Individual Treatment & Recovery Planning Page 3 of 5

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1 WCHO PIHP/CA POLICY fr the LIVINGSTON-WASHTENAW COORDINATING AGENCY Plicy and Prcedure Individual Treatment and Planning Prcess Plicy Department: Crdinating Agency Authr: Marci Scalera Apprval Date 4/17/12 Lcal Plicy Number (if used) Implementatin Date 5/1/12 I. PURPOSE The purpse f this plicy is t establish the requirements fr individualized treatment and recvery planning. Cnsistent with a recvery riented system f care, treatment and recvery plans must be a prduct f the client s active invlvement and infrmed agreement. Direct client invlvement in establishing the gals and expectatins fr treatment is required t ensure apprpriate level f care determinatin, identify true and realistic needs and increase the client s mtivatin t participate in treatment. By participating in the develpment f their recvery plan, clients can identify resurces they already be familiar with in their cmmunity and begin t learn abut additinal available services. Treatment and recvery planning requires an understanding that each client is unique and each plan must be develped based upn the individual needs, gals, desires and strengths f each client. The planning prcess can be limited by the infrmatin that is gathered in the assessment r by actual treatment planning frms. These planning frms shuld be reviewed n at least an annual basis t ensure that the infrmatin that is being gathered r the manner in which it is recrded cntinues t supprt the individualized treatment and recvery planning prcess. II. REVISION HISTORY DATE REV. NO. MODIFICATION March/2012 III. IV. POLICY It is the plicy f the Livingstn/Washtenaw Substance Abuse Crdinating Agency (CA) that every client seeking substance abuse services shall participate in the develpment f his r her treatment and recvery plan. (Administrative Rules fr Substance Abuse Prgrams in Michigan, prmulgated under PA 368 f 1978, as amended). PERSONS AFFECTED Individual Treatment & Recvery Planning Page 1 f 5

2 This plicy applies t all staff, vlunteers, peers and student/interns f the Livingstn/Washtenaw Crdinating Agency (CA), its cre prviders and its cntracted netwrk f substance use prviders. All CA prviders must be licensed and accredited by ne f fur natinal accreditatin bdies V. DEFINITIONS Nne VI. STANDARDS Treatment and recvery planning begins at the time the client enters treatment either directly r based n a referral frm an access system, and ends when the client cmpletes frmal treatment services. Planning shuld be a dynamic prcess that evlves beynd the first r secnd sessin when required dcumentatin has been cmpleted. Thrughut the treatment prcess, as the client s needs change, the plan must be revised t meet the new needs f the client. Recvery Planning is undertaken as a cmpnent f the treatment plan and shuld prgress as the client mves thrugh the treatment prcess. It is imprtant that the recvery plan be a viable and wrkable plan fr the client and that upn discharge he/she is able t cntinue alng his/her recvery path with guidance frm his/her plan. It is nt acceptable that the recvery plan be develped the day befre a client s planned discharge frm treatment services. The treatment and recvery plans are nt limited t just the client and the cunselr. The client can request any family members, friends r significant thers t be invlved in the prcess. Once each plan is cmpleted, the client, cunselr and ther invlved individuals must sign the frm indicating understanding f the plan and the expectatins. Establishing Gals and Objectives The initial step in develping an individualized treatment and recvery plan invlves the cmpletin f a bipsychscial assessment. This is a cmprehensive assessment that includes current and histrical infrmatin abut the client. Frm this assessment, the needs and strengths f the client are identified and it is this infrmatin that assists the cunselr and the client in establishing the gals and bjectives that will be fcused n in treatment. The identified strengths can be used t help meet treatment gals. After strengths are identified, the cunselr assists the client in using these strengths t accmplish the identified gals and bjectives. Identifying strengths f the client can prvide mtivatin t participate in treatment and may take the fcus ff any negative situatins that surrund the client getting invlved in treatment-- such as legal prblems, wrk prblems, relatinship prblems, etc. Writing the Plan Once the gals and bjectives are jintly decided n, they are recrded in the planning dcument utilized by the prvider. Gals must be stated in the client s wrds. Each gal that is written dwn shuld be directly tied t a need that was identified in the assessment. Once a gal has been identified, then the bjectives the steps that need t be taken t achieve the gal are recrded. The bjective must be develped with the client but d nt have t be recrded in the client s exact wrds. The bjectives need t be written in a manner in which they can be Individual Treatment & Recvery Planning Page 2 f 5

