The Quality Review PEE DEE MENTAL HEALTH CENTER QA/CARF NEWSLETTER JULY 2008 Welcome back to the Quality Assurance/CARF Newsletter. In this issue we would like to provide medical record training on the Person Centered Recovery Focused Plan of Care (POC) (Please begin using the following format on October 1, 2008) Person Centered Care is a highly individualized comprehensive approach to assessment and services. It takes into account each individual s and family s history, strengths, needs, and vision of their own recovery including attention to the issues of culture, spirituality, trauma, and other factors. The service plans and outcomes are built upon respect for the unique preferences, strengths, and dignity of each person. In Person Centered Planning the plan is based on what the client wants and needs. The professional plays a role in planning and delivery of interventions and supports and recognizes the importance of family and community supports. The Key Elements of Person Centered Planning is: encourages the strengthening and development of supports, views the development of natural supports as an equal responsibility of the client, family, and clinicians, before a person centered planning meeting is initialed, the clinician and client should consider who to invite to be part of the treatment based on the needs and goals of the client, and finally ensure commitment of all involved in the treatment. What does this do the client? 1. Reinforces the belief and values of recovery and 2. Individualizes services based on the client s preferences, choice, and abilities 5 Principle Dimensions of Person Centeredness: Understanding needs from a broad bio psycho social perspective rather than a deficit or symptom driven perspective The ability to see the client as person and not diminished or dehumanized in any way by him/her seeking help The sharing of power and responsibility in decision making The recognition of a therapeutic alliance and partnership between the provider and the client The ability to view the provider as person and not case him/her into a position of power or undue authority In the mental health field the medical model is being replaced by a framework of recovery, wellness, and resilience. Principles of hope, empowerment, and self determination are central to this approach as each client/family articulates their vision and begins to map out their own unique roadmap to recovery. Medical Model is not the same as Medical Necessity. Medical Model is a philosophy of deficit based approaches to treatment. Medical Necessity is ensuring that services provided during treatment are necessary to treat the client (as determined by the authorizing physician). Components of Successful Care The Assessment has two components the diagnosis (accurate) and the interpretive summary (relevant). The role of the Interpretive Summary is: Gathering assessment data is about what The interpretive summary is about how and why More than just compiling and re stating the assessment data Out of the bits and pieces of the assessment data, we create an understanding of the individual and family that extends beyond mere facts Documents the rationalization and justification for the provider s recommendations and suggestions Creates the platform for developing the POC and charting the course for recovering and resilience Explains the goals, identifies the barriers, orders priority of tasks and objectives, substantiates the level of care, clarifies the diagnosis, explains the role of culture and ultimately justifies the interventions/services provided to the client and family The Stages of Change Include: Pre contemplation: the individual has not yet considered the possibility of change and seldom presents voluntarily for treatment. The provider s job is to increase the person s perception of risks and problems with his or her current behavior. 1
Contemplation: the individual is ambivalent, vacillating between motivations to change and justifications for not changing. At this stage, the provider should strengthen the person s ability to change his/her current behavior by heightening awareness of the risks of not changing. Preparation (or determination): the individual experiences the motivation to change and the provider helps the person determine the best course of action to pursue. Action: the point at which the individual seeks services and the provider helps the person take the necessary steps towards services. Maintenance: the individual attempts to sustain the change and the provider helps to identify strategies to prevent relapse and promote ongoing recovery Using the stages of change framework offers a positive perspective and allows for re framing problems and circumstances in a way that leads to alliance, hope, and success. The provider can help the client understand what stage he/she is in and can map out what lies ahead. Strengths, Needs, Abilities, and Preferences (SNAPS) (These are the foundation of the treatment goals and objectives listed in the Plan of Care) Strengths and Abilities: refer to characteristics of the clients, or elements in the client s life, used in the past or present to help them cope with stressful situations. Are used in treatment planning help promote client s success in reaching his/her goals. Examples of Strengths: principles, religious beliefs, supportive friends, supportive family, being able to work, being able to care for others despite own problems, and hope. If a client has a supportive family member, then that member can be brought into the treatment process, with client s permission, and ask that they help client with access to medication and transportation. Example of Abilities: listens to adults, attends to activities of daily living, skills in reading and writing, asks for help, capacity to learn, learns from errors, talents, saves money, able to take care of self, follows instructions, and recognizes side effects of medications. If the client has the ability to type, this could be used in treatment as a way of asking client to research information in the internet to help him/her manage their symptoms. Needs: refer to the client s problems and symptoms and serve as the basis for goal information. Examples of Needs: learn about my illness, to remain in school, a job, companionship, supervision of daily living, services from other agencies, and to be monitored closely at home. Preferences: refers to what the client wants in terms of the practical aspects of treatment. The following questions may help the client to state their preferences: 1. If we could accommodate you would you prefer a male or female counselor or a counselor familiar with your particular culture, spiritual beliefs, and/or race? 2. If we could accommodate would you prefer having your appointments first thing in the morning, over lunch time, before 4:00 p.m. or after 5:00 p.m.? Examples of Preferences: appointment times, specific program, and or a therapist of same or opposite sex. Plan of Care (POC) is a road map, the goal of service is the destination, and consistent with the client s vision of recovery. Goals should reflect the client s and the family s clearest articulation of the destination and the primary reason for seeking help and receiving services. The goals should be broad general statements that express the individual s and family s desire for change and improvement in their lives. If it often appropriate to have only one goal that captures the essence of the individual s and family s vision of their recovery and service needs. Having too many goals or goals that are too specific can seriously undermine the planning process. Developing Goals: goals are developed from information gained during the assessment and the understanding derived from the Interpretive Summary. The assessment process helps to identify each individual s and family s unique attributes, including needs, problems, strengths, resources, barriers and priorities in reaching the goals. In a person center approach, the provider s responsibilities are: 1. to help the individual and family identify and express those issues and needs 2. to help frame the resolution of those needs as goals to be included on the Plan of Care. Example of Goal Statements: I want to stop fighting with my brother/sister, I want to get a car, I want to get a job, I want to live with my family, and I want to stay out of trouble with my parents. 2
