Presenters: Ahlam Elbedewe, LSW Briannon O Connor, PhD David Eckert, LMHC, NCC, CRC. The Managed Care Technical Assistance Center of New York

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1 Presenters: Ahlam Elbedewe, LSW Briannon O Connor, PhD David Eckert, LMHC, NCC, CRC The Managed Care Technical Assistance Center of New York

2 Who is MCTAC?

3 MCTAC Partners

4 Respond to questions and comments from the previous two webinars Please post in the comments section live during this session also Review components of effective case conceptualization Discuss conceptualization of a case example using the Five P s framework Review components of effective treatment planning Consider appropriate treatment goals for the case example Identify key points for communication with MCOs

5 Who would be responsible for answering why previous services was not successful before the individual sought care the current organization? Would this question be answered in referral documentation? What training is required for our utilization management specialist/liaison? Is this approach to case conceptualization suggested by MCOs?

6 Case conceptualization is a process whereby therapist and client work collaboratively to first describe and then explain the issues a client presents using theory. Its primary function is to guide [treatment] in order to relieve client distress and build client resilience (Kuyken, Padesky and Dudley, 2008) The Five P s Presenting problems: Demographics, identify needs Predisposing factors: History of problems and treatment; biological, environmental, psychological, interpersonal factors Precipitating factors: Contextual information; things that immediately precede problems Perpetuating factors: Behavioral, biological, and cognitive factors; interpersonal stressors Protective/positive factors: Strengths and supports Kuyken, Padesky and Dudley, 2008; Macneil et al., 2012

7 Ms. Amy Cook, 28yo, divorced African American Female Self referred for Substance Abuse Treatment Services Identified her primary problem as alcohol use (6 beers daily), along with regular cocaine use (weekly: 2-3 times $30 dollars worth ). Alcohol use for 18 years and cocaine use for 12 years. Initially her cocaine and alcohol use had been recreational, however, Amy s use had quickly become a more serious problem with daily use by the time she was 20 years old. Amy explained that her tolerance had quickly increased and before she realized it, she needed more of the substance to get the same effect. She had not experienced any serious side effects or medical complications. When asked about medical issues, Amy denied having any blackouts, tremors, seizures or delirium tremors. Amy reported that she had been told she had Hypertension in the past, but was not currently experiencing any difficulty related to this medical condition and was not taking any medication.

8 At the time of her intake assessment, Amy was cooperative, alert and oriented x 3 with her speech well within normal limits. Amy was appropriately dressed and groomed. Amy was asked about her current and past psychological functioning by the intake counselor and denied being troubled by any psychological or emotional problems, unrelated to her drug and alcohol use, in the last thirty days. When asked about her general psychological functioning, Amy denied having any hallucinations or delusions, now or in the past. Amy denied having any difficulty with her thinking process at this time, but reported that in the past she has had difficulty concentrating and at times has had racing thoughts. Amy denied having any thoughts of suicide or homicide at this time, or in the past 30 days and reported that she had never attempted suicide at any time in her life. Amy presented with a full range of affect and showed moderate insight. Amy s self-concept was appropriate, her memory was good and her judgment did not appear to be impaired.

9 Amy completed all but one year of high school, and received specialized training as a welder. Her most recent job was as a parking attendant. Her longest period of continuous employment was just over one year, and she has worked irregularly throughout her adult life. Amy reported her current financial support comes mainly from her grandmother and from her employment.

10 Amy reports involvement with legal issues Driving without a license, three DUI s, possession charges, and prostitution On probation for shop lifting, writing bad checks, and probation violations Currently on probation

11 Currently living with her grandmother, who raised her. She is a mother of 4 children (ages 11,7,4,2). She was 17 yo when she had her first child. The older two sons are living in foster care. The younger two daughters have complex health problems and developmental delays; they live with another relative. She is no longer in contact with any of the children's fathers (three men), and was only briefly married to the second man. She reported that both of her parents, several uncles and aunts, and both of her siblings all have significant drinking and/or drug use problems. She has no close friends and a distant, conflicted relationship with family members other than the grandmother with whom she has almost always lived. She has great difficulty in "getting along" with people. She was physically abused as a child, which prompted her move to the grandmother's home. Amy described alcohol as part of her family experience from her earliest memories. Amy talked about how drug use later became a normal part of family gatherings for her and her siblings. Amy shared that she did not feel that she had any problems socially, emotionally or psychologically until she was in her late teens. Amy reported that she began to spend more time with people that used illicit substances and began to get into trouble for shoplifting and prostitution, something she did to support her drug use.

12 At the time of her intake, Amy reported that she had never been hospitalized for any major medical problems She reported hypertension as a chronic medical problem but denied that it interfered with her life.