3 measured fr prgress tward cmpletin alng with a targeted cmpletin date. The cmpletin dates must be realistic t the client r the chances f cmpliance with treatment are greatly reduced. Establishing Treatment Interventins The next cmpnent f the plan is t determine the interventin(s) that will be used t assist the client in being able t accmplish the bjective. What act r actins will the client take t achieve a gal and what actin will the cunselr take t assist the client in achieving the gal. Again, these actins must be mutually agreed upn t prvide the best chance f success fr the client. Framewrk fr Treatment The individualized treatment and recvery plan prvides the framewrk by which the services shuld be prvided. Any individual r grup sessins that the client participates in must address r be related t the gals and bjectives in the plan. When prgress ntes are written, they reflect what gal(s)/bjective(s) were addressed during a treatment sessin. The prgress ntes recrded by the clinician, shuld dcument any adjustments/changes t the treatment and recvery plan. Once a change is decided n, it shuld then be added t the plan in the frmat described abve. Treatment Plan Prgress Reviews Plans must be reviewed and this review must be dcumented in the client recrd. The frequency f the reviews can be based n the time frame in treatment (60, days) r n the number f treatment episdes that have taken place since admissin r since the last review (8,10,12 episdes). The reviews must include input frm all clinicians/treatment/recvery prviders invlved in the care f the client as well as any ther individuals the client invlved in their plan. This review shuld reflect n the prgress the client has made tward achieving each gal and/r bjective, the need t keep specific gals/bjectives r discntinue them, and the need t add any additinal gals/bjectives due t new needs f the client. As with the initial plan, the client, clinician and ther relevant individuals shuld sign this review. The plan and plan reviews nt nly serve as tls t prvide care t the client, they help in the administrative functin f service authrizatins. All decisins cncerning, but nt limited t, length f stay, transfer, discharge, cntinuing care and authrizatins by the CA must be based n individualized determinatins f need and n prgress tward treatment and recvery gals and bjectives. Such decisins must nt be based n arbitrary criteria such as pre-determined time r payment limits. Plicy Mnitring and Review The CA will mnitr cmpliance with individualized treatment and recvery planning and these reviews will be made available t the Bureau f Substance Abuse and Addictin Services (BSASS) during site visits. BSAAS will als review fr individualized treatment and recvery planning during the prvider site visits. Reviews f plans will ccur in the fllwing manner: A review f the bipsychscial assessment t determine where and hw the needs were identified A review f the plan t check fr: Matching gals t need Needs frm the assessment are reflected in the gals n the plan Individual Treatment & Recvery Planning Page 3 f 5

4 Gals are in the client s wrds and are unique t the client. N standard r rutine gals that are used by all clients Measureable bjectives the ability t determine if and when an bjective will be cmpleted Target dates fr cmpletin the dates identified fr cmpletin f the gals and bjectives are unique t the client and nt just rutine dates put in fr cmpletin f the plan Interventin strategies the specific types f strategies that will be used in treatment- grup therapy, individual therapy, cgnitive behaviral therapy, didactic grups, etc. Signatures client, cunselr and ther invlved individuals Recvery planning activities are taking place during the treatment episde A review f prgress ntes t ensure dcumentatin relates t gals and bjectives A review f the treatment and recvery plan prgress review t check fr: Prgress nte infrmatin matching what is in the review Ratinale fr cntinuatin/discntinuatin f gals/bjectives New gals and bjectives develped with client input Client participatin/feedback present in the review Signatures VII. VIII. I. See Standards abve. EHIBITS Nne REFERENCES Reference: 42 CFR Parts 400 et al. (Balanced Budget Act) Check if applies: 45 CFR Parts 160 & 164 (HIPAA) 42 CFR Part 2 (Substance Abuse) Michigan Mental Health Cde Act 258 f 1974 Michigan Department f Cmmunity Health (MDCH) Medicaid Cntract MDCH Substance Abuse Cntract Michigan Medicaid Prvider Manual Standard Numbers: Individual Treatment & Recvery Planning Page 4 f 5

5 ADDITIONAL REFERENCES: Mee-Lee, D., Shulman, G.D., Fishman, M., Gastfriend, D.R., & Griffith, J.J. (Eds.) (2001). ASAM Patient Placement Criteria fr the Treatment f Substance-Related Disrders, Secnd Editin-Revised (ASAM PPC-2R). Chevy Chase, MD: American Sciety f Addictin Medicine, Inc. Miller, Sctt, Mee-Lee, David, Plum, Bill and Hubble, Mark. (2005). Making Treatment Cunt: Client-Directed, Outcme Infrmed Clinical Wrk with Prblems Drinkers. Jhn Wiley & Sns, Inc., Hbken, N.J. Natinal Institute n Drug Abuse (2000). Principles f Drug Addictin Treatment. Washingtn D.C.: NIDA Sctt, D. Miller, Barry L. Duncan. (2000). Paradigm Lst: Frm Mdel-Driven t Client- Directed, Outcme Infrmed Clinical Wrk. Institute fr the Study f Therapeutic Change, Chicag, Illinis.. PROCEDURES WHO Substance Abuse Cre Prvider Crdinating Agency DOES WHAT Cnducts cmprehensive bipsychscial assessment. Using a strength based apprach, establishes Gals and Objectives in cnjunctin with the client. Plan must be written in measurable terms with target cmpletin dates and prgress reprted. Plans must define interventins that will be used t address the gals. Prvider schedules plan reviews at least minimally 90 days, but may review sner as necessary. Will mnitr cmpliance with individualized treatment planning during site visits. Individual Treatment & Recvery Planning Page 5 f 5