Although these goals are not treatment or disorder specific, they are affected by mental illness. Recovery and rehabilitation are concerned with helping people lead their lives to the fullest potential. Rehabilitation helps people to restore their lives to their former level of functioning. Objectives: Objectives are the changes necessary to help the client/family meet their goals. Objectives identify the immediate focus of treatment. Objectives are the incremental tasks the client and family will focus on, bit by bit, as they move towards their goal. Action Oriented and Behavioral Terms: Historically we focused on process over outcomes, so we see many objectives written as client will gain insight, have understanding, and be able to accept. Objectives are typically ACTION words, behavioral, specific, and measurable. Objectives should state desired changes in behavior. Occasionally, it may refer to the identification of triggering factors. In such situations, target dates should cover no more than two to three sessions. Achieving objectives usually requires the client/family to master new skills and abilities that support them in developing more effective responses to their needs and challenges. A properly written objective typically begins with the client and/or family will.. and describes the desirable, significant or meaningful change in behavior, status or function as a step towards reaching the larger goal. Key Features of Objectives: Reasonable Measurable Appropriate to treatment setting Achievable Understandable to the individual Time specific Written in behaviorally specific language Responsive to the client s disability/disorder/challenges and stage of recovery Appropriate to the client s age, development, and culture Objectives should be SMART: S: Simple/Specific/Straightforward M: Measurable A: Achievable/Action Oriented R: Reasonable T: Target Date Measurability: The intended change should be obvious and readily observed by the client and family as well as the provider. It is acceptable to measure change by observation, self report, completion of an assignment. Other measures are standardized tests, urine drug screens, journals, behavior charts, or diary cards. Strength Based Approach: Objectives should describe positive changes that build on past accomplishments and existing resources. Objectives should reflect an increase in functioning and ability, along with attainment of new skills rather than merely a decrease of symptoms. Achievability: Objectives should be: Realistic, Developmentally Appropriate, Culturally Appropriate, and Reflective of the client s strengths and limitations. Target Dates: A person centered, recovery focused approach to treatment planning has target dates that are relevant to the scope of the objective, the client s and family s motivation and the resources available to support and facilitate the change. Target Dates are specific to each objective, predict how long it will take the individual to achieve the change, and motivate actions and organize energies. The target dates established for objectives carries, an important message for the provider as well as the client that, Change is Expected. Setting extended target dates subtly communicates a 3
message of low expectations and hopelessness. As a general rule, consider 90 days as an upper limit time frame for clients in active treatment. Ninety days is a reasonable period for review and reassessment and corresponds to our 90 day Progress Summary requirement. Discharge/Transition Planning: Must be developed at the onset of treatment in collaboration with the client/family Should be individualized and reference the client s symptoms, behaviors, and/or circumstances Be realistic. A statement such as when client is symptom free for one year may be unlikely for some clients If the condition of the client is such that the client is not expected to be discharge in some time, one may make reference to the client s likely transition to another level of care or independence when the client meets specific treatment goals Avoid blanket phrases, especially when these convey hopelessness when the client dies or when the client moves out of the area Update the discharge plan according to the client s progress or lack of progress in treatment There is a clear link between goals and discharge/transition planning Goal achievement reflect the resolution of the problems or needs that initially led the client/family to seek services Periodic Assessment of Client s Progress: Refers to the periodic assessment and monitoring of the client s progress in reference to the treatment goals and objectives Usually occurs on a quarterly basis Services to assess the appropriateness of the treatment plan and the effectiveness of the interventions. It also helps identify new or unmet needs. It is a collaborative effort done with the client and as appropriate, family members, and any other providers or community supports that assist the client in reaching his/her goals. It should be a formal process to reassess treatment needs. Recovery Plan of Care (RPOC) Requirements: The RPOC must be developed, signed,and dated by the MHP and reviewing physician within 90 calendar days from the date a client enters the system The maximum duration of the RPOC is 12 months from the date the physician s signature on the RPOC The RPOC should be signed by the client and/or family member Should include the clients name and client identification number Primary diagnosis, which is the basis for treatment, including code and description according to the current edition of Diagnosis and Statistical Manual of Mental Disorders (DSM) In case of multiple diagnoses, all which are relevant to the treatment should be recorded, especially those of cooccurring disorder These should be integrated into the RPOC with specific goals and objectives coordinated with the appropriate service providers Treatment goals and objectives Client s strengths, needs, abilities, and preferences Referrals to other service providers outside of DMH and the specific contact information Discharge/transition plan which should be developed with the client/family at the beginning of treatment but also requires clinician input Additions and Changes to the RPOC: New services added to the RPOC or increases in the frequencies of existing services must be authorized by a physician with his/her initials and the date except for WRAPS and MH NOS which may be authorized by either a MD or a LPHA. In the situations where new services, or changes, in the frequencies of existing services are authorized by a physician over the phone (not face to face), should be clearly documented in the record as an SPD. The SPD note should be signed by the physician and the entry on the RPOC should also be initialed and dated by the MD as soon as possible. For Additional Information Please Contact: Cassandra A. McCray, MA, QA/CARF Director, Corporate Compliance/HIPAA Officer at 843-317-4089 extension 318 4
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