Collaborative Documentation on Daily Living Activities Regardless of Age

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1 Collaborative Documentation on Daily Living Activities Regardless of Age Katherine Hirsch and Annie Jensen MTM Services 0 Learning Objectives Participants will be able to identify the benefits of the collaborative documentation process from three perspectives: Improvement in Quality of life for direct care and support staff Compliance with documentation submission standards within each agency Enhanced therapeutic alliance with clients and recovery focused service documentation with all documentation that is completed with clients including the DLA-20 Participants will understand the function of the DLA-20, and how it is used to identify a clients strengths and functional needs in relation to their Daily Living Activities. Participants will understand how the DLA-20 is used to identify clients function throughout treatment and to collaborate with the client throughout the process of the assessment, the treatment plan and progress notes to maintain a client centered approach which continues to assess improvements in functioning. Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 1 1

2 Medical Necessity 3 essential components to establish medical necessity: 1.Diagnosis of a mental, behavioral, or emotional disorder Serious mental illness (SMI), severe & persistent mental illness (SPMI), serious emotional disturbance (SED), or alcohol/drug dependence See American Psychiatric Association (APA) DSM- IV for diagnostic criteria 2.Disorder has been diagnosed in the past year 3.Disorder results in functional impairment which substantially interferes with or limits one or more daily life activities Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 2 Using the Daily Living Activities Scale to establish Medical Necessity This means that functional impairment(s) in daily living activities must be present in clinical documentation in order to establish medical necessity. Providers & clients collaborate on 20 ADLs in one tool and cross cut symptoms/diagnoses with anchors, to demonstrate functional impairments in daily living. Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 3 2

3 Daily Living Activities Functional Assessment 4 The DLA-20 is a 10 minute, one page summary functional assessment Designed to be an objective tool for use by trained directcare staff Proven to be reliable and valid (No more guessing a number within a range of functioning) 20 specific daily living activities that are assessed Level of impairment for each type of activity is rated on a seven-point scale (1 through 7) Lower numbers indicate more severe impairment A 7 indicates complete absence of impairment for that activity Designed to assess what activities of daily living are strengths and what are the areas of need Tool quickly identifies where client outcomes are needed so clinicians can address those functional deficits on individualized service plans. For each client, one DLA sheet can be used five times to track progress across repeated assessments (recommended: every 3 to 6 months) Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 20 Areas Scored on the DLA-20 Health Practices Housing Stability Communication Safety Managing Time Managing Money Nutrition Problem Solving Family Relationships Alcohol and Drug Use Leisure Community Social Network Sexuality Productivity Coping Skills Behavior Norm Personal Hygiene Grooming Dress Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 3

4 How to Score the DLA For each of the 20 daily living activities, you will assign a score (1 7) that reflects your client s functioning in the past 30 days Think of the DLA as a snapshot of your client s life in the past month Scoring Strengths A strength means that, compared to the rest of the population, client s functioning is within normal limits Score these activities as 5, 6, or 7 Scoring Weaknesses A weakness means that, compared to the rest of the population, client s functioning is impaired and not within normal limits Score these activities as 1, 2, 3, or 4 Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 6 Collaborative Documentation What is Collaborative Documentation? > Collaborative Documentation is a process in which clinicians and clients collaborate in the documentation of the Assessment, Service Plan, and Progress Notes. > CD is a clinical tool that provides clients with the opportunity to provide their input and perspective on services and progress, and allows clients and providers the opportunity to clarify their understanding of important issues and focus on outcomes. > The Client must be present and engaged in the process of documentation development. Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 7 4

5 Collaborative Documentation Appropriate for use in all clinical processes: Assessment DLA-20 Assessment Updates Service Planning Service Plan Updates Progress Notes Office Based or in Community with Individuals, Families & Groups Katherine Hirsch, LCSW, Clinical Consultant 8 Collaborative Documentation Can: Improve client engagement and involvement Help focus clinical work on change and positive outcomes Improve compliance Save you time and create capacity Improve quality of life of clinicians Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 9 5

