Review from Session 4

Transcription

1 Zakia Clay, MSW, LCSW Ann Reilly MA, LSW, CPRP Anthony Zazzarino MA, LPC, CPRP Rutgers, The State University of New Jersey Review from Session 4 Comprehensive Rehabilitation Needs Assessment Knowledge, Skills, Resources Form Learning Objectives Review Knowledge, Skills, Resource (KSR) and its connection to the rehabilitation plan. Practice developing an Individualized Rehabilitation Plan. Identify stages of change and its importance in developing appropriate interventions. Develop a framework for documentation (Data, Assessment, Plan - DAP). Describe the critical components of a progress note.

2 Rehabilitation Plan Process CRNA: Identifies goals. KSR Form: Helps identify the critical components needed to achieve the goal. Once prioritized to 3 to 5 identified areas, written in S-M-A-R-T format, becomes the objectives in the Rehabilitation Plan. Rehabilitation Plan: Incorporates the CRNA with the KSR form. Adds S-M-A-R-T interventions to match objectives and drives the intentional billable services. Why Individualized Rehabilitation Planning? Links the steps to achieve the goal with the interventions Interventions aim to eliminate the deficits Identifies who is responsible for doing what, by when, for how long, and where Increases sense of accountability Operationally defines the rehabilitation team approach (Anthony, Cohen, Farkas, Gagne, 2002) Individualized Rehabilitation Plan (IRP) Rehabilitation and recovery goals Objectives Strategy/intervention to be employed Anticipated outcomes Expected frequency and duration of each activity Type of practitioner to provide the service Location service to be provided (Larosiliere, 2011)

3 Individualized Rehabilitation Plan Example Interventions Assist Review Check-in Support Encourage Transport Are these terms you currently use? What is the intended service that you are providing? Individualized Rehabilitation Plan Activity Part 1 (10 min) Step 1: Partner up with someone that you don t know Step 2: Identify a NEW goal that you are working on Step 3: Work with your partner to break the goal down into the critical components utilizing the KSR Form Switch roles at the buzzer

4 Individualized Rehabilitation Plan Activity Part 2 (10 min) Step 1: Identify your strengths and areas for improvement by checking off the appropriate boxes on the KSR form. Step 2: Talk with your partner; prioritize 3 to 5 areas of need that your want to work on first. Step 3: Break down the 3 to 5 prioritized items into S-M-A-R-T format. Switch roles at the buzzer Individualized Rehabilitation Plan Activity Part 3 (10 min) Transfer the information from the KSR Form to your Individualized Rehabilitation Plan Keep in mind: Strengths S-M-A-R-T objectives Develop S-M-A-R-T interventions to match each objectives Switch roles at the buzzer Rehabilitation Plan Process CRNA: Identifies goals. KSR Form: Helps identify the critical components needed to achieve the goal. Once prioritized to 3 to 5 identified areas, written in S-M-A-R-T format, becomes the objectives in the Rehabilitation Plan. Rehabilitation Plan: Incorporates the CRNA with the KSR form. Adds S-M-A-R-T interventions to match objectives and drives the intentional billable services.

5 Stages of Change Maintenance Precontemplation Action Contemplation Preparation Stages of Change Pre-Contemplation-Not seeing a problem behavior or not considering change. Contemplation-Acknowledging that there is a problem but struggling with ambivalence. Weighing pros and cons and the benefits and barriers to change. Preparation-Taking steps and getting ready to change. Action-Making the change and living the new behaviors, which is an all-consuming activity. Maintenance-Maintaining the behavior change that is now integrated into the person's life. (Miller, 2009) Goal: I will secure a part time job by 12/15/14

6 Stages of Change Activity How does this translate to visits Pre-Contemplation Contemplation/Preparation Action Maintenance Outreach Trusting Relationship Practical Support Assessment Motivational Interventions Education Skill building Social Support Cognitive Behavioral Interventions Planning Recovery Lifestyle Social Support Rehabilitation Plan Revisions Goal (s) have been accomplished Consumer no longer wants to work on chosen goal (s) Unforeseen events Disengagement Incarcerations/Hospitalizations

7 Documentation Should be: Concise Timely Readable Easily understood Complete Accurate Must relate to a service on the rehabilitation plan There is adequate content for time billed Should reflect the intervention(s) being addressed during the visit D-A-P Format Data Assessment Plan Data Review of consumers follow-up activities Specific interventions Linkage to the rehabilitation goal Data Consumer report

8 Assessment Consumer response to the intervention Assessment of progress towards IRP goals, objectives, and interventions Assessment of change in consumer behavior Plan Staff/Consumer next steps Date and time of next service delivery Plan Progress Note Example

9 D-A-P Checklist Golden Thread of Documentation CRNA Rehabilitation Plan Progress Note Documentation Do s and Don ts Why do some claims get returned?

10 References Alexander, M. J., & Haugland, G. (2000). Integrating services for cooccurring disorders. Final report prepared for the New York State Conference of Local Mental Hygiene Directors. Orangeburg, NY: Center for the Study of Issues in Public Mental Health, Nathan S.Kline Institute for Psychiatric Research. Retrieved from Services%20for%20CoOccurring%20Disorders_ pdf Anthony, W., Cohen, M., Farkas, M., & Gagne, C. (2002).Psychiatric rehabilitation. (2nd ed., pp ). Boston: Center for Psychiatric Rehabilitation. Larosiliere, V (2011). Community Support Services [memo]. Retrieved from o_provi ders.pdf. References (continued) Miller, W.. & Rollnick, S. (2009). Ten things that Motivational interviewing is not. Behavioral And Cognitive Psychotherapy, 37, Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing. New York: Guilford Press. New Vitae. (2014). Documentation, the D.A.P. Format, and Writing Incident Reports [Module #5]. Quakertown, PA: Human Resources. References (continued) Pratt, C. W., Gill, K. J., N.M, & Roberts, M. M. (2014). Psychiatric Rehabilitation. (3 rd ed.) San Diego, CA: Elsevier Inc. Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of selfchange of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), Retrieved from /2010/426/Readings/Theoretical%20Framework/Stages%20of %20Change%20%20Prochaska% pdf