13 Amy reported that she had been treated for drug abuse on 4 occasions, with 2 of these episodes being brief detoxification for alcohol use. Amy explained that she had attempted detoxification programs, but that she typically had resumed her substance use in a matter of days. Amy denied attending any treatment programs after leaving detoxification for more than a few days at a time. Amy did report sporadic participation in AA/NA meetings. Amy reported that her longest period of abstinence had been for 60 days. Amy explained that she had been substance free for 4 weeks.

14 Treatment targets the functional deficits to reduce or eliminate the impact of the diagnoses. (Established in the Treatment Plan) Documentation needs to include: Treatment has been ordered or prescribed by the appropriate individual credentials are critical The service should be generally accepted as effective for the mental illness/addiction being treated The individual must be willing to participate in treatment The individual must be able to benefit from services provided, and they are in the right level of care There must be evidence of active client participation in treatment

15 Well-written objectives drive effective Treatment Plans! Follow a specific formula: Simple, Measurable, Achievable Realistic, and Time-limited (SMART) Realistic, Understandable, Measurable, Behavioral, and Achievable Objectives should be written with client and crossed off the list when achieved

16 Objectives: Amy will work towards her sobriety and recovery and within the next 90 days, will find sponsorship through 12 step group. Within the next 4-6 weeks, Amy will call her grandmother and brother and ask them to attend a family therapy session. For the next 3 months, Amy will report on her weekly attendance to 12 step meetings. Within next 4 weeks, Amy will bring to session her job application log and attendance to employment service agency. Amy will coordinate with probation officer for an in person check in by week 6 to meet with counselor and Amy to discuss progress

17 Simple, Measurable, Achievable Realistic, and Time-limited (SMART) Goals/Objectives/Interventions: (identified in collaboration with client) 1. Work toward sobriety and recovery Objective: Within the next 90 days, Amy will get the support of a sponsor through her local AA/NA group. Intervention: Attend regular individual and group sessions, providing urine samples as requested 1. Obtain better employment so that she could become financially self-sufficient and not rely on grandmother Objective: Before the end of the year, Amy will identify areas of interest and a list of potential employers, along with exploring available employment and vocational services Intervention: Meet with vocational specialist as the local One-Stop Employment Center 2. Address chronic medical condition of hypertension Objective: Find a doctor that will help develop a course of treatment that can help her manage her Hypertension Intervention: Utilize referral services offered by Managed Care Organization (as needed) 3. Address legal obligations to probation Objective: Throughout the time Amy is on Probation, she will remain in good standing Intervention: Provide urine samples as requested, attend scheduled appointments with officer, attend all group and individual sessions scheduled

18 Diagnosis: Alcohol Use Disorder: Severe Cocaine Use Disorder: Severe Presenting Problems: Excessive use of substances impeding on daily functioning, Lack of social supports, untreated chronic medical condition, Legal issues Predisposing Factors: Family hx of SUD, legal issues, interpersonal relationship strains, financial strain, medical condition potentially perpetuated by SUD, hx of tx drop out, risk taking behaviors Precipitating Factors: Untreated medical condition potentially perpetuated by SUD, High risk use, interpersonal, legal, financial stressors Perpetuating Factors: Limited support network, strained interpersonal relationships, medical condition, low self esteem, history of trauma and continuous use Protective/positive Factors: Past history of sobriety, 12 step involvement, some family support, a safe living situation, strong desire to change her life

19 As part of the initial substance use evaluation process, the treating program completed the LOCADTR with client. Level of care determination was for Outpatient Rehabilitation Services

20 For people who have lower relapse potential and higher recovery capital (individual strengths that support recovery, such as housing, family, or job) Abstinence based drug treatment program for people who live at home or in the community Clinic includes Intensive Outpatient Service all admissions to IOS should be reported to the plan. Most programs will use the LOCADTR report to notify. Programs are required to complete a LOCADTR for all admissions within 3 visits. Plans may not require calls, reports or other routine requests for authorization for clinic admission. Programs may be reviewed by plans for clinic admission standards if practices trigger an approved admission review target.

21 How will the treatment impact Amy s individualized psychosocial needs? Why is this treatment necessary? What else has been tried and why hasn t it been sufficient? Would she be successful in a lower level of care? Why or why not? What will be accomplished by this treatment? How does this treatment fit into the bigger picture of Amy s recovery? How will you know when a treatment goal has been achieved? What are you looking for? How will you monitor it?

22 What strengths and supports does she have that will facilitate discharge/transition to lower level of care and recovery? Where is the evidence that recovery goals are member driven? Is Amy willing to participate in rehabilitation activities? What is the proposed time period for the treatment plan? Clinical justification with measurable goals and objectives Are there anticipated barriers treatment success? What is in place to address these barriers?

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