6 Collaborative Documentation Requires a Shift in Thinking We need to stop thinking of clinical documentation as paperwork and start thinking about it as the clinical work. Be prepared to be more transparent as a provider. Be prepared to decrease how much you are writing. A great note does not mean a long note. Remember that it is OK to Agree to Disagree. Be prepared to shift your language to client friendly language that will still maintain medical necessity. Use clients language and terms that client can understand and/or relate to because using technical terminology can negatively impact treatment. Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 10 Documentation Strategies That Support Collaboration Key is to develop a meaningful clinical 11 narrative that follows the Golden Thread so that Collaborative Documentation can support: A natural, meaningful conversation Efficiency Medical necessity and compliance Medical Necessity implies Focus on functioning in three key documents Pulling the Golden Thread from the diagnostic assessment (1) through to the individualized treatment plan (2) and finally to the progress notes (3) Diagnostic Assessment Treatment Plan Progress Notes Describing signs and symptoms associated with diagnosis is not sufficient; must describe specific functional impairments Symptom-based plans are not enough; must include functionality-based treatment goals Willa S. Presmanes, Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW Progress reviews cannot be purely subjective; must document specific and measurable improvements in functioning 6

7 Collaborative Documentation: Intake/ Assessment Know your assessment instrument! Option 1 (Preferred) Take one content section at a time Presenting Problem Psychiatric Hx Family Hx, etc. Discuss the section with the client/ family Enter into system allowing client to see and comment/clarify Option 2 Sit with client and complete assessment item by item allowing client to see and comment/clarify Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 12 Collaborative Documentation: Intake/ Assessment Complete DLA 20 We are going to complete this form to assist us in better understanding how your symptoms are impairing your daily life Diagnoses: Talk with client about what diagnoses really are and then share your current conclusions and document with client. Use the symptoms they describe and the data from DLA 20 Interpretative/Clinical Summary Say OK, let sum up what we ve discussed today. Document with the client. Identified Needs/ Problems Develop clearly identified and prioritized Behavioral Health Needs (Problem Areas) that can be used to establish Goals. Utilize the DLA-20 data and current symptoms to identify the clients assessed need. This will be the link from the assessment to the goal. Say, So the areas that we ve identified that we should work on together are 1:.., 2:, etc. If the client doesn t want to work on one or more of these record that with the client. Katherine Hirsch and Annie Jensen, LCSW, Clinical Consultant 13 7

8 Service Planning Goals Definition: A Goal is a general statement of outcome related to an identified need in the clinical assessment which stems from the DLA-20 identified areas of need. A goal statement takes a particular identified need and answers the question, What do we (clinician and client) want the outcome of our work together to be, as we address this identified need? Willa S. Presmanes, MTM Services & NCCBH 14 Service Planning: From goals come specific objectives Service Plan Objectives are observable, measurable, changes in symptoms, behaviors, functioning, skills, knowledge, support level. etc. that relate to achievement of the goal, and are expected to result from planned interventions. The Assessment should identify the baseline levels of symptoms, functional/ skill deficits and behaviors that constitute the basis for the identified needs. Objectives are stated changes in these baselines. Willa S. Presmanes, MTM Services & NCCBH 15 8

9 Collaboratively Documenting Treatment Plan Objectives Attempt to develop a measurable and observable outcome that: Will be apparent to the client Meaningful to the client Achievable in a reasonable amount of time Can be assessed in an objective way Objectives are important to allow you and the client to tell if the work you are doing together is working. Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 16 Collaboratively Documenting Treatment Plan Interventions and Services Interventions Discuss the Intervention(s)/ Strategy(s) that will be used to help achieve the objective. Document with the client. Help them understand that this is what you will do to help them walk up the staircase. Services: Discuss the modality/service that the intervention(s) will be provided in as well as the planned frequency and duration. Review recommended frequency and confirm what they are able/ willing to commit to. Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 17 9

10 Keys to Completing Progress Note Be aware of the treatment goals and objectives. Start every session by reviewing the previous weeks note ( Plan Section) Break up the note (Many complete Mental status at beginning of the session) Interact normally with the client during session Wrap-up the session and complete note collaboratively Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 18 How do I do a CD progress Note? At end of session (Time usually used for Wrap Up ) say, Lets review, SUMMARIZE and write down the important parts of our session today. 1. New, salient information provided by client. 2. Changes in mental status 3. Goal(s) and Objective(s) that were focused on 4. Interventions Provided 5. Client s response to intervention (today) What did we do today that was helpful. 6. Client s progress re the Goal/ objective being addressed (Functioning) 7. Plan for continuing work ( What are you going to do? What an I going to do? What are we going to do together?) Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 19 10

