legal document.

97 Documentation: Basic Guidelines Legal Issues & Recommendations: Document non-routine calls, missed sessions, and consultations with other professionals. Avoid reporting staff problems in case notes, including staff conflict and disagreements. Chart client s non-conforming behavior. Record unauthorized discharges and elopements. Note limitations of the treatment provided to the client.

98 Concurrent Documentation Completed in the presence of the client with their input. Think of this in terms of how your physician documents their work with you while you are in the exam room. This gives the client an opportunity to assist in documentation that they agree to, and takes away the mystery of what is written about in the chart. This is not always an option with all clients. Use your clinical judgment.

99 What will you take with you back to your work?

100 Evaluations Thank you for sharing your feedback on our programming with us! We use this information to improve our services and to share information with SAMHSA about our work. Please complete the Evaluation Form and the Thirty-Day Follow Up Consent Form. If you complete our Thirty-Day Follow Up survey, we will thank you with a $5 coffee card.

101 Visit Us Online! Upcoming trainings The range of training and technical assistance services we offer Resources and links on key topics