11 Collaborative Documentation As A Clinical Tool The Plan was a much more powerful section when completed with the client. Tasks or skills that the client had a agreed to try were noted and reviewed at the beginning of the next session. (What is the client going to do) Tasks that I agreed to complete were noted and reviewed at next session as well. (What is the staff going to do) Topics that we did not have time to address. (What are we going to do together at the beginning of the next session) Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 20 Keys to Completing Progress Notes with Children Engagement Techniques: Use simple rewards Encourage the client to tell parent/ guardian about what we did today Identify activity client can do while completing the note (Squiggle game, jumping jacks, coloring, stress ball) Explain the need for their help with your homework. ( Help client understand what you need from them and how their input will help you. ) Value what the client says, using quotes when appropriate. Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 21 11

12 Collaborative Documentation Strategies General Tips: Assume that your clients will read their documentation at some point. Let clients see the computer/ documentation as it is being developed Agree to disagree! Do as much as you can. Identify the aspects of documentation that are most important to do collaboratively. Start with clients that you think will be receptive and who you are comfortable with. Then continue implementation from there. Start the process with new clients right away. Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 22 Client Vignette Katherine Hirsch and Annie Jensen, LCSW, Clinical Consultant 12

13 DLA-20 Coping Skills Jonny is somewhat accepting of adult correction and follows it some of the time until he is distracted with something else. He occasionally becomes angry and discouraged when he is given consequences for failing to complete a task. His teacher appears to be losing her patience with his classroom behavior. Mother is more effective in keeping him on task, but that is due to 1 on 1 attention she can provide. Jonny is easily distractible. Willa S. Presmanes Compliant MH Goals that relate to DLA-20 that need measureable objectives Examples of goals: Jonny wants to be able to concentrate in class and follow directions when given so he can engage in school and home without conflict or consequences. Jonny will be able to complete a task with no more than two prompts so he can participate in a group/team activity without distracting peers Mom wants her son Jonny to be able to focus and follow directions so he can succeed in school and to decrease constant redirection at home. Willa S. Presmanes, MTM Services & NCCBH 13

14 Example: Measurable OBJECTIVES Using functional challenges (<=4 DLA20 scores) Jonny will increase concentration and follow through as evidence by completing a task with 1-2 prompts so that he can participate in more classroom, leisure and home activities. Jonny will identify three coping skills and utilize a coping skill after prompted to assist in decreasing impulsive/ distractive behaviors so that client is succeeding in school/home/ community activities. Jonny will express when he needs help from his teacher by giving her a thumbs up signal at least 1 time a day so that he can improve his communication skills and ability to access supports. Willa S. Presmanes, MTM Services & NCCBH Progress Note Summary Revision Date: Page 1 Note Type: Weekly Bi-Weekly Monthly / Date Range: From through Organization Name: MTM Services Program Name: C and A Individual s Name (First / MI / Last): Jonny Record #: DOB: 6/22/2006 Goal(s)/Objective(s) Addressed As Per Individual s Individualized Action Plan: Yes / No Goal 1 Goal Goal Goal Objective 1 Objective Objective Objective Objective Objective Objective Objective Objective Objective Objective Objective Objective Objective Objective Objective Services / Interventions Provided During This Period: Jonny and this writer focused on starting a project together that requires us to take turns, work together and take our time. During today's session we played with clay and were working on making a figure. This writer was taking turns with Jonny to complete this clay figure. We were addressing ways of managing when we are taking turns and how to follow through with our own task. Jonny did a great job of expressing his frustration when he did not want to wait for his turn and also worked on taking his time during his turn so that the work was done well. Response to Services / Intervention(s) and Progress Toward Goals and Objectives: Jonny stated that he enjoyed playing with the clay but that it was hard to take turns. He stated that he likes how our object turned out. Jonny did a great job following directions and staying on task today. He appears to be showing progress in managing his impulsive behavior and following 1 step task directions. Plan / Additional Information: Jonny will 1)participate in at least one family activity that requires people to take turns to continue working on managing his impulsive behaviors 2) Ask for help at least three times this week from family, friend or teacher 3) Complete at least three tasks this week with no more than 2 prompts. Clinician will contact Jonny's teacher to see how he is improving in class Next session we will work together to continue working on taking turns and following 1-2 step directions. Individual s Signature (Optional): Date: Completed By - Print Staff Name/Credentials: Staff Signature: Date: Supervisor - Print Name/Credentials (if applicable): Supervisor Signature: Date: Date of Service Staff Identifier Loc. Code Service Code Mod 1 Mod 2 Mod 3 Mod 4 Start Time Stop Time Duration in Minutes Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 14

15 Questions Katherine C. Hirsch, LCSW, and Annie Jensen, LCSW